The medical assessment of the increasing number of migrant children is a growing challenge both throughout Europe and globally. In continental Europe, there were 222,100 asylum seekers in 2022 alone, 19% of whom were unaccompanied asylum-seeking children (UASC).1 Permanent-type migration and asylum applications were at a record high to Organization for Economic Cooperation and Development countries in 2022, with preliminary figures for 2023 showing a further increase.2 With ongoing global geopolitical instability and the recent war in Sudan, Ukraine and the Middle East, these numbers are likely to continue to increase. The provision of healthcare for all children is increasingly recognized as a global priority, demonstrated by the UN’s 2030 Sustainable Development Goal commitment to universal health coverage, and the Convention of Rights of the Child stating that all children have a right to the best possible health.3 We use the term migrant child to mean a child or an adolescent (<18) who has moved or settled in another country and experienced unfavorable conditions, including war and violence, socioeconomic deprivation, healthcare and education limitations.4 Migrant children are at increased risk of infections, with potentially serious personal and public health implications. Historically, in Europe, tuberculosis (TB), HIV and hepatitis B5 were prioritized in screening for this population, but significant rates of other infections have been documented,6–8 and suggest other infections are also important in terms of personal and public health. With constantly changing patterns of migration, practices of assessment require regular evaluation; for example, rates of latent and active TB have been much lower in migrant children from Ukraine than expected based on recorded prevalence in the country.2,9 Throughout the United Kingdom and Europe, it is encouraging that a variety of guidance exists for infection screening in migrant and refugee children, but there remains a lack of consensus regarding best practices. What Is the Current Guidance? Multiple recommendations exist to guide infection screening of migrant and refugee children, including by the European Academy of Paediatrics,4 European Center for Disease Control,10 and country-specific guidance in the United Kingdom,11,12 Switzerland,13 Ireland,14 Italy,15 Germany16 and Australia,17 as well as international World Health Organization guidance18; summarized in Table 1. These largely share similar principles, emphasizing recommendations for holistic healthcare offered by trained professionals to all children, including a detailed assessment of infection risk. However, the limited evidence underpinning recommendations results in inconsistency even within guidelines originating from the same country. TABLE 1. - Existing Guidelines for Infection Screening in Migrant Children in Europe and Beyond Country/Organization Year Published Population Included Voluntary or Mandatory Diseases Included as Routine Diseases Included as Risk-based Setting National Switzerland13 2016 Asylum seekers Voluntary TB, HIV, HBV, HIV Schistosomiasis, strongyloidiasis, stool for ova, cysts and parasites, Chagas disease, syphilis Community (primary care) United Kingdom/RCPCH11 2022 Asylum seekers Voluntary TB, HBV, HCV, HIV, STIs, stool ova, cysts and parasites Schistosomiasis, strongyloidiasis Not specified United Kingdom/OHID12 2021 Asylum seekers TB mandatory pre-entry screening via some entry routes, voluntary None TB, HIV, HBV, HCV, schistosomiasis, strongyloidiasis, stool for ova, cysts and parasites, malaria, Chagas, STIs, diphtheria Not specified Ireland14 2015 All migrants, including returning emigrants, those who come voluntarily to work, asylum seekers undocumented or irregular migrants Voluntary None TB, Hep B, Hep C, HIV, stool for ova cysts and parasites, STIs Not specified Germany16 2016 Asylum seekers in accommodation or reception centers Mandatory TB universally, mandatory medical examination Stool for ova, cysts and parasites in some states Community or in reception centers Italy15 2013 All migrants Voluntary TB, HBV, HCV, HIV, syphilis routinely Schistosomiasis, strongyloidiasis, Toxocara, malaria risk-based Not specified European European Academy of Paediatrics4 2019 Migrant children Voluntary TB, HBV, HCV, HIV, schistosomiasis, syphilis, stool for ova, cysts and parasites Malaria Not specified European Center for Disease Control10 2018 All migrants Voluntary TB HBV, HCV, HIV, schistosomiasis, Strongyloidiasis risk-based Not specified International Australia17 2017 Refugees, asylum seekers Voluntary TB (HIV and HBV if unaccompanied minor) HIV (if accompanied minor) HCV, STIs Not specified WHO Guidance18 2018 All migrants Does not specify recommendation TB Mention of HIV, HBV, HCV, syphilis as good practice No clear recommendation HBV indicates hepatitis B virus; HCV, hepatitis C virus; OHID, office for health improvement and disparities; RCPCH, Royal College of Paediatrics and Child Health; STIs, sexually transmitted infections; TB, tuberculosis; WHO, World Health Organization. In addition, even in conditions with clear guidance and good evidence, consistent implementation remains challenging.19,20 In the United Kingdom, for example, only 12% of those migrants recommended to have hepatitis B virus testing in 2016 were actually screened.21 In a 2019 systematic review, 3 European countries (Greece, Spain and Portugal), were found to offer no routine health assessment at all to migrant and refugee children.22 Who Should be Screened—and for Which Infections? Child migrants are a heterogeneous group and the risk of infection may depend on country of origin, reason for migration, journey route and duration and whether formal or informally arranged. In Europe and the United Kingdom, an increasing number of UASC arrive via unsafe routes,23,24 despite efforts to strengthen formal resettlement programs throughout the region.23 Children arriving via the latter, such as the United Kingdom Afghan resettlement program of 2022,23 may, by contrast, have left their home country more quickly by air, without exposure to the prolonged journeys, under poor conditions, experienced by those fleeing on their own. A particularly vulnerable group of children consists of undocumented migrants, who have proven worse health outcomes in every health domain.25 Screening can be individualized based on risk assessment (eg, for all infections in Sweden,26 or for strongyloidiasis and schistosomiasis in Switzerland based on endemicity in host country13) or offered as a predetermined panel of tests (as recommended in UASC clinics in the United Kingdom7). While a risk-based approach may enable rationalization of tests with beneficial cost implications, and most formal guidance recommends screening children based on incidence in country of origin,10,12,14 evidence from the UASC population suggests that this approach may miss infections. For example, a recent study found strongyloidiasis in migrant children from the Middle East (4% of Iranian children) and schistosomiasis in children from Afghanistan (1.9% of Afghan children),7 areas listed as “non-endemic” in some European guidelines,10,13 and likely resulting from transit through endemic countries in route to the destination country. Similarly, routine testing for sexually transmitted infections (STIs) is important,7 due to the high risk of sexual violence in this population.8 Recent evidence, however, suggests a poor correlation between disclosed sexual history or history of abuse in the UASC population and risk of STIs.8 Despite this, routine STI testing is only recommended in a handful of European guidelines.4,11,13 Furthermore, in centers where infection screening happens separately from initial medical assessment, retaking a detailed history in order to risk assess is time-consuming and may cause retraumatization.27 A panel-based approach with tailoring based on significant population determiners may be a better pragmatic approach. Some European guidelines recommend testing for parasitic diseases that pose long-term health risks and occur with significant prevalence in migrant and refugee children. These include schistosomiasis, strongyloidiasis, Chagas disease and giardiasis.4,7,13 Assessment for scabies and other skin infections is also recommended due to the reported high prevalence.6 Several infections are both of public health concern and pose a personal health risk. Contact tracing and prevention of transmission may be challenging due to communal accommodation and frequent relocation of migrant and refugee children. For example, almost all European countries recommend testing for TB.10,12,13,28 There is, however, significant variation in the type of testing used for TB in children, including chest x-ray, interferon-gamma release assay, and tuberculin skin testing, and different ages at which these are recommended.6,7,8,13 Amongst viruses, hepatitis B, C and HIV are the most universally recommended due to both personal and public health risks.12,13,18,28 New public health challenges are likely to occur; for example, diphtheria is currently increasing in Europe in migrant settings29 and measles may pose a next challenge. A key policy controversy in infection screening in migrant and refugee children is whether screening should be on a mandatory16,22 or voluntary basis.11,14,22 Voluntary screening is offered in Scandinavian countries, Ireland and the United Kingdom, and involves a wider panel of infections and a holistic approach. Countries performing mandatory testing typically base policies around “protecting” host populations rather than assessing the individual health needs of the child.19,22 Mandatory testing more often involves limited screening, for example for TB alone, often by chest x-ray only.28 In some European countries children are held in quarantine until results are available, whilst in another children with TB or certain STIs are immediately sent back to their host country.22 Such policies violate international law,3 and are problematic in that they promote and reinforce stigma, a key barrier to accessing healthcare in migrants,30 with fear of losing immigration status featuring prominently in the literature in countries with both mandatory and voluntary programs.18 There is evidence that voluntary screening is more acceptable to migrant groups, especially when these groups are provided with adequate information and education about screening programs.30 What Does Good Care Look Like?—Examples of Best Practice From the available evidence, key aspects of importance to child migrants accessing healthcare include the use of interpreters18 and staff with training in the provision of healthcare for asylum-seeking and refugee populations.31 There is evidence that community settings are more acceptable to young people than hospital-based settings.28 Inclusion health (staff trained in strategies to help young people with multiple overlapping risk factors for health problems),32 continuity of care,18 and holistic assessment27 including signposting to health and social support resources11 are further examples of best practice. The most successful health assessments “make every encounter count” and take the opportunity to support and ask about education, mental health and social determinants of health, whilst providing treatment (and ideally immunizations) in the same setting.27 The United Kingdom,33 the Netherlands,34 Australia35 and Sweden18 have good examples of local provision of an integrated system with treatment in the same setting. Currently, existing guidance is limited to recommendations for the diseases for which one should screen. There is a lack of guidance for service design and delivery, which is key for the implementation of recommendations. Of note, none of the guidance in Table 1 includes recommendations on documentation and administrative systems to support these needs. Asylum-seeking children and young people are known to face multiple barriers in accessing healthcare, including language barriers,8 unfamiliarity with local health systems,32 stigmas, psychological trauma19 and poverty (including digital poverty, meaning a lack of resources to interact with the online world).27 Ideally, services will be adapted to address these challenges, including bespoke administrative processes, use of materials in other languages, and clear documentation (digital and paper) that follows children throughout their healthcare journey, thus anticipating likely relocation.33 What Is Important Beyond the Individual? Infection screening programs need to be cost-effective. There is limited evidence regarding this, however, most systematic reviews suggest moderate to high cost-effectiveness, particularly for TB and hepatitis B screening, and particularly in high prevalence settings (eg, effectiveness has been demonstrated where TB infection rates exceed 14% prevalence).28,36 There is, however, scarce evidence for effectiveness and cost-effectiveness for screening for strongyloidiasis and schistosomiasis. Presumptive treatment with albendazole for helminthic infections is recommended in some guidance,10,13 with limited evidence that this is cost-effective,10 although presenting a low risk of encephalopathy and neurologic symptoms in cases with concomitant loiasis or neurocysticercosis.10 Beyond cost implications, service development and delivery for asylum-seeking children remains challenging. Planning infection screening for child migrants is a challenge due to variability in demand depending on geopolitical events, lack of consensus and lack of underpinning evidence. Political prioritization of migrant groups is lacking in many European countries, and funding healthcare for inclusion groups is challenging, hindering efforts to implement guidance. Examples of effective institutional frameworks include the Dutch system of bespoke general practices for asylum seekers34 and the NHS England framework for inclusion health. However, despite these frameworks, healthcare provision in both contexts is uneven; for example, in the Netherlands, not all reception centers offer a healthcare center, and, in the United Kingdom, considerable variability in service availability is noted. Institutional frameworks and guidelines require funding and political will to be translated to meaningful service provision. CONCLUSIONS AND RECOMMENDATIONS The recent publication of several guidelines for infection screening of migrant children in Europe is a clearly positive development. In addition, the recommendations are regularly adapted and efforts to generate evidence to support those recommendations are seen in many countries. Inconsistencies and lack of consensus will however persist in a field where epidemiological patterns may fluctuate, evidence remains limited, and where healthcare may be subject to political context. Furthermore, the implementation of guidance and recommendations remains a major challenge. Based on available data and recommendations, we recommend voluntary asymptomatic screening, ideally in a dedicated setting or migrant health clinic. A universal panel of investigations is likely to be more feasible and realistic than individual risk assessment, with the caveat that frequent reevaluation of shifts in populations and epidemiology is essential. Screening alone is likely to be of limited value unless accompanied by education, awareness programs, and efforts to reduce stigma. Use of interpreters, appropriately translated materials, and appropriate cultural adaptations are important, with a focus on making “every encounter count.” Clear written, and transferrable communication is essential. Furthermore, ensuring that all screening and treatment of infections is free of charge is paramount to promoting access to care. National and European investment in robust and consistent data collection on the health status and needs of migrants, with a particular focus on evaluating the effectiveness and cost-effectiveness of existing programs is needed. Engagement of migrant and refugee children in research studies is important to ensure that services meet their health needs. For effective delivery of care, multidisciplinary coordination between health, social care and education systems is essential. Beyond this, political will and prioritization remain essential to underpin the delivery of equitable and high-quality care in this vulnerable population, and advocacy to this end remains a responsibility of healthcare professionals.
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