20 June 2019
According to the UN, every minute 20 people leave their home and everything else behind to escape from persecution, war or terror.[1] This World Refugee Day, CoMO is considering the effect that the global refugee crisis has on public health, and in particular, meningitis.
In countries where meningitis is already prevalent, conflict and protracted crises can worsen already high rates of meningitis by disrupting access to health services, food, sanitation and clean water. When the conditions become so dire that people start to flee their homes, the journey is often long and very dangerous. Constant movement from one overcrowded transit centre or settlement to another fosters the spread of dangerous diseases and, tragically, children under the age of five bear the greatest burden of indirect conflict-related mortality.[2] Infants born during the perilous journeys are at a significantly increased risk of meningitis, septicaemia, hypothermia and pneumonia and yet they often lack access to appropriate medical services.[3]
In 2012, the Gaga camp of eastern Chad saw an outbreak of meningitis due to the poor living conditions and constant migrations that facilitate the spread of disease. Fortunately, site managers and the International Medical Corps quickly sprang into action, setting up vaccination points and maintaining a vigilant eye on all camps that lie in the ‘meningitis belt’, a strip of land that stretches from East to West across Africa where the conditions favour meningitis outbreaks.[4] Mass vaccination campaigns that attain high-coverage and are initiated early on in an outbreak have seen incredible results in containing diseases, as verified in multiple studies in refugee camps across the continent.[5][6] It is also a very cost-effective means of reducing morbidity and mortality, particularly among young children, as demonstrated in a study on vaccination campaigns in Somalia, one of the countries with the highest number of refugees in the world.[7] The use of the Hib vaccine and PCV10 (pneumococcal conjugate vaccine 10) reduced pneumonia cases and deaths by at least 20%, an impressive figure considering that prevention in such a setting is more feasible than treatment.
Beyond saving lives and containing the outbreak, the use of vaccines during humanitarian emergencies has the added benefit of reducing antimicrobial resistance by preventing the diseases and infections that would be treated with antibiotics. Antimicrobial resistance is a significant threat to global health, and this is especially true in refugee settings, as it inhibits the efficacy of treating diseases like meningitis and a recent study showed that approximately a third of refugees or asylum seekers carried or were infected with antimicrobial resistant organisms. Travelling great distances, while refugees transport these antimicrobial resistant organisms and diseases, it is important to recognise that those who bear the greatest risk are, by far, the refugees themselves.[8]
As many of our members are aware, even in countries with relatively well-resourced healthcare systems, treating diseases as aggressive as meningitis poses a challenge. Building robust public health systems is now more important than ever as health services in medium and high income countries are further burdened. Some doctors even report being confronted by diseases typically associated with conflicts and preventable diseases from people who have been unable to access routine immunisations.[9] There have also been damaging misunderstandings around these diseases that have impacted refugees. Regional prosecutors in Italy, for example, claimed that the rescue ship Aquarius could not dock in Italian ports because infectious diseases such as HIV, meningitis and tuberculosis could be spread from the clothes worn by migrants.[10] Meningitis transmission, however, is dependent on close or lengthy contact with a carrier and cannot be passed via clothing at all!
Unfortunately, there have been some truly tragic examples of these public health failures reported over the past few years. Hamid Kehazaei, a refugee held in Manus Island - Australia’s controversial offshore immigration detention centre – died of sepsis in 2014 after contracting a routine leg infection. While a serious infection, the coroner pointed to a lack of suitable antibiotics and inadequate care as the cause of Hamid’s death.[11] More recently, Jakelin Caal, a Guatemalan girl held in a U.S. immigration detention centre, died as a result of streptococcal sepsis at only 7 years-old.[12] When it comes to the fast-acting nature of diseases like meningitis and sepsis, appropriate medical care has to be timely and able to recognise rapid clinical deterioration to avoid loss of life.
People escaping war, crises and persecution have been welcomed in countries all over the world for hundreds of years, whether it was the Jewish refugees in the 1930s or Kosovans in the 1990s.[13] Many people who now live in comfort with a secure citizenship status are descendants of people who arrived to that country precariously, seeking a better future. This World Refugee Day CoMO supports the theme “You, me and those came before” to encourage all to consider our roots, where we are now and how we can do better to ensure public health reflects ideals of equality.
References
[1] https://www.un.org/en/events/refugeeday/background.shtml [2] https://immunizationevidence.org/featured_issues/vaccination-during-conflict-and-forced-migration/ [3] https://ecdc.europa.eu/en/publications-data/assessing-burden-keyinfectious-diseases-affecting-migrant-populations-eueea [4] https://www.internationalmedicalcorps.org.uk/meningitis-outbreak-chad-refugee-camps [5] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2810886/ [6] https://www.outbreakobservatory.org/outbreakthursday-1/8/10/2017/meningitis-spreading-in-yemen [7] https://www.ncbi.nlm.nih.gov/pubmed/26061190 [8] https://immunizationevidence.org/sources/antimicrobial-resistance-among-migrants-in-europe-systematic-review-and-meta-analysis/ [9] https://www.washingtonpost.com/news/world/wp/2018/08/30/feature/millions-of-venezuelans-are-fleeing-to-latin-american-cities-the-region-may-never-be-the-same/?utm_term=.3859dce37fda [10] https://www.independent.co.uk/news/world/europe/italy-migrant-rescue-ships-aquarius-sos-mediterranean-health-hiv-matteo-salvini-a8643096.html [11] https://www.rnz.co.nz/international/pacific-news/362948/death-of-iranian-refugee-on-manus-preventable-says-coroner [12] https://www.reuters.com/article/us-usa-immigration-death/guatemalan-migrant-girl-in-u-s-custody-died-of-sepsis-autopsy-report-idUSKCN1RA2NF [13] https://refugeeweek.org.uk/theme-of-refugee-week-2019/
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