Guidelines for healthcare professionals on accepting refugee children from Ukraine
The consequences of Russian aggression against Ukraine have caused irreparable damage to all spheres of life of the population, not only in Ukraine, but also in the countries receiving the flow of refugees. A truly unprecedented wave of migration swept over not only Europe, but also North America. It was one of the largest migrations in the world in recent decades. According to various sources, the number of migrants from Ukraine has recently approached 8 million, and internal migration in Ukraine has amounted to more than 8 million. All segments of the population became vulnerable: women, men, children. There are separated families, dead relatives and friends, and orphaned children. Wartime requires special rules for providing assistance to the population: social, financial, medical, and psychological. The most vulnerable category of victims is children. The number of internally displaced children is more than 200,000. More than 2 million children have left Ukraine, and this number is growing every day. Providing assistance to children injured during hostilities falls on the shoulders of not only state structures, but also volunteer organizations. Limitations in obtaining medical care lead to unpredictable consequences. Deprived of the home environment and traditional care of their parents, being in constant fear, children deeply experience what is happening to them. Overcrowding in migration camps during transit to other cities and countries, unsettled housing, poor nutrition, psychological trauma put children at risk of contracting infectious diseases and exacerbating chronic diseases.
Armed conflicts directly and indirectly affect children, especially in relation to health issues. The United Nations Convention on the Rights of the Child (1989) clearly defines the rights of children.
One new document is particularly interesting. It is called “Recommendations of the Swiss Pediatric Society on the provision of medical care to refugee children from Ukraine” ("PEDIATRIC REFUGEES FROM UKRAINE: GUIDANCE FOR HEALTH CARE PROVIDERS" Fabienne N. Jaeger, Christoph Berger at all.) These recommendations were developed with an emphasis on Switzerland in April 2022 as part within the Delphi process (a method of using collective intelligence in predicting scientific research on methods of warfare), but may well be used in any other country due to its universality.
This document contains the following groups of recommendations:
- language difficulties;
- general pediatric examination;
- mental health;
- vaccinations;
- screening for tuberculosis, HIV, hepatitis B and C;
- information services about preventive and medical care.
Let's consider the main ones.
Language
Not all children arriving from Ukraine speak English or other national languages. Most Ukrainians understand Russian and often Polish, as this language is close to Ukrainian. Ideally, care for children should be provided by staff who are fluent in these languages, but in their absence, interpreters are the gold standard for contact between children and medical staff. It is high-quality and affordable translation that can shorten the path of diagnosis and treatment, avoid unnecessary manipulations and misunderstandings. For these purposes, it is recommended to use appropriate volunteer organizations which provide translation services.
Recommendations:
- professional translators have an advantage;
- when volunteers participate, it is necessary to explain to them the rules of interpretation and privacy;
- accuracy in translating sensitive issues;
- caution in using translation software;
- avoid the participation of underage interpreters.
General pediatric examination (General Pediatrics)
The first step is to assess the urgency of treatment or special care for the child, for example in children with type 1 diabetes or HIV infection, and the potential need for isolation or protection. A full pediatric assessment of the child's status should be performed, including, if possible, information about vaccinations, past infectious and somatic diseases, as well as an assessment of psychological status.
Recommendations:
- identification of priority medical needs and drug provision;
- providing care for chronic diseases and developmental delays;
- medical examination taking into account age;
- newborn screening;
- assessment of the psychosocial situation and adaptation to new living conditions;
- assessment of the resources of the guardian in relation to the child;
- informing about national and local resources for migrants;
- recommendations for disease prevention according to age;
- informing about the health care system, emergency care, actions in an emergency;
- providing the guardian with complete medical information, documents on vaccinations, studies, treatment recommendations in written or electronic form.
Vaccinations
It should be noted that the vaccination calendar in Ukraine and other countries may differ, so it is very important to collect detailed information about vaccinations carried out in Ukraine: terms, schedules, contraindications. In the absence of certain vaccinations, it is necessary to vaccinate as soon as possible. Only documented vaccines should be considered.
MMR: Measles, Mumps and Rubella
Optimal protection against MMR is a two-dose vaccination (MMR vaccine is a combination vaccine against measles, mumps and rubella; it is a mixture of attenuated viruses of the three diseases). In the absence of documentation of MMR vaccination, it should be taken into account that additional doses of MMR are not harmful, as pre-existing immunity will destroy attenuated vaccine viruses before they can replicate.
Recommendations:
- Any child older than 9 months without documented MMR vaccination should receive the first dose unless contraindicated. The second dose must be given more than 1 month later at the age of at least 12 months;
- Any child older than 12 months and adolescents with one documented vaccine should receive a second dose of MMR unless contraindicated.
Chickenpox (Varicella)
In this case, it is required to carefully collect the anamnesis of the child. A clear understanding of the word "chicken pox" and a description of the disease from the child or caregiver should be achieved.
Recommendations:
- questioning the child or caregiver about chicken pox they had;
- documentary evidence of two vaccinations in case of a negative history of chickenpox;
- if the history of varicella is unclear or negative, any undocumented child or adolescent older than 11 years of age should be vaccinated with the first dose of varicella vaccine. The second dose should be given 4 to 6 weeks later;
- a child or adolescent with a single dose of varicella more than 1 month old should receive a second dose if there are no contraindications;
- any unvaccinated child older than 9 months should be vaccinated with two doses of varicella vaccine if the following risk factors are present: immunosuppression, nephrotic syndrome, severe atopic dermatitis, HIV without immunosuppression, prolonged stay in a refugee camp.
Hepatitis B
General vaccination of children in Ukraine is recommended at birth. But vaccination coverage rates remain quite low, ranging from 28% to 80% depending on the region.
Recommendations:
- children who are fully vaccinated against hepatitis B do not need further immunizations;
- partially vaccinated children should received the next vaccine with three doses, with an interval of at least 4 months between the second and third doses;
- unvaccinated children should be screened serologically for anti-HBsAg (hepatitis B surface antigen), anti-HBc (hepatitis B core antibody ) indicative of infection, and quantitative anti-HBs (Hepatitis B surface antibody) indicative of immunization;
- if a quantitative anti-HBs result is ≥100 IU/L, the child is considered fully immunized and protected; not subject to further vaccination. If anti-HBs levels are ≥10 but <100 IU/L, at least a single hepatitis B booster is recommended. If infection has been excluded but anti-HBs is negative, full hepatitis B immunization is recommended;
- in the presence of acute or chronic hepatitis B, a consultation with a gastroenterologist or infectious disease specialist may be necessary.
Poliomyelitis
Ukraine has low polio vaccination coverage.
Recommendations:
- include polio vaccines in all recommended revaccinations;
- with documented vaccination information, ensure that the child has received at least three doses of polio vaccine.
Tuberculosis
The incidence of tuberculosis in Ukraine (73 per 100,000 people) is much higher than in Switzerland (5 per 100,000 people). In addition, the risk of contracting tuberculosis increases significantly in wartime, in refugee camps. All children with fever and long-term inflammatory respiratory diseases should be considered as potentially infected with tuberculosis.
Recommendations:
- all children and adolescents arriving from Ukraine are subject to TB screening;
- screening is recommended: an interferon gamma release assay or a tuberculin-skin test (TST);
- be aware that measles vaccination may temporarily suppress the response to TB testing, causing false positive results. Therefore, TB testing should be done either at the same time as measles vaccination or one month after vaccination;
- any of the listed conditions require urgent diagnosis for tuberculosis: cough for more than 2 weeks, weight loss, developmental delay, prolonged fever over 38°C, lethargy, and decreased activity.
Human immunodeficiency virus (HIV)
The rate of HIV infection in Ukraine is 37.5 per 100,000 people, which is the second highest frequency in Europe.
Recommendations:
- maternal serological screening in the following cases: doubtful negative screening during pregnancy, risk factors for HIV infection;
- urgent appeal to an infectious disease specialist in the following cases: initially confirmed HIV infection, interruption or lack of treatment, before resuming antiretroviral therapy (ART- antiretroviral therapy);
- adolescents receiving antiretroviral therapy should be referred to an infectious disease specialist within 1 month for a routine examination and treatment adjustment.
Hepatitis C
Hepatitis C has a significantly higher prevalence in Ukraine than in Europe. Most Ukrainians do not know their hepatitis C serostatus.
Recommendations
Serological screening for hepatitis C virus should be carried out for all children arriving from Ukraine.
Mental health issues
The current military situation in Ukraine and expulsion from the country affect all families without exception, and especially children, which is manifested in the following psychological suffering:
- hyperexcitability;
- sleep disorders;
- nightmares;
- anxiety attacks;
- mutism (lack of speech in response to a strong psychological stimulus);
- nighttime urinary incontinence (bedwetting).
- In addition, the experience of war can exacerbate the course of pre-existing mental illnesses.
Recommendations:
- registration of signs of psychological distress;
- assessment of the need of children and caregivers for psychiatric support and specialized care.
For more information on the Recommendations, please follow the link: