In a small sample of adult Syrian refugees (n=44) presenting at GeoSentinel sites after migration, 5 cases of active TB (3 pulmonary, 2 extrapulmonary) and 4 cases of latent TB infection (LTBI) were identified 38. Initial screening data from Texas and Illinois indicate that approximately 10% of newly arrived Syrian refugees have LTBI, as detected by IGRA/TST 39. This is consistent with findings from GeoSentinel surveillance data. However, preliminary screening data from Canada indicate substantially lower rates of LTBI in newly arriving Syrian refugees. Of 26,166 Syrian refugees screened upon arrival between November 2015 and February 2016, only 2 (<1%) were found to have LTBI 40.
The prevalence of chronic infectious hepatitis (B and C) among Syrian refugees appears to be low. In a recent cross-sectional survey of Syrian refugees residing in Iraq (N=880), 3.86% (34/880) were found to be infected with hepatitis B virus 41. Screening performed in unaccompanied Syrian children (<18 years) revealed no cases of hepatitis B among 448 screened children 38. Initial domestic screening of Syrian refugees in Texas arriving between January 2012 and July 2016 found 1.2% (3/259) of those screened had hepatitis B infection 39. Until additional data become available that confirm these low rates, Syrian refugees should continue to be screened for chronic hepatitis B virus infection.
Estimated hepatitis C virus infection prevalence is quite low in the general Syrian population (0.4%), as well as in surrounding countries, including Iraq (0.2%), Jordan (0.3%), and Lebanon (0.2%) 42. Among high-risk groups in the same countries, hepatitis C prevalence was considerably higher, particularly in Syria, where prevalence was estimated to be 47.4% 42. Hepatitis C virus infection is a major health concern in Egypt, with prevalence estimated to be greater than 10% nationally 43, 44. Among Syrian refugees, few hepatitis C screening data are available. In the aforementioned cohort of 880 Syrian refugees living in Iraq, and 480 unaccompanied children screened in Berlin, no cases of hepatitis C were detected 38, 42. Until further data are available, those with risk factors, and those for whom routine screening in the U.S. is recommended (e.g., born during 1945-1965), should be screened in accordance with current U.S. recommendations.
HIV and Syphilis
HIV and syphilis appear to be uncommon in resettled Syrian refugees. Data collected from domestic medical screening of Syrian refugees in Texas arriving between January 2012 and July 2016 revealed low rates of HIV and syphilis infection. Of those screened, 0.8% (2/261) were found to be HIV-positive, and syphilis infection was found in 0.7% (1/140) 39. Although reported infection rates are low, routine screening according to the Domestic Refugee Screening Guidelines for HIV Infection and Sexually Transmitted Diseases should be followed until further data become available.
The majority of Syrian refugees are receiving albendazole and ivermectin prior to departure to the United States. Routine post-arrival stool ova (eggs) and parasite testing is likely not cost-effective and is not routinely recommended for Syrian refugees. Domestic screening physicians and providers should refer to CDC’s Domestic Intestinal Parasite Guidance.
Giardiasis has been detected in Syrian refugees and can be associated with subtle symptoms such as abdominal complaints, loose stool, flatulence, and eructation. Giardiasis has been associated with failure to thrive in children. A lower threshold to screen or test children younger than 5 years of age who may not verbalize symptoms or express overt signs of infection is reasonable. When screening is performed, stool antigen testing is more sensitive and convenient than stool ova and parasite examination. U.S. clinicians should note that overseas presumptive parasite treatments are not effective in treating Giardiasis.
Leishmaniasis is caused by infection with Leishmania parasites, which are spread by the bite of phlebotomine sand flies. Leishmaniasis is endemic to Syria. There are several different forms of leishmaniasis in people. The most common forms are cutaneous leishmaniasis, which causes skin sores, and visceral leishmaniasis, which affects several internal organs (usually spleen, liver, and bone marrow). Cutaneous leishmaniasis is the most common form of the disease observed in Syrian refugees. L. tropica and L. major have been reported in Syrian refugees in Lebanon 45. In 2013, 1,033 new cases of leishmaniasis were reported in Lebanon, with approximately 97% of cases occurring in Syrian refugees 46. Cutaneous leishmaniasis has also been reported in refugees in Turkey 47, 48, as well as in Syrian refugees screened at a GeoSentinel site in Berlin, Germany 38.
Currently, there is no additional screening recommended to detect leishmaniasis. However, clinicians should be aware of the disorder and consider it in the differential diagnosis of any Syrian with chronic skin sores or other symptoms that might indicate infection (e.g., chronic cutaneous lesions). Information on the diagnosis and management of leishmaniasis may be accessed at the CDC Division of Parasitic Diseases website.
Echinococcosis is a parasitic disease caused by infection with the larval stage of Echinococcus granulosus, a tapeworm found in dogs (definitive host), sheep, cattle, goats, and pigs (intermediate hosts). Echinococcosis is classified as either cystic or alveolar. Cystic echinococcosis (CE), or hydatid disease, is the primary form of echinococcosis found in Syrian refugees. Most people with CE infections are asymptomatic. However, in some cases, CE causes harmful, slow-growing cysts in the liver, lungs, and other organs. These cysts often grow for years and go unnoticed and neglected. Clinical presentation is highly variable. Most often, clinical presentation is due to mass effect—as the cyst grows, it impinges on local tissues causing discomfort and/or abnormal test results (e.g., increased liver function tests). Infection may also be incidentally noted when diagnostic procedures are done for other reasons (e.g., chest X-ray). Cyst rupture may result in anaphylactic reactions, including death, when the contents of the cyst are released. This can occur spontaneously following trauma, or, most importantly, when clinical evaluation/intervention is being attempted.
Currently, no additional screening is recommended for asymptomatic refugees. However, when a cystic lesion is noted, echinococcosis diagnosis should be considered. Expert advice should be obtained prior to performing any invasive diagnostic or intervention procedures. Further information is available from the CDC Division of Parasitic Diseases website.
Chronic and non-communicable diseases have been reported in Syrian refugees. Chronic and non-communicable conditions in this population include anemia, cancer, hypertension, diabetes, malnourishment, renal disease, and hemoglobinopathies/thalassemias.
In a recent survey of Syrian refugee households (n=1550) residing in non-camp settings in Jordan, half of all households reported having at least one household member with a previous diagnosis with one of five non-communicable diseases: arthritis, cardiovascular disease, chronic respiratory diseases, diabetes, or hypertension 49. Among adults (>18 years of age) in the survey population, hypertension prevalence was highest (10.7%), followed by arthritis (7.1%), diabetes (6.1%), cardiovascular disease (4.1%), and chronic respiratory disease (2.9%). However, disease prevalence was substantially higher for older refugees, particularly those 60 years of age or older (Table 3) 49. Additionally, in a separate survey (n=210) among elderly Syrian refugees (>60 years of age) living in Lebanon, 22% of respondents reported high cholesterol, while 15% reported chronic pain. Digestive tract and neurological diseases were reported by 9% and 5% of survey participants, respectively 50.