Neglected Tropical Diseases and migrants: a global health challenge amid access barriers and lack of gold standard diagnostics

This thesis concerns the Health of Migrants, with particular attention to "neglected" tropical diseases (NTDs) and other infections, and is based on the experience of daily screening and clinical work carried out for several years at the outpatient clinic of the National Institute for Migration and Poverty ( INMP) in Rome, and on scientific collaboration with the IRCCS Sacro Cuore Don Calabria for Infectious and Tropical Diseases and the University of Verona. The thesis is structured in 5 main chapters, each of which consists of a short introduction and one or more scientific articles (6 articles in total). Each chapter develops from a specific research question. Chapter 1 deals with the institutional and socio-cultural barriers that hinder migrants' access to the national health system, having as a case study the anthropological approach to Chagas' disease screening in Latin American migrants. Through the case study, a general approach to foreign patients that takes into account cultural, social and linguistic differences is indicated. Chapter 2 deals with infectious disease screening in neglected and 'invisible' persons: minors and trafficked Nigerian women, also addressing issues such as barriers to access to care for migrants. The first paper, on a large cohort, shows that migrant minors are generally healthy and do not pose a significant risk to the native population. The second work surprisingly shows that, in trafficked sex workers, noncommunicable NTDs, such as strongyloidiasis and schistosomiasis, are much more common than sexually transmitted diseases (STDs) and HIV. Chapter 3 describes the process that led, through complex inter-institutional work in which I was personally involved, as a member of the technical group and writing committee,to the first national guidelines in Italy for infectious disease screening in asylum seekers and refugees, which added two important non-communicable NTDs, namely strongyloidiasis and schistosomiasis, to the traditional communicable infections. Chapter 4 describes, through the largest prospective study ever conducted in Europe, the prevalence of the two NTDs and transmissible infections in African refugees and asylum seekers, noting an impressive number of people with urinary and intestinal schistosomiasis and (to a lesser extent) strongyloidiasis, and emphasizes the lack of a diagnostic gold standard for the two infections and the need for improved 4 screening tests. Chapter 5 deals with the evaluation of a new serological test (not yet commercially available) for strongyloidiasis, demonstrating reasonably good sensitivity and specificity. In the same line, Chapter 5 goes on to indicate current and future lines of research to improve the screening and diagnosis of schistosomiasis. We conclude that the healthcare management of migrants is extremely complex and challenging, involving at the same time science, ethics, solidarity, rights, politics and determinants of health, thus becoming a global health challenge.