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Lisbon (ptp004/16.06.2018/09:10) - "While the major immigration and refugee movements over the past years have brought some major challenges for neurology, they have also turned up some previously undreamed of opportunities to gather fresh insights into brain disorders diseases such as multiple sclerosis and stroke. We have to make the most of this potential," said Prof Antonio Federico (Siena) at the 4th Congress of the European Academy of Neurology (EAN) in Lisbon.
A series of international studies looking at the health of immigrants delivered new insights into the relationship between genetics, environmental influences and the risk of brain disorders. Canada's PRESARIO study compared the health status of almost one million new arrivals with that of around three million immigrants who had been in the country for five or more years. It found that first generation immigrants had a much lower stroke risk at a young age than those who had been living in Canada for some time - even though they had inhibited access to the health system and lower income. "The study authors concluded that the risk of suffering a stroke was less a question of genetics, but more down to environmental factors such as diet," Prof Federico explained.
A Norwegian study looked at the prevalence of multiple sclerosis (MS) in immigrants from various countries of origin. What they found showed that MS was most widespread among those individuals who came to Norway from Europe and North America. African and Asian immigrants were only affected to a limited extent. The prevalence of MS in immigrants in Norway reflected the uneven worldwide distribution patterns. One insight uncovered by the study was a sharp rise in cases of MS in second-generation Pakistani immigrants. "This lends additional weight to the theory that strong environmental factors raise the risk of MS," the expert said.
An Italian study looked at the health of 114 refugees from 25 countries living in Tuscany. Their health-related quality of life varied according to country of origin, mother tongue and, not insignificantly, the city that they were first registered in. As the majority were young and healthy, they only rarely required medical treatment. "The data on quality of life showed that the group led a less healthy lifestyle than the local Italian population. They consumed more alcohol and tobacco, had a diet that was higher in sugar and fat and were less physically active. This all served to increase their risk of brain disorders," Prof Federico summarised.
Identifying rare diseases in Europe
Immigration from other continents poses something of an issue for neurologists trained in Europe, particularly when it comes to patients' medical histories, where geographical and seasonal factors come into play. "The majority of people come from countries for which we already have a clear picture of public health conditions. But as soon as they start to come from more remote regions, accessing all of the medically-relevant information becomes more difficult," Prof Federico explained. Brain disorders found in immigrants can cover a broad spectrum of conditions including diseases linked to genetics and infections that doctors from the host country would not normally come into contact with. "Behçet's disease is an exceptionally rare disease in Europe, but is relatively common in parts of Asia Minor, the Middle East and the Far East. If this disease is not diagnosed and treated in time, it can lead to serious neurological and cognitive complications," he added.
When treating refugees from war zones, it also needs to be borne in mind that they will most likely be traumatised, also due to their experiences in transit as displaced persons, and will come up against numerous difficulties in the country they arrive in. "This ongoing physical and psychological burden can trigger neurological conditions in refugees such as chronic tension headaches," Prof Federico cautioned. If a refugee is accommodated in cramped communal living quarters, they are also exposed to the risk of contracting acute and potentially fatal diseases. Varicella zoster virus infection, influenza, hepatitis, tuberculosis (incl. CNS tuberculosis), brucellosis and typhus can all have a detrimental effect on the nervous system. The spread of infectious diseases is not only a medical issue, it also stokes fears among local populations. "Immigrants are not dangerous, but they are at risk," said Prof. Federico. It has been shown that infectious diseases carried by migrants have virtually no influence on European epidemiology. That said, the overall prevalence of infectious diseases can be higher among immigrants than the general population of the host country. "This makes strict screening programs all the more important, as they enable infectious diseases to be identified in time and treated properly - through measures such as ensuring sufficient stocks of vaccinations are available," he explained.
Cultural and language barriers
When health issues do arise, immigrants often end up spending longer in hospital than patients from the host country. "Part of this is attributable to cultural and linguistic communication barriers. In many cases, the individuals affected have difficulty expressing their health issues and we are obliged to wait for interpreters before we can get to the bottom of their medical history," Prof Federico reported. It should also be taken into account that some patients come from cultures that stigmatise brain disorders such as epilepsy, and that such conditions are underdiagnosed or insufficiently treated as a result. "We definitely have to make sure that our healthcare systems provide sufficient medical care for all people, no matter whether they are from the original population or have only just arrived." As a general rule, immigrants tend to know very little about the healthcare systems in the country they arrived in. Cultural differences, low socioeconomic status, a lack of formal education and language barriers are the main obstacles to accessing healthcare systems. "This is why it is so important to ensure immigrants are better informed," Prof Federico concluded.
Sources: Federico A: Neurology and migrants: What we know, what we learned by neurosciences, what we can do? Journal of Neurological Sciences October 15, 2017, Volume 381, Supplement; Saposnik G, Redelmeier DA, Lu H et al : Risk of premature stroke in recent immigrants (PRESARIO): population-based matched cohort study. Neurology. 2010 Feb 9;74(6); Berg-Hansen P, Moen SM,Sandvik L et al: Prevalence of multiple sclerosis among immigrants in Norway. Mult Scler. 2015 May;21(6); Nante N, Gialluca L, Troiano G, Verzuri A et al: Refugees and asylum seekers' quality of life: a Italian experience: Agnese Verzuri. European Journal of Public Health, Volume 26, Issue suppl_1, 1 November 2016; Castelli F, Sulis G: Migration and infectious diseases. Clin Microbiol Infect. 2017 May;23(5); Khan MS, Osei-Kofi A, Omar A, Kirkbride H, Kessel A, Abbara A, Heymann D, Zumla A, Dar O: Pathogens, prejudice, and politics: the role of the global health community in the European refugee crisis. Lancet Infect Dis 2016; 16; Ozaras R, Balkan II, Yemisen M: Prejudice and reality about infection risk among Syrian refugees. Lancet Infect Dis 2016; 16; de Waure C, Bruno S, Furia G, Di Sciullo L, Carovillano S, Specchia ML, Geraci S, Ricciardi W: Health inequalities: an analysis of hospitalizations with respect to migrant status, gender and geographical area. BMC Int Health Hum Rights 2015; 15: 2; Ekmekci PE: Syrian Refugees, Health and Migration Legislation in Turkey. J Immigr Minor Health 2016 Mar 19. [Epub ahead of print].
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