Crossing Borders, Sharing Journeys: Effective Capacity Building with Immigrant and Refugee Groups

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As refugees and migrants spend longer in the country of destination, their health status may converge with that of the host population 1. Based on figures available in published literature, standardized mortality ratio estimates tend to be lower in refugees and migrants than in the European host population for all-cause mortality, neoplasms, mental and behavioural conditions, injuries, endocrine disorders and digestive conditions, but higher for infections, external causes, diseases of the blood and blood-forming organs and cardiovascular diseases Fig.

Summary standardized mortality ratios for refugees and migrants compared with the host population in the WHO European Region for various mortality causes. Notes: Mortality causes are based on the all-cause mortality and International Classification of Diseases 10th Revision; values below 1. Most literature regarding refugee and migrant health in the WHO European Region has addressed communicable diseases, with less information on the risk for NCDs, such as cardiovascular diseases, stroke and cancer; risks for these NCDs can increase with duration of stay in the host country 4 , 5.

Factors such as country of origin, specific health outcome considered, and duration and socioeconomic conditions of stay have a major impact on refugee and migrant health and so studies can have differing or contesting observations 6 — 9. Refugee and migrant health is highly complex, with risks and exposures associated with the displacement and the migratory process, respectively, and the social determinants of health in the host country. Consequently, it is often difficult to generalize research findings to wider refugee and migrant populations in a country, in a region or globally, and this should be kept in mind when considering information on the health status of refugees and migrants in the WHO European Region The legal status of different migrant groups e.

Research from Finland indicated that forced displacement may be related to an increase in risk of death from cardiovascular diseases Irregular migrants in the WHO European Region have been shown to be at greater risk of poor mental health than migrants with documentation or the host populations Refugees and asylum seekers may have elevated rates of perinatal mortality and prevalence of PTSD 13 , Gender is an additional important aspect to consider when analysing refugee and migrant health but data are rarely disaggregated by sex and there is no systematic, comparable information on those who do not fit the typical binary male and female categories.

This report highlights the gender aspects wherever data are available. When studying the health status of refugees and migrants, it is also important to recognize that outcomes are often a result of an entire lifetime of risks and exposures, which may have occurred before, during or after the displacement or migratory process. For example, children belonging to different migrant groups often have greater health differences than those between migrant children in general and non-migrant children in European countries, and elderly migrants who have aged within the destination country may face different issues to those who migrate in older age.

It is important have a life-course approach to refugee and migrant health, similar to the general population. However, such an approach is limited by lack of data, especially on elderly migrants 15 — Tailored health care can only be provided if the needs of a population group are understood. However, in general, there is a lack of comprehensive, routinely collected and comparable data focusing on refugee and migrant health in the WHO European Region, which limits the ability to draw generalized conclusions within this report. This is particularly true for certain vulnerable groups such as irregular migrants.

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One of the main findings and challenges of developing the report was the use of different terminologies to refer to refugees and migrants. Documents reviewed used different terms such as foreign born, foreign origin and immigrants to refer to refugees and migrants, making it impossible to differentiate outcomes among groups. If the target group for a study was clearly mentioned in the source article, it is reflected in the report.

In other instances, as indicated in Chapter 1 , the term refugees and migrant is used. Other issues that hamper analysis include differences in national surveillance systems; data confidentiality issues and gaps in existing data; methodology issues such as the geographical area studied and the size of the study population; and the lack of reliability in calculations of disease prevalence or incidence rates among refugee and migrant populations.

Best efforts have been made to identify and utilize in this report as much of the available information as possible to generate an overview of refugee and migrant health in the WHO European Region. The chapter begins with a description of the health profile of this population and then examines health care organization and delivery in the WHO European Region. Identified gaps in coverage and discrepancies are discussed plus the specific issues of achieving culturally sensitive health systems.

Data for this report were obtained from a scoping review of recent literature more than 13 documents, mainly since published in English and Russian and identified in the Cochrane Library, Embase, PubMed and Web of Science databases. Systematic literature reviews, grey literature and primary studies were also reviewed as were documents and data provided by some Member States and collaborators. Additional desk reviews were conducted when necessary. Although there is perhaps more information available in terms of migration and health with regard to communicable diseases than for other conditions or illnesses 18 , there are fewer studies on surveillance systems, which limit an understanding of the total impact of migration on European infectious disease epidemiology.

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  • Aggregated data do indicate that increased transmission of communicable diseases is often seen among refugees and migrants, but transmission from the refugee and migrant population to the host population is considered to be low and mostly related to poor living conditions and vaccination coverage gaps in the host population 19 — In terms of acute or newly acquired infections, refugees and migrants are generally at the same risk for respiratory and gastrointestinal diseases as other residents and travellers. However, circumstances encountered before, during and after displacement and migration can influence outcomes.

    Breakdown in health systems in the country of origin can lead to lack of immunization 23 , particularly in children, and poor living conditions in transit or at the destination country can create risks for acquiring infections, including vaccine-preventable diseases 19 , Living with poor sanitation and contaminated water before or during the migratory journey increases the risk for a variety of infections: bacterial, viral and parasitic Common skin and eye infections scabies and conjunctivitis and upper respiratory tract infections are often identified in refugees and migrants rescued at sea 26 — The proportion of HIV and TB cases attributed to the refugee and migrant population varies geographically across the Region, with those Member States with low endemic levels mostly western Member States showing a higher proportion of cases within the refugee and migrant population 30 , Detection and surveillance systems for imported infections are routine components of national health systems in the Region and are integrated into activities that support the International Health Regulations 21 , However, infections in those migrating have minimal public health implications for most host populations in the WHO European Region.

    Population mobility between and across areas of varying incidence and prevalence for many important infections may have epidemiological consequences for the public health systems of countries. The course of infectious diseases also varies, with some being latent or chronic. This may explain observations indicating that, in general, refugee and migrant populations in the Region can be disproportionately affected by TB, hepatitis B virus HBV infection, HIV infection and some tropical or parasitic infections e.

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    • For a variety of reasons, refugees and migrants may arrive in Europe with incomplete or interrupted immunization schedules 24 , thus leaving them vulnerable to vaccine-preventable diseases in transit 35 , 36 and destination countries and potentially creating a public health challenge for underimmunized or unvaccinated populations in the host countries. Factors such as language, cultural and economic barriers, and uncertain legal status can influence the vulnerability of refugees and migrants to vaccine-preventable diseases. For example, children who migrated to Germany were three times more likely to be unvaccinated against measles than host children 38 ; this lower coverage was also seen in Italy and Spain By comparison, migrant status had no effect on influenza vaccination status in older migrants or those at greater risk of influenza in Germany Diphtheria is a vaccine-preventable disease of potential concern as the majority of refugees and migrants arriving in Europe have come from countries where the disease is endemic and are likely to have been exposed to risk factors such as overcrowding and poor hygiene during transit or upon arrival In —, cases of diphtheria 25 with cutaneous diphtheria were reported among recently arrived refugees and asylum seekers in 12 countries Austria, Belgium, Finland, France, Germany, Latvia, Lithuania, the Netherlands, Norway, Spain, Sweden and the United Kingdom Similar to influenza vaccinations, migrant populations have been observed to have lower vaccination rates against human papillomavirus These differences have been attributed to factors such as integration and improved linguistic capacity over time.

      Migration and asylum

      The diverse nature of refugee and migrant populations coupled with differences in the duration, direction and conditions of their travel to the WHO European Region make it difficult to draw general conclusions about vaccination status and unmet needs. Given the safety of most modern immunizing agents, the immediate response to new arrivals is to ensure provision of the basic vaccines based on the immunization schedule of the country of their residence.

      In Member States with large resident refugee and migrant populations, modified national immunization schedules for those with interrupted or undocumented vaccination histories can provide general guidance to health care providers A WHO review found that only some Member States in the Region had a national immunization programme that considered refugees and migrants in the programme Fig. Immunization programmes are discussed further under Preventive care.

      TB presents a set of ambiguous symptoms and diagnosis is not always straightforward. Large disparities in national TB notification rates make it harder to assess the regional impact of migration-related TB.

      Refugees and migrants arriving from countries with high prevalence of TB are at greater risk of infection 49 but the epidemiological and health system impact is less apparent in countries with a high host prevalence Table 2. However, data detected so far suggest there is only a limited risk for the resident population Many factors contribute to the epidemiology of TB in refugees and migrants in the Region, including the prevalence of TB in origin and transit countries, the conditions experienced in transit and in reception centres, living and working conditions in the host country, latent TB infection, malnutrition and lack of access to health care The activation of latent infection following arrival in the host country is one of the main drivers of TB among refugees and migrants For this reason, countries that only recently became a destination for refugees and migrants may not observe the impact of activated disease for some time In addition, national health systems may not consistently record refugee or migrant status or the diagnosis of comorbidities.

      Rates of AMR are rising globally for diseases such as TB and there is concern that increased migration might contribute to this burden in Europe Box 2. Prevention and care measures for TB including cross-border TB control and care are discussed under Preventive care. Table 2. Proportions of TB cases attributed to people of foreign origin in the total population in selected countries. This has important implications for those HIV prevention programmes that are focused on pre-arrival risks.

      The proportion of HIV cases among refugees and migrants within the total population of a country also widely varies geographically across the WHO European Region Table 2. AMR occurs when microorganisms change in ways that render ineffective the medications used to cure their infections.

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      This is a major concern because a resistant infection may kill, can spread to others and imposes huge costs to individuals and society Rates of AMR are rising globally and there is concern that increased displacement and migration might contribute to the burden in Europe. Although surveillance for AMR in the WHO European Region is among the most advanced in the world, there are limited data available on the role of displacement and migration on the burden in the Region. Existing evidence suggests that refugees and migrants are exposed to conditions that are favourable for the development of AMR.

      A recent review found that the pooled prevalence of any carriage or infection with antimicrobial-resistant organisms was higher in refugees and asylum seekers The pooled prevalence of antibiotic-resistant organisms was slightly higher in community settings with large numbers of refugees and migrants, such as refugee camps and detention facilities The review did not find evidence of high rates of transmission of AMR from refugees and migrants to host populations. In addition to the need for improved living conditions, access to health care and initiatives to facilitate detection of and appropriate high-quality treatment for antibiotic-resistant infections during transit and in host countries, protocols to prevent and control AMR should include measures to address the challenges faced by refugees and migrants Proportions of migrants among total number of people living with HIV in selected countries.

      This indicates that migration-associated cases are predominantly regional as opposed to intercontinental in the eastern part of the WHO European Region. As for the general population, certain groups may have increased rates of infection In Europe, refugees and migrants are more likely to be diagnosed at a later stage of their HIV infection Reasons for this could be discrepancies and gaps in HIV prevention for refugees and migrants originating from countries with high HIV incidence; stigma and discrimination; migrant status and fear of administrative consequences; gaps in HIV testing services among refugees and migrants; and barriers to uptake and lack of understanding of service availability 35 , 62 , The process of displacement and migration can create additional vulnerable situations where infections can occur 64 , such as exposure to sexual violence with potential for transmission of sexually transmitted infections STIs 65 , substance abuse and secondary risk-taking behaviours linked to poverty, isolation and marginalization Prevalences of HBV and HCV in refugees and migrants have tended to reflect the prevalence of infection at their place of origin With the exception of migrants from eastern Europe and central Asia, chronic hepatitis B was more commonly observed in refugees than in migrant populations studied In particular, older migrants had increased risk, with a seroprevalence of anti-HCV antibodies of 2.

      HCV infection among refugees and migrants from countries of high endemicity ranged from 0. Evidence from western Europe suggested that refugees and migrants originating from regions of higher HBV prevalence had greater rates of chronic infection in some countries of destination Table 2. Some diseases are uncommon in the majority of countries of the WHO European Region, and those assessing and providing care for refugees and migrants should be familiar with the epidemiology and distribution of such diseases.

      Tropical and parasitic infections e. Lack of recognition, diagnosis and treatment of latent or chronic infection may be followed by more serious complications, including disseminated infection Shigellosis is often endemic in countries of origin or transit. Although shigellosis among refugees presents a very low threat to the total population in the Region, poor hygiene in refugee reception centres can put the refugee population at greater risk, as well as individuals working in these facilities Leishmaniasis and colonization with antibiotic-resistant Gram-negative bacteria are the most frequently reported infectious diseases in Syrian refugees and migrants in Europe, while scabies, louse-borne relapsing fever, Plasmodium vivax malaria and schistosomiasis are most frequently reported among Eritrean refugees and migrants A higher incidence of intestinal parasitic infections has been seen in migrant children compared with the host population in Italy The risk for re-emergence of malaria in Europe is attributed to people in transit from sub-Saharan Africa Risk of re-emergence of malaria is attributed to P.

      This was exemplified by the epidemic of malaria in Tajikistan in —, including re-establishment of Plasmodium falciparum malaria, which was linked to the influx of refugees and migrants from Afghanistan, as well as re-establishment of indigenous transmission of P. While accurate estimates of infections leading to Chagas disease are challenging, as many as cases of Chagas disease were identified in Europe in Global prevalence rates of infection in migrants from Latin America in Europe are around 4.

      Chagas disease poses the additional risk of blood-borne transmission, and countries hosting large migrant populations from endemic areas may consider introducing transfusion-related questions or screening of blood for transfusion 72 , For these diseases, health professionals also need to be aware that they can occur in travellers to destinations where these diseases are endemic, including refugees and migrants and their descendants later returning to the country of origin 34 , 43 , 73 , 74 , 81 — Results vary within studies on the influence that migration has on the NCD burden 6 — 9.

      In Spain and Denmark, the prevalence among refugees and migrants for NCDs such as cardiovascular diseases, stroke and cancer were either lower or similar to the host population.

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      Where it was lower over the first few years after arrival, prevalence seemed to converge over time with that of the host population 4 , 5. Box 2. In the adult population age 18—69 years , risk was low in 0. For men aged 18—69 years, In the age group 18—69 years, The prevalence of hypertension was This section provides an overview of NCDs that have received the most research attention for refugees and migrants in the WHO European Region and is followed by a section on mental health issues.

      Additionally, evidence from the Russian Federation seemed to indicate that obesity rates are higher in all groups of migrants living there compared with the non-migrant population Migrant girls in childhood or adolescence from north Africa are seen to have a higher prevalence of overweight and obesity than their male counterparts, reinforcing the observation that there is a gender difference for this health risk See also Obesity and diabetes in children.