Europeans' support for refugees of varying background is stable over time.

Protracted global conflicts during the past decade have led to repeated major humanitarian protection crises in Europe. During the height of the Syrian refugee crisis at the end of 2015, Europe hosted around 2.3 million people requesting asylum1. Today, the ongoing war in Ukraine has resulted in one of the largest humanitarian emergencies in Europe since World War II, with more than eight million Ukrainians seeking refuge across Europe2. Here we explore whether repeated humanitarian crises threaten to exhaust solidarity and whether Europeans welcome Ukrainian asylum seekers over other asylum seekers3,4. We conducted repeat conjoint experiments during the 2015-2016 and 2022 refugee crises, asking 33,000 citizens in 15 European countries to evaluate randomly varied profiles of asylum seekers. We find that public preferences for asylum seekers with specific attributes have remained remarkably stable and general support has, if anything, increased slightly over time. Ukrainian asylum seekers were welcomed in 2022, with their demographic, religious and displacement profile having a larger role than their nationality. Yet, this welcome did not come at the expense of support for other marginalized refugee groups, such as Muslim refugees. These findings have implications for our theoretical understanding of the drivers and resilience of public attitudes towards refugees and for policymakers tasked to find effective responses to the enduring stress on the asylum system5-8.

Refugee settlements are highly exposed to extreme weather conditions.

Involuntary displacement from conflict and other causes leads to clustering of refugees and internally displaced people, often in long-term settlements. Within refugee-hosting countries, refugee settlements are frequently located in isolated and remote areas, characterized by poor-quality land and harsh climatic conditions. Yet, the exposure of refugee settlements to climatic events is underresearched. In this article, we study the exposure of the 20 largest refugee settlements worldwide to extreme variations in climatic conditions. The analysis integrates exposure of camp locations compared to the national trends for both slow- and rapid-onset events and includes descriptive statistics, signal-to-noise analyses, and trend analyses. Our findings show that most refugee settlements included face relatively high exposure to slow-onset events, including high temperatures (for settlements in Kenya, Ethiopia, Rwanda, Sudan, and Uganda), low temperatures (in the case of Jordan and Pakistan), and low levels of rainfall (in Ethiopia, Rwanda, Kenya, and Uganda) compared to national averages. Our findings for rapid-onset events-heatwaves, coldwaves, and extreme rainfall-are less conclusive compared to country trends, although we find relatively high exposure to extreme rainfall in Cox's Bazar, Bangladesh. Our analyses confirm that refugee populations are exposed to extreme weather conditions postdisplacement, which, in combination with their sociopolitical exclusion, poses a threat to well-being and increased marginalization. Our findings call for an inclusive and integrated approach, including refugees and their host communities, in designing climate adaptation and sustainable development policies, in order to promote equitable sustainable development pathways in refugee-hosting countries.

Disease burden among Ukrainians forcibly displaced by the 2022 Russian invasion.

The Russian invasion of Ukraine on February 24, 2022, has displaced more than a quarter of the population. Assessing disease burdens among displaced people is instrumental in informing global public health and humanitarian aid efforts. We estimated the disease burden in Ukrainians displaced both within Ukraine and to other countries by combining a spatiotemporal model of forcible displacement with age- and gender-specific estimates of cardiovascular disease (CVD), diabetes, cancer, HIV, and tuberculosis (TB) in each of Ukraine's 629 raions (i.e., districts). Among displaced Ukrainians as of May 13, we estimated that more than 2.63 million have CVDs, at least 615,000 have diabetes, and over 98,500 have cancer. In addition, more than 86,000 forcibly displaced individuals are living with HIV, and approximately 13,500 have TB. We estimated that the disease prevalence among refugees was lower than the national disease prevalence before the invasion. Accounting for internal displacement and healthcare facilities impacted by the conflict, we estimated that the number of people per hospital has increased by more than two-fold in some areas. As regional healthcare systems come under increasing strain, these estimates can inform the allocation of critical resources under shifting disease burdens.

Varied Prevalence of Antimalarial Drug Resistance Markers in Different Populations of Newly Arrived Refugees in Uganda.

Newly arrived refugees offer insights into malaria epidemiology in their countries of origin. We evaluated asymptomatic refugee children within 7 days of arrival in Uganda from South Sudan and the Democratic Republic of Congo (DRC) in 2022 for parasitemia, parasite species, and Plasmodium falciparum drug resistance markers. Asymptomatic P. falciparum infections were common in both populations. Coinfection with P. malariae was more common in DRC refugees. Prevalences of markers of aminoquinoline resistance (PfCRT K76T, PfMDR1 N86Y) were much higher in South Sudan refugees, of antifolate resistance (PfDHFR C59R and I164L, PfDHPS A437G, K540E, and A581G) much higher in DRC refugees, and of artemisinin partial resistance (ART-R; PfK13 C469Y and A675V) moderate in both populations. Prevalences of most mutations differed from those seen in Ugandans attending health centers near the refugee centers. Refugee evaluations yielded insights into varied malaria epidemiology and identified markers of ART-R in 2 previously little-studied countries.

Epidemiology of SARS-CoV-2 in Kakuma Refugee Camp Complex, Kenya, 2020-20211.

Understanding SARS-CoV-2 infection in populations at increased risk for poor health is critical to reducing disease. We describe the epidemiology of SARS-CoV-2 infection in Kakuma Refugee Camp Complex, Kenya. We performed descriptive analyses of SARS-CoV-2 infection in the camp and surrounding community during March 16, 2020‒December 31, 2021. We identified cases in accordance with national guidelines.We estimated fatality ratios and attack rates over time using locally weighted scatterplot smoothing for refugees, host community members, and national population. Of the 18,864 SARS-CoV-2 tests performed, 1,024 were positive, collected from 664 refugees and 360 host community members. Attack rates were 325.0/100,000 population (CFR 2.9%) for refugees,150.2/100,000 population (CFR 1.11%) for community, and 628.8/100,000 population (CFR 1.83%) nationwide. During 2020-2021, refugees experienced a lower attack rate but higher CFR than the national population, underscoring the need to prioritize SARS-CoV-2 mitigation measures, including vaccination.

Medical consequences of "contingency accommodation" for people seeking asylum: thematic analysis of a survey from professionals working in contingency accommodation.

BACKGROUND: Concerns about the housing of migrants and asylum seekers have escalated since the COVID-19 pandemic. From the use of quasi-detention facilities and so-called contingency accommodation to outbreaks of diphtheria in processing centres, there is a worrying trend to normalise potentially damaging conditions. The aim of this study was to assess the health risks posed by contingency housing for asylum seekers in the UK. METHODS: In this cross-sectional survey, a 10-point online questionnaire was sent to professional networks working with refugees and asylum seekers within the UK. Responses were collected between March 4, and April 11, 2022, using a mixture of convenience and snowballing sampling approach. The objectives of the survey were (1) to identify and document unmet needs, (2) to offer practical support, and (3) to map out services and organisation. The survey was designed by six medical professionals with experience of working with migrants and validated by three doctors who had experience running out-reach medical clinics for asylum seekers within contingency accommodation. Background details of geographical location and occupation were collected, and a combination of closed and open questions were used to collect information across five domains (medical, legal social, integration, and basic essentials) using a social determinants of health framework. A code book thematic analysis using a deductive/inductive hybrid approach was used to identify health and social needs as well as specific rights being denied. FINDINGS: There were 68 responses from around the UK, of which 30 (44%) were health-care professionals, and 38 (56%) were from the wider voluntary sector. 45 (67%) had visited an accommodation site, and 21 (33%) had worked with those living in contingency accommodation in other respects. Respondents reported observations regarding sites across most parts of the UK. Major themes of access to health-care, access to other services, barriers to access, and safeguarding were identified, with subthemes on access to primary care, maternity, and mental health services (eg, "Vast unmet need in mental health provision, several suicide attempts"); access to basic essential services (eg, "Food was not fit for purpose" "[c]hildren often did not receive breakfast"); education, and legal support; and frequent moving and communication. INTERPRETATION: Through several themes we highlight the substantial impact of structural isolation of asylum seekers through contingency housing, its major effects on wellbeing and the exacerbation of health inequities. We are using these results to work with asylum seekers and local non-governmental organisations to campaign for improved housing conditions. Study limitations include sampling bias, and a lack of voices of those with lived experience. FUNDING: None.

Recording and analysing ethnicity in public health research: a bibliographical review and focus group discussions with young migrants and refugees in the UK.

BACKGROUND: The ethnicity data gap hinders public health research from addressing ethnic health inequity in the UK, especially for under-served young, migrant populations. We aimed to review how ethnicity was captured, reported, analysed, and theorised within policy-relevant research. METHODS: For this bibliographical review, we reviewed a selection of the 1% most highly cited population health papers reporting UK ethnicity data in MEDLINE and Web of Science databases between Jan 1, 1946, and July 31, 2022, and extracted how ethnicity was recorded and analysed. We included cross-sectional, longitudinal cohort studies, and randomised trials using only UK populations, which were peer-reviewed, were written in English, and reported ethnicity and any health-related outcomes. We held three focus groups with ten participants aged 18-25 years, from Nigeria, Turkistan, Syria, Yemen, and Iran to help us shape and interpret our findings, and asked "How should ethnicity be asked inclusively, and better recorded?" and "Does ethnicity change over time or context? If so, why?". We consolidated feedback from our focus groups into a co-created poster with recommendations for researchers studying ethnicity and health. Written informed consent was obtained for focus group participation. FINDINGS: Of 44 papers included in the review, 19 (43%) used self-reported ethnicity, but the number of ethnic categories provided varied. Of 27 papers that aggregated ethnicity, 13 (48%) provided justification. Only eight (18%) explicitly theorised how ethnicity related to health. The focus groups agreed that (1) ethnicity should not be prescribed by others (individuals could be asked to describe their ethnicity in free-text, which researchers could synthesise to extract relevant dimensions of ethnicity for their research) and (2) Ethnicity changes over time and context according to personal experience, social pressure, and nationality change. The lived experience of ethnicity of migrants and non-migrants is not fully interchangeable, even if they share the same ethnic category. INTERPRETATION: Researchers should communicate clearly how ethnicity is operationalised in their studies, with appropriate justification for clustering and analysis that is meaningfully theorised. Our study was limited by its non-systematic nature. Implementing the recommendation to capture ethnicity via free text remains challenging in administrative data systems. FUNDING: UCL Engagement Beacon Bursary.

Status of HIV and comorbidities in refugees with HIV from Ukraine.

PURPOSE: To describe the clinical characteristics of refugees with HIV from Ukraine that seek continuation of medical care in Germany. METHODS: Fourty-six refugees with HIV that had left Ukraine between 24 February and 30 December 2022 were examined. Information on patients' history was obtained using a standardized questionnaire for clinical care. Interviews were conducted in Russian during their first clinical presentation. RESULTS: Fourty-six persons (41 females and 5 males) were included and their mean age was 39.6 (±8.4) years. The mean time since HIV diagnosis was 8.0 (median, IQR 7.15) years and 70.3% of participants currently received tenfofovir-DF, lamividine and dolutegravir. Most refugees had an undetectable HIV viral load and their current mean CD4 T cell count was 702 (SD ± 289) per µL. Serology revealed previous hepatitis B infection in 50.4% without evidence for replication, with undetectable anti-hepatitis B surface antigen in the remaining refugees. Antibodies against hepatitis C were present in 23 refugees (50%), but only 10 patients had been diagnosed with hepatitis C previously. Five refugees had undergone successful antiviral treatment for hepatitis C. Detectable HCV-RNA was evident in nine patients (19.6%). Sixteen (38.6%) refugees had a positive tuberculosis (TB) interferon gamma release assay, and four were on TB treatment for previously diagnosed infection. One had been diagnosed with multidrug-resistant (MDR) TB, two with pre-extensively drug-resistant (pre-XDR) TB and two with XDR TB and were treated with combinations of second-line and novel agents according to WHO guidelines. CONCLUSIONS: Based on this preliminary analysis of a not fully representative cohort, refugees with HIV from Ukraine were young, mostly healthy females highly adherent to antiretroviral therapy. The rate of transmittable co-infections urges early diagnostic evaluation and treatment.

The burden of infectious diseases throughout and after the COVID-19 pandemic (2020-2023) and Russo-Ukrainian war migration.

Understanding how the infectious disease burden was affected throughout the COVID-19 pandemic is pivotal to identifying potential hot spots and guiding future mitigation measures. Therefore, our study aimed to analyze the changes in the rate of new cases of Poland's most frequent infectious diseases during the entire COVID-19 pandemic and after the influx of war refugees from Ukraine. We performed a registry-based population-wide study in Poland to analyze the changes in the rate of 24 infectious disease cases from 2020 to 2023 and compared them to the prepandemic period (2016-2019). Data were collected from publicly archived datasets of the Epimeld database published by national epidemiological authority institutions. The rate of most of the studied diseases (66.6%) revealed significantly negative correlations with the rate of SARS-CoV-2 infections. For the majority of infectious diseases, it substantially decreased in 2020 (in case of 83%) and 2021 (63%), following which it mostly rebounded to the prepandemic levels and, in some cases, exceeded them in 2023 when the exceptionally high annual rates of new cases of scarlet fever, Streptococcus pneumoniae infections, HIV infections, syphilis, gonococcal infections, and tick-borne encephalitis were noted. The rate of Clostridioides difficile enterocolitis was two-fold higher than before the pandemic from 2021 onward. The rate of Legionnaires' disease in 2023 also exceeded the prepandemic threshold, although this was due to a local outbreak unrelated to lifted COVID-19 pandemic restrictions or migration of war refugees. The influx of war migrants from Ukraine could impact the epidemiology of sexually transmitted diseases. The present analysis indicates that continued efforts are needed to prevent COVID-19 from overwhelming healthcare systems again and decreasing the control over the burden of other infectious diseases. It also identifies the potential tipping points that require additional mitigation measures, which are also discussed in the paper, to avoid escalation in the future.

Overuse of antibiotics for urinary tract infections in pregnant refugees, Lebanon.

Objective: To determine whether adding urine culture to urinary tract infection diagnosis in pregnant women from refugee camps in Lebanon reduced unnecessary antibiotic use. Methods: We conducted a prospective, cross-sectional study between April and June 2022 involving pregnant women attending a Médecins Sans Frontières sexual reproductive health clinic in south Beirut. Women with two positive urine dipstick tests (i.e. a suspected urinary tract infection) provided urine samples for culture. Bacterial identification and antimicrobial sensitivity testing were conducted following European Committee on Antimicrobial Susceptibility Testing guidelines. We compared the characteristics of women with positive and negative urine culture findings and we calculated the proportion of antibiotics overprescribed or inappropriately used. We also estimated the cost of adding urine culture to the diagnostic algorithm. Findings: The study included 449 pregnant women with suspected urinary tract infections: 18.0% (81/449) had positive urine culture findings. If antibiotics were administered following urine dipstick results alone, 368 women would have received antibiotics unnecessarily: an overprescription rate of 82% (368/449). If administration was based on urine culture findings plus urinary tract infection symptoms, 144 of 368 women with negative urine culture findings would have received antibiotics unnecessarily: an overprescription rate of 39.1% (144/368). The additional cost of urine culture was 0.48 euros per woman. Conclusion: A high proportion of pregnant women with suspected urinary tract infections from refugee camps unnecessarily received antibiotics. Including urine culture in diagnosis, which is affordable in Lebanon, would greatly reduce antibiotic overprescription. Similar approaches could be adopted in other regions where microbiology laboratories are accessible.

Mental health problems and help-seeking behaviours of Syrian refugee adolescents: mediating role of self-stigma.

BACKGROUND: Although common mental health problems have been widely studied with self-stigma, few studies have focused on the mediating effect of self-stigma in the relationship between mental health problems and help-seeking behaviours of refugee adolescents. Therefore, the purpose of the present study was to examine whether self-stigma mitigates the adverse effects of stress, anxiety, and depression symptoms on the help-seeking behaviours of Syrian adolescents living in Turkey. METHODS: The participants of this study included 488 Syrian refugee adolescents (boys, 63.73%; girls, 3627%) living in Turkey. Participants completed the Depression Anxiety Stress Scale and General Help-Seeking Scale and Self-Stigma of Seeking Psychology Help Scale. RESULTS: The findings revealed that stress (ß = 0.19, p < 0.01), anxiety (ß = 0.12, p < 0.05), and depression (ß = 0.17, p < 0.01) had significant and positive predictive effects on self-stigma, but not on help-seeking behaviours. Also, self-stigma (ß = -0.12, p < 0.01) had a significant negative predictive effect on help-seeking behaviours. With regard to the indirect effects, the findings showed that self-stigma fully mediated the associations between stress - help-seeking [effect = -0.05, 95% confidence interval (CI) -0.11 to -0.01], anxiety - help-seeking (effect = -0.04, 95% CI -0.09 to -0.01)], and depression - help-seeking (effect = -0.05, 95% CI -0.12 to -0.01). CONCLUSIONS: Our findings highlight the potential negative effects of self-stigma on the help-seeking behaviours of Syrian refugee adolescents, both directly and indirectly. These results can be used to develop and implement effective and efficient interventions to address the unmet mental health needs of refugee adolescents.

War exposure, post-traumatic stress symptoms and hair cortisol concentrations in Syrian refugee children.

Altered secretion of cortisol, the primary effector of the hypothalamus-pituitary-adrenal axis, has been proposed as a means by which traumatic experiences compromise later mental health. However, despite the popularity of cortisol as a potential biomarker for stress and adversity, findings are inconsistent, and little is known about the impact of war-related trauma on stress physiology of children and adolescents. Here we aimed to evaluate the relationships between war exposure, current living conditions, hair cortisol concentrations (HCC) and post-traumatic stress disorder (PTSD) symptoms in a large cohort of Syrian refugee children and adolescents (6-18 years) and their caregiver. This longitudinal observational study assessed Syrian refugee children and adolescents in two waves, 1 year apart, within informal tented settlements in Lebanon. The relationships between war exposure, time since leaving Syria, PTSD symptoms and HCC were investigated using linear mixed-model regression utilising both waves of data collected (Y1: N = 1574, Y2: N = 923). Hair cortisol concentration was positively, but weakly associated with the number of war-related events experienced. This was limited to those who were at least 12 years old at the time of war exposure. Conversely, HCC decreased with time since leaving Syria. HCC was also associated with PTSD symptoms but not with the quality of their current living conditions. This study revealed that changes to hypothalamic-pituitary-adrenal axis activity may accompany both earlier war exposure and current PTSD symptoms in children and adolescents. Additionally, early adolescence may be a particularly sensitive time in terms of trauma-related changes to the hypothalamic-pituitary-adrenal axis.

Health Risks of Unaccompanied Immigrant Children in Federal Custody and in US Communities.

Unaccompanied immigrant children continue to arrive at the US-Mexico border and are at high risk for ongoing abuse, neglect, and poor mental and physical health. We are medical and legal experts in the fields of immigrant and refugee health, child abuse, and the legal rights of international refugee and migrant children. We provide an overview of US federal agencies with custody of unaccompanied immigrant children, a summary of medical care provided while in custody, and recent findings from the independent Juvenile Care Monitor Report mandating new custodial conditions for immigrant children while in federal custody. We provide recommendations to improve the health and well-being of unaccompanied immigrant children while in custody and once released to US sponsors. (Am J Public Health. 2024;114(3):340-346. https://doi.org/10.2105/AJPH.2023.307570).

Prevalence of abnormalities seen on orthopantomograms performed for forensic age estimation in unaccompanied minor asylum seekers.

OBJECTIVES: Evaluate the prevalence of radiological anomalies on orthopantomograms (OPT) performed as part of forensic age estimation in unaccompanied minors. METHODS: This is a retrospective study conducted on 208 OPT examinations requested by a magistrate. These OPTs were interpreted independently by two readers to establish the number of missing teeth (MT), presence of dental fillings (DF), and dental anomalies (DA). The presence of radiolucent (RL), radiopaque, and mixed lesions was also assessed. RESULTS: Most radiologic anomalies were RL, detected on 41% and 39% of the subjects evaluated for R1 and R2, respectively, with a mean of 1.3 ± 2.4 (1-16) and 1.1 ± 2 (1-13) RL lesions per subject. Among the RL identified, the majority were dental (70% for R1 and 65% for R2), all of which had a suspected infectious origin. Among readers, 43% and 41% of the subjects evaluated presented MT, 21% and 15% presented DF, and 22% and 20% presented DA for R1 and R2, respectively. The inter- and intra-observer reproducibility for OPT classification was considered excellent (Kappa = 0.84, 95% CI 0.78-0.90, and Kappa = 0, 95, 95% CI 0.86-0.99). DISCUSSION: There was a non-negligible prevalence of radiological anomalies in OPT studies performed for forensic age estimation. Most of these lesions were suspected to be infectious in origin, potentially requiring medical care. This constitutes an ethical dilemma inherent in the judicial expertise injunction requiring a limited specific response. CLINICAL RELEVANCE STATEMENT: This study highlights a non-negligible prevalence of supposedly infectious radiological abnormalities. The restricted possibility for the legal expert to declare these abnormalities raises ethical and medical questions. KEY POINTS: • Orthopantomograms can be performed as part of forensic age estimation. • Results indicate the majority of radiological anomalies detected on OPTs were of suspected infectious origin. • These findings give rise to ethical and medical questions about the way in which these forensic examinations are carried out.

Neurological Care of Refugees and Other Forcibly Displaced Persons.

There are more than 100 million forcibly displaced persons (FDPs) in the world today, including a high number of people who experience neurologic symptoms and presentations. This review summarizes the conceptual frameworks for understanding neurological health risks and conditions across the migration journey (premigration, migration journey, and postmigration) and life span, including special attention to pediatric FDPs. The interaction with psychiatric illness is discussed, as well as the available published data on neurologic presentations in FDPs in the medical literature. A social determinant of health lens is used to provide ways in which forcible displacement can influence brain health and neurological outcomes. Priorities and future needs for the neurological care of refugees and other FDPs are suggested.

Age assessment in unaccompanied minors: assessing uniformity of protocols across Europe.

Age assessment of migrants is crucial, particularly for unaccompanied foreign minors, a population facing legal, social, and humanitarian challenges. Despite existing guidelines, there is no unified protocol in Europe for age assessment.The Forensic Anthropology Society of Europe (FASE) conducted a comprehensive questionnaire to understand age estimation practices in Europe. The questionnaire had sections focusing on the professional background of respondents, annual assessment numbers, requesting parties and reasons, types of examinations conducted (e.g., physical, radiological), followed protocols, age estimation methods, and questions on how age estimates are reported.The questionnaire's findings reveal extensive engagement of the forensic community in age assessment in the living, emphasizing multidisciplinary approaches. However, there seems to be an incomplete appreciation of AGFAD guidelines. Commonalities exist in examination methodologies and imaging tests. However, discrepancies emerged among respondents regarding sexual maturity assessment and reporting assessment results. Given the increasing importance of age assessment, especially for migrant child protection, the study stresses the need for a unified protocol across European countries. This can only be achieved if EU Member States wholeheartedly embrace the fundamental principles outlined in EU Directives and conduct medical age assessments aligned with recognized standards such as the AGFAD guidelines.

Forensic age estimation at the University Center of Legal Medicine Lausanne-Geneva: a retrospective study over 12 years.

With the undeniable increase in asylum requests from unaccompanied alleged minors, age estimation of living individuals has become an essential part of the routine work in European forensic centers. This study aims to review the forensic age estimations performed in our center since 2010, to evaluate the state-of-the-art of this practice in Switzerland with the evolution of the methodology according to upcoming recommendations. Our institute's expert reports performed between 2010 and 2022 were retrospectively analyzed. We gathered the following parameters: demographic data, morphological characteristics, alleged age compared with the assessed minimum age, sexual maturation, dental and bone age. When available, we collected personal and family history, medical history, records of torture-related/self-inflicted injuries, and information about eating habits that might affect skeletal development. Data collection amounted to 656 cases. Forensic age estimations ordered by the Swiss Secretariat for Migration (SEM) represented 76.4% of cases, with 23.6% of them ordered by the Court/Public Prosecutor. Most alleged minors were male (94.5%) and came from Afghanistan (53.4%). Adjunction of CT scans of the sternoclavicular joints was necessary in 86.4% of cases. Only 25.2% of our reports concluded on most probable minority, with 55.6% of definite majors; in 19.2% of our cases, minority could not be excluded. This study aspires to further broaden our expertise regarding forensic age estimations. Given the increasing migratory flows, we can expect a notable increase in the frequency of these requests. Consequently, this study aims to promote a multidisciplinary approach and the international standardization of the methodology of these estimations.

Overcoming denominator problems in refugee settings with fragmented electronic records for health and immigration data: a prediction-based approach.

BACKGROUND: Epidemiological studies in refugee settings are often challenged by the denominator problem, i.e. lack of population at risk data. We develop an empirical approach to address this problem by assessing relationships between occupancy data in refugee centres, number of refugee patients in walk-in clinics, and diseases of the digestive system. METHODS: Individual-level patient data from a primary care surveillance system (PriCarenet) was matched with occupancy data retrieved from immigration authorities. The three relationships were analysed using regression models, considering age, sex, and type of centre. Then predictions for the respective data category not available in each of the relationships were made. Twenty-one German on-site health care facilities in state-level registration and reception centres participated in the study, covering the time period from November 2017 to July 2021. RESULTS: 445 observations ("centre-months") for patient data from electronic health records (EHR, 230 mean walk-in clinics visiting refugee patients per month and centre; standard deviation sd: 202) of a total of 47.617 refugee patients were available, 215 for occupancy data (OCC, mean occupancy of 348 residents, sd: 287), 147 for both (matched), leaving 270 observations without occupancy (EHR-unmatched) and 40 without patient data (OCC-unmatched). The incidence of diseases of the digestive system, using patients as denominators in the different sub-data sets were 9.2% (sd: 5.9) in EHR, 8.8% (sd: 5.1) when matched, 9.6% (sd: 6.4) in EHR- and 12% (sd 2.9) in OCC-unmatched. Using the available or predicted occupancy as denominator yielded average incidence estimates (per centre and month) of 4.7% (sd: 3.2) in matched data, 4.8% (sd: 3.3) in EHR- and 7.4% (sd: 2.7) in OCC-unmatched. CONCLUSIONS: By modelling the ratio between patient and occupancy numbers in refugee centres depending on sex and age, as well as on the total number of patients or occupancy, the denominator problem in health monitoring systems could be mitigated. The approach helped to estimate the missing component of the denominator, and to compare disease frequency across time and refugee centres more accurately using an empirically grounded prediction of disease frequency based on demographic and centre typology. This avoided over-estimation of disease frequency as opposed to the use of patients as denominators.

HIV Vulnerabilities Associated with Water Insecurity, Food Insecurity, and Other COVID-19 Impacts Among Urban Refugee Youth in Kampala, Uganda: Multi-method Findings.

Food insecurity (FI) and water insecurity (WI) are linked with HIV vulnerabilities, yet how these resource insecurities shape HIV prevention needs is understudied. We assessed associations between FI and WI and HIV vulnerabilities among urban refugee youth aged 16-24 in Kampala, Uganda through individual in-depth interviews (IDI) (n = 24), focus groups (n = 4), and a cross-sectional survey (n = 340) with refugee youth, and IDI with key informants (n = 15). Quantitative data was analysed via multivariable logistic and linear regression to assess associations between FI and WI with: reduced pandemic sexual and reproductive health (SRH) access; past 3-month transactional sex (TS); unplanned pandemic pregnancy; condom self-efficacy; and sexual relationship power (SRP). We applied thematic analytic approaches to qualitative data. Among survey participants, FI and WI were commonplace (65% and 47%, respectively) and significantly associated with: reduced SRH access (WI: adjusted odds ratio [aOR]: 1.92, 95% confidence interval [CI]: 1.19-3.08; FI: aOR: 2.31. 95%CI: 1.36-3.93), unplanned pregnancy (WI: aOR: 2.77, 95%CI: 1.24-6.17; FI: aOR: 2.62, 95%CI: 1.03-6.66), and TS (WI: aOR: 3.09, 95%CI: 1.22-7.89; FI: aOR: 3.51, 95%CI: 1.15-10.73). WI participants reported lower condom self-efficacy (adjusted ß= -3.98, 95%CI: -5.41, -2.55) and lower SRP (adjusted ß= -2.58, 95%CI= -4.79, -0.37). Thematic analyses revealed: (1) contexts of TS, including survival needs and pandemic impacts; (2) intersectional HIV vulnerabilities; (3) reduced HIV prevention/care access; and (4) water insecurity as a co-occurring socio-economic stressor. Multi-method findings reveal FI and WI are linked with HIV vulnerabilities, underscoring the need for HIV prevention to address co-occurring resource insecurities with refugee youth.