Comprehensive infectious disease screening in a cohort of unaccompanied refugee minors in Germany from 2016 to 2017: A cross-sectional study

Management and outcome of cutaneous diphtheria in adolescent refugees in Germany, June 2022 - October 2023

OBJECTIVES

From September 2022 an increase in Corynebacterium diphtheriae (C. diphtheriae) infections was reported in Europe. Our study focuses on 31 adolescent and young adult refugees with cutaneous C. diphtheriae infections detected in Germany. We examined treatment regimens and outcomes to provide targeted insights into the management of this infection.

METHODS

We distributed a standardized survey, focused on children and adolescents presenting to paediatric clinics through the German Paediatric Infectious Diseases Society (DGPI) and additional professional contacts in Germany. Data were extracted from routine medical documentation and reported anonymously.

RESULTS

A total of 31 individuals with cutaneous C. diphtheriae infection were reported by 9 centres. Two of these showed diphtheria toxin (DT) related systemic symptoms and four exhibited systemic inflammation requiring complex management. The remaining 25 cases, with exclusively cutaneous manifestations, were afebrile. Treatment with topical antiseptics and systemic antibiotics, mainly aminopenicillin/beta-lactamase inhibitors (BLI) (35%) or clindamycin (25%), achieved eradication in all but two cases treated with aminopenicillin/BLI. Treatment duration varied between 5 and 17 days.

CONCLUSIONS

In refugees presenting with chronic skin wounds, C. diphtheriae should be included into the differential diagnosis. Fever seems to be a valuable marker to differentiate severe cases with potentially DT-mediated sequelae from exclusively cutaneous diphtheria (CD). For afebrile CD, topical antiseptics and oral antibiotic therapy with clindamycin for 7 days, followed by clinical surveillance appears to be a safe treatment regimen. Patients with CD who present with fever or pharyngitis should be thoroughly investigated including blood and pharyngeal swab cultures.

Hepatitis B infection and immunity in migrant children and pregnant persons in Europe: a systematic review and meta-analysis

BACKGROUND

The WHO's global hepatitis strategy aims to achieve viral hepatitis elimination by 2030. Migrant children and pregnant persons represent an important target group for prevention strategies. However, evidence on the burden of chronic hepatitis B (CHB) infection and the factors affecting its incidence is lacking.

METHODS

EMBASE, Global Health, Global Index Medicus, Web of Science and Medline were searched for articles in any language from 1 January 2012 to 8 June 2022. Studies reporting CHB prevalence, disease severity, complications and/or prevention strategies, including vaccination, prevention of vertical transmission and access to care/treatment for migrant children and pregnant migrants, were included. Pooled estimates of CHB prevalence and hepatitis B vaccination (HBV) coverage among migrant children were calculated using random effects meta-analysis.

FINDINGS

42 studies were included, 27 relating to migrant children and 15 to pregnant migrants across 12 European countries, involving data from 64 773 migrants. Migrants had a higher incidence of CHB than host populations. Among children, the pooled prevalence of CHB was higher for unaccompanied minors (UAM) (5%, [95% CI: 3-7%]) compared to other child migrants, including internationally adopted children (IAC) and refugees (1%, [95% CI: 1-2%]). Region of origin was identified as a risk factor for CHB, with children from Africa and pregnant migrants from Africa, Eastern Europe and China at the highest risk. Pooled estimates of HBV vaccine coverage were lower among UAM (12%, [95% CI: 3-21%]) compared to other child migrants (50%, [95% CI: 37-63%]).

CONCLUSION

A range of modifiable determinants of HBV prevalence in migrant children and pregnant persons were identified, including sub-optimal screening, prevention and continuum of care. There is a need to develop evidence-based approaches in hepatitis care for these groups, thereby contributing towards global viral hepatitis elimination goals.

A Retrospective Longitudinal Study of Refugees With Eosinophilia at an Academic Center in the United States From 2015 to 2020

Background

Refugees to the United States frequently have parasitic infections. If untreated, parasites can cause severe complications. The purpose of this study was to investigate the incidence, management, and outcomes of eosinophilia as a biomarker for parasites.

Methods

We conducted a retrospective longitudinal chart review of consecutive refugees attending 3 refugee clinics in Rhode Island that manage the health care of all pediatric and adult refugees.

Results

Among 812 refugees who met inclusion criteria, 147 (18.1%) had eosinophilia upon arrival and almost half had ≥1 symptom. The rates and severity of eosinophilia in those with predeparture presumptive treatment records who did (112/115, 97.4%) or did not (488/498, 98.0%) receive predeparture antiparasitic treatment were similar. All refugees with eosinophilia had ≥1 parasitic test in the United States. The most common attributable parasites were Schistosoma and Strongyloides stercoralis. Overall, parasites were detected in 63 (42.9%) of 147 refugees with eosinophilia by either stool testing, serology, or blood smear, but testing was inconsistent and likely underestimated true incidence. Only some of the identified parasites typically cause eosinophilia. Forty-five (30.6%) refugees with eosinophilia received antiparasitics in the United States. Of 81 (55.1%) individuals who had repeat blood tests, eosinophilia had resolved in 52 (64.2%). Five individuals (3.4%) had alternative diagnoses, including eczema, myelofibrosis, and drug allergy.

Conclusions

Our findings support Centers for Disease Control and Prevention recommendations to screen for eosinophilia in newly arrived refugees. Follow-up after 3-6 months is critical to confirm resolution of residual eosinophilia, which frequently occurs after effective predeparture treatment or if eosinophilia persists, to diagnose active parasitic infections.

From evidence to practice: A systematic review-based diagnostic algorithm for paediatric eosinophilia across socioeconomic context

AIM

Paediatric eosinophilia is a common clinical dilemma, often leading to resource- and time-consuming assessments. We aim to evaluate the main aetiologies of eosinophilia in children from different socioeconomic settings and propose a diagnostic algorithm.

METHODS

A systematic literature review was conducted through PubMed, Embase and the Cochrane Library. Studies published from January 2012 to June 2023 reporting the incidence and aetiology of peripheral eosinophilia in children were included. Evidence from studies on children originating from low- or high-income countries was compared.

RESULTS

A total of 15 observational studies, encompassing 3409 children, were included. The causes of eosinophilia varied based on the children's origin and the eosinophilia severity. In children from high-income countries, allergic diseases were the leading cause, with a prevalence of 7.7%-78.2%, while parasitosis ranged from 1.0% to 9.1%. In children from low-income countries, parasitosis was predominant, ranging from 17.7% to 88.3%, although allergic diseases were found in 2.5%-4.8% of cases. Concerning severity, allergic diseases were the leading cause of mild-to-moderate eosinophilia; parasitosis was associated with moderate-to-severe eosinophilia, while immunological disorders were mostly found in severe cases.

CONCLUSION

We developed a step-up diagnostic algorithm that considers the child's origin and eosinophilia severity and could optimise resource allocation.

Prevalence of infectious diseases, immunity to vaccine-preventable diseases and chronic medical conditions among Ukrainian refugees in Germany - A cross sectional study from the German Network University Medicine (NUM)

BACKGROUND

Vulnerability to infectious diseases in refugees is dependent on country of origin, flight routes, and conditions. Information on specific medical needs of different groups of refugees is lacking. We assessed the prevalence of infectious diseases, immunity to vaccine-preventable diseases, and chronic medical conditions in children, adolescents, and adult refugees from Ukraine who arrived in Germany in 2022.

METHODS

Using different media, we recruited Ukrainian refugees at 13 sites between 9-12/2022. An antigen test for acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) infection, serologies for a range of vaccine-preventable diseases, as well as interferon gamma release assays (IGRAs) for tuberculosis (TB), and SARS-CoV-2 were performed. We assessed personal and family history of chronic medical conditions, infectious diseases, vaccination status, and conditions during migration.

RESULTS

Overall, 1793 refugees (1401 adults and 392 children/adolescents) were included. Most participants were females (n = 1307; 72·3%) and from Eastern or Southern Ukraine. TB IGRA was positive in 13% (n = 184) of the adults and in 2% (n = 7) of the children. Serology-based immunological response was insufficient in approximately 21% (360/1793) of the participants for measles, 32% (572/1793) for diphtheria, and 74% (1289/1793) for hepatitis B.

CONCLUSIONS

We show evidence of low serological response to vaccine-preventable infections and increased LTBI prevalence in Ukrainian refugees. These findings should be integrated into guidelines for screening and treatment of infectious diseases in migrants and refugees in Germany and Europe. Furthermore, low immunity for vaccine-preventable diseases in Ukrainians independent of their refugee status, calls for tailor-made communication efforts.

Prevention, testing, and treatment interventions for hepatitis B and C in refugee populations: results of a scoping review

BACKGROUND AND AIMS

Refugees are at higher risk for hepatitis B (HBV) and hepatitis C (HCV), but often face unique healthcare barriers to vaccination, testing, and treatment. This scoping review aimed to identify and characterize HBV and HCV prevention and care services serving refugee populations globally.

METHODS

A literature search was conducted on Embase, Cochrane, and PubMed databases. Research studies published in English between January 2010 to July 2022 describing an HBV or HCV prevention, testing, or treatment intervention for refugees were included.

RESULTS

There were a total of 69 articles reporting viral hepatitis prevalence, implementation of services, or economic modelling. Of the 38 implementation studies, 14 were stand-alone HBV and/or HCV interventions, while 24 studies included HBV and/or HCV in an intervention targeting multiple infectious diseases and/or parasitic infections. Interventions commonly included a testing (n = 30) or referral (n = 24) component. Frequently reported features to promote program accessibility included bilingual services (n = 25), community partnerships (n = 21), and multidisciplinary staff members (n = 18), such as cultural and/or linguistic mediators, community health workers, community health leaders, lay health workers, local health staff, members of the refugee community, and social workers. The most commonly reported challenge was the transience of refugees (n = 5). Twenty studies noted funding sources, of which twelve reported governmental funding (not including national health insurance) and eight reported that refugees received national health insurance.

CONCLUSIONS

This is the first scoping review to characterize the types of hepatitis prevention, screening, and treatment interventions serving refugee populations globally. Published experiences of HBV and HCV services for refugee populations remain limited. Additional efforts are needed to disseminate models of hepatitis interventions for refugees to ensure access to care for this key population. To achieve hepatitis elimination globally, best practices must be identified and shared to expand access to hepatitis services for refugee populations.

Travel- and migration-associated epidermal parasitic skin diseases. A review

Epidermal parasitic skin diseases are a family of parasitic diseases which occur globally or are frequent in special settings. Epidermal parasitic skin diseases occur in travelers and migrants, although epidemiology and/or clinical manifestations differ between these groups. The objective of this study is to summarize the existing knowledge concerning tungiasis, hookworm-related cutaneous larva migrans, scabies, pediculosis capitis and pediculosis corporis in the context of travel and migration, and to identify risk factors for infection. The PUBMED database was searched using the terms tungiasis, cutaneous larva migrans, scabies, pediculosis capitis, pediculosis corporis in combination with travel, migrant, or refugee from 2000 to 2022. Tungiasis and cutaneous larva migrans were the epidermal parasitic skin diseases most commonly reported in travelers. Outbreaks with up to 36 cases occurred in groups of adventure-travelers. The clinical manifestation differed from those in inhabitants of endemic areas and were usually circumscript and moderate. Scabies was very rarely reported in travelers but causes a high disease burden in migrants and refugees. The infestation of refugees with body and head lice caused louse-borne relapsing fever in refugees arriving by boat from Africa. Travel advice concerning prevention of epidermal parasitic skin diseases requires knowledge on their epidemiology in the settings they are endemic.

A systematic review of barriers and facilitators for hepatitis B and C screening among migrants in the EU/EEA region

Introduction

Hepatitis B and C are a threat to public health. Screening of high-risk groups, such as migrants from high-endemic areas, enables early identification and treatment initiation. This systematic review identified barriers and facilitators for hepatitis B and C screening among migrants in the European Union/European Economic Area (EU/EEA).

Methods

Following PRISMA guidelines, databases PubMed, Embase via Ovid, and Cochrane were searched for English articles published between 1 July 2015 and 24 February 2022. Articles were included, not restricted to a specific study design, if they elaborated on HBV or HCV screening in migrant populations from countries outside Western Europe, North America, and Oceania, and residing in EU/EEA countries. Excluded were studies with solely an epidemiological or microbiological focus, including only general populations or non-migrant subgroups, or conducted outside the EU/EEA, without qualitative, quantitative, or mixed methods. Data appraisal, extraction, and quality assessment were conducted and assessed by two reviewers. Barriers and facilitators were categorized into seven levels based on multiple theoretical frameworks and included factors related to guidelines, the individual health professional, the migrant and community, interaction, the organization and economics, the political and legal level, and innovations.

Results

The search strategy yielded 2,115 unique articles of which 68 were included. Major identified barriers and facilitators to the success of screening related to the migrant (knowledge and awareness) and community level (culture, religion, support) and the organizational and economic level (capacity, resources, coordinated structures). Given possible language barriers, language support and migrant sensitivity are indispensable for facilitating interaction. Rapid point-of-care-testing is a promising strategy to lower screening barriers.

Discussion

The inclusion of multiple study designs provided extensive insight into barriers, strategies to lower these barriers, and facilitators to maximize the success of screening. A great variety of factors were revealed on multiple levels, therefore there is no one-size-fits-all approach for screening, and initiatives should be adopted for the targeted group(s), including tailoring to cultural and religious beliefs. We provide a checklist of facilitators and barriers to inform adapted interventions to allow for optimal screening impact.

Infectious disease screening outcomes and reducing barriers to care for unaccompanied asylum-seeking children: a single-centre retrospective clinical analysis

OBJECTIVE

Evaluate the Unity Clinic's infectious disease screening programme for unaccompanied asylum-seeking children (UASC), calculate rates of infection and identify further health needs.

DESIGN

Retrospective audit of electronic patient data.

SETTING AND PATIENTS

UASC who attended the Unity Clinic between 1 November 2019 and 22 March 2022.

MAIN OUTCOME MEASURES

Baseline demographics, social, mental health and journey details, infection screening and investigation results.

RESULTS

155 UASC were reviewed: 89% (138 of 155) male, median age 17 years (IQR 16-17). Most frequent countries of origin were Sudan, Eritrea and Afghanistan. Median duration of travel to the UK (n=79) was 2 years (IQR 0.5-4); 35.6% (47 of 132) arrived by boat and 54.5% (72 of 132) by road. 44.8% (69 of 154) had one or more positive infection screening results: 22.7% (35 of 154) and 1.3% (2 of 154) positive for latent and active tuberculosis, respectively; 4.6% (7 of 152) chronic active hepatitis B and 17.1% (26 of 152) for past infection; 1.3% (2 of 154) for HIV; 13.0% (19 of 146) for Strongyloides. There were three cases of syphilis (n=152; 2.0%) and one chlamydia (n=148; 0.7%)-none of whom disclosed prior sexual activity during screening. 39.6% (61 of 154) and 27.9% (43/154) reported disturbances to mood or sleep, respectively. 55.2% (85 of 154) disclosed traumatic incidents during and/or prior to their journey, including physical and sexual assault.

CONCLUSIONS

The Unity Clinic provides a thorough infectious disease screening service for UASC following national guidance. Results highlight the need for universal, non-judgemental screening for sexually transmitted infections, as targeted screening would not identify positive cases. High rates of well-being issues and previous abuse emphasise the need for multidisciplinary, collaborative approaches to care.

Health and Vaccination Status of Unaccompanied Minors After Arrival in a European Border Country: A Cross-sectional Study (2017-2020)

BACKGROUND

Unaccompanied and separated children (UASC) are a high-risk group for infectious diseases and information on their vaccination status is scarce. Different approaches are used to screen newly arrived minors in Europe. The aim of this study was to describe the health status and serological protection against different vaccine-preventable diseases among UASC to inform public health decision-making.

METHODS

Retrospective study of all UASC seen at an international health reference center in Barcelona (Spain) between January 2017 and February 2020. Screening results were analyzed using binary logistic regression with adjustment for symptoms, geographic origin, and time since arrival.

RESULTS

We studied 289 UASC (88.9% males; median age, 17 years). At least one infection was diagnosed in 136 minors (47.1%). There was a high prevalence of intestinal parasites (22.8%), latent tuberculosis infection (22.5%), and hepatitis B (5.2%), even in asymptomatic individuals, and especially among UASC from sub-Saharan Africa (odds ratio, 2.5; 95% confidence interval, 1.5-4.0, P < 0.001). We did not observe a significant association between clinical symptoms and the presence of infection or differences in the prevalence of different infections according to number of months since arrival. Protection against hepatitis B virus (36%), measles (80%), and varicella (83%) was suboptimal.

CONCLUSIONS

Our results highlight the importance of screening and vaccination programs for UASC arriving in Europe, especially border countries. Protocols should be adjusted according to geographic origin. Absence of symptoms does not necessarily rule out infection, highlighting the importance of screening in asymptomatic minors. These programs are a public health priority and should not be neglected during the current COVID-19 pandemic.

[Care of infectious diseases in underage refugees exemplified by Ukraine]

Background

By early June 2022, around 300,000 children and adolescents from Ukraine were registered in the German central registry for foreigners.The updated recommendations for action should provide the foundations for an evidence-based and targeted care for the diagnosis and prevention of infectious diseases in underage refugees and asylum seekers, exemplified by Ukraine.

Objective

The recommendations for action are intended to support medical personnel in the care of minor refugees in order to1) ensure early recognition and completion of an incomplete vaccination status,2) diagnose and treat common infectious diseases,3) ensure early recognition and treatment of infectious diseases that are rare in the German healthcare system.

Material and methods

The recommendations for action were drafted as level 1 (S1) guidelines coordinated by the Association of the Scientific Medical Societies in Germany (AWMF) and were adapted to the situation of refugees from Ukraine.The recommendations were compiled by a representative expert panel appointed by the participating professional societies in an informal consensus and finally officially adopted by the board of directors of all societies concerned.

Results

Recommendations are given for the extent of the medical evaluation of minor refugees, including the medical history and physical examination, adapted to the situation of refugees from Ukraine. A blood count and screening for tuberculosis, hepatitis B and C as well as human immunodeficiency virus (HIV) infections are recommended for all minor refugees.For a rapid completion of the vaccination status, an age-related and indications-related prioritization of individual vaccinations will be undertaken.

Conclusion

In view of the continuing high numbers of refugees not only from Ukraine, a further professionalization of medical health care is necessary. For this purpose, the necessary structural and personnel framework conditions need to be accomplished.

Scabies epidemiology in health care centers for refugees and asylum seekers in Greece

Background

Scabies is a global health concern disproportionately affecting vulnerable populations such as refugees and asylum seekers. Greece is a main point of entry in Europe for refugees, but epidemiological data on scabies in this population are scarce. We aimed to describe the epidemiology of scabies, including trends over the study period.

Methodology/Principal findings

Data were collected from June, 2016 to July, 2020, using the surveillance system of the Greek National Public Health Organization. Daily reports on scabies and other infectious diseases were submitted by staff at health centers for refugees/asylum seekers. Observed proportional morbidity for scabies was calculated using consultations for scabies as a proportion of total consultations.

There were a total of 13118 scabies cases over the study period. Scabies was the third most frequently observed infectious disease in refugees/asylum seekers population after respiratory infections and gastroenteritis without blood in the stool. The scabies monthly observed proportional morbidity varied between 0.3% (August 2017) to 5.7% (January 2020). Several outbreaks were documented during the study period. The number of cases increased from October 2019 until the end of the study period, with a peak of 1663 cases in January 2020, related to an outbreak at one center. Spearman correlation test between the number of reported scabies cases and time confirmed an increasing trend (ρ = 0.67).

Conclusions/Significance

Scabies is one of the most frequently reported infectious diseases by health care workers in refugee/asylum seekers centers in Greece. Observed proportional morbidity for scabies increased over time and there were several outbreaks. The current surveillance system with daily reports of the new cases effectively detects new cases in an early stage. Public health interventions, including mass drug administration, should be considered to reduce the burden of scabies in refugee/migrant populations.

Scabies is a skin disease caused by the ectoparasitic mite Sarcoptes scabiei var. hominis. Most people with scabies have a diffuse and pruritic rash, while the most complicated forms of the infection can lead to bacterial infections and sepsis. Scabies is a global health concern and in 2017, the World Health Organization (WHO) added it to the portfolio of conditions prioritized by WHO’s Department of Control of Neglected Tropical Diseases. However, the prevalence of scabies among refugees residing in camps in Greece has not been thoroughly investigated. In this study, we wanted to obtain an overview of scabies epidemiology and identify trends over time. To do so, we analyzed data extracted from epidemiological reports submitted each week as part of the Greek National Public Health Organization. Our findings confirmed the high prevalence of scabies among refugees residing in the camps and identified a clear trend of significant increase over time. Public health interventions, like mass drug administration with ivermectin, could help restrain the dissemination of the disease and lower its burden among refugees.

[Updated recommendations on the treatment of infectious diseases in refugees in childhood and adolescence in Germany (situation as of 30 March 2022), registered as S1 guidelines (AWMF-Register Nr. 048-017)]

Background

Based on 190,000 applications for asylum, Germany remains a top destination for refugees and asylum seekers in Europe. The updated recommendations are considered evidence-based and targeted guidelines for the diagnosis and prevention of infectious diseases in underage refugees and asylum seekers.

Objective

The objective of these recommendations is to guide medical staff in the care of minor refugees, in particular to:1. assure early recognition and completion of incomplete vaccination status,2. diagnose and treat common infectious diseases,3. recognize and treat imported infectious diseases that are considered uncommon to the German healthcare system.

Material and methods

The recommendations have been formally written to be published as AWMF S1 guidelines.This includes a representative expert panel appointed by several professional societies, and formal adoption of the recommendations by the board of directors of all societies concerned.

Results

Recommendations are given for the medical evaluation of minor refugees, including medical history and physical examination. A blood count as well as screening for tuberculosis and hepatitis B should be offered to all minor refugees. In addition, screening for other infectious diseases like hepatitis C, HIV or schistosomiasis should be considered depending on age and country of origin. Vaccinations are recommended based on both age and country of origin.

Conclusion

As thousands of minor refugees continue to seek shelter in Germany every year, professional health care with adequate financial support needs to be established to ensure an appropriate medical treatment of this particularly vulnerable population.

Toxocariasis in migrant children: A 6 years' experience in a reference pediatric unit in Spain

BACKGROUND

Toxocariasis is a worldwide distributed zoonosis that affects characteristically children. Clinical presentation is highly variable, often asymptomatic, and treatment duration is controversial.

METHODS

A retrospective descriptive study (January 2014-December 2019) was performed in a referral Unit for Pediatric Tropical Diseases. Patients younger than 18 years of age diagnosed with toxocariasis were included.

RESULTS

Out of 931 children screened for toxocariasis, 49 (5.3%) were seropositive. The median age was 11.0 years, 55.1% male and 30.6% referred contact with puppies. Overall, 34.7% were Latin-American, 24.5% Asiatic, 20.4% European, and 20.4% African. Only 34.7% presented symptoms, gastrointestinal the most common (52.9%). The 57.1% of children presented eosinophilia and 50% elevated total IgE. Most cases (95.9%) corresponded to covert toxocariasis. All children were treated with albendazole for 5-14-21 days, and 4 children required a second course. Follow-up data were available in 32 children (65.3%) for a median of 7 months, showing a progressive decline in eosinophils, IgE-titers and ELISA optical density.

CONCLUSION

Toxocariasis is mostly asymptomatic in children and eosinophilia is not always present. Serological tests should be included in migrant health screening and in the diagnostic assessment of eosinophilia. Eosinophil count, IgE-titers and ELISA optical-density could be useful during follow-up.

An opportunity for global antimicrobial stewardship research: Refugee populations

Antimicrobial resistance is a well-known global health threat that has higher prevalence in the refugee population. Although guidance has been provided by the World Health Organization and Centers for Disease Control and Prevention on implementing antimicrobial stewardship in lower- and middle-income countries, as well as by the United Nations Refugee Agency on other infection prevention and control efforts, no specific guidance exists for implementation of stewardship in this population. We highlight challenges specific to this population, review recent studies of interest within this space, and propose a research agenda to help move stewardship forward in the refugee population. We advocate for the importance of this issue, particularly given recent current events of geopolitical volatility that render this population more vulnerable, in the setting of its already well-known numerous health challenges.

International migration of unaccompanied minors: trends, health risks, and legal protection

The global population of unaccompanied minors-children and adolescents younger than 18 years who migrate without their legal guardians-is increasing. However, as data are not systematically collected in any region, if collected at all, little is known about this diverse group of young people. Compared with adult migrants, unaccompanied minors are at greater risk of harm to their health and integrity because they do not have the protection provided by a family, which can affect their short-term and long-term health. This Review summarises evidence regarding the international migration and health of unaccompanied minors. Unaccompanied minors are entitled to protection that should follow their best interests as a primary consideration; however, detention, sometimes under the guise of protection, is a widespread practice. If these minors are provided with appropriate forms of protection, including health and psychosocial care, they can thrive and have good long-term outcomes. Instead, hostile immigration practices persist, which are not in the best interests of the child.

Association between psychosocial functioning, health status and healthcare access of asylum seekers and refugee children: a population-based cross-sectional study in a German federal state

BACKGROUND

The mental health condition and healthcare needs of asylum seeking and refugee (ASR) children may go unrecognized if barriers to healthcare access exist accompanied by exclusive focus on somatic illness. We analysed the relationship between psychosocial functioning, health status and healthcare access of ASR children.

METHODS

During 2018, 560 ASR adults in 58 collective accommodations in Germany's 3rd largest federal state were randomly sampled and assessed. The parent-reported Strengths and Difficulties Questionnaire (SDQ) was used to assess child psychosocial functioning. SDQ dimensions (Emotional, Conduct, Peer, Hyperactivity, Prosocial, Total) were compared by demographics (sex, age, region of origin, time since arrival, subjective social status), health status (long-lasting illness, physical limitation, pain) and healthcare access (utilization: paediatrician, specialist, dentist, psychologist, hospital/emergency department, prescribed medicines; and unmet needs: for paediatrician/specialist, reduced spending to cover healthcare cost). Age and sex-adjusted odds ratios (AOR, 95%CI-Confidence Intervals) for scoring in borderline/abnormal ranges in SDQ dimensions were estimated through logistic regression depending on children' health status and healthcare access.

RESULTS

We analysed parents' answers pertaining to 90 children aged 1-17 years old, 57% of which were girls and 58% with (Eastern or Western) Asian nationality. Scoring in the borderline/abnormal range of the SDQ Total Difficulties score was associated with feeling bodily pain (compared to no pain, AOR, 95%CI = 3.14, 1.21-8.10) and with an unmet need for a specialist during the previous year (4.57, 1.09-19.16). Borderline/abnormal SDQ Emotional scores were positively associated with a long-lasting illness (5.25, 1.57-17.55), physical limitation (4.28, 1.49-12.27) and bodily pain (3.00, 1.10-8.22), and negatively associated with visiting a paediatrician (0.23, 0.07-0.78), specialist (0.16, 0.04-0.69), and the emergency department (0.27, 0.08-0.96).

CONCLUSION

Poor psychosocial functioning among ASR children is associated with somatic problems, unmet medical needs, and lower healthcare utilisation. Somatic clinical encounters with ASR should include children' mental health symptomatology assessment, especially in those with worst physical health conditions.

High diagnostic yield of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) in the diagnosis of adolescent pulmonary tuberculosis

Background

The microbiological diagnosis of pulmonary tuberculosis (Tb) in a pediatric population is hampered by both low pathogen burden and noncompliance with sputum sampling. Although endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has been found useful for the evaluation of mediastinal pathologies in adults, for children, sparse data are available. Here, we have evaluated EBUS-TBNA as a diagnostic procedure in children and adolescents with suspected pulmonary Tb.

Methods

In this retrospective analysis, we reviewed the charts of unaccompanied refugee minors (URM) who were admitted between January 2016 and July 2018 and who, during their initial medical screening upon arrival in Germany, were found to have abnormal radiological pulmonary and mediastinal findings and/or immunological results indicative of Tb. For each patient, basic sociodemographic data, clinical features and data on diagnostic procedures performed were assessed. These included imaging, immunodiagnostic tests and microbiological data derived from sputum, bronchoalveolar lavage, EBUS-TBNA, bronchoscopy and pleural fluid sampling. All patients who underwent invasive sampling procedures were included in the study.

Results

Out of 42 URM with suspected Tb, 34 fulfilled the study’s inclusion criteria. Ages ranged from 14 to 17 years. All were of African origin, with 70.0% coming from Somalia, Eritrea and Ethiopia. Among the 21 patients for whom EBUS-TBNA was performed, the diagnostic yield was high: 66.7% positive results (MTb detected either by acid-fast stain, culture or PCR in 4.8, 42.9 and 61.9% of samples, respectively). Multidrug-resistant MTb was found in two patients from Somalia. No complications were associated with the procedure. Overall, pulmonary Tb was diagnosed in 29 patients (85.3%), miliary Tb in two patients (5.9%) and latent Tb in three patients (8.8%).

Conclusions

EBUS-TBNA is a sensitive and safe method with high diagnostic yield in the evaluation of pediatric patients with mediastinal pathology and suspected Tb.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-021-06413-z.

Nutritional Status of Adolescent Afghan Refugees Living in Peshawar, Pakistan

Pakistan has hosted millions of Afghan refugees over the last several decades. Due to poor socioeconomic status, food insecurity and inadequate access to health care, these refugees are considered to be at high risk of malnutrition. Previous studies on nutritional assessment of high-risk populations (refugees) have focused mainly on women and children (0-59 months). The current study aims to assess nutritional status of adolescent Afghan refugees; the population who are equally vulnerable to malnutrition and its consequences. In this cross sectional study, the nutritional status of 206 adolescent (10-19 years old) Afghans boys and girls living in a refugee camp in Peshawar, Pakistan was assessed using standard methods. The results indicate a prevalence of stunting, thinness, and overweight and obesity at 35.3%, 4.4% and 14.8%, respectively. Furthermore, there was a significantly high prevalence of micronutrient deficiencies (vitamin D, 80.5%; vitamin B12, 41.9%; and folate, 28.2%); and anemia (10.1%). Together, these findings indicate that this vulnerable population group suffers from the double burden of malnutrition and are thus at serious risk of impaired psychosocial cognitive development, general ill-health and diminished wellbeing. This study therefore highlights the urgent need to include adolescents in regular screening and intervention programs of such at-risk populations.