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

Abstract

Background

Information regarding the prevalence of infectious diseases (IDs) in child and adolescent refugees in Europe is scarce. Here, we evaluate a standardized ID screening protocol in a cohort of unaccompanied refugee minors (URMs) in a municipal region of southwest Germany.

Methods and findings

From January 2016 to December 2017, we employed a structured questionnaire to screen a cohort of 890 URMs. Collecting sociodemographic information and medical history, we also performed a standardized diagnostics panel, including complete blood count, urine status, microbial stool testing, tuberculosis (TB) screening, and serologies for hepatitis B virus (HBV) and human immunodeficiency virus (HIV). The mean age was 16.2 years; 94.0% were male, and 93.6% originated from an African country. The most common health complaints were dental problems (66.0%). The single most frequent ID was scabies (14.2%). Of the 776 URMs originating from high-prevalence countries, 7.7% and 0.4% tested positive for HBV and HIV, respectively. Nineteen pathogens were detected in a total of 119 stool samples (16.0% positivity), with intestinal schistosomiasis being the most frequent pathogen (6.7%). Blood eosinophilia proved to be a nonspecific criterion for the detection of parasitic infections. Active pulmonary TB was identified in 1.7% of URMs screened. Of note, clinical warning symptoms (fever, cough >2 weeks, and weight loss) were insensitive parameters for the identification of patients with active TB. Study limitations include the possibility of an incomplete eosinophilia workup (as no parasite serologies or malaria diagnostics were performed), as well as the inherent selection bias in our cohort because refugee populations differ across Europe.

Conclusions

Our study found that standardized ID screening in a URM cohort was practicable and helped collection of relevant patient data in a thorough and time-effective manner. However, screening practices need to be ameliorated, especially in relation to testing for parasitic infections. Most importantly, we found that only a minority of infections were able to be detected clinically. This underscores the importance of active surveillance of IDs among refugees.

Abstract

Ales Janda and colleagues report on screening for infectious diseases in a cohort of unaccompanied refugee minors in Germany.

Author summary

Why was this study done?

• Unaccompanied refugee minors (URMs)—refugees under 18 years of age who migrate without being accompanied by a parent or a custodian—belong to the most vulnerable subgroup of refugees.

• Little is known about the prevalence and clinical presentation of infectious diseases (IDs) among pediatric refugees or URMs in particular.

• A better understanding of the frequency and clinical presentation of IDs among minor refugees is of high priority in order to improve their healthcare and develop more effective ID screening strategies for this population.

What did the researchers do and find?

• We evaluated a systematic ID screening algorithm for refugee minors among a cohort of 890 URMs in a municipal area located in southwest Germany during 2016–2017.

• We found scabies to be the most prevalent ID (present in 14.2% of URMs), whereas active tuberculosis and human immunodeficiency virus (HIV) infection were of relatively low prevalence (1.7% and 0.4%, respectively).

• Parasite screening through serial stool investigations of patients with eosinophilia had a low diagnostic yield yet was associated with significant costs and logistic challenges.

• In general, most of the diagnosed chronic infections among URMs were not detected clinically.

What do these findings mean?

• Among refugees, ID screening needs to be performed independently of clinical complaints because most infections cause nonspecific symptoms or are asymptomatic.

• Moving forward, ID screening among refugees urgently needs to be standardized across Europe, including the implementation of digital health records that are easily accessible to healthcare providers across all transit countries.