The current global refugee crisis peaked between 2015 and 2017. In 2015, the highest levels of forced displacement were observed and the numbers of refugees and asylum seekers from different countries dramatically increased.
By late 2017, the number of people attempting to cross borders was still high but receding. The crisis saw an unparalleled number of people on the move and enormous diversity with regard to age, gender and medical requirements. Amongst the people affected and forced to leave their countries where also many children. According to the World Health Organization, around one million asylum-seeking children were registered in the European Union between 2015 and 2017. Many of them – approximately one in five – arrived unaccompanied by a caregiver. An ECR Special Focus session will take a close look at the specifics of imaging and managing such patients.
Boy A’s bone age is approximately 14 years, whereas the boy in image B has a bone age of 17 years. Both stages of skeletal maturation are within the normal range for this chronological age (provided by Lil-Sofie Ording Müller).
Besides the usual risks associated with fleeing, these people faced particular problems when arriving at their destinations, including discrimination, marginalisation, exclusion and problems with regard to healthcare delivery.
Migrants and refugees often have complex health needs and medical problems that can include physical injuries and psychological trauma. Due to circumstances such as being separated from family or left behind, psychological issues particularly affect children, who represent a highly vulnerable group.
As a large proportion of migrant and refugee children originate from low and middle-income countries, where they often face poor housing and sanitary environments, inadequate nutrition and inaccessible medical care, they have a higher prevalence of pre-existing infectious diseases such as hepatitis B or tuberculosis compared with host populations. Poor hygiene conditions during flight and insufficient vaccine coverage may further increase the risk of contracting infectious diseases. Migrant and refugee children may also suffer from non-communicable diseases such as chronic respiratory disease and diabetes, which may be undermanaged and exacerbated when they are forced to flee their countries. On top of all this are malnutrition, overexertion, sleep deprivation, extreme stress and other factors, which adversely affect the physical and mental health of these children.
Healthcare teams face significant challenges when caring for migrant and refugee children. They are confronted with different problems, ranging from unknown backgrounds, lack of reliable patient medical history, fear and distrust, as well as cultural and language barriers, which may pose major hurdles in regard to medical examination and treatment.
“Health professionals must address the complex health and social needs of refugees, often in cross-cultural interactions. Overcoming social and cultural barriers and building confidence are major challenges when providing healthcare to migrant and refugee children,” said the chair of today’s session, Prof. Michalle Soudack, Director of the Department of Pediatric Radiology at the Safra Children’s Hospital in Ramat Gan, Israel.
After Soudack’s introduction, two experts will focus on the epidemiology of infectious and chronic diseases in migrant and refugee children. First, Prof. Anders Hjern, from the Institute for Epidemiology, Karolinska Institute, Stockholm, Sweden, will discuss the subject from the clinician’s perspective. Following his presentation, Prof. Berna Oguz, from the Department of Radiology, University of Hacettepe, Ankara, Turkey, will address the topic from the radiologist’s perspective and familiarise attendees with the spectrum of imaging findings among refugee populations.
Last, but not least, Dr. Lil-Sofie Ording Müller, from the Department of Radiology and Nuclear Medicine, Oslo University Hospital, Norway, will discuss medical age determination for legal purposes, which may be requested by courts and other government authorities in order to properly follow all legal procedures where age is relevant. Methods used for determining a person’s chronological age include physical examination, x-rays of the hands and a dental examination to record dentition status and evaluate an orthopantomogram. Another suggested method is a thin-slice CT of the medical clavicular epiphyses or MRI of the knee. For optimal accuracy, it is advised to use multiple methods in combination. However, there is no universally accepted method for medical age determination and there is conflicting evidence about the accuracy and reliability of the available methods, which may generate significant margins of error. Moreover, ethical concerns have been raised about medical examinations for age determination because they can potentially endanger the health of those being examined and violate the privacy and dignity of young people who may already be severely traumatised.
In November 2019, the World Medical Association published a statement on medical age determination of unaccompanied minor asylum seekers, recommending that medical methods for age determination must only be used in exceptional cases and only after all non-medical methods have been exhausted. Furthermore, it is noted that any medical methods that could involve a health risk for the applicant (e.g. radiological examinations without a medical indication) or that infringe upon the dignity or privacy of an already potentially traumatised asylum seeker (e.g. genital examinations) must be avoided.
During her presentation, Ording Müller will go over these and other principles and limitations of radiological age determination, define the role of the paediatric radiologist within the process, and discuss ethical considerations in regard to medical age determination.
Please note that for pre-recorded sessions published during the ECR Highlight Weeks, there will be no chairpersons. However, we still wanted to keep Professor Soudack’s statement for the article as she initially gave it.
Special Focus Session
SF 9b Imaging of migrant and refugee children
- Challenge of promoting health of refugee and migrant children in Europe
- Anders Hjern; Stockholm/SE
- Imaging of emerging diseases in refugee and migrant children
- Berna Oguz; Ankara/TR
- Age determination for legal purpose
- Lil-Sofie Ording Müller; Oslo/NO
FURTHER READING
Weinrich JM, Diel R, Sauer M et al (2017) Yield of chest X-ray tuberculosis screening of immigrants during the European refugee crisis of 2015: a single-centre experience. Eur Radiol. 27(8):3244-3248: european-radiology.org/4684
De Tobel J, Hillewig E, de Haas MB et al (2019) Forensic age estimation based on T1 SE and VIBE wrist MRI: do a one-fits-all staging technique and age estimation model apply? Eur Radiol. 29(6):2924-2935: european-radiology.org/5944
Li Y, Huang Z, Dong X et al (2019) Forensic age estimation for pelvic X-ray images using deep learning. Eur Radiol. 29(5):2322-2329: european-radiology.org/5791
Ottow C, Schulz R, Pfeiffer H, Heindel W, Schmeling A, Vieth V (2017) Forensic age estimation by magnetic resonance imaging of the knee: the definite relevance in bony fusion of the distal femoral- and the proximal tibial epiphyses using closest-to-bone T1 TSE sequence. Eur Radiol. 27(12):5041-5048: european-radiology.org/4880