Seasonal patterns of communicable disease incidence and antibiotic prescribing in Moria refugee camp, Greece.

BACKGROUND: Infectious diseases remain a major risk for refugees living in camps. Limited research has been undertaken into the burden and impact of infections in the current refugee crisis around the Mediterranean.This analysis examines the frequency and incidence rates of common infections, and use of antibiotics at a healthcare facility inside Moria refugee camp on the island of Lesvos, Greece, during the winter and summer seasons of 2019. METHODS: This is a retrospective analysis of routinely, prospectively collected service data from the main acute healthcare facility inside Moria camp. RESULTS: Of a total of 9601 consultations, 25.16% were for infections (winter: 31.53%, summer: 19.45%). Respiratory, skin and gastrointestinal infections were the most frequent, with incidence rates up to 3.5 times, 50 times and twice as high as those in Western Europe, respectively. Antibiotic prescribing was high (27.7% of all respiratory infections) with high use of broad-spectrum antibiotics (40.2%), raising concerns about induction of antimicrobial resistance. CONCLUSIONS: The burden of infectious diseases in refugee camps remains high throughout all seasons. Antimicrobial stewardship programmes should be adapted to refugee camp settings to prevent the development of unnecessary antimicrobial resistance. Improving living conditions and access to healthcare in refugee camps is likely to reduce infection rates and antimicrobial resistance among refugees.

Lessons to learn from the analysis of routine health data from Moria Refugee Camp on Lesvos, Greece.

BACKGROUND: Refugees in humanitarian settings commonly experience many health needs and barriers to access healthcare; health data from these settings are infrequently reported, preventing effective healthcare provision. This report describes health needs of refugees in Moria Camp on Lesvos, Greece-Europe's largest refugee camp. METHODS: A set of routinely collected service data of 18 131 consultations of 11 938 patients, attending a primary care clinic in the camp over 6 months in 2019-20, was analysed retrospectively, focusing on chronic health conditions. RESULTS: The most frequent chronic conditions were musculoskeletal pain (25.1%), mental health (15.9%), cardiac (12.7%) and endocrine conditions (8.9%). In all, 70.4% of consultations were for acute health problems, with high rates of injuries and wounds (20.8%), respiratory infections (12.5%), gastroenteritis (10.7%) and skin problems (9.7%), particularly scabies. CONCLUSIONS: The prevalence of acute and chronic health problems is high in this setting, with some likely attributable to the deplorable living conditions in the camp. Despite its magnitude, the interpretability of routine health data is limited. A research agenda is identified, and a framework for chronic disease management in refugee camps is proposed.

Beyond arrival: safeguarding unaccompanied asylum-seeking children in the UK.

Unaccompanied children (also called unaccompanied minors) are children who have been separated from both parents and other relatives and are not being cared for by an adult who, by law or custom, is responsible for doing so. From 2010 to 2020, unaccompanied minors accounted on average for 15.4% of the total number of first-time asylum applicants aged less than 18 years in the UK. These young people risk their lives and undergo traumatic journeys in search of a better life. However, when they arrive in the UK, they are vulnerable to significant ongoing traumatic experiences.In this review, we look at the reasons young people are forced to flee their countries, how they make their journey, and the risks and dangers they face along the way. We examine safety and victimisation risks faced by children and young people after arrival in the UK, which mechanisms and processes exist to safeguard these individuals, and examine the data available on outcomes of unaccompanied asylum-seeking child (UASC. Finally, we share two case examples that represent both the strengths and weaknesses of existing processes for UASC.

The prevalence of familial vesicoureteric reflux in infants with normal antenatal scans.

AIM: To determine the prevalence of familial vesicoureteric reflux (VUR) by studying the outcomes of screening in a contemporary cohort of newborns with normal antenatal kidney scans. METHODS: A review of screening outcomes in newborns with a first degree relative with VUR, normal antenatal scans and no prior urine infections between 2014-2019 at three maternity units in the North East of England was conducted. Imaging consisted of micturating cystourethrogram (MCUG) in all and renal tract ultrasound scan (RUS) routinely in two units and by clinician preference in one unit. RESULTS: At a median age of 59 days, 265 infants underwent MCUG. High-grade VUR (Grades 3-5) was detected in 13 (4.9%) and low-grade VUR (Grades 1-2) in 24 (9.1%). In the 152 infants who had a RUS, abnormalities were detected in 21 (13.8%). An abnormal postnatal RUS has a low positive predictive value (14.3%) for high-grade VUR, but a normal RUS has a high negative predictive value (95.4%). CONCLUSION: Compared to historical cohorts from two decades ago, the yield from familial VUR screening is low and unjustifiable in the setting of normal antenatal anomaly scans.

A Whole-child, whole-family approach to health assessments for asylum-seeking children.

In 2020, 21% of people who sought asylum in the UK were children. This population has complex interconnecting health and social needs. Assessment requires a holistic approach, with consideration of physical and mental health in addition to social and developmental well-being, within the whole family group. A trauma-informed life-cycle and intergenerational care approach is important. This article, aimed at all health professionals who may work with asylum-seeking families, outlines the best practice principles for undertaking health assessments in migrant children and young people.

Health needs of accompanied refugee and asylum-seeking children in a UK specialist clinic.

AIM: To identify health needs and healthcare access barriers of accompanied refugee and asylum-seeking (RAS) children in the North East of England, and pilot a new service model to address these. METHODS: Mixed-methods study (retrospective analysis of routinely collected service data, qualitative data from focus groups) of children who attended a hospital-based specialist clinic. RESULTS: Over two years, 80 children were referred to this service. Most frequent diagnoses (total n = 104) were anaemia (n = 17), neurodevelopmental (n = 12), respiratory (n = 12) and mental health (n = 9) conditions. Mild-moderate stunting (23%), overweight and obesity (41%), stunting with obesity (9%) and micronutrient deficiencies (vitamin D (66%), vitamin A (40%) and manifest (14%) or latent (25%) iron deficiency anaemia) were highly prevalent. 62% of children had experienced psychological trauma, and 39% had abnormal results in psychosocial wellbeing screening. 21% of children required secondary or tertiary care, 8% mental health referrals, and 47% were followed up in this specialist clinic. Focus groups with families and the community report unaddressed health needs and substantial barriers of access to health care. CONCLUSION: Refugee and asylum-seeking children have substantial health needs and healthcare access barriers that are not routinely addressed. The authors propose a service model for healthcare provision.

Modelling interventions to control COVID-19 outbreaks in a refugee camp.

BACKGROUND: In the absence of effective treatments or vaccines, non-pharmaceutical interventions are the mainstay of control in the COVID-19 pandemic. Refugee populations in displacement camps live under adverse conditions that are likely to favour the spread of disease. To date, only a few cases of COVID-19 have appeared in refugee camps, and whether feasible non-pharmaceutical interventions can prevent the spread of the SARS-CoV-2 virus in such settings remains untested. METHODS: We constructed the first spatially explicit agent-based model of a COVID-19 outbreak in a refugee camp, and applied it to evaluate feasible non-pharmaceutical interventions. We parameterised the model using published data on the transmission rates and progression dynamics of COVID-19, and demographic and spatial data from Europe's largest refugee camp, the Moria displacement camp on Lesbos, Greece. We simulated COVID-19 epidemics with and without four feasible interventions. RESULTS: Spatial subdivision of the camp ('sectoring') was able to 'flatten the curve', reducing peak infection by up to 70% and delaying peak infection by up to several months. The use of face masks coupled with the efficient isolation of infected individuals reduced the overall incidence of infection, and sometimes averted epidemics altogether. These interventions must be implemented quickly in order to be maximally effective. Lockdowns had only small effects on COVID-19 dynamics. CONCLUSIONS: Agent-based models are powerful tools for forecasting the spread of disease in spatially structured and heterogeneous populations. Our findings suggest that feasible interventions can slow the spread of COVID-19 in a refugee camp setting, and provide an evidence base for camp managers planning intervention strategies. Our model can be modified to study other closed populations at risk from COVID-19 or future epidemics.

An Occupational Health Survey of British Mountain Guides Operating Internationally.

INTRODUCTION: Professional mountain guides face significant occupational health risks, including injuries, accidents, environmental exposures, chronic musculoskeletal strain, and psychological stressors. This study aims to investigate these risks and their impact on the quality of life of a group of international British mountain guides. METHODS: This self-reported online survey included demographics; acute and chronic occupational conditions; and questions on general health, lifestyle, symptoms of post-traumatic stress disorder (PTSD), and quality of life based on the World Health Organization quality of life [WHOQOL-BREF] questionnaire. RESULTS: Responses were received from 67 (32%) of the approached guides. Knee pain (75%), back and neck pain (62%), hand/upper extremity problems (51%), and lower limb injuries (49%) were the most commonly reported individual occupational health problems. Chronic eye problems were reported by 8%, and 5% reported skin cancer. Twenty-nine percent were on regular medications, which were mainly analgesics for chronic musculoskeletal complaints. Mountain guides have a healthy lifestyle, with lower rates of being overweight/obese, alcohol consumption, and smoking than the average UK population. Fourteen (61%) of the 23 guides responding to the PTSD questions reported experiencing life-threatening traumatic incidents, and 4 (25%) of this subgroup appear to have had some symptoms of PTSD. The quality of life assessment showed that the studied mountain guides have a high quality of life. CONCLUSIONS: Musculoskeletal problems are the main occupational health problems experienced by the study group. New findings include a low but important prevalence of ultraviolet radiation-associated conditions. One in 3 guides have experienced significant psychological trauma, and one quarter of these had symptoms of PTSD.

Reducing unnecessary chest X-rays, antibiotics and bronchodilators through implementation of the NICE bronchiolitis guideline.

Chest X-rays (CXR), antibiotics and inhaled/nebulized therapy are overused in bronchiolitis, despite evidence-based guidelines suggesting supportive management only. This study investigates the effect of the implementation of the NICE bronchiolitis guideline in a secondary paediatric unit in England. We present a quality improvement project with a completed audit cycle (winter 2014-2015 and 2015-2016) pre- and post-implementation of the NICE bronchiolitis guideline. The educational intervention included sessions for raising awareness of appropriate and inappropriate management of bronchiolitis for both clinicians and nursing staff. As a result, the number of chest radiographs reduced fivefold (from 20 to 4% of patients, absolute reduction 16%), antibiotics reduced more than threefold (from 22 to 6% of patients, absolute reduction 16%) and inhaled/nebulised treatment up to twofold (from 30 to 16%, absolute reduction 14%). Overall NICE guideline compliance rose from 28 to 63%. CONCLUSION: Implementation of the NICE bronchiolitis guideline supported by a simple educational intervention can effectively reduce the number of inappropriate chest radiographs and antibiotic prescribing in bronchiolitis, and enhance compliance with the NICE guideline. What is Known: • Bronchiolitis management in paediatric units in the UK is variable, with poor evidence for existing guidance. Best available evidence was compiled into the NICE guideline, aiming to standardize care. • Some evidence exists for the effectiveness of quality improvement approaches to improve the management of bronchiolitis. What is New: • NICE guidance can be effectively applied to a department using simple educational tools. • Effective NICE implementation reduces the rates of unnecessary chest radiograph and antibiotic administration for patients admitted with bronchiolitis in District General Hospitals.

Oral anti-pseudomonal antibiotics for cystic fibrosis.

BACKGROUND: Pseudomonas aeruginosa is the most common bacterial pathogen causing lung infections in people with cystic fibrosis and appropriate antibiotic therapy is vital. Antibiotics for pulmonary exacerbations are usually given intravenously, and for long-term treatment, via a nebuliser. Oral anti-pseudomonal antibiotics with the same efficacy and safety as intravenous or nebulised antibiotics would benefit people with cystic fibrosis due to ease of treatment and avoidance of hospitalisation. This is an update of a previous review. OBJECTIVES: To determine the benefit or harm of oral anti-pseudomonal antibiotic therapy for people with cystic fibrosis, colonised with Pseudomonas aeruginosa, in the:1. treatment of a pulmonary exacerbation; and2. long-term treatment of chronic infection. SEARCH METHODS: We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register comprising references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings.We contacted pharmaceutical companies and checked reference lists of identified trials.Date of last search: 08 July 2016. SELECTION CRITERIA: Randomised or quasi-randomised controlled trials comparing any dose of oral anti-pseudomonal antibiotics, to other combinations of inhaled, oral or intravenous antibiotics, or to placebo or usual treatment for pulmonary exacerbations and long-term treatment. DATA COLLECTION AND ANALYSIS: Two authors independently selected the trials, extracted data and assessed quality. We contacted trial authors to obtain missing information. MAIN RESULTS: We included three trials examining pulmonary exacerbations (171 participants) and two trials examining long-term therapy (85 participants). We regarded the most important outcomes as quality of life and lung function. The analysis did not identify any statistically significant difference between oral anti-pseudomonal antibiotics and other treatments for these outcome measures for either pulmonary exacerbations or long-term treatment. One of the included trials reported significantly better lung function when treating a pulmonary exacerbation with ciprofloxacin when compared with intravenous treatment; however, our analysis did not confirm this finding. We found no evidence of difference between oral anti-pseudomonal antibiotics and other treatments regarding adverse events or development of antibiotic resistance, but trials were not adequately powered to detect this. None of the studies had a low risk of bias from blinding which may have an impact particularly on subjective outcomes such as quality of life. The risk of bias for other criteria could not be clearly stated across the studies. AUTHORS' CONCLUSIONS: We found no conclusive evidence that an oral anti-pseudomonal antibiotic regimen is more or less effective than an alternative treatment for either pulmonary exacerbations or long-term treatment of chronic infection with P. aeruginosa. Until results of adequately-powered future trials are available, treatment needs to be selected on a pragmatic basis, based upon any available non-randomised evidence, the clinical circumstances of the individual, the known effectiveness of drugs against local strains and upon individual preference.

A perspective on IL-7Rα deficient T-B+NK+ severe combined immunodeficiency.

The management of patients with IL-7Rα deficient, T-B+NK+ severe combined immunodeficiency (SCID) is a challenge in absence of adequate diagnostic and treatment modalities. An infant diagnosed as SCID at 6 months of age, who received only supportive treatment is described. We present a different perspective of SCID that is managed in a low-middle income country with lack of resources for definitive therapy.

Oral anti-pseudomonal antibiotics for cystic fibrosis.

BACKGROUND: Pseudomonas aeruginosa is the most common bacterial pathogen causing lung infections in people with CF and appropriate antibiotic therapy is vital. Antibiotics for pulmonary exacerbations are usually given intravenously, and for long-term treatment, via a nebuliser. Oral anti-pseudomonal antibiotics with the same efficacy and safety as intravenous or nebulised antibiotics would benefit people with CF due to ease of treatment and avoidance of hospitalisation. OBJECTIVES: To determine the benefit or harm of oral anti-pseudomonal antibiotic therapy for people with CF, colonised with Pseudomonas aeruginosa, in the:1. treatment of a pulmonary exacerbation; and 2. long-term treatment of chronic infection. SEARCH METHODS: We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register comprising references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings.We contacted pharmaceutical companies and checked reference lists of identified trials.Date of last search: 28 June 2013. SELECTION CRITERIA: Randomised or quasi-randomised controlled trials comparing any dose of oral anti-pseudomonal antibiotics, to other combinations of inhaled, oral or intravenous antibiotics, or to placebo or usual treatment for pulmonary exacerbations and long-term treatment. DATA COLLECTION AND ANALYSIS: Two authors independently selected the trials, extracted data and assessed quality. We contacted trial authors to obtain missing information. MAIN RESULTS: We included three trials examining pulmonary exacerbations (171 participants) and two trials examining long-term therapy (85 participants). We regarded the most important outcomes as quality of life and lung function. The analysis did not identify any statistically significant difference between oral anti-pseudomonal antibiotics and other treatments for these outcome measures for either pulmonary exacerbations or long-term treatment. One of the included trials reported significantly better lung function when treating a pulmonary exacerbation with ciprofloxacin when compared with intravenous treatment; however, our analysis did not confirm this finding. We found no evidence of difference between oral anti-pseudomonal antibiotics and other treatments regarding adverse events or development of antibiotic resistance, but trials were not adequately powered to detect this. None of the studies had a low risk of bias from blinding which may have an impact particularly on subjective outcomes such as quality of life. The risk of bias for other criteria could not be clearly stated across the studies. AUTHORS' CONCLUSIONS: We found no conclusive evidence that an oral anti-pseudomonal antibiotic regimen is more or less effective than an alternative treatment for either pulmonary exacerbations or long-term treatment of chronic infection with P. aeruginosa. Until results of adequately-powered future trials are available, treatment needs to be selected on a pragmatic basis, based upon any available non-RCT evidence, the clinical circumstances of the individual, the known effectiveness of drugs against local strains and upon individual preference.

Plasmodium knowlesi infection: a diagnostic challenge.

Plasmodium knowlesi malaria is an uncommon, but highly prevalent parasitic infection in parts of Malaysia. This is the case of a 14-year-old Singaporean boy presenting to our emergency department with an 11-day history of fever following a school trip to Malaysia. Hepatosplenomegaly was the only clinical finding; laboratory tests showed thrombocytopaenia, lymphopaenia, mild anaemia and liver transaminitis. Specific malaria antigen tests were negative, but the peripheral blood film showed plasmodia with atypical features, with a parasite load of 0.5%. PCR confirmed the diagnosis of P knowlesi. The patient was successfully treated with chloroquine. The clinical course of P knowlesi malaria is indistinguishable from that of Plasmodium falciparum. This case highlights the importance of taking detailed travel history, careful examination of malaria blood films and judicious use of molecular techniques. Antigen tests alone may have missed a malaria diagnosis altogether, while blood film examination may wrongly identify the species as Plasmodium malariae or P falciparum. Third-generation PCR assays can be used to reliably identify P knowlesi.