Title: Decision strategy for infection diagnostics in unaccompanied asylum-seeking minors (UASM)

Alexander Kramer

School of Public Health, Bielefeld University, Germany


Alexander Krämer is an expert in the field of Public Health with background in internal medicine and epidemiology, and one of the founders of the first School of Public Health in Germany at Bielefeld University. Research fields include from a global public health perspective: urban health, climate change, infectious diseases and refugee health. As senior professor he is the director of the Graduate Research Programme FlüGe at Bielefeld University, Germany, addressing refugee health from an inter- and transdisciplinary perspective ( Krämer is editor and author of 10 books (e.g. “Modern infectious disease epidemiology”; “Refugee health”; both Springer) and of more than 300 articles in international scientific journals (


Background: Currently in Germany and other countries there is no systematic approach to diagnose potential infections in refugees, besides infectious lung TB, measles, varicella, and scabies when hosted in collective accommodation. 
Objectives and methods: We used a three-stage approach to develop a strategy of decision making of rational evidence-based screening for communicable diseases in UASM. First, we conducted a systematic review of the last 10 years to collect and evaluate the available data in this heterogeneous group (mostly males). Second, we analyzed primary data on 346 UASM from a travel clinic in Bielefeld, Germany. Third, we used data from WHO about the burden of these diseases in UASM’s countries of origin.
Results: According to the systematic review, cohort rates were 6.8% for latent TB infection (LTBI) and 0.5% for TB in minors from Afghanistan, 26-32% for LTBI and 3.4-3.5% for TB among those from Eritrea, Ethiopia or Somalia (1 study). Overall, HBV-infection prevalence ranged from 1.6 to 1.7%; in sub-Saharan Africa (SSA) that prevalence was 8.8% (1 study). The prevalence of HIV among female UASM who gave birth was 4.5% (all from SSA). Enteric pathogens’ prevalence ranged from 29.2-50%, highest disease burden from the Middle East (Syria) and Africa. Overall, Schistosomiasis ranged from 5.2-7.5%. In sub-group analysis, that prevalence reached 24.7% (SSA) and 56.3% (Eritrea). In our empirical study of UASM in Bielefeld, Germany, prevalence of communicable diseases also substantially depended on the country of origin of UASM. This is reflected by the general background of infections like TB, HIV, HBV and Schistosomiasis in various world regions by WHO and the Global Burden of Disease Study.
Conclusion and (preliminary) recommendations: 
Our results show that it is possible and necessary to base clinical decisions of diagnostic procedures and subsequent health care provision on central characteristics of the refugee population. Screening is one strategy to improve early detection of infection and disease. However, to ensure screening is beneficial, the decision to undertake screening needs to be evidenced-based. Information from the literature, our empirical study in Bielefeld, and infectious disease prevalence profiles in the countries of origin were used to develop the following recommendations: 
HIV: We consider screening pregnant UASM originating from SSA as high priority and UASM originating from the Middle East as low priority. HBV: Screening UASM from countries where the seroprevalence of chronic hepatitis B virus infection is moderate or high (i.e., ≥ 2% positive for hepatitis B surface antigen) as high priority. Tuberculosis: UASM from the Middle East are low priority. Schistosomiasis: Screening UASM from SSA as high priority. Enteric pathogens: UASM from SSA and from the Middle East as high priority. Helicobacter pylori: UASM from all regions high priority.
Limitations and further research: Only few studies on UASM were available and our empirical study from Germany is not representative. In addition to the impact of country of origin, other determinants will have to be included, such as gender, age, travel route and duration (!), as well as further contextual, individual and time-varying risks. This evidence will allow to focus on those refugees in most need. Thus financial resources can be allocated efficiently and economically.