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

Medical care and initial health status of French children returnees from jihadist group operation areas: A cross-sectional study from 2017 to 2020 in one referral French hospital

INTRODUCTION

The return of foreign fighters's children whose parents joined the so called « islamic state » in the Iraq-Syrian area, had been a very controversial topic. Since 2017, a national procedure in France has been designed to coordinate their care, including a systematic pediatric medical assessment.

METHODS

The aim of this cross-sectional study was to assess the prevalence rate of diseases diagnosed at their arrival in France. Demographic characteristics and clinical assessment of all the children included in this procedure in one paediatric center between 2017 and 2020 were retrospectively collected.

FINDINGS

We included 70 children (44M, 26F; mean age: 4.9 years old (±3.8)). In average, they crossed two countries, mainly Syria (n = 55), Turkey (n = 53) and Iraq (n = 18). At least one parent was deceased or incarcerated in respectively 25 (36 %) and 50 cases (71 %). Main pathologies were infectious diseases (n = 14, 20 %), including one lymph node tuberculosis. Mild nutritional impairment (n = 55, 78%-95 %), stunting (n = 13, 19%-95 %), psychomotor troubles (n = 18, 26 %) and psychological or behavior troubles (n = 36, 51 %) were also reported. Nutritional impairment was associated with a longer stay abroad (aOR 4.34, 95 % CI [1.21-18.24], p = 0.03) whereas no significant association was found between the other diseases and age, birth country or length of stay abroad.

CONCLUSIONS

Nutritional impairment and psychomotor or behaviour troubles were more frequent than other diseases in our cohort. These results emphasize the importance of considering the developmental aspects of these young children who experimented multiple potentially psychic traumatic events.

Emergency care utilization by refugee children compared to controls: A statewide database analysis

BACKGROUND

Refugees face barriers to accessing healthcare despite provision of short-term services after arrival. Limited access to sustained primary care may lead to increased emergency department (ED) utilization and little is known regarding how refugee children access emergency care.

OBJECTIVE

To compare the proportion of ED claims and median level of service (LOS) between refugee children and general population controls in a statewide claims database.

METHODS

We conducted a retrospective cohort study of medical claims for patients aged 0 to 18 years old in a statewide claims database from 2014-2019. Refugee claims were identified using deterministic linkage of children with known refugee status. Procedure and diagnosis ICD9/10, Healthcare Common Procedure Coding System, and Current Procedural Terminology codes were obtained from the statewide database to indicate type of claim (ED vs outpatient) and LOS. Demographics were extracted from a data warehouse. Primary outcome was the number of ED claims per 1000 combined ED and outpatient claims. LOS was measured as a proxy for ED visit complexity. We compared demographics, frequency of claims, and median LOS using chi-square.

RESULTS

There were 5,590,808 total claims with 1,235,476 ED claims. Median number of ED claims per individual patient was the same between groups, however the proportion of claims related to an ED visit was significantly higher in the refugee population than the general population controls (244 vs 221, p = 0.001). Median LOS for ED claims was Level 3 (99283) and there was no difference between groups.

CONCLUSION

Proportion of ED claims was higher in a refugee population compared to controls with no differences in LOS, indicating higher ED utilization among refugees for all acuity levels. Further study is needed to determine if healthcare disparities account for this difference and if population specific services may support the care of the refugee children.

Emergency Care for Refugee Patients at Suceava Hospital, Romania: Challenges and Insights from the First Year of the Russian-Ukrainian Conflict

BACKGROUND

The ongoing military conflict in Ukraine has had a devastating impact on children's health, exposing them to a range of illnesses. The aim of this study was to analyze the most common medical conditions among Ukrainian children since the beginning of the conflict, with a focus on identifying and understanding these problems in a wartime setting.

METHOD

To assess the health status of affected children, we collected data from 422 pediatric patients who presented to the emergency department. The analysis included reviewing medical records, documenting the nature of illness, treatments administered, and the need for hospitalization.

RESULTS

Preliminary results indicate that interstitial pneumonia, contusions, gastroenterocolitis, and traumatic brain injury were the most common conditions. Of the 422 children studied, 80% received appropriate care without hospitalization, while 20% were admitted for further evaluation.

CONCLUSIONS

Interstitial pneumonia was diagnosed in 23% of patients, highlighting the vulnerability of the respiratory system under conflict conditions. Contusions were predominant among musculoskeletal injuries, accounting for 81% of cases, and gastroenterocolitis was diagnosed in 46% of patients, reflecting the impact of poor living conditions.

Effect of households' members disability and serious illness on public health insurance subscription among urban refugees during the COVID-19 pandemic in Kenya

BACKGROUND

The adverse selection theory speculates a high level of demand for health insurance by people with vulnerable health conditions. However, the COVID-19 pandemic changed the prevailing narratives and pattern of healthcare utilization in many African countries. This study estimated the effects of household member's disability and presence of serious illness on the probability of National Hospital Insurance Fund (NHIF) subscription with the average treatment effect (ATE) and average treatment effect on the treated (ATET).

METHODS

The data were collected telephonically in 2020 using the sampling frame of the United Nations High Commission on Refugees (UNHCR). The respondents were refugees with active phone numbers who were registered by the UNHCR in Nairobi, Mombasa and Nakuru cities. A total of 2,438 completed the surveys. The data were analysed with Treatment Effects Probit regression model using the regression adjustment estimator.

RESULTS

The results showed that 24.89% of the respondents had health insurance. Also, 3.28%, 1.39% and 2.46%, respectively suffered from physical, cognitive and sensory disability, while 8.28% had some form of serious illness. The Probit regression results showed that probability of being health insured significantly increased (p < 0.05) with membership of community-based organizations (CBO), asset index, possession of bank savings account, residence in Nairobi and household size, while residence in Nakuru reduced it. The ATE for physical and cognitive disabilities were significant (p < 0.05) with 0.1100 and 0.1816, respectively, while that for serious illness was 0.1046 (p < 0.01). The ATET for physical disability and serious illness were also significant (p < 0.05) with 0.1251 and 0.0996, respectively.

CONCLUSION

It was concluded that efforts to facilitate NHIF subscriptions among the refugees should be channelled among people with disability and serious illness. In addition, there is the need to promote refugees' welfare through employment that can induce formal savings and promote less reliance on informal borrowing. The operational mechanisms and differences in healthcare service distribution between the three cities should be considered along some salient interventions for health insurance subscription that are channelled through some CBOs.

Global prevalence of anemia in displaced and refugee children: A comprehensive systematic review and meta-analysis

BACKGROUND

Anemia due to living condition disproportionally affects the global refugee children. Nutritional deficiency particularly iron deficiency is the primary causes of anemia. Hence, we conducted a systemic review and meta-analysis on the prevalence of anemia among refugee children.

METHODS

We searched systematically all relevant studies on the prevalence of anemia among refugee children including under the age of 18 years, which were conducted between 2009 and 2023 in English from PubMed, Embase, Scopus, Cochran library and other gray literatures such as google scholar. Two researchers independently screened articles based on their title and abstract. The Joana Brigg's Institute (JBI) checklist was used to assess the quality of studies. Random effect model was utilized to calculate the pooled estimate of anemia. Higgins I2 statistics and Egger's test were analyzed to check heterogeneity and publication bias, respectively. Subgroup analysis by continent, age group of the children and year of study was employed to identify the source of heterogeneity.

RESULT

A total of 14 studies were included in the final meta-analysis. Most of the studies were from Asian countries followed by African countries. The pooled prevalence of anemia among global refugee children was 36.54 with (95% CI: 23.79, 49.28). There was moderate level of heterogeneity between the studies (I2 = 68.91, P<0.001). The highest pooled prevalence of anemia in refugee children was reported in African, it was 56.1%, whereas the lowest pooled prevalence of anemia was in N. America, it was 12.66%. The prevalence of anemia was highest (53.88) in studies done among under-five refugee children.

CONCLUSION

The global prevalence of anemia among refugee children is found to be moderate public health problem. Anemia prevalence is more common in African refugee children. Intervention and prevention for should be focused especially for refugees found in low- and middle-income countries.

Doctors' experience providing primary care for refugee women living with chronic pain: a qualitative study

BACKGROUND

The experiences of GPs in Australia highlight key considerations regarding workload demands, remuneration incentives and the practical implications of working in regions with high ethnic density. This exploration helps to understand the elements that influence GPs delivery of care, particular for refugee women who exhibit disproportionately higher rates of chronic pain. This qualitative study explored the experiences of GPs providing care for refugee women living with chronic pain.

METHODS

Semi-structured interviews were undertaken with 10 GPs (9 female and 1 male) practicing across metropolitan Melbourne, Australia. GPs were recruited via purposive sampling and a snowballing strategy. Participants work experience ranged from one to 32 years. Audio recordings of the interviews were transcribed verbatim and stored in qualitative data Nvivo 12 software for coding. Transcripts of interviews were analysed thematically using a phenomenological approach.

RESULTS

Three overarching themes were identified: (1) meeting the needs of refugee women living with chronic pain; (2) the role of the GP; and (3) the challenges of the health care system. These themes reflected the complexity of consultations which arose, in part, from factors such as trust, the competencies of clinician's and the limitations posed by time, funding and interpreter use.

CONCLUSION

GPs acknowledged the uniqueness of refugee women's chronic pain needs and whilst doctors welcomed care, many were often challenged by the complex nature of consultations. Those that worked in settings that aligned with refugee women's needs highlighted the importance of cultivating culturally safe clinical environments and listening to their patients' stories. However, system level challenges such as time, funding and resource constraints created significant challenges for GPs. Exploring GPs experiences allows for a better understanding of how vectors of disadvantage intersect in health care and highlights the need to better support doctors to improve health care provision for refugee women living with chronic pain.

Health assessments of refugee minors arriving in Norway - a modified Delphi study among health professionals in primary care settings

BACKGROUND

Refugee minors are considered particularly vulnerable to negative health consequences from war, flight and resettlement. Offering health assessments after arrival in a host country could uncover unmet health needs and provide access to treatment. In Norway, a national guide describes these assessments, but little is known about its implementation especially for refugee minors. Thus, the aim of this study was first to explore how health assessments of refugee minors are carried out, second how health professionals perceive the needs of refugee minors and third, the competencies they perceive as necessary to meet the needs of refugee minors.

METHOD

A modified Delphi study in three rounds was conducted using online surveys and one focus group to collect data on the needs and resources of refugee minors, essential factors for a good and health assessment practice. Participants were 54 health professionals responsible for early health assessments of refugee minors, throughout the Norwegian municipalities, working in primary care settings. Quantitative data was analysed descriptively, and qualitative data with content analysis.

RESULTS

Health assessments of refugee minors were predominantly conducted by public health nurses, but the organisational structures surrounding assessments varied greatly according to the size of the municipalities and to how much resources were allocated. The feeling of safety was found to be paramount to ensure a good start in a new country for refugee minors. The top four competences professionals should have, were 'general communication skills', a 'health professional background', 'expertise in children's health' and 'knowledge about the national guide'. To ensure good health services for refugee minors, improved, more comprehensive, and mandatory directives for children and young individuals was highlighted.

CONCLUSION

Although most refugee minors were invited and attend health assessments, one third of participating municipalities did not offer health assessments to all newcomers and the organisation and content of the assessments were diverse. Several topics, especially mental health, were postponed or not routinely addressed, contrasting with current knowledge of unmet health needs for this group. Missing documentation, practical barriers and providing general health information took time away from doing the actual assessments. The perceived needs of refugee minors were safety and stability, combined with meaningful activities, thus a coordinated effort from several services is necessary. Suggestions for improvements were more time given to assessments, better organisation and co-operation, improved competence and guidelines adjusted for age.

"Vaccinating your child during an emergency is more important than ever": a randomised controlled trial on message framing among Ukrainian refugees in Poland, 2023

BackgroundSince February 2022, the start of the full-scale war in Ukraine, millions of women and children have fled the country. Vaccination of refugee children is important to protect this vulnerable population from disease.AimWe investigate the determinants of vaccination intention in refugee mothers from Ukraine residing in Poland and test the effect of three message frames.MethodsParticipants were randomised into either a control group or one of three intervention groups encouraging vaccination using a specific frame: (i) trust in the Polish health system, (ii) ease of access to vaccination or (iii) risk aversion. Primary outcomes were intention to vaccinate a child in Poland and clicking on a vaccination scheduling link.ResultsThe study was completed by 1,910 Ukrainian refugee mothers. Compared with the control group, the risk aversion message significantly increased vaccination intention (adjusted odds ratio (AOR): 2.35, 95% confidence interval (CI): 1.25-4.42) and clicking on the vaccine scheduling link (AOR: 1.53, 95% CI: 1.12-2.09). Messages around trust and ease of access did not have an effect. Important determinants of vaccination intention were perceived importance of vaccination (AOR: 1.12 95% CI: 1.01-1.25) and trusting vaccination information official health institutes (AOR: 1.40 95% CI: 1.06-1.83) and social media (AOR: 2.09 95% CI: 1.33-3.27).DiscussionUsing a risk aversion frame highlighting the vulnerability to infection that refugees face resulted in increased vaccination intention and clicks on a vaccination scheduler. Health workers who interact with Ukrainian refugees could use this frame in their vaccination communication.

Perspectives of refugee parents and unaccompanied minors on initial health assessment and access to care

To explore the needs, expectations, and experiences of asylum-seeking parents and unaccompanied minors under the age of 18 years on the initial health assessment for children and adolescents and access to care upon entry in the Netherlands, We conducted five semi-structured focus group discussions with asylum-seeking parents and unaccompanied minors, from Syria, Eritrea, Afghanistan, and other Middle-East and African countries, supported by professional interpreters. To triangulate findings, semi-structured interviews with health care professionals involved in care for refugee children were conducted. Transcripts of focus group discussions were inductively and deductively coded and content analyzed; transcripts of interviews were deductively coded and content analyzed. In total, 31 asylum-seeking participants: 23 parents of 101 children (between 0 and 18 years old), 8 unaccompanied minors (between 15 and 17 years), and 6 healthcare professionals participated. Parents and minors expressed that upon entry, their needs were met for vaccinations, but not for screening or care for physical and mental health problems. Parents, minors, and health professionals emphasized the necessity of appropriate information and education about health, diseases, and the health system. Cultural change was mentioned as stressful for the parent-child interaction and parental well-being.     Conclusion: The perspectives of refugee parents and unaccompanied minors revealed opportunities to improve the experience of and access to health care of refugees entering the Netherlands, especially risk-specific screening and more adequate education about health, diseases, and the Dutch health care system. What is Known: •  Refugees have specific health needs due to pre-flight, flight, and resettlement conditions. Health assessment upon entry was non-obligatory in the Netherlands, except for the tuberculosis screening. Health needs were not always met, and refugees experienced barriers in access to care. What is New: • The initial health assessment met the needs concerning vaccinations but mismatched the needs regarding physical and mental health assessment. Screening for specific risk-related diseases and mental health could enable refugee parents and minors to engage better with the health system.

Sibling-Support for Adolescent Girls (SSAGE): A study protocol for a pilot randomized-controlled trial of a whole-family, gender transformative approach to preventing mental illness among forcibly displaced adolescent girls

BACKGROUND

Forcibly displaced adolescents face increased risks for mental illness and distress, with adolescent girls disproportionately affected in part due to heightened gender inequity. Although the family unit has the potential to promote healthy development in adolescents, few family interventions have employed a gender transformative approach or included male siblings to maximize benefits for adolescent girls.

METHODS

This study will assess a whole-family and gender transformative intervention-Sibling Support for Adolescent Girls in Emergencies (SSAGE)-to prevent mental health disorders among adolescent girls in Colombia who were recently and forcibly displaced from Venezuela. The study will employ a hybrid type 1 effectiveness-implementation pilot randomized control trial (RCT) to test the program's effectiveness to explore determinants of implementation to establish the feasibility, acceptability, and fidelity of SSAGE. To address these aims, we will enroll 180 recently arrived, forcibly displaced adolescent girls in an RCT and examine the program's effectiveness in the prevention of mental illness (through reduction in anxiety, depression, interpersonal sensitivity, and somatization symptoms) one-month post-intervention. We will use contextually adapted to collect data on the hypothesized mechanistic pathways, including family attachment, gender-equitable family functioning, self-esteem, and coping strategies. The implementation evaluation will employ mixed methods to assess the program's feasibility, acceptability, fidelity, and barriers and facilitators to successful implementation.

DISCUSSION

Findings can support humanitarian program implementation, as well as inform policy to support adolescent girls' mental health and to prevent the myriad disorders that can arise as a result of exposure to displacement, conflict, and inequitable gender norms.

Supporting Migrant Children in Pediatric Settings: Lessons Learned from the US Migrant Humanitarian Crisis Response

This article examines the influx of migrants to the United States and highlights current global and local immigration trends. The authors focus on migrant children-specifically the effect of migration trauma in the context of humanitarian responses to the intentional movement of migrants to Democrat-led cities across the US to humanize the compounded effects of migration trauma, restrictive immigration policies, and the current resettlement landscape for migrants. The authors are directly involved with supporting migrant arrivals who have relocated to Chicago from the southern border, and apply field knowledge to articulate current barriers to accessing health care and best practices within pediatric settings supporting migrant arrivals. Clinical and practice implications for medical providers in pediatric settings are included. The article also highlights the role of interdisciplinary collaboration in providing health care to asylum-seeking migrants and implications for transdisciplinary workforce development in this area. [Pediatr Ann. 2024;53(5):e171-e177.].

Prevalence of undernutrition among migrant, refugee, internally displaced children and children of migrated parents in lower-middle-income countries: A meta-analysis of published studies from last twelve years

BACKGROUND AND AIMS

This review aims to estimate the prevalence of undernutrition among migrants, refugees, internally displaced children, and children of migrated parents living in lower-middle-income countries.

METHODS

PubMed, Scopus, Science-Direct, CINAHL-Plus, & Google Scholar were searched for peer-reviewed evidence published between January 2010 to March 2023. Two researchers independently examined the studies and retrieved the data. The internal and external validity of the studies was assessed using the NIH quality assessment tool, and a checklist adapted from Downs & Black, Bracht & Glass, and Del Siegle's guidelines. A random effect model was chosen to pool the estimates. Subgroup analysis, Meta-regression, and sensitivity analysis were done to explore the source of heterogeneity and the robustness of estimates.

RESULTS

Among the 1978 records initially searched, 21 studies were selected for analysis. The pooled prevalence estimates for stunting, wasting, and underweight were estimated to be 29.39% (Confidence Interval [CI] 21.69-37.73; I2 99%; p < 0.01), 12.76% (CI 7.84-18.68; I2 99%; P < 0.01), and 24.05% (CI 16.17-32.94; I2 100%; p < 0.001) respectively. Among different WHO regions, all three undernutrition estimates were higher in LMICs belonging to the Southeast Asian region (Stunting 37.62%; wasting 14.28% and underweight 31.24%). Undernutrition among migrant Indian children was 43.55%, 18.71%, and 37.45% respectively. High heterogeneity was noted across all estimates with I2-value >90%. Sensitivity analysis across indicators showed the stability of our estimates.

CONCLUSIONS

The extent of undernutrition, particularly wasting was high among migrant/refugee children living in lower-middle-income countries. Measures should be taken to strengthen the government-subsidized public food distribution system, increase healthcare outreach, and ensure public health insurance coverage among the migrant population.

A systematic review of studies on resilience and risk and protective factors for health among refugee children in Nordic countries

The Nordic welfare model is often used as an example for the promotion of health and wellbeing, even in vulnerable groups of children, such as refugees. Nonetheless, there are no published reviews on resilience and/or risk and protective factors for physical and mental health among refugee children living in Nordic countries. In this systematic review, we identified 5181 studies on the topic, screened titles, and abstracts, viewed 632, and finally included 26 studies. These studies described 18 samples with a total of 34,080 individuals ranging in ages 0-18 years. Overall, the studies were of good quality. Nearly all studies assessed adversity. Six studies reported physical health outcomes and all studies mental health outcomes, most often post-traumatic stress disorder and anxiety. None explicitly studied resilience. While we found that age and sex are the most frequently studied  risk- and protective factors, findings are inconclusive, since the direction of the associations was different in the different studies. This systematic review indicates that there is still a need for well-designed and -powered studies using clear definitions of key study concepts to examine health outcomes and resilience among refugee children in Nordic countries.

Refugee child health: a systematic review of health conditions in children aged 0-6 years living in high-income countries

This study describes the extent, quality and cultural appropriateness of current research on the health conditions of refugee children aged 0-6 years settled in high-income countries. A systematic review was conducted, including original articles published on the health conditions experienced by refugee children. A total of 71 papers were included. The studies varied considerably in their research design, population characteristics and health conditions. Studies included information on 37 different health conditions, with the majority non-communicable diseases, in particular growth, malnutrition and bone density. Although the studies identified a wide range of health issues, a coordinated effort to prioritise research on particular health topics was lacking, and health conditions studied do not align with the global burden of disease for this population. Additionally, despite being rated medium-high quality, most studies did not describe measures taken to ensure cultural competency and community involvement in their research. We suggest a coordinated research effort for this cohort, with greater emphasis on community engagement to improve the evidence-base of the health needs of refugee children after settlement.

Changing landscape of paediatric refugee health in South Western Sydney, Australia: a retrospective observational study

OBJECTIVES

To examine the changing health needs of refugee children and young people (CYP) entering Australia, in relation to key government policy changes.

STUDY DESIGN

Retrospective analysis of health service use data over 11 years.

SETTING

Paediatric refugee clinics in South Western Sydney (SWS), the Australian region with the largest annual resettlement of refugees.

PARTICIPANTS

Refugee CYP (≤25 years) attending the SWS paediatric refugee clinics for their first visit between 2009 and 2019.

MEASURES

Clinician defined health conditions categorised as communicable and non-communicable disease (NCD).

RESULTS

Data were analysed for 359 CYP, mean age 9.3 years; 212 male (59.1%). Most CYP (n=331, 92.2%) had health problems identified; 292 (81.3%) had ≥1 NCD and 24 (6.7%) had ≥1 communicable disease. The most frequent individual NCDs were dental disease (n=128, 35.7%) and vitamin D deficiency (n=72, 20.1%). Trend analysis showed increased odds of identifying an NCD from 2013 onwards (crude OR 1.77, 95% CI 1.06 to 2.96). Neurodevelopmental problems, especially Global Developmental Delay (n=31, 8.6%), emerged as more prevalent issues in the latter half of the decade. There were significantly increased odds of identifying a neurodevelopmental problem in 2016-2019, especially in 2016-2017 (adjusted OR 2.93, 95% CI 1.34 to 6.40). Key policy changes during this period included acceptance of refugees with disabilities from 2012, additional Australian Humanitarian Programme intake from the Eastern Mediterranean region and mandatory offshore processing for those seeking asylum by boat from 2013. In response to the changing needs, local health services adopted nurse-led primary healthcare screening, early childhood services, youth and disability clinics.

CONCLUSIONS

Refugee CYP in Australia are presenting with a growing burden of NCDs, with neurodevelopmental problems contributing. Government policy changes affect the sociodemographics of resettled populations, influencing health profiles. Paediatric refugee health services need to be responsive to the changing needs of these populations to optimise well-being.

Emergency paediatric medicine consultation-a practical guide to a consultation with refugee and asylum-seeking children within the paediatric emergency department

There are increasing numbers of refugee and asylum-seeking children entering the UK annually who face significant barriers to accessing healthcare services. Clinicians working in the emergency department should have an awareness of the journeys children may have taken and the barriers they face in accessing care and have a holistic approach to care provision. We conducted a narrative literature review and used experiential knowledge of paediatricians working in the Paediatric Emergency Department to formulate a step-by-step screening tool. We have formulated a step-by-step screening tool, CCHILDS (Communication, Communicable diseases, Health-physical and mental, Immunisation, Look after (safeguarding), Deficiencies, Sexual health) which can be used by healthcare professionals in the emergency department.

CONCLUSION

Due to increasing numbers of refugee and asylum-seeking children, it is important that every point of contact with healthcare professionals is an impactful one on their health, well-being and development. Future work would include validation of our tool.

WHAT IS KNOWN

•The number of refugees globally are rapidly increasing, leading to an increase in the number of presentations to the PED. These patients are often medically complex and may have unique and sometimes unexpected presentations that could be attributed to by their past. There are a multitude of resources available outlining guidance on the assessment and management of refugee children.

WHAT IS NEW

•This review aims to succinctly summarise the guidance surrounding the assessment of refugee children presenting to the PED and ensure that healthcare professionals are aware of the pertinent information regarding this cohort. It introduces the CCHILDS assessment tool which has been formulated through a narrative review of the literature and acts as a mnemonic to aid professionals in their assessment of refugee children in the PED.

Caring for resettled refugee children in the United States: guidelines, challenges and public health perspectives

The global refugee crisis has become an urgent, pressing humanitarian issue, with an estimated 37 million children forcibly displaced from their homes due to conflict, persecution, violence and other human rights violations by mid-2022. Of these children, only a small percentage are eligible for resettlement in a new country. This narrative review examines the physical health needs of resettled refugee children (RRC) in the United States. By analyzing nutrition and growth, infectious diseases, and general health care/screening measures, a set of comprehensive, evidence-based guidelines and public health perspectives are formulated to facilitate ongoing discussion to ensure that RRC receive equitable health care access. An urgent call to action emphasizes cross-border collaboration between governments, public health experts, refugee populations, and disease preparedness authorities in order to prioritize the physical health of RRC. This review will provide primary care providers, public health professionals, social service workers, and community advocates with up-to-date recommendations to meet the health needs of RRC in the U.S.

General practitioners' perspectives on the management of refugee health: a qualitative study

OBJECTIVE

To explore general practitioners' (GPs) perceptions of the challenges and facilitators to managing refugee healthcare needs in regional Australia.

SETTING

A regional community in Australia involved in the resettlement of refugees.

PARTICIPANTS

Nine GPs from five practices in the region.

DESIGN

A qualitative study based on semistructured interviews conducted between September and November 2020.

RESULTS

The main challenges identified surrounded language and communication difficulties, cultural differences and health literacy and regional workforce shortages. The main facilitators were clinical and community supports, including refugee health nurses and trauma counselling services. Personal benefits experienced by GPs such as positive relationships, satisfaction and broadening scope of practice further facilitated ongoing healthcare provision.

CONCLUSIONS

Overall, GPs were generally positive about providing care to refugees. However, significant challenges were expressed, particularly surrounding language, culture and resources. These barriers were compounded by the regional location. This highlights the need for preplanning and consultation with healthcare providers in the community both prior to and during the settlement of refugees as well as ongoing support proportional to the increase in settlement numbers.

Stunting and Overweight Prevalence Among Resettled Yazidi, Syrian, and Iraqi Pediatric Refugees

This cohort study compares growth abnormalities between Yazidi and non-Yazidi pediatric refugees.

Anemia among Syrian Refugee Children Aged 6 to 23 Months Living in Greater Beirut, Lebanon, including the Voices of Mothers' and Local Healthcare Staff: A Mixed-Methods Study

Globally, the prevalence of anemia among children during the period of complementary feeding is high. A cross-sectional, mixed-methods study was conducted to examine the main determinants of anemia among Syrian refugee children aged 6 to 23 months (n = 215) and to illuminate the knowledge, attitudes and perceptions of their mothers and Lebanese healthcare staff on its causes and available treatment options. 42% of the children and 20% of their mothers were anemic. Determinants of child anemia were the mother having anemia or not knowing that fish/seafood is a source of iron; the child having been acutely ill the last two weeks or receiving cow's milk, but not consuming iron-rich infant formula, added fats/oils, or fruits in the previous 24 hours. Several Syrian mothers knew some causes of anemia and named dizziness as a leading symptom but did not mention flesh foods as a key source of heme iron. They reported financial constraints in accessing iron-rich foods and supplements. Lebanese doctors largely gave appropriate dietary advice and prescribed iron supplements as treatment. Multisectoral interventions are needed that combine medical and financial support with nutrition counseling for mothers to reduce the high burden of anemia among young children living in a multiple crises situation.

Prevalence of hepatitis B virus amongst refugees, asylum seekers and internally displaced persons in low- and middle-income countries: A systematic review

Hepatitis B, caused by the hepatitis B virus (HBV), is a global public health issue that affects 290 million people worldwide. Most people with hepatitis B are in low- and middle-income countries (LMIC), where health systems and resources are often constrained. Refugees, asylum seekers and internally displaced persons (IDPs) often face barriers in seeking health care and are a priority population at risk of hepatitis B. No systematic review to date has evaluated the prevalence of hepatitis B amongst refugees in in LMIC. We undertook a systematic review of the literature identifying 28 studies addressing this topic. Though few studies on this topic exist, the available evidence suggests a high prevalence amongst refugees in LMIC, with wide variation between and within countries. Possible risk factors contributing to hepatitis B include unsafe injections, low immunization coverage, low awareness, mother-to-child transmission, and limited health services. Further study is needed to better understand the prevalence and risk factors for hepatitis B amongst refugees in LMIC, to inform public health responses. Vulnerable populations such as refugees are an important group to consider in national and global efforts to eliminate hepatitis B.

Impact of Coronavirus Pandemic on Tuberculosis and Other Imported Diseases Screening among Migrant Minors in Spain

BACKGROUND

In recent decades, the increase in population movements has turned the focus to imported diseases. The COVID-19 pandemic has negatively impacted the access to health care systems, especially in highly vulnerable populations. We address the effects of the pandemic on the health screening of migrant unaccompanied minors (UM) in Spain.

METHOD

Retrospective cross-sectional study including UM screened for imported diseases with a unified protocol at a pediatric reference unit for tropical and infectious diseases in Madrid, Spain. We compared the pre-pandemic (2018-2019) and post-pandemic periods (2020-2021).

RESULTS

A total of 192 minors were screened during the study period, with a drop in UM's referral to our center in the post-pandemic years (140 in 2018-2019 vs. 52 in 2020-2021). Out of 192, 161 (83.9%) were diagnosed with at least one medical condition. The mean age was 16.8 years (SD 0.8) and 96.9% were males. Most cases were referred for a health exam; only 38% of children were symptomatic. Eosinophilia was present in 20.8%. The most common diagnosis were latent tuberculosis infection (LTBI) (72.9%), schistosomiasis (15.1%), toxocariasis (4.9%) and strongyloidiasis (4.9%). The prevalence of LTBI did not vary significantly (69.3% vs. 82.7%, p = 0.087). A total of 38% of the patients diagnosed with LTBI never started treatment or were lost to follow-up, as were two out of three patients with active pulmonary tuberculosis.

CONCLUSIONS

In this series, the number of UM referred for health screening has dropped dramatically after the COVID pandemic, and two years after the beginning of the pandemic, access to care is still limited. Lost to follow-up rates are extremely high despite institutionalization. Specific resources, including multidisciplinary teams and accessible units are needed to improve diagnoses and linkage to care in this vulnerable population.

Nutritional and health status of adult Syrian refugees in the early years of asylum in Germany: a cross-sectional pilot study

BACKGROUND

Migration is usually accompanied by changes in the social, cultural, and religious environment, socioeconomic status, and housing conditions, all of which affect nutritional health. In a cross-sectional study, we assessed the dietary intake as well as nutritional and health situation in a population of Syrian refugees who have resided in Germany for at least six months up to four years since 2015. The primary aim of this pilot study was to evaluate the nutritional and health status in comparison to reference values.

METHODS

Between December 2018 and March 2020, 114 adult Syrian refugees were included in the study. The subjects filled out questionnaires on sociodemographic variables, exercise, and nutrition behavior (three-day nutrition record). After a fasting blood draw, the subjects were examined for anthropometric parameters (height, weight, body mass index, waist circumference, waist-hip ratio, and body composition via a bioelectrical impedance analyzer). Various blood markers including iron status, hematological parameters, Vitamin D status, lipid metabolism, glucose metabolism, and total homocysteine (tHcy) were measured.

RESULTS

About half of the participants (71 male, 43 female) had lived in Germany for less than three years. Over 60% of men and 30% of women were overweight (BMI 25-30 kg/m2) or obese (BMI > 30 kg/m2), while 79% of men and 74% of women observed an elevated body fat mass. The evaluation of the three-day nutrition records revealed an unfavorable supply situation for numerous critical nutrients. More than half of the women (53.5%) had depleted iron stores (serum ferritin < 15 µg/l). The 25-OH-Vitamin D blood levels showed a high prevalence of Vitamin D insufficiency (25-49.9 nmol/l: 38% of men and 21% of women) and deficiency (< 25 nmol/l: 44% of men and 70% of women). 83% of men and 67% of women showed tHcy levels in plasma > 10 nmol/l. Fasting insulin levels and the HOMA-IR index indicate a risk for insulin resistance. Hyperlipidemia was prevalent, especially in males with 24% showing hypertriglyceridemia (> 150 mg/dl) and LDL-hypercholesterolemia (> 130 mg/dl).

CONCLUSIONS

The nutritional and health status of the cohort of Syrian refugees in Germany examined in this study is unsatisfactory, and many of the investigated refugees are at risk for developing cardiovascular disease and type 2 diabetes mellitus. Further studies are required to investigate the nutritional and health situation of refugees. This is obligatory to find ways to avoid malnutrition with all its associated health, sociodemographic, and economic consequences.

Exploring the Impact of a Family-Focused, Gender-Transformative Intervention on Adolescent Girls' Well-Being in a Humanitarian Context

While family functioning interventions show promise for improving adolescent girls' well-being in humanitarian contexts, few programs employ a gender-transformative approach to maximize benefits for adolescent girls. This paper presents findings from a mixed-methods pilot evaluation of a whole-family, gender-transformative intervention conducted with Syrian refugee families in Jordan. The Siblings Support of Adolescent Girls in Emergencies program was implemented with 60 Syrian refugee households in Azraq and Za'atari camps in Jordan. A quantitative survey was administered to 18 households at baseline and endline, and researchers conducted qualitative interviews and focus group discussions with caregivers, paired interviews and participatory discussions with adolescents, and key informant interviews with program mentors. Paired t-tests revealed statistically significant improvements in mental distress, resilience, and gender equitable attitudes in the full sample and for girls only and marginally significant improvements in family functioning. Qualitative findings revealed improvements in four domains of girls' well-being-self-efficacy, self-confidence, pro-social behavior, and mental health-through three primary pathways: family members' increased gender equitable attitudes, healthier intrahousehold communication, and greater affective involvement. Findings from this mixed-methods evaluation point to the potential value in merging gender-transformative and whole-family approaches in humanitarian programming to maximize positive impacts for adolescent girls.

Health and illness in migrants and refugees arriving in Europe: analysis of the electronic Personal Health Record system

BACKGROUND

The electronic Personal Health Record (ePHR) is a health information system that registers health data on newly arriving migrants and was implemented in eight European countries (Bulgaria, Croatia, Cyprus, Greece, Italy, Romania, Serbia and Slovenia). This is a cross-sectional study aimed to describe the health problems and health status of all migrants attended at health clinics as part of the health assessment programme established in the reception centres (2016-2019).

METHODS

Data were collected on demographics, clinical and laboratory findings and diagnostics performed, including medical records. We classified all diseases using pre-specified algorithms according to information on pre-specified variables from the ePHR questionnaire, ICD-10 codes, positive laboratory findings or review of medical records. Crude proportions were calculated and odds ratios (OR) estimated using logistic regression modelling.

RESULTS

The ePHR dataset contained a total of 19 564 clinical episodes in 14 436 individuals, recorded between January 2016 and October 2019. Most individuals (75%) were refugees or asylum seekers (22%) from 92 different nationalities. There were 2531/19 564 (12.9%) infectious diseases episodes reported during the study period, being 1283/2531 (50.7%) of them pharyngo-tonsillitis, 529 (20.9%) scabies, 158 (6.2%) viral hepatitis and 156(6.1%) lower respiratory infections. There were 2462 (17.1%) individuals with non-communicable diseases reported; including 821 (5.7%) cardiovascular diseases, 1183 (8.2%) neurological condition, 644 (4.5%) Diabetes mellitus and 212 (1.5%) kidney disease cases. Having Diabetes Mellitus (adjusted OR, aOR 3.3, [95% confidence interval, CI 2.7-4.1], P < 0.001), and neurological disorders (aOR 1.8, [95% CI 1.4-2.2], P < 0.001) were associated with cardiovascular disorders in the multivariable logistic regression model.Mental health problems were reported in 641/14 436 (4.4%) individuals and were associated with increasing age. Furthermore, 610 episodes of acute injuries were reported among 585/14 436 (4.1%) people, 517 (88.4%) of them in men (P < 0.001).

CONCLUSIONS

The ePHR is a valuable tool to efficiently collect health-related data to better address migrant health issues. We described a mostly healthy population with many acute infectious disease episodes particularly in children, but also with significant number of chronic conditions and less frequent injuries or mental health problems.

[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.

Paediatric refugees from Ukraine: guidance for health care providers

BACKGROUND

With the invasion of Ukraine by the Russian Army in February 2022, refugees, the majority of whom are women and children, started fleeing the war to neighbouring countries. Even before the current escalation, the conflict in the eastern part of Ukraine has led to the internal displacement of more than 200,000 children, and many others have experienced attacks, e.g. on schools. This inevitably leads to limitations in health care delivery. During transit, overcrowding, poor shelter and vulnerability may further put refugees at increased risk for infectious diseases. This consensus document aims to provide information and guidance regarding health issues that paediatricians and general practitioners may face when caring for Ukrainian children.

METHODS

Members of the Migrant Health Reference Group of Paediatrics Switzerland and the Paediatric Infectious Disease Group in Switzerland developed this recommendation between March and April 2022 in a modified Delphi process.

RESULTS

A total of 50 recommendations were agreed on with a ≥80% consensus. These include the following topics: i) general aspects, including interpreter services, urgent health needs, personal history and general check-ups; ii) mental health, including how to search for signs of psychological distress without going into traumatic details; iii) vaccinations, including recommendations for evaluation and catch-up; iv) screening for tuberculosis, human immunodeficiency virus, and hepatitis B and C; and v) providing age-appropriate preventive and health service information.

CONCLUSION

This document provides current evidence and guidance when caring for paediatric refugees from Ukraine. The recommendations focus on Switzerland but may well be used in other countries. These are based on current evidence and may need to be adapted to individual situations and once further evidence becomes available.

Dietary Intake and Nutritional Status among Refugees in Host Countries: A Systematic Review

Refugees remain vulnerable to acute food insecurity, malnutrition, and critically inadequate food and nutrient intake after migration, regardless of the economic level of the host country. We conducted this systematic review to summarize and evaluate the dietary intake and nutritional status among refugees resettled in non-camp settings worldwide. We searched PubMed and Web of Science databases to review relevant studies published between 2009 and 2020 using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We also conducted an additional manual search through PubMed and Google Scholar. Studies that evaluated both dietary intake and nutritional status of refugees in host countries were included. A total of 15 articles from 10 countries were included and assessed for study quality and outcomes. Poor dietary diversity and insufficient intake of specific food groups were reported. In addition to these dietary patterns, a high prevalence of stunting, underweight, and anemia was reported, particularly among children. A double burden of malnutrition was also observed across and within studies. Post-resettlement dietary intake and nutritional status of refugees are both influenced by factors at the pre- and post-resettlement stages as refugees transition to their host countries. Those factors, including pre-resettlement experiences, host country resources, socioeconomic status, acculturation, and food security, were summarized and presented in a conceptual model. There is a need for comprehensive dietary and health screening as well as culturally appropriate and sustainable nutrition education resources and interventions for refugees to improve their diet and nutrition. Longitudinal studies and novel methodological approaches are also suggested to measure changes in refugees' food intake and nutritional status as well as to further investigate factors associated with these 2 components.

Description and evaluation of a pathway for unaccompanied asylum-seeking children

OBJECTIVE

(1) To describe a novel integrated pathway for unaccompanied asylum-seeking children (UASC).(2) To evaluate a population engaged with this service.

DESIGN

Description of the integrated pathway (objective 1) and retrospective evaluation, using data from community paediatrics, infectious diseases (IDs) screening and a sexual health (SH) service (objective 2).

SETTING

Unlinked data were collected from three services across three National Health Service (NHS) trusts in London.

PATIENTS

All Camden UASC engaged with the service from 01 January 2016 to 30 March 2019.

INTERVENTIONS

A multidisciplinary approach prioritising the health needs of UASC including a childre and adolescent mental health service (CAMHS) clinican and a health improvement practitioner. There are low thresholds for onward referral and universal asymptomatic screening of UASC for ID.

MAIN OUTCOME MEASURES

Data on demographics, unmet health needs and known outcomes.

RESULTS

Data were available for 101 UASC, 16% female, median age 16 years (range 14-17). Physical assault/abuse was reported in 67% and 13% disclosed sexual assault/abuse, including 38% of female UASC. Mental health symptoms were documented in 77%. IDs warranting treatment were identified in 41% including latent tuberculosis (25%) and schistosomiasis (13%). Interpreters were required for 97% and initial non-attendance rates at follow-up were 40% (ID) and 49% (SH).

CONCLUSIONS

These data demonstrate high rates of historical physical and sexual assault/abuse, unmet physical, mental and emotional health needs among UASC and significant barriers to engaging with services. An integrated pathway has been successfully implemented and shown to deliver appropriate, joined-up care for UASC, consistent with current recommendations, with the potential to improve outcomes.

Strengthening Tuberculosis Services for Children and Adolescents in Low Endemic Settings

In low tuberculosis-burden countries, children and adolescents with the highest incidence of tuberculosis (TB) infection or disease are usually those who have immigrated from high-burden countries. It is, therefore, essential that low-burden countries provide healthcare services to immigrant and refugee families, to assure that their children can receive proper testing, evaluation, and treatment for TB. Active case-finding through contact tracing is a critical element of TB prevention in children and in finding TB disease at an early, easily treated stage. Passive case-finding by evaluating an ill child is often delayed, as other, more common infections and conditions are suspected initially. While high-quality laboratory services to detect Mycobacterium tuberculosis are generally available, they are often underutilized in the diagnosis of childhood TB, further delaying diagnosis in some cases. Performing research on TB disease is difficult because of the low number of cases that are spread over many locales, but critical research on the evaluation and treatment of TB infection has been an important legacy of low-burden countries. The continued education of medical providers and the involvement of educational, professional, and non-governmental organizations is a key element of maintaining awareness of the presence of TB. This article provides the perspective from North America and Western Europe but is relevant to many low-endemic settings. TB in children and adolescents will persist in low-burden countries as long as it persists throughout the rest of the world, and these wealthy countries must increase their financial commitment to end TB everywhere.

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.

Vitamin D Deficiency Is Associated With Higher Hospitalization Risk From COVID-19: A Retrospective Case-control Study

CONTEXT

One risk factor for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is postulated to be vitamin D deficiency. To better understand the role of vitamin D deficiency in the disease course of COVID-19, we undertook a retrospective case-control study in North West England.

OBJECTIVE

To examine whether hospitalization with COVID-19 is more prevalent in individuals with lower vitamin D levels.

METHODS

The study included individuals with test results for serum 25-hydroxyvitamin D (25[OH]D) between April 1, 2020, and January 29, 2021, from 2 districts in North West England. The last 25(OH)D level in the previous 12 months was categorized as "deficient" if less than 25 nmol/L and "insufficient" if 25 to 50 nmol/L.

RESULTS

The study included 80 670 participants. Of these, 1808 were admitted to the hospital with COVID-19, of whom 670 died. In a primary cohort, median serum 25(OH)D in nonhospitalized participants with COVID-19 was 50.0 nmol/L (interquartile range [IQR], 34.0-66.7) vs 35.0 nmol/L (IQR, 21.0-57.0) in those admitted with COVID-19 (P < 0.005). In a validation cohort, median serum 25(OH)D was 47.1 nmol/L (IQR, 31.8-64.7) in nonhospitalized vs 33.0 nmol/L (IQR, 19.4-54.1) in hospitalized patients. Age-, sex-, and season-adjusted odds ratios for hospital admission were 2.3 to 2.4 times higher among participants with serum 25(OH)D <50 nmol/L compared with those with normal serum 25(OH)D levels, without excess mortality risk.

CONCLUSION

Vitamin D deficiency is associated with higher risk of COVID-19 hospitalization. Widespread measurement of serum 25(OH)D and treatment of insufficiency or deficiency may reduce this risk.

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.

Description of a migrant pediatric population visiting the Toulouse Children's Hospital emergency department

BACKGROUND

Today, one in eight migrants and one in two refugees are children. Since this population has been less studied than the adult population, there is little data available on the state of health of this pediatric migrant population and the reasons they seek care.

OBJECTIVE

The objective of this study was to describe the sociodemographic and medical characteristics of a pediatric migrant population visiting an emergency department in order to better understand their specific needs.

MATERIALS AND METHODS

This was a retrospective observational study using data from medical records and social surveys of migrant children who had visited the Toulouse pediatric emergency department between 1 January 2018 and 31 December 2018.

RESULTS

A total of 203 migrant children, i.e., 344 emergency visits, were analyzed. The average age of the children was 3.3 years old. More than half (58.1%) of the children were from Eastern Europe; 71% visited due to infectious pathologies. The severity of the reasons for visiting (90% of the reasons for visiting had a CCMU (Clinical Classification of Emergency Patients) of 1 or 2) and the hospitalization rate (9%) were not higher in the pediatric migrant population than in the general pediatric population. We discovered associated diagnoses (e.g., scabies, anemia, oral and dental disorders) in connection with migration and/or the resulting vulnerability. There was a language barrier in 78% of the visits analyzed with underuse of professional interpreting (7%).

CONCLUSION

Because of the journey they make, migrant children are likely to have specific health needs and require dedicated care.

Body mass index and associated factors among refugees living in North Rhine-Westphalia, Germany: a cross-sectional study

Background

This study aims to determine: (i) information on overweight and obesity, represented by body mass index using measured anthropometric data, among refugees living in North Rhine-Westphalia, Germany, (ii) how body mass index changed throughout the migratory journey to Germany, and (iii) factors influencing body mass index.

Methods

The study utilizes data from the FlueGe health study, a cross-sectional study conducted by Bielefeld University. The data was collected between February and November 2018 in which participants were recruited in several cities in North Rhine-Westphalia (N = 326). We analyzed differences in body mass index before the escape, upon arrival, and since arrival as well as correlations between body mass index since arrival and explanatory variables using linear regression models.

Results

The overall prevalence of overweight and obesity before the escape (t0), upon arrival (t1) and since arrival (t2) were 55.2% (150/272), 45.6% (133/292) and 54.8% (171/312), respectively, with 16.2% (44/272), 12.0% (35/292) and 16.0% (50/312) being obese. There was a significant change between t0 and t1 (p < 0.001), and between t1 and t2 (p < 0.001), but no change over time (between t0 and t2, p = 0.713). Results from multivariate linear regression showed that high education, male sex, higher body mass index before the escape, Iranian or Iraqi nationality, and sobriety were the significant factors for body mass index since arrival. However, when focusing on those who have reported weight gain only, higher body mass index before the escape, male sex, and Iraqi nationality were the significant factors.

Conclusions

Overweight and obesity were common among refugees after settlement in Germany. In particular, sociodemographic factors were associated with a higher body mass index since arrival. Thus, it is important to develop and apply nutrition-related intervention programs for adult refugees that are culturally appropriate and tailored to education level and sex.

Subclinical tuberculosis in children: diagnostic strategies for identification reported in a 6-year national prospective surveillance study

BACKGROUND

Subclinical tuberculosis (TB) is well recognized and defined as a disease state with absent or non-recognized symptoms. The study identifies factors associated with subclinical TB and diagnostic strategies in a low-burden, high-resource country.

METHODS

Data was collected between December 2013 to November 2019 through the Swiss Pediatric Surveillance Unit (SPSU). Children with culture/molecular confirmed TB, or who were treated with ≥3 anti-mycobacterial drugs, were included.

RESULTS

A total of 138 (80%) children with TB disease were included in the final analysis, of which 43 (31%) were subclinical. The median age of children with subclinical compared to symptomatic TB was 3.7(IQR 2.2 to 7) and 9.7(IQR 2.7 to 14.3) years, respectively (p=0.003). The cause of investigation for TB was recorded in 31/43 (72.1%) of children with subclinical TB, and included contact exposure in 25 (80.6%). In children with subclinical TB, diagnosis was made by a combination of the following abnormal/confirming results: culture/molecular + immunodiagnostic + chest radiography in 12 (27.9%), immunodiagnostic + chest radiography in 19 (44.2%), culture/molecular + chest radiography in 2 (4.7%), culture + immunodiagnostic in 1 (2.3%), chest radiography only in 8 (18.6%) and immunodiagnostic only in 1 (2.3%) case.

CONCLUSION

A notable proportion of children with TB had subclinical disease. This highlights the importance of non-symptom-based TB case finding in exposed children and refugees from high-TB-prevalence settings. TB screening in these asymptomatic children should therefore include a combination of immunodiagnostic testing and imaging followed by culture and molecular testing.

Vitamin D Status among First-Generation Immigrants from Different Ethnic Groups and Origins: An Observational Study Using the Canadian Health Measures Survey

One in five Canadians are first-generation immigrants. Evidence suggests the baseline risk for vitamin D (vitD) deficiency is increased among immigrants who move from equatorial to northern countries. We investigated the prevalence and determinants of vitD deficiency/insufficiency among first-generation immigrants compared with native-born Canadians and identified explanatory covariables. We used a cross-sectional design with data from the national Canadian Health Measures Survey (Cycles 3 and 4) (11,579 participants aged 3-79 years). We assessed serum 25-hydroxyvitamin D (S-25(OH)D) levels, sociodemographic and environmental factors, immigration status, length of time in Canada, vitD-rich food intake, ethnicity, and place of birth. Immigrants had lower mean S-25(OH)D than non-immigrants (51.23 vs. 62.72 nmol/L, p < 0.001). Those with younger age at the time of immigration (<18 years) had a high risk for low vitD, and S-25(OH)D levels increased with the length of time they had lived in Canada. The highest deficiency levels were in immigrants born in Morocco, India, and Lebanon compared with native-born Canadians. Ethnicity was the factor most strongly associated with S-25(OH)D. Compared with the white ethnic grouping, the Japanese had the highest level of vitD deficiency, followed by Arabs and Southeast Asians. Ethnic variations, dietary intake, and lifestyle factors are the main predictors of/explanatory factors for vitD status among Canadian immigrants.

Initiation and completion of treatment for latent tuberculosis infection in migrants globally: a systematic review and meta-analysis

Background

Latent tuberculosis infection (LTBI) is one of the most prevalent infections globally and can lead to the development of active tuberculosis disease. In many low-burden countries, LTBI is concentrated within migrant populations often because of a higher disease burden in the migrant's country of origin. National programmes consequently focus on screening and treating LTBI in migrants to prevent future tuberculosis cases; however, how effective these programmes are is unclear. We aimed to assess LTBI treatment initiation and outcomes among migrants, and the factors that influence both.

Methods

For this systematic review and meta-analysis, we searched Embase, MEDLINE, and Global Health, and manually searched grey literature from Jan 1, 2000, to April 21, 2020. We included primary research articles reporting on LTBI treatment initiation or completion, or both, in migrants and excluded articles in which data were not stratified by migrant status, or in which the data were related to outcomes before 2000. There were no geographical or language restrictions. All included studies were quality appraised using recognised tools depending on their design, and we assessed the heterogeneity of analyses using I². We extracted data on the numbers of migrants initiating and completing treatment. Our primary outcomes were LTBI treatment initiation and completion in migrants (defined as foreign-born). We used random-effects meta-regression to examine the influence of factors related to these outcomes. The study is registered with PROSPERO (CRD42019140338).

Findings

2199 publications were retrieved screened, after which 39 publications from 13 mostly high-income, low-burden countries were included in our analyses, with treatment initiation and completion data reported for 31 598 migrants positive for LTBI, with not all articles reporting the full pathway from initiation to completion. The pooled estimate for the true proportion of migrants testing positive who initiated treatment was 69% (95% CI 51–84; I²= 99·62%; 4409 of 8764). The pooled estimate for the true proportion of migrants on treatment in datasets, who subsequently completed it was 74% (95% CI = 66–81; I²= 99·19%; 15 516 of 25 629). Where data were provided for the entire treatment pathway, the pooled estimate for the true proportion of migrants who initiated and completed treatment after a positive test was only 52% (95% CI 40–64; I²= 98·90%; 3289 of 6652). Meta-regression showed that LTBI programmes are improving, with more recent reported data (2010–20) associated with better rates of treatment initiation and completion, with multiple complex factors affecting treatment outcomes in migrants.

Interpretation

Although our analysis highlights that LTBI treatment initiation and completion in migrants has improved considerably from 2010–20, there is still room for improvement, with drop out reported along the entire treatment pathway. The delivery of these screening and treatment programmes will require further strengthening if the targets to eradicate tuberculosis in low-incidence countries are to be met, with greater focus needed on engaging migrants more effectively in the clinic and understanding the diverse and unique barriers and facilitators to migrants initiating and completing treatment.

Funding

European Society of Clinical Microbiology and Infectious Diseases, the Rosetrees Trust, the National Institute for Health Research, and the Academy of Medical Sciences.

Health screening among children newly granted asylum in Denmark

AIM

To describe the findings and recommendations of the general health assessment (GHA) of newly resettled refugee children in Denmark.

METHODS

This cross-sectional study included children (aged <18 years) undergoing GHA from 2017 to 2019 at a university hospital Section of Immigrant Medicine. GHA was offered to all refugees newly resettled in the Municipality of Copenhagen. It comprised of a structured questionnaire, clinical examination, blood test and recommendations.

RESULTS

In the study period, 107 children were eligible, 100 children had a GHA performed and of whom all were included in the study. Trauma was reported in 61% (n = 61/100) of children. The median duration of the asylum-seeking process was 18 months (IQR: 8-24), and the highest number of relocations was nine. Latent tuberculosis (n = 2/100 [2%]) was the only infectious disease diagnosed. Specific recommendations for follow-up were frequent and included referral to specialist departments (n = 26/100 [26%]), suggestions for family doctor (n = 96/100 [96%]) and for municipality (n = 62/100 [62%]).

CONCLUSION

Self-reported trauma was frequent among 100 newly resettled refugee children. For most children, the asylum process was protracted and included several relocations. Specific follow-up recommendations were given to the vast majority. GHA may contribute to improving health, which could possibly support integration for the child and family.

Health needs of accompanied refugee and asylum-seeking children in a UK specialist clinic

AIM

To identify health needs and healthcare access barriers of accompanied refugee and asylum-seeking (RAS) children in the North East of England, and pilot a new service model to address these.

METHODS

Mixed-methods study (retrospective analysis of routinely collected service data, qualitative data from focus groups) of children who attended a hospital-based specialist clinic.

RESULTS

Over two years, 80 children were referred to this service. Most frequent diagnoses (total n = 104) were anaemia (n = 17), neurodevelopmental (n = 12), respiratory (n = 12) and mental health (n = 9) conditions. Mild-moderate stunting (23%), overweight and obesity (41%), stunting with obesity (9%) and micronutrient deficiencies (vitamin D (66%), vitamin A (40%) and manifest (14%) or latent (25%) iron deficiency anaemia) were highly prevalent. 62% of children had experienced psychological trauma, and 39% had abnormal results in psychosocial wellbeing screening. 21% of children required secondary or tertiary care, 8% mental health referrals, and 47% were followed up in this specialist clinic. Focus groups with families and the community report unaddressed health needs and substantial barriers of access to health care.

CONCLUSION

Refugee and asylum-seeking children have substantial health needs and healthcare access barriers that are not routinely addressed. The authors propose a service model for healthcare provision.

Pediatric Tuberculosis Disease during Years of High Refugee Arrivals: A 6-Year National Prospective Surveillance Study

BACKGROUND

In Europe, surveillance and monitoring of pediatric tuberculosis (TB) remains important, particularly in the light of migration in recent years. The aim of the study was to evaluate incidence rates of childhood TB and detailed diagnostic pathways and treatment.

METHODS

Data were collected through the Swiss Pediatric Surveillance Unit (SPSU) from December 2013 to November 2019. Monthly -notifications are obtained from the 33 pediatric hospitals in the SPSU, and a detailed questionnaire was sent out upon notification. Inclusion criteria were children and adolescents aged up to 15 years with culture- or molecular-confirmed TB disease or for whom a treatment with ≥3 antimycobacterial drugs had been initiated. Data were compared with age-matched notification data from the Swiss Federal Office of Public Health (FOPH).

RESULTS

Of the 172 cases notified to SPSU, a detailed questionnaire was returned for 161 (93%) children, of which 139 met the inclusion criteria. Reasons for exclusion were age >15 years, double reporting, and not fulfilling the criteria for TB disease. During the same time period, 172 pediatric TB cases were reported to the FOPH, resulting in an incidence of 2.1 per 100,000, ranging from 1.4 to 2.8 per year, without a clear trend over time. In the 64 (46.0%) foreign-born children, incidence rates were higher and peaked in 2016, with 13.7 per 100,000 (p = 0.018). The median interval between arrival in Switzerland and TB diagnosis was 5 (IQR 1-21) months, and 80% were diagnosed within 24 months of arrival. In 58% of the cases, TB disease was confirmed by culture or molecular assays. Age >10 years, presence of fever, or weight loss were independent factors associated with confirmed TB.

CONCLUSION

The annual pediatric TB incidence rate only varied among foreign-born children and was highest in 2016 when refugee influx peaked in Europe. Importantly, most foreign-born children with TB were diagnosed within 2 years after arrival in Switzerland. Thus, the early period after arrival in Switzerland is associated with a higher risk of TB disease in children, and this should be considered for screening guidance in refugees.

A Scoping Review of the Health of African Immigrant and Refugee Children

Migration is a growing phenomenon around the world, including within the African continent. Many migrants, especially African children, face challenges related to health and social inclusion and can face increased health risks. A systematic scoping review of available literature on the health of African migrant children across the globe was conducted to offer insight into these health risks. The review was conducted over a 15-month period from January 2019 to April 2020, yielding 6602 articles once duplicates were removed. This search included electronic databases, reference lists of articles reviewed, and searches of libraries of relevant organisations. A total of 187 studies met the inclusion criteria, of which 159 were quantitative, 22 were qualitative, and 6 used mixed methods. The findings reveal decreased health in this population in areas of nutrition, infectious diseases, mental health, birth outcomes, sexual and reproductive health, physical and developmental health, parasitic infections, oral health, respiratory health, preventative health, endocrine disorders, health care services, and haematological conditions. The findings offer insights into factors influencing the health of African immigrant and refugee children. Further studies, especially qualitative studies, are needed to determine barriers to service access after migration and to investigate other underexplored and overlooked health concerns of African migrant children, including pneumonia and child maltreatment.

Global mobility, travel and migration health: clinical and public health implications for children and families

Exponential growth of the world's population combined with increased travel has dramatically increased the spread of infectious diseases. Although there has been significant focus on migration, the major contributors to the transmission of communicable diseases are travel and tourism not migration. Given that children represent up to 10% of international travellers, it is critical to the health of all age groups to ensure that tailored guidance for children is considered in public health policy and guidelines, and pandemic responses. To further support pandemic preparedness, public health systems need to strengthen ties with communities and health systems. In addition, travel and migration issues need to be included as core competencies in medical education. Ensuring that clinicians who care for children have knowledge of travel and migration health will foster a better health outcome in an increasingly mobile population at risk of emerging infectious diseases.Abbreviations CDC: Centers for Disease Control and Prevention; DGMQ: CDC Division of Global Migration and Quarantine; EID: emerging infectious diseases; EU: European Union; VFR: visiting friends and relatives; IOM: United Nations International Organization for Migration; LPR: lawful permanent resident; US: United States of America; WHO: World Health Organization.

Martins MR. Migration as a Determinant in the Development of Children Emotional and Behavior Problems: A Quantitative Study for Lisbon Region, Portugal

The role of migration as a determinant in child mental health has been demonstrated in a number of studies. However, results are not always consistent, and the research continues to be scarce, especially in Portugal. We examined the association between sociodemographic profiles and the chance for the development of emotional and behavioral difficulties in a group of 420 children, immigrant (n = 217) and born in Portugal to Portuguese born parents (n = 203). We used a structured questionnaire to obtain sociodemographic information and the Strength and Difficulties Questionnaire (SDQ). Descriptive statistics were used to characterize children and their families; variables were compared between groups using the Chi-squared, Fisher’s Exact Test, or the Mann–Whitney U test and logistic regression was used to analyze the association between socio-demographic factors and emotional and behavioral difficulties. Results showed a pattern of social and mental health inequalities with immigrant children at a disadvantage: they are more often part of families with low income and where parents had low skilled jobs. Internalizing behaviors are more frequent in immigrants than in children born in Portugal to Portuguese-born parents (p = 0.001) whereas a high total SDQ difficulties score (p = 0.039) and externalizing behaviors were more frequent in 1st generation immigrant children (p = 0.009). A low family income (aOR 4.5; 95% CI: 1.43–13.95), low parental education level (aOR 2.5; 95% CI: 1.11–5.16), and being a first-generation immigrant child (aOR 2.2; 95% CI: 1.06–4.76) increased significantly the chance of developing emotional and behavioral difficulties. This study contributes to the identification of children vulnerable to mental health problems who can benefit from monitoring, early detection and preventive interventions in order to mitigate possible negative outcomes in the future.

Hypovitaminosis D in migrant children in Switzerland: a retrospective study

Cholecalciferol (vitamin D₃) is essentially known for its role in the phosphocalcic metabolism and its associated pathologies, such as rickets. In Switzerland, 35 to 50% of children are vitamin D deficient. Due to skin colour, poor nutrition, living conditions and cultural practices, migrant population is particularly at risk. Our aim is to attest the prevalence of hypovitaminosis D in children arriving in Switzerland. We retrospectively assessed 528 children's vitamin D status and parathyroid hormone, phosphate and calcium levels between 2015 and 2018 by electrochemiluminescence and spectrophotometry. Cholecalciferol was considered insufficient under 50 nmol/L and severely deficient below 25 nmol/L. Seventy-three percent of children showed hypovitaminosis D and 28% had a severe deficiency. Highest prevalence of deficiency was found in children from Eastern Mediterranean (80%) and African regions (75%). Severe deficiency was more prevalent in the South East Asian (39%) and Eastern Mediterranean regions (33%) and more frequent in females. Deficiency was more frequent and more severe in winter. Hypovitaminosis D increased with age. Two children presented with all three biological manifestations associated to severe hypovitaminosis D (hyperparathyroidism, hypocalcaemia and hypophosphatemia).Conclusion: A majority of migrant children presented with hypovitaminosis D. They should be supplemented to prevent complications. A strategy could be to supplement all children at arrival and during wintertime without regular vitamin D level checks. What is Known: Hypovitaminosis D is frequent in children and can lead to bone-related complications. Migrant children are particularly at risk of deficiency. What is New: Three-quarters of migrant children evaluated at our migrant clinic in Geneva's children hospital are deficient in vitamin D, one third severely. A strategy to correct the deficiency would be to supplement all migrant children at arrival and in winter.

Foreign background and older age of children were associated with infection in Swedish tuberculosis contacts

AIM

We present our results using interferon-gamma release assays in any child <18 years or tuberculin skin tests in Bacille Calmette-Guérin unvaccinated children for tuberculosis contact investigation in Stockholm, Sweden.

METHODS

During 2000-2019, we investigated 892 children with a median age of seven years. We explored associations between TB infection and characteristics such as closeness to contact, age, sex, BCG status and foreign origin.

RESULTS

The overall rates were for TB infection 10.2% (n = 91) and for TB disease 1.1% (n = 10). In addition to infectiousness of index case and closeness of contact, foreign background, male sex and increasing age were independently associated with infection. In foreign-born children, the rates of tuberculosis infection and disease were 18.7% and 3.9%, respectively. In 18/46 (39%) infected foreign-born children, a baseline negative tuberculosis test supported a diagnosis of recent infection.

CONCLUSION

Foreign background, older age and male sex were associated with infection. In a significant proportion of infected children, a previous negative test made recent infection likely.

Child modern slavery, trafficking and health: a practical review of factors contributing to children's vulnerability and the potential impacts of severe exploitation on health

Child trafficking is a form of modern slavery, a rapidly growing, mutating and multifaceted system of severe human exploitation, violence against children, child abuse and child rights violations. Modern slavery and human trafficking (MSHT) represents a major global public health concern with victims exposed to profound short-term and long-term physical, mental, psychological, developmental and even generational risks to health. Children with increased vulnerability to MSHT, victims (in active exploitation) and survivors (post-MSHT exploitation) are attending healthcare settings, presenting critical windows of opportunity for safeguarding and health intervention. Recognition of child modern slavery victims can be very challenging. Healthcare providers benefit from understanding the diversity of potential physical, mental, behavioural and developmental health presentations, and the complexity of children's responses to threat, fear, manipulation, deception and abuse. Healthcare professionals are also encouraged to have influence, where possible, beyond the care of individual patients. Research, health insights, advocacy and promotion of MSHT survivor input enhances the collaborative development of evidence-based approaches to prevention, intervention and aftercare of affected children and families.