. 2019 Jan 31;3(1):bmjpo-2018-000364. doi: 10.1136/bmjpo-2018-000364

Table 2.

Original research articles

First author and year	Country	Study population	Study design	Sample size (children only)	Summary of findings
Huemer et al ⁴¹ (2011)	Austria	African UASC 15–18 years old	Observational cohort	41	56% of African UASC had at least one mental health diagnosis by structured clinical interview. The most common diagnoses were adjustment disorder, PTSD and dysthymia.
Derluyn et al ⁴² (2007)	Belgium	UASC*	Cross-sectional survey	142	Between 37% and 47% of the unaccompanied refugee youths had severe or very severe symptoms of anxiety, depression and post-traumatic stress when screened with the Hopkins Symptoms Checklist 37A. Girls and those having experienced many traumatic events are at even higher risk for the development of these emotional problems.
Derluyn⁴³ (2008)	Belgium	Migrant and native adolescents 10–21 years	Cross-sectional survey	1249 migrant/602 native	Migrant adolescents experienced more traumatic events than their Belgian peers and showed higher levels of peer problems and avoidance symptoms. Non-migrant adolescents demonstrated more symptoms of anxiety, externalising problems and hyperactivity. Factors influencing the prevalence of emotional and behavioural problems were the number of traumatic events experienced, gender and the living situation.
Van Berlaer et al ¹⁰ (2016)	Belgium	Asylum seekers	Single facility cross-sectional study	391	Primarily reported outcomes in adults. Nearly half of asylum seekers and two-thirds of children<5 years suffered from infections. Among children<5 years, 50% had respiratory diseases (n=76), 20% digestive disorders (n=30), 14% skin disorders (n=21) and 7% suffered from injuries (n=10).
Vervliet et al ⁴⁴ (2014)	Belgium	UASC 14–17 years old	Longitudinal cohort	103	UASC reported an average of 7.5 traumatic experiences at the study start. The mean number of reported daily stressors increased over the study period. Participants had high scores for anxiety, depression and internalising symptoms. There were no significant differences in mental health scores over time. The number of traumatic experiences and the number of daily stressors were associated with significantly higher symptom levels of depression (daily stressors), anxiety and PTSD (traumatic experiences and daily stressors).
Hatleberg et al ¹⁴ (2014)	Denmark	Children<15 years old in Denmark	Epidemiological surveillance study	323	323 TB cases were reported in children aged<15 years in Denmark between 2000 and 2009. The incidence of childhood TB declined from 4.1 per 100 000 to 1.9 per 100 000 during the study period. Immigrant children comprised 79.6% of all cases. Among Danish children, the majority were<5 years and had a known TB exposure. Pulmonary TB was the most common presentation.
Montgomery³⁸ (2008)	Denmark	Refugees 11–23 years old	Longitudinal cohort	131	Follow-up study in refugee children after 9 years. Participants reported a mean of 1.8 experiences of discrimination. An association was found between discrimination, psychological problems and social adaptation. Perceived discrimination predicted internalising behaviours. Social adaptation was protective, correlating negatively with discrimination as well as externalising and internalising behaviours.
Montgomery³⁷ (2010)	Denmark	Refugees 11–23 years old	Longitudinal cohort	131	Same population as Montgomery (2008). On arrival, the children experienced high rates of clinically significant psychological problems which reduced markedly at 9-year follow-up. Persistent symptoms were associated with higher number of types of stressful events after arrival, suggesting environmental factors play an important role in resilience and recovery from psychological trauma.
Heudorf et al ²⁰ (2016)	Germany	UASC<18 years old	Observational cohort	119	UASC arriving in Frankfurt during October–November 2015 had high levels of drug resistant microbial flora. Enterobacteriaceae with ESBL were detected in 42 of 119 (35%) youth. Nine youth had flora with additional resistance to fluoroquinolones (8% of total screened).
Kulla et al ³¹ (2016)	Germany	Refugee infants and children* rescued at sea	Observational cohort	293	Among the 2656 refugees rescued by a German Naval Force frigate between May and September 2015, 19 (0.7 %) were infants and 274 (10.3 %) were children. 27% of all patients required treatment by a physician due to injury or illness and were defined as ‘sick’. One infant (5.2%) and 38 children (13.9%) were identified as sick. Predominant diagnoses were dermatological diseases, internal diseases and trauma.
Marquardt et al ¹¹ (2016)	Germany	UASC 12–18 years old	Cross-sectional survey	102	Pilot study that employed purpose sampling for a non-representative subset of UASC in Bielefeld, Germany. 59% of the youth had at least one infection and 20% suffered parasitic infections. 13.7% were diagnosed with mental illness. 17.6% were found to have iron deficiency anaemia. Overall, the youth had a low prevalence of non-communicable diseases (<2.0%).
Michaelis et al ²³ (2017)	Germany	Asylum seekers with Hepatitis A	Epidemiological surveillance study	231	Asylum seeking children 5–9 years old accounted for 97 of 278 (35%) reported HAV cases among asylum seekers during September 2015 to March 2016. The predominant subgenotype was 1B, a strain previously reported in the Middle East, Turkey, Pakistan and East Africa. There was one case of transmission from an asymptomatic child to a nursery nurse working in a mass accommodation centre.
Mellou et al ²⁴ (2017)	Greece	Refugees, asylum seekers and migrants† living in hosting facilities in Greece	Observational study	152	Report on HAV infection among refugees in hosting facilities in Greece April–December 2016. A total of 177 cases were found, of which 152 were in children<15 years old.
Pavlopoulou et al ³³ (2017)	Greece	Migrant and refugee‡ children 1–14 years old	Single facility prospective cross-sectional study	300	Survey of immigrant and refugee children presenting for health examination within 3 months of their arrival, May 2010 and March 2013. The main health problems found included unknown vaccination status (79.3%), elevated blood lead levels (30.6%), dental problems (21.3%), eosinophilia (22.7%) and anaemia (13.7%). Eight children (2.7%) were diagnosed with latent tuberculosis based on Mantoux and chest X-ray and two cases were confirmed with QuantiFERON-TB Gold testing.
Ciervo et al ¹⁹ (2016)	Italy	Asylum seeking adolescents<18 years	Case series	3	Description of Louse-borne relapsing fever in three Somali adolescents who were seeking asylum.
Bean et al ⁴⁵ (2007)	The Netherlands	UASC<18 years old	Prospective cohort study	582	The self-reported psychological distress of refugee minors was found to be severe (50%) and of a chronic nature (stable for 1 year) and was confirmed by reports from the guardians (33%) and teachers (36%). The number of self-reported adverse life events was strongly related to the severity of psychological distress.
Seglem et al ⁴⁶ (2011)	Norway	UASC	Cross-sectional survey	414	Surveyed of UASC who were granted a residence permit in Norway from 2000 to 2009. The youth ranged from 11 to 27 years at the time of the survey. The study found that UASC are a high-risk group for mental health problems also after resettlement in a new country, with high prevalence of depression and PTSD.
Belhassen-Garcia et al ¹⁵ (2015)	Spain	Immigrant children and young people†<18 years old	Observational cohort	373	Immigrants<18 years of age coming from Sub-Saharan Africa, North Africa and Latin America were prospectively screened between January 2007 and December 2011. Latent tuberculosis was found in 12.7% (36/285), Active TB infection in 1% (3/285), HBV in 4.3% (15/350) and HCV in 2.35% (8/346). None (0/358) were HIV positive.
Bennet¹⁶ (2017)	Sweden	UASC<18 years old	Observational cohort	2422	2422 UASC were screened for tuberculosis with a Mantoux tuberculin skin test or a QuantiFERON-TB Gold. 349 had a positive test, of which 16 had TB disease and 278 latent tuberculosis infections (LTBI). Children originating from the horn of Africa had high prevalence of latent TB and TB disease.
Hjern et al ³⁹ (2013)	Sweden	Migrant and native 15 year- olds	Cross-sectional survey	76 229	In a national survey using the KIDSCREEN instrument, the psychological well-being in foreign-born children from Africa and Asia was found to be much lower (−0.8 in Z-scores) compared with the majority population if the student body consisted mainly of native students from the majority population. Scores were very similar to the majority population in schools where at least 50% had two foreign-born parents. Bullying explained much of this difference.
Riddel⁵⁹ (2016)	Sweden	UASC 9–18 years old	Qualitative interviews	53	The youth described experience of extreme violence and exploitation as well as lack of access to physical and mental healthcare. They describe lengthy asylum procedures, delays in receiving a guardian, lack of access to interpreters and inexperienced and inadequately trained staff among guardians in the accommodation centres. Girls and younger children reported being housed with older boys and experiencing bullying and harassment in their accommodation facilities.
Alkahtani et al ⁸ (2014)	England	Refugee children in the East Midlands compared with native controls	Case-control	117 migrant/99 native	Comparison made between the children of 50 refugee parents (n=117 children) with children of 50 English parents (n=99 children), with median ages 5 and 4 years, respectively. Refugee children were more likely to receive prescribed medicines during the previous month (p=0.008) and 6 months (p<0.001) than English children and were less likely to receive over the counter (OTC) medicines in the past 6 months (p=0.009). The findings suggest financial barrier in access to medication.
Bronstein⁴⁷ (2012)	UK	Afghan UASC 13–18 years	Cross-sectional survey	222	One third of youth were found to score above the cut-off on a validated PTSD-screening instrument.
Bronstein⁴⁸ (2013)	UK	Afghan UASC 13–18 years	Cross-sectional survey	222	In a survey using the Hopkins Symptoms Checklist 37A, 31.4% scored above cut-offs for emotional and behavioural problems, 34.6% for anxiety and 23.4% for depression. Scores increased with time after arrival in the UK and load of premigration traumatic events.
Hodes et al ⁴⁹ (2008)	UK	UASC (13–18 years old) and accompanied refugee children (13–19 years old)	Cross-sectional survey	78 UASC and 35 accompanied	UASC had experienced high levels of traumatic events (mean of 6.8 events, range 0–16) and reported high levels of post-traumatic stress symptoms compared with accompanied children. Predictors of high posttraumatic symptoms included low-support living arrangements, female gender and experience of trauma. Among UASC, post-traumatic symptoms increased with age. High depressive scores were associated with female gender and region of origin in UASC.
Baillot et al ³² (2018)	Multiple	Asylum seekers	Literature review, in-depth interviews with experts in EU-based FGM interventions	N/A	FGM is an important basis for asylum claims girls and women in Europe. Monitoring and interventions vary between countries. There are no pooled data, however, as variations in reporting practices between countries preclude the evaluation or monitoring of FGM-based asylum claims in the EU.
Odone et al ¹⁸ (2015)	Multiple	Migrants to the EU†	Literature review, analysis of European Surveillance System data and information from experts	N/A	Primarily reported outcomes in adults. From 2000 to 2009, 15.3% of reported paediatric TB cases in the EU/EEA were of foreign origin. This figure is lower than the proportion of foreign-born reported TB cases in the overall population (26%). Norway, Sweden and Austria reported a higher number of foreign-origin TB cases than native-origin TB cases among children<15 years. Risk-based analysis is limited because surveillance data in most EU/EEA countries do not distinguish between children born in the host country to foreign-born parents from those born to native parents.
Stubbe Østergaard et al ⁵⁷ (2017)	Multiple	Asylum seekers and undocumented migrant children<18 years	Survey and desk review	N/A	Surveyed child health professionals, NGOs and European Ombudspersons for Children in 30 EU/EEA countries and Australia and reviewed official documents. Entitlements for asylum seeking, refugee and irregular migrants in the EU are variable; however, only five countries (France, Italy, Norway, Portugal and Spain) explicitly entitle all migrant children, irrespective of legal status, to receive equal healthcare to that of its nationals. The needs of irregular migrants from other EU countries are often overlooked in European healthcare policy.
Villadsen et al ³⁰ (2010)	Multiple	Stillbirths and neonatal deaths of infants born to mothers of Turkish origin	Retrospective prevalence study	239 387	Includes data from nine EU countries. The stillbirth rates were higher in infants born to Turkish mothers than in the native population in all countries. The neonatal mortality was variable, with elevated risks for infants of Turkish mothers in Denmark, Switzerland, Austria and Germany, and lower rates in Netherlands, the UK and Norway when compared with the native populations.
Williams et al ²² (2016)	Multiple	Migrants§	Literature review, survey of 30 countries, and information from experts	N/A	National surveillance systems do not systematically record migration-specific information. Experts attributed measles outbreaks to low vaccination coverage or particular health or religious beliefs and considered outbreaks related to migration to be infrequent. The literature review and country survey suggested that some measles outbreaks in the EU/EEA were due to suboptimal vaccination coverage in migrant populations.
Hjern et al ⁶⁰ (2017)	EU27	Migrant children<18 years	Cross-sectional survey to clinicians, national child ombudsmen and NGOs	N/A	Seven EU countries (Belgium, France, Italy, Norway, Portugal and Spain and Sweden) explicitly entitle all non-EU migrant children, irrespective of legal status, to receive equal healthcare to that of its nationals. Twelve European countries have limited entitlements to healthcare for asylum seeking children, including Germany that stands out as the country with the most restrictive healthcare policy for migrant children. The needs of irregular migrants from other EU countries are often overlooked in European healthcare policy.

*Age groups not clearly defined.

†Migrant status not clearly defined.

‡Immigrants were defined as the children of parents with long- term residence permit who entered Greece for family reunification. The remaining children, including refugees, asylum seekers or irregular migrants were defined as ‘refugees’.

§Variable definitions of migrants between countries and between studies.

ESBL, extended spectrum beta-lactamases; HAV, Hepatitis A Virus; LTBI, latent tuberculosis infections; OTC, over the counter; PTSD, post-traumatic stress disorder; TB, tuberculosis.