# The Cascade of Care for Infectious Diseases in Newly Arrived Refugees

## TL;DR

This study examines how newly arrived refugees in Denmark progress through healthcare after being diagnosed with infectious diseases, finding that many are lost to follow-up, which limits the effectiveness of screening programs.

## Contribution

The study reveals significant loss to follow-up in refugee healthcare after infectious disease screening, highlighting systemic barriers in high-income countries.

## Key findings

- Only 43% of refugees with hepatitis B surface antigen attended regular follow-up.
- Loss to follow-up occurred in 57% of hepatitis B cases and both hepatitis C cases.
- Only one syphilis case completed follow-up according to national guidelines.

## Abstract

Public health relevance—How does this work relate to a public health issue?
Newly arrived refugees are routinely screened for infectious diseases, yet little is known about what happens after a positive screening result and whether individuals successfully complete the cascade of care.Loss to follow-up after screening represents a critical gap in infectious disease control and refugee health, with potential consequences for both individual health outcomes and population-level disease prevention.

Newly arrived refugees are routinely screened for infectious diseases, yet little is known about what happens after a positive screening result and whether individuals successfully complete the cascade of care.

Loss to follow-up after screening represents a critical gap in infectious disease control and refugee health, with potential consequences for both individual health outcomes and population-level disease prevention.

Public health significance—Why is this work of significance to public health?
The study demonstrates that even in a high-income country with systematic post-arrival screening, substantial attrition occurs after diagnosis, limiting the effectiveness of screening programmes.Findings highlight structural and organisational barriers within healthcare systems that may undermine equity in access to diagnosis, treatment, and long-term follow-up for refugee populations.

The study demonstrates that even in a high-income country with systematic post-arrival screening, substantial attrition occurs after diagnosis, limiting the effectiveness of screening programmes.

Findings highlight structural and organisational barriers within healthcare systems that may undermine equity in access to diagnosis, treatment, and long-term follow-up for refugee populations.

Public health implications—What are the key implications or messages for practitioners, policy makers and/or researchers in public health?
Screening programmes must be accompanied by strengthened systems ensuring continuity of care, including clear referral pathways, consistent guideline adherence, and systematic use and documentation of professional interpreters.Policymakers and researchers should prioritise interventions that address social, organisational, and communication-related barriers to follow-up in refugee health, in order to maximise the public health benefit of post-arrival screening initiatives.

Screening programmes must be accompanied by strengthened systems ensuring continuity of care, including clear referral pathways, consistent guideline adherence, and systematic use and documentation of professional interpreters.

Policymakers and researchers should prioritise interventions that address social, organisational, and communication-related barriers to follow-up in refugee health, in order to maximise the public health benefit of post-arrival screening initiatives.

(1) Background: Post-arrival screening for infectious diseases is routinely offered to newly arrived refugees in Denmark, including tests for hepatitis B virus (HBV), hepatitis C virus (HCV), human immunodeficiency virus (HIV), and syphilis. This study aimed to examine the cascade of care following positive screening results in a local cohort of refugees in Denmark, with a focus on subsequent clinical management, follow-up, and outcomes. (2) Methods: This retrospective cohort study included 1506 newly arrived refugees of all ages and countries of origin. All were offered a post-arrival infectious disease screening in Denmark. Clinical records were reviewed to assess progression through the cascade of care, including referral, evaluation, follow-up, and clinical outcomes among individuals with positive screening results. (3) Results: Of the 1506 screened refugees, 33 (2.2%) had at least one positive screening result. Among the 15 individuals with detectable hepatitis B surface antigen, six (43%) attended regular follow-up, while eight (57%) were lost during the cascade of care. Two participants screened positive for HCV antibodies; both underwent initial clinical evaluation, but their subsequent care trajectories differed due to repeated non-attendance or undocumented reasons. Only one participant with non-specific syphilis antibodies completed follow-up in accordance with national guidelines. One participant was diagnosed with HIV and successfully linked to care. (4) Conclusions: The prevalence of screened infectious diseases in this local Danish refugee cohort was low and consistent with findings from comparable settings. Although post-arrival screening facilitates the identification of infectious diseases, substantial loss to follow-up occurred after initial diagnosis, limiting the effectiveness of follow-up and treatment. These findings highlight the need for targeted, interdisciplinary strategies addressing organisational, social, and individual barriers to improve continuity of care following screening.