ED care of refugee populations from sub-Saharan Africa

Authors: Paul Omagor, MD (EM Resident Physician, Makerere University, Uganda); Tracy Walczynski, MD (EM Attending Physician, SEED Global Health, Mbarara University of Science and Technology, Uganda); Jessica Pelletier, DO, MHPE (APD, EM Attending Physician, University of Missouri-Columbia, USA) // Reviewed by: Marina Boushra, MD (EM-CCM Attending, Cleveland Clinic, USA); Alex Koyfman, MD (@EMHighAK); Brit Long, MD (@long_brit)

Case

A 16-year-old female with no remarkable past medical history is brought by her family to the Uganda refugee reception center after fleeing from Khartoum, Sudan two weeks ago. She presents with a seven-day history of fever, fatigue, and myalgias associated with decreased oral intake and an episode of seizure-like activity three hours prior to arrival. A review of systems is notable for nausea and vomiting but no diarrhea. She also endorses dysuria, cough, and neck rigidity.

At the reception center, the patient is exhibiting altered mentation, with a respiratory rate (RR) of 28 breaths/minute, SpO2 92% on room air, heart rate of 142 bpm, a blood pressure (BP) of 88/52 mmHg, and temperature 38.7° C. Her pupils are 3 mm and reactive, her neck is supple, Kernig’s and Brudzinski’s signs are difficult to assess, and point-of-care glucose reveals hypoglycemia. She has prolonged capillary refill time, moderate to severe pallor, and cool extremities. Physical examination is notable for an infected-appearing wound to the right lower extremity, measuring 3×5 cm and bandaged in dirty clothing. 

History of Present Illness

The collateral history indicates that her symptoms began one week into her journey, but medical care was inaccessible at the time. The family reports no history of food allergies, insect bites, or contact with sick individuals. The patient did not receive pre-travel prophylaxis for malaria, hepatitis A, or yellow fever. She has no significant medical or surgical history, immunodeficiency, or hematologic disorders, and is not on any medications. Additionally, there is no family history of seizure disorders. Her prior residence was in a slum of Khartoum where she was up-to-date on immunizations as per the Sudanese health regulations.

Physical Exam

HEENT: Normal hair distribution, nontender scalp without swelling. The neck is supple with a macular rash present. Conjunctival pallor is present. There are no conjunctival hemorrhages, nasal passages are clear, and there is no oral erythema or exudate.

Chest: Tachypneic, tachycardic with regular rhythm and no murmurs, rubs, or gallops. There are bilateral crackles. No jugular venous distention. The distal extremities are poorly perfused. There is no peripheral edema. BP is improved to 99/61 mmHg without intervention.

Abdomen: Soft with mild tenderness to palpation in the epigastric area. No guarding, rigidity, or rebound, and there is no organomegaly. Bowel sounds are normal.

Genitourinary: No costovertebral angle tenderness, no genital injuries noted.

Neurological and Musculoskeletal: Responds to voice, pupils equal and reactive to light. Power and sensation are grossly intact and tendon reflexes are normal. 

Differential Diagnosis

  • Septic shock secondary to a soft tissue infection, bacteremia, pneumonia, or urinary tract infection
  • Severe malaria
  • COVID-19, tuberculosis (TB)/ human immunodeficiency virus (HIV), dengue hemorrhagic fever, influenza

Action Points at the Reception Center

  • Activate safety precautions, including: full personal protective equipment (PPE), patient and family isolation, notification of the hospital and public health officers
  • Tepid sponging for fever
  • Land evacuation with staff by vehicle to the main hospital

Note: The reception center is not equipped with oxygen, fluids, emergency medications, or resuscitation equipment.

ED Evaluation

Transport to the ED from the refugee reception center takes 1 hour. After isolation, the patient is placed on supplemental oxygen therapy at 15 L/min via a non-rebreather mask.  Intravenous (IV) crystalloids, IV paracetamol (acetaminophen), and IV dextrose are administered. Surgical wound debridement and dressing are performed and the malaria rapid diagnostic test (MRDT) is noted to be positive. Samples are drawn for type and crossmatch, complete blood count, and blood chemistry.

Labs

Laboratory workup in the ED is notable for a leukocytosis of 41,000/L, hemoglobin of 6.5 g/dL, thrombocytopenia of 96 × 109/L, prothrombin time (PT) of 16.1 seconds (normal 11-14 seconds), activated partial thromboplastin time (aPTT) of 59.6 seconds (normal 30-40 seconds), creatinine of 3.11 mg/dL, sodium of 145 mEq/L, potassium of 5.4 mEq/L, aspartate aminotransferase (AST) of 1004 U/L, creatine kinase (CK) of 196 U/L, lactate of 4.2 mmol/L, and C-reactive protein of 31 mg/dL. HIV testing and Gene Xpert for tuberculosis (TB) are negative. Blood cultures are obtained and later reveal Staphylococcus aureus resistant to clindamycin, erythromycin, and tetracycline.

Imaging

Chest x-ray findings are suggestive of bilateral lobar consolidations and peribronchial ground-glass opacity, consistent with pneumonia.

Medical Management

Oxygen therapy is continued for hypoxia. The patient is noted to be hemodynamically unstable, with evidence of elevated anion gap metabolic acidosis, lactic acidemia,  hepatic impairment, hypoglycemia, positive malaria testing, acute kidney injury (AKI), and coagulopathy. Based on available hospital resources, the patient is treated for septic shock secondary to pneumonia and an infected wound using broad-spectrum antibiotics and IV crystalloid fluids. She receives IV antimalarials for severe malaria (as defined by AKI, anemia, electrolyte imbalance, and a history of convulsions). Hypoglycemia is managed with IV dextrose. A whole blood transfusion is initiated for the management of her anemia. She receives IV calcium gluconate and bicarbonate as well as oral potassium binders for hyperkalemia. Anticonvulsants are administered for further seizure prevention, and antipyretics are given for fever.

Case Resolution

The patient and family remain in isolation and receive risk stratification assessment for a notifiable disease of public health concern. She is sent to the medical ward after three days in the ED with the diagnoses of resolving septic shock, severe malaria, and AKI.

Background: Refugees on the Rise

As of 2022, it was estimated that there were 35.3 million refugees globally, with 80% of the refugee population located in Africa.1 By the end of 2023, 117.3 million people had been forcibly displaced, representing 1 in 69 individuals or 1.5% of the global population.2 Refugee crises predominantly result from wars, political instability, and economic challenges. About three-quarters of the countries in sub-Saharan Africa serve as origin or destination points for refugees.3 Countries such as Somalia, South Sudan, Sudan, the Democratic Republic of Congo, and Eritrea have been major origins of refugee emigration while nations like Uganda, Kenya, and Ethiopia play key roles as destinations.4,5 Of particular concern is the Sudanese conflict, which began in April 2023, and which has caused the largest internal displacement of a population in documented history.2 A large number of African refugees also seek refuge in the United States (US). 43% of refugees admitted into the US in the first 8 months of the 2023 fiscal year were from Africa.4

Unfortunately, refugees face significant health challenges, including the burden of disease associated with high-risk transition environments, the fragility of healthcare systems, and barriers to healthcare access.7-11 Injuries and communicable diseases account for over 75% of deaths among refugees.8 In light of the growing number of refugees from sub-Saharan Africa due to humanitarian crises, ED clinicians must be prepared to evaluate these patients comprehensively and recognize potential life threats that are unique to this population. This article is intended to empower American emergency clinicians with confidence to care for a growing patient population that we may be unfamiliar with treating. This article will focus on ED considerations for the adolescent/adult refugee patient from sub-Saharan Africa.

It should be noted that much of the data on refugees from sub-Saharan Africa (Figure 1) arises from Uganda, since this nation ranks fifth in the world for sheltering the largest number of refugees as of 2023. It is the only country in the top five refugee-hosting nations located in Africa.9 Though the healthcare landscape and cultural context in Uganda is very different from the US, there is much we can learn from other countries that accept refugees in large numbers. 

Figure 1. Where is sub-Saharan Africa? Dark green = sub-Saharan Africa, orange = the Sahel, yellow = the Sahara. Open-access image source: By M.Bitton – Own work, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=127895205

Infectious Disease Exposure

It is estimated that, on average, refugees seeking refuge in Uganda visit a health facility 1.8 times per month and that 80-120 refugees are screened daily for infectious diseases in the triage and emergency units.10 This burden of infectious disease is markedly higher than for the general population.11 The increased burden of infectious disease in refugees may be a result of poor living conditions in their home country prior to departure, during travel, and upon arrival to their final destination. Clinicians should have a low threshold to place refugee patients on isolation precautions if there is suspicion for infection with TB.12 Those with altered mental status, headache, meningismus, focal neurologic deficits, or seizure-like activity should receive isolation given concerns for meningitis; this is of particular concern for refugees arriving from the African meningitis belt of sub-Saharan Africa (Table 1).13

After appropriately isolating patients when necessary and addressing acute life threats, a thorough travel, exposure, vaccination, and sexual history should be obtained.14 A head-to-toe examination should be performed, including an evaluation of the inside of the mouth and all skin surfaces to look for signs of infection. Careful auscultation should be undertaken, as murmurs, rubs, or muffled heart sounds may suggest sequelae of TB. Adventitious breath sounds should raise concern for community-acquired pneumonia or TB. Signs of malnutrition – which places patients at higher risk for infection – can include cachexia, muscular wasting, sunken eyes, redundant skin folds, edema, brittle skin and hair, bradycardia, hypotension, and hypothermia.15-16

Laboratory and imaging workups should be targeted to the individual history and physical examination of the particular patient. Refugee patients, particularly those without access to outpatient care resources, may need screening for gastrointestinal (GI) parasites, acute flaccid paralysis, measles, malaria, tuberculosis, and other infectious diseases specific to sub-Saharan Africa that are not commonly seen in the American context (Table 1). Depending on additional risk factors (and the ability of the care team to follow up with patients who are being discharged), strong consideration should be made to screen for hepatitis A/B/C, HIV, and sexually transmitted infections (STIs).12

Table 1. Infectious/communicable disease considerations for refugee patients from sub-Saharan Africa. List of conditions adapted from: https://wwwnc.cdc.gov/travel/destinations/traveler/none/uganda

AFB = acid fast bacilli, AMB = African meningitis belt, ART = antiretroviral therapy, CDC = Centers for Disease Control and Prevention, CT = computed tomography, cVDPV = circulating vaccine-derived poliovirus, DRC = Democratic Republic of the Congo, GI = gastrointestinal, GU = genitourinary, HAV = hepatitis A virus, HFRS = hemorrhagic fever with renal syndrome, HIV = human immunodeficiency virus, HPS = hantavirus pulmonary syndrome, HSV = herpes simplex virus, ID = infectious disease, IFA = immunofluorescence assay, Ig = immunoglobulin, IV = intravenous, IVDU = IV drug use, IVIG = IV immune globulin, LAD = lymphadenopathy, LP = lumbar puncture, NAAT = nucleic acid amplification test, NP = nasopharyngeal, PCR = polymerase chain reaction, PEP = post-exposure prophylaxis, PLEX = plasma exchange therapy, RDT = rapid diagnostic test, RT = real time, TB = tuberculosis, US = United States, WB = Western blot. 

* = in US. **https://www.cdc.gov/mosquitoes/php/arbonet/. *** = GI symptoms, right upper quadrant abdominal pain, jaundice. ^ = AMB, a region of sub-Saharan Africa consisting of > 20 countries which have an unusually high incidence of bacterial meningitis and frequency of outbreaks; nearly half of global bacterial meningitis cases occur in the AMB.66 ^^ = a form of polio that arises from the oral polio vaccine (OPV) in regions where there is system lack of vaccination or undervaccination.

 

Treatment considerations: Malaria

Treatment for newly diagnosed malaria infection will depend upon whether the infection is uncomplicated or severe (Table 2-3). Severe malaria is typically caused by P. falciparum malaria infection and is defined as parasitemia in combination with ≥1 of the following clinical features in the absence of alternate causes: acidosis, bleeding, convulsions, hypoglycemia, impaired consciousness, jaundice, prostration, pulmonary edema, renal impairment, severe anemia, or shock.84 All patients with severe malaria need inpatient admission, ideally to the intensive care unit (ICU). Uncomplicated malaria patients who are able to access prescription medication can be discharged home.57

Emergency clinicians should strongly consider infectious disease (ID) consult or speaking with the Centers for Disease Control and Prevention (CDC) for treatment recommendations in cases of newly-diagnosed malaria given that malaria is not endemic in the US. Resistance patterns vary depending on where the disease was acquired. The CDC hotline is 1-855-856-4713 (toll-free) or 1-770-488-7100 (all hours), email address malaria@cdc.gov.57

Table 2. Malaria treatment options.57 Adapted from: Long B, MacDonald A, Liang SY, et al. Malaria: A focused review for the emergency medicine clinician. The American Journal of Emergency Medicine. 2024;77:7-16. doi:10.1016/j.ajem.2023.11.035

*Complicated/severe malaria requires treatment with intravenous versus intramuscular artesunate. This will be transitioned to oral medication if the patient is improving after 4 doses. **May only be used in trimesters 2-3.

 

Table 3. Severe malaria management.84

Adapted from: World Health Organization (WHO). WHO Guidelines for Malaria.; 2023. Accessed June 11, 2023. https://www.who.int/publications/i/item/guidelines-for-malaria

AED = antiepileptic drug, FFP = fresh frozen plasma, HOB = head of bed, I&O = intake and output, IV = intravenous, IVF = intravenous fluid, LOC = level of consciousness, NG = nasogastric, NIPPV = non-invasive positive pressure ventilation, ORS = oral rehydration solution, PRBC = packed red blood cells

 

Treatment considerations: TB

The preferred initial regimen for patients with drug-susceptible TB is combination therapy with rifampin, isoniazid, pyrazinamide, and ethambutol (RIPE therapy) either 5 or 7 days weekly for 8 weeks, which is considered the intensive phase. This is followed by a continuation phase with rifampin-isoniazid combination therapy either 5 or 7 days weekly for 18 weeks. Numerous alternative agents and regimens exist depending on resistance patterns. Emergency clinicians should strongly consider ID consult prior to starting treatment for TB given that resistance patterns are complicated and vary depending on where the infection was acquired.85

Disposition decisions should be determined in close discussion with ID. Patients who are asymptomatic or clinically stable, are able to self-isolate, have appropriate follow-up, and can access outpatient prescriptions may be suitable for discharge. Patients who are systemically ill, cannot care for or isolate themselves, or who are unable to access outpatient prescriptions should be admitted.81

Treatment considerations: persons under investigation for viral hemorrhagic fevers

History-taking in refugee patients from sub-Saharan Africa should be include inquiry  regarding the patient’s country of origin and other areas through which they traveled prior to reaching the United States. Patients who have spent time in rural areas or on farms with exposure to wild animals are at higher risk for viral exposure. The ED clinician should look up those particular regions before entering the room to determine whether the patient has traveled through any viral hemorrhagic fever outbreak zones. Conservative precautions for those with flu-like illnesses (fevers, myalgias, GI symptoms), rashes, or bleeding should be placed on contact, droplet, and airborne precautions until a full history and physical examination can be performed. Malaria should be excluded, and laboratory testing (where available) should be sought to rule out any viral hemorrhagic fevers for which the patient is at high risk. Specific viral hemorrhagic fevers and their typical geographic ranges can be found in Table 4; more details by disease can be found in Table 1.

Table 4. Viral hemorrhagic fevers and their regions in Africa.43,86

DRC = Democratic Republic of the Congo

 

Trauma

Refugees arriving in Uganda are prone to higher risks of injury due to austere conditions during emigration from their home countries.87 The majority of the injuries seen in the ED are associated with violent conflicts. These patients suffer from untreated physical injuries, including gunshot wounds, shrapnel, accidents, envenomations, sequelae of physical or sexual assault, and heat exhaustion/heat stroke.8,88 Careful inquiry and a head-to-toe evaluation are necessary to exclude traumatic injuries. Diagnostic imaging should be targeted to the specific injuries of the patient.

Malnutrition

Refugees arriving or living in Uganda face a significant malnutrition burden, with a Global Acute Malnutrition (GAM) rate of 9.1%, just below the World Health Organization’s emergency threshold.11 Similarly high rates of malnutrition are noted among refugees arriving in resource-rich countries.89 The high malnutrition rate is caused by factors such as a heavy disease burden, particularly malaria, as well as poor food consumption and inadequate infant and child feeding practices.11 Programs such as the Supplementary Feeding Program (SFP) are instituted at the time of arrival where mothers are taught how to make nutritious food locally for themselves and their children and educated about nutritional sustainability and food safety.90 However, these efforts are not yet sufficient to fully combat the burden of malnutrition faced by refugee families. Patients with non-severe malnutrition (i.e. normal vital signs, no signs of end-organ damage) should receive social work or case management consults to ensure that they are set up with proper outpatient resources. 

ED clinicians are unlikely to have the time or resources needed to calculate anthropomorphic measures such as weight-for-length Z-scores. However, mid-upper arm circumference (MUAC) is a simple anthropometric measure that can be used to identify muscle wasting. MUAC < 115 mm is indicative of severe acute malnutrition (SAM) and indicates the need for admission.91 SAM may also be identified based on end-organ manifestations. These may include unstable vital signs, lethargy, irritability, confusion, hypoglycemia, hepatobiliary dysfunction, or AKI.92 Refugee patients with SAM, dehydration, or shock should be admitted for further management.93

Psychosocial Challenges

Refugees in the region face profound psychological challenges, including depression (noted in about half of refugees), anxiety, and post-traumatic stress disorder (PTSD) (seen in about one-third of refugees).94 The process of isolating patients for infectious disease can compound PTSD and needs careful explanation to avoid misinterpretation as incarceration or forced separation from family.

Notably, 61 out of 200 female refugees report experiences of sexual and gender-based violence, including domestic violence (24%) and rape (19%), which leave enduring psychological scars.95 These mental health afflictions frequently compel refugees to seek care in the ED. The inadequacy of community medical resources exacerbates their conditions, leading some individuals to experience debilitating pain and contemplate suicide. Without timely medical interventions in the ED, many survivors remain trapped in a cycle of suffering from significant injuries, adversely impacting their quality of life and intensifying their psychological distress. In addition to addressing physical injuries secondary to violence, clinicians should screen refugee patients for suicidality, engage forensic nurse examiners for victims of assault, and connect patients with social work or case management resources. STI testing and prophylaxis should take place when indicated.

It is critical to ensure that clinicians communicate with patients in their native language in order to obtain accurate information and maximize building a trusting relationship. The American College of Emergency Physicians (ACEP) advocates using formal interpreters.96 All patients have the right to an interpreter under Section III of the Americans with Disabilities Act (ADA).97 Using family or friends as interpreters is an inadequate substitute for a formal interpreter, as patients may not wish for their private health information to be shared. In addition, informal interpreters may not possess the medical terminology necessary to accurately convey the content of ED conversations to patients.98

The Emergency Medical Treatment and Labor Act mandates a medical screening exam for all patients presenting to the ED.99  Refugee patients should receive reassurance that they will receive care in the ED regardless of their ability to pay. Where available, they should receive consultations from social work or case management to discuss means of financial assistance.

Refugees may be more likely to seek care in the ED for non-emergent concerns. This stems from the fact that refugees may be unaware of the intricacies of the healthcare system, do not have the financial means to access outpatient care, cannot afford to take time off of work during business hours when primary care offices are open, or do not have access to transportation to see a primary care physician.100 -101 Rather than becoming frustrated, clinicians should seek to be empathetic and understand the unique circumstances under which these patients have sought care in the ED. Efforts should be made to address primary care concerns (as time allows) and to connect patients to outpatient resources such as free and sliding scale clinics if they are uninsured. 

Pearls and Pitfalls

  • Refugees from sub-Saharan Africa are on the rise.
  • This population is at high risk for infectious disease, traumatic injury, and complex psychological trauma
  • There should be a low threshold to isolate patients with suspected communicable diseases
  • These patients may have nowhere else to go to seek care; they should be treated with compassion and connected to appropriate resources

#FOAMed:

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