How do you proceed?

Refugees and migrants arriving from Ukraine require careful review of all vaccine records, medical notes (if available), and a full history and physical exam. Use of a certified medical translator is paramount. General vaccination requirements for Ukrainian refugees include measles, polio, and COVID-19, but also pertussis, diphtheria, tetanus, and hepatitis A, amongst others. ^{Reference Matheson, Young, Mamo, Yun and Frerich15,16} All patients should undergo tuberculosis screening with an interferon gamma receptor antigen (IGRA) blood test and be referred to the local health department if they exhibit signs or symptoms of active tuberculosis (i.e., cough, fever, weight loss, failure to thrive, night sweats, hemoptysis). ^{Reference Matheson, Young, Mamo, Yun and Frerich15,16} Patients should also be screened at intake for hepatitis B, hepatitis C, and HIV.

While not a medical requirement for resettlement in the US, clinicians should strongly consider screening patients from countries with increasing rates of multidrug resistance (MDR), including human conflict zones such as Ukraine. Among others, increasing numbers of MDR Klebsiella pneumoniae and Acinetobacter baumanii, both carbapenem resistant, have been detected in patients both within Ukraine and resettled elsewhere. Risk factors include war-related injuries, prior hospitalization, and prior antibiotic use. ^{Reference Petrosillo, Petersen and Antoniak17,Reference Ljungquist, Nazarchuk and Kahlmeter18} The European Centre for Disease Prevention and Control (ECDC) recommends pre-emptive isolation and MDRO screening, in particular carbapenem-resistant Enterobacterales (CRE), for patients with traumatic wounds. ¹⁹ In this scenario, if screening reveals infection with an MDRO such as CRE, a multidisciplinary treatment approach is recommended. This includes consultation with an Infectious Diseases specialist for selection and monitoring of appropriate antimicrobial therapy, such as meropenem-vaborbactam, ceftazidime-avibactam, or imipenem-cilastatin-relebactam. ^{Reference Tamma, Heil, Justo, Mathers, Satlin and Bonomo20} Wound care, debridement, and need for reconstruction should also be coordinated with a surgical subspecialty, e.g., Plastic Surgery.

How do you proceed?

People living with HIV (PLHIV) are at risk of various opportunistic infections including Mycobacterium tuberculosis, Cryptococcus neoformans, and Pneumocystis jirovecii pneumonia, among others. The patient in this case raises suspicion for tuberculosis (TB). In 2021, it was estimated that there were 10.6 million people who developed TB, 6% of whom were PLHIV. ²¹ Notably, 30 high TB burden countries account for 86% of all TB in the world, including the DRC, Uganda, South Africa. ²² Concerningly, human conflict is associated with decreased notification rates of TB and up to 20 times increase in TB. ^{Reference Kimbrough, Saliba, Dahab, Haskew and Checchi23}

Because of the immune dysregulation in HIV, screening for TB in PLHIV is crucial. A four-symptom screening tool (current cough, fever, weight loss, or night sweats) should be used. ²⁴ If any one of these four symptoms is positive, then further testing should be performed, including chest radiography and sputum samples for acid-fast bacillus (AFB) smear, culture, and nucleic acid amplification testing (NAAT). Because of the high incidence of latent TB in PLHIV, the CDC requires AFB smear and culture to be performed even in asymptomatic patients in the refugee population. ^{Reference Beeler, Regan, Mitchell and Barnett25}

Treatment typically consists of two months of an intensive phase with isoniazid, rifampin, pyrazinamide, and ethambutol given daily, with four months of continuation phase (isoniazid, rifampin, and ethambutol) given daily. ^{26,Reference Duarte, Munsiff and Nahid27} Additionally, the rates of multidrug-resistant TB (MDR-TB), which is resistant to both isoniazid and rifampin with or without resistance to other first-line anti-TB agents, are increasing. ^{Reference Zignol, Dean and Falzon28} PLHIV are at high risk of MDR-TB due to delays in diagnosis, higher mycobacterial loads, malabsorption of isoniazid, rifampin, and pyrazinamide, and nosocomial transmission of MDR-TB. ^{Reference Wells, Cegielski and Nelson29} Notably, human conflict disrupts healthcare services, and consequently TB treatment, leading to an increase in MDR-TB. NAAT allows for rapid identification of MDR-TB while cultures are in process. All TB therapy should be coordinated with local health department guidance, and MDR-TB is best managed by an Infectious Diseases specialist to assist with regimen selection. Notably, there is increased risk of TB conversion in migrant populations within the first five years of arrival to a low-TB-incidence country from a high-TB-incidence country. ^{Reference van den Boogaard, Slump, Schimmel, van der Hoek, van den Hof and de Vries30}

The incidence of TB in people experiencing homelessness is ten times greater than that of the general population. ^{Reference Tibbetts, Ottoson and Tsukayama31} This patient resides in a shelter and will need to be isolated and rapidly treated in order to prevent transmission to others. In collaboration with local public health officials, residents of the shelters should undergo contact investigations and screenings due to their higher likelihood of exposure to TB. Additionally, Directly Observed Therapy is highly recommended to ensure adherence to the treatment regimen.

Beyond understanding the medical issues affecting asylum seekers, it is important for providers to be aware of the unique psychosocial challenges faced by this population. Our previous qualitative work involved interviews with providers working at clinics in Southeast Michigan that care for large populations of patients from asylee, refugee, and immigrant backgrounds. ^{Reference Croxton, Ladines-Lim, Schurz, Guetterman and Patel8,Reference Fazel, Wheeler and Danesh9} One emergent theme from these interviews was the nuance and subtleties with which psychosocial trauma may manifest. Our work revealed some patients exhibited increased levels of stress, post-traumatic stress disorder, and homesickness. Trauma may present as nonspecific physical symptoms, such as abdominal pain, headaches, or fatigue, without a clear organic cause. All asylum seekers should be screened for evidence of torture, human trafficking, and sexual and gender-based violence. Comprehensive care for patients who arrive in the US from other countries ought to be trauma-informed and recognize the psychological impact of displacement, for which various other resources can provide guidance. ^{Reference Ravi and Little32}

How do you proceed?

Poliomyelitis, a vaccine-preventable illness, has resurged in conflict zones. While polio was previously eradicated from Palestine, the World Health Organization detected poliovirus (vaccine-derived poliovirus type 2) in wastewater in June 2024 due to destruction of healthcare infrastructure during the current humanitarian crisis. ^{33,Reference Grotto, Agha, Abu Al-Halaweh, Davidovitch, McKee and Nitzan34} In August 2024, the first case was confirmed in a ten-month-old unvaccinated child. Factors such as the dissolution of healthcare services and routine immunization programs contributed to the re-emergence of polio. Afghanistan and Pakistan remain polio-endemic countries.

The virus has three serotypes and spreads via the oral-fecal route. Though carriers may be asymptomatic, 1 in 200 to 1 in 2,000 will develop paralysis. Severe cases can result in quadriplegia, respiratory failure, and rarely death. ^{Reference Estívariz, Routh and Wassilak35}

The inactivated polio vaccine was developed by Jonas Salk, who licensed the first version in 1955, with wide distribution in the US. The oral poliomyelitis vaccine was designed by Sabin and contains live attenuated viral strains. Most recently, the novel oral polio vaccine type 2 has been used in an oral mass vaccination campaign in Gaza, with successful administration rounds in September and October 2024 and without any additional cases reported since August 2024. ³⁶ Still, ongoing transmission has been confirmed as of January 2025 via environmental sampling, ³⁶ underscoring the difficulty of protecting vulnerable populations in the face of massive conflict and dismantled public health infrastructure. ^{33,Reference Kunichoff, Mills and Asi37}

For this patient in question, it is important to understand the historical legacy of his illness and ensure that he and his family receive appropriate ancillary care, which may include referrals to physical therapy, orthotics, and adaptive equipment. He and his siblings should receive age-appropriate vaccines, including the polio vaccine, if indicated.