Infectious diseases and migrant worker health in Singapore: a receiving country's perspective

Access to healthcare services and factors associated with unmet needs among migrants in Phuket Province, Thailand, 2023: a cross-sectional mixed-method study

BACKGROUND

Phuket Province is a major tourist destination with a migrant workforce accounting for 10% of its population. Despite governmental efforts to adjust health insurance policies, migrants face healthcare access challenges. This study examines the current healthcare access situation and factors associated with unmet needs among migrants in Phuket Province.

METHODS

We used a cross-sectional mixed-methods approach, recruiting participants through snowball sampling from the Migrant Health Volunteer Network. Quantitative data were gathered using self-administered questionnaires, with unmet need defined as desired outpatient or recommended inpatient services not received at government hospitals. Multivariable logistic regression identified unmet need predictors, and we assessed the mediating effect of health insurance status. Qualitative data from three focus groups on healthcare access provided context and enriched the quantitative findings.

RESULTS

This study includes 296 migrants mainly from Myanmar. The overall unmet need prevalence was 14.86%, mainly attributed to having undocumented status (34.09%), affordability issues (20.45%), and language barriers (18.18%). Working in the fishery industry significantly increased unmet needs risk (aOR 2.68, 95% CI 1.08-6.62). Undocumented status contributed a marginal total effect of 4.86 (95% CI 1.62-14.54), with a natural indirect effect through uninsured status of only 1.16 (95% CI 0.88-1.52). Focus group participants used various medical resources, with insured individuals preferring hospital care, but faced obstacles due to undocumented status and language barriers.

CONCLUSION

Valid legal documents, including work permits and visas, are crucial for healthcare access. Attention to fishery industry practices is needed. We recommend stakeholder discussions to streamline the process of obtaining and maintaining these documents for migrant workers. These improvements could enhance health insurance acquisition and ultimately improve healthcare affordability for this population. These insights could be applied to migrant workers in other urban and suburban area of Thailand regarding access to government healthcare facilities.

Modeling tuberculosis transmission flow in China, 2010-2012

BACKGROUND

China has the third largest number of TB cases in the world, and the average annual floating population in China is more than 200 million, the increasing floating population across regions has a tremendous potential for spreading infectious diseases, however, the role of increasing massive floating population in tuberculosis transmission is yet unclear in China.

METHODS

29,667 tuberculosis flow data were derived from the new smear-positive pulmonary tuberculosis cases in China. Spatial variation of TB transmission was measured by geodetector q-statistic and spatial interaction model was used to model the tuberculosis flow and the regional socioeconomic factors.

RESULTS

Tuberculosis transmission flow presented spatial heterogeneity. The Pearl River Delta in southern China and the Yangtze River Delta along China's east coast presented as the largest destination and concentration areas of tuberculosis inflows. Socioeconomic factors were determinants of tuberculosis flow. Some impact factors showed different spatial associations with tuberculosis transmission flow. A 10% increase in per capita GDP was associated with 10.2% in 2010 or 2.1% in 2012 decrease in tuberculosis outflows from the provinces of origin, and 1.2% in 2010 or 0.5% increase in tuberculosis inflows to the destinations and 18.9% increase in intraprovincial flow in 2012. Per capita net income of rural households and per capita disposable income of urban households were positively associated with tuberculosis flows. A 10% increase in per capita net income corresponded to 14.0% in 2010 or 3.6% in 2012 increase in outflows from the origin, 44.2% in 2010 or 12.8% increase in inflows to the destinations and 47.9% increase in intraprovincial flows in 2012. Tuberculosis incidence had positive impacts on tuberculosis flows. A 10% increase in the number of tuberculosis cases corresponded to 2.2% in 2010 or 1.1% in 2012 increase in tuberculosis inflows to the destinations, 5.2% in 2010 or 2.0% in 2012 increase in outflows from the origins, 11.5% in 2010 or 2.2% in 2012 increase in intraprovincial flows.

CONCLUSIONS

Tuberculosis flows had clear spatial stratified heterogeneity and spatial autocorrelation, regional socio-economic characteristics had diverse and statistically significant effects on tuberculosis flows in the origin and destination, and income factor played an important role among the determinants.

Characteristics of migrant workers admitted from the emergency department

INTRODUCTION

Emergency department (ED) admissions for non-work-related injuries and illnesses in the migrant worker (MW) population in Singapore are not well studied. We aimed to examine ED triage acuity and bills associated with admissions among MW for non-trauma, workplace injury (WI) trauma, and non-workplace injury (NWI) trauma.

METHODS

In this retrospective observational study, we included all work permit holders admitted to hospital via the ED of three public hospitals from 1 May 2016 to 31 October 2016. Data obtained from medical records included demographics, triage acuity and bill information.

RESULTS

There were 1,750 unique patients accounting for 1,788 admissions. The median age was 33 (interquartile range 27-40) years, with a male predominance of 67%. Trauma accounted for 33% ( n = 595) of admissions, and of these, 73% ( n = 433) were due to WI. Admissions for NWI, as compared to WI, were more likely to present as high acuity P1 cases (43% vs 24%, P < 0.001), be conveyed by ambulance (49% vs 24%, P < 0.001) and result in trauma team activations (29% vs 7%, P < 0.001). More NWI admissions (22%, 36/162) exceeded the insurance claim limit under prevailing healthcare policies, as compared to WI admissions (3%, 13/433).

CONCLUSION

Migrant workers are admitted to hospital for non-trauma conditions more frequently than for trauma. Non-workplace injury trauma may be severe. Non-trauma and NWI admissions can result in large bills that exceed mandatory insurance coverage. Recent changes to healthcare policy governing MW to allow copayment of large bills and better access to primary care are timely.

Knowledge of the workers of the construction industry about acquired immunodeficiency syndrome and associated factors

BACKGROUND

Sexually Transmitted Infections (STIs), such as Human Immunodeficiency Virus (HIV) transmitted by biological, socioeconomic and cultural factors that increase the vulnerability of certain population groups such as civil construction workers.

OBJECTIVE

To evaluate the knowledge of workers in the construction industry about infection by HIV and associated factors.

METHODS

A cross-sectional, analytical study was conducted, including 381 construction workers, in the cities of João Pessoa, Cabedelo, and Santa Rita, in the State of Paraíba, Brazil, performed through interviews, using a data collection instrument with social demographic variables and the HIV Knowledge Questionnaire. Data were analyzed using descriptive measures, and for comparison between the categories the Kruskal-Wallis test was used, with margin of error of 5%.

RESULTS

A predominance of male workers was observed (97.4%) among 381 workers; aged 30-39 (34.1%); married (81.4%); with up to eight years of education (66.6%); family income of up to 2x the minimum wage (52.8%) and coming from the country (43.8%). The average of correct responses was 63.3%, with higher indices (70.0%) related to transmission and forms of prevention. There were higher percentages of hits among those who had studied for 12 years or more. Workers from the capital of Paraíba presented a higher number of correct responses (67.44%).

CONCLUSIONS

There is a low index of knowledge of construction workers about HIV, highlighting their consequent vulnerability to acquiring this infection.

The impact of anthropogenic climate change on pediatric viral diseases

The adverse effects of climate change on human health are unfolding in real time. Environmental fragmentation is amplifying spillover of viruses from wildlife to humans. Increasing temperatures are expanding mosquito and tick habitats, introducing vector-borne viruses into immunologically susceptible populations. More frequent flooding is spreading water-borne viral pathogens, while prolonged droughts reduce regional capacity to prevent and respond to disease outbreaks with adequate water, sanitation, and hygiene resources. Worsening air quality and altered transmission seasons due to an increasingly volatile climate may exacerbate the impacts of respiratory viruses. Furthermore, both extreme weather events and long-term climate variation are causing the destruction of health systems and large-scale migrations, reshaping health care delivery in the face of an evolving global burden of viral disease. Because of their immunological immaturity, differences in physiology (e.g., size), dependence on caregivers, and behavioral traits, children are particularly vulnerable to climate change. This investigation into the unique pediatric viral threats posed by an increasingly inhospitable world elucidates potential avenues of targeted programming and uncovers future research questions to effect equitable, actionable change. IMPACT: A review of the effects of climate change on viral threats to pediatric health, including zoonotic, vector-borne, water-borne, and respiratory viruses, as well as distal threats related to climate-induced migration and health systems. A unique focus on viruses offers a more in-depth look at the effect of climate change on vector competence, viral particle survival, co-morbidities, and host behavior. An examination of children as a particularly vulnerable population provokes programming tailored to their unique set of vulnerabilities and encourages reflection on equitable climate adaptation frameworks.

Preventive knowledge, attitude, and vaccination challenges for COVID-19 among Myanmar refugees and irregular migrants in Malaysia

Access to vaccinations is crucial for everyone in the fight against the COVID-19 pandemic, regardless of migration or refugee status. This study explored COVID-19 prevention knowledge, attitudes, and vaccination challenges among refugees and irregular migrants from Myanmar in Malaysia. This study employed a descriptive mixed-method approach. Convenience sampling was used to conduct an online survey of 174 participants and two focus groups (N = 14). The majority (51.7 %) were refugees, and 48% were irregular migrant workers. In this study, 90.9% of the participants used social networks and social media chats to obtain information about COVID-19, 84.1% understood and found the vaccination campaign helpful, and 44.2% were aware of it. Although 70% of the participants considered vaccination crucial, 95% said that they would not take it because of fear of arrest and deportation, even though they considered vaccination necessary. Approximately 21.2% of the workers reported that their employers did not provide masks or hand sanitisers. Most of the participants (39.7 %) lived in dormitories provided by their employers. This puts them at a higher risk of infection because of the difficulty in practising social distancing. As part of COVID-19 prevention, the government should grant an amnesty period and work with migrant civil society organisations to administer vaccinations and effective measures for all immigrant populations in Malaysia.

A qualitative exploration of factors that influence the uptake of tuberculosis services by low-skilled migrant workers in Singapore

INTRODUCTION

Singapore relies heavily on migrant workers to build its country and harbours a relatively large population of these workers. Importantly, tuberculosis (TB) remains a pernicious threat to the health of these workers and in line with the United Nations High-Level Meeting in 2023, this paper aims to uncover the qualitative discourse facing migrant workers' uptake of TB services and provide policy recommendations to enable more equitable access to TB services for this population.

METHODS

In-depth interviews were carried out with the migrant worker population recruited from a non-governmental organisation in Singapore that serves migrant workers through the provision of primary healthcare services, counselling, and social assistance. Interviews stopped once thematic saturation was achieved and no new themes and subthemes were found.

RESULTS

A total of 29 participants were interviewed, including 16 Bangladeshis and 13 Chinese, aged between 22 and 54 years old, all worked in the construction sector. Four key themes emerged. They are (1) General TB knowledge: Misconceptions are prevalent, where we found that participants were aware of the disease but did not possess a clear understanding of its pathophysiology and associated health effects, (2) Contextual knowledge and perception of associated policies related to TB in Singapore: low awareness among migrant workers as participants' accounts depicted a lack of information sources in Singapore especially on issues related to healthcare including TB, (3) Attitude to towards TB: Motivation to seek treatment is underpinned by ability to continue working and (4) Stigma: mixed perception of how society views TB patients. The gaps identified in migrant workers' TB knowledge, their attitude towards the disease and their perception of the availability of TB-related services is despite Singapore's efforts to curb community spread of TB and its proactive initiatives to reduce the prevalence.

CONCLUSION

Our study illuminates the various aspects that policymakers need to home in on to ensure this vulnerable group is sufficiently supported and equitably cared for if they develop active TB during their stay in Singapore as they contribute to the nation's economy. Leveraging the COVID-19 pandemic as a window of opportunity to improve overall healthcare access for vulnerable groups in Singapore can be a starting point.

"My young life, finished already?": a qualitative study of embedded social stressors and their effects on mental health of low-wage male migrant workers in Singapore

BACKGROUND

Increasing evidence shows low-wage migrant workers experience a high prevalence of mental health disorders and adverse health outcomes. Significant disparities in health services usage among migrant workers create added vulnerability to health complications. However, much remains unclear about how vulnerabilities are constructed in migrant worker populations. Additionally, no studies in Singapore have attempted to critically examine the degree to which social environment and structures affect the health and wellbeing of migrant workers. Therefore, this study aimed to critically situate the socio-structural factors creating conditions of vulnerability among migrant workers using a social stress perspective.

METHODS

We conducted semi-structured individual and group interviews with migrant workers focused on individual life experiences, community experiences (individual and collective social capital), health (mental and physical health concerns) and stress response behaviours. We used a grounded theory approach to identify sources of stress and stress responses and uncover pathways to social vulnerabilities.

RESULTS

Findings from 21 individual and 2 group interviews revealed that migrant workers were embedded in a cycle of chronic stress driven by structural factors that were mutually reinforced by stressors arising from their social environment. Socio-structural stressors enacted as poor living, working and social conditions resulted in their negative quality-of-life appraisal. Stressors arising from being "foreign" resulted in anticipated stigma, concealment, and healthcare avoidance. These factors synergistically created a persistent mental health burden for migrant workers.

CONCLUSIONS

Findings highlight the need to address the mental health burden placed on migrant workers and create avenues for migrant workers to seek psychosocial support to manage their stressors.

Health-care access and utilization among HIV-infected men who have sex with men in two Chinese municipalities with or without lockdown amidst early COVID-19 pandemic

City lockdown is critical to successfully contain the COVID-19 pandemic. The impact of lockdown and COVID-19 pandemic on healthcare among vulnerable population has yet to be explicated. A cross-sectional survey was conducted among HIV-infected men who have sex with men (MSM) in Wuhan with city lockdown and Shanghai without lockdown, and healthcare interruptions were evaluated and compared. A logistic regression analysis was employed to examine associates of HIV-related healthcare interruptions and compromised mental health. Compared to participants in Shanghai (N = 440), HIV-infected MSM in Wuhan (N = 503) had significantly higher proportion of untimely availability of antiretroviral drugs (ARVs) (20.6% vs. 8.4%), obtaining ARVs from outside institutions (29.1% vs. 8.1%), postponed non-AIDS treatment (6.4% vs. 2.8%) and untimely follow-up appointments (33.4% vs. 14.5%). HIV-related healthcare interruptions were positively associated with lockdown (OR = 4.89, 95% CI: 3.49-6.85) and non-local residence (OR = 1.91, 95% CI: 1.37-2.64). Compromised mental health, including insomnia and generalized anxiety disorders, was associated with non-local residence (OR  = 1.35, 95% CI: 1.01-1.81) and healthcare interruptions (OR = 1.34, 95% CI: 1.01-1.79). HIV-infected MSM are vulnerable to healthcare interruptions and mental health problems during the COVID-19 pandemic, underscoring the need for tailored intervention strategies to minimize deleterious health consequences.

Implications of the COVID-19 pandemic for urban informal housing and planning interventions: Evidence from Singapore

The outbreak of the COVID-19 pandemic revealed the crucial role of social distancing and hygiene practices in reducing virus transmission and thus revealed the high risk of infection in urban informal housing. Through an empirical study of Singapore's infectious situation and antiepidemic measures, this paper shows that the number of infected migrant workers living in dormitories was three hundred times greater than the number of infected local urban residents, not only because of the migrants' 'vulnerable' position but also because their living conditions fostered widespread transmission of the virus. The dwelling conditions of migrant dormitories, such as overcrowded living spaces, widely shared sanitation facilities, and poor hygiene practices, present great challenges to standard prevention strategies and control measures. Adverse health impacts resulting from the lockdown of dormitories during the COVID-19 pandemic suggest the importance of planning intervention in the dwelling conditions of informal housing, and indicate a need for the governments' active reforms of building codes and health care systems to promote the health of disadvantaged groups and then create more inclusive and healthy cities for all the society.

The COVID-19 Pandemic and the Migrant Population for HIV Diagnosis and Care Follow-Up: They Are Left Behind

The coronavirus 2019 (COVID-19) pandemic has posed numerous worldwide challenges. The level of social vulnerability of the migrant population is disproportionately higher than other populations. Recent reports have shown that the access to care for the migrant population (i.e., non-French nationality patients) were greatly impacted during this pandemic. Thus, we would like to highlight the significant impact of the COVID-19 pandemic on care follow-up in those migrant people infected with HIV who receive HIV care in France. Two groups of patients were defined: that is, patients with continuous care and patients with a loss of follow-up of at least one year during the COVID-19 pandemic. Among 672 HIV patients, 19 (2.7%) patients were lost to follow-up for at least one year during the COVID-19 pandemic. We found no significant difference for gender (p = 0.332) or age (p = 0.115) between the two groups. However, patients with a loss of follow-up were mainly migrants rather than from the other group (p < 0.001), and the same results were observed for the nation of birth (89.5% vs. 44%, p < 0.001). In our hospital, most of the patients who were living abroad but had HIV care in France before the COVID epidemic (mainly retired migrants) were lost to follow-up during the COVID-19 pandemic. To date, most of them have not resumed HIV care in France and we do not know their present situation. We can only observe that the COVID-19 pandemic has predominately disrupted the HIV care of migrant populations. Do not let them be left behind!

Migrant Food Handlers’ Impacts on Food Quality and Safety in Malaysia Food Service Industry

This study aims to empirically examine the migrant food handlers’ perceived knowledge, skills, and attitudes and their impact on food quality and safety in the context of Malaysia’s foodservice industry. Using the data gathered from 198 supervisors and managers from food premises in Malaysia and analysis using SPSS (version 20) and SmartPLS 3.0 software, this research found that migrant food handlers have moderate perceived knowledge, skills and attitudes in food handling practices impact the food quality and safety. Specifically, this study confirmed that knowledge and attitudes positively and significantly affect food quality and food safety. However, insignificant results were found between skills and food safety, even though it showed a substantial impact on food quality. The findings are original and unique. It is one of the first studies to investigate the knowledge, skills, and attitude of migrant food handlers their effect on food quality and food safety, especially in Malaysia. Besides, this study extends the established theories from the literature on knowledge, skills and attitudes analysing in the foodservice sector. Therefore, this research finding is valuable for food services practitioners to focus on enhancing food quality and safety through the migrant workforce.

Barriers to Practicing COVID-19 Preventive Behaviors Among Migrant Workers in Qatar: A Qualitative Study During the First Wave of the Pandemic

Objectives: Manual and Craft Workers (MACWs), who constitute more than 80% of the population, were identified to be a vulnerable group to COVID-19 in Qatar. The goal of this study is to identify the limitations face MACWs in Qatar towards practicing the COVID-19 preventive measures and thereby designing behavioral change strategies. Methods: This is a qualitative research study in which individual interviews and focus group discussions were utilized for a deep understanding of the phenomenon from key informants. Four onlive individual interviews and four focus groups (n = 55) were conducted and transcribed verbatim. Inductive qualitative analysis was followed to discover the themes of the interviews. Data were analyzed using constant comparative techniques. Results: Major themes elicited from the analysis revealed that the barriers to following COVID-19 preventive behaviors among migrant workers in Qatar included barriers related to knowledge and risk perception; lifestyle and habits; nature of work and living conditions, and barriers related to health communication, diversified cultures, and languages. Conclusion: The findings would support constructing culturally sensitive health education messages and planning for effective health communication campaigns.

Estimating transmission dynamics of SARS-CoV-2 at different intraspatial levels in an institutional outbreak

Introduction

Large, localised outbreaks of COVID-19 have been repeatedly reported in high-density residential institutions. Understanding the transmission dynamics will inform outbreak response and the design of living environments that are more resilient to future outbreaks.

Methods

We developed an individual-based, multilevel transmission dynamics model using case, serology and symptom data from a 60-day cluster randomised trial of prophylaxes in a densely populated foreign worker dormitory in Singapore. Using Bayesian data augmentation, we estimated the basic reproduction number and the contribution that within-room, between-level and across-block transmission made to it, and the prevalence of infection over the study period across different spatial levels. We then simulated the impact of changing the building layouts in terms of floors and blocks on outbreak size.

Results

We found that the basic reproduction number was 2.76 averaged over the different putative prophylaxes, with substantial contributions due to transmission beyond the residents’ rooms. By the end of ~60 days of follow up, prevalence was 64.4 % (95 % credible interval 64.2–64.6 %). Future outbreak sizes could feasibly be halved by reducing the density to include additional housing blocks, or taller buildings, while retaining the overall number of men in the complex.

Discussion

The methods discussed can potentially be utilised to estimate transmission dynamics at any high-density accommodation site with the availability of case and serology data. The restructuring of infrastructure to reduce the number of residents per room can dramatically slow down epidemics, and therefore should be considered by policymakers as a long-term intervention.

Population-based variations of a core resistome revealed by urban sewage metagenome surveillance

Sewage-based surveillance is widely employed to understand the occurrence and distribution of antimicrobial resistance (AMR) in urban community. However, there are limited studies which investigated the sewage of different sources within community. The present study used metagenomics to decipher the AMR profiles in five sources: local residence's source, animal source, migrant workers' source, clinical source , and urban wastewater treatment plant influent. A core resistome of ARGs was found across all samples, accounting for 81.4%-93.3% of the abundance of total resistome with only 17.3% diversity, irrespective of the sewage sources. Clinically relevant ARGs were identified in the core resistome across all wastewater sources. This included genes conferring resistance to beta-lactams as biomarkers of hospital sewage. The pet center wastewater showed a high abundance of genes encoding resistance to tetracycline, which is a commonly used veterinary antibiotic. The resistome profile of sewage from the migrant workers' dormitories showed a slight variation to that of the local residential population, suggesting possible differences in the human gut resistome of the foreign/migrant population, with biomarkers of genes encoding resistance to fosfomycin, fosmidomycin, kasugamycin, MLS, and polymyxin. The co-localization of ARGs and plasmid, MGEs and integrative and conjugative elements (ICEs) could explain variations in the core resistome, presumably a result of high antibiotic selection pressure. Further analysis showed a specific host-associated resistance pattern, in which core hosts mediated the core resistome profile. The core BMRGs were also co-localized with MGEs/ICEs and carried by core potential bacterial hosts. Local healthy population carried the lowest ARG load (copy number discharged by each person per day) but contributed the highest ARG burden (copy number discharged by the population). This study elucidates population-based variations of a core resistome, and further provides important insights into source tracking and management of AMR in urban environments.

Association between resident status and patients' experiences of primary care: a cross-sectional study in the Greater Bay Area, China

OBJECTIVES

Patients' experiences are important part of health services quality research, but it's still unclear whether patients' experiences are influenced by resident status. This study aimed to evaluate the association between resident status and patients' primary care experiences with the focus on migrants vs local residents.

DESIGN

A cross-sectional study using multistage cluster random sampling was conducted from September to November 2019. The data were analysed using general linear models.

SETTING

Six community health centres in Guangzhou, China.

PARTICIPANTS

1568 patients aged 20 years or older.

MAIN OUTCOME MEASURES

Patients' primary care experiences were assessed using the Primary Care Assessment Tool. The 10 domains included in Primary Care Assessment Tool (PCAT) refers to first contact-utilisation, first contact-access, ongoing care, coordination (referral), coordination (information), comprehensiveness (services available), comprehensiveness (services provided), family-centredness, community orientation and cultural competence from patient's perspective.

RESULTS

1568 questionnaires were analysed. After adjusting for age, sex, education, annual family income, self-perceived health status, chronic condition, annual medical expenditure and medical insurance, the PCAT total scores of the migrants were significantly lower than those of local residents (β=-0.128; 95% CI -0.218 to -0.037). Migrants had significantly lower scores than local residents in first contact utilisation (β=-0.245; 95% CI -0.341 to -0.148), ongoing care (β=-0.175; 95% CI -0.292 to -0.059), family-centredness (β=-0.112; 95% CI -0.225 to 0.001), community orientation (β=-0.176; 95% CI -0.286 to -0.066) and cultural competence (β=-0.270; 95% CI -0.383 to -0.156), respectively.

CONCLUSION

Primary care experiences of migrants were significantly worse off than those of local residents, especially in terms of primary care utilisation, continuity and cultural competence. Given the wide disparity in primary care experiences between migrants and local residents, Chinese healthcare system reform should focus on improving quality of primary care services for migrants, overcoming language barriers and creating patient-centred primary care services.

Prevalence of measles antibodies among migrant workers in Singapore: a serological study to identify susceptible population subgroups

Background

In 2019, two clusters of measles cases were reported in migrant worker dormitories in Singapore. We conducted a seroprevalence study to measure the level of susceptibility to measles among migrant workers in Singapore.

Methods

Our study involved residual sera of migrant workers from seven Asian countries (Bangladesh, China, India, Indonesia, Malaysia, Myanmar and the Philippines) who had participated in a survey between 2016 and 2019. Immunoglobulin G (IgG) antibody levels were first measured using a commercial enzyme-linked immunosorbent assay (ELISA) test kit. Those with equivocal or negative IgG results were further evaluated using plaque reduction neutralization test (PRNT).

Results

A total of 2234 migrant workers aged 20–49 years were included in the study. The overall prevalence of measles IgG antibodies among migrant workers from the seven Asian countries was 90.5% (95% confidence interval 89.2–91.6%). The country-specific seroprevalence ranged from 80.3 to 94.0%. The seroprevalence was significantly higher among migrant workers born in 1965–1989 than those born in 1990–1999 (95.3% vs. 86.6%, p < 0.0005), whereas there was no significant difference by gender (90.8% in men vs. 89.9% in women, p = 0.508). 195 out of 213 samples with equivocal or negative ELISA results were tested positive using PRNT.

Conclusion

The IgG seroprevalence in migrant workers was below the herd immunity threshold of 95% for measles. Sporadic outbreaks may occur in susceptible individuals due to high transmissibility of measles virus. Seroprevalence surveys can help identify susceptible subgroups for vaccination.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-022-07066-2.

Seroprevalence of IgG antibodies against diphtheria antitoxin among migrant workers in Singapore, 2016-2019

Background

Since the last local case of diphtheria in 1992, there had not been any case in Singapore until an autochthonous case was reported in 2017. This fatal diphtheria case of a migrant worker raised concerns about the potential re-emergence of locally transmitted toxigenic diphtheria in Singapore. We conducted a seroprevalence study to assess the immunity levels to diphtheria among migrant workers in Singapore.

Methods

Residual sera from migrant workers who hailed from Bangladesh, China, India, Indonesia, Malaysia, Myanmar and the Philippines were tested for anti-diphtheria toxoid immunoglobulin G (IgG) antibodies. These migrant workers previously participated in a survey between 2016 and 2019 and had provided blood samples as part of the survey procedure.

Results

A total of 2176 migrant workers were included in the study. Their overall mean age was 27.1 years (standard deviation 5.0), range was 20–43 years. The proportion having at least basic protection against diphtheria (antitoxin titres ≥ 0.01 IU/ml) ranged from 77.9% (95% confidence interval [CI] 72.8 – 82.3%) among migrant workers from Bangladesh to 96.7% (95% CI 92.5 – 98.6%) in those hailing from Malaysia. The proportion showing full protection (antitoxin titres ≥ 0.10 IU/ml) ranged from 10.1% (95% CI 6.5 – 15.4%) in Chinese workers to 23.0% (95% CI 17.1 – 30.3%) in Malaysian workers. There were no significant differences in the proportion with at least basic protection across birth cohorts, except for those from Bangladesh where the seroprevalence was significantly lower in younger migrant workers born after 1989.

Conclusions

The proportions having at least basic protection against diphtheria in migrant workers from five out of seven Asian countries (India, Indonesia, Malaysia, Myanmar and the Philippines) were higher than 85%, the threshold for diphtheria herd immunity. Seroprevalence surveys should be conducted periodically to assess the level of immunity against diphtheria and other vaccine preventable diseases in migrant worker population, so that appropriate interventions such as booster vaccination can be implemented proactively to prevent sporadic outbreaks.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-12528-y.

Factors That Prevent Mosquito-Borne Diseases among Migrant Workers in Taiwan: Application of the Health Belief Model in a Church-Based Health Promotion Study

Background: Southeast Asian countries have long been considered epidemic areas for mosquito-borne diseases (MBDs), and most imported cases of infectious diseases in Taiwan are from these areas. Taiwanese migrant workers are mainly of Southeast Asian nationality, and of these, 22% are Filipino. Migrant workers’ knowledge of MBDs and self-protection behaviors are beneficial to disease prevention and treatment. This study aims to understand the effectiveness of a health education intervention (HEI) for Filipino migrant workers in Taiwan and explores the factors affecting preventive practices. Methods: The study was conducted between May to September 2018. Participants were recruited from two Catholic churches in Taichung City. A professional delivered a 30 min HEI in person, and a structured questionnaire was used to acquire and assess participants’ knowledge, health beliefs, and preventive behaviors for MBDs before and after the intervention. Results: A total of 291 participants were recruited. The intervention program showed a positive impact on the migrant worker’s knowledge and the perceived severity, perceived benefits, perceived barriers, and preventive practices. Knowledge, perceived severity, and perceived barriers were factors influencing preventive practices in Filipino migrant workers. Conclusions: The results of this study demonstrated that we can direct our efforts towards three areas: improving foreign migrant workers’ awareness of diseases, emphasizing the severity of the disease, and eliminating possible hindrances in the future. As one example, migrant workers could be proactively provided with routine medical examinations and multilingual health education lectures to improve knowledge and preventive practices to contain the spread MBDs.

Explaining Neighbourhood Variations in the Incidence of Dengue Fever in Jeddah City, Saudi Arabia

The rapid growth and development of cities is a contributing factor to the rise and persistence of dengue fever (DF) in many areas around the world. Many studies have examined how neighbourhood environmental conditions contribute to dengue fever and its spread, but have not paid enough attention to links between socio-economic conditions and other factors, including population composition, population density, the presence of migrant groups, and neighbourhood environmental conditions. This study examines DF and its distribution across 56 neighbourhoods of Jeddah City, Saudi Arabia, where the incidence of dengue remains high. Using stepwise multiple regression analysis it focuses on the key ecological correlates of DF from 2006-2009, the years of the initial outbreak. Neighbourhood variations in average case rates per 10,000 population (2006-2009) were largely predicted by the Saudi gender ratio and socio-economic status (SES), the respective beta coefficients being 0.56 and 0.32 (p < 0.001). Overall, 77.1% of cases occurred in the poorest neighbourhoods. SES effects, however, are complex and were partly mediated by neighbourhood population density and the presence of migrant groups. SES effects persisted after controls for both factors, suggesting the effect of other structural factors and reflecting a lack of DF awareness and the lack of vector control strategies in poorer neighbourhoods. Neighbourhood environmental conditions, as measured by the presence of surface water, were not significant. It is suggested that future research pay more attention to the different pathways that link neighbourhood social status to dengue and wider health outcomes.

Low-wage migrant workers during coronavirus disease 2019: a social determinants analysis

The severe acute respiratory syndrome coronavirus 2 pandemic has had disproportionate effects on economically and socially marginalized people. We explore the effects on low-wage migrant workers (migrant workers) in three countries: Singapore, South Korea and Brazil, through the lens of the social determinants of health. Our analysis shows that governments missed key opportunities to mitigate pandemic risks for migrant workers. Government measures demonstrate potential for effective and sustainable policy reform, including universal and equitable access to healthcare, social safety nets and labour rights for migrant workers-key concerns of the Global Compact for Migration. A whole-of-society and a whole-of-government approach with Health in All Policies, and migrant worker frameworks developed by the World Health Organization could be instrumental. The current situation indicates a need to frame public health crisis responses and policies in ways that recognize social determinants as fundamental to health.

The effectiveness of backward contact tracing in networks

Effective control of an epidemic relies on the rapid discovery and isolation of infected individuals. Because many infectious diseases spread through interaction, contact tracing is widely used to facilitate case discovery and control. However, what determines the efficacy of contact tracing has not been fully understood. Here we reveal that, compared with 'forward' tracing (tracing to whom disease spreads), 'backward' tracing (tracing from whom disease spreads) is profoundly more effective. The effectiveness of backward tracing is due to simple but overlooked biases arising from the heterogeneity in contacts. We argue that, even if the directionality of infection is unknown, it is possible to perform backward-aiming contact tracing. Using simulations on both synthetic and high-resolution empirical contact datasets, we show that strategically executed contact tracing can prevent a substantial fraction of transmissions with a higher efficiency-in terms of prevented cases per isolation-than case isolation alone. Our results call for a revision of current contact-tracing strategies so that they leverage all forms of bias. It is particularly crucial that we incorporate backward and deep tracing in a digital context while adhering to the privacy-preserving requirements of these new platforms.

Health-seeking behaviour of foreign workers in Singapore: Insights from emergency department visits

INTRODUCTION

Foreign workers (FWs) on work permit face unique health challenges and potential barriers to healthcare. We aimed to examine the epidemiology, attendance patterns, disposition, and adherence to follow-up, by FWs on work permit to two emergency departments (EDs) in Singapore.

METHODS

In this retrospective observational study, we included consecutive FWs on work permit who registered at the EDs of two public restructured hospitals from 1 May 2016 to 31 October 2016. Data obtained from electronic medical records included patient demographics, triage acuity, disposition, ED diagnoses and bill information.

RESULTS

There were 6,429 individual FWs on work permit who contributed to 7,157 ED visits over the 6-month study period, with male predominance (72.7%, 4672/6429), and median age of 31 (interquartile range 26 to 38) years. A high proportion of these FWs were triaged to low-acuity status compared to the general ED population (66.9% versus 45.9%, P<0.001). Trauma-related injuries contributed to 34.4% of their visits, and were more likely to result in admission compared to non-trauma-related conditions (18.7% vs 15.2%, P<0.001). FWs engaged in shipyard, construction and process industries were more likely to be discharged "against medical advice" (14.8% vs 3.2%, P<0.001), and default their specialist outpatient follow-up (50.1% vs 34.2%, P<0.001) for non-trauma-related conditions compared to trauma-related injuries.

CONCLUSION

In Singapore, the EDs of public restructured hospitals provide healthcare safety nets to FWs on work permit. These workers made more low-acuity visits compared to the general population during the study period and may face potential barriers to admission and follow-up.

Stressors and coping strategies of migrant workers diagnosed with COVID-19 in Singapore: a qualitative study

INTRODUCTION

The health, psychological and socioeconomic vulnerabilities of low-wage migrant workers have been magnified in the COVID-19 pandemic, especially in high-income receiving countries such as Singapore. We aimed to understand migrant worker concerns and coping strategies during the COVID-19 pandemic to address these during the crisis and inform on comprehensive support needed after the crisis.

METHODS

In-depth semi-structured interviews were carried out with migrant workers diagnosed with COVID-19. The participants were recruited from a COVID-19 mass quarantine facility in Singapore through a purposive sampling approach. Interviews were transcribed verbatim and thematic analysis performed to derive themes in their collective experience during the crisis.

RESULTS

Three theme categories were derived from 27 interviews: migrant worker concerns during COVID-19, coping during COVID-19 and priorities after COVID-19. Major stressors in the crisis included the inability to continue providing for their families when work is disrupted, their susceptibility to infection in crowded dormitories, the shock of receiving the COVID-19 diagnosis while asymptomatic, as well as the isolating conditions of the quarantine environment. The workers coped by keeping in contact with their families, accessing healthcare, keeping updated with the news and continuing to practise their faith and religion. They looked forward to a return to normalcy after the crisis with keeping healthy and having access to healthcare as new priorities.

CONCLUSION

We identified coping strategies employed by the workers in quarantine, many of which were made possible through the considered design of care and service delivery in mass quarantine facilities in Singapore. These can be adopted in the set-up of other mass quarantine facilities around the world to support the health and mental well-being of those quarantined. Our findings highlight the importance of targeted policy intervention for migrant workers, in areas such as housing and working environments, equitable access to healthcare, and social protection during and after this crisis.

Singapore's Pandemic Preparedness: An Overview of the First Wave of COVID-19

A global response to the rapid spread of the 2019 novel coronavirus disease (COVID-19) is imperative in order to reduce mortality and morbidity as well as preventing a country's health system from collapse. Singapore showed exceptional leadership in the containment of the spread of the virus, however through April 2020 the country experienced exponential growth in the number of infections, particularly migrant workers living in dormitories. The following historical case study provides an overview of Singapore's country profile, their healthcare system and the country's non pharmaceutical measures taken to mitigate and contain the spread of COVID-19 in the first few months of the pandemic. We explore the impact COVID-19 had on Singapore's economy at that time and the implications of the resultant social and political disruptions. We conclude our study by using mathematical modelling to explore confirmed COVID-19 cases in Singapore's local community and those living in dormitories and use this data to forecast the progression of the epidemic in Singapore given the non-pharmaceutical interventions in place at that time. Our results indicate the COVID-19 outbreak in Singapore increased 3-fold the initial doubling rate of 22.5 days in the first 2 months of the outbreak to 6.7 days in the 5th month; We note a faster doubling rate of 4.9 days for those living in dormitories compared to a doubling rate of 13.5 days for the rest of the community.

Healthcare for migrant workers in destination countries: a comparative qualitative study of China and Malaysia

OBJECTIVES

This paper explores policies addressing migrant worker's health and barriers to healthcare access in two middle-income, destination countries in Asia with cross-border migration to Yunnan province, China and international migration to Malaysia.

DESIGN

Qualitative interviews were conducted in Rui Li City and Tenchong County in Yunnan Province, China (n=23) and Kuala Lumpur, Malaysia (n=44), along with review of policy documents. Data were thematically analysed.

PARTICIPANTS

Participants were migrant workers and key stakeholders with expertise in migrant issues including representatives from international organisations, local civil society organisations, government agencies, medical professionals, academia and trade unions.

RESULTS

Migrant health policies at destination countries were predominantly protectionist, concerned with preventing transmission of communicable disease and the excessive burden on health systems. In China, foreign wives were entitled to state-provided maternal health services while female migrant workers had to pay out-of-pocket and often returned to Myanmar for deliveries. In Malaysia, immigration policies prohibit migrant workers from pregnancy, however, women do deliver at healthcare facilities. Mandatory HIV testing was imposed on migrants in both countries, where it was unclear whether and how informed consent was obtained from migrants. Migrants who did not pass mandatory health screenings in Malaysia would runaway rather than be deported and become undocumented in the process. Excessive attention on migrant workers with communicable disease control campaigns in China resulted in inadvertent stigmatisation. Language and financial barriers frustrated access to care in both countries. Reported conditions of overcrowding and inadequate healthcare access at immigration detention centres raise public health concern.

CONCLUSIONS

This study's findings inform suggestions to mainstream the protection of migrant workers' health within national health policies in two middle-income destination countries, to ensure that health systems are responsive to migrants' needs as well as to strengthen bilateral and regional cooperation towards ensuring better migration management.

COVID-19 and Undiagnosed Pre-diabetes or Diabetes Mellitus Among International Migrant Workers in Singapore

Objective: Migrant workers, a marginalized and under-resourced population, are vulnerable to coronavirus disease 2019 (COVID-19) due to limited healthcare access. Moreover, metabolic diseases—such as diabetes mellitus (DM), hypertension, and hyperlipidemia—predispose to severe complications and mortality from COVID-19. We investigate the prevalence and consequences of undiagnosed metabolic illnesses, particularly DM and pre-diabetes, in international migrant workers with COVID-19.

Methods: In this retrospective analysis, we analyzed the medical records of international migrant workers with laboratory-confirmed COVID-19 hospitalized at a tertiary hospital in Singapore from April 21 to June 1, 2020. We determined the prevalence of DM and pre-diabetes, and analyzed the risk of developing complications, such as pneumonia and electrolyte abnormalities, based on age and diagnosis of DM, and pre-diabetes.

Results: Two hundred and fouty male migrant workers, with mean age of 44.2 years [standard deviation (SD), 8.5years], were included. Twenty one patients (8.8%) were diagnosed with pre-diabetes, and 19 (7.9%) with DM. DM was poorly controlled with a mean HbA1c of 9.9% (SD, 2.4%). 73.7% of the patients with DM and all the patients with pre-diabetes were previously undiagnosed. Pre-diabetes was associated with higher risk of pneumonia [odds ratio (OR), 10.8, 95% confidence interval (CI), 3.65–32.1; P < 0.0001], hyponatremia (OR, 8.83; 95% CI, 1.17–66.6; P = 0.0342), and hypokalemia (OR, 4.58; 95% CI, 1.52–13.82; P = 0.0069). Moreover, patients with DM or pre-diabetes developed COVID-19 infection with lower viral RNA levels.

Conclusions: The high prevalence of undiagnosed pre-diabetes among international migrant workers increases their risk of pneumonia and electrolyte abnormalities from COVID-19.

Association Between Socioeconomic Factors and the COVID-19 Outbreak in the 39 Well-Developed Cities of China

Background: Socioeconomic factors play an indispensable role in the spread of emerging infectious diseases. Few studies have investigated the role of socioeconomic factors in the spread of COVID-19.

Methods: The number of COVID-19 cases in the 39 well-developed cities of China was aggregated by searching the publicly available sources. Socioeconomic indicators (e.g., population, population density, gross domestic product, rural-to-urban migrants, urbanization rate, per-person disposable income, and level of health care) in these cities were also aggregated from the Bureau of Statistics. The data referring to travelers from Wuhan were collected from the Baidu Migration database. A multiple stepwise linear regression model was performed to identify the independent risk factors of the number of cases.

Results: As of Mar 19, 2020, a total of 5,939 cases were reported in the 39 well-developed cities with almost half of total cases in China outside of Hubei. The number of cases ranged 20–576, and the median number of cases was 93 (IQR 54–180) in these cities. Nine socioeconomic variables including the number of travelers from Wuhan, population, native population, gross domestic product, Per-person GDP, the number of hospitals, the number of rural-to-urban migrants, traffic capacity, and person-disposable income were recognized as potential contributors of the number of cases. Results of multiple linear regression showed a statistically significant association between the number of cases and the number of travelers from Wuhan (t = 6.746, P = 0.000) and the number of rural-to-urban migrants (t = 3.776, P = 0.001) in these cities. However, other seven potential contributors were not associated with the number of cases. Moreover, a well-fitted multiple regression model was built in this study, and a regression equation was as follows: Y = 0.007X_t + 0.200X_m (adjusted R² = 0.833).

Conclusions: Travelers from Wuhan and rural-to-urban migrants were independently associated with the COVID-19 outbreak in the 39 well-developed cities of China. These findings suggested that travelers from an epicenter and rural-to-urban migrants should be paid more attention in the early stage of the COVID-19 outbreak in the well-developed cities.

Health and well-being issues of Nepalese migrant workers in the Gulf Cooperation Council countries and Malaysia: a systematic review

OBJECTIVE

To summarise the evidence on health and well-being of Nepalese migrant workers in the Gulf Cooperation Council (GCC) countries and Malaysia.

DESIGN

Systematic review.

DATA SOURCES

EMBASE, MEDLINE, Scopus and Global Health databases.

ELIGIBILITY CRITERIA

Studies were eligible if they: (1) included Nepalese migrant workers aged 18 or older working in the GCC countries or Malaysia or returnee migrant workers from these countries; (2) were primary studies that investigated health and well-being status/issues; and (3) were published in English language before 8 May 2020.

STUDY APPRAISAL

All included studies were critically appraised using Joanna Briggs Institute study specific tools.

RESULTS

A total of 33 studies were eligible for inclusion; 12 studies were conducted in Qatar, 8 in Malaysia, 9 in Nepal, 2 in Saudi Arabia and 1 each in UAE and Kuwait. In majority of the studies, there was a lack of disaggregated data on demographic characteristics of Nepalese migrant workers. Nearly half of the studies (n=16) scored as 'high' quality and the rest (n=17) as 'moderate' quality. Five key health and well-being related issues were identified in this population: (1) occupational hazards; (2) sexual health; (3) mental health; (4) healthcare access and (5) infectious diseases.

CONCLUSION

To our knowledge, this is the most comprehensive review of the health and well-being of Nepalese migrant workers in the GCC countries and Malaysia. This review highlights an urgent need to identify and implement policies and practices across Nepal and destination countries to protect the health and well-being of migrant workers.

Burnout and Associated Factors Among Health Care Workers in Singapore During the COVID-19 Pandemic

OBJECTIVES

The strain on health care systems due to the COVID-19 pandemic has led to increased psychological distress among health care workers (HCWs). As this global crisis continues with little signs of abatement, we examine burnout and associated factors among HCWs.

DESIGN

Cross-sectional survey study.

SETTING AND PARTICIPANTS

Doctors, nurses, allied health professionals, administrative, and support staff in 4 public hospitals and 1 primary care service in Singapore 3 months after COVID-19 was declared a global pandemic.

METHODS

Study questionnaire captured demographic and workplace environment information and comprised 3 validated instruments, namely the Oldenburg Burnout Inventory (OLBI), Safety Attitudes Questionnaire (SAQ), and Hospital Anxiety and Depression Scale (HADS). Multivariate mixed model regression analyses were used to evaluate independent associations of mean OLBI-Disengagement and -Exhaustion scores. Further subgroup analysis was performed among redeployed HCWs.

RESULTS

Among 11,286 invited HCWs, 3075 valid responses were received, giving an overall response rate of 27.2%. Mean OLBI scores were 2.38 and 2.50 for Disengagement and Exhaustion, respectively. Burnout thresholds in Disengagement and Exhaustion were met by 79.7% and 75.3% of respondents, respectively. On multivariate regression analysis, Chinese or Malay ethnicity, HADS anxiety or depression scores ≥8, shifts lasting ≥8 hours, and being redeployed were significantly associated with higher OLBI mean scores, whereas high SAQ scores were significantly associated with lower scores. Among redeployed HCWs, those redeployed to high-risk areas in a different facility (offsite) had lower burnout scores than those redeployed within their own work facility (onsite). A higher proportion of HCWs redeployed offsite assessed their training to be good or better compared with those redeployed onsite.

CONCLUSIONS AND IMPLICATIONS

Every level of the health care workforce is susceptible to high levels of burnout during this pandemic. Modifiable workplace factors include adequate training, avoiding prolonged shifts ≥8 hours, and promoting safe working environments. Mitigating strategies should target every level of the health care workforce, including frontline and nonfrontline staff. Addressing and ameliorating burnout among HCWs should be a key priority for the sustainment of efforts to care for patients in the face of a prolonged pandemic.

Four Patients with COVID-19 and Tuberculosis, Singapore, April-May 2020

Coronavirus disease (COVID-19) and tuberculosis (TB) developed in 4 foreign workers living in dormitories in Singapore during April–May 2020. Clinical manifestations and atypical radiographic features of COVID-19 led to the diagnosis of TB through positive interferon-gamma release assay and culture results. During the COVID-19 pandemic, TB should not be overlooked.

Migrant workers and COVID-19

Objectives

Daily numbers of COVID-19 in Singapore from March to May 2020, the cause of a surge in cases in April and the national response were examined, and regulations on migrant worker accommodation studied.

Methods

Information was gathered from daily reports provided by the Ministry of Health, Singapore Statues online and a Ministerial statement given at a Parliament sitting on 4 May 2020.

Results

A marked escalation in the daily number of new COVID-19 cases was seen in early April 2020. The majority of cases occurred among an estimated 295 000 low-skilled migrant workers living in foreign worker dormitories. As of 6 May 2020, there were 17 758 confirmed COVID-19 cases among dormitory workers (88% of 20 198 nationally confirmed cases). One dormitory housing approximately 13 000 workers had 19.4% of residents infected. The national response included mobilising several government agencies and public volunteers. There was extensive testing of workers in dormitories, segregation of healthy and infected workers, and daily observation for fever and symptoms. Twenty-four dormitories were declared as ‘isolation areas’, with residents quarantined for 14 days. New housing, for example, vacant public housing flats, military camps, exhibition centres, floating hotels have been provided that will allow for appropriate social distancing.

Conclusion

The COVID-19 pandemic has highlighted migrant workers as a vulnerable occupational group. Ideally, matters related to inadequate housing of vulnerable migrant workers need to be addressed before a pandemic.

Knowledge Level and Hand Hygiene Practice of Nepalese Immigrants and Their Host Country Population: A Comparative Study

Nepali people are one of the ethnic minority immigrants of Hong Kong. This epidemiological investigation aims to determine and compare the knowledge level and hand hygiene (HH) behaviour of the Nepali people and the population of their host country (i.e., native Chinese population of Hong Kong). A total of 1008 questionnaires were collected via an online platform. The overall knowledge level of the native population towards HH was considerably higher than that of the Nepali respondents. Lower levels of knowledge in young and older people were noted. Reduced HH knowledge was also observed in people with low educational level or with comorbid illness(es). Significant differences between groups were noted in the self-reported hand washing behaviours. Regarding hand drying, more Nepalese than native Chinese respondents always/sometimes dried their hands on their clothing irrespective whether after performing handwashing in public washrooms or at home. Misconceptions and suboptimal practices on HH were prevalent in the two populations. The findings of this comparative study offer valuable information for the development of culturally sensitive health educational programs to enhance HH practices for the ethnic minorities and native Chinese population.

A Prospective Study on the Impact and Out-of-Pocket Costs of Dengue Illness in International Travelers

Although the costs of dengue illness to patients and households have been extensively studied in endemic populations, international travelers have not been the focus of costing studies. As globalization and human travel activities intensify, travelers are increasingly at risk for emerging and reemerging infectious diseases, such as dengue. This exploratory study aims to investigate the impact and out-of-pocket costs of dengue illness among travelers. We conducted a prospective study in adult travelers with laboratory-confirmed dengue and recruited patients at travel medicine clinics in eight different countries from December 2013 to December 2015. Using a structured questionnaire, we collected information on patients and their health-care utilization and out-of-pocket expenditures, as well as income and other financial losses they incurred because of dengue illness. A total of 90 patients participated in the study, most of whom traveled for tourism (74%) and visited countries in Asia (82%). Although 22% reported hospitalization and 32% receiving ambulatory care while traveling, these percentages were higher at 39% and 71%, respectively, after returning home. The out-of-pocket direct and indirect costs of dengue illness were US$421 (SD 744) and US$571 (SD 1,913) per episode, respectively, averaging to a total out-of-pocket cost of US$992 (SD 2,052) per episode. The study findings suggest that international travelers incur important direct and indirect costs because of dengue-related illness. This study is the first to date to investigate the impact and out-of-pocket costs of travel-related dengue illness from the patient's perspective and paves the way for future economic burden studies in this population.

Migration Health: Highlights from Inaugural International Society of Travel Medicine (ISTM) Conference on Migration Health

PURPOSE OF REVIEW

International migration is a global phenomenon that is growing in scope, complexity and impact. The inaugural International Society of Travel Medicine (ISTM) International Conference on Migration Health provided a forum to discuss scientific evidence on the broad issues relevant to migration health. This review summarises the key health issues, with a focus on infectious diseases, current effective strategies and future considerations presented at this forum and in the recent literature.

RECENT FINDINGS

Migrants face health disparities for both communicable and non-communicable diseases. Their heightened infectious disease risks, compared to host populations, are related to pre-migration exposures, the circumstances of the migration journey and the receptivity and access to health services in their receiving countries. While the prevalence of infectious diseases identified through screening programmes are generally low, delays in diagnosis and treatment for a range of treatable infectious diseases result in higher morbidity and mortality among migrants. Barriers to care in host countries occur at the patient, provider and health systems levels. Coordinated and inclusive health services, healthcare systems and health policies, responsive to patient diversity reduce these barriers. Structural barriers to healthcare provision impede equitable care to migrants and refugees. Public health and medical professionals have a role in advocating for policy reforms.

Case Report: Acute Hepatitis E in a Pediatric Traveler Presenting with Features of Autoimmune Hepatitis: A Diagnostic and Therapeutic Challenge

Hepatitis E virus (HEV) is globally the most common cause of acute viral hepatitis. In industrialized countries, HEV infection can be seen in travelers returning from hyperendemic countries or in individuals at risk for autochthonous infection due to zoonotic exposure. Hepatitis E virus infection is often unrecognized and at times misdiagnosed because of nonspecific findings that can overlap with other causes of hepatitis, including autoimmune hepatitis (AIH). Although most cases of acute HEV infection resolve spontaneously and do not require treatment, life-threatening acute liver failure may occur in some cases. We discuss the case of an 8-year-old boy returning from Bangladesh with progressive acute liver injury and a clinical profile suggestive of AIH, who showed a favorable response to corticosteroid treatment before the diagnosis of an acute HEV infection could be established.

Severe dengue in travellers: pathogenesis, risk and clinical management

RATIONALE FOR REVIEW

Dengue is a frequent cause of febrile illness among travellers and has overtaken malaria as the leading cause of febrile illness for those traveling to Southeast Asia. The purpose is to review the risk of dengue and severe dengue in travellers with a particular focus on the pathogenesis and clinical management of severe dengue.

RISK, PATHOGENESIS AND CLINICAL MANAGEMENT

The risk of travel-acquired dengue depends on destination, season and duration of travel and activities during travel. Seroconversion rates reported in travellers, therefore, vary between <1% and >20%. The most common life-threatening clinical response to dengue infection is the dengue vascular permeability syndrome, epidemiologically linked to secondary infection, but can also occur in primary infection. Tertiary and quaternary infections are usually associated with mild or no disease. Antibody-dependent enhancement, viral factors, age, host factors and clinical experience of the managing physician modulate the risk of progressing to severe dengue. The relative risk of severe dengue in secondary versus primary infection ranges from 2 to 7. The absolute risk of severe dengue in children in highly endemic areas is ~0.1% per year for primary infections and 0.4% for secondary infections. About 2-4% of secondary infections lead to severe dengue. Severe dengue and death are both relatively rare in general travellers but more frequently in those visiting friends and relatives. Clinical management of severe dengue depends on judicious use of fluid rehydration.

CONCLUSIONS

Although dengue is a frequent cause of travel illness, severe dengue and deaths are rare. Nevertheless, dengue infections can interrupt travel and lead to evacuation and major out-of-pocket costs. Dengue is more frequent than many other travel-related vaccine preventable diseases, such as hepatitis A, hepatitis B, rabies, Japanese encephalitis and yellow fever, indicating a need for a dengue vaccine for travellers.

Are migrant workers in Singapore receiving adequate healthcare? A survey of doctors working in public tertiary healthcare institutions

INTRODUCTION

Migrant workers comprise about one-fifth of Singapore's resident population and form a substantial and vital component of the nation's workforce. However, limited data is available regarding the barriers that migrant workers face in accessing healthcare from the healthcare providers' perspective.

METHODS

We conducted a survey on doctors working in four restructured hospitals in Singapore, to assess what they perceived to be barriers faced by migrant workers in accessing healthcare. We also assessed the doctors' understanding of migrant-health-related policies in Singapore.

RESULTS

A total of 427 survey responses were collected. Most respondents were senior doctors (senior residents or consultants) who had been practising medicine for a median of ten years. Among doctors, the most common perceived barriers to migrant workers accessing healthcare were related to culture/language (92.3%) and finances (healthcare cost) (81.0%). Of the six questions asked pertaining to migrant healthcare policy in Singapore, the respondents achieved a median of four correctly answered questions (interquartile range 3-5), and about 55% were unaware or unsure of available resources for migrant workers.

CONCLUSION

Our study identified healthcare providers' perceived barriers to the delivery of healthcare to migrant workers, which corroborate previously published data reported by migrant workers themselves. Further efforts should be directed towards diminishing these barriers and increasing the literacy of migrant health among healthcare workers.

Pre-vaccination screening strategies for the use of the CYD-TDV dengue vaccine: A meeting report

The first licensed dengue vaccine, CYD-TDV (Dengvaxia) is efficacious in seropositive individuals, but increases the risk for severe dengue in seronegative persons about two years after administration of the first dose. For countries considering the introduction of Dengvaxia, WHO recommends a pre-vaccination screening strategy whereby only persons with evidence of a past dengue infection would be vaccinated. Policy-makers need to consider the risk-benefit of vaccination strategies based on such screening tests, the optimal age to introduce the vaccine, communication and implementation strategies. To address these questions, the Global Dengue and Aedes-transmitted diseases Consortium (GDAC) organized a 3-day workshop in January 2019 with country representatives from Asia and Latin America. The meeting discussions highlighted many challenges in introducing Dengvaxia, in terms of screening test characteristics, costs of such tests combined with a 3-dose schedule, logistics, achieving high coverage rates, vaccine confidence and communication; more challenges than for any other vaccine introduction programme. A screening test would require a high specificity to minimize individual risk, and at the same time high sensitivity to maximize individual and population benefit. The underlying seroprevalence dependent positive predictive value is the best indicator for an acceptable safety profile of a pre-vaccination screening strategy. The working groups discussed many possible implementation strategies. Addressing the bottlenecks in school-based vaccine introduction for Dengvaxia will also benefit other vaccines such as HPV and booster doses for tetanus and pertussis. Levels of public trust are highly variable and context specific, and understanding of population perceptions and concerns is essential to tailor interventions, monitor and mitigate risks.

Megatrends in Infectious Diseases: The Next 10 to 15 Years

It has been about 100 years since the Spanish influenza pandemic of 1918-19 that killed an estimated 50 million individuals globally. While we have made remarkable progress in reducing infection-related mortality, infections still account for 13 to 15 million deaths annually. This estimate is projected to remain unchanged until 2050. We have identified 4 megatrends in infectious diseases and these are “emerging and re-emerging infections”, “antimicrobial resistance”, “demographic changes” and “technological advances”. Understanding these trends and challenges should lead to opportunities for the medical community to reshape the future. Further inroads will also require broad approaches involving surveillance, public health and translating scientific discoveries into disease control efforts. Key words: Antimicrobial resistance, Demographic changes, Emerging infections, Technological advances

Reducing infectious disease inequities among migrants

BACKGROUND

migration has reached unprecedented levels, with 3.6% of the world's population living outside their country of birth. Migrants comprise a substantial proportion of high-income country populations, are at increased risk of a range of infectious diseases, compared to native-born populations and may experience worse health outcomes due to barriers accessing timely diagnoses and treatment. Poor access to essential healthcare services can be attributed to several factors, including language and cultural barriers and lack of specific inclusive health policies.

METHODS

This review draws on evidence from the immigrant health and travel medicine literature, with a focus on infectious disease risks. It presents strategies to reduce barriers to healthcare access through health promotion and screening programs both at the community and clinic level and the delivery of linguistically and culturally competent care. The Methods: Salud Entre Culturas (SEC) 'Health Between Cultures' project from the Tropical Medicine Unit at the Hospital Ramon y Cajal in Madrid is described as an effective model of care.

RESULTS

For those providing healthcare to migrant populations, the use of community-consulted approaches are considered best practice in the development of health education, health promotion and the delivery of targeted health services. At the clinic-level, strategies optimizing care for migrants include the use of bilingual healthcare professionals or community-based healthcare workers, cultural competence training of all clinic staff, the appropriate use of trained interpreters and the use of culturally appropriate health promotion materials.

CONCLUSIONS

Multifaceted strategies are needed to improve access, community knowledge, community engagement and healthcare provider training to provide appropriate care to migrant populations to reduce infectious disease disparities.

Non-communicable diseases in migrants: an expert review

BACKGROUND

Non-communicable diseases (NCDs) remain a major challenge in the 21st century. High-income countries (HICs) populations are ethnically and culturally diverse due to international migration. Evidence suggests that NCDs rates differ between migrants and the host populations in HICs. This paper presents a review of NCDs burden among migrant groups in HICs in Europe, North America and Australia with a major focus on cardiovascular diseases (CVDs), cancer and diabetes.

METHODS

We performed a narrative review consisting of scholarly papers published between 1960 until 2018.

RESULTS

CVD risk differs by country of origin, country of destination and duration of residence. For example, stroke is more common in sub-Sahara African and South-Asian migrants, but lower in North African and Chinese migrants. Chinese migrants, however, have a higher risk of haemorrhagic stroke despite the lower rate of overall stroke. Coronary heart disease (CHD) is more common in South-Asian migrants, but less common in sub-Saharan and north African migrants although the lower risk of CHD in these population is waning. Diabetes risk is higher in all migrants and migrants seem to develop diabetes at an earlier age than the host populations. Migrants in general have lower rates of overall cancer morbidity and mortality than the host populations in Europe. However, migrants have a higher infectious disease-related cancers than the host populations in Europe. In North America, the picture is more complex. Data from cross-national comparisons indicate that migration-related lifestyle changes associated with the lifestyle of the host population in the country of settlement may influence NCDs risk among migrants in a very significant way.

CONCLUSION

With exception of diabetes, which is consistently higher in all migrant groups than in the host populations, the burden of NCDs among migrants seems to depend on the migrant group, country of settlement and NCD type. This suggests that more work is needed to disentangle the key migration-related lifestyle changes and contextual factors that may be driving the differential risk of NCDs among migrants in order to assist prevention and clinical management of NCDs in these populations.

Spectrum of illness in migrants to Canada: sentinel surveillance through CanTravNet

BACKGROUND

Due to ongoing political instability and conflict in many parts of the world, migrants are increasingly seeking asylum and refuge in Canada.

METHODS

We examined demographic and travel correlates of illnesses among migrants to Canada to establish a detailed epidemiologic framework of this population for Canadian practitioners. Data on ill-returned Canadian travellers presenting to a CanTravNet site between 1 January 2015 and 31 December 2015 were analyzed.

RESULTS

During the study period, 2415 ill travellers and migrants presented to a CanTravNet site, and of those, 519 (21.5%) travelled for the purpose of migration. Sub-Saharan Africa (n = 160, 30.8%), southeast Asia (n = 84, 16.2%) and south central Asia (n = 75, 14.5%) were the most common source regions for migrants, while the top specific source countries, of 98 represented, were the Philippines (n = 45, 8.7%), China (n = 36, 6.9%) and Vietnam (n = 31, 6.0%). Compared with non-migrant travellers, migrants were more likely to have a pre-existing immunocompromising medical condition, such as HIV or diabetes mellitus (P < 0.0001), and to require inpatient management of their illness (P < 0.0001). Diagnoses such as tuberculosis (n = 263, 50.7%), hepatitis B and C (n = 78, 15%) and HIV (n = 11, 2.1%) were over-represented in the migrant population compared with non-migrant travellers (P < 0.0001). Most cases of tuberculosis in the migrant population (n = 263) were latent (82% [n = 216]); only 18% (n = 47) were active.

CONCLUSIONS

Compared with non-migrant travellers, migrants were more likely to present with a communicable infectious disease, such as tuberculosis, potentially complicated by an underlying immunosuppressing condition such as HIV. These differences highlight the divergent healthcare needs in the migrant population, and underscore the importance of surveillance programmes to understand their burden of illness. Intake programming should be adequately resourced to accommodate the medical needs of this vulnerable population of new Canadians.

Migrant Workers and Physical Health: An Umbrella Review

Migrants are mainly employed in “3D jobs” which are dirty, dangerous, and difficult, are characterized by monotony and intense rhythms, and are found in sectors with higher risks such as construction, heavy industry, and agriculture. The aim of this study is to construct a systematic review in order to identify the main occupational risks and occupational diseases of this category. Research included articles published from 2013 to 2018 on major online databases (PubMed, Cochrane Library, and Scopus), which were obtained using a combination of keywords (migrant workers, expatriates, physical health, diseases, illnesses, travel, travelers, work, and occupational medicine). The online search included 1109 references. We excluded 977 studies because they were unrelated to physical health and another 64 due to duplication. There were 68 articles which were analyzed, including six reviews and 62 original articles. The main risks which emerged are developing infectious diseases, metabolic cardiovascular diseases and manifesting a lower quality of life, in particular due to difficulties in accessing local health services. It will be crucial to implement the role of occupational medicine in order to introduce multilevel interventions designed to prevent work-related injuries and illnesses, and to promote healthier working environments.