Meeting special requirements

People who arrive at the federal initial processing centers (Bundeasylzentren/BAZ) have very different biographies and migration histories. What they have in common, however, is the hope of receiving medical care that takes their suffering seriously. The FOPH’s concept “Healthcare for asylum seekers in federal asylum centers and in cantonal collective accommodation” defines the basic structures of healthcare.

People who arrive at the federal initial processing centers (Bundeasylzentren/BAZ) have very different biographies and migration histories. What they have in common, however, is the hope of receiving medical care that takes their suffering seriously. The FOPH’s concept “Healthcare for asylum seekers in federal asylum centers and in cantonal collective accommodation” defines the basic structures of healthcare [1].

Each center has a team of nursing staff who are the primary contact persons for all medical questions. After the arrival of the asylum seeker, hereinafter referred to as AGP, the nursing staff will carry out a computer-based initial medical information (MEI) in the language of origin within the first three days. This is mandatory and contains general information on healthcare, communicable diseases, vaccinations and personal health issues (Fig. 1) . This is followed by the initial medical consultation (MEK). This is voluntary, but is usually taken up. This survey is also based on a computer-assisted program, spoken in the language of origin. It deals more specifically with pre-existing illnesses and current symptoms (Fig. 1) . In particular, an integrated tuberculosis question set (including information on the country of origin) allows the calculation of a TB score. If the score is above the discriminatory value of 10, a chest X-ray is performed and the AGP is triaged to the medical consultation. This is followed by an assessment of the skin conditions with regard to scabies. If wounds are present, wound swabs are taken for general bacteriology and diphtheria.

Basic care is regulated differently in Switzerland

As part of the MEI/MEK, the nursing staff carry out the recommended vaccinations based on the FOPH recommendations “Recommendations for vaccinations and for the prevention and outbreak management of communicable diseases in federal asylum centers and cantonal collective accommodation” [2]. These include a first dose of DiTePaPolio and the first dose of MMRV. All AGP without vaccination documents, i.e. almost all AGP, are considered unvaccinated according to the Swiss recommendations and receive the complete basic immunization without prior titer determination [3]. This comprises two doses of MMRV four weeks apart and three doses of DiTePaPolio 0/2/8 months. Children are vaccinated in standard pediatric care according to the Swiss vaccination schedule [4].

Basic medical care is regulated differently in the various federal asylum centers in Switzerland. There is mainly the model of a central physician with on-site consultation hours, a central physician in his/her own external medical practice or care provided by an outpatient clinic/institution. What they all have in common, however, is that triage to the consultation is carried out by the nursing staff, based on the findings in the MEK or the consultation. the presence of chronic illnesses requiring treatment, acute complaints or the wish of the AGP. Outside consultation hours, nursing staff can contact the center doctor by telephone or e-mail at any time in the event of acute problems or medical questions.

All AGP are covered by health insurance from registration in the BAZ, in principle under the family doctor model. However, as with the Swiss population, independent visits to an emergency ward are common. Referrals to specialist physicians are generally made by the center physician.

The medical consultation is characterized by several challenging aspects. The AGP have had different and often negative experiences with medical systems, whether in their country of origin or on the migration route. This mistrust is initially easy to perceive in medical consultations. As the persons are usually accommodated in the federal asylum structures for 140 days, there are only a few consultations depending on the clinical picture. This time factor makes it difficult to develop a relationship of trust. Regardless of these aspects and the intercultural differences, an interested, benevolent and respectful attitude on the part of the center doctor contributes to the AGP feeling valued in the consultation and daring to open up. As a rule, consultations are held with the help of a telephone interpreting service. This can sometimes lead to the problem that an interpreter in the required language is not available ad hoc. In this case, an attempt is made to work with online translation tools, and sometimes a same-language supervisor from the center can be called in. Translations by family members should be avoided in the adult sector due to a lack of neutrality.

The aim of medical treatment is to alleviate suffering, avert dangerous courses and complications and prevent the spread of infectious diseases. Common clinical pictures are also frequent in the center consultation hours. In particular, the incidence of non-communicable diseases, with the exception of mental illnesses and the consequences of physical violence or injuries, does not differ fundamentally compared to the general population [5]. Overall, however, the migration population is younger, older migrants are rather rare and therefore also polymorbid AGP.

Chronic diseases such as type 2 diabetes mellitus and art. Hypertension, are often already pre-treated. It is then a matter of prescribing equivalent medication available in Switzerland and optimizing the target values. Additional cardiologic examinations may be necessary if the patient is hospitalized.

If there is chronic pain and residual musculoskeletal restrictions following trauma or injury, the measures and clarifications that have been carried out to date and their progress over time are evaluated. Radiological examinations are used as a supplement if the probability of therapeutically relevant findings is high. Surgical interventions are generally not recommended and, if a benefit from an orthopaedic intervention cannot be ruled out, the situation should be assessed after transfer to the cantonal or regional authorities. in the event of a positive asylum decision. Documenting and recording the consequences of trauma and violence, even if they are no longer medically relevant, is often crucial for the AGP, as it is a matter of confirming the suffering suffered and may have an impact on the ongoing asylum procedure.

Psychological support often desired

A similar situation exists with psychological complaints. Many AGP have had stressful experiences in their country of origin or on the migration route and have been subjected to injustice, violence and torture. Many people expressed a desire for psychological support after arriving at the BAZ. Sleep disorders and nightmares as well as anxiety or depressive feelings are prevalent. All AGP who express a wish for psychological support are either referred to psychiatrists in private practice who preferably speak the language of the AGP, or to a consultation for transcultural psychiatry at the Psychiatric University Hospital. The waiting times are usually several months, so that psychiatric medication is often prescribed by the center doctor. The choice falls on psychotropic drugs with a favorable effect/side-effect profile, which do not have to be initiated, can be stopped easily and do not pose a risk of dependency. Sertraline is suitable for depression and anxiety and Trittico for depression and sleep disorders. If the psychological symptoms are severe, suicidal or psychotic, the AGP are admitted to the psychiatric emergency ward. Opiate-dependent AGP can enter a substitution program of the city of Bern. An internal BAZ dispensing program for pregabalin and rivotril was stopped due to the high potential for violence among the users. Alternatively, a low-potency neuroleptic (quetiapine) is offered.

Infectious diseases with a broad spectrum

The spectrum of transmissible diseases is extended by some specific infectious diseases [5]. Common clinical pictures are described in more detail below.

Skin infections resp. Superinfected skin lesions are very common. The wounds are usually located on the lower extremities or hands. AGP travel long distances, which can lead to blisters on the feet or injuries, and there is often also a scabies infection. Due to the marginal hygienic conditions on the road or in refugee accommodation, bacterial superinfections occur, most frequently with streptococci or Staphylococcus aureus.

The wound swab is taken for general bacteriology and diphtheria. In the case of pronounced inflammatory changes, antibiotic therapy is initiated, usually amoxicillin-clavulanic acid 1 g 3×1 for 5-7 days. Once the smear test result is available, the antibiotic therapy is adjusted as necessary to take account of resistance. Surgical treatment of wounds (debridement or incisions) is rarely necessary and the wound usually has few complications.

In the second half of 2022, there was an increase in skin and pharyngeal diphtheria in Swiss and European asylum structures [6]. Due to this outbreak situation, screening for diphtheria in the presence of skin lesions was established at the BAZ Bern as part of the MEI/MEK. Those affected were most frequently unaccompanied minor asylum seekers (UMA) from Afghanistan who entered Switzerland via the Balkan route. Their vaccination status was unknown, a lack of basic immunization against DiTe can be assumed. The most common manifestation of diphtheria was toxin-positive skin diphtheria (Fig. 2). Genetic analyses were able to prove that different bacterial strains were involved, thus ruling out transmission in the BAZ. Unfortunately, however, there was an outbreak of pharyngeal diphtheria in a family whose members were all unvaccinated and also opposed DiTe vaccination at the BAZ (Fig. 3) . Several family members had to be treated with antitoxin in addition to antibiotic therapy. The antitoxin was obtained from the army pharmacy using a logistically complex procedure. The cantonal medical office was closely involved.

Diphtheria and scabies infections are widespread

Corynebacterium diphtheriae is transmitted by droplet or smear infection. Not all strains produce toxin, which is responsible for the high morbidity and mortality of the disease. Diphtheria can manifest itself as skin or throat diphtheria. The skin lesions are non-specific and pharyngeal diphtheria does not always show the classic picture with pseudomembranous coatings on the tonsils. The diphtheria vaccination protects against the toxin, but not against colonization by the bacteria. Asymptomatic carriers are common and can pass on the infection (Fig. 4).

All persons with toxin-positive cutaneous diphtheria are screened for pharyngeal colonization, treated with antibiotics, vaccinated and placed in isolation. If there is a high rate of macrolide resistance, treatment is with amoxicillin 1 g 3×1 for 14 days. Isolation can be ended after 14 days of antibiotic therapy and two negative throat and/or skin swabs within 48 hours. All contact persons, i.e. people who are in the same room, receive a throat swab and prophylactic antibiotic treatment, also with amoxicillin 1 g 3×1 for seven days. They are placed in quarantine. The latter can be lifted after 48 hours of antibiotic therapy and a negative throat swab. The DiTe vaccination is given on entry or, if the AGP have refused at that time, immediately as part of the post-exposure measures.

Many AGP suffer from scabies infections (scabies). The mite disease manifests itself through nocturnal itching and skin lesions, which present themselves in different ways and can occur almost anywhere on the body. Typical are the interdigital burrows caused by the egg-laying female parasites. The itching and skin changes are ultimately caused by the immune reaction. Adults are treated with ivermectin p.o. Ivermectin is produced as an extemporaneous formulation in a pharmacy in Bern. Due to the life cycle of the mites, the weight-adapted single dose (Table 1) must be administered repeatedly after 14 days. Infants, pregnant or breastfeeding women are treated with Permethrin Crème® 5%. The cream must be applied all over the body. This procedure is also repeated after ten days.

Washing all clothes and bed linen at 60 degrees that were worn or slept in during the three to four days before the start of therapy is essential. Textiles that cannot be washed should be placed in the freezer for two days.

With increasing migration from sub-Saharan Africa, cases of pleuro-pulmonary or lymph node tuberculosis are on the rise. A TB screening is integrated into the MEK, which provides a score consisting of country of origin, B symptoms and pulmonary symptoms. If the score is above 10, a chest X-ray and a medical examination are performed. If there are suspicious radiological changes and/or clinical symptoms, two sputum samples are taken for tuberculosis (direct preparation, PCR and culture) and the AGP is isolated until negative results are available. In close cooperation with the Pneumology and Infectiology departments at Inselspital, further imaging (CT) or bronchoscopic examinations are carried out depending on the findings. If tuberculosis is confirmed, a 4-step tuberculostatic therapy is initiated according to the scheme. As a rule, the AGP are isolated in the BAZ and receive the therapy as DOT, if their state of health permits. De-isolation is carried out according to the conventional criteria, i.e. 14 days under therapy and two negative sputum tests for TB.

AGP without a vaccination document are considered unvaccinated

Systematic screening for STDs does not take place at the BAZ Bern. Screening is symptom-oriented or based on an appropriate medical history (e.g. after experiencing sexual violence). Hepatitis is also not actively screened or treated. With a stay of 140 days at the center, the expense would be disproportionate. However, screening for STDs and hepatitis C is recommended depending on the risk situation in the country of origin, the personal medical history and the probability of a positive asylum decision, i.e. a sufficient length of stay in Switzerland until successful completion of medical treatment.

As already mentioned, all AGPs are considered unvaccinated if they do not have a vaccination document [3]. The recommended initial vaccinations are carried out in the federal asylum centers (Table 2) . These include DiTePaPolio 0/2/8 mths, whereby the first two vaccine doses can usually be administered, depending on the length of stay. The two MMRV 0/1 month vaccine doses are also administered. Overall, the vaccinations are accepted by the majority of AGPs, with an average vaccination rate of 80%. Vaccination complications are extremely rare, in particular there were no anaphylactic reactions.

Infants and young children are vaccinated by a pediatrician in accordance with the Swiss vaccination schedule. After transfer to the canton, the missing doses of the initial vaccinations should be supplemented and further vaccinations should be carried out depending on age and risk constellations. In particular, the hepatitis B vaccination, the HPV vaccination, the meningococcal vaccination and the TBE vaccination should be considered.

In the case of pregnant AGP, only the DiTePaPolio is performed and an MMRV serology is taken. If there is no immunity to MMRV, an attempt is made to place the pregnant woman in a quieter part of the BAZ with as little contact as possible with other AGP or children. In addition, non-immune pregnant women are immediately given interdisciplinary care (infectious diseases/obstetrics) after possible contact with MMRV and, if necessary, treated with immunoglobulins immediately after exposure. After birth, the recommendation is to catch up on the two MMR or varicella vaccine doses.

Take-Home-Messages

• The aim of medical treatment in the BAZ is to alleviate suffering, avert dangerous courses and complications and prevent the spread of infectious diseases. Psychological complaints are common and must be carefully evaluated and monitored.
• The examination of the skin conditions is central. Scabies and cutaneous diphtheria are common and must be actively sought and promptly treated. Skin wounds should be swabbed for general bacteriology and diphtheria.
• TB must always be ruled out in the case of cough and B symptoms.
• AGP are considered unvaccinated according to Swiss recommendations and receive the first doses of complete basic immunization in the BAZ without prior titer determination: MMRV (0/1 month) and DiTePaPolio (0/2/8 months).

Literature:

1. www.bag.admin.ch/dam/bag/de/dokumente/mt/i-und-i/gesundheitsversorgung-asyl/konzept-bag-sem.pdf.download.pdf/konzept-bag-sem-de.pdf (last accessed: 15.12.2023).
2. www.bag.admin.ch/dam/bag/de/dokumente/mt/i-und-i/gesundheitsversorgung-asyl/empfehlungen-impfungen-ausbruchsmanagement-asyl.pdf.download.pdf/empfehlungen-impfungen-ausbruchsmanagement-asyl-de.pdf (last accessed: 15.12.2023).
3. Tarr P, et al: Vaccinations in adult refugees. Switzerland Med Forum 2016; 16(4950): 1075-1079.
4. www.bag.admin.ch/bag/de/home/gesund-leben/gesundheitsfoerderung-und-praevention/impfungen-prophylaxe/schweizerischer-impfplan.html (last accessed: 15.12.2023).
5. Alberer, et al: Diseases in refugees and asylum seekers. Dtsch med Wochenschr 2016; 141(1): e8-e15.
6. Kofler J, Ramette A, Iseli P, et al: Ongoing toxin-positive diphtheria outbreaks in a federal asylum center in Switzerland, analysis July to September 2022. Euro Surveill 2022; 27(44).
7. Truelove SA, Keegan LT, Mosset WJ, et al: Clinical and Epidemiological Aspects of Diphtheria: A Systematic Review and Pooled Analysis. Clinical Infectious Diseases 2020; 71: 89-97; doi: 10.1093/cid/ciz808.
8. Leaflet Scabies Cantonal Medical Service Bern 27.9.21.

HAUSARZT PRAXIS 2024; 19(1): 4–9