Diagnosing Displaced Populations

If you are at all aware of current politics, you are aware of the refugee crisis. The United Nations High Commissioner for Refugees Global Trends report estimates that 65.3 million people were displaced from their homes as refugees or internally displaced persons in 2015. Refugees are a population at risk for many diseases and health complications, and also lack access to adequate diagnostic testing. The average length of conflict-induced displacement is 17 years, resulting in significant healthcare ramifications. The health of refugees is important for obvious general humanitarian reasons, because the risk of spread to the host population when refugees find asylum, and for the burden untreated chronic diseases place on the healthcare systems of host countries.

The most common diseases in refugee camps are communicable, and include diarrheal disease, acute respiratory disease, measles, malaria, meningitis, TB, and HIV. Poor sanitary conditions and close accommodations are driving factors for these diseases. Loss of infrastructure in the country of origin increases the likelihood that a refugee will enter camp with a communicable disease. For example, disruption of vector control programs or efforts in a volatile country increase the risk of vector-borne diseases such as malaria. Breakdown of vaccine programs increases risk of vaccine-preventable diseases; the low vaccine rates in areas producing most of the world’s refugees contributes to the mortality of measles in refugee camps.

While there’s no denying that communicable diseases are a huge threat to refugee populations, non-communicable diseases (NCDs) are also a significant burden. In 2008, the WHO estimated 63% of deaths occurring globally were attributable to NCDs. The number is projected to increase to 55 million by 2030, with the most rapid rise expected to occur in developing countries – which are also the main source of displaced persons. Displaced persons are also more vulnerable to NCDs because of risks associated with population movements, including psychosocial disorders, reproductive health problems, higher newborn mortality, drug abuse, nutritional disorders, alcoholism and exposure to violence. Unfortunately, there is not much published on the incidence of NCDs in refugee populations, but at least two studies describe diabetes, hypertension, and seizure disorders are frequent diagnoses in refugee camps. A study of Congolese refugees found 9.5 cases of diabetes/100,000, 5.9 cases of seizure disorders/100,000, and 2.6 cases of diabetes/100,000. A Belgian study found a high number of refugees with chronic diseases and interrupted maintenance treatments in addition to those with diabetes, hypertension, and seizure disorders. Not diagnosing and managing non-communicable diseases in refugee populations increases the risk of morbidity and mortality in these populations, and means that the refugee will present a larger burden to the health system of the country in which the refugee finds asylum. Any loss of function due to an unmanaged NCD – loss of limbs from diabetic neuropathy, for example – will impact the future livelihood of a displaced person.

Increasing rates of antimicrobial resistance, of malaria and TB for example, make it even more important the that correct diagnosis – including pathogen strain where appropriate – is made before treatment is started. However, most health-related efforts in refugee populations focus on disease prevention and control, and less with building diagnostic capacity. The CDC Division of Global Migration and Quarantine (DGMQ) recommends testing refugees for infectious disease, especially those with long latency. Some of the diseases the DGMQ recommends testing for include malaria, TB, and intestinal parasites. There’s less guidance regarding testing for non-communicable diseases. The WHO recommends “ensuring the essential diagnostic equipment, core laboratory tests and medication for routine management of NCDs are available in the primary health care system”, with no further detail.

There’s very little in the peer-reviewed or even lay literature about the availability of laboratory diagnostics, but from what is available and anecdotally, diagnostics are often not at the forefront of medical efforts in refugee camps. The Belgian medical team consisted of 400+ volunteer medical staff, and yet was severely under-supported in terms of diagnostics.

Challenges to bringing laboratory diagnostics include infrastructure needs and cost. Unfortunately, lab diagnostics are not cheap! The United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) spent $6.9 million USD to operate comprehensive labs in 124 of it’s 139 health facilities. Infrastructure needs – electricity and clean water –  and the need for trained personnel are common limitations to operating diagnostic laboratories in resource-poor settings such as refugee camps. Political instability also contributes to the challenge. In 2013, the DGMQ reported that the Dadaab refugee camp, home to over 300,000 refugees, had a fully functioning comprehensive laboratory. In May 2016, this camp was closed due to safety risks, eliminating the laboratory resource.

So what do we do? I have to be honest that – even though I thought I knew about this problem – writing this blog post has been eye-opening for me and I’m not sure I can answer the question. I’m definitely going to be thinking about this for some time. In the meantime, I think being aware of the problem of limited access to diagnostic laboratory testing in refugee populations is a good start. We need to get a better understanding of the scope of the problem. We should be ready and able to provide specific recommendations for meeting diagnostic needs in these populations including most appropriate diagnostics given clinical needs, infrastructure, and available treatment options. The road toward a solution will include global collaboration, research, and advocacy.

–Sarah Riley, PhD, DABCC, is passionate about bringing the lab out of the basement and into the forefront of global health.