Vitamin D Deficiency Among Newly Resettled Refugees in Massachusetts

Health needs of refugee children identified on arrival in reception countries: a systematic review and meta-analysis

BACKGROUND

The worldwide number of refugees has considerably increased due to ongoing wars, national instability, political persecution and food insecurity. In Europe, about one-third of all refugees are children, an increasing number of which are travelling alone. There are often no systematic medical health assessments for these refugee children on entry in reception countries despite the fact that they are recognised as an at-risk population due to increased burden of physical and mental health conditions. We aimed to perform a systematic review of the literature to describe the health status of refugee children on entering reception countries.

METHODS

A systematic search of published literature was conducted using the terms refugee, immigrant or migrant, medical or health, and screening.

RESULTS

Of the 3487 potentially relevant papers, 53 population-based studies were included in this review. This systematic review showed that refugee children exhibit high estimated prevalence rates for anaemia (14%), haemoglobinopathies (4%), chronic hepatitis B (3%), latent tuberculosis infection (11%) and vitamin D deficiency (45%) on entry in reception countries. Approximately one-third of refugee children had intestinal infection. Nutritional problems ranged from wasting and stunting to obesity.

CONCLUSIONS

Refugee children entering reception countries should receive comprehensive health assessments based on the outcomes of this systematic review, national budgets, cost-effectiveness and personal factors of the refugees. The health assessment should be tailored to individual child health needs depending on preflight, flight and postarrival conditions.A paradigm shift that places focus on child health and development will help this vulnerable group of children integrate into their new environments.

PROSPERO REGISTRATION NUMBER

122561.

Providing Care for Children in Immigrant Families

Children in immigrant families (CIF), who represent 1 in 4 children in the United States, represent a growing and ever more diverse US demographic that pediatric medical providers nationwide will increasingly encounter in clinical care. Immigrant children are those born outside the United States to non-US citizen parents, and CIF are defined as those who are either foreign born or have at least 1 parent who is foreign born. Some families immigrate for economic or educational reasons, and others come fleeing persecution and seeking safe haven. Some US-born children with a foreign-born parent may share vulnerabilities with children who themselves are foreign born, particularly regarding access to care and other social determinants of health. Therefore, the larger umbrella term of CIF is used in this statement. CIF, like all children, have diverse experiences that interact with their biopsychosocial development. CIF may face inequities that can threaten their health and well-being, and CIF also offer strengths and embody resilience that can surpass challenges experienced before and during integration. This policy statement describes the evolving population of CIF in the United States, briefly introduces core competencies to enhance care within a framework of cultural humility and safety, and discusses barriers and opportunities at the practice and systems levels. Practice-level recommendations describe how pediatricians can promote health equity for CIF through careful attention to core competencies in clinical care, thoughtful community engagement, and system-level support. Advocacy and policy recommendations offer ways pediatricians can advocate for policies that promote health equity for CIF.

Prevalence of Nutritional Deficiencies Among Populations of Newly Arriving Government Assisted Refugee Children to Kitchener/Waterloo, Ontario, Canada

This study examined the variation among ethnic populations in prevalence of anemia, vitamin D and B12 deficiencies among refugee children. A retrospective chart review of 388 government assisted refugee children ≤ 16 years of age, seen at the Refugee Health Clinic in Kitchener, Canada from January 2009 to December 2014 was conducted. Vitamin D levels were only collected until December 1st 2010 (116 children). 15.7% were anemic (25% < 5 years, 8.7% 5-11 years, and 18.3% 12-16 years old) with Somali children having the lowest hemoglobin levels compared to those from Iraq, Afghanistan and Myanmar. 53.5% were vitamin D deficient (25(OH)D < 50 nmol/L), seen most commonly in Iraqis and Afghans. 11.2% had vitamin B12 levels < 150 pmol/L. Providers' knowledge of prevalence of nutritional deficiencies related to region of origin, can guide appropriate screening and treatment options to promote longer term cognitive, physical and developmental health.

Randomised Controlled Trial Comparing Daily Versus Depot Vitamin D3 Therapy in 0-16-Year-Old Newly Settled Refugees in Western Australia Over a Period of 40 Weeks

Vitamin D deficiency is highly prevalent in newly settled refugees in Western Australia (WA). If adherence to daily vitamin D therapy is problematic, depot therapy is a therapeutic alternative. The aim of this study was to compare daily versus depot treatment and factors influencing the therapeutic outcome. Newly settled refugees (n = 151) with 25(OH)D levels less than 78 nmol/L were randomised to receive daily or depot vitamin D therapy with eight weekly interval follow up to 40 weeks. Biochemical and clinical parameters were collected at each visit. Generalized Linear Mixed Models (GLMM) examined the longitudinal changes over time controlling for confounders including age, gender, treatment arm, season, country of refuge/origin and sun exposure score. Participants were aged 5.5 months to 16.0 years (75 males, 83 females). Both treatment groups achieved vitamin D sufficiency. The daily treatment group had significantly higher 25(OH)D levels at each visit post baseline and a higher proportion of participants with levels above 50 nmol/L at all time points. Time, treatment group, calcium and sun exposure score were significant predictors of 25(OH)D serum levels. Depot vitamin D therapy is an alternative to daily treatment in this at-risk group of children and adolescents in whom treatment adherence is problematic.

Global Overview of Vitamin D Status

Vitamin D deficiency occurs all over the world, mainly in the Middle East, China, Mongolia, and India. This article focuses on the vitamin D status in adults. Risk groups include older persons, pregnant women, and non-Western immigrants. Adequate vitamin D status, defined as serum 25-hydroxyvitamin D greater than 50 nmol/L, is present in less than 50% of the world population, at least in winter. Preventative strategies, such as increasing fish consumption, fortification of foods, use of vitamin D supplements, and advice for moderate sunlight exposure, are warranted.

Vitamin D levels and influencing predictors in refugee children in Sherbrooke (Quebec), Canada

BACKGROUND AND OBJECTIVE

Suboptimal vitamin D levels and associated complications are on the rise. Vulnerable populations, like refugee children, are further at risk. Studies on the vitamin D levels in refugee children are limited. The primary objective of this cross-sectional retrospective study was to determine the level of serum 25-hydroxyvitamin D (25-(OH)D) in the paediatric refugee population residing in Sherbrooke, Quebec, Canada. The secondary objective was to determine variables predicting vitamin D levels.

METHODS

Refugees under the age of 19 years arriving in Sherbrooke, Quebec, Canada, evaluated by the refugee clinic between March 2013 and April 2014, were included in the study. Vitamin D levels upon arrival and variables including age, sex, body mass index, season of arrival and season of test, ethnicity, previous country of residence and duration of stay in Canada from time of arrival were recorded. The protocol was approved by the scientific and ethics board of respective institutions.

RESULTS

A total of 138 subjects were included in the study from the Middle East, Central Asia and South East Asia, Africa and South America. The mean 25-(OH)D serum value was 55 nmol/L (insufficient). Fourteen per cent of subjects were vitamin D deficient and 64% were vitamin D insufficient as per Canadian Paediatric Society threshold guidelines. Gender (P=0.022), age (P<0.001), latitude (P<0.001) and season of testing (P=0.022) predict vitamin D status.

CONCLUSIONS

This study concluded that refugee children have insufficient vitamin D levels. Gender, age, latitude and season of testing have an impact in predicting vitamin D status.

Vitamin D status in patients attending a Danish migrant health clinic: a clinical retrospective study

Non-western migrants and ethnic minority populations in western countries are particularly at risk of vitamin D deficiency due to darker skin color and low sun exposure. The aim of this study was to examine levels of 25-OH vitamin D in patients attending a Danish health clinic for migrants. Patients attending the clinic represent a distinct group of migrants with longstanding, unresolved symptoms and often multiple illnesses. In this retrospective study, data on patient demographics and vitamin D levels were extracted from the medical records of 156 patients attending a Migrant Health Clinic in 2008-2011 who were considered at-risk for low vitamin D, mainly due to symptoms of diffuse pain in the muscles, bones or joints. Over the follow-up period of 1 year, the number of patients with vitamin D below 50 nmol/L decreased from 80 to 56%. The median vitamin D level increased from 27 nmol/L [(interquartile ranges (IQR 14.5-45.0)] at baseline to 45 nmol/L (IQR 26.5-64.5) at follow-up. Patient consultations with a holistic approach and close follow-up can help patients with complex symptoms and language barriers to overcome barriers to treatment and adherence, thus leading to improved levels of vitamin D.

Health Profiles of Newly Arrived Refugee Children in the United States, 2006-2012

OBJECTIVES

We conducted a large-scale study of newly arrived refugee children in the United States with data from 2006 to 2012 domestic medical examinations in 4 sites: Colorado; Minnesota; Philadelphia, Pennsylvania; and Washington State.

METHODS

Blood lead level, anemia, hepatitis B virus (HBV) infection, tuberculosis infection or disease, and Strongyloides seropositivity data were available for 8148 refugee children (aged < 19 years) from Bhutan, Burma, Democratic Republic of Congo, Ethiopia, Iraq, and Somalia.

RESULTS

We identified distinct health profiles for each country of origin, as well as for Burmese children who arrived in the United States from Thailand compared with Burmese children who arrived from Malaysia. Hepatitis B was more prevalent among male children than female children and among children aged 5 years and older. The odds of HBV, tuberculosis, and Strongyloides decreased over the study period.

CONCLUSIONS

Medical screening remains an important part of health care for newly arrived refugee children in the United States, and disease risk varies by population.

Nutrition for refugee children: risks, screening, and treatment

Pediatric refugees are at an increased risk for growth and nutritional deficits. As more children are resettled to the United States, it is important to screen appropriately in order to identify any growth or nutritional issues. Resettled refugee children continue to be at risk for both over- and undernutrition, therefore culturally appropriate education and counseling should be provided to improve long-term health.

Performance evaluation of Siemens ADVIA Centaur and Roche MODULAR Analytics E170 Total 25-OH Vitamin D assays

OBJECTIVES

To evaluate the newly developed Roche MODULAR Analytics E170 Total Vitamin D and the Siemens ADVIA Centaur Vitamin D Total assays.

MATERIALS AND METHODS

Assays were evaluated using the Clinical and Laboratory Standards Institute protocols. Split patient samples were compared with LC-MS/MS and DiaSorin LIAISON assays (n=79 including 15 specimens with detectable endogenous 25-OH vitamin D(2)). Assay accuracy was also evaluated using the Vitamin D External Quality Assessment Scheme (DEQAS) samples.

RESULTS

The ADVIA Centaur and E170 assays demonstrated maximum total CVs of 14.1% and 5.9%, respectively. Both showed excellent linearity (R(2)>0.99). The ADVIA Centaur assay demonstrated interference with bilirubin at 800 μmol/L, hemolysis at 1.25 g/L, and triglycerides at 2.8 mmol/L. Compared to LC-MS/MS, the ADVIA Centaur assay demonstrated a R(2) value of 0.893, average bias of -8.8%; the E170 assay an R(2) value of 0.872, average bias of 14.3% with underestimation of 25-OH vitamin D(2). Compared to the LIAISON assay, the ADVIA Centaur assay demonstrated an R(2) value of 0.781, average bias of -17.3%; the E170 assay an R(2) value of 0.823, average bias of 11.4%. The ADVIA Centaur and E170 assays demonstrated a biases of <20% in 10/10 and 8/10 DEQAS samples, respectively.

CONCLUSIONS

The ADVIA Centaur and E170 vitamin D assays demonstrated acceptable linearity, imprecision, and accuracy. The E170 assay demonstrated consistent underestimation of 25-OH vitamin D(2) levels. Compared with LC-MS/MS, the ADVIA Centaur assay demonstrated a higher R(2) value and a smaller average bias than the E170 assay.