Paediatric refugees from Ukraine: guidance for health care providers.

BACKGROUND: With the invasion of Ukraine by the Russian Army in February 2022, refugees, the majority of whom are women and children, started fleeing the war to neighbouring countries. Even before the current escalation, the conflict in the eastern part of Ukraine has led to the internal displacement of more than 200,000 children, and many others have experienced attacks, e.g. on schools. This inevitably leads to limitations in health care delivery. During transit, overcrowding, poor shelter and vulnerability may further put refugees at increased risk for infectious diseases. This consensus document aims to provide information and guidance regarding health issues that paediatricians and general practitioners may face when caring for Ukrainian children. METHODS: Members of the Migrant Health Reference Group of Paediatrics Switzerland and the Paediatric Infectious Disease Group in Switzerland developed this recommendation between March and April 2022 in a modified Delphi process. RESULTS: A total of 50 recommendations were agreed on with a ≥80% consensus. These include the following topics: i) general aspects, including interpreter services, urgent health needs, personal history and general check-ups; ii) mental health, including how to search for signs of psychological distress without going into traumatic details; iii) vaccinations, including recommendations for evaluation and catch-up; iv) screening for tuberculosis, human immunodeficiency virus, and hepatitis B and C; and v) providing age-appropriate preventive and health service information. CONCLUSION: This document provides current evidence and guidance when caring for paediatric refugees from Ukraine. The recommendations focus on Switzerland but may well be used in other countries. These are based on current evidence and may need to be adapted to individual situations and once further evidence becomes available.

Determinants of Modern Paediatric Healthcare Seeking in Rural Côte d'Ivoire.

Objectives: To determine factors that influence healthcare seeking among children with fatal and non-fatal health problems. Methods: Last disease episodes of surviving children and fatal outcomes of children under 5 years of age were investigated by means of an adapted social autopsy questionnaire administered to main caregivers. Descriptive analysis and logistic models were employed to identify key determinants of modern healthcare use. Results: Overall, 736 non-fatal and 82 fatal cases were assessed. Modern healthcare was sought for 63.9% of non-fatal and 76.8% of fatal cases, respectively. In non-fatal cases, young age, caregiver being a parent, secondary or higher education, living <5 km from a health facility, and certain clinical signs (i.e., fever, severe vomiting, inability to drink, convulsion, and inability to play) were positively associated with modern healthcare seeking. In fatal cases, only signs of lower respiratory disease were positively associated with modern healthcare seeking. A lack of awareness regarding clinical danger signs was identified in both groups. Conclusion: Interventions promoting prompt healthcare seeking and the recognition of danger signs may help improve treatment seeking in rural settings of Côte d'Ivoire and can potentially help further reduce under-five mortality.

Risk factors for the carriage of Streptococcus infantarius subspecies infantarius isolated from African fermented dairy products.

Streptococcus infantarius subsp. infantarius (Sii) has been identified as predominant lactic acid bacteria in spontaneously fermented dairy products (FDPs) in sub-Saharan Africa including Côte d'Ivoire. However, Sii belongs to the Streptococcus bovis/Streptococcus equinus complex (SBSEC). Most SBSEC members are assumed to be involved as opportunistic pathogens in serious diseases in both humans and animals. A population-based cross-sectional survey, including 385 participants was conducted in Korhogo, northern Côte d'Ivoire, to identify risk factors for Sii fecal carriage, including consumption of local FDPs. A structured questionnaire was used to gather participant's socio-demographic and economic characteristics, their relation to livestock and dietary habits. In addition, fresh stool and milk samples were collected. The identification of Sii was done using a SBSEC-specific PCR assay targeting 16S rRNA and groEL genes. The overall prevalence of SBSEC and Sii carriage was 23.2% (confidence interval CI 95% = 18.9-27.5) and 12.0% (CI 95% = 8.4-15.5) for stool, respectively. Prevalence of Sii was significantly higher in consumers of artisanal butter compared with non-consumers (57.1% vs 10.1%, odds ratio OR: 11.9, 95% CI: 3.9-36.6), as well as in persons handling livestock (OR = 3.9; 95% CI = 1.6-9.3) and livestock primary products (OR = 5.7; 95% CI = 2.3-14.3). The closer contact with livestock was a risk factor for Sii fecal carriage. Sii strains were isolated from fresh and fermented milk products with a prevalence of 30.4% and 45.4%, respectively. Analysis of Sii population structure through the SBSEC multi locus sequence typing assay revealed a close relationship across human and dairy isolates, possibly linked to a Kenyan human isolate. All these outcomes underline the interest of in-depth investigations on the ecology, potential reservoirs and pathways of contamination by Sii at the human-animal-environment interface in comparison to yet to be collected data from Europe, Asia and the Americas to further elucidate the various roles of Sii.

Barriers to and solutions for addressing insufficient professional interpreter use in primary healthcare.

BACKGROUND: The aim of this nationwide study was to investigate barriers to adequate professional interpreter use and to describe existing initiatives and identify key factors for successful interpreter policies in primary care, using Switzerland as a case study. METHODS: Adult and paediatric primary care providers were invited to participate in an online cross-sectional questionnaire-based study. All accredited regional interpreter agencies were contacted first by email and, in the absence of a reply, by mail and then by phone. Local as well as the national health authorities were asked about existing policies. RESULTS: 599 primary care physicians participated. Among other reasons, physicians identified cumbersome organization (58.7%), absent financial coverage (53.7%) and lack of knowledge on how to arrange interpreter interventions (44%) as main barriers. The odds of organising professional interpreters were 6.6-times higher with full financial coverage. Some agencies confirmed difficulties providing professional interpreters for certain languages at a timely manner. Degrees of coverage of professional interpreter costs (full coverage to none) and organization varied between regions resulting in different levels of unmet needs. CONCLUSIONS: Professional interpreter use can be improved through the following points: increase awareness and knowledge of primary care providers on interpreter use and organization, ensure financial coverage, as well as address organizational aspects. Examples of successful interventions exist.

The migration-related language barrier and professional interpreter use in primary health care in Switzerland.

BACKGROUND: With increased international migration, language barriers are likely becoming more relevant in primary care. The aim of this study was to investigate the language barrier in paediatric and adult primary care, present its consequences, reveal how it is overcome, as well as highlight the use of and potential unmet needs for professional interpreters, using Switzerland as a case study. METHODS: Primary healthcare providers were invited nation-wide to participate in an online questionnaire on language barriers faced and interpreter use. RESULTS: More than 90% of the 599 participants in this nation-wide cross-sectional study face relevant language barriers at least once a year, 30.0% even once a week. Using family members and friends for translations is reported as the most frequent resort for overcoming the language barrier (60.1% report it for more than 50% of encounters), followed by "using gestures" (32.0%) or just accepting the insufficient communication (22.9%). Minors interpret frequently (frequent use: 23.3%). Two thirds of physicians facing language barriers never have access to a professional interpreter, the majority (87.8%) though would appreciate their presence and approximately one quarter of these even see a cost-saving potential. Multiple consequences affecting quality of care in the absence of professional interpreters are identified. CONCLUSION: Language barriers are relevant in primary care. Improved access to professional interpreters is warranted.

Pregnancy-related morbidity and risk factors for fatal foetal outcomes in the Taabo health and demographic surveillance system, Côte d'Ivoire.

BACKGROUND: Reliable, population-based data on pregnancy-related morbidity and mortality, and risk factors for fatal foetal outcomes are scarce for low- and middle-income countries. Yet, such data are essential for understanding and improving maternal and neonatal health and wellbeing. METHODS: Within the 4-monthly surveillance rounds of the Taabo health and demographic surveillance system (HDSS) in south-central Côte d'Ivoire, all women of reproductive age identified to be pregnant between 2011 and 2014 were followed-up. A questionnaire pertaining to antenatal care, pregnancy-related morbidities, delivery circumstances, and birth outcome was administered to eligible women. Along with sociodemographic information retrieved from the Taabo HDSS repository, these data were subjected to penalized maximum likelihood logistic regression analysis, to determine risk factors for fatal foetal outcomes. RESULTS: A total of 2976 pregnancies were monitored of which 118 (4.0%) resulted in a fatal outcome. Risk factors identified by multivariable logistic regression analysis included sociodemographic factors of the expectant mother, such as residency in a rural area (adjusted odds ratio (aOR) = 2.87; 95% confidence interval (CI) 1.31-6.29) and poorest wealth tertile (aOR = 1.79; 95% CI 1.02-3.14), a history of miscarriage (aOR = 23.19; 95% CI 14.71-36.55), non-receipt of preventive treatment such as iron/folic acid supplementation (aOR = 3.15; 95% CI 1.71-5.80), only two doses of tetanus vaccination (aOR = 2.59; 95% CI 1.56-4.30), malaria during pregnancy (aOR = 1.94; 95% CI 1.21-3.11), preterm birth (aOR = 4.45; 95% CI 2.82-7.01), and delivery by caesarean section (aOR = 13.03; 95% CI 4.24-40.08) or by instrumental delivery (aOR = 5.05; 95% CI 1.50-16.96). Women who paid for delivery were at a significantly lower odds of a fatal foetal outcome (aOR = 0.39; 95% CI 0.25-0.74). CONCLUSIONS: We identified risk factors for fatal foetal outcomes in a mainly rural HDSS site of Côte d'Ivoire. Our findings call for public health action to improve access to, and use of, quality services of ante- and perinatal care.

Challenges and opportunities for healthcare workers in a rural district of Chad.

BACKGROUND: Trained healthcare workers are an essential resource for effective health systems. However, healthcare workers' perspective on healthcare, the challenges they face to provide quality health services, and opportunities to improve motivation and providing adequate care are rarely investigated in resource-constrained settings of sub-Saharan Africa. METHODS: All reachable nurses of Abou Deia, a primarily rural district in the south-eastern part of Chad, were invited to participate. In-depth interviews were conducted to assess current challenges and opportunities faced in daily work, including factors that influence motivation and social wellbeing. Particular emphasis was placed on paediatric care. RESULTS: Eight nurses were interviewed. Main work challenges pertained to overall workload, a lack of training and support regarding a serious case mix to be managed on their own, adverse working conditions, issues related to the local communities, and the impact of postings on nurses' private life. Poor working conditions and perceived lack of recognition emerged as the main demotivating factors. Motivation to improve nurses' skills so that they can provide good care, coupled with small, suggested changes in working conditions and health care organisation provide opportunities worth exploring to improve health workers' satisfaction, motivation and the care they can provide. CONCLUSIONS: Health workers in a predominantly rural district in Chad face a wide variety of challenges, and hence their perspectives need to be taken into account to improve health services interventions that aim at enhancing quality of care. Nurses' willingness to further develop skills and knowledge, proactive search of solutions to remedy stock-outs of drugs and other medical devices, and motivational factors to improve the quality of care represent important opportunities for improving health services for all.

Côte d'Ivoire Dual Burden of Disease (CoDuBu): Study Protocol to Investigate the Co-occurrence of Chronic Infections and Noncommunicable Diseases in Rural Settings of Epidemiological Transition.

BACKGROUND: Individual-level concomitance of infectious diseases and noncommunicable diseases (NCDs) is poorly studied, despite the reality of this dual disease burden for many low- and middle-income countries (LMICs). OBJECTIVE: This study protocol describes the implementation of a cohort and biobank aiming for a better understanding of interrelation of helminth and Plasmodium infections with NCD phenotypes like metabolic syndrome, hypertension, and diabetes. METHODS: A baseline cross-sectional population-based survey was conducted over one year, in the Taabo health and demographic surveillance system (HDSS) in south-central Côte d'Ivoire. We randomly identified 1020 consenting participants aged ≥18 years in three communities (Taabo-Cité, Amani-Ménou, and Tokohiri) reflecting varying stages of epidemiological transition. Participants underwent health examinations consisting of NCD phenotyping (anthropometry, blood pressure, renal function, glycemia, and lipids) and infectious disease testing (infections with soil-transmitted helminths, schistosomes, and Plasmodium). Individuals identified to have elevated blood pressure, glucose, lipids, or with infections were referred to the central/national health center for diagnostic confirmation and treatment. Aliquots of urine, stool, and venous blood were stored in a biobank for future exposome/phenome research. In-person interviews on sociodemographic attributes, risk factors for infectious diseases and NCDs, medication, vaccinations, and health care were also conducted. Appropriate statistical techniques will be applied in exploring the concomitance of infectious diseases and NCDs and their determinants. Participants' consent for follow-up contact was obtained. RESULTS: Key results from this baseline study, which will be published in peer-reviewed literature, will provide information on the prevalence and co-occurrence of infectious diseases, NCDs, and their risk factors. The Taabo HDSS consists of rural and somewhat more urbanized areas, allowing for comparative studies at different levels of epidemiological transition. An HDSS setting is ideal as a basis for longitudinal studies since their sustainable field work teams hold close contact with the local population. CONCLUSIONS: The collaboration between research institutions, public health organizations, health care providers, and staff from the Taabo HDSS in this study assures that the synthesized evidence will feed into health policy towards integrated infectious disease-NCD management. The preparation of health systems for the dual burden of disease is pressing in low- and middle-income countries. The established biobank will strengthen the local research capacity and offer opportunities for biomarker studies to deepen the understanding of the cross-talk between infectious diseases and NCDs. TRIAL REGISTRATION: International Standard Randomized Controlled Trials Number (ISRCTN): 87099939; http://www.isrctn.com/ISRCTN87099939 (Archived by WebCite at http://www.webcitation.org/6uLEs1EsX).

Causes of death in the Taabo health and demographic surveillance system, Côte d'Ivoire, from 2009 to 2011.

BACKGROUND: Current vital statistics from governmental institutions in Côte d'Ivoire are incomplete. This problem is particularly notable for remote rural areas that have limited access to the health system. OBJECTIVE: To record all deaths from 2009 to 2011 and to identify the leading causes of death in the Taabo health and demographic surveillance system (HDSS) in south-central Côte d'Ivoire. DESIGN: Deaths recorded in the first 3 years of operation of the Taabo HDSS were investigated by verbal autopsy (VA), using the InterVA-4 model. InterVA-4 is based on the World Health Organization 2012 VA tool in terms of input indicators and categories of causes of death. RESULTS: Overall, 948 deaths were recorded, of which 236 (24.9%) had incomplete VA data. Among the 712 deaths analyzed, communicable diseases represented the leading causes (58.9%), with most deaths attributed to malaria (n=129), acute respiratory tract infections (n=110), HIV/AIDS (n=80), and pulmonary tuberculosis (n=46). Non-communicable diseases accounted for 18.9% of the deaths and included mainly acute abdomen (n=38), unspecified cardiac diseases (n=15), and digestive neoplasms (n=13). Maternal and neonatal conditions accounted for 8.3% of deaths, primarily pneumonia (n=19) and birth asphyxia (n=16) in newborns. Among the 3.8% of deaths linked to trauma and injury, the main causes were assault (n=6), accidental drowning (n=4), contact with venomous plants/animals (n=4), and traffic-related accidents (n=4). No clear causes were determined in 10.0% of the analyzed deaths. CONCLUSIONS: Communicable diseases remain the predominant cause of death in rural Côte d'Ivoire. Based on these findings, measures are now being implemented in the Taabo HDSS. It will be interesting to monitor patterns of mortality and causes of death in the face of rapid demographic and epidemiological transitions in this part of West Africa.

Health & Demographic Surveillance System Profile: The Taabo Health and Demographic Surveillance System, Côte d'Ivoire.

The Taabo Health and Demographic Surveillance System (HDSS) is located in south-central Côte d'Ivoire, approximately 150 km north-west of Abidjan. The Taabo HDSS started surveillance activities in early 2009 and the man-made Lake Taabo is a key eco-epidemiological feature. Since inception, there has been a strong interest in research and integrated control of water-associated diseases such as schistosomiasis and malaria. The Taabo HDSS has generated setting-specific evidence on the impact of targeted interventions against malaria, schistosomiasis and other neglected tropical diseases. The Taabo HDSS consists of a small town, 13 villages and over 100 hamlets. At the end of 2013, a total population of 42 480 inhabitants drawn from 6707 households was under surveillance. Verbal autopsies have been conducted to determine causes of death. Repeated cross-sectional epidemiological surveys on approximately 5-7% of the population and specific, layered-on haematological, parasitological and questionnaire surveys have been conducted. The Taabo HDSS provides a database for surveys, facilitates interdisciplinary research, as well as surveillance, and provides a platform for the evaluation of health interventions. Requests to collaborate and to access data are welcome and should be addressed to the secretariat of the Centre Suisse de Recherches Scientifiques en Côte d'Ivoire: [secretariat@csrs.ci].

Migrant-friendly hospitals: a paediatric perspective--improving hospital care for migrant children.

BACKGROUND: The European Union (EU) Migrant-Friendly Hospital (MFH) Initiative, introduced in 2002, promotes the adoption of care approaches adapted to meet the service needs of migrants. However, for paediatric hospitals, no specific recommendations have been offered for MFH care for children. Using the Swiss MFH project as a case study, this paper aims to identify hospital-based care needs of paediatric migrants (PMs) and good service approaches. METHODS: Semi-structured interviews were conducted with principal project leaders of five paediatric hospitals participating in the Swiss MFH project. A review of the international literature on non-clinical hospital service needs and service responses of paediatric MFHs was conducted. RESULTS: Paediatric care can be complex, usually involving both the patient and the patient's family. Key challenges include differing levels of acculturation between parents and children; language barriers; cultural differences between patient and provider; and time constraints. Current service and infrastructural responses include interpretation services for PMs and parents, translated information material, and special adaptations to ensure privacy, e.g., during breastfeeding. Clear standards for paediatric migrant-friendly hospitals (P-MFH) are lacking. CONCLUSIONS: International research on hospital care for migrant children is scarce. The needs of paediatric migrants and their families may differ from guidance for adults. Paediatric migrant needs should be systematically identified and used to inform paediatric hospital care approaches. Hospital processes from admission to discharge should be revised to ensure implementation of migrant-sensitive approaches suitable for children. Staff should receive adequate support, such as training, easily available interpreters and sufficient consultation time, to be able to provide migrant-friendly paediatric services. The involvement of migrant groups may be helpful. Improving the quality of care for PMs at both policy and service levels is an investment in the future that will benefit native and migrant families.

The health of migrant children in Switzerland.

OBJECTIVE: Over 22 % of children and adolescents living in Switzerland have a migrant background. The aim of this systematic literature review is to give an overview of health needs of paediatric migrants in Switzerland. METHODS: Three databases (Embase, Medline, Global health) were systematically searched for quantitative primary research on the health outcomes of migrant minors (<18-year old) in Switzerland, including articles published since 2000 in French, German, Italian or English. Citation chasing and search of non-indexed literature was also performed. RESULTS: Thirty publications were identified. Compared to their Swiss peers, migrant children had higher hospitalisation (+40 %) and intensive care admission rates, more dental cavities, twice the odds of being obese, and migrant adolescents seemed more frequently affected by psychological problems and twice as often requesting abortions. Certain infectious diseases (tuberculosis, intestinal parasites, H. pylori infection, Hepatitis A) were more prevalent. Increased neonatal and infant mortality rates were found in Turkish and African babies. CONCLUSION: Children of migrants may have distinct health needs. They should benefit from migrant paediatric care and health promotion activities that recognise these.

Reproductive health care for asylum-seeking women - a challenge for health professionals.

BACKGROUND: Dealing with pregnancy, childbirth and the care of newborn babies is a challenge for female asylum seekers and their health care providers. The aim of our study was to identify reproductive health issues in a population of women seeking asylum in Switzerland, and to examine the care they received. The women were insured through a special Health Maintenance Organisation (HMO) and were attending the Women's Clinic of the University Hospital in Basel. We also investigated how the health professionals involved perceived the experience of providing health care for these patients. METHODS: A mixed methods approach combined the analysis of quantitative descriptive data and qualitative data obtained from semi-structured interviews with health care providers and from patients' files. We analysed the records of 80 asylum-seeking patients attending the Women's Clinic insured through an HMO. We conducted semi-structured interviews with 10 care providers from different professional groups. Quantitative data were analysed descriptively. Qualitative data analysis was guided by Grounded Theory. RESULTS: The principal health problems among the asylum seekers were a high rate of induced abortions (2.5 times higher than in the local population), due to inadequate contraception, and psychosocial stress due to the experience of forced migration and their current difficult life situation. The language barriers were identified as a major difficulty for health professionals in providing care. Health care providers also faced major emotional challenges when taking care of asylum seekers. Additional problems for physicians were that they were often required to act in an official capacity on behalf of the authorities in charge of the asylum process, and they also had to make decisions about controlling expenditure to fulfil the requirements of the HMO. They felt that these decisions sometimes conflicted with their duty towards the patient. CONCLUSION: Health policies for asylum seekers need to be designed to assure access to adequate contraception, and to provide psychological care for this vulnerable group of patients. Care for asylum seekers may be emotionally very challenging for health professionals.