Responding to Migrant and Refugee Healthcare Needs in Ireland

The number of international migrants residing in the Republic of Ireland has increased substantially, from 350 600 in 2000 to 746 300 in 2015.1 This reflects a worldwide trend of increasing migration.2,3 Migrants have a number of specific health needs. The growth in the number of migrant residents in Ireland poses challenges for health services which require adaptation and creative solutions. The terms “asylum seeker,” “refugee,” and “migrant” can be confusing. The 1951 Refugee Convention on the Status of Refugees defines asylum seekers as those fleeing persecution or conflict and therefore seeking international protection. A refugee is an asylum seeker whose claim has been approved, though some migrants fleeing war or persecution are considered by the United Nations (UN) to be refugees before they receive asylum and may enjoy prima facie refugee status. An economic migrant is someone whose primary motivation for leaving their home country is improved employment opportunities and economic gain. The term “migrant” is generally accepted as an umbrella term to encompass these three groups. For ease of discussion, the term “refugee” as used in this perspective article embraces asylum seekers and refugees. This essay explores the health needs specific to refugees and to economic migrants as well as the health needs common to migrants in general. The majority of migrants traverse international borders in search of better economic and social opportunities.3 Other migrants are forced to flee their native countries by war, economic, political, cultural, or environmental conditions. Migrants may experience immediate and lifelong health repercussions because of moving across borders.4 Ireland is currently experiencing a mixed-migration phenomenon, where economic migrants and refugees are arriving simultaneously. There is considerable diversity amongst migrants in Ireland; the 2011 Census showed 199 countries of origin, the most common of which were Poland, the United Kingdom, Lithuania, Latvia, and Nigeria.5 It is expected that Middle Eastern countries will rank higher in the 2016 Census figures because of the large efflux of refugees fleeing violence. Both economic migrants and refugees have complex health needs including addressing infectious diseases, malnourishment, gender-specific issues, cultural adaptation, and mental health. While voluntary migrants may experience positive repercussions such as improved income or better employment opportunities in their new country, they are also frequently subject to racism, psychological stress, poor http://ijtmgh.com Int J Travel Med Glob Health. 2017 Feb;5(1):1-4 doi 10.15171/ijtmgh.2017.01 TMGH IInternational Journal of Travel Medicine and Global Health J


Introduction
The number of international migrants residing in the Republic of Ireland has increased substantially, from 350 600 in 2000 to 746 300 in 2015. 1 This reflects a worldwide trend of increasing migration. 2,3Migrants have a number of specific health needs.The growth in the number of migrant residents in Ireland poses challenges for health services which require adaptation and creative solutions.
The terms "asylum seeker, " "refugee, " and "migrant" can be confusing.The 1951 Refugee Convention on the Status of Refugees defines asylum seekers as those fleeing persecution or conflict and therefore seeking international protection.A refugee is an asylum seeker whose claim has been approved, though some migrants fleeing war or persecution are considered by the United Nations (UN) to be refugees before they receive asylum and may enjoy prima facie refugee status.An economic migrant is someone whose primary motivation for leaving their home country is improved employment opportunities and economic gain.The term "migrant" is generally accepted as an umbrella term to encompass these three groups.For ease of discussion, the term "refugee" as used in this perspective article embraces asylum seekers and refugees.This essay explores the health needs specific to refugees and to economic migrants as well as the health needs common to migrants in general.
The majority of migrants traverse international borders in search of better economic and social opportunities. 3Other migrants are forced to flee their native countries by war, economic, political, cultural, or environmental conditions.Migrants may experience immediate and lifelong health repercussions because of moving across borders. 4Ireland is currently experiencing a mixed-migration phenomenon, where economic migrants and refugees are arriving simultaneously.There is considerable diversity amongst migrants in Ireland; the 2011 Census showed 199 countries of origin, the most common of which were Poland, the United Kingdom, Lithuania, Latvia, and Nigeria. 5It is expected that Middle Eastern countries will rank higher in the 2016 Census figures because of the large efflux of refugees fleeing violence.
Both economic migrants and refugees have complex health needs including addressing infectious diseases, malnourishment, gender-specific issues, cultural adaptation, and mental health.While voluntary migrants may experience positive repercussions such as improved income or better employment opportunities in their new country, they are also frequently subject to racism, psychological stress, poor expedition team and voluntary, blanket, written informed consent from the participants for training, treatment, and evacuation were obtained prior to beginning the study.All frostbite patients were included, while patients of nonfreezing cold injuries were excluded.Age, gender, occupation (mountaineer/porter/student/native resident), and knowledge of frostbite and cold weather preparedness (availability and adequate usage of cold weather clothing) were noted by the researcher on-site during the course of treatment.Preexisting risk of frostbite was assessed based on a prior history of frostbite and the consumption of tobacco or alcohol.Histories were collected from the participants to determine the altitude, duration, and probable causes of the cold injury.1][12] Dehydration was assessed subjectively based on a history of increased thirst at the time of injury, dry mucous membranes, and tachycardia.
Evacuation was often postponed until a suitable window of opportunity arose, determined by conditions of weather, communication, or evacuation capability.On-site management was initiated on presentation and continued until evacuation/healing.Elevation of the affected area and avoidance of high/low temperature exposure and movement such as rubbing and massaging were ensured.Intact blisters were preserved, while ruptured blisters were debrided and bandaged.Oral doses of diclofenac sodium 50 mg and amoxicillin-clavulanate 1000 mg were given twice a day. 5,10,12,13etanus toxoid was not given as all patients had been preimmunized.
Supervised therapeutic rewarming was initiated on-site after ensuring protection from refreezing or excessive movement and continued until evacuation/healing.1][12][13] Passive rewarming was done using sleeping bags, blankets, and by increasing ambient temperature to augment active rewarming. 12Exposure to dry heat such as a flame or stove was avoided.A bucket, mug, saucepan, or messtin was used in the absence of a designated rewarming contain.Aloe vera 10% cream was applied over frostbitten areas, including blisters. 12Oxygen and surgical debridement were not offered.The decision to evacuate was made based on the degree of injury, altitude/location of presentation, availability of supervised care, and previous history of cold injury.Primary responses to on-site treatment were monitored by relief of symptoms, healing of injuries, and return of function.The secondary outcome was the avoidance of evacuation in early frostbite patients.Descriptive statistics with percentages were calculated.Further prevention was advised to all patients.
Evacuation under protection was done for 45.45% patients (second-and third-degree frostbite), and efforts to reduce continued exposure to cold were made during the evacuation.All third-degree frostbite patients were evacuated (Table 4).Many patients had to be treated on-site because of delayed evacuation.Therapeutic rewarming was well tolerated by all patients, albeit blistering, swelling, and pain occurred or increased after rewarming in 29 (16.86%)patients.All medications were well tolerated by all patients without any significant side effects.In 62 out of 107 (57.94%, 95% CI: 48.59%-67.29%)first-degree frostbite cases and 22 out of 59 (37.29%, 95% CI: 24.95%-49.63%)second-degree frostbite cases, the patients were treated on-site and returned to their normal routine at a high altitude while being kept under observation (Table 4).Active therapeutic rewarming was effective.Passive rewarming had limitations as the study was conducted on-site in low ambient temperatures.Preventive measures such as preventive rewarming; contact precautions against strong soap, metals, and fuel; highperformance, expanded polytetrafluoroethylene clothing in layers; 100 ml non-alcoholic, non-caffeinated warm fluid per kg body weight per day; exercise, and education were implemented. 12,14

Discussion
On-site treatment of frostbite in this study reflects the potential possibility of optimal treatment, avoidance of the requirement of evacuation, and early reversal to routine activities at high altitude.Therapeutic and preventive rewarming along with nonsteroidal anti-inflammatory drugs (NSAIDs) and Aloe vera can definitely be attempted under controlled and protected conditions in limited-resource, high altitude camps outside the hospital setup.People with first-and seconddegree frostbite presenting early for medical help can be treated under high altitude field conditions with therapeutic rewarming forming the mainstay of treatment, although

Number of patients
Altitude it is advisable only in situations of delayed evacuation.The outcome of this study was positive, though it cannot be quantified in view of ethical limitations, because no controlarm patients were included.Therapeutic rewarming on-site, as attempted in these patients, is in accordance with the latest guidelines and thus furthers the concept of physiological cold injury reversal. 12,15Aloe vera, a potent anti-prostacyclin, inactivates bradykinins in vitro and reduces tissue loss. 12he occurrence of frostbite in healthy, knowledgeable travelers with prior cold weather experience is attributable to natural factors like unforeseen cold exposure as well as individual limitations in judgment, attitude, and behavior.Frostbite at high altitude occurs early due to the synergistic effects of cold, hypoxia, and dehydration often presenting as comorbidity with hypoxic disorders. 12Hypoxia-induced cerebral impairment, noted around 4570 m/15000 ft, may affect a traveler's ability to assess frostbite risk. 5,9,12,16In their study of 1500 patients with high altitude frostbite in the Karakoram region of the Himalayas, however, Hashmi et al found a significant association between altitude and frostbite incidence and severity.The extent and severity of frostbite also depended on temperature, duration of exposure, and individual susceptibility. 8,12Chronic smokers, alcoholics, residents of tropical climates, and those who have previously had frostbite are more prone to frostbite, while cold-experienced or cold-acclimatized individuals may have reduced susceptibility. 17Cold-induced distal vasoconstriction leads to frostbite developing in the toes and feet, fingers and hands, ears, face, and groin region. 12,18As seen in this study, first-degree frostbite involving the fingers/hands and toes is the most common. 12,19The relative inactivity of fingers while walking, frequent exposure due to personal and professional work, and inadvertent touching of cold surfaces may be contributory.Toe tips may be affected because of prolonged standing, extended outdoor work, and during sleep.
Emerging therapies with a recombinant tissue plasminogen activator, prostacyclin, nerve blocks, and oxygenation are applicable in third-and fourth-degree frostbite, but they are yet to be tested in the field on a large scale. 1,10,11In the current study, therapeutic rewarming was tried only in first-and second-degree frostbite cases.The use of vasodilators, Chinese herbs, infrared exposure, and antimicrobial prophylaxis have been claimed to be beneficial. 12,20,21he successful treatment of frostbite is dependent on situational complexity.The presentation of frostbite and associated ailments to medical authorities may be delayed because of the unavailability of medical personnel; inaccessibility due to weather, terrain, or communication; a false sense of bravado; fear of deinduction from the team or mission; and poor judgment about the injury due to numbness. 9,16,22,23High altitude-induced lassitude and indifference lead to outdoor inactivity and negligence.By the time a patient presents, the discovery of severe frostbite is expected in high-intensity, long-duration missions, such as traveler explorations, summit ascents, organized training, ferry loading by porters, and in the exuberance of mountaineers.
The present study was conducted in low-resource setups where in-patient facilities, laboratory and imaging services, advanced treatment and patient monitoring infrastructures were non-existent.Communication and evacuation facilities were severely compromised by inclement weather conditions.Patient management was done in mountain tents. 9,16,24The subjective parameters, the absence of controls, and the absence of detailed guidelines may limit conclusions from this study, implying the need for further work in suitable field conditions or appropriate simulations incorporating elements of cold acclimatization, risk assessment of cold injuries, and appropriate modeling. 8,9,17,25,26Multi-centric research on frostbite can help quantify the contributions of various etiologic factors; ascertain the initiation, course, and prognosis of frostbite; formulate observational diagnostic parameters; and identify feasible, effective interventions regarding evacuation and treatment.An interdisciplinary approach incorporating translational medicine and operations management capabilities is required to develop better guidelines for mountain and cold environments.

Conclusion
Frostbite can occur in people with cold-experienced and knowledgeable travelers.While it is already known that therapeutic rewarming is effective in hospital environments, the present study adds that therapeutic and preventive rewarming can be attempted in controlled and protected conditions in limited-resource setups outside the hospital.With this advancement in the existing knowledge, frostbites can be treated under high-altitude field conditions with certain limitations, although it is advisable only in situations of ft 12000-14000 ft 15000-17000 ft 18000-20000 ft 21000-23000 ft 24000

Table 1 .
Distribution of Patients (N=172) in Place and Occupation

Table 2 .
Presentation of Frostbite

Table 3 .
Contributory Cold Exposure in Frostbite Patients Presentation of Frostbite at Various Altitude.

Table 4 .
Treatment and Evacuation of Frostbite Patients