Clinical assessment is a neglected component of outbreak preparedness: evidence from refugee camps in Greece

Seasonal patterns of communicable disease incidence and antibiotic prescribing in Moria refugee camp, Greece

BACKGROUND

Infectious diseases remain a major risk for refugees living in camps. Limited research has been undertaken into the burden and impact of infections in the current refugee crisis around the Mediterranean.This analysis examines the frequency and incidence rates of common infections, and use of antibiotics at a healthcare facility inside Moria refugee camp on the island of Lesvos, Greece, during the winter and summer seasons of 2019.

METHODS

This is a retrospective analysis of routinely, prospectively collected service data from the main acute healthcare facility inside Moria camp.

RESULTS

Of a total of 9601 consultations, 25.16% were for infections (winter: 31.53%, summer: 19.45%). Respiratory, skin and gastrointestinal infections were the most frequent, with incidence rates up to 3.5 times, 50 times and twice as high as those in Western Europe, respectively. Antibiotic prescribing was high (27.7% of all respiratory infections) with high use of broad-spectrum antibiotics (40.2%), raising concerns about induction of antimicrobial resistance.

CONCLUSIONS

The burden of infectious diseases in refugee camps remains high throughout all seasons. Antimicrobial stewardship programmes should be adapted to refugee camp settings to prevent the development of unnecessary antimicrobial resistance. Improving living conditions and access to healthcare in refugee camps is likely to reduce infection rates and antimicrobial resistance among refugees.

Knowledge, Attitudes and Perception of Mosquito Control in Different Citizenship Regimes within and Surrounding the Malakasa Open Accommodation Refugee Camp in Athens, Greece

The study aims to evaluate the Knowledge, Attitude and Perception (KAP) of different societal groups concerning the implementation of targeted community-based mosquito surveillance and control interventions in different citizenship regimes. Targeted surveys were carried out within Malakasa camp for migrants and refugees, neighboring residential areas and urban areas in the wider Athens metropolitan area to investigate different knowledge levels and the role that both local and migrant communities can play in the implementation of community-based interventions based on their attitudes and perceptions. A scoring system was used to rate the collected responses. Results indicate different levels of KAP among the various groups of respondents and different priorities that should be considered in the design and execution of community interventions. Findings indicate a lower level of Knowledge Attitudes and Perceptions for the migrants, while the rate of correct answers for Perception significantly improved for migrants following a small-scale information session. The study highlights disparities in the levels of knowledge for certain public health issues and the feasibility of certain approaches for alleviating health-related challenges such as mosquito-borne diseases. Findings suggest that essential preparedness is needed by public authorities to respond to public health challenges related to migration and the spread of vector-borne diseases.

Care delivery among refugees and internally displaced persons affected by complex emergencies: a systematic review of the literature

Aim

This study reviews the empirical evidence on care delivery in complex emergencies (CEs) to better understand ways of improving care delivery and mitigating inequity in care among refugees and internally displaced persons (IDPs) in CEs.

Subject and methods

A systematic search was conducted in Web of Science, MEDLINE, PubMed and Embase. A manual search was conducted in the WHO Global Index Medicus and Google Scholar. Peer-reviewed English-language publications that reported results on care delivery in CEs were included for review. There was no limitation on the year or the geographical location of the studies. The content of the publications was qualitatively analysed, and the results are thematically presented in tabular form.

Results

Thirty publications were identified. Information regarding coverage, accessibility, quality, continuity and comprehensiveness of care service delivery was extracted and synthesized. Findings showed that constant insecurity, funding, language barriers and gender differences were factors impeding access to and coverage and comprehensiveness of care delivery in CEs. The review also showed a preference for traditional treatment among some refugees and IDPs.

Conclusion

Evidence from this systematic review revealed a high level of unmet healthcare need among refugees and IDPs and the need for a paradigm shift in the approach to care delivery in CEs. We recommend further research aimed at a more critical evaluation of care delivery in CEs with a view to providing a more innovative and context-specific care service delivery in these settings.

A cross-sectional survey of sociodemographic characteristics, primary care health needs and living conditions of asylum-seekers living in a Greek reception centre

Background

In 2019, a migrant camp on the Greek island of Samos designed for 650 people was home to a growing population of over 5500. We aimed to quantitatively describe living conditions and health needs in the camp.

Methods

A questionnaire was designed with reference to international humanitarian standards, following a consultative process with the asylum-seeker population. Domains assessed included demographics, living conditions, safety/vulnerability, and health. The questionnaire was piloted and then conducted in June 2019 on a sample of asylum seekers.

Results

Five hundred participants, predominantly from Afghanistan and the Democratic Republic of Congo (DRC). Of these, 79.4% lived in tents. Respondents cared for a total of 570 children; 20.6% of women were pregnant, 35.4% had experienced violence, 83% psychological distress, 71% skin disease, 66% diarrhoea and vomiting, and 64% respiratory disease. Accommodation, sanitation, and nutrition fell below internationally recognised standards, and poor access to water was significantly associated (p < 0.001) with respiratory disease, diarrhoea and vomiting, skin disease ,and psychological distress.

Conclusions

Living conditions in the Samos camp fall below basic humanitarian standards and are associated with poor health status. Further research is imperative to analyse and monitor the diverse, varying needs of asylum-seekers and inform policies to improve conditions.

Population dynamics, pathogen detection and insecticide resistance of mosquito and sand fly in refugee camps, Greece

BACKGROUND

As of 2015 thousands of refugees are being hosted in temporary refugee camps in Greece. Displaced populations, travelling and living under poor conditions with limited access to healthcare are at a high risk of exposure to vector borne disease (VBD). This study sought to evaluate the risk for VBD transmission within refugee camps in Greece by analyzing the mosquito and sand fly populations present, in light of designing effective and efficient context specific vector and disease control programs.

METHODS

A vector/pathogen surveillance network targeting mosquitoes and sand flies was deployed in four temporary refugee camps in Greece. Sample collections were conducted bi-weekly during June-September 2017 with the use of Centers for Disease Control (CDC) light traps and oviposition traps. Using conventional and molecular diagnostic tools we investigated the mosquito/sand fly species composition, population dynamics, pathogen infection rates, and insecticide resistance status in the major vector species.

RESULTS

Important disease vectors including Anopheles sacharovi, Culex pipiens, Aedes albopictus and the Leishmania vectors Phlebotomus neglectus, P. perfiliewi and P. tobbi were recorded in the study refugee camps. No mosquito pathogens (Plasmodium parasites, flaviviruses) were detected in the analysed samples yet high sand fly Leishmania infection rates are reported. Culex pipiens mosquitoes displayed relatively high knock down resistance (kdr) mutation allelic frequencies (ranging from 41.0 to 63.3%) while kdr mutations were also detected in Ae. albopictus populations, but not in Anopheles and sand fly specimens. No diflubenzuron (DFB) mutations were detected in any of the mosquito species analysed.

CONCLUSIONS

Important disease vectors and pathogens in vectors (Leishmania spp.) were recorded in the refugee camps indicating a situational risk factor for disease transmission. The Cx. pipiens and Ae. albopictus kdr mutation frequencies recorded pose a potential threat against the effectiveness of pyrethroid insecticides in these settings. In contrast, pyrethroids appear suitable for the control of Anopheles mosquitoes and sand flies and DFB for Cx. pipiens and Ae. albopictus larvicide applications. Targeted actions ensuring adequate living conditions and the establishment of integrated vector-borne disease surveillance programs in refugee settlements are essential for protecting refugee populations against VBDs.

Does refugee status matter? Medical needs of newly arrived asylum seekers and resettlement refugees - a retrospective observational study of diagnoses in a primary care setting

BACKGROUND

Providing adequate healthcare to newly arrived refugees is considered one of the significant challenges for the German healthcare system. These refugees can be classified mainly into two groups: asylum seekers (who have applied for asylum after arrival in Germany and are waiting for the refugee-status decision) and resettlement refugees (who have already been granted asylum status before arriving in Germany). Whereas earlier studies have explored the health status of asylum seekers especially in terms of mental and behavioural disorders and infectious diseases without distinguishing between these two groups, our study aims to evaluate possible relationships of asylum status and medical needs of these two groups with a special focus on mental and behavioural disorders and infectious diseases.

METHODS

In this retrospective observational study, collected data on all asylum-seeker and resettlement-refugee patients (N = 2252) of a German reception centre (August 2017 to August 2018) is analysed by absolute and relative frequencies and medians. Patient data, collected by chart review, include age, gender, country of origin, asylum status, and diagnoses (ICD-10). To describe the relationship between sociodemographic factors (including asylum status) and diagnoses, we used tests of significance and bivariate correlations with Spearman correlation coefficients. All collected data are pseudonymised.

RESULTS

Of all 2252 patients, 43% were resettlement refugees. In almost all ICD-10 categories, asylum seekers received significantly more diagnoses than resettlement refugees. According to our data, asylum seekers presented with mental and behavioural disorders nine times more often (9%) than resettlement refugees (1%). In the case of infectious diseases, the results are mixed: asylum seekers were twice as frequently (11%) diagnosed with certain infectious and parasitic diseases than resettlement refugees (5%), but resettlement refugees were treated twice as often (22% of the asylum seekers and 41% of the resettlement refugees) for diseases of the respiratory system, of which 84% were acute respiratory infections (in both groups).

CONCLUSION

This study indicates that patients with unregulated migration more frequently present symptoms of psychiatric diseases and somatoform symptoms than resettlement refugees. A health policy approach within migration policy should aim to enable persecuted persons to migrate under regulated and safe conditions.

TRIAL REGISTRATION

German Clinical Trials Register: DRKS00013076, retrospectively registered on 29.09.2017.

Universal health coverage for refugees and migrants in the twenty-first century

Migration is a determinant of health. Tackling the health needs of migrants and refugees will require action at the local, national, and global levels. Over the past 12 months, BMC Medicine has published a collection of articles under the title Migrant and Refugee Health ( https://www.biomedcentral.com/collections/migrant-and-refugee-health ) addressing a range of health issues affecting refugees and migrants in their countries of origin, on transit, and in their destination countries. In light of these articles, we herein discuss the complex and wide-ranging healthcare needs of different refugee groups in their destination countries as well as the need for accessible and culturally appropriate health services.

Impact of the Refugee Crisis on the Greek Healthcare System: A Long Road to Ithaca

Greece is the country of "Xenios Zeus", the Ancient Greek god of foreigners and hospitality; however, it is also the main point of entry to Europe. Since the beginning of 2014, 1,112,332 refugees crossed the borders of Greece. Overall, 33,677 children and adolescent refugees sought asylum in Greece from 2013 to 2017, while 57,042 refugees are currently being hosted. The rapid entry of refugees into Greece raised the critical issue of health policy. The Greek National Health Service (NHS) faces many challenges. Adequate economic and human support is essential if this situation is to be managed successfully. However, Greece still bears the burden of the economic downturn since 2009. In fact, the crisis led to shortages in crucial equipment, and unmet health needs for both locals and refugees. The NHS deals with traumatic experiences, as well as cultural and linguistic differences. Overcrowded reception centers and hotspots are highly demanding and are associated with severe disease burden. This highlights the importance of guidelines for medical screening, healthcare provision, and a well-managed transition to definitive medical facilities. Furthermore, non-governmental organizations make an essential contribution by ensuring appropriate support to refugee minors, especially when they experience poor access to the NHS.

Key Dimensions for the Prevention and Control of Communicable Diseases in Institutional Settings: A Scoping Review to Guide the Development of a Tool to Strengthen Preparedness at Migrant Holding Centres in the EU/EEA

Migrant centres, as other institutions hosting closed or semi-open communities, may face specific challenges in preventing and controlling communicable disease transmission, particularly during times of large sudden influx. However, there is dearth of evidence on how to prioritise investments in aspects such as human resources, medicines and vaccines, sanitation and disinfection, and physical infrastructures to prevent/control communicable disease outbreaks. We analysed frequent drivers of communicable disease transmission/issues for outbreak management in institutions hosting closed or semi-open communities, including migrant centres, and reviewed existing assessment tools to guide the development of a European Centre for Disease Prevention and Control (ECDC) checklist tool to strengthen preparedness against communicable disease outbreaks in migrant centres. Among articles/reports focusing specifically on migrant centres, outbreaks through multiple types of disease transmission were described as possible/occurred. Human resources and physical infrastructure were the dimensions most frequently identified as crucial for preventing and mitigating outbreaks. This review also recognised a lack of common agreed standards to guide and assess preparedness activities in migrant centres, thereby underscoring the need for a capacity-oriented ECDC preparedness checklist tool.