Approximately 70,000-90,000 refugees are resettled to the United States each year, and during the next 5 years, 50,000 Congolese refugees are expected to arrive in the United States. The International Organization for Migration (IOM) performs refugee medical examinations overseas for the U.S. Refugee Resettlement Program. In 2014, IOM reported that a large number of U.S.-bound Congolese refugees from Uganda had spleens that were enlarged on examination. During two evaluations of refugee populations in western Uganda in March and July 2015, refugees with splenomegaly on physical examination were offered additional assessment and treatment, including abdominal ultrasonography and laboratory testing. Among 987 persons screened, 145 (14.7%) had splenomegaly and received further testing. Among the 145 patients with splenomegaly, 63.4% were aged 5-17 years (median = 14.8 years). There was some evidence of family clustering, with 33 (22.7%) of the 145 cases occurring in families.Overall, 144 of the 145 patients had abdominal ultrasonography, 122 (84.7%) of whom had massive splenomegaly (defined as >4 standard deviations above the local mean for splenic size, adjusted for height, based on the World Health Organization ultrasonography protocol) (1); 135 (93%) patients had normal liver architecture; and eight (5.5%) had hepatic nodules or masses. Specimens from 39 (26.9%) patients tested positive for malaria using rapid diagnostic testing; thin blood smear tests performed for all 145 cases were negative (thick films were not performed). Specimens from 134 (92.4%) patients were positive for Plasmodium falciparum merozoite surface protein 1 immunoglobulin G, indicating past exposure to P. falciparum. Specimens from three persons (2.1%) were positive for Schistosoma mansoni ova by stool wet preparation; no Schistosoma ova were detected in urine specimens. Enzymelinked immunosorbent assay (rK39 ELISA) tests for infection by Leishmania were negative for all patients; however, one (0.7%) patient was positive by serology. Specimens from five (3.5%) patients were positive for hepatitis B surface antigen, and 10 (6.9%) had detectable hepatitis C virus antibodies.Fewer than 33% of refugees had evidence of an active infection known to cause splenomegaly at the time of assessment (via positive malaria antigen, hepatitis B antigen, or Schistosoma ova). Low rates of serologic evidence of past or current leishmaniasis and hepatitis C eliminated these diseases as a common etiology. Although a definitive underlying etiology could not be determined, malariaassociated splenomegaly is one consideration: among potential infectious agents, malaria was the most prevalent, although active infection was found in less than one third of persons with splenomegaly. Malaria-associated splenomegaly is a diagnosis of exclusion and occurs following repeated malaria infections. The condition persists despite the absence of active parasitemia and usually resolves within 6 months after antimalarial treatment if subsequent malaria exposure can be prevented (...
Hepatitis B virus (HBV) vaccination patterns and the understanding of its risks among healthcare workers (HCWs) is a critical step to decrease transmission. However, the depth of this understanding is understudied. We distributed surveys to HCWs in 12 countries in Africa. Surveys had nine multiple-choice questions that assessed HCWs' awareness and understanding of HBV. Participants included consultants, medical trainees, nurses, students, laboratory personnel, and other hospital workers. Surveys were completed anonymously. Fisher's exact test was used for analysis, with a P-value of < 0.05 considered significant; 1,044 surveys were collected from Kenya,
In 2014, panel physicians from the International Organization for Migration (IOM), who conduct Department of State–required predeparture examinations for U.S.-bound refugees at resettlement sites in Uganda, noticed an unusually high number of Congolese refugees with enlarged spleens, or splenomegaly. Many conditions can cause splenomegaly, such as various infections, liver disease, and cancer. Splenomegaly can result in hematologic disturbances and abdominal pain and can increase the risk for splenic rupture from blunt trauma, resulting in life-threatening internal bleeding. On CDC’s advice, panel physicians implemented an enhanced surveillance and treatment protocol that included screening for malaria (through thick and thin smears and rapid diagnostic testing), schistosomiasis, and several other conditions; treatment of any condition identified as potentially associated with splenomegaly; and empiric treatment for the most likely etiologies, including malaria and schistosomiasis. CDC recommended further treatment for malaria with primaquine after arrival, after glucose-6-phosphate dehydrogenase testing, to target liver-stage parasites. Despite this recommended treatment protocol, 35 of 64 patients with available follow-up records had splenomegaly that persisted beyond 6 months after resettlement. Among 85 patients who were diagnosed with splenomegaly through abdominal palpation or ultrasound at any point after resettlement, 53 had some hematologic abnormality (leukopenia, anemia, or thrombocytopenia), 16 had evidence of current or recent malaria infection, and eight had evidence of schistosomiasis. Even though primaquine was provided to a minority of patients in this cohort, it should be provided to all eligible patients with persistent splenomegaly, and repeated antischistosomal therapy should be provided to patients with evidence of current or recent schistosomiasis. Given substantial evidence of familial clustering of cases, family members of patients with known splenomegaly should be proactively screened for this condition.
Background Many of the factors that increase risk of child marriage are common among refugees and internally displaced persons (IDPs). We sought to address the gaps in knowledge surrounding child marriage in displaced and host populations in the Kurdistan Region of Iraq (KRI). Methods A multistage cluster sample design was employed collecting data of KRI host communities, Iraqi IDPs, and Syrian refugees. Interviews were conducted in eligible households, requiring at least one adult female and one female adolescent present, addressing views of marriage, demographics and socioeconomic factors. Household rosters were completed to assess WHO indicators, related to child marriage including completed child marriage in females 10–19 and completed risk of previously conducted child marriages in females 20–24. Results Interviews were completed in 617 hosts, 664 IDPs, and 580 refugee households, obtaining information on 10,281 household members and 1,970 adolescent females. Overall, 10.4% of girls age 10–19 were married. IDPs had the highest percentage of married 10–19-year-old females (12.9%), compared to the host community (9.8%) and refugees (8.1%). Heads of households with lower overall education had higher percentages of child marriage in their homes; this difference in prevalence was most notable in IDPs and refugees. When the head of the household was unemployed, 14.5% of households had child marriage present compared to 8.0% in those with employed heads of household. Refugees and IDPs had larger percentages of child marriage when heads of households were unemployed (refugees 13.1%, IDPs 16.9%) compared to hosts (11.9%). When asked about factors influencing marriage decisions, respondents predominately cited family tradition (52.5%), family honor (15.7%), money/resources (9.6%), or religion (8.0%). Over a third of those interviewed (38.9%) reported a change in influencing factors on marriage after displacement (or after the arrival of refugees in the area for hosts). Conclusions Being an IDP in Iraq, unemployment and lower education were associated with an increase in risk for child marriage. Refugees had similar percentages of child marriage as hosts, though the risk of child marriage among refugees was higher in situations of low education and unemployment. Ultimately, child marriage remains a persistent practice worldwide, requiring continued efforts to understand and address sociocultural norms in low socioeconomic and humanitarian settings.
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