Health Status of Asylum Seekers, Spain

INTRODUCTION

The rising rate of conflicts and the unsafe situation caused by reasons of ethnicity, religion, gender, sexual orientation, political opinion, or nationality entail an increase in the number of migratory movements. According to United Nations High Commissioner for Refugees (UNHCR), forced displacements affected 65.3 million people by the end of 2015 (an increase of over 50% in the past 5 years), with 40.8 million displaced internally, 21.3 million refugees, and 3.2 million asylum applicants.¹

In 2015, in Europe, the number of asylum requests was double that of 1992, with 29% being minors and 23% of the minors being unaccompanied.² Specifically, the number of asylum requests in the European Union (EU) in 2015 was 1,321,600, of which 1% were made in Spain (15,000). The EU countries with the most requests were Germany (476,510), Hungary (177,135), and Sweden (162,450), although most were denied.³ In addition to the dangers in their countries of origin, many of these refugees flee using dangerous migration routes.^3,4 It is estimated that 3,771 people died in 2015 attempting to cross the Mediterranean Sea.¹ The main countries of origin of people arriving in Europe via the Mediterranean were the Arab Republic of Syria (50%), Afghanistan (21%), Iraq (9%), Eritrea (4%), Pakistan (3%), Iran (2%), Somalia (2%), Morocco (1%), and Sudan (1%).¹

Some diseases could be more prevalent in this population as a result of the characteristics of the countries of origin or transit (geoepidemiology or deficient healthcare and sanitation systems), the precarious conditions during the migratory process, or the different conditions in shelters and centers in the receiving countries.^5,6 As for infectious diseases, different studies of immigrant populations have described elevated rates of latent tuberculosis infection (LTBI) (sub-Saharan Africans 46–71%; Latin Americans 19–47%; Asians 30–51%; and East Europeans 43–58%), positive surface antibody hepatitis B (HBsAg) (sub-Saharan Africans 9–15%; Latin Americans 0–7%; Asians 0–3%; and East Europeans 4%) and intestinal parasites (sub-Saharan Africans 3–39%; Latin Americans 2–13%; Asians 22–30%; and East Europeans 0–10%).^7–10 Mental health is another significant challenge in this group.¹¹ A review of studies published in 2005 based on interviews with refugees residing in rich member countries of the Organisation for Economic Co-operation and Development (Australia, Canada, Italy, New Zealand, Norway, United Kingdom, and United States) shows that post-traumatic stress can be 10 times more frequent in refugees than in local populations.¹² Another study in Amsterdam revealed that frequent transfers of minors between shelters for asylum applicants led to the appearance of mental health problems.¹³ In Germany, one survey showed that the most common mental health problems referred by asylum applicants were depression (55%), anxiety (40%), and post-traumatic stress (18%).¹⁴ As for noncommunicable diseases (NCD), a study conducted in Switzerland on asylum applicants and refugees from the Middle East showed that this group of diseases was the second cause of emergency room visits: psychiatric illness (24%), NCD (10%), and infectious diseases (3%).¹⁵

Although some European institutions and societies have issued documents with recommendations on healthcare for asylum seekers, there are few studies that describe in detail the main health problems affecting recently arrived asylum applicants in Europe.^16,17

In 2013, a partnership was launched between the Vall d’Hebron-Drassanes Tropical Medicine and International Health Unit (Barcelona, Spain) and social agencies (public and private) that take care of immigrants in vulnerable social conditions (such as asylum seekers, homeless, or unaccompanied minors). This agreement included an initial health exam for all those who requested it, along with health education activities for immigrants and workers at the host institutions. The purpose of this study is to describe the health status of the asylum seekers who visited this center.

MATERIALS AND METHODS

A descriptive retrospective population study was conducted including all asylum seekers who requested a medical exam (with or without symptoms) at the Vall d’Hebron-Drassanes Tropical Medicine and International Health Unit (Barcelona, Spain) between July 2013 and June 2016.

According to the 1951 Refugee Convention in Geneva and the 1967 protocol in New York, an asylum seeker is a “A person who seeks safety from persecution or serious harm in a country other than his or her own and awaits a decision on the application for refugee status under relevant international and national instruments.” Following Spanish law, once international protection is requested, the foreigner cannot be expelled until the application is resolved. In Spain, asylum-seekers, without economic resources, can benefit from social services for covering their basic needs in conditions of dignity, lawyer assistance, access to interpreters; and health care assistance.¹⁸

In Catalonia, the Spanish region where the study was conducted, asylum seekers have the same health rights as the autochthonous population. In the case of economic immigrants, immediate access to primary health is given to those who are registered in the city council and face economic scarcity.¹⁹

The visits and analyses were standardized based on national and international guidelines.^16,17,20,21 This included medical history, physical exam and analysis depending on geoepidemiological history (migratory route and country of origin), and the presence of symptoms (Table 1). The following infectious diseases were considered in the study: endemic infections from tropical areas (malaria, schistosomiasis, filariasis, and intestinal parasites) and worldwide international infections with a high prevalence in some areas (tuberculosis [TB], human immunodeficiency virus [HIV], hepatitis B virus [HBV], hepatitis C virus [HCV], and syphilis). Vaccination was offered to individuals without immunity for HBV.

The study variables were as follows:

1. 1.Geoepidemiological variables: gender, date of birth, country of birth, country of origin, arrival date, migration route (land-maritime or airplane), consultation request date, date of first consultation, and language in which the clinical interview was conducted (native or Spanish/Catalan). The residency time in Spain was calculated using the date of the first consultation and the arrival date. Consultation delay was calculated using the date of the first consultation and the consultation request date.
2. 2.Clinical variables: reason for consultation, medical history, and diagnosis; indication for HBV vaccine, number of doses administered, and referral to the transcultural psychiatric service (based on the symptoms or patient request).

Hepatitis B and HCV were tested in persons coming from countries with prevalence ≥ 2%.^20,21 Human immunodeficiency virus was assessed when the prevalence at the country of origin was ≥ 1%.²¹ In addition, given the high prevalence of sexual abuse in this population, according to some sources, those viral infections and syphilis were offered to those cases that were exposed to this situation.²² The LTBI was screened in asylum seekers coming from countries with high incidence rates of TB (≥ 20 cases/100,000 population per year), with ≤ 35 years of age who had been living ≤ 5 years in European countries with low prevalence of TB.²³ Individuals older than 35 years were not screened because the risks of chemoprophylaxis outweigh the potential benefits, unless they have a documented contact with an active case of TB.²¹ The LTBI was diagnosed using the tuberculin test (TT), and Quantiferon-TB Gold test (IGRAs) was performed in individuals with TT ≥ 5 mm or when TT could not be done. The chest X-ray was done when TT ≥ 5 mm or IGRAs was positive and when suspected symptoms were present. LTBI was considered in those cases with a normal chest X-ray and IGRAs ≥ 0.35 UI/mL (or TT ≥ 10 mm if IGRAs was not available).²⁴ Intestinal parasites are distributed worldwide, particularly in tropical area with poor sanitation conditions, and were consequently assessed based on the country of origin and migratory route.²⁵ Schistosomiasis screening was performed in cases coming from endemic countries.²⁶ Polymerase chain reaction for malaria was performed in cases coming from countries with high transmission (> 1 case per 1,000 population).²⁷

This unit has a community health service that employs community health workers who facilitate patient–provider communication in the case of linguistic or cultural barriers.

The study was carried out in accordance with the Harmonized Tripartite Standards for Good Clinical Practice, following the current national regulations (Law 14/2007 pf Biomedical Research) and the Ethical principles derived from the Declaration on Helsinki. The confidentiality of the data of the subjects participating in the study is guaranteed in compliance with the Spanish Organic Law 15/1999, of December 13, on the Protection of Personal Data. This research was evaluated and approved by the Clinical Research Ethics Committee of the Vall d’Hebron Hospital in Barcelona and was conducted using clinical best practices.

Univariate analysis of our dataset included measures of distribution, central tendency (median or average if the standard deviation was > 20%), and dispersion (standard deviation and interquartile range). Bivariate analysis of categorical was carried out using the χ² test or the Fisher’s exact test for small samples. To compare continuous variables, the Student’s t or the Mann–Whitney U test was used. Hypothesis testing was conducted with a 5% alpha risk and 95% confidence intervals. To that end, multiple logistic regression was performed to identify factors associated with the presence of infectious diseases in asylum seekers by gender, age, area of origin, time elapsed between arrival to Spain and consultation date, and migratory route. The statistical analysis was carried out using the SPSS 23.00^® program (IBM Corp. 2015, Armonk, NY).

RESULTS

DISCUSSION

The asylum seekers who visited our center were mostly young adult males from Ukraine, the Arabic Republic of Syria, and Pakistan. The distribution based on the country of origin of our patients differs from that observed in Europe as a whole, where most asylum applicants are from the Arabic Republic of Syria, Afghanistan, and Iraq.¹ Spain ranks third in Europe among asylum applicants from Ukraine (the fourth highest nationality in the list of asylum applicants in Europe), probably drawn by the Ukrainian community that was established in Spain in the early 1990s after the break-up of the Soviet Union.^1,28 Barcelona has the fifth highest Pakistani population in Europe, with most Pakistanis living in the center of the city, very close to the area where the study was conducted.²⁹ The average age of the asylum applicants in our population was higher than that of official sources (76% ≤ 35% versus 83% ≤ 35% years).² One possible explanation is the low number of unaccompanied minors requesting asylum who arrive in Spain, 25 (0.7% of the European total) in 2015, according to official data. The countries with the most cases were Sweden, Germany, Hungary, and Austria.² Our sample’s gender distribution (67% male) was similar to that reported by official sources (45–80% male).² Four of the 10 asylum applicants used a land-maritime migratory route to reach their destination (despite the risks). This percentage was even higher in immigrants from Asia and sub-Saharan Africa.

Even though most cases exhibited no symptoms (95%), an infectious disease was diagnosed in 23% of our sample. LR in our study demonstrated that area of origin, gender, and migratory route were factors associated with the presence of infectious diseases. These data seem to support the recommendation to personalize the screening protocols for infectious diseases in asylum applicants based on geoepidemiological data.^16,17 The prevalence of LTBI (4–41%) was notable because 5–10% of the cases could turn into TB.²⁴ However, our sample’s LTBI was below that observed in other groups of immigrants (19–71%).^7–10 This study incorporates IGRAs into the screening protocol, whereas other series only consider the TT, a test that can give positive results in a population vaccinated with the Bacillus Calmette-Guérin (BCG) or infected with other mycobacteria. BCG vaccination has been available for more than 80 years and it is recommended by the World Health Organization (WHO) in newborns living in countries with high prevalence of TB. The coverage is higher than 80% of population in most countries.³⁰ In addition, the BCG scar is only present in 50% of the cases, and self-report is an unreliable source of information.³¹ Consequently, we considered everyone in our sample having the BCG vaccine. The treatment of LTBI is not without side effects, which is why some organizations recommend the use of IGRAs in this group.^32,33 However, as IGRAs remains an expensive test, other studies recommend the use of sequential strategies (using TT and IGRAs) for the diagnosis of LTBI.^34,35 One case of active, noncontagious TB was diagnosed (0.3%), which is the same as or even lower than the rate observed in the immigrant population in other series (0–6%).^7–10

The presence of intestinal parasites was similar to or lower than that observed in other migrant series (2–39%).^7–10 We have no documented data, but a possible explanation is the availability of presumptive parasitic treatment given to asylum seekers in some countries offered by some organizations during the migratory journey³⁶ Moreover, some centers base their parasitological diagnoses on serological techniques for two helminths (Schistosoma sp. and S. stercoralis).³⁷ However, the serology test for schistosomiasis remains positive for a long time after treatment, and thus, resolved and active infection cannot be distinguished. In addition, serology may provide false negative results, especially in cases with S. haematobium infection.³⁸ Therefore, this strategy could erroneously estimate the real prevalence of this helminth. Many serologic test for S. stercoralis are quite sensitive but could crossreact with other parasites. Furthermore, results could remain positive sometime after the treatment. However, stool examination for S. stercoralis requires large experience. Thus, the use of the serology is indicated in patients with eosinophilia because it is present in up to 75% of the cases with S. stercoralis.³⁹ However, there are different opinion on how to screen S. stercoralis in asymptomatic patients, without eosinophilia or risk factors for hyperinfection syndrome.^37,40,41

The HBsAg was present in 0–17%, similar to the rate in other migrant series (0–15%).^7–10 The prevalence of HIV (1%) was just slightly above the rate estimated worldwide (0.8%).⁴²

Only 3% of the cases were referred for a transcultural psychiatry consultation, which hampers an assessment of the psychiatric disorders present in asylum applicants. The prevalence of mental disorders was between 0% and 4% in another study with economic migrants.⁸ According to the WHO, the overall rates of mental disorders in refugees vary substantially across different studies because of their heterogeneous background, the context and situation in the host country, and the quality of the studies.⁴³ In this study, the largest obstacle of addressing this population was the high level of difficulty in handling clinical situations that combine traumatic experiences with obvious communication barriers. Significant cultural differences and large legal/social components of migrant life often condition symptoms’ progression. The WHO considers that the most important challenges providing mental health to refugees are language barriers, differences in belief systems, cultural expectations, and establishing trust.⁴³

Fortunately, community health workers from our unit assisted with most of the consultations done with these eight individuals. The presence of these workers is essential for a culturally competent approach. Such approach, however, has some unique features that warrant further consideration, such as the loss of control by the psychiatrist or the various relational dynamics that arise between the parties present at the consultation.

In general, the legal and social status of these people is the cause of their symptoms. Once the threats are resolved, the intensity of the symptoms will tend to dissipate. It could be that a number of them were able to stop their psychiatric treatments after a small number of visits.

About 16% referred a previous NCD, the most frequent involving smoking (16%), respiratory (6%), and cardiovascular (3%) disorders. Other studies showed higher prevalence of NCD among economic migrants (19–27%).^44,45 According to the International Organization of Migration, migrants face different social determinants that expose them to more risks for their health. This situation is usually worse in women, minors, and lower skilled migrants, especially in irregular situation.⁴⁶ Many economic migrants live in this situation, which could partly explain their higher NCD prevalence compared with asylum seekers.

The rate of smoking in ≥ 15 years old migrants was lower than that reported in Spain (27–31%) and similar to that observed in other countries (Ukraine 14–49% and Pakistan 3–42%).⁴⁷ In general, our sample exhibited low rates of NCD, such as 2% for high blood pressure and 2% for diabetes in those who were 18 years and older. In the world’s adult population, it is estimated that 22% have high blood pressure and 10% are patients with diabetes.⁴⁸ Another study in Germany also showed low rates of NCD in asylum applicants (cardiovascular disease 9%, pulmonary disease 6%).¹⁴ These data can be explained in part because the population is younger than the European population and because they generally have healthier life habits.⁴⁹

Around 83% (77–94% depending on area of origin) completed the visits until they received the results or, if necessary, the treatment. This is below the rate observed in other studies.^8,10,50 Moreover, only 22% completed the vaccination schedule for hepatitis B, despite the free and effective nature of this preventive activity because one-fourth of HBsAg cases can develop into cirrhosis and liver cancer.^51,52 One likely explanation is that the unstable status of this group during the postarrival months result in multiple residency relocations, hampering clinical monitoring.

There are some limitations for this study. First, because this was a small sample, we cannot extrapolate the study data to the entire population of asylum seekers. Second, the study center had health workers from some of the communities, which could explain why the linguistic barrier was not a significant factor in the rate at which medical appointments were kept. However, this resource was not available for some communities, such as the Ukrainian one. This barrier can lower the quality of some of the recorded data. Third, the fear that some asylum applicants had of not being accepted by the receiving country could also account for the large number of asymptomatic cases or the few cases that referred mental health problems. Finally, our screening protocols for infectious diseases were based on national and international guidelines; however, some recommendations could vary among the different sources and consequently produce different estimations on its prevalence.

In short, most asylum seekers in this study were generally healthy young men from Asia or Eastern Europe, with higher rates of infectious diseases in men from sub-Saharan Africa or Asia and those arriving by land-maritime routes. As a result, it seems appropriate to personalize protocols based on these geoepidemiological data. The rate of mental health and NCD was infrequent. Unstable living arrangements upon arriving at the receiving country could account for the failure to keep medical appointments and vaccination schedules, although linguistic and cultural barriers could also play a role.