BMJ Open€¦ · Reports on refugee camp patients generally focus on diseases under surveillance,...

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A REFUGEE CAMP IN THE CENTER OF EUROPE: CLINICAL

CHARACTERISTICS OF ASYLUM SEEKERS ARRIVING IN

BRUSSELS

Journal: BMJ Open

Manuscript ID bmjopen-2016-013963

Article Type: Research

Date Submitted by the Author: 20-Aug-2016

Complete List of Authors: van Berlaer, Gerlant; Universitair Ziekenhuis Brussel, Department of Emergency and Disaster Medicine; Vrije Universiteit Brussel Faculteit Geneeskunde en Farmacie, Research Group on Emergency and Disaster Medicine Bohle Carbonell, Francisca; Médecins du Monde / Doctors of the World Belgium , Medical Department, Operations Department Manantsoa, Sofie; Médecins du Monde / Doctors of the World Belgium , Medical Department, Operations Department de Béthune, Xavier; Médecins du Monde / Doctors of the World Belgium , Medical Department, Operations Department Buyl, Ronald; Vrije Universiteit Brussel Faculteit Geneeskunde en Farmacie, Department of Public Health, Biostatistics and Medical Informatics Research Group Debacker, Michel; Universitair Ziekenhuis Brussel, Department of Emergency and Disaster Medicine; Vrije Universiteit Brussel Faculteit Geneeskunde en Farmacie, Research Group on Emergency and Disaster Medicine Hubloue, Ives; Universitair Ziekenhuis Brussel, Department of Emergency and Disaster Medicine; Vrije Universiteit Brussel Faculteit Geneeskunde en Farmacie, Research Group on Emergency and Disaster Medicine

<b>Primary Subject Heading</b>:

Emergency medicine

Secondary Subject Heading: Epidemiology, Global health, Infectious diseases

Keywords: ACCIDENT & EMERGENCY MEDICINE, EPIDEMIOLOGY, International health services < HEALTH SERVICES ADMINISTRATION & MANAGEMENT, Epidemiology < INFECTIOUS DISEASES, PRIMARY CARE, PUBLIC HEALTH

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TITLE PAGE

Full title


CHARACTERISTICS OF ASYLUM SEEKERS ARRIVING IN BRUSSELS

Gerlant van Berlaer 1,2

, Francisca Bohle Carbonell 3, Sofie Manantsoa

3, Xavier de Béthune

3,

Ronald Buyl 3, Michel Debacker

2, Ives Hubloue

1,2

1 Department of Emergency Medicine, Universitair Ziekenhuis Brussel, Brussels, Belgium 2 Research Group on Emergency and Disaster Medicine, Vrije Universiteit Brussel, Brussels, Belgium. 3 Médecins du Monde / Doctors of the World Belgium - Medical Department, Operations Department, Brussels, Belgium. 4 Department of Public Health, Biostatistics and Medical Informatics Research Group, Vrije Universiteit Brussel, Brussels,

Belgium.

Corresponding Author details:

Gerlant van Berlaer, M.D. Laarbeeklaan 101, BE-1090 Brussels, Belgium. [email protected] - tel

+32476284242 - fax +3224775120.

Full addresses co-authors:

Francisca Bohle Carbonell, R.N. rue Botanique 75, BE-1210 Saint-Josse-ten-Noode, Belgium.

[email protected] - +32486089960.

Sofie Manantsoa, R.N. Kruidtuinstraat 75, BE-1210 Sint-Joost-Ten-Node, Belgium.


Xavier de Béthune, M.D., Kruidtuinstraat 75, BE-1210 Sint-Joost-Ten-Node, Belgium.


Ronald Buyl, Ph.D. - Laarbeeklaan 103, BE-1090 Brussels, Belgium. [email protected] - +32495544106.

Michel Debacker, M.D. Laarbeeklaan 101, BE-1090 Brussels, Belgium. [email protected] -

+3224775155.

Ives Hubloue, Ph.D. Laarbeeklaan 101, BE-1090 Brussels, Belgium. [email protected] - +3224775153.

Word count: 3034 words

Abbreviations used:

IBM SPSS International Business Machines Corporation, Statistical Package for Social Science (Chicago,

Illinois, USA).

ICD-10 World Health Organisation International Classification of Diseases version 10

IQR Interquartile range

MdM Médecins du Monde/Doctors of the World

PTSD Post-traumatic Stress Disorder

RC Refugee Camp

UNHCR United Nations High Commission for Refugees

WHO World Health Organisation

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ABSTRACT

Background

In the summer of 2015, the exodus of Syrian war refugees and saturation of refugee camps in neighboring

countries led to the influx of asylum-seekers in European countries, including Belgium. This study aims to

describe their demographic and clinical characteristics.

Hypothesis is that among asylum-seekers in a huddled refugee camp – even in a well-developed country with all

medical facilities – respiratory, digestive and other medical problems typical of refugee camps will emerge soon.

Methods

Using a descriptive cross-sectional study design, physicians of Médecins du Monde prospectively registered age,

gender, origin, medical complaints and diagnoses of all patients presenting to an erected Field Hospital in

Brussels in September 2015. Diagnoses were post-hoc categorized according to the International Classification

of Diseases.

Results

Of 4037 patients examined in the Field Hospital, 3907 were included and analyzed for this study. Over 11% of

patients suffered from injuries, but these were outnumbered by the proportion of patients with respiratory (36%),

dental (9%), skin (9%) and digestive (8%) diagnoses. More than 49% had features of infections at the time of the

consultation.

Conclusion

Asylum seekers arriving in a refugee camp in Brussels after a long and hazardous journey, suffer mostly from

respiratory, dental, skin and digestive diseases. Still one of seven suffers from injury. These findings – consistent

with other reports – should be anticipated when composing Emergency Medical Teams and Interagency

Emergency Health or similar Kits to be used in a Field Hospital, even in a Western European country.

Key words: migration; access to health care; disaster relief; homelessness, international health

STRENGTHS AND LIMITATIONS OF THIS STUDY

The strengths of this study:

- The study includes a considerable number of well documented complaints and physicians' diagnoses in asylum-

seekers arriving in Western Europe.

- Since Belgium registered 5512 asylum-seekers in September 2015, this study sample is of considerable

proportion.

- A literature search reveals that epidemiological studies on health problems of asylum-seekers in Europe are

very scarce.

- At our best knowledge this has not been reported in such detail before.

This study has several limitations:

- The study included only patients self-presenting or referred by Outpatient Assistance Teams to the Field

Hospital in the autumn of 2015, preventing extrapolation to all asylum-seekers and other seasons.

- A number of diagnoses remained tentative, since laboratory and imaging tests were unavailable.

- Patient's anonymity prevented longitudinal follow-up.

- The lack of uniform standards to collect complaints and diagnoses makes comparison with other data sets

challenging.

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MAIN TEXT

INTRODUCTION

Background/rationale

Persons fleeing their home country are considered 'asylum-seekers' until a contracting state is willing to provide

the official status of 'refugee' as disclosed in the Geneva Convention on Refugees.[1]

The continuing exodus from Middle-East countries, driven by the Syrian civil war and overcrowding of refugee

camps in neighboring countries, forced asylum-seekers using any conveyance fleeing towards the European

Union. In the summer of 2015, the number of asylum-seekers in Belgium increased considerably.[2]

People applying for asylum need to register at the Belgian Immigration Office in the center of Brussels, a

necessary step before being entitled to shelter, clothing, food and (medical) assistance. A high daily influx of

asylum-seekers and a limitation to a maximum of 250 registrations per workday created an accumulation of

hundreds, not yet included in the asylum procedure, camping in a park in front of the Belgian Immigration

Office. In a spontaneous humanitarian response, volunteers of the ad hoc "Belgian Civilian Platform" organized

an improvised shelter camp and provided clothing and food.

The Belgian branch of the independent international non-governmental organization Médecins du Monde

(MdM) erected a field hospital in the camp. MdM provided free medical care, psychological and social support,

and sanitary facilities to over 4000 asylum-seekers in September 2015.

Of 5512 requests for asylum registered at the Belgian Immigration Office in September 2015, 482 (9%) were

from unaccompanied minors, and only 628 were granted asylum.[2] Belgium accepted 0.8% of all asylum-

seekers reaching Europe in 2015.[3]

A prerequisite to adopting any evidence-based approach in humanitarian assistance is to assemble solid evidence

from results of relevant empirical studies.[4] Collecting reliable data will always be difficult in emergency

situations, as healthcare providers prioritize treating patients over documenting, and control groups are usually

not available.[4-6]

Reports on refugee camp patients generally focus on diseases under surveillance, or elucidate immediate effects

of disasters (estimated numbers of dead, injured and displaced) and late consequences such as outbreaks and

mental health problems.[6-8] As in every refugee or internally displaced person camp around the world - usually

in third world countries - specific patterns of pathology are to be expected, secondary to poor sanitary conditions

and overcrowding.[8-10] A literature search reveals that epidemiological studies on health problems of asylum-

seekers in Europe are scarce.[8,11-13]

Objectives

This study aims to document demographics of asylum-seekers who arrived in a refugee camp in Brussels in

September 2015; to describe complaints, diagnoses and comorbidities of patients presenting to a Field Hospital;

and to formulate recommendations for future relief operations.

The study hypothesis is that health problems typical for refugee camps will emerge soon, even in a camp set up

in a Western European capital.

MATERIALS AND METHODS

Study design

A retrospective descriptive cross-sectional sample analysis was performed on prospectively obtained medical

records, collected by MdM from September 5th to October 5th 2015. This time interval corresponds to the

period that the refugee camp and Field Hospital were present in Brussels.

The study protocol was approved by the Ethical Committee of the Universitair Ziekenhuis Brussel, Belgium.

Setting

Within the refugee camp, MdM erected a level I Medical Field Hospital, consisting of units for 24/7 ambulatory

healthcare and psychosocial support.[14] The MdM team comprised over 400 physicians, nurses, pharmacists,

logisticians, and translators, most of them volunteers. An Outpatient Assistance Team provided healthcare for

patients not able to leave their tents.

Triage was performed by trained nurses. Each patient was subsequently interviewed and examined by

physicians. Diagnoses were based on complaints and physical examination, as MdM had limited access to

diagnostic capability. Patients were treated on the spot if appropriate, vaccinated when needed, and received

explanations in their own language. Supplies were retrieved from the MdM stockpile and donations. Patients

requiring emergency care, lab tests, medical imaging, or hospitalization were transferred to hospitals in the

Brussels area. Patients requiring follow-up were requested to represent to the Field Hospital or referred to

primary or dental care facilities, or new-born consultations, with referral letters.

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Participants

All patients presenting spontaneously or referred by Outpatient Assistance Teams to the Field Hospital were

eligible for inclusion. Patients with missing date of presentation, chief complaint, or single primary diagnosis

were excluded afterwards. Patients in Belgium are legally considered "minor" when younger than 18, and "child"

when younger than 15 years old.

Variables

A prospectively designed template was used to register data for all patients: age, gender, country of origin, date

of arrival in Belgium, whether and when patients had requested or received an appointment at the Belgian

Immigration Office or were already officially registered as asylum-seeker, location of shelter, all physical and

mental complaints, the “chief complaint”, and all pre-existing comorbidities.[15,16] One primary diagnosis per

patient was recorded according to a list of 50 possible diagnoses, adapted from case descriptions in the WHO

"Communicable disease control in emergencies" field manual, the Sphere Project Handbook, and a template

used in previous humanitarian operations.[15,17,18] Post-hoc, trained physicians classified these diagnoses into

categories, adapted from ICD-10 as described in table 2.[19] All patients with clinical signs of local or

generalized infection were classified as a subgroup of "infectious diseases". Finally, referral was recorded.

Data sources

MdM trained all personnel in collecting data, which were anonymised according to the Helsinki Declaration, and

introduced in an Excel® database.[5] A data sharing and research collaboration agreement was signed between

MdM and the Research Group on Emergency and Disaster Medicine, Vrije Universiteit Brussel, Belgium.

Bias

Data were recorded by different healthcare providers, and the anonymous records did not allow distinguishing

patients possibly inserted twice, potentially introducing sampling bias. Diagnoses were classified post-hoc,

possibly introducing categorization bias.

Statistical methods Patients with missing or unreadable data were excluded. Descriptive statistics for discrete outcome variables

were presented as frequencies (n), proportions (%), and for quantitative variables (age, number of patients) as

measures of central tendency and dispersion (median, range, interquartile range IQR). The analyses were broken

down for age categories (<5, 5-14, and >15years old), gender, and period (weeks).

Multiple logistic regression analysis was performed to identify factors associated with the asylum-seekers’ health

problems, by using 'infection' as an outcome variable, by using origin (other versus Syria, Iraq, Morocco and

Afghanistan), age category (0-15, >15 years old) and gender as predictors. Analyses were carried out by using

IBM® SPSS® v23.0. All tests were performed using an α-level of 0.05.

RESULTS

Participants

MdM examined 4037 patients in total, with a median of 137 per day (range 23-199) as shown in Supplementary

Figure 1. After exclusion of 130 incomplete forms, 3907 patients were included and analyzed.

Descriptive data

Of all included patients, 3355 (86%) were male, 510 (13%) were female; from 42 (0.8%) the gender was

unknown. Median age was 28 years (range 0-93;IQR 12). As Figure 1 and Supplementary Figure 2 illustrate:

78% (n=3049) were adult men, 9% (n= 355) adult women and over 10% (n=391) minors, of whom 303 children

(8%); including 149 (4%) aged 5-14, and 153 (4%) aged under five. The age of 86 (2%) adults and children was

unknown.

Figure 1: Age distribution of patients by gender

The region of origin is presented in Figure 2. Patients came from 63 different countries (as presented in

Supplementary Figure 3), but most from Iraq (n=1950/3778;52%), Syria (n=737;20%), Morocco (n=365;10%),

Afghanistan (n=117;3%), and Palestine (n=96;3%). Some 1% (n= 42) were stateless or came from other

continents.

Figure 2: Regions of origin of asylum-seekers (%)

The time interval between arrival in Belgium and consultation, the state of asylum procedure and location of

shelter are presented in Table 1.

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Table 1: Demographic and social details of the sample

n %

Time interval of arrival in

Belgium

0-7 days 2251 57·6

8-31 days 629 17·7

32-365 days 338 8·7

>365 days 240 6·1

Unknown 386 9·9

Asylum procedure

Appointment at BIO to start procedure 1292 33·1

No appointment at BIO to start procedure 1006 25·7

Asylum procedure initiated, waiting for decision 167 4·3

Asylum request denied 69 2·3

Not applicable 91 2·3

Unknown 1282 32·8

Location of accommodation

Brussels refugee camp (tents) 2209 57·8

Other refugee camps 495 13·0

Governmental asylum-seeker centres 362 9·3

Open air 77 2·0

Relatives and friends 29 0·7

Foster family 17 0·4

Other 51 1·3

Unknown 576 14·7

BIO: Belgian Immigration Office

Outcome data

A total of 5768 complaints (106 different types) were recorded: 2486 patients (64%) had one single complaint,

1039 (27%) expressed two, 320 (8%) three, and 61 (2%) four or more complaints.

Most common complaints were: cough (n=619/3907;16%), sore throat (n=590;15%), tooth pain (n=406;10%),

rhinorrhea (n=397;10%), headache (n=374;10%), limb pain (n=248;6%), skin wounds (n=236;6%), flu-like

symptoms (n=154;4%), accidental trauma (n=151;4%), lack of chronic medication (n=138;4%), and abdominal

pain (n=130;3%). Some 3% complained of fever (n=101), 2% of anxiety (n=82), and more than 3% (n=126)

represented for follow-up.

Categorized according to ICD-10, 56% of all patients expressed respiratory complaints (n=2198), 12% had

digestive complaints (n=482), 12% had musculoskeletal complaints (n=458), 11% was injured (n=429), 11% had

neurological complaints (n=427), 10% had skin problems (n=406), and 10% expressed dental complaints

(n=406).[19] All other categories represented less than 5% of all patients.

More than 7% of patients reported comorbidities (n=279), most commonly arterial hypertension (n=103) and/or

diabetes (n=96). Patients also reported asthma (n=19), old fractures (n=15), epilepsy (n=14), rheuma (n=10),

recent delivery (n=7), neoplasms (n=6), gastrointestinal (n=5), genitourinary (n=4), or mental disorders (n=3).

Of patients with interrupted maintenance treatment (n= 138), 72 had comorbidities: diabetes (24), hypertension

(14), asthma (12), epilepsy (8), psychiatric disorders (2) and withdrawal (2). Seven reported lost eyewear, six

infants lacked pediatric formula.

Main results

As represented in Figure 3 and Table 2, the most common primary diagnoses consisted of upper respiratory tract

infections (31%), dental caries (8%), skin infections (8%), gastroenteritis (7%), skin wounds and burns (6%),

musculoskeletal disorders (6%), accidental trauma (6%). Mental disorders were present in 2%. No patient died,

one was resuscitated, and 35 (1%) were victims of intentional violence in their country of origin, or during the

journey to Brussels. Two women had just delivered and five new-born babies attended.

Figure 3: Twenty most common primary diagnoses observed in asylum-seekers (%)

Table 2 and Figure 4 indicate the distribution of diagnostic categories. The most frequent were respiratory

disorders (35.5%), far ahead of injury (11.6%), dental (9.5%), skin (8.6%), digestive (7.8%), and

musculoskeletal diagnoses (6.1%). In 19 cases (0.5%) there was no actual medical or mental diagnosis, but the

patient requested personal attention or sought assistance for social problems.

Analysis of the distribution of diagnostic categories per week did not reveal any considerable changes over time.

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Table 2: Diagnostic categories, primary diagnoses and case descriptions

CATEGORY n % PRIMARY DIAGNOSIS n % CASE DESCRIPTIONS

NO DIAGNOSIS 19 0·5 no medical diagnosis 19 0·5 social problem, attention seeker

RESPIRATORY 1388 35·5

upper respiratory tract infection 1199 30·7 ear, nose, throat, sinus, larynx infections, flu (upper ARI)

lower respiratory tract infection 120 3·1 dyspnoea, and raised respiratory rate, signs of lower ARI

asthma exacerbation 69 1·8 wheezing and/or respiratory oppression

EYE & ADNEXA 67 1·7 eye disorder 65 1·7 eye infection and irritation

vision problem 2 0·1 diminished or troubled vision, blindness

DENTAL 372 9·5 dental abscess 56 1·4 clinical suspicion of dental abscess

dental caries 316 8·1 caries with or without pain

DIGESTIVE 303 7·8

watery diarrhea/abdominal 281 7·2 loose stools, vomiting, abdominal pain, intestinal parasitosis

bloody diarrhoea 5 0·1 loose stools with visible blood (suspicion of dysentery)

malnutrition 15 0·4 clinical, weight/height >70% or MUAC <110/160 (child/adult)

cholera 0 0·0 severe dehydrating diarrhoea/confirmed case non-endemic area

jaundice 2 0·1 acute onset of icterus (skin, conjunctivae, urine)

NEUROLOGICAL 142 3·6

suspected meningitis 1 0·0 fever and clinical signs of meningeal irritation

flaccid paralysis 0 0·0 child ≥1 limb(s) (incl· Guillain Barré) or any age polio suspicion

CVA, headache, convulsions 141 3·6 headache, convulsions, stroke, coma

GENITOURINARY 97 2·5

sexual transmittable disease 19 0·5 suspected STD, vaginal infections with fluor, genital infection

urinary tract infection 59 1·5 dys-, alg-, pollakisuria, with/without fever, flank pain, or + dipstick

gynaecological disorder 19 0·5 irregular menses, breast problems, vaginal bleeding, abortion

PERIPARTUM 28 0·7

neonatal illness 1 0·0 newborns with problems

neonatal tetanus 0 0·0 neonate not sucking/crying normally, rigidity, convulsions

healthy new-born baby 4 0·1 healthy baby <3 weeks old

delivery 2 0·1 Mother: imminent delivery or post-partum (<3 weeks)

(presumed) pregnant 21 0·5 suspected or confirmed pregnancy

SKIN 335 8·6 skin infection 294 7·5 redness, pain, abcedation with signs of local infection

skin affection 41 1·0 redness, xerosis, urticaria, psoriasis without infection

GENERAL 154 3·9

surgical cases other than trauma 24 0·6 herniations, swollen testicles, cysts, haemorrhoids,…

fever of unknown origin 9 0·2 >37·,5°C axillary or > 38·0°C rectal, without specific diagnosis

malaria 0 0·0 confirmed or suspected malaria, simple or serious

measles 0 0·0 fever and clinical suspicion of measles (vaccinated or not)

clinical anaemia 3 0·1 history, pallor, weakness

diabetes 70 1·8 diabetes as main problem, or crisis/ketoacidosis

other 35 0·9 all that is not classified elsewhere

intoxication 8 0·2 suspected or confirmed substance abusus

neoplasm 5 0·1 suspected or confirmed oncological disease

MENTAL 76 1·9 mental disorder 76 1·9 PTSD, insomnia, stress, suspicious aspecific complaints

VIOLENCE 35 0·9 trauma from aggression 34 0·9 trauma due to intentional individual injury including rape

CBRN 1 0·0 injury from chemical/biological/radiological/nuclear assaults

INJURY 454 11·6 accidental trauma 213 5·5 accidental trauma from incident, accident (non-violent trauma)

acute wounds 241 6·2 non-intentional acute skin wounds, burns

MUSCULOSKELETAL 239 6·1 musculoskeletal disorder 239 6·1 non-traumatic pain (muscles, back, pelvic belt, joints), rheuma

CIRCULATORY 71 1·8 hypertension/cardiac disorder 71 1·8 symptomatic hypertension, palpitations, angina pectoris

FATALITY 1 0·0 resuscitation 1 0·0 any condition requiring resuscitation of vital functions

death 0 0·0 deceased patients

FOLLOW-UP CASES 126 3·2

follow-up wound dressings 57 1·5 follow-up of wound dressings and injections / vaccinations

follow-up fractures & casts 18 0·4 follow-up old fractures & casts cases

follow-up other 51 1·3 follow-up of chronic illness, other cases

TOTAL 3907 100 Total 3907 100

subanalysis

infectious cases 1900 48·6 all cases with features of infection

ARI: acute respiratory infection, MUAC: middle upper arm circumference, CVA: cerebrovascular accident, incl:

including, STD: sexually transmittable disease, PTSD: post-traumatic stress disorder, CBRN: chemical-burns-

radiological-nuclear incidents, +: positive

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Figure 4: Proportion of diagnostic categories observed in asylum-seekers (%)

Subgroup analyses

Features of infection were found in 1900 (49%) patients, with an even higher frequency (63%) in children

younger than five.

The multiple logistic regression analysis in Table 3 shows that asylum-seekers from Syria and Iraq, and children

have a higher risk for infection.

Table 3: Predictive factors for infectious diseases from a multiple logistic regression analysis

O.R. 95% C.I. of O.R.

p-value Lower Upper

Origin (reference: other countries) Syria 1·91 1·54 2·38 <0·0001

Iraq 1·85 1·54 2·21 <0·0001

Morocco 0·99 0·76 1·29 0·95

Afghanistan 1·42 0·95 2·12 0·09

Gender (reference: male) female 0·77 0·63 0·95 0·01

Age (reference ≥15 years old) <15 years old 1·64 1·28 2·10 <0·0001

C.I. confidence interval; O.R. odds ratio

Children aged under five represented 4% of the population, with equally distributed gender and a median age of

two (range 0-5;IQR 3). The majority originated from Middle-East countries (n=118;77%), median time in

Belgium was three days (range 0-1500;IQR 9), and most sheltered in tents (n=94;61%). The distribution of

diagnostic categories indicates that 50% had respiratory diseases (n=76), 20% digestive disorders (n=30), 14%

skin disorders (n=21), and 7% suffered from injuries (n=10). Five (3%) were newborns of which one had to be

hospitalized for bronchiolitis with severe dyspnea.

Patients were asked to represent for follow-up in 3% cases (n=121) to the Field Hospital, and in 4% (n=152) to

ambulant consultations, mainly for arterial tension and blood glucose measurements. Referrals were organized

for 412 patients (11%): 205 to dentists (5%), 117 (3%) to Emergency Departments, 70 to psychotherapists (2%),

and 20 (0.5%) to mother & new-born care consultations. Children younger than five were referred 27 times (18%

of young children): 15 to ambulant follow-up, six to new-born consultations, and two each to Emergency

Departments, dentists, and psychiatrists.

DISCUSSION

Key results Most asylum-seekers arriving in Brussels were young men, contrasting to the usual population distribution in

internally displaced persons and refugee camps (50% children, 30% women and 20% men).[17] The shortest

route between Syria and Brussels is 4000 kilometers, unsuited for children, women, and older men, who rather

remained in refugee camps near their country of origin.[9,20-23]

Almost half of the asylum-seekers, and two thirds of children younger than five suffered from infections. The

multiple logistic regression analysis suggests that asylum-seekers from Syria and Iraq, and children have a

higher risk of infection. Also, the Immigration Office registration delay postponed entitlement to shelter, food,

and (medical) assistance, and the encampment in austere conditions possibly contributed to the large proportion

of infections.[10,11,24]

The overwhelming presence of (mostly upper) acute respiratory infections (ARI) is consistent with existing

reports as visualized in table 4.[8,9,12,13,15,20,25] A possible explanation is that most people from the Middle-

East and Africa arrived in autumn, in a cold and rainy environment, and were confronted with the typical

respiratory viruses of Western Europe, they were never exposed to before.[11,24] Because of huddling in

refugee camps, and many patients coughing, these viruses spread rapidly.[11] This carries a possible burden, as

acute respiratory infections are a major cause of morbidity and mortality among displaced people.[25]

Contrarily, the same conditions did not result in a similar spread of intestinal, genitourinary or eye infections, as

is usually seen in internally displaced persons or refugee camps.[12,15,23,24] This was possibly owing to

appropriate management of sanitary facilities by MdM.

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The important share of dental problems is unusually high for any refugee camp, but consistent with other reports

on Syrian refugees.[9,13,26] It must be considered that most patients were Iraqi who already fled their country

after the 2002 invasion to become refugees in Syria, where access to dental or any health care was limited.[9,27]

Their long exhausting travel with limited healthcare facilities might have contributed to transform caries into

dental abscesses.

While undertaking their journey, many of the asylum-seekers halted in several different camps along the way,

sleeping in any fleabag they could find, possibly resulting in the many scabies infections observed.[8,11,12,23]

The proportion of skin infections is consistent with available European reports, but higher than seen in other

internally displaced persons and refugee populations analyzed the same way.[8,12,15]

Violent trauma, injuries and musculoskeletal problems were present in almost 20% of the asylum-seekers, with a

wide variety of causes: accidental trauma was usually from falls, not always related to the journey; acute wounds

were either blisters on feet from walking long distances, or infected wounds caused by barbed wire.[28] The

musculoskeletal issues - back and limb pain in young men - were often related to the journey as

well.[8,10,12,20] The number of war-related injuries was limited; most had been treated long before arrival in

Brussels.[20]

The proportion of mental disorders was rather low (2%), in contrast to other studies reporting incidences of up to

one third.[8,10,22,29,30] Possibly, language barriers, the limited time per consultation, and the fact that most

patients were young men from Middle East countries - not easily expressing emotions to strangers in tents -

might have contributed to this low proportion. We do suspect underreporting of mental problems, as MdM

recorded more use of psychological consultations in the Field Hospital than registered in this study.

Table 4: Comparison of proportional ranges found in other studies on RC and IDP populations (%)

study situation

Res

pir

ato

ry

Ey

e &

adn

exa

Den

tal

Dig

esti

ve

Gen

ito

ruri

nar

y

Sk

in

Men

tal

Vio

len

ce

Inju

ry

Musc

ulo

skel

etal

Cir

cula

tory

Infe

ctio

us

case

s

NC

D

Nu

mber

this study RC in Brussels 35·5 1·7 9·5 7·8 2·5 8·6 1·9 0·9 12·5 6·1 1·8 48·6 7·0 3907

ranges in literature

3-56 2-12 4-21 4-12 3-8 2-9 0-38 0-3 1-39 0-15 1-22 6-90 2-50

Alberer M et al12 RC in Germany 23·0 3·6 3·5 9·7 5·3 7·7 1·1

7·7 2·2 39·9 2·6 548

Marquard L et al13 Refugee minors in Germany

20·6

13·7

58·8 <2·0 102

Bischoff A et al8 Refugees in Switzerland 14·1

8·8 13·7 8·6 14·5 4·4 6·3

979

Escobio F et al20 MSF on Balkan route 25·0

30·0

3500

Mateen F et al9 Refugees in Jordan 11·0 10·0 12·1

3·0

1·3 3·4

9·0 22·0 <7·0 11-22 7642

McKenzie E at al29 Refugees in Jordan

1·8

2526

Doocy S et al21 Refugees in Jordan

50·3 1550

Gammouth O et al22 Jordan RC

29·5

30·3 765

UNHCR23 RC in Jordan 29·7 2·2 2·7 5·6 3·5 1·3 0·5 4·3 5·3 72·1 21·8 694280

UNHCR23 RC in Iraq 56·4 3·3

11·7 4·7 4·8 0·5 0·2 2·2 0·1 3·2 89·6 7·4 127401

UNHCR23 RC in Lebanon 27·1 4·5 3·0 4·6 1·4 0·1 0·9 2·0 89·3 8·3 52060

North C et al30 Review mental health*

11-38

222 studies

Bellos A et al25 Review ARI in crises* 3-55

36 studies

Calvasina P et al26 Immigrants in Canada* 9·4 2126

van Berlaer G et al15 FH & IDP in Haiti* 16·5 4·2

10·7 6·8 4·0 2·5 0·0 38·7

1·7 37·8 3·3 2795

RC: refugee camp, NCD: non-communicable diseases, MSF: Médecins Sans Frontières, ARI: acute respiratory

infections, FH: field hospital, IDP: internally displaced persons; * = studies on IDP and refugees not from the Syrian

crisis

We did not detect a changing pattern of diagnostic categories over time, possibly because the population of the

camp was replaced regularly with new arrivals.

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An important part (3%) needed referral to EDs for varying reasons: suspected fractures, stitches (as stitching in

field hospitals encompass risks of wound infection), pneumonia, confusion, and convulsions or syncope,

oncologic patients who ran out of maintenance treatment. Many referrals were made to dentists' offices, as well

as to psychiatrists-psychologist when signs of post-traumatic stress disorder were present. Referrals to ambulant

consultations were ordinarily for deregulated diabetes and arterial hypertension.

The prevalence of 7% of non-communicable chronic diseases (mainly diabetes, hypertension and asthma) found

in this study population was lower than the range in earlier reports, possibly due to the limited number of aged

asylum-seekers.[21] Some 138 patients (4%) lacked maintenance treatment medication, of which 72 had chronic

comorbidities like diabetes and hypertension, and were therefore at risk for deregulation of their clinical

condition.

Only 19 enrolled patients (0.5%) did not get a specific medical diagnosis, but were categorized as seeking

attention or non-medical support. This is a much lower proportion than reported in Switzerland by Bischoff and

colleagues.[8]

It is difficult to draw conclusions from this study about the importation of communicable diseases, one of the

mythical concerns raised about immigrants.[8,10,11] Belgium screens asylum-seekers for tuberculosis, but not

for human immunodeficiency virus, measles, polio, or pertussis, diseases usually quoted in the context of

refugees.[8,12,24,27] Whenever suspicion was raised patients were transferred to hospitals for investigation.

None of these tests yielded positive results in September 2015.

Limitations and strengths This study has several limitations. The study included only patients self-presenting or referred by Outpatient

Assistance Teams to the Field Hospital in the autumn of 2015, preventing extrapolation to all asylum-seekers

and other seasons. A number of diagnoses remained tentative, since laboratory and imaging tests were

unavailable. Patient's anonymity prevented longitudinal follow-up. The lack of uniform standards to collect

complaints and diagnoses makes comparison with other data sets challenging.[6,7]

The strength of this study is the considerable number of well documented complaints and physicians' diagnoses

in asylum-seekers arriving in Western Europe. At our best knowledge this has not been reported in such detail

before. Since Belgium registered 5512 asylum-seekers in September 2015, this study sample is of considerable

proportion.[2]

Interpretation Asylum seekers arriving in a refugee camp in Brussels after a long and hazardous journey suffer mostly from

respiratory, dental, skin and digestive diseases, and one of seven is injured. Half of this population shows

features of infection; with asylum-seekers from Syria and Iraq, and children being most vulnerable.

The high proportion of respiratory diseases, as in any internally displaced persons or refugee camp worldwide,

urges to take acute respiratory infection preventive measures: adequate shelter, overcrowding reduction,

malnutrition prevention and treatment, and scaling up vaccination coverage, in order to meet the Health 2020

policy framework goals.[24,25] Adequate sanitary facilities are imperative to prevent the spread of infections.

Early and resolute healthcare may avoid short and long term complications of infectious, dental, mental, and

mother & child problems, which otherwise could lead to higher healthcare expenditure for the hosting

population.[10,20]

In Emergency Medical Teams treating asylum-seekers there is an early role for general and emergency

physicians, pediatricians, gynecologists, midwives, dentists, and interpreters.[9,13,25-27] Scaling up with

diabetes and hypertension specialists and psychologists is recommended.[6,8,10,21,22,29,30] In our experience,

volunteers are much easier recruited for the first group.

Generalisability

The results of this study can help to better organize healthcare for asylum-seekers residing in camps, particularly

with respect to the composition of the medical assistance teams and the medical resources.[6,7] However, in

order to meet the specific and changing needs of asylum-seekers arriving in Europe, more research is needed to

compare and confirm our findings.

The development of a standardized template to prospectively collect and subsequently analyse and report health

might make a substantial contribution to provide the evidence base for the effectiveness and efficiency of the

preparation, management and mitigation of humanitarian emergencies.[4,6,7,16]

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ACKNOWLEDGMENTS

Competing interests

The authors declare that they have no competing interests to declare.

Funding There was no funding source for this study.

Fees for open access publication will be paid by the Research Group on Emergency and Disaster Medicine, Vrije

Universiteit Brussel, Brussels, Belgium.

World Health Organization Standards for registration of all human medical research

All authors have completed the Unified Competing Interest form atwww.icmje.org/coi_disclosure.pdf (available

on request from the corresponding author).

Registration of the study

Trial ID ISRCTN 13523620.

Ethical approval Approval of the Commission of Medical Ethics (O.G. 016) of the Universitair Ziekenhuis Brussel, Brussels,

Belgium was obtained (B.U.N. 143201526433).

Informed Consent and patient details

The free and informed consent of the subjects and/or their legal guardians was obtained before their inclusion in

this study. No details on individual patients are given in the manuscript; all patients were anonymised in the

registry and database according to the Helsinki Declaration..

Data sharing statement

A data sharing and research collaboration agreement was signed between Médecins du Monde and the Research

Group on Emergency and Disaster Medicine, Vrije Universiteit Brussel, Belgium.

The corresponding author, Gerlant van Berlaer, had full access to all the data in the study and had final

responsibility for the decision to submit for publication.

Availability of data and materials

The dataset supporting the conclusions of this article is available from the corresponding author on simple

request.

Submission declaration and verification

Our work has not been published previously, and is not under consideration for publication elsewhere. Its

publication is approved by all authors and tacitly or explicitly by the responsible authorities where the work was

carried out, and that, if accepted, it will not be published elsewhere in the same form, in English or in any other

language, including electronically without the written consent of the copyright-holder.

Open access

The authors prefer to publish "open access". Upon acceptance of the manuscript, the authors will complete an

exclusive 'License Agreement'.

Authorship: individual contributions of each author

- conception and design of the study: GvB, FBC, SM, RB

- acquisition of data: GvB, FBC, SM, XdB

- analysis and interpretation of data: RB, GvB, XdB, SM

- drafting the article: GvB, FBC, SM, XdB, RB

- revising the manuscript: SM, XdB, RB, MDB, IH

- final approval of the version submitted: GvB, FBC, SM, XdB, RB, MDB, IH

GvB was responsible for the study setup, was main investigator and principal author of the article. As the

guarantor of the paper, GvB accepts full responsibility for the work and the conduct of the study; he had access

to the data, and controlled the decision to publish.

FBC designed the prospective patient files, was responsible for the training of the data collectors, and for the

correct collection of data. She wrote parts of the methods and data interpretation section.

SM is the Medical Coordinator for Belgian projects of Médecins du Monde (Doctors of the World) in Brussels,

and contributed to the text regarding background, methods and discussion.

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XdB is the Medical Director of Médecins du Monde (Doctors of the World) in Brussels, and was responsible for

the final check of results, and the build-up and editing of the discussion section.

RB is professor in biostatistics and medical informatics, invaluable for the setup of the study, the processing of

the data, and for the interpretation of the results, including appropriate statistics and graphics.

MD and IH, both professors of the European Master in Disaster Medicine, corrected the setup and finalisation of

the study, contributed with scientific remarks, helped finding the appropriate references and made many

corrections to the final text.

FIGURES LEGENDS





APPENDICES (not to be published)

- Approval of the Commission of Medical Ethics (O.G. 016) of the Universitair Ziekenhuis Brussel, Brussels,

Belgium. B.U.N. 143201526433.

- Data Sharing and Research Collaboration Agreement signed between Médecins du Monde and the Research


- STROBE statement form.

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1 United Nations High Commissioner for Refugees (UNHCR). Convention and Protocol relating to the

Status of Refugees. Geneva, Switzerland: Office of the UNHCR, Communications and Public

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2 Office of the Commissioner General for Refugees and Stateless Persons. Asylum statistics September

2015. Available at http://www.cgra.be/sites/default/files/asylumstat_september_2015.pdf . Last

accessed June 29th 2016.

3 European Commission, Eurostat. Record number of over 1.2 million first time asylum seekers registered

in 2015. Available at http://ec.europa.eu/eurostat/web/products-press-releases/-/3-04032016-AP. Last


4 Debacker M, Hubloue I, Dhondt E, et al. Utstein-style template for uniform data reporting of acute

medical response in disasters. PLoS Curr 2012; 4:e4f6cf3e8df15a.

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6 Gerdin M, Clarke M, Allen C, et al. Optimal Evidence in Difficult Settings: Improving Health

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Switzerland: an epidemiological study. Eur J Public Health 2009;19:59-64.

9 Mateen F, Carone M, Al-Saedy H, et al. Medical conditions among Iraqi refugees in Jordan: data from

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451.

10 Langlois E, Haines A, Tomson G, Ghaffar A. Refugees: towards better access to health-care services.

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11 Stich A. Coming in to the cold - Access to health care is urgently needed for Syrian refugees. Travel

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12 Alberer M, Wendeborn M, Löscher T, Seilmaier M. Erkrankungen bei Flüchtlingen und

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13 Marquardt L, Krämer A, Fischer F, Prüfer-Krämer L. Health status and disease burden of

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Med Int Health 2016;21:210–218.

14 Norton I, von Schreeb J, Aitken P, Herard P, Lajolo C. Classification and minimum standards for

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15 van Berlaer G, Staes T, Danschutter D, et al. Disaster preparedness and response improvement:

comparison of the 2010 Haiti earthquake-related diagnoses with baseline medical data. Eur J Emerg

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16 Mowafi H, Dworkis D, Bisanzo M, et al. Making recording and analysis of chief complaint a priority

for global emergency care research in low-income countries. Acad Emerg Med 2013;20:1241–1245.

17 Connolly MA, ed. Communicable disease control in emergencies: a field manual. Geneva: World

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18 The Sphere Project. Sphere Handbook 2011 (English). Available at

http://www.sphereproject.org/handbook/. Last accessed June 29th 2016.

19 WHO. International statistical classification of diseases and health related problems: 10th

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WHO Geneva 2010.

20 Escobio F, Echevarria J, Rubaki S, Viniczai V. Health assistance of displaced people along the Balkan

route. Lancet 2015;386:2475.

21 Doocy S, Lyles E, Roberton T, Akhu-Zaheya L, Oweis A, Burnham G. Prevalence and care-seeking for

chronic diseases among Syrian refugees in Jordan. BMC Public Health 2015;15:1097.

22 Gammouh O, Al-Smadi A, Tawalbeh L, Khoury L. Chronic diseases, lack of medications, and

depression among Syrian refugees in Jordan, 2013-2014. Prev Chronic Dis 2015;12:E10.

23 UNHCR. At a glance: health data for Syrian refugees (Iraq, Jordan and Lebanon). UNHCR 2014.

Available at https://data.unhcr.org/syrianrefugees/download.php?id=5635. Last accessed June 29th

2016.

24 Connolly M, Gayer M, Ryan M, Salama P, Spiegel P, Heymann D. Communicable diseases in complex

emergencies: impact and challenges. Lancet 2004;364:1974–83.

25 Bellos A, Mulholland K, O'Brien K, Qazi S, Gayer M, Checchi F. The burden of acute respiratory

infections in crisis-affected populations: a systematic review. Confl Health 2010;4:3.

26 Calvasina P, Muntaner C, Quiñonez C. The deterioration of Canadian immigrants' oral health: analysis

of the Longitudinal Survey of Immigrants to Canada. Community Dent Oral Epidemiol 2015;43:424–

32.

27 Ben Taleb Z, Bahelah R, Fouad FM, Coutts A, Wilcox M, Maziak W. Syria: health in a country

undergoing tragic transition. Int J Public Health 2015;60:S63–72.

28 Smith J, Daynes L. Borders and migration: an issue of global health importance. Lancet Glob Health

2016;4:e85–6.

29 McKenzie E, Spiegel P, Khalifa A, Mateen F. Neuropsychiatric disorders among Syrian and Iraqi

refugees in Jordan: a retrospective cohort study 2012-2013. Confl Health 2015;9:10.

30 North CS, Pfefferbaum B. Mental health response to community disasters: a systematic review. JAMA

2013; 310:507–518.

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195x133mm (150 x 150 DPI)

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199x124mm (150 x 150 DPI)

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180x115mm (150 x 150 DPI)

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184x101mm (150 x 150 DPI)

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Page 1 of 2

ONLINE ONLY SUPPLEMENTARY MATERIAL Supplementary Figure 1: Daily number of consultations (n)

Supplementary Figure 2: Distribution of patients between adult men, women and minors (<18 years old)

0

20

40

60

80

100

120

140

160

180

200

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

evacuation of the camp

men 78%

women 9%

minors 10%

unknown 3%

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Supplementary Figure 3: Countries of origin of asylum-seeking patients in Belgium in September 2015 (n)

1938

729

361

114 94 71 64 49 48 36 24 22 20 19 17 16 15 14 13 13

144

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1

STROBE Statement—checklist of items that should be included in reports of observational studies

Item

No

Page

No Recommendation

Title and abstract 1 1,2 (a) Indicate the study’s design with a commonly used term in the title or

the abstract

2 (b) Provide in the abstract an informative and balanced summary of what

was done and what was found

Introduction

Background/rationale 2 3 Explain the scientific background and rationale for the investigation being

reported

Objectives 3 3 State specific objectives, including any prespecified hypotheses

Methods

Study design 4 3 Present key elements of study design early in the paper

Setting 5 3 Describe the setting, locations, and relevant dates, including periods of

recruitment, exposure, follow-up, and data collection

Participants 6 4 (a) Cohort study—Give the eligibility criteria, and the sources and

methods of selection of participants. Describe methods of follow-up

Case-control study—Give the eligibility criteria, and the sources and

methods of case ascertainment and control selection. Give the rationale for

the choice of cases and controls

Cross-sectional study—Give the eligibility criteria, and the sources and

methods of selection of participants

n/a (b) Cohort study—For matched studies, give matching criteria and number

of exposed and unexposed

Case-control study—For matched studies, give matching criteria and the

number of controls per case

Variables 7 4 Clearly define all outcomes, exposures, predictors, potential confounders,

and effect modifiers. Give diagnostic criteria, if applicable

Data sources/

measurement

8* 4 For each variable of interest, give sources of data and details of methods

of assessment (measurement). Describe comparability of assessment

methods if there is more than one group

Bias 9 4 Describe any efforts to address potential sources of bias

Study size 10 4 Explain how the study size was arrived at

Quantitative variables 11 4 Explain how quantitative variables were handled in the analyses. If

applicable, describe which groupings were chosen and why

Statistical methods 12 4 (a) Describe all statistical methods, including those used to control for

confounding

4-5 (b) Describe any methods used to examine subgroups and interactions

4-5 (c) Explain how missing data were addressed

4-5 (d) Cohort study—If applicable, explain how loss to follow-up was

addressed

Case-control study—If applicable, explain how matching of cases and

controls was addressed

Cross-sectional study—If applicable, describe analytical methods taking

account of sampling strategy

4-5 (e) Describe any sensitivity analyses

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2

Results

Participants 13* 4 (a) Report numbers of individuals at each stage of study—eg numbers potentially

eligible, examined for eligibility, confirmed eligible, included in the study,

completing follow-up, and analysed

4-5 (b) Give reasons for non-participation at each stage

n/a (c) Consider use of a flow diagram

Descriptive data 14* 4-6 (a) Give characteristics of study participants (eg demographic, clinical, social) and

information on exposures and potential confounders

4-6 (b) Indicate number of participants with missing data for each variable of interest

n/a (c) Cohort study—Summarise follow-up time (eg, average and total amount)

Outcome data 15* n/a Cohort study—Report numbers of outcome events or summary measures over time

n/a Case-control study—Report numbers in each exposure category, or summary

measures of exposure

5 Cross-sectional study—Report numbers of outcome events or summary measures

Main results 16 5-7 (a) Give unadjusted estimates and, if applicable, confounder-adjusted estimates and

their precision (eg, 95% confidence interval). Make clear which confounders were

adjusted for and why they were included

n/a (b) Report category boundaries when continuous variables were categorized

5-7 (c) If relevant, consider translating estimates of relative risk into absolute risk for a

meaningful time period

Other analyses 17 7 Report other analyses done—eg analyses of subgroups and interactions, and

sensitivity analyses

Discussion

Key results 18 7-9 Summarise key results with reference to study objectives

Limitations 19 9 Discuss limitations of the study, taking into account sources of potential bias or

imprecision. Discuss both direction and magnitude of any potential bias

Interpretation 20 9 Give a cautious overall interpretation of results considering objectives, limitations,

multiplicity of analyses, results from similar studies, and other relevant evidence

Generalisability 21 9 Discuss the generalisability (external validity) of the study results

Other information

Funding 22 10 Give the source of funding and the role of the funders for the present study and, if

applicable, for the original study on which the present article is based

*Give information separately for cases and controls in case-control studies and, if applicable, for exposed and

unexposed groups in cohort and cross-sectional studies.

Note: An Explanation and Elaboration article discusses each checklist item and gives methodological background and

published examples of transparent reporting. The STROBE checklist is best used in conjunction with this article (freely

available on the Web sites of PLoS Medicine at http://www.plosmedicine.org/, Annals of Internal Medicine at

http://www.annals.org/, and Epidemiology at http://www.epidem.com/). Information on the STROBE Initiative is

available at www.strobe-statement.org.

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CHARACTERISTICS OF ASYLUM SEEKERS ARRIVING IN

BRUSSELS

Journal: BMJ Open

Manuscript ID bmjopen-2016-013963.R1

Article Type: Research

Date Submitted by the Author: 10-Oct-2016

Complete List of Authors: van Berlaer, Gerlant; Universitair Ziekenhuis Brussel, Department of Emergency and Disaster Medicine; Vrije Universiteit Brussel Faculteit Geneeskunde en Farmacie, Research Group on Emergency and Disaster Medicine Bohle Carbonell, Francisca; Médecins du Monde / Doctors of the World Belgium , Medical Department, Operations Department Manantsoa, Sofie; Médecins du Monde / Doctors of the World Belgium , Medical Department, Operations Department de Béthune, Xavier; Médecins du Monde / Doctors of the World Belgium , Medical Department, Operations Department Buyl, Ronald; Vrije Universiteit Brussel Faculteit Geneeskunde en Farmacie, Department of Public Health, Biostatistics and Medical Informatics Research Group Debacker, Michel; Universitair Ziekenhuis Brussel, Department of Emergency and Disaster Medicine; Vrije Universiteit Brussel Faculteit Geneeskunde en Farmacie, Research Group on Emergency and Disaster Medicine Hubloue, Ives; Universitair Ziekenhuis Brussel, Department of Emergency and Disaster Medicine; Vrije Universiteit Brussel Faculteit Geneeskunde en Farmacie, Research Group on Emergency and Disaster Medicine

<b>Primary Subject Heading</b>:

Emergency medicine

Secondary Subject Heading: Epidemiology, Global health, Infectious diseases

Keywords: ACCIDENT & EMERGENCY MEDICINE, EPIDEMIOLOGY, International health services < HEALTH SERVICES ADMINISTRATION & MANAGEMENT, Epidemiology < INFECTIOUS DISEASES, PRIMARY CARE, PUBLIC HEALTH


BMJ Open on June 21, 2020 by guest. P

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Page 1 of 15

TITLE PAGE

Full title


CHARACTERISTICS OF ASYLUM SEEKERS ARRIVING IN BRUSSELS

Gerlant van Berlaer 1,2

, Francisca Bohle Carbonell 3, Sofie Manantsoa

3, Xavier de Béthune

3,

Ronald Buyl 3, Michel Debacker

2, Ives Hubloue

1,2

1 Department of Emergency Medicine, Universitair Ziekenhuis Brussel, Brussels, Belgium 2 Research Group on Emergency and Disaster Medicine, Vrije Universiteit Brussel, Brussels, Belgium. 3 Médecins du Monde / Doctors of the World Belgium - Medical Department, Operations Department, Brussels, Belgium. 4 Department of Public Health, Biostatistics and Medical Informatics Research Group, Vrije Universiteit Brussel, Brussels,

Belgium.

Corresponding Author details:

Gerlant van Berlaer, M.D. Laarbeeklaan 101, BE-1090 Brussels, Belgium. [email protected] - tel

+32476284242 - fax +3224775120.

Full addresses co-authors:

Francisca Bohle Carbonell, R.N. rue Botanique 75, BE-1210 Saint-Josse-ten-Noode, Belgium.


Sofie Manantsoa, R.N. Kruidtuinstraat 75, BE-1210 Sint-Joost-Ten-Node, Belgium.


Xavier de Béthune, M.D., Kruidtuinstraat 75, BE-1210 Sint-Joost-Ten-Node, Belgium.


Ronald Buyl, Ph.D. - Laarbeeklaan 103, BE-1090 Brussels, Belgium. [email protected] - +32495544106.

Michel Debacker, M.D. Laarbeeklaan 101, BE-1090 Brussels, Belgium. [email protected] -

+3224775155.

Ives Hubloue, Ph.D. Laarbeeklaan 101, BE-1090 Brussels, Belgium. [email protected] - +3224775153.

Word count:

Abstract: 230 words

Manuscript: 3385 words

Abbreviations used:

IBM SPSS International Business Machines Corporation, Statistical Package for Social Science (Chicago,

Illinois, USA).

ICD-10 World Health Organisation International Classification of Diseases version 10

IQR Interquartile range

MdM Médecins du Monde/Doctors of the World

PTSD Post-traumatic Stress Disorder

RC Refugee Camp

UNHCR United Nations High Commission for Refugees

WHO World Health Organisation

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ABSTRACT

Background

In the summer of 2015, the exodus of Syrian war refugees and saturation of refugee camps in neighboring

countries led to the influx of asylum-seekers in European countries, including Belgium.

This study aims to describe the demographic and clinical characteristics of asylum-seekers that arrived in a

huddled refugee camp, in the center of a well-developed country with all medical facilities.

Methods

Using a descriptive cross-sectional study design, physicians of Médecins du Monde prospectively registered age,

gender, origin, medical complaints and diagnoses of all patients presenting to an erected Field Hospital in

Brussels in September 2015. Diagnoses were post-hoc categorized according to the International Classification

of Diseases.

Results

Of 4037 patients examined in the Field Hospital, 3907 were included and analyzed for this study. Over 11% of

patients suffered from injuries, but these were outnumbered by the proportion of patients with respiratory (36%),

dental (9%), skin (9%) and digestive (8%) diagnoses. More than 49% had features of infections at the time of the

consultation.

Conclusion

Asylum seekers arriving in a refugee camp in Brussels after a long and hazardous journey, suffer mostly from

respiratory, dental, skin and digestive diseases. Still one of seven suffers from injury. These findings – consistent

with other reports – should be anticipated when composing Emergency Medical Teams and Interagency

Emergency Health or similar Kits to be used in a Field Hospital, even in a Western European country.

Key words: migration; access to health care; disaster relief; homelessness, international health

Data repository (DRYAD): http://dx.doi.org/10.5061/dryad.p9b21

STRENGTHS AND LIMITATIONS OF THIS STUDY

The strengths of this study:

- The study includes a considerable number of well documented complaints and physicians' diagnoses in asylum-

seekers arriving in Western Europe.

- Since Belgium registered 5512 asylum-seekers in September 2015, this study sample is of considerable

proportion.

- A literature search reveals that epidemiological studies on health problems of asylum-seekers in Europe are

very scarce.

- At our best knowledge this has not been reported in such detail before.

This study has several limitations:

- The study included only patients self-presenting or referred by Outpatient Assistance Teams to the Field

Hospital in the autumn of 2015, preventing extrapolation to all asylum-seekers and other seasons.

- A number of diagnoses remained tentative, since laboratory and imaging tests were unavailable.

- Patient's anonymity prevented longitudinal follow-up.

- The lack of uniform standards to collect complaints and diagnoses makes comparison with other data sets

challenging.

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MAIN TEXT

INTRODUCTION

Background/rationale

Persons fleeing their home country are considered 'asylum-seekers' until a contracting state is willing to provide

the official status of 'refugee' as disclosed in the Geneva Convention on Refugees.[1]

The continuing exodus from Middle-East countries, driven by the Syrian civil war and overcrowding of refugee

camps in neighboring countries, forced asylum-seekers using any conveyance fleeing towards the European

Union. In the summer of 2015, the number of asylum-seekers in Belgium increased considerably.[2]

People applying for asylum need to register at the Belgian Immigration Office in the center of Brussels, a

necessary step before being entitled to shelter, clothing, food and (medical) assistance. A high daily influx of

asylum-seekers and a limitation to a maximum of 250 registrations per workday created an accumulation of

hundreds, not yet included in the asylum procedure, camping in a park in front of the Belgian Immigration

Office. In a spontaneous humanitarian response, volunteers of the ad hoc "Belgian Civilian Platform" organized

an improvised shelter camp and provided clothing and food.

The Belgian branch of the independent international non-governmental organization Médecins du Monde

(MdM) erected a field hospital in the camp. MdM provided free medical care, psychological and social support,

and sanitary facilities to over 4000 asylum-seekers in September 2015.

Of 5512 requests for asylum registered at the Belgian Immigration Office in September 2015, 482 (9%) were

from unaccompanied minors, and only 628 were granted asylum. The other applicants were either formally

rejected (3526 cases), postponed (748 cases) or definitively refused (610 cases). The latter received an order to

leave the territory.[2] Belgium accepted 0.8% of all asylum-seekers reaching Europe in 2015.[3]

A prerequisite to adopting any evidence-based approach in humanitarian assistance is to assemble solid evidence

from results of relevant empirical studies.[4] Collecting reliable data will always be difficult in emergency

situations, as healthcare providers prioritize treating patients over documenting, and control groups are usually

not available.[4–6]

Reports on refugee camp patients vary widely in methodology, points of interest, and are often expert opinions

or undocumented statements. Most focus on communicable diseases (vector-, air-, food-, blood- and waterborne

diseases and infections) such as tuberculosis, malaria, and HIV/AIDS , or elucidate immediate effects of

disasters (estimated numbers of dead, injured and displaced) and late consequences such as outbreaks,

epidemics, and mental health problems.[6–10] As in every refugee or internally displaced person camp around

the world - usually in third world countries - specific patterns of pathology are to be expected (especially

respiratory, gastrointestinal, and skin infections), secondary to poor sanitary conditions and overcrowding, but

also increase of non-communicable diseases (malnutrition, cancer, chronic lung diseases) and comorbidities

(especially diabetes and hypertension) imposing vulnerability due to interruption of care, and psychosocial

disorders following violence, journeys in austere circumstances, and the settlement in a new - sometimes hostile

- environment.[8,11–13] A literature search reveals that epidemiological studies on health problems of asylum-

seekers in Europe are scarce, and that they have been conducted in a wide variety of settings (hospital, asylum

home, refugee camp, governmental structures) and have highlighted different issues (hygiene, infectious

diseases, chronic health problems, mental health, unaccompanied minors), but never provided a comprehensive

and complete overview.[8,9,14–17] Yet it is estimated that one in six refugees has a physical health problem

severe enough to affect their life, and two thirds have experienced anxiety or depression.[18]

Objectives

This study aims to document demographics of asylum-seekers who arrived in a refugee camp in Brussels in

September 2015; to describe complaints, comorbidities, diagnoses and diagnosis categories of patients

presenting to a Field Hospital in a Refugee Camp, set up in a Western European capital; and to formulate

recommendations for future relief operations.

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MATERIALS AND METHODS

Study design

A retrospective descriptive cross-sectional sample analysis was performed on prospectively obtained medical

records, collected by MdM from September 5th to October 5th 2015. This time interval corresponds to the

period that the refugee camp and Field Hospital were present in Brussels.

The study protocol was approved by the Ethical Committee of the Universitair Ziekenhuis Brussel, Belgium.

Setting

Within the refugee camp, MdM erected a level I Medical Field Hospital, consisting of units for 24/7 ambulatory

healthcare and psychosocial support.[19] The MdM volunteer team comprised over 400 certified physicians,

nurses, pharmacists, logisticians, and interpreters. MdM registered all volunteers and verified their diploma and

license to work in Belgium. An Outpatient Assistance Team with a physician, a nurse, and an interpreter,

provided on-the-spot healthcare for patients not able to leave their tents, or referred them to the Field Hospital

for further care when necessary.

Registration on admission and basic triage in urgent and less urgent patients was performed by trained nurses.

Each patient was subsequently interviewed and examined by physicians, with competent interpreters present

during all clinical encounters. Diagnoses were based on complaints and physical examination, as MdM had

limited access to diagnostic capability. Patients were treated on the spot if appropriate, vaccinated when needed,

and received explanations in their own language. Supplies were retrieved from the MdM stockpile and

donations. Patients requiring emergency care, lab tests, medical imaging, or hospitalization were transferred to

hospitals in the Brussels area. Patients requiring follow-up were requested to represent to the Field Hospital or

referred to primary or dental care facilities, or new-born consultations, with referral letters.

Participants

All patients presenting spontaneously to the Field Hospital or examined by the Outpatient Assistance Teams

were eligible for inclusion. Patients with missing date of presentation, chief complaint, or single primary

diagnosis were excluded afterwards. Patients in Belgium are legally considered "minor" when younger than 18,

and "child" when younger than 15 years old.

Variables

A prospectively designed template was used to register data for all patients: age, gender, country of origin (the

country the patient was born in, or lived in before fleeing home for the first time), date of arrival in Belgium,

whether and when patients had requested or received an appointment at the Belgian Immigration Office or were

already officially registered as asylum-seeker, location of shelter, all physical and mental complaints, the “chief

complaint”, and all pre-existing comorbidities.[20,21] One primary diagnosis per patient was recorded according

to a list of 50 possible diagnoses, adapted from case descriptions in the WHO "Communicable disease control in

emergencies" field manual, the Sphere Project Handbook, and a template used in previous humanitarian

operations.[20,22,23] Post-hoc, trained physicians classified these diagnoses into categories, adapted from ICD-

10 as described in table 2.[24] All patients with clinical signs of local or generalized infection were classified as

a subgroup of "infectious diseases". Finally, referral was recorded.

Data sources

MdM trained all personnel in collecting data, which were anonymised according to the Helsinki Declaration, and

introduced in an Excel® database.[5] A data sharing and research collaboration agreement was signed between

MdM and the Research Group on Emergency and Disaster Medicine, Vrije Universiteit Brussel, Belgium.

Bias

Data were recorded by different healthcare providers, and the anonymous records did not allow distinguishing

patients possibly inserted twice, potentially introducing sampling bias. Diagnoses were classified post-hoc,

possibly introducing categorization bias.

Statistical methods

Patients with missing or unreadable data were excluded. Descriptive statistics for discrete outcome variables

were presented as frequencies (n), proportions (%), and for quantitative variables (age, number of patients) as

measures of central tendency and dispersion (median, range, interquartile range IQR). The analyses were broken

down for age categories (<5, 5-14, and >15years old), gender, and period (weeks).

Multiple logistic regression analysis was performed to identify factors associated with the asylum-seekers’ health

problems, by using 'infection' as an outcome variable, by using origin (other versus Syria, Iraq, Morocco and

Afghanistan), age category (0-15, >15 years old), gender, arrival time in Belgium, asylum state, and shelter

location as predictors. Analyses were carried out by using IBM® SPSS® v23.0. All tests were performed using

an α-level of 0.05.

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RESULTS

Participants

MdM examined 4037 patients in total, with a median of 137 per day (range 23-199) as shown in Supplementary

Figure 1. After exclusion of 130 incomplete forms, 3907 patients were included and analyzed.

Descriptive data

Of all included patients, 3355 (86%) were male, 510 (13%) were female; from 42 (0.8%) the gender was

unknown. Median age was 28 years (range 0-93;IQR 12). As Figure 1 and Supplementary Figure 2 illustrate:

78% (n=3049) were adult men, 9% (n= 355) adult women and over 10% (n=391) minors, of whom 303 children

(8%); including 149 (4%) aged 5-14, and 153 (4%) aged under five. The age of 86 (2%) adults and children was

unknown. The Outpatient Assistance Teams provided care to 46 patients (1.18%) of whom two had to be

referred for advanced care.


The region of origin is presented in Figure 2. Patients came from 63 different countries (as presented in

Supplementary Figure 3), but most from Iraq (n=1950/3778;52%), Syria (n=737;20%), Morocco (n=365;10%),

Afghanistan (n=117;3%), and Palestine (n=96;3%). Some 1% (n= 42) were stateless or came from other

continents.

Figure 2: Countries and regions of origin of asylum-seekers

The time interval between arrival in Belgium and consultation, the state of asylum procedure and location of

shelter are presented in Table 1.

Table 1: Demographic and social details of the sample

n %

Time interval of arrival in

Belgium

0-7 days 2251 57.6

8-31 days 629 17.7

32-365 days 338 8.7

>365 days 240 6.1

Unknown 386 9.9

Asylum procedure

Appointment at BIO to start procedure 1292 33.1

No appointment at BIO to start procedure 1006 25.7

Asylum procedure initiated, waiting for decision 167 4.3

Asylum request denied 69 2.3

Not applicable 91 2.3

Unknown 1282 32.8

Location of accommodation

Brussels refugee camp (tents) 2209 57.8

Other refugee camps 495 13.0

Governmental asylum-seeker centres 362 9.3

Open air 77 2.0

Relatives and friends 29 0.7

Foster family 17 0.4

Other 51 1.3

Unknown 576 14.7

BIO: Belgian Immigration Office

Outcome data

A total of 5768 complaints (106 different types) were recorded: 2486 patients (64%) had one single complaint,

1039 (27%) expressed two, 320 (8%) three, and 61 (2%) four or more complaints.

Most common complaints were: cough (n=619/3907;16%), sore throat (n=590;15%), tooth pain (n=406;10%),

rhinorrhea (n=397;10%), headache (n=374;10%), limb pain (n=248;6%), skin wounds (n=236;6%), flu-like

symptoms (n=154;4%), accidental trauma (n=151;4%), lack of chronic medication (n=138;4%), and abdominal

pain (n=130;3%). Some 3% complained of fever (n=101), 2% of anxiety (n=82), and more than 3% (n=126)

represented for follow-up.

Categorized according to ICD-10, 56% of all patients expressed respiratory complaints (n=2198), 12% had

digestive complaints (n=482), 12% had musculoskeletal complaints (n=458), 11% was injured (n=429), 11% had

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neurological complaints (n=427), 10% had skin problems (n=406), and 10% expressed dental complaints

(n=406).[24] All other categories represented less than 5% of all patients.

More than 7% of patients reported comorbidities (n=279), most commonly arterial hypertension (n=103) and/or

diabetes (n=96). Patients also reported asthma (n=19), old fractures (n=15), epilepsy (n=14), rheuma (n=10),

recent delivery (n=7), neoplasms (n=6), gastrointestinal (n=5), genitourinary (n=4), or mental disorders (n=3).

Of patients with interrupted maintenance treatment (n= 138), 72 had comorbidities: diabetes (24), hypertension

(14), asthma (12), epilepsy (8), psychiatric disorders (2) and withdrawal (2). Seven reported lost eyewear, six

infants lacked pediatric formula.

Main results

As represented in Figure 3 and Table 2, the most common primary diagnoses consisted of upper respiratory tract

infections (31%), dental caries (8%), skin infections (8%), gastroenteritis (7%), skin wounds and burns (6%),

musculoskeletal disorders (6%), accidental trauma (6%). Mental disorders were present in 2%. No patient died,

one was resuscitated, and 35 (1%) were victims of intentional violence in their country of origin, or during the

journey to Brussels. Two women had just delivered and five new-born babies attended.


Table 2 and Figure 4 indicate the distribution of diagnostic categories. The most frequent were respiratory

disorders (35.5%), far ahead of injury (11.6%), dental (9.5%), skin (8.6%), digestive (7.8%), and

musculoskeletal diagnoses (6.1%). In 19 cases (0.5%) there was no actual medical or mental diagnosis, but the

patient requested personal attention or sought assistance for social problems.

Analysis of the distribution of diagnostic categories per week did not reveal any considerable changes over time.

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Table 2: Diagnostic categories, primary diagnoses and case descriptions

CATEGORY n % PRIMARY DIAGNOSIS n % CASE DESCRIPTIONS

NO DIAGNOSIS 19 0.5 no medical diagnosis 19 0.5 social problem, attention seeker

RESPIRATORY 1388 35.5

upper respiratory tract infection 1199 30.7 ear, nose, throat, sinus, larynx infections, flu (upper ARI)

lower respiratory tract infection 120 3.1 dyspnoea, and raised respiratory rate, signs of lower ARI

asthma exacerbation 69 1.8 wheezing and/or respiratory oppression

EYE & ADNEXA 67 1.7 eye disorder 65 1.7 eye infection and irritation

vision problem 2 0.1 diminished or troubled vision, blindness

DENTAL 372 9.5 dental abscess 56 1.4 clinical suspicion of dental abscess

dental caries 316 8.1 caries with or without pain

DIGESTIVE 303 7.8

watery diarrhea/abdominal 281 7.2 loose stools, vomiting, abdominal pain, intestinal parasitosis

bloody diarrhoea 5 0.1 loose stools with visible blood (suspicion of dysentery)

malnutrition 15 0.4 clinical, weight/height >70% or MUAC <110/160 (child/adult)

cholera 0 0.0 severe dehydrating diarrhoea/confirmed case non-endemic area

jaundice 2 0.1 acute onset of icterus (skin, conjunctivae, urine)

NEUROLOGICAL 142 3.6

suspected meningitis 1 0.0 fever and clinical signs of meningeal irritation

flaccid paralysis 0 0.0 child ≥1 limb(s) (incl. Guillain Barré) or any age polio suspicion

CVA, headache, convulsions 141 3.6 headache, convulsions, stroke, coma

GENITOURINARY 97 2.5

sexual transmittable disease 19 0.5 suspected STD, vaginal infections with fluor, genital infection

urinary tract infection 59 1.5 dys-, alg-, pollakisuria, with/without fever, flank pain, or + dipstick

gynaecological disorder 19 0.5 irregular menses, breast problems, vaginal bleeding, abortion

PERIPARTUM 28 0.7

neonatal illness 1 0.0 newborns with problems

neonatal tetanus 0 0.0 neonate not sucking/crying normally, rigidity, convulsions

healthy new-born baby 4 0.1 healthy baby <3 weeks old

delivery 2 0.1 Mother: imminent delivery or post-partum (<3 weeks)

(presumed) pregnant 21 0.5 suspected or confirmed pregnancy

SKIN 335 8.6 skin infection 294 7.5 redness, pain, abcedation with signs of local infection

skin affection 41 1.0 redness, xerosis, urticaria, psoriasis without infection

GENERAL 154 3.9

surgical cases other than trauma 24 0.6 herniations, swollen testicles, cysts, haemorrhoids,…

fever of unknown origin 9 0.2 >37.,5°C axillary or > 38.0°C rectal, without specific diagnosis

malaria 0 0.0 confirmed or suspected malaria, simple or serious

measles 0 0.0 fever and clinical suspicion of measles (vaccinated or not)

clinical anaemia 3 0.1 history, pallor, weakness

diabetes 70 1.8 diabetes as main problem, or crisis/ketoacidosis

other 35 0.9 all that is not classified elsewhere

intoxication 8 0.2 suspected or confirmed substance abusus

neoplasm 5 0.1 suspected or confirmed oncological disease

MENTAL 76 1.9 mental disorder 76 1.9 PTSD, insomnia, stress, suspicious aspecific complaints

VIOLENCE 35 0.9 trauma from aggression 34 0.9 trauma due to intentional individual injury including rape

CBRN 1 0.0 injury from chemical/biological/radiological/nuclear assaults

INJURY 454 11.6 accidental trauma 213 5.5 accidental trauma from incident, accident (non-violent trauma)

acute wounds 241 6.2 non-intentional acute skin wounds, burns

MUSCULOSKELETAL 239 6.1 musculoskeletal disorder 239 6.1 non-traumatic pain (muscles, back, pelvic belt, joints), rheuma

CIRCULATORY 71 1.8 hypertension/cardiac disorder 71 1.8 symptomatic hypertension, palpitations, angina pectoris

FATALITY 1 0.0 resuscitation 1 0.0 any condition requiring resuscitation of vital functions

death 0 0.0 deceased patients

FOLLOW-UP CASES 126 3.2

follow-up wound dressings 57 1.5 follow-up of wound dressings and injections / vaccinations

follow-up fractures & casts 18 0.4 follow-up old fractures & casts cases

follow-up other 51 1.3 follow-up of chronic illness, other cases

TOTAL 3907 100 Total 3907 100

subanalysis

infectious cases 1900 48.6 all cases with features of infection

ARI: acute respiratory infection, MUAC: middle upper arm circumference, CVA: cerebrovascular accident, incl:

including, STD: sexually transmittable disease, PTSD: post-traumatic stress disorder, CBRN: chemical-burns-

radiological-nuclear incidents, +: positive

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Subgroup analyses

Features of infection were found in 1900 (49%) patients, with an even higher frequency (63%) in children

younger than five.

The multiple logistic regression analysis in Table 3 shows that asylum-seekers from Syria and Iraq, and children

have a higher risk for infection. We did not detect any other significant risk factors.

Table 3: Predictive factors for infectious diseases from a multiple logistic regression analysis

O.R. 95% C.I. of O.R.

p-value Lower Upper

Origin (reference: other countries) Syria 1.91 1.54 2.38 <0.0001

Iraq 1.85 1.54 2.21 <0.0001

Morocco 0.99 0.76 1.29 0.95

Afghanistan 1.42 0.95 2.12 0.09

Gender (reference: male) female 0.77 0.63 0.95 0.01

Age (reference ≥15 years old) <15 years old 1.64 1.28 2.10 <0.0001

C.I. confidence interval; O.R. odds ratio

Children aged under five represented 4% of the population, with equally distributed gender and a median age of

two (range 0-5;IQR 3). The majority originated from Middle-East countries (n=118;77%), median time in

Belgium was three days (range 0-1500;IQR 9), and most sheltered in tents (n=94;61%). The distribution of

diagnostic categories indicates that 50% had respiratory diseases (n=76), 20% digestive disorders (n=30), 14%

skin disorders (n=21), and 7% suffered from injuries (n=10). Five (3%) were newborns of which one had to be

hospitalized for bronchiolitis with severe dyspnea.

Patients were asked to represent for follow-up in 3% cases (n=121) to the Field Hospital, and in 4% (n=152) to

ambulant consultations, mainly for arterial tension and blood glucose measurements. Referrals were organized

for 412 patients (11%): 205 to dentists (5%), 117 (3%) to Emergency Departments, 70 to psychotherapists (2%),

and 20 (0.5%) to mother & new-born care consultations. Children younger than five were referred 27 times (18%

of young children): 15 to ambulant follow-up, six to new-born consultations, and two each to Emergency

Departments, dentists, and psychiatrists.

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DISCUSSION

Key results Most asylum-seekers arriving in Brussels were young men, contrasting to the usual population distribution in

internally displaced persons and refugee camps (50% children, 30% women and 20% men).[22] The shortest

route between Syria and Brussels is 4000 kilometers, unsuited for children, women, and older men, who rather

remained in refugee camps near their country of origin.[11,25–28]

Almost half of the asylum-seekers, and two thirds of children younger than five suffered from infections. The

multiple logistic regression analysis suggests that asylum-seekers from Syria and Iraq, and children have a

higher risk of infection. Also, the Immigration Office registration delay postponed entitlement to shelter, food,

and (medical) assistance, and the encampment in austere conditions possibly contributed to the large proportion

of infections.[12,14,29]

The overwhelming presence of (mostly upper) acute respiratory infections (ARI) is consistent with existing

reports as visualized in table 4.[8,11,15,16,20,25,30] A possible explanation is that most people from the

Middle-East and Africa arrived in autumn, in a cold and rainy environment, and were confronted with the typical

respiratory viruses of Western Europe, they were never exposed to before.[14,29] Because of huddling in

refugee camps, and many patients coughing, these viruses spread rapidly.[14] This carries a possible burden, as

acute respiratory infections are a major cause of morbidity and mortality among displaced people.[30]

Contrarily, the same conditions did not result in a similar spread of intestinal, genitourinary or eye infections, as

is usually seen in internally displaced persons or refugee camps.[15,20,28,29] This was possibly owing to

appropriate management of sanitary facilities by MdM.

The important share of dental problems is unusually high for any refugee camp, but consistent with other reports

on Syrian refugees.[11,16,31] It must be considered that most patients were Iraqi who already fled their country

after the 2002 invasion to become refugees in Syria, where access to dental or any health care was

limited.[11,32] Their long exhausting travel with limited healthcare facilities might have contributed to

transform caries into dental abscesses.

While undertaking their journey, many of the asylum-seekers halted in several different camps along the way,

sleeping in any fleabag they could find, possibly resulting in the many scabies infections observed.[8,14,15,28]

The proportion of skin infections is consistent with available European reports, but higher than seen in other

internally displaced persons and refugee populations analyzed the same way.[8,15,20]

Violent trauma, injuries and musculoskeletal problems were present in almost 20% of the asylum-seekers, with a

wide variety of causes: accidental trauma was usually from falls, not always related to the journey; acute wounds

were either blisters on feet from walking long distances, or infected wounds caused by barbed wire.[33] The

musculoskeletal issues - back and limb pain in young men - were often related to the journey as

well.[8,12,15,25] The number of war-related injuries was limited; most had been treated long before arrival in

Brussels.[25]

The proportion of mental disorders was rather low (2%), in contrast to other studies reporting incidences of up to

one third.[8,12,27,34,35] Even though MdM provided a separate tent (with sufficient privacy and constant

availability of interpreters), it is still possible that language barriers, limited time per consultation,, and the fact

that most patients were young men from Middle East countries - not easily expressing emotions to strangers in

tents - might have contributed to this low proportion. We do suspect underreporting of mental problems, as

MdM recorded more use of secondary psychological consultations in the Field Hospital than registered in this

study.

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Table 4: Comparison of proportional ranges found in other studies on RC and IDP populations (%)

study situation

Res

pir

ato

ry

Ey

e &

adn

exa

Den

tal

Dig

esti

ve

Gen

ito

ruri

nar

y

Sk

in

Men

tal

Vio

len

ce

Inju

ry

Musc

ulo

skel

eta

l

Cir

cula

tory

Infe

ctio

us

case

s

NC

D

Nu

mber

this study RC in Brussels 35.5 1.7 9.5 7.8 2.5 8.6 1.9 0.9 12.5 6.1 1.8 48.6 7.0 3907

ranges in literature

3-56 2-12 4-21 4-12 3-8 2-9 0-38 0-3 1-39 0-15 1-22 6-90 2-50

Alberer M et al15 RC in Germany 23.0 3.6 3.5 9.7 5.3 7.7 1.1

7.7 2.2 39.9 2.6 548

Marquard L et al16 Refugee minors in Germany

20.6

13.7

58.8 <2.0 102

Bischoff A et al8 Refugees in Switzerland 14.1

8.8 13.7 8.6 14.5 4.4 6.3

979

Escobio F et al25 MSF on Balkan route 25.0

30.0

3500

Mateen F et al11 Refugees in Jordan 11.0 10.0 12.1

3.0

1.3 3.4

9.0 22.0 <7.0 11-22 7642

McKenzie E at al34 Refugees in Jordan

1.8

2526

Doocy S et al26 Refugees in Jordan

50.3 1550

Gammouth O et al27 Jordan RC

29.5

30.3 765

UNHCR28 RC in Jordan 29.7 2.2 2.7 5.6 3.5 1.3 0.5 4.3 5.3 72.1 21.8 694280

UNHCR28 RC in Iraq 56.4 3.3

11.7 4.7 4.8 0.5 0.2 2.2 0.1 3.2 89.6 7.4 127401

UNHCR28 RC in Lebanon 27.1 4.5 3.0 4.6 1.4 0.1 0.9 2.0 89.3 8.3 52060

North C et al35 Review mental health*

11-38

222 studies

Bellos A et al30 Review ARI in crises* 3-55

36 studies

Calvasina P et al31 Immigrants in Canada* 9.4 2126

van Berlaer G et al20 FH & IDP in Haiti* 16.5 4.2

10.7 6.8 4.0 2.5 0.0 38.7

1.7 37.8 3.3 2795

RC: refugee camp, NCD: non-communicable diseases, MSF: Médecins Sans Frontières, ARI: acute respiratory

infections, FH: field hospital, IDP: internally displaced persons; * = studies on IDP and refugees not from the Syrian

crisis

We did not detect a changing pattern of diagnostic categories over time, possibly because the population of the

camp was replaced regularly with new arrivals.

Referral to EDs was needed in 3% of the consultations, for varying reasons: suspected fractures, stitches (as

stitching in field hospitals encompass risks of wound infection), pneumonia, confusion, and convulsions or

syncope, oncologic patients who ran out of maintenance treatment. Many referrals were made to dentists' offices,

as well as to psychiatrists-psychologist when signs of post-traumatic stress disorder were present. Referrals to

ambulant consultations were ordinarily for deregulated diabetes and arterial hypertension.

The prevalence of 7% of non-communicable chronic diseases (mainly diabetes, hypertension and asthma) found

in this study population was lower than the range in earlier reports, possibly due to the limited number of aged

asylum-seekers.[26] Some 138 patients (4%) lacked maintenance treatment medication, of which 72 had chronic

comorbidities like diabetes and hypertension, and were therefore at risk for deregulation of their clinical

condition. For these patients, MdM provided all necessary medication and materials (like insulin, beta blockers,

puffs, blood glucose meters, urine ketone strips) and provided follow up or referral.

Nineteen patients (0.5%) did not get a specific medical diagnosis, but were categorized as seeking attention for

their distressing situation, or looking for non-medical support.

Long term conditions (including vector- and blood borne infections such as leishmaniasis, malaria, hepatitis B

and Helicobacter pylori) may have under presented or been under diagnosed, as healthcare providers focused

more on identifying acute conditions.

It is difficult to draw conclusions from this study about the importation of communicable diseases, one of the

mythical concerns raised about immigrants.[8,12,14] Belgium screens asylum-seekers for tuberculosis, but not

for human immunodeficiency virus, measles, polio, or pertussis, diseases usually quoted in the context of

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refugees.[8,15,29,32,36] Whenever suspicion was raised patients were transferred to hospitals for investigation.

None of these tests yielded positive results in September 2015.

Limitations and strengths This study has several limitations. The study included only patients self-presenting or referred by Outpatient

Assistance Teams to the Field Hospital in the autumn of 2015, preventing extrapolation to all asylum-seekers

and other seasons. A number of diagnoses remained tentative, since laboratory and imaging tests were

unavailable. Patient's anonymity prevented longitudinal follow-up. The lack of uniform standards to collect

complaints and diagnoses makes comparison with other data sets challenging.[6,7]

The strength of this study is the considerable number of well documented complaints and physicians' diagnoses

in asylum-seekers arriving in Western Europe. At our best knowledge this has not been reported in such detail

before. Since Belgium registered 5512 asylum-seekers in September 2015, this study sample is of considerable

proportion.[2]

Interpretation Asylum seekers arriving in a refugee camp in Brussels after a long and hazardous journey suffer mostly from

respiratory, dental, skin and digestive diseases, and one of seven is injured. Half of this population shows

features of infection; with asylum-seekers from Syria and Iraq, and children being most vulnerable.

The high proportion of respiratory diseases, as in any internally displaced persons or refugee camp worldwide,

urges to take acute respiratory infection preventive measures: adequate shelter, overcrowding reduction,

malnutrition prevention and treatment, and scaling up vaccination coverage, in order to meet the Health 2020

policy framework goals.[29,30] Adequate sanitary facilities are imperative to prevent the spread of infections.

Early and resolute healthcare may avoid short and long term complications of infectious, dental, mental, and

mother & child problems, which otherwise could lead to higher healthcare expenditure for the hosting

population.[12,25]

In Emergency Medical Teams treating asylum-seekers there is an early role for general and emergency

physicians, pediatricians, gynecologists, midwives, dentists, and interpreters.[11,16,30–32] Scaling up with

diabetes and hypertension specialists and psychologists is recommended.[6,8,12,26,27,34,35] In our experience,

volunteers are much easier recruited for the first group.

Generalisability

The results of this study can help to better organize healthcare for asylum-seekers residing in camps, particularly

with respect to the composition of the medical assistance teams and the medical resources.[6,7] However, in

order to meet the specific and changing needs of asylum-seekers arriving in Europe, more research is needed to

compare and confirm our findings.

The development of a standardized template to prospectively collect and subsequently analyse and report health

might make a substantial contribution to provide the evidence base for the effectiveness and efficiency of the

preparation, management and mitigation of humanitarian emergencies.[4,6,7,21]

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ACKNOWLEDGMENTS

Competing interests

The authors declare that they have no competing interests to declare.

Funding There was no funding source for this study.

Fees for open access publication will be paid by the Research Group on Emergency and Disaster Medicine, Vrije

Universiteit Brussel, Brussels, Belgium.

World Health Organization Standards for registration of all human medical research

All authors have completed the Unified Competing Interest form atwww.icmje.org/coi_disclosure.pdf (available

on request from the corresponding author).

Registration of the study

Trial ID ISRCTN 13523620.

Ethical approval Approval of the Commission of Medical Ethics (O.G. 016) of the Universitair Ziekenhuis Brussel, Brussels,

Belgium was obtained (B.U.N. 143201526433).

Informed Consent and patient details

The free and informed consent of the subjects and/or their legal guardians was obtained before their inclusion in

this study. No details on individual patients are given in the manuscript; all patients were anonymised in the

registry and database according to the Helsinki Declaration..

Data sharing statement

A data sharing and research collaboration agreement was signed between Médecins du Monde and the Research


The corresponding author, Gerlant van Berlaer, had full access to all the data in the study and had final

responsibility for the decision to submit for publication.

Availability of data and materials

Data repository (DRYAD): http://dx.doi.org/10.5061/dryad.p9b21.

Submission declaration and verification

Our work has not been published previously, and is not under consideration for publication elsewhere. Its

publication is approved by all authors and tacitly or explicitly by the responsible authorities where the work was

carried out, and that, if accepted, it will not be published elsewhere in the same form, in English or in any other

language, including electronically without the written consent of the copyright-holder.

Open access

The authors prefer to publish "open access". Upon acceptance of the manuscript, the authors will complete an

exclusive 'License Agreement'.

Authorship: individual contributions of each author - conception and design of the study: GvB, FBC, SM, RB

- acquisition of data: GvB, FBC, SM, XdB

- analysis and interpretation of data: RB, GvB, XdB, SM

- drafting the article: GvB, FBC, SM, XdB, RB

- revising the manuscript: SM, XdB, RB, MDB, IH

- final approval of the version submitted: GvB, FBC, SM, XdB, RB, MDB, IH

GvB was responsible for the study setup, was main investigator and principal author of the article. As the

guarantor of the paper, GvB accepts full responsibility for the work and the conduct of the study; he had access

to the data, and controlled the decision to publish.

FBC designed the prospective patient files, was responsible for the training of the data collectors, and for the

correct collection of data. She wrote parts of the methods and data interpretation section.

SM is the Medical Coordinator for Belgian projects of Médecins du Monde (Doctors of the World) in Brussels,

and contributed to the text regarding background, methods and discussion.

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XdB is the Medical Director of Médecins du Monde (Doctors of the World) in Brussels, and was responsible for

the final check of results, and the build-up and editing of the discussion section.

RB is professor in biostatistics and medical informatics, invaluable for the setup of the study, the processing of

the data, and for the interpretation of the results, including appropriate statistics and graphics.

MD and IH, both professors of the European Master in Disaster Medicine, corrected the setup and finalisation of

the study, contributed with scientific remarks, helped finding the appropriate references and made many

corrections to the final text.

FIGURES LEGENDS





APPENDICES (not to be published)

- Approval of the Commission of Medical Ethics (O.G. 016) of the Universitair Ziekenhuis Brussel, Brussels,

Belgium. B.U.N. 143201526433.

- Data Sharing and Research Collaboration Agreement signed between Médecins du Monde and the Research


- STROBE statement form.

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29 Connolly M, Gayer M, Ryan M, Salama P, Spiegel P, Heymann D. Communicable diseases in complex

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ONLINE ONLY SUPPLEMENTARY MATERIAL Supplementary Figure 1: Daily number of consultations (n)

Supplementary Figure 2: Distribution of patients between adult men, women and minors (<18 years old)

0

20

40

60

80

100

120

140

160

180

200

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

evacuation of the camp

men 78%

women 9%

minors 10%

unknown 3%

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Supplementary Figure 3: Countries of origin of asylum-seeking patients in Belgium in September 2015 (n)

1938

729

361

114 94 71 64 49 48 36 24 22 20 19 17 16 15 14 13 13

144

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1

STROBE Statement—checklist of items that should be included in reports of observational studies

Item

No

Page

No Recommendation

Title and abstract 1 1,2 (a) Indicate the study’s design with a commonly used term in the title or

the abstract

2 (b) Provide in the abstract an informative and balanced summary of what

was done and what was found

Introduction

Background/rationale 2 3 Explain the scientific background and rationale for the investigation being

reported

Objectives 3 3 State specific objectives, including any prespecified hypotheses

Methods

Study design 4 3 Present key elements of study design early in the paper

Setting 5 3 Describe the setting, locations, and relevant dates, including periods of

recruitment, exposure, follow-up, and data collection

Participants 6 4 (a) Cohort study—Give the eligibility criteria, and the sources and

methods of selection of participants. Describe methods of follow-up

Case-control study—Give the eligibility criteria, and the sources and

methods of case ascertainment and control selection. Give the rationale for

the choice of cases and controls

Cross-sectional study—Give the eligibility criteria, and the sources and

methods of selection of participants

n/a (b) Cohort study—For matched studies, give matching criteria and number

of exposed and unexposed

Case-control study—For matched studies, give matching criteria and the

number of controls per case

Variables 7 4 Clearly define all outcomes, exposures, predictors, potential confounders,

and effect modifiers. Give diagnostic criteria, if applicable

Data sources/

measurement

8* 4 For each variable of interest, give sources of data and details of methods

of assessment (measurement). Describe comparability of assessment

methods if there is more than one group

Bias 9 4 Describe any efforts to address potential sources of bias

Study size 10 4 Explain how the study size was arrived at

Quantitative variables 11 4 Explain how quantitative variables were handled in the analyses. If

applicable, describe which groupings were chosen and why

Statistical methods 12 4 (a) Describe all statistical methods, including those used to control for

confounding

4-5 (b) Describe any methods used to examine subgroups and interactions

4-5 (c) Explain how missing data were addressed

4-5 (d) Cohort study—If applicable, explain how loss to follow-up was

addressed

Case-control study—If applicable, explain how matching of cases and

controls was addressed

Cross-sectional study—If applicable, describe analytical methods taking

account of sampling strategy

4-5 (e) Describe any sensitivity analyses

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2

Results

Participants 13* 4 (a) Report numbers of individuals at each stage of study—eg numbers potentially

eligible, examined for eligibility, confirmed eligible, included in the study,

completing follow-up, and analysed

4-5 (b) Give reasons for non-participation at each stage

n/a (c) Consider use of a flow diagram

Descriptive data 14* 4-6 (a) Give characteristics of study participants (eg demographic, clinical, social) and

information on exposures and potential confounders

4-6 (b) Indicate number of participants with missing data for each variable of interest

n/a (c) Cohort study—Summarise follow-up time (eg, average and total amount)

Outcome data 15* n/a Cohort study—Report numbers of outcome events or summary measures over time

n/a Case-control study—Report numbers in each exposure category, or summary

measures of exposure

5 Cross-sectional study—Report numbers of outcome events or summary measures

Main results 16 5-7 (a) Give unadjusted estimates and, if applicable, confounder-adjusted estimates and

their precision (eg, 95% confidence interval). Make clear which confounders were

adjusted for and why they were included

n/a (b) Report category boundaries when continuous variables were categorized

5-7 (c) If relevant, consider translating estimates of relative risk into absolute risk for a

meaningful time period

Other analyses 17 7 Report other analyses done—eg analyses of subgroups and interactions, and

sensitivity analyses

Discussion

Key results 18 7-9 Summarise key results with reference to study objectives

Limitations 19 9 Discuss limitations of the study, taking into account sources of potential bias or

imprecision. Discuss both direction and magnitude of any potential bias

Interpretation 20 9 Give a cautious overall interpretation of results considering objectives, limitations,

multiplicity of analyses, results from similar studies, and other relevant evidence

Generalisability 21 9 Discuss the generalisability (external validity) of the study results

Other information

Funding 22 10 Give the source of funding and the role of the funders for the present study and, if

applicable, for the original study on which the present article is based

*Give information separately for cases and controls in case-control studies and, if applicable, for exposed and

unexposed groups in cohort and cross-sectional studies.

Note: An Explanation and Elaboration article discusses each checklist item and gives methodological background and

published examples of transparent reporting. The STROBE checklist is best used in conjunction with this article (freely

available on the Web sites of PLoS Medicine at http://www.plosmedicine.org/, Annals of Internal Medicine at

http://www.annals.org/, and Epidemiology at http://www.epidem.com/). Information on the STROBE Initiative is

available at www.strobe-statement.org.

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