A retrospective cross-sectional study of risk factors for communicable disease diagnoses among refugees in mainland Greek camps, 2016-2017

Communicable disease risk is high in refugee camps and reception centers. To better understand the risks for communicable disease diagnoses among refugees and asylum seekers, this study assesses individual- and camp-level risk factors among individuals utilizing Médecins du Monde clinics in four large refugee camps-Elliniko, Malakasa, Koutsochero, and Raidestos-on mainland Greece between July 2016 and May 2017. Descriptive statistics are reported for the demographic characteristics of the study population and for communicable disease burdens within the four camps-Elliniko, Malakasa, Raidestos, and Koutsochero. A hierarchical generalized linear model was used to assess risk factors for communicable disease diagnoses while accounting for individual-level clustering. This study shows marginal patterns in risk factors for communicable disease. Males had marginally higher risk of communicable disease diagnosis than females (OR = 1.12; 95% CI 0.97-1.29), and increased age was more protective against communicable disease for females (OR = 0.957; 95% CI 0.953-0.961) than for males (OR = 0.963; 95% CI 0.959-0.967). Communicable disease risk was significantly different between camps, with Elliniko (OR = 1.58; 95% CI 1.40-1.79) and Malakasa (OR = 1.43; 95% CI 1.25-1.63) having higher odds of communicable disease than Raidestos. The demographic and epidemiologic profiles of displaced populations differ across settings, and epidemiologic baselines for displaced populations are fundamental to evidence-informed provision of humanitarian aid. Further, while influences and risks for negative health outcomes in complex emergencies are broadly, the causal mechanisms that underpin these relationships are not as well understood. Both practitioners and researchers should engage with further research to elucidate the mechanisms through which these risks operate among displaced populations, including multilevel analyses.

RSV Infection in Refugees and Asylum Seekers: A Systematic Review and Meta-Analysis

Respiratory diseases, including respiratory syncytial virus (RSV) infections, are common reasons for seeking healthcare among refugees and asylum seekers. A systematic review with meta-analysis was designed to appraise all the available evidence on RSV infections among individuals in refugee camps. Three medical databases (PubMed, Embase, and Scopus) as well as the preprint repository medRxiv.org were searched for eligible observational studies, and the collected cases were pooled in a random-effects meta-analysis model. Heterogeneity was assessed using the I2 statistics. Funnel plots and a regression analysis were calculated for analyzing reporting bias. Eventually, six studies were retrieved from three areas (Bangladesh, Thailand, and Kenya), with pooled estimates of 129.704 cases per 1000 samples (95% CI 66.393 to 237.986) for RSV compared to 110.287 per 1000 people for influenza A (95% CI 73.186 to 162.889), 136.398 cases per 1000 people (95% CI 84.510 to 212.741) for human adenovirus (HAdV), 69.553 per 1000 people (95% CI 49.802 to 96.343) for parainfluenzavirus (PIFV), and 60.338 per 1000 people (95% CI 31.933 to 111.109) for human metapneumovirus (hMPV). Using influenza A as a reference group, the risk for a positive specimen was greater for RSV (relative risk [RR] 1.514, 95% CI 1.396 to 1.641) and HAdV (RR 1.984, 95% CI 1.834 to 2.146) and lower for influenza B (RR 0.276, 95% CI: 0.239 to 0.319), PIFV (RR: 0.889, 95% CI 0.806 to 0.981), and hMPV (RR 0.594, 95% CI 0.534 to 0.662). In summary, high rates of RSV infections were documented among individuals sheltered in refugee camps, stressing the importance of specifically designed preventive strategies.

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.

A mixed-method approach to determining contact matrices in the Cox's Bazar refugee settlement

Contact matrices are an important ingredient in age-structured epidemic models to inform the simulated spread of the disease between subgroups of the population. These matrices are generally derived using resource-intensive diary-based surveys and few exist in the Global South or tailored to vulnerable populations. In particular, no contact matrices exist for refugee settlements-locations under-served by epidemic models in general. In this paper, we present a novel, mixed-method approach for deriving contact matrices in populations, which combines a lightweight, rapidly deployable survey with an agent-based model of the population informed by census and behavioural data. We use this method to derive the first set of contact matrices for the Cox's Bazar refugee settlement in Bangladesh. To validate our approach, we apply it to the UK population and compare our derived matrices with well-known contact matrices collected using traditional methods. Our findings demonstrate that our mixed-method approach successfully addresses some of the challenges faced by traditional and agent-based approaches to deriving contact matrices. It also shows potential for implementation in resource-constrained environments. This work therefore contributes to a broader aim of developing new methods and mechanisms of data collection for modelling disease spread in refugee and internally displaced person (IDP) settlements and better serving these vulnerable communities.

Factors associated with access to dental care among refugees: A systematic review of quantitative studies

OBJECTIVES

To identify, appraise and synthesize the published evidence from quantitative studies on the individual and contextual-level factors determining access to dental care among refugees worldwide.

METHODS

A systematic literature search was conducted until the last week of February 2022 in four electronic databases - MEDLINE, Embase, Web of Science (all databases) and APA PsycINFO - without any restrictions. Quantitative studies published in English language and meeting the a priori eligibility criteria were reviewed and data extracted. Quality assessment was conducted using the National Institutes of Health tool. The identified factors were stratified according to the framework of the Behavioural Model of Health Services Use, and the evidence related to each of these factors was summarized in tables. Narrative synthesis of the findings was conducted.

RESULTS

The search retrieved 6776 unique records, of which 69 were deemed eligible for full-text screening and nine studies were included in the final data analysis and synthesis. The studies were rated to be of 'fair' quality at best. Self-reported previous dental visits was the most commonly used measure of access. Associations between individual-level factors and dental care access were most frequently examined (predisposing [n = 6], need [n = 2] and enabling [n = 1]), while the contextual-level factors were rarely examined (predisposing and enabling [n = 1, each]).

CONCLUSIONS

Individual-level predisposing factors, such as English language proficiency, education, health and dental literacy and acculturation and integration, were shown to be significantly associated with refugees' access. There is limited evidence to determine the effect of individual enabling and need and contextual factors.

Handwashing among caregivers of young children in a protracted and complex refugee and immigration context: a mixed methods study on the Thai-Myanmar border

Introduction

Protracted refugee situations create complex contexts that present significant health risks for young children. Effective hand hygiene practices by caregivers can reduce respiratory infections and diarrhoeal disease, the two largest contributors to mortality among children between 1 month and 5 years of age. This study documented handwashing patterns and access to water, sanitation and hygiene (WASH) infrastructure among caregivers of young children living along the Thai-Myanmar border, one of the world's most protracted and complex refugee and immigration contexts. It also examined the association between handwashing and socio-demographic variables and captured participants' explanations for when and how hands are washed. The study broadened the scope of previous research by also including the large number of caregivers living outside formal camps.

Methods

Caregivers of children attending 11 preschools in Tak province, Thailand participated in a mixed-methods cross-sectional study. Quantitative questionnaire data (n = 384) were supplemented by a thematic analysis of data from in-depth interviews (n = 9).

Results

Fewer than half the caregivers reported routinely washing their hands before preparing meals or after using the latrine/toilet. Fewer than one-in-five routinely used soap in these situations. Interviewees explained that handwashing was only necessary when a substance could be felt or seen, in which case wiping with a cloth or a rinsing with water were sufficient to clean hands. However, their explanations also suggested some potential avenues for culturally appropriate and feasible interventions to improve hand hygiene.

Conclusion

The results confirmed previous research on the multi-dimensional barriers to good hand hygiene in protracted refugee situations and other low-resource settings. Additional investment to overcome shortages in the infrastructure necessary to support good hand hygiene and creative means of drawing on and developing human capital will be necessary to realize the potential hand hygiene holds for reducing ill-health and mortality among young children living in these contexts.

Climate change and the displaced person: how vectors and climate are changing the landscape of infectious diseases among displaced and migrant populations

BACKGROUND

As the climate crisis grows, so does the global burden of displacement. Displacement, whether a direct or indirect consequence of natural disaster, can lead to dire health sequelae. Skin health is no exception to this, with dermatologic disease being a leading concern reported by those who care for displaced persons. Health professionals who provide dermatologic care for displaced persons benefit from understanding how climate change impacts the global profile of infectious agents.

METHODS

This review was performed using PubMed and Google Scholar. Search terms included climate change, displaced person, internally displaced person, and refugee, as well as searches of infectious disease dermatology and the specific diseases of interest. Case reports, case series, reviews, and original research articles were included in this review. Non-English studies were not included.

RESULTS

In this manuscript several key infectious agents were identified, and we discuss the skin manifestations and impact of climate change on cutaneous leishmaniasis, dengue, chikungunya, zika, malaria, pediculosis, cutaneous larva migrans, cholera, and varicella zoster.

CONCLUSIONS

Climate change plays a significant role in the challenges faced by displaced persons, including their skin health. Among the many consequences of climate change is its altering of the ecological profile of infectious agents and vectors that impact displaced persons. Being familiar with this impact can improve dermatologic care for this vulnerable population.

Climate Change and the Public Health Imperative for Supporting Migration as Adaptation

In an era of accelerating global climate change, human mobility has reached unprecedented levels. While it is acknowledged that many cases of human migration in the context of climate change are forced or involuntary, particularly where adaptation measures have failed to achieve sufficient resiliency of communities against impending slow- and sudden-onset disasters. There are also many cases where migration is, itself, a voluntary adaptive measure to secure otherwise unattainable physical safety and life-sustaining resources. It is in these cases that migration can be viewed as adaptation. Under the right policy conditions, it is possible for such adaptive migration to save countless lives. Moreover, it can achieve remarkable health and well-being gains for otherwise vulnerable communities residing on environmentally degrading lands and disproportionately suffering from the health impacts of climate change. While several activists have spoken loudly on the topic of climate migration, emphasizing the human rights imperative for supportive global policy action, the public health community has not been equally vocal nor unanimous in its stance. This paper, a product of the World Federation of Public Health Associations (WFPHA) Environmental Health Working Group, aims to rectify this gap, by analyzing adaptive climate migration through a public health lens. In doing so, it argues that creating an enabling environment for adaptive climate migration is not just a human rights imperative, but also a public health one. This argument is supported by evidence demonstrating how creating such an enabling environment can synergistically support the fulfillment of key public health services and functions, as outlined under the internationally endorsed Global Charter for the Public's Health of the WFPHA.

The impact of neglected tropical diseases on women and girl refugees: A call for increased awareness and strategic intervention

As the number of forcibly displaced women and girls increases, it becomes ever important to recognize the negative health impacts of being displaced. Women and girl refugees are disproportionately affected by sexual and gender-based violence and mental health concerns. In addition to these health concerns in women, crowding and lack of clean water in refugee camps leads to the spread of infectious diseases in general. Neglected tropical diseases (NTDs) are infectious diseases of poverty found in tropical areas, and longstanding infections lead to significant morbidity. Particularly for women, these diseases can impact fertility, chronic disease in pregnancy, and social stigma. Despite being a high-risk group, there are minimal data on the impact of NTDs on the health of Women and girl refugees. Diseases such as schistosomiasis, soil-transmitted helminth infections, strongyloidiasis, and leishmaniasis have all been shown to affect Women and girl refugees, but the majority of these data describe NTDs in this population only after resettlement. Access to medical care with providers that are knowledgeable about NTDs while in situations of displacement as well as after third-country resettlement is crucial to their timely diagnosis and treatment to prevent longstanding sequalae. More studies in this at-risk population are needed to understand the extent of this issue and begin to work towards lasting, equitable healthcare.

Health Risks During Ukrainian Humanitarian Crisis

Background

The unprecedented exodus in the history of the European Union of more than 6 million Ukrainian refugees (May 13, 2022) is a cause for concern and could lead to a new difficult situation in terms of infectious disease control. Following the SARS-CoV-2 pandemic, Europe is facing a new challenge that could lead to a new wave of COVID-19 and an increase in the number of cases of tuberculosis or eradicated diseases, such as polio.

Aim

The purpose of this analysis was to provide an overview of lung diseases and health risks that could be encountered in refugees from Ukraine and translated to European Union`countries.

Methods

A systematic review was conducted in PubMed, World Health Organization, the UN Refugee Agency and the government's websites. Selected publications investigated the health problems arising from Ukrainian population migration from conflict areas and their impact on the public health system in the adoptive countries. The main potentially contagious diseases in Ukraine have also been reviewed.

Results

The population of Ukraine has serious public health problems such as SARS-CoV-2 infection, multidrug-resistant tuberculosis, high levels of drug resistance and difficulties with an effective vaccination program, so there are significant risks of developing epidemics in transit or host countries. The current crisis has major peculiarities because the migrants were not concentrated in the camps but there was a dispersion of them on large territories of European countries.

Conclusion

In order to meet the health needs of refugees, it is necessary to adapt health systems culturally and linguistically, to train health workers on the particularities of existing diseases in the countries of refugee origin, and to facilitate collection of medical data on migrants' health.

Epidemiological modelling in refugee and internally displaced people settlements: challenges and ways forward

The spread of infectious diseases such as COVID-19 presents many challenges to healthcare systems and infrastructures across the world, exacerbating inequalities and leaving the world’s most vulnerable populations at risk. Epidemiological modelling is vital to guiding evidence-informed or data-driven decision making. In forced displacement contexts, and in particular refugee and internally displaced people (IDP) settlements, it meets several challenges including data availability and quality, the applicability of existing models to those contexts, the accurate modelling of cultural differences or specificities of those operational settings, the communication of results and uncertainties, as well as the alignment of strategic goals between diverse partners in complex situations. In this paper, we systematically review the limited epidemiological modelling work applied to refugee and IDP settlements so far, and discuss challenges and identify lessons learnt from the process. With the likelihood of disease outbreaks expected to increase in the future as more people are displaced due to conflict and climate change, we call for the development of more approaches and models specifically designed to include the unique features and populations of refugee and IDP settlements. To strengthen collaboration between the modelling and the humanitarian public health communities, we propose a roadmap to encourage the development of systems and frameworks to share needs, build tools and coordinate responses in an efficient and scalable manner, both for this pandemic and for future outbreaks.

Infectious disease surveillance for refugees at borders and in destination countries: a scoping review

BACKGROUND

Data on infectious disease surveillance for migrants on arrival and in destination countries are limited, despite global migration increases, and more are needed to inform national surveillance policies. Our study aimed to examine the scope of existing literature including existing infectious disease surveillance activities, surveillance methods used, surveillance policies or protocols, and potential lessons reported.

METHODS

Using Arksey and O'Malley's six-stage approach, we screened four scientific databases systematically and 11 websites, Google, and Google Scholar purposively using search terms related to 'refugee' and 'infectious disease surveillance' with no restrictions on time-period or country. Title/abstracts and full texts were screened against eligibility criteria and extracted data were synthesised thematically.

RESULTS

We included 20 eligible sources of 728 identified. Reporting countries were primarily European and all were published between 1999 and 2019. Surveillance methods included 9 sources on syndromic surveillance, 2 on Early Warning and Response (EWAR), 1 on cross-border surveillance, and 1 on GeoSentinel clinic surveillance. Only 7 sources mentioned existing surveillance protocols and communication with reporting sites, while policies around surveillance were almost non-existent. Eleven included achievements such as improved partner collaboration, while 6 reported the lack of systematic approaches to surveillance.

CONCLUSION

This study identified minimal literature on infectious disease surveillance for migrants in transit and destination countries. We found significant gaps geographically and on surveillance policies and protocols. Countries receiving refugees could document and share disease surveillance methods and findings to fill these gaps and support other countries in improving disease surveillance.

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.

Operational response simulation tool for epidemics within refugee and IDP settlements: A scenario-based case study of the Cox's Bazar settlement

The spread of infectious diseases such as COVID-19 presents many challenges to healthcare systems and infrastructures across the world, exacerbating inequalities and leaving the world's most vulnerable populations most affected. Given their density and available infrastructure, refugee and internally displaced person (IDP) settlements can be particularly susceptible to disease spread. In this paper we present an agent-based modeling approach to simulating the spread of disease in refugee and IDP settlements under various non-pharmaceutical intervention strategies. The model, based on the June open-source framework, is informed by data on geography, demographics, comorbidities, physical infrastructure and other parameters obtained from real-world observations and previous literature. The development and testing of this approach focuses on the Cox's Bazar refugee settlement in Bangladesh, although our model is designed to be generalizable to other informal settings. Our findings suggest the encouraging self-isolation at home of mild to severe symptomatic patients, as opposed to the isolation of all positive cases in purpose-built isolation and treatment centers, does not increase the risk of secondary infection meaning the centers can be used to provide hospital support to the most intense cases of COVID-19. Secondly we find that mask wearing in all indoor communal areas can be effective at dampening viral spread, even with low mask efficacy and compliance rates. Finally, we model the effects of reopening learning centers in the settlement under various mitigation strategies. For example, a combination of mask wearing in the classroom, halving attendance regularity to enable physical distancing, and better ventilation can almost completely mitigate the increased risk of infection which keeping the learning centers open may cause. These modeling efforts are being incorporated into decision making processes to inform future planning, and further exercises should be carried out in similar geographies to help protect those most vulnerable.

Challenges and Effects of the COVID-19 Pandemic on Asylum Seeker Health at the U.S.-Mexico Border

Purpose: The coronavirus disease 2019 (COVID-19) pandemic presents health care challenges to asylum seekers living in congregate encampments, including those along the U.S.-Mexico border. It is necessary to understand the impact of the pandemic among this population to address health care needs, reduce transmission, and diminish COVID-19-related morbidity. Methods: Thirty interviews were conducted with asylum seekers and health care professionals in a temporary camp in Matamoros, Mexico to determine challenges, perceptions, and effects of the COVID-19 pandemic. Interviews were coded in NVivo12 by using a team-based approach. Results: The pandemic caused significant mental health burdens but no perceived adverse physical effects, with the U.S. border closure and health care access barriers as more pressing concerns. Participants reported access to information about COVID-19 but had varied levels of knowledge and adherence to disease reduction strategies due to camp conditions. Most participants believed that they had special protection from COVID-19, including strong immune systems or from God. The nongovernmental organizations providing health care and sanitation faced multiple challenges to implement new policies to manage COVID-19. The institution of required temperature checks and quarantine of COVID-19 positive patients led to distrust, decreased seeking of health care services among asylum seekers, and possible underreporting of COVID-19 cases. Conclusion: Our findings among asylum seekers in a Matamoros camp highlight the challenges to implementing disease reduction policies in low-resource congregate camps. Policies to address disease outbreaks focusing on the social determinants of health, health care access barriers, and community engagement may be more acceptable to asylum seekers, suggesting the need for effective strategies to provide prevention information that complements such measures.

Infectious disease outbreaks among forcibly displaced persons: an analysis of ProMED reports 1996-2016

Background

The United Nations Refugee Agency (UNHCR) estimates the number of forcibly displaced people increased from 22.7 million people in 1996 to 67.7 million people in 2016. Human mobility is associated with the introduction of infectious disease pathogens. The aim of this study was to describe the range of pathogens in forcibly displaced populations over time using an informal event monitoring system.

Methods

We conducted a retrospective analysis of ProMED, a digital disease monitoring system, to identify reports of outbreak events involving forcibly displaced populations between 1996 and 2016. Number of outbreak events per year was tabulated. Each record was assessed to determine outbreak location, pathogen, origin of persons implicated in the outbreak, and suspected versus confirmed case counts.

Results

One hundred twenty-eight independent outbreak events involving forcibly displaced populations were identified. Over 840,000 confirmed or suspected cases of infectious diseases such as measles, cholera, cutaneous leishmaniasis, dengue, and others were reported in 48 destination countries/territories. The average rate of outbreak events concerning forcibly displaced persons per total number of reports published on ProMED per year increased over time. The majority of outbreak events (63%) were due to acquisition of disease in the destination country.

Conclusion

This study found that reports of outbreak events involving forcibly displaced populations have increased in ProMED. The events and outbreaks detected in this retrospective review underscore the importance of capturing displaced populations in surveillance systems for rapid detection and response.