Abstract:Shigellosis is endemic in most developing countries and thus a known risk in refugees and internally displaced persons. In 2015, a massive influx of refugees into Greece, due to the political crisis in the Middle East, led to the development of appropriate conditions for outbreaks of communicable diseases as shigellosis. We present a cluster of 16 shigellosis cases in refugees, detected by the implementation of a syndromic notification system in one transit centre in Athens, between 20 August and 7 October 201… Show more
“…After removal of duplicates, 2274 articles were screened for eligibility, of which 376 were included in the full-text screening ( figure 1 ). 23 articles 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 reporting on antibiotic resistance in 2319 migrants met the inclusion criteria and were included in the systematic review; 15 articles reporting prevalence data on AMR in migrants were included in the main meta-analysis ( table 1 ). Figure 1 Study selection …”
SummaryBackgroundRates of antimicrobial resistance (AMR) are rising globally and there is concern that increased migration is contributing to the burden of antibiotic resistance in Europe. However, the effect of migration on the burden of AMR in Europe has not yet been comprehensively examined. Therefore, we did a systematic review and meta-analysis to identify and synthesise data for AMR carriage or infection in migrants to Europe to examine differences in patterns of AMR across migrant groups and in different settings.MethodsFor this systematic review and meta-analysis, we searched MEDLINE, Embase, PubMed, and Scopus with no language restrictions from Jan 1, 2000, to Jan 18, 2017, for primary data from observational studies reporting antibacterial resistance in common bacterial pathogens among migrants to 21 European Union-15 and European Economic Area countries. To be eligible for inclusion, studies had to report data on carriage or infection with laboratory-confirmed antibiotic-resistant organisms in migrant populations. We extracted data from eligible studies and assessed quality using piloted, standardised forms. We did not examine drug resistance in tuberculosis and excluded articles solely reporting on this parameter. We also excluded articles in which migrant status was determined by ethnicity, country of birth of participants' parents, or was not defined, and articles in which data were not disaggregated by migrant status. Outcomes were carriage of or infection with antibiotic-resistant organisms. We used random-effects models to calculate the pooled prevalence of each outcome. The study protocol is registered with PROSPERO, number CRD42016043681.FindingsWe identified 2274 articles, of which 23 observational studies reporting on antibiotic resistance in 2319 migrants were included. The pooled prevalence of any AMR carriage or AMR infection in migrants was 25·4% (95% CI 19·1–31·8; I2 =98%), including meticillin-resistant Staphylococcus aureus (7·8%, 4·8–10·7; I2 =92%) and antibiotic-resistant Gram-negative bacteria (27·2%, 17·6–36·8; I2 =94%). The pooled prevalence of any AMR carriage or infection was higher in refugees and asylum seekers (33·0%, 18·3–47·6; I2 =98%) than in other migrant groups (6·6%, 1·8–11·3; I2 =92%). The pooled prevalence of antibiotic-resistant organisms was slightly higher in high-migrant community settings (33·1%, 11·1–55·1; I2 =96%) than in migrants in hospitals (24·3%, 16·1–32·6; I2 =98%). We did not find evidence of high rates of transmission of AMR from migrant to host populations.InterpretationMigrants are exposed to conditions favouring the emergence of drug resistance during transit and in host countries in Europe. Increased antibiotic resistance among refugees and asylum seekers and in high-migrant community settings (such as refugee camps and detention facilities) highlights 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...
“…After removal of duplicates, 2274 articles were screened for eligibility, of which 376 were included in the full-text screening ( figure 1 ). 23 articles 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 reporting on antibiotic resistance in 2319 migrants met the inclusion criteria and were included in the systematic review; 15 articles reporting prevalence data on AMR in migrants were included in the main meta-analysis ( table 1 ). Figure 1 Study selection …”
SummaryBackgroundRates of antimicrobial resistance (AMR) are rising globally and there is concern that increased migration is contributing to the burden of antibiotic resistance in Europe. However, the effect of migration on the burden of AMR in Europe has not yet been comprehensively examined. Therefore, we did a systematic review and meta-analysis to identify and synthesise data for AMR carriage or infection in migrants to Europe to examine differences in patterns of AMR across migrant groups and in different settings.MethodsFor this systematic review and meta-analysis, we searched MEDLINE, Embase, PubMed, and Scopus with no language restrictions from Jan 1, 2000, to Jan 18, 2017, for primary data from observational studies reporting antibacterial resistance in common bacterial pathogens among migrants to 21 European Union-15 and European Economic Area countries. To be eligible for inclusion, studies had to report data on carriage or infection with laboratory-confirmed antibiotic-resistant organisms in migrant populations. We extracted data from eligible studies and assessed quality using piloted, standardised forms. We did not examine drug resistance in tuberculosis and excluded articles solely reporting on this parameter. We also excluded articles in which migrant status was determined by ethnicity, country of birth of participants' parents, or was not defined, and articles in which data were not disaggregated by migrant status. Outcomes were carriage of or infection with antibiotic-resistant organisms. We used random-effects models to calculate the pooled prevalence of each outcome. The study protocol is registered with PROSPERO, number CRD42016043681.FindingsWe identified 2274 articles, of which 23 observational studies reporting on antibiotic resistance in 2319 migrants were included. The pooled prevalence of any AMR carriage or AMR infection in migrants was 25·4% (95% CI 19·1–31·8; I2 =98%), including meticillin-resistant Staphylococcus aureus (7·8%, 4·8–10·7; I2 =92%) and antibiotic-resistant Gram-negative bacteria (27·2%, 17·6–36·8; I2 =94%). The pooled prevalence of any AMR carriage or infection was higher in refugees and asylum seekers (33·0%, 18·3–47·6; I2 =98%) than in other migrant groups (6·6%, 1·8–11·3; I2 =92%). The pooled prevalence of antibiotic-resistant organisms was slightly higher in high-migrant community settings (33·1%, 11·1–55·1; I2 =96%) than in migrants in hospitals (24·3%, 16·1–32·6; I2 =98%). We did not find evidence of high rates of transmission of AMR from migrant to host populations.InterpretationMigrants are exposed to conditions favouring the emergence of drug resistance during transit and in host countries in Europe. Increased antibiotic resistance among refugees and asylum seekers and in high-migrant community settings (such as refugee camps and detention facilities) highlights 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...
“…Our concern is that in refugee camps, alternative means of investigating a case may not be readily available. Interviewing a patient or their family is often used in other situations, but this may not be accurate in a refugee camp as refugees may not wish to disclose symptoms [ 14 ]. Furthermore, the extent to which refugees who are migrating through Europe can be traced so that information can be verified is unknown.…”
Section: Discussionmentioning
confidence: 99%
“…However, there is some evidence to suggest that these assessments may be especially difficult to achieve in a refugee camp. For example, an investigation of a shigellosis outbreak in a refugee camp in Greece may have underestimated the outbreak size due to difficulties in language, under-diagnosis of cases with mild symptoms, or denial of symptoms from patients unwilling to risk a delay to departure from the refugee camp [ 14 ].…”
BackgroundRefugees may have an increased vulnerability to infectious diseases, and the consequences of an outbreak are more severe in a refugee camp. When an outbreak is suspected, access to clinical information is critical for investigators to verify that an outbreak is occurring, to determine the cause and to select interventions to control it. Experience from previous outbreaks suggests that the accuracy and completeness of this information is poor. This study is the first to assess the adequacy of clinical characterisation of acute medical illnesses in refugee camps. The objective is to direct improvements in outbreak identification and management in this vulnerable setting.MethodsWe collected prospective data in 13 refugee camps in Greece. We passively observed consultations where patients presented with syndromes that might warrant inclusion into an existing syndromic surveillance system and then undertook a structured assessment of routine clinical data collection to examine the extent to which key clinical parameters required for an outbreak response were ascertained and then documented.ResultsA total of 528 patient consultations were included. The most common presenting condition was an acute respiratory illness. Clinicians often made a comprehensive clinical assessment, especially for common syndromes of respiratory and gastrointestinal conditions, but documented their findings less frequently. For fewer than 5% of patients were a full set of vital signs ascertained and so the severity of patient illnesses was largely unknown. In only 11% of consultations was it verified that a patient who met the case criteria for syndromic surveillance reporting based on an independent assessment was reported into the system.DiscussionOpportunities exist to strengthen clinical data capture and recording in refugee camps, which will produce a better calibrated and directed public health response.ConclusionInformation of significant utility for outbreak response is collected at the clinical interface and we recommend improving how this information is recorded and linked into surveillance systems.Electronic supplementary materialThe online version of this article (10.1186/s12916-018-1015-9) contains supplementary material, which is available to authorized users.
“…An investigation of a shigellosis outbreak in a refugee camp in Greece showed that the outbreak size was underestimated due to difficulties in language, under-diagnosis of cases with mild symptoms, or denial of symptoms from patients unwilling to risk a delay in departure [96]. In addition, it was reported that a full set of vital signs were measured in fewer than 5% of patients; thus, the severity of the disease remained largely unknown [28,76].…”
Section: The Refugee Crisis Challenges the Greek Healthcare Systemmentioning
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.
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