In the second quarter of 2017 there were 7778 (including 1606 dependants and 547 unaccompanied children) applications for asylum in the UK.1 The health needs of asylum-seeking children are wide ranging and can vary depending on their country of origin, broadly dividing into infectious diseases, anaemia, vitamin deficiencies and potential growth retardation, dental and mental health.
INFECTIOUS DISEASES
Asylum-seeking children have probably not been immunised as per UK immunisation schedule. They are also at higher risk of certain infections.
TUBERCULOSIS (TB)
TB is common among asylum seekers, its detection and treatment being particularly important in children who are at higher risk of latent TB Infection (LTBI) reactivation and more likely to have extra-pulmonary spread, including TB meningitis.2 Of 1825 screened refugee children in Massachusetts, 25% had a positive tuberculin (purified protein derivative [PPD]) test.3 Chest X-rays screen for active pulmonary TB but do not identify LTBI.
MALARIA
It is estimated that each year globally there are between 300 and 500 million cases of malaria, contributing to between 1 and 3 million deaths, mainly in young African children.4 Although most cases of imported malaria in Europe are from those settled in non-endemic countries travelling to their home country (where malaria is endemic) on holiday,4 5% of children in one Australian paediatric refugee clinic (75% were from Africa) had malaria.5 Splenomegaly, fever, and thrombocytopaenia can indicate malaria and should prompt testing.
SEXUALLY TRANSMITTED INFECTIONS (STIS)
It is unclear how many refugees, adults or children, have human immunodeficiency virus (HIV). Up until 2010, in the US the Immigration and Naturalization Act prevented most of those infected with HIV from entering the country and those seeking refuge under the asylum-seeking programme were not required to be tested. One study in Minnesota, which assessed for STIs in 18 516 refugees, found that 136 (2.0%) of 6765 were positive for HIV. Other STIs detected in this study were 183 (1.1%) of 17 235 seropositive for syphilis, 15 (0.6%) of 2512 positive for Chlamydia, and 5 (0.2%) of 2403 positive for gonorrhoea; 6 (0.1%) of 5873 were positive for multiple STIs.6 In Sheikh’s Australian study of refugee children, 4% were carriers of hepatitis B.5 Although the Minnesota figures do not relate specifically to children, GPs should consider the possibility of STIs, especially in older children if suspected of being sexually active.
HELMINTH AND PROTOZOAN INFECTION
Intestinal infection in children, including helminth infection (for example, Ascaris lumbricoides or hookworm, schistosomiasis) and protozoan infections (for example, Giardia lamblia and Dientamoeba fragilis), can cause malnutrition and malabsorption, iron-deficiency anaemia, intestinal obstruction, and growth retardation. Shiekh’s Australian study of refugee children found that 16% had schistosomiasis.5 In Massachusetts, 21% of 1825 refugee children screened had parasitic infection.3 Even if children are asymptomatic, GPs should have a low threshold for testing for worm infestation.
ANAEMIA, VITAMIN DEFICIENCIES, AND POTENTIAL GROWTH RETARDATION
In Sheikh’s Australian study of refugee children 61% had low (<50 nmol/L) serum 25(OH)D3; 15% were anaemic.5 Geltman’s assessment of 1825 recently arrived refugee children found that 12% (overall) and 28% (younger than 2 years of age) were anaemic. Geltman also found that Eastern European refugees tended to be overweight whereas those from developing countries were more likely to experience growth retardation.3 Anaemia and growth abnormalities should be excluded in asylum-seeking children.
DENTAL HEALTH
Many asylum-seeking children have never seen a dentist or even used a toothbrush or fluoridated toothpaste. Of the 1825 refugee children in the Massachusetts study, 62% had dental caries.3 The dental health of asylum-seeking children tends to vary depending on their country of origin. Another US-based study found African refugee children had a similar likelihood of having untreated caries as compared with African American children, whereas white refugee children (mostly from Eastern Europe) were 9.4 times more likely to have untreated caries as white US children.7 If opportunity arises, GPs should enquire if asylum-seeking children have regular dental reviews.
MENTAL HEALTH
Experiencing stressors while in their country of origin, during their flight to safety and during settlement in the host country, asylum-seeking children are at increased risk of psychiatric disorders, especially post-traumatic stress disorder, depression, and anxiety. Exposure to violence is a key risk factor, whereas stable settlement and social support in the host country have a positive effect on the child’s psychological functioning. GPs should ask about the mental health of asylum-seeking children and be familiar with local service provision.
- © British Journal of General Practice 2018