In January 2012 there were over 5 million foreigners resident in Spain, 15.8% of whom were under 16.1 Like their parents, immigrant children and those born into families who have arrived recently are at greater risk of suffering from imported diseases unfamiliar to healthcare staff, with certain exceptions such as tuberculosis that are also very prevalent in Spain. In addition, the large number of international adoptions, as well as the increase in travel to low-income countries, are conducive to the presence of these diseases in Spain.2,3 They are diseases contracted in another country and diagnosed in the host country, where they are either absent or of low prevalence, but they can entail high morbidity and mortality. Although some of them will not be transmitted in the same way as in the country of origin, because of differences in climatic and vectorial conditions, others may represent a potential risk to population health.4–6

There are various handbooks devoted to the care of immigrant paediatric patients, and protocols for diagnosis, treatment, and screening in cases of risk of vertical transmission or after trips to high-risk countries.7–12 Use of protocols, teamwork, and continuing education, as well as specialised training for resident physicians should make it possible to detect and treat imported infections promptly and also to optimise resources devoted to the care of these patients.

In response to the increase in consultations on imported diseases in our unit, a specialised clinic was created in 2009 to provide comprehensive treatment for problems affecting immigrant children or children of immigrants with risk factors and internationally adopted children, as well as those arising from travel to high-risk areas. Since it began we have worked on formulating diagnostic and therapeutic guidelines, set out in various consensus protocols.

This article analyses the first years of operation of our clinic, examining the characteristics of the patients treated and their diseases, and also the advantages of a centralised service in terms of quality of care and teaching.

We conducted a retrospective study analysing the first three years (January 2009 to December 2011) of operation of the Imported Infectious Diseases Clinic in our unit.

Firstly, we analysed the knowledge generated since its establishment, by evaluating newly formulated protocols and clinical practice guidelines and group work with specialists in other areas and with learned societies, as well as the dissemination of that knowledge through meetings, publications and online communication.

Secondly, we analysed the clinical care delivered in terms of its quality and characteristics. The quality of care provided was assessed in respect of its accessibility. For this purpose we evaluated the delay in initial assessment, defined as the time that elapses from referral to visit, as well as the possibility of consultation by telephone. The study describes patient characteristics, reason for and source of referral, and the disease detected. A descriptive analysis was performed by reviewing the medical histories of patients of paediatric age (<18) seen during the study period. We excluded those evaluated in the emergency department or hospitalization, which gave rise to 147 referrals, but did not require subsequent follow-up. In view of the diversity of the patients, and in order to analyse them better, they were grouped into three categories, according to the reason for their assessment.

Group 1 consisted of asymptomatic patients referred for imported disease screening, including adopted and immigrant children attending with their families. Their demographic and clinical characteristics were described: age, sex, anthropometrics (according to Carrascosa's growth curves13), region of origin as defined by the WHO,14 time from arrival in our country to first visit, and referring specialist. We also evaluated the degree of adherence to our protocols in the area of infectious disease, defined as the number of performed examinations compared to the number of examinations that should have been requested according to the risk group, by disease and region of origin. Table 1 shows the examinations performed.

Group 2 included patients who sought services for symptoms of some kind after travel to a tropical or subtropical region. We analysed their demographic and clinical data: age, sex, country visited, type of journey, defined as Visiting Friends and Relatives (VFR: travel whose primary purpose is to visit friends and relatives, where there is a gradient of epidemiological risk between normal place of residence and destination)15 or non-VFR, whether the patient was assessed or not in a specialised medical unit before travelling, symptoms, and diagnoses performed.

Group 3 contained patients at risk of vertical transmission of imported diseases: patients whose mothers were diagnosed with Chagas disease (ChD), human T-lymphotropic virus (HTLV) or malaria during pregnancy. We analysed their demographic data (age and sex) and maternal data (region of origin) as well as complementary examinations required according to the protocol (Table 2) and diagnoses performed.16–18 We excluded patients assessed for being at risk of other diseases, such as hepatitis B and C viruses, human immunodeficiency virus and other infections by toxoplasma, rubella, cytomegalovirus, and herpes (TORCH), since these are not classified as imported infections due to their prevalence among native patients.

The statistical study was carried out using the Statistical Package for the Social Sciences (v. 20) (SPSS, Chicago, IL, USA). We used the chi-squared test to compare qualitative variables, and set the statistical significance level at p<0.05. This study was approved by the clinical research ethics committee.

With regard to knowledge generated, six diagnostic and therapeutic protocols, available on the unit's website (www.upiip.com), were formulated.16–21 In addition, we worked jointly with various learned societies and produced five publications.22–26 As for the quality of care in terms of accessibility, no delay was observed in access to a first visit. Furthermore, over 85 telephone consultations were made per year, mainly to obtain information about results, minimising impact on the day-to-day lives of families by reducing hospital visits.

316 patients were seen (52.5% boys, 47.5% girls), of whom 191 (60%) belonged to Group 1, 57 (18%) to Group 2 and 68 (22%) to Group 3. A total of 921 visits took place, 661 in person (71.8%) and 260 consultations by telephone (28.2%), giving an overall ratio of 2.9 visits per patient.

This study analyses the first years of operation of a hospital paediatric unit devoted to the care of imported infectious diseases, examining the patients’ characteristics, the advantages of centralised care and the contributions of the unit. It is, moreover, the first published study of this kind that analyses a substantial number of patients.

Protocols were formulated by updating existing guidelines. Outpatient care was centralised and diagnostic and therapeutic follow-up was carried out in conformity with the developed protocols. The quality of care, assessed in terms of accessibility of first contact with the specialist, could be described as very good, given the possibility of immediate access by telephone and absence of delay for the first visit. It was impossible, for logistical reasons, to carry out a patient and/or family satisfaction survey, even though this is key data for evaluating quality of care.

Even though the patients involved in this study were very heterogeneous, classifying them into the three groups mentioned enabled us to carry out a clear and detailed analysis of the current state of the clinic. In contrast to other studies, an assessment of adherence to agreed protocols was conducted, beyond the clinical and demographic description of the patients.

We observed a high frequency of infectious diseases in the group of asymptomatic patients. The screening programmes enabled us to diagnose diseases with few clinical manifestations that could pose a risk to both individual and public health, without incurring high healthcare costs. Overall we observed acceptable adherence to the protocol, although one must be critical of some results. The percentage of patients screened for tuberculosis was strikingly low (45%). Despite following WHO screening recommendations we can see that coverage with the tuberculin test in our study remains low.27,28 10.5% of the 86 patients studied presented with M. tuberculosis infection. Many patients were probably screened in their health centres, and therefore a new determination at the time of our assessment was not considered necessary, but this information is difficult to obtain, since part of the study was carried out before the introduction of shared electronic medical histories. Even so, we wish to stress the importance of proper tuberculosis screening for appropriate management both of patients and of epidemiological control in our society.

Regarding the initial study of intestinal parasitoses, and the directed search for them in the eosinophilia study, we observed a high percentage of parasitic infections in asymptomatic patients.

As has been commented, targeted testing is recommended for the screening of some infectious diseases, such as ChD, HTLV or Plasmodium spp., according to the place of origin. For patients assessed and at risk of ChD we observed appropriate testing by serological tests, with adherence to the protocol of over 90%. With regard to HTLV infection, a review of the literature, excluding screening of vertical transmission, reveals no conclusive data for screening in asymptomatic children from high-risk areas.29,30 In our study, serological tests were requested when confronted with HTLV in 14.3% of the patients at risk, without any infected patients being observed, and it has therefore been eliminated from the routine examination of immigrant patients. As for infection by Plasmodium spp., several cases of asymptomatic or submicroscopic malaria have been described, mainly by P. falciparum in patients from Sub-Saharan Africa.31–34 Although there is no consensus for screening in asymptomatic patients, it seems clear that they should be tested using PCR techniques, especially in at-risk groups such as pregnant women, children and HIV patients from endemic areas.32,34 In our study, 30% of the patients at risk were examined for submicroscopic malaria, with one positive for P. falciparum, which represents 4% of those tested, similar to the prevalence found by Matisz et al.33 This is a point of improvement and may be due to the excellent state of the patients at the time of the consultation.

Our analysis of patients seen after travel to high-risk areas showed appropriate follow-up of these patients. The main symptoms observed, consistent with the literature, were gastrointestinal symptoms and fever.35–37 Although the high risk of exposure to potentially serious diseases is well known, the rate of medical consultation before travelling was strikingly low, as is also the case in other studies.37 We think it is important to emphasise the desirability, for families planning such journeys, of being assessed at a specialised international vaccination centre, as a way of improving prophylaxis, vaccinations and other general measures.

In the vertical transmission risk group we observed adherence to the protocols of close to 100%. The study published by our group in 2012 describes the impact of the implementation of ChD screening on at-risk pregnant women.24 Our study included patients at risk of vertical transmission and also patients outside the neonatal period, and this enabled us to diagnose and treat three patients infected by T. cruzi. As is the case with ChD, studies have been published on the screening of pregnant women at risk of HTLV, although this type of screening is not established as a routine procedure in pregnancy.17,29,30. The same cannot be said of the risk of congenital malaria, where there are little published data on the control and follow-up of these newborns. We therefore consider that consensus practice guidelines are needed for better management of these patients.9,18

The aim of this study, as well as analysing our patients and the actions taken, is to make healthcare staff aware of the importance of these diseases. We believe that further studies along these lines are needed in order to be able to define which examinations for assessing these diseases are really necessary and cost-efficient.

The limitations of our study are its retrospective character and also the lack of indicators of population coverage in the screening of these diseases. Nevertheless, it offers a detailed description of the current state of the clinic, in terms both of clinical and demographic data and of quality of care and teaching.

The changes that are taking place in patterns of migration and socio-economic conditions will force us to adapt units of this kind to the new realities.

The authors have no conflicts of interest to declare.