what happens to refugees once they arrive in europe

Visc Med. 2017 Aug; 33(four): 295–300.

Migrants and Refugees in Europe: Challenges, Experiences and Contributions

Tobias Schilling

^aInterdisciplinary Emergency Department, Katharinenhospital Stuttgart, Stuttgart, Deutschland

Stephan Rauscher

^aInterdisciplinary Emergency Section, Katharinenhospital Stuttgart, Stuttgart, Germany

Christian Menzel

^aInterdisciplinary Emergency Department, Katharinenhospital Stuttgart, Stuttgart, Federal republic of germany

Simon Reichenauer

^aInterdisciplinary Emergency Section, Katharinenhospital Stuttgart, Stuttgart, Frg

Martina Müller-Schilling

^bDepartment of Internal Medicine I, University Hospital Regensburg, Regensburg, Germany

Stephan Schmid

^bDepartment of Internal Medicine I, Academy Hospital Regensburg, Regensburg, Germany

Michael Selgrad

^bDepartment of Internal Medicine I, University Infirmary Regensburg, Regensburg, Frg

Abstruse

Due to the current geopolitical situation more refugees from crisis countries were and will be treated in Europe. In 2015 the number of displaced people reached an unprecedented level, with more than one million crossing into Europe. The migration itself tin can impair both mental and physical wellness. Therefore, the provision of medical care for refugees and migrants is a novel and major challenge for the wellness care systems in Europe. In this commodity nosotros describe our experiences and contribution in providing medical intendance for refugees who have newly arrived in Stuttgart, Baden-Wuerttemberg, Germany. Furthermore, nosotros report our experiences from a tertiary referral University center in Regensburg, Bavaria, Federal republic of germany. We focus on challenges in both the outpatient and the inpatient setting, with a special focus on intensive care patients. In improver, we provide an overview well-nigh the spectrum of diseases in this specific patient accomplice.

Keywords: European refugee crisis, Displaced people, Refugees, Migrants, Migration, Health intendance, Wellness problems

Introduction

Due to the geopolitical situation the number of refugees and migrants in Europe has increased in the by years. On a global scale, the number of migrants worldwide has reached 244 million in 2015, which represents iii% of the earth population [1]. The European Union (Eu) comprises 28 member states, and in 2014 3.8 1000000 people migrated to the EU, with most of them, i.east. 1.9 million refugees, being from non-member countries [2]. In 2015 over 65 one thousand thousand people migrated, with more half of them originating from war-torn countries such equally Syria, Transitional islamic state of afghanistan, and Somalia. Especially, the countries in the southeast of Europe were confronted with waves of refugees; due east.thou., about one one thousand thousand migrants crossed the Greek border in 2015 [3].

Migration itself does not count equally a take a chance cistron for health, but the circumstances of migration are frequently associated with concrete, mental and social health disorders. Furthermore, refugees and migrants come from very different regions to Europe; therefore, the range of expectable diseases and health problems varies considerably.

Information technology is well known that the bloodshed and morbidity pattern of foreign-born individuals living in the Eu varies widely among different population groups compared with the native population [4, 5]. The state of origin and the local epidemiology are important factors when considering diseases in newly arrived migrants and refugees. Although the likelihood is low that certain infectious diseases will occur amongst migrants, they should all the same exist considered in order to brand sure that infectious diseases are diagnosed timely to control the chance of disease spread [6, 7, 8, 9].

There is a considerable burden of communicable and non-catching disease amidst newly arrived refugees and migrants.

In this review, we focus on specific aspects of medical intendance for newly arrived migrants and refugees in Europe. Nosotros study our experience in providing health care at reception of large cohorts of refugees in 2015 and in building upwardly reception centers in a multidisciplinary team, besides as our experience in inpatient care.

Specific Challenges during Early Settlement in a Reception Center in Stuttgart, Germany

The arrival of large numbers of refugees within a short time period is a challenge for the medical system in its entirety. Health intendance should be provided by a multidisciplinary squad in coordination with the local health intendance systems and other organizations.

We depict our experiences from a big community hospital in Stuttgart, Germany, in the summer and autumn of 2015. On a Sunday in Baronial 2015, the staff of the emergency department was notified that a reception heart had been established that day in a local concert and sports hall housing around 500 refugees, mostly from Syria and Afghanistan. The refugees had travelled via the Balkan route and were transferred to Stuttgart from the Austrian border in buses. Immediately later the arrival in the reception centre, the first patients were transported to our emergency section, and within the first 24 h ambulance services and general practitioners were constantly chosen to the newly established reception eye. Nosotros realized presently that health treat refugees and asylum seekers should be based on a holistic approach, including early wellness cess and management of communicable and non-communicable diseases, such as chronic diseases equally well as mental and social bug, including the provision of ongoing intendance. The following obstacles for the establishment of an inclusive and culturally sensitive health organisation were encountered in our emergency department:

– Communication with the patients was difficult or impossible as almost of them spoke neither German language nor English. Translators had to exist organized, and waiting times for translators amounted sometimes to several hours.
– Furthermore, to ensure efficient communication, cultural mediators and interpreters had to be identified and integrated in the medical care team.
– Triage had to be organized to prioritize patients with acute illness - both physical and mental -, in particular for sensitive patient groups, i.due east. children, unaccompanied minors, pregnant women, and the elderly.
– The funding of the medical intendance for refugees was backed by local government; however, the requirements for documentation and billing were completely different from other patients and therefore caused an actress workload for the emergency department.
– Prescribing medications as usual was impossible as most refugees could not obtain the medication with a prescription from local pharmacies due to a lack of health insurance and coin.
– Afterward having received handling, patients that had arrived by ambulance did non know how to render to the refugee centre as they had neither money nor knowledge of the identify to utilize public transport systems.

We realized soon that treating these patients in the emergency section was very inefficient. Therefore, nosotros organized consultation hours in the refugee center with physicians from our infirmary and medical assistance from the volunteers of the Club of Saint John and the German language Red Cross. All of the physicians were volunteers - not only from our emergency department merely also from other departments of our hospital. Thus, nosotros established a multidisciplinary squad, recruiting interpreters, cultural mediators, and social workers in guild to coordinate care provision and follow-up amidst various providers in the refugee center. This resulted in an most firsthand comeback of the medical state of affairs and marked a starting betoken of an inclusive and culturally sensitive wellness care immediately afterward inflow in the refugee center.

As soon every bit these medical consultation services were established in the refugee camp, the number of calls of ambulance services and the number of patients that presented themselves to the emergency department dropped to almost null while nosotros saw upwards to 50 patients in the refugee camp every day (fig. i).

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Reduction of the ambulance emergency services and the number of patients that presented themselves to the emergency room (ER) at the hospital afterward installation of a daily dr. consultation service at the refugee camp.

Most of the patients could be treated sufficiently in the military camp. We were confronted with airway infections, small wounds, pain caused by old battlefield injuries also as scabies and lice. A modest proportion of the patients was sent to hospital outpatient clinics or to practitioners (by and large dentists and gynecologists), if the treatment could not exist organized directly in the heart.

Apart from some cases of suspected tuberculosis (TB), we saw near no serious medical conditions or major traumatic injuries that required in-infirmary emergency treatment. This was probably due to the fact that refugees who started the long journey to Europe were by and large in a good medical condition and those who acquired serious diseases or trauma during the journey had already been identified and had received medical treatment in Austria or in Bavaria close to the Austrian border.

Furthermore, advice with the patients in the refugee middle was much easier because other refugees - in add-on to the interpreters in our team - volunteered to translate from the mother tongue of the patient to English.

In addition, we organized the supply of medications from a chemist's close by which delivered the prescribed medications already 'individualized' and labelled with the name of the patient and with a finely tuned medication regimen included.

Later on a few days of rest in the eye nigh of the refugees recovered and the number of refugees needing medical care decreased. Especially diseases that are related to poor hygienic conditions during the journeying, such equally scabies or lice, almost disappeared afterwards ii–iii weeks.

During the autumn of 2015, several other refugee centers were established in Stuttgart to accommodate up to 2,500 people. Due to our skillful experiences with immediate-onset consultation hours in the first centre, we established consultation hours in all other camps upon arrival of the refugees and migrants. As a result, we were able to provide instant intendance and to efficiently coordinate intendance provision and follow-up amidst various other providers and settings. Equally the need for medical care was but very high at the beginning, i.due east. directly after the arrival of the refugees in Frg, and decreased during the following weeks and equally the number of refugees in the camps declined, information technology was possible to integrate the refugees into our public health system. Thus, the consultation hours in the centers could exist terminated after half-dozen months and had non only provided immediate and efficient care for the arriving migrants and refugees only likewise generated a holistic approach that resulted in the integration of the refugees in our public wellness organization.

In conclusion, intersectoral collaboration is important to run across the different needs of this special patient population, multidisciplinary teams have to exist formed, and newly arrived migrants should receive an immediate health reception or welcome in the refugee center. All post-obit medical actions and interventions should be coordinated from the local refugee middle, and all services and providers that were involved in the treatment of refugees demand to exist informed almost special characteristics of refugee care: communication, mental and concrete care, ship logistics, supply of medications, and requirements for documentation and billing.

Specific Communicable and Not-Communicable Diseases and Challenges

Different aspects need to be considered when analyzing the migration process regarding infectious diseases, e.chiliad. the country of origin, the period from the move to first arrival, settlement in refugee camps/other reception sites, and resettlement.

Wellness Issues during Travel and First Arrival

The elapsing of the migration status can have a meaning bear on on the health of migrants and refugees. The most common health problems may exist related to problems in their home countries and the journey, representing a variety of diseases including accidental injuries, gynecological and obstetric complications, dermatological diseases, cardiovascular events, gastrointestinal and respiratory problems, and mental illness [10, 11]. Available evidence underlines that infectious diseases are not a wellness priority at commencement arrival [12, 13, fourteen]. A very recent work from Germany assessed the health status of 214 aviary seekers, and the main wellness problem was psychological illness while the prevalence of infectious and chronic diseases was depression [fifteen]. Withal, vulnerable groups (children and elderly), considering that they spent long periods on their journey, are decumbent to respiratory and gastrointestinal infections and dermatological diseases (scabies) due to poor aseptic too every bit living weather [12, 16]. A farther important challenge is due to gender-specific problems, such equally maternal, reproductive issues and admission to contraception. Furthermore, female refugees are at high risk of sexual corruption and pregnancy due to poor admission to contraception [17]. Nutritional problems, exposure to violence, and possible drug and alcohol abuse may increase the run a risk for non-communicable diseases [18]. Therefore, access to preventive wellness intendance (screening) too as prenatal and obstetric intendance is mandatory and crucial for refugees and migrants subsequently showtime inflow.

Wellness Bug in Refugee Camps and Other Reception Sites

'The relation between migration and infectious disease is complicated', is stated in an editorial in The Lancet Infectious Diseases from 2016, and 'there is no systematic clan between migration and importation of infectious diseases' [xix]. The World Health Organisation (WHO) does non recommend compulsory mass screening of refugees. However, the WHO does recommend health checks for both infectious diseases and not-catching diseases. Screening programs should be rationalized and evidence-based and address newly arrived refugees from countries with a big disease burden. Particularly, assessment of immunization status might be important to reduce the risk of outbreaks. In an attempt to constitute more testify for health assessment and health care, a new initiative between Cochrane, Wiley, Kevin Pottie, Leo Ho, and Evidence Aid identified some of the most relevant medical conditions equally perceived past experts who have been involved either in guideline evolution or 'on the frontline', thus straight addressing the needs of refugees and asylum seekers [20]. In the first instance, the collaboration decided on the following priority conditions to be addressed:

– Common mental health disorders (including posttraumatic stress disorder (PTSD) and depression): PTSD is highly prevalent in children and adolescents who have experienced trauma and is associated with high personal and health costs. In particular, newly arrived people present with anxiety disorders, depression, alcoholism, and drug abuse equally a consequence of traumatic experiences related to war, dislocation, and physical and sexual abuse.
– Vaccine-preventable diseases: Well-documented outbreaks of vaccine-preventable diseases among migrants and refugees such as measles or varicella have been reported [21]. Thus, access to vaccination is of prime importance. Co-ordinate to the WHO, vaccinations may include: measles, mumps, and rubella (for children below 15 years); poliomyelitis for children and adults from countries exporting poliovirus; meningococcal illness; tetanus, pertussis, and diphtheria; and influenza depending on the season [22].
– Skin atmospheric condition (including impetigo, scabies, and cellulitis): Skin infections are common amongst those forcibly displaced, as they have to endure inadequate shelter and sanitation while travelling or in crowded reception centers. Vector-borne diseases such every bit lice-, flea- and mite-transmitted infections are mutual under conditions with poor hygienic standards.
– TB: Refugees and asylum seekers are at higher take chances of getting infected or developing TB, depending on the TB incidence in their country of origin and poor access to health services during migration. Early diagnosis and effective handling should exist provided by the countries receiving these people.
– Sexual and physical violence: Women are at loftier hazard for sexual and concrete violence equally well every bit gender-based violence.

One of the most important factors because infectious diseases are the state of origin and the local epidemiology. According to the WHO, screening of migrants for diseases is not obligatory. Withal, screening for defined diseases such equally latent TB, viral hepatitis, and intestinal parasites in high-gamble groups was shown to be cost-effective [23, 24].

The most common disease screened in Eu countries is TB [25]. Others include homo immunodeficiency virus (HIV), hepatitis B, hepatitis C, and, to a bottom extent, sexually transmitted diseases and vaccine-preventable diseases.

Pulmonary TB represents the disease with the greatest concerns. Syrian arab republic, Iraq, Afghanistan, Eritrea, and Somalia are the most common countries of migrants and refugees coming to the EU, with an incidence of TB varying from 17 new cases per 100,000 in Syria upward to 499 per 100,000 in Eritrea [26]. The boilerplate TB rate in the European union is 39 per 100,000 inhabitants [27]. In this context, a recent systematic review of 51 studies on crisis-affected populations described a twenty-fold increment of TB cases amongst them [28]. Therefore, a rapid and efficient clinical evaluation of refugees and migrants after arrival is mandatory. Because the cardinal symptoms of TB (fever, cough of at least 2 weeks' duration, weight loss, nighttime sweats), the majority of individuals at risk tin exist identified and should be referred to a hospital for assessment and early handling initiation. In a population-based cross-exclusive study, Aldridge et al. [29] screened 476,455 visa applicants in the UK for TB, and migrants reporting contact with an private with TB had the highest risk of TB at pre-entry screening. Equally a consequence, the authors telephone call for a comprehensive and collaborative approach between countries with pre-entry screening programs besides equally wellness services in the countries of origin and migration to tackle the affliction [29].

Wellness Problems later Resettlement

Afterwards resettlement, chronic infections come to the fore that have already been acquired in the country of origin. The nigh of import infections according to current testify are infections with HIV, chronic viral hepatitis, Helicobacter pylori, and other chronic parasitic infections. For these atmospheric condition, knowledge of the prevalence of the infection in the country of origin is mandatory.

The prevalence of HIV in the v almost common countries of origin of refugees and migrants is relatively low; however, 35% of new HIV cases in the Eu are owing to migrants [27, thirty]. Interestingly, current show shows that HIV is oft caused in the postal service-migration phase in the Eu [31]. This underlines the importance of education and prevention.

Chronic hepatitis B shows the highest seroprevalence rate among migrants and refugees. This especially accounts for people from East asia and sub-Saharan Africa (HBsAg-positive > 10%) [32]. For hepatitis C, a recent systematic review and meta-analysis including information from 38,635 migrants revealed a seroprevalence of 1.nine% among migrants from all world regions. Older age and region of origin, especially sub-Saharan Africa, Asia, and Eastern Europe, were the strongest predictors of HCV seroprevalence reaching more than ii% [33].

Refugees and immigrants from developing countries settling in industrialized countries have a loftier prevalence of H. pylori and therefore an increased risk for the evolution of H. pylori-associated complications such as peptic ulcer disease and gastric cancer [34]. A contempo piece of work demonstrated that screening for H. pylori in migrants and refugees is toll-constructive and has the potential to reduce the take chances of gastric cancer and peptic ulcer disease [35].

Experiences from a Medical Intensive Care Unit at a Academy Medical Center of Tertiary Care in Eastern Bavaria

Comprehensive information on migrant and refugee health in the intensive intendance setting is rare in the current literature. Ane written report from Turkey reported that refugees presented to intensive care units (ICUs) with common infections (pneumonia and urinary tract infections), but had high mortality rates [36].

As stated higher up, most refugees with very serious diseases were identified in reception centers near the border between Bavaria and Austria. These patients were admitted to local hospitals.

Defined patients in life-threatening weather condition were transferred to our medical ICU at the University Hospital Regensburg, Germany.

Birthday, v refugees in very severe medical conditions were treated at our ICU from the summertime of 2015 until the bound of 2016. All patients were male and aged less than 50 years. They originated from the Middle East and/or North Africa. Many of the patients needed mechanical ventilation and/or the use of vasopressors to maintain circulation.

Notably, all of the patients suffered from previously undiagnosed chronic diseases (e.g. liver cirrhosis, lymphoma, AIDS) aggravated past common infections, which were caused during the long and troublesome journey.

All patients presented with sepsis or septic shock generally due to pneumonia. Although all patients were isolated equally a precaution according to the local recommendations, microbiological analyses showed no multidrug-resistant bacteria.

Despite the different native languages of the patients, communication could be ensured at all times with the help of translators (generally volunteers amid our employees), who could be contacted at whatever time via a volunteer service in our hospital. All relatives of the patients were closely involved in the treatment by our interprofessional team of the ICU.

Taken together, refugees treated at our ICU presented with infections similar to the host population (pneumonia and urinary tract infections), which is in line with the current literature [14, 36].

In conclusion, migrants with non-infectious disease may exist more than vulnerable every bit a result of the difficult conditions during their journey. On the one hand, displacement results in the interruption of continuous care that is essential for the direction of chronic diseases. On the other manus, every bit with our patients on the intensive care ward, the diagnosis of chronic, non-communicable disease had not been established due to lack of access or decimation of health care systems in their country of origin.

Overall, 51% of refugees study chronic disease [37]. In line with communicable diseases, the state of origin accounts for specific epidemiologic profiles besides for non-communicable diseases. Diabetes mortality rates are college in migrants from Due north Africa, the Caribbean, and Southern asia [17, 22, 38]. Migrants from West Africa have a higher incidence of cerebrovascular illness, and those originating from Transitional islamic state of afghanistan, Iraq, and Due north Africa suffer more often from coronary heart disease [5, 17, 39]. Migrants accept a higher risk for cancers that are related to infections, such as hepatocellular carcinoma, cervical cancer, and gastric cancer [forty, 41].

Conclusion

– Involuntary migration is a global claiming.

– The number of displaced people reached an unprecedented level at a total of 60 meg people worldwide in 2015. For a better understanding, table 1 gives an overview virtually definitions of the terms aviary seeker, migrant, and refugee [42, 43, 44].

Table i

Definitions of the terms asylum seeker, migrant, and refugee

Aviary seeker	An individual who is seeking international protection and sanctuary in a country other than the one of his/her usual settlement. Not every asylum seeker volition ultimately exist recognized as a refugee, but every refugee is initially an asylum seeker.

Migrant	There is no universally accepted definition of the term 'migrant'. Migrants may remain in the habitation land or host country, move on to another country, or move back and forth between countries.

Refugee	A person who, owing to well-founded fear of persecution for reasons of race, organized religion, nationality, membership of a detail social group, or political opinions, is outside the land of his/her nationality and is unable or, attributable to such fright, is unwilling to avail himself/herself of the protection of that land.

– In 2015, more than ane million people crossed into Europe.
– The continuing migration waves create economic and social as well every bit health-related challenges for the host countries.
– The brunt of hosting large populations of displaced people requires improved coordination and cooperation by European countries.
– A long-term solution for the refugee crunch is to undertake all efforts in club to reduce the socioeconomic and health inequalities that drive consistently increasing populations worldwide to become refugees.
– A brusque-term solution would exist to increment preparedness for the management of the specific diseases - catching and non-communicable - in this patient population. All interventions should be based on evidence, global disease patterns, and medical needs during the migration procedure.
– Early interventions in refugee camps will non only help the refugees at an private level but will aid their integration in their host state.
– Early on intervention strategies volition also protect the public health of host countries.
– Close collaboration between physicians, wellness care workers, and public regime is mandatory to provide adequate medical care for refugees and migrants. The task equally well as claiming for the future is the integration of refugees and migrants into the existing health care systems in Europe.

Disclosure Statement

The authors have no conflict of interest to declare.

Notes

Tobias Schilling and Stephan Rauscher share first authorship. Stephan Schmid and Michael Selgrad share last authorship.

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