ABSTRACT

This paper focuses on the critical yet often overlooked issue of Neglected Tropical Diseases (NTDs), particularly those that lead to Neurocognitive Impairment (NCI-NTDs), in the context of child migration. Amid a global migration crisis, the study underscores the ethical necessity of early screening and interventions for NCI-NTDs as these at-risk children transition into new communities in host countries. While NTDs are predominantly diseases of poverty, often marginalized by global healthcare initiatives, they impose a substantial burden on affected children, especially migrants. The overarching message is that early identification of NCI-NTDs is essential for both enhanced healthcare outcomes and equal educational opportunities for this vulnerable group. The paper posits that utilizing non-invasive diagnostic markers, such as signs of anemia or speech delays, can serve as crucial preliminary indicators requiring further assessment. By dissecting the intricate connections between health status, migratory experience, and educational access, the paper advocates for a multi-disciplinary and culturally nuanced strategy to address these health inequities. Central to the discussion is how healthcare and educational systems can seamlessly integrate early detection and intervention methods to improve both the health and educational trajectories of migrant children plagued by NCI-NTDs.

1.     Introduction

The global migration crisis has brought attention to the unique challenges faced by migrant children. Among these challenges, the prevalence and impact of Neglected Tropical Diseases (NTDs), particularly Neurocognitive Impairment-Associated Neglected Tropical Diseases (NCI-NTDs), on this vulnerable population remain largely understudied. When migrant children arrive in a new host country, there exists an ethical imperative to conduct screenings for these conditions as these young individuals integrate into their new communities.

NTDs constitute a group of diverse and debilitating illnesses that disproportionately affect populations in resource-constrained regions of the world.[1] These diseases, which include a range of parasitic, bacterial, and viral infections, have garnered their name due to their tendency to afflict marginalized communities often overlooked by global health agendas.[2] Despite their relative obscurity on the global stage, NTDs burden affected populations enormously, perpetuating a cycle of poverty, ill health, and reduced economic productivity. Within this context, children bear a significant share of the NTD-related burden, grappling with health challenges that can shape their development and prospects.[3] Moreover, a particularly salient aspect of this challenge relates to the vulnerabilities experienced by children burdened by NTDs, who must also contend with the complexities of forced migration and the process of resettling in new host countries.

Among these affected groups, migrant children represent a unique and often overlooked population grappling with intricate health and educational challenges. This paper delves into the crucial issue of NTDs, with a specific emphasis on NCI-NTDs and their profound implications for the health and education of migrant children. This paper’s primary aim is to underscore the pivotal role of early detection and intervention in addressing NCI-NTDs within this vulnerable demographic.

This paper argues that early detection of NCI-NTDs in migrant children is indispensable for improving their health outcomes and ensuring equitable access to education. By examining the intricate relationship between health, migration, and education, we can emphasize the pressing need for a collaborative and culturally sensitive approach to addressing these health disparities among vulnerable populations as they settle into new communities.

Considering the multifaceted challenges these NCI-NTDs pose in migrant children, the driving question is how can early detection and intervention strategies be effectively integrated into healthcare and education systems to optimize health and educational outcomes for this demographic. In the subsequent sections of this paper, the complexities of NCI-NTDs in migrant children will be discussed, exploring their health implications, the challenges of forced migration, diagnostic complexities, and the educational and social consequences of cognitive impairment. This analysis aims to provide insights into the critical role of early detection in enhancing the health and education of migrant children affected by NCI-NTDs.

2.     Clinical Manifestations of NCI-NTDs

NCI-NTDs represent a category of diseases caused by a diverse array of pathogens, including bacteria, helminths, and protozoa. These diseases share a common, unsettling feature: their ability to impact the neurological and cognitive functions of individuals who become infected. NCI-NTDs, while encompassing a broad spectrum of pathogens, are united by their potential to induce neuro-inflammation, chronic anemia, and nutrient diversion within the human body, which can all lead to cognitive delays. Such diseases can cause delays in cognitive development, impair learning, and result in diminished school performance. Table 1 provides a list of the most prevalent NCI-NTDs posing a risk of cognitive regression in children:

Facilitated by environments conducive to disease propagation and hindered access to comprehensive healthcare, these conditions disproportionately impose a load of health adversities, leaving a lasting impact on cognitive and developmental trajectories.[5] The intricate interplay of mechanisms that underscores how these NCI-NTDs influence cognitive development in children is characterized by intricacy and diversity, reflecting an amalgamation of distinct pathophysiological mechanisms.

2.1.      Neuroinflammation

Neuroinflammation emerges as a prevailing mechanism that traverses multiple NCI-NTDs. These pathogens infiltrate neural tissues, provoking immune responses that disrupt neural circuits and upset neurotransmitter equilibrium.[6] Such inflammation interferes with vital cognitive processes, including memory, attention, and information processing.[7] Moreover, prolonged inflammation  causes and accelerates long-term neurodegenerative disease, playing a central role in the early development of chronic conditions, including dementia.[8] Schistosomiasis and neurocysticercosis exemplify this mechanism, where pronounced neuroinflammation contributes to cognitive impairments such as memory deficits and information processing difficulties.[9]

2.2.     Chronic Anemia

The intricacies of chronic anemia unfold as a shared outcome across various NCI-NTDs, where blood loss, iron deficiency, and nutrient diversion orchestrated by parasitic infections collectively contribute to a reduction in the blood’s capacity to carry oxygen.[10] This cascade of events results in insufficient oxygen supply to critical brain regions, disrupting cognitive functions that rely on optimal oxygenation.[11] Within this complex backdrop, the interplay between anemia and NCI-NTDs becomes evident, revealing insights into the impacts on cognitive well-being.

A quintessential example of this dynamic is the context of hookworm infection, a helminthic disease that highlights the duality of mechanisms contributing to chronic anemia. Blood loss and hemolysis, integral to the hookworm’s attachment to the intestinal lining and subsequent consumption of blood, are responsible for sustaining a state of persistent anemia.[12] Notably, this dual mechanism sets the stage for the emergence of persistent fatigue, dizziness, heart palpitations, and even the desire to eat dirt.[13] Beyond their physiological implications, these symptoms have far-reaching cognitive ramifications, as they hinder cognitive engagement, impede effective learning, and cast shadows over academic achievement.[14]

Among the array of NCI-NTDs, the case of severe malaria is a stark illustration of how rapid blood cell destruction leads to acute anemia.[15] Hemolysis and hemorrhagic destruction contribute to the immediate and intense reduction in red blood cell count, a hallmark of severe anemia.[16] However, the implications transcend the immediate physiological impact. Severe malaria’s enduring effect on the nervous system brings to the forefront the cognitive repercussions. Lasting cognitive and memory impairments, coupled with subtler neuropsychiatric issues, underscore the intricate web connecting anemia to cognitive functions.[17] [18] This stands as a compelling testament to the profound implications of chronic anemia in the context of NCI-NTDs.

Diving deeper into the landscape of NCI-NTDs and chronic anemia, it becomes evident that the manifestations of anemia are remarkably diverse, each disease painting its unique course of impact. Table 2 shows the varied mechanisms that underlie anemia induction across diseases such as schistosomiasis, A. lumbricoides, S. stercoralis, Giardiasis, and African Trypanosomiasis. What further enriches this exploration is how these diseases disrupt iron utilization, red blood cell production, and the equilibrium of the hematological system. The result is a tapestry of symptoms and consequences that reflect the intricacies of each disease’s interaction with anemia.

For diseases with the primary mechanism of blood loss and hemolysis, a persistent assault on the red blood cell count results in classic anemic symptoms such as fatigue, weakness, and pale skin. In contrast, helminthic diseases like hookworm infection perpetuate chronic anemia by attaching to the intestinal lining and consuming blood, leading to fatigue, dizziness, heart palpitations, and sometimes heart failure.[20] In a study conducted by Tomasheck et al. among Burundian refugee children in western Tanzanian refugee camps, alarming rates of anemia in children under five years of age were revealed. Anemia-specific mortality rates in this group reached a peak of 2.51 deaths per 10,000 per day, surpassing the typical mortality rate for this age group in stable developing country populations.[21] These findings underscore the gravity of the anemia issue within the refugee camp, primarily attributed to factors like elevated rates of malaria infection, hookworm infestation, and insufficient dietary iron intake.

Furthermore, a 2006 prevalence study conducted by John M. De Pasquale of Georgia State University assessed the occurrence and severity of three common soil-transmitted helminths among schoolchildren residing in rural, mountainous regions of eastern Haiti. The study’s findings revealed substantial variations in the prevalence rates of these infections across different Haitian regions, with some areas reporting rates as high as 74%.[22] These results underscore the considerable burden of soil-transmitted helminth infections, particularly among school-aged children in Haiti. These findings stress the pressing need for targeted interventions and healthcare measures to address the risk of these infections among migrant children arriving in the United States from Haiti.

A different route is taken by infections like A. lumbricoides and S. stercoralis, causing intestinal damage that disrupts nutrient absorption.[23] This results in anemia intertwined with malnutrition, leading to frailty, pallor, and compromised immune function. Giardiasis augments this narrative by impairing nutrient absorption and inducing chronic inflammation, yielding symptoms ranging from abdominal discomfort to mental lethargy.[24]

African trypanosomiasis inhibits bone marrow activity and red blood cell production, leading to a profound depletion of oxygen-carrying cells.[25] The resulting fatigue, confusion, and neurological disturbances illustrate anemia’s extensive consequences. In contrast, severe malaria’s rapid destruction of red blood cells manifests as immediate and intense anemia, underscored by fever, chills, and jaundice.

These diverse presentations unite under distinct categories of anemia induction: blood loss and hemolysis, inflammation and iron disruption, nutrient diversion, and erythropoiesis inhibition. The underlying mechanisms connecting these diseases are rooted in the disruption of iron utilization, red blood cell production, and hematological equilibrium. Recognizing the multifaceted ways anemia unfolds across NCI-NTDs is essential for designing tailored interventions that address the unique challenges posed by each disease and considering the broader implications of anemia on individual health and well-being.

2.3.     Direct Neural Invasion

Direct neural invasion is another common pathway wherein specific NCI-NTDs infiltrate neural tissues directly, inducing physical damage that disrupts cognitive development.[26] For instance, leprosy-causing bacteria infiltrate peripheral nerves, impairing sensory and motor functions, which, in turn, affect cognitive processes reliant on these functions.[27] Migrant children afflicted by leprosy may grapple with challenges in fine motor skills, tactile perception, and spatial awareness, impacting their overall cognitive capacities.[28] Table 3 presents a selection of these NCI-NTDs in which direct neural invasion results in various neurological impairments:

By understanding the general consequences of these NCI-NTDs and some commonalities among them, it is crucial to focus attention on the overall mechanisms that underlie their impact on cognitive development and the specific challenges faced by migrant children who are disproportionately affected. These impairments encompass various domains of cognitive function, including memory, attention, learning, and problem-solving skills.

Neurological symptoms directly influence cognitive processes. Seizures, tremors, and motor and sensory impairment bear immediate cognitive consequences, interrupting attention, memory, and overall cognitive functioning. For example, neurocysticercosis, linked to the tapeworm T. solium, is associated with seizures and headaches that can culminate in cognitive difficulties over time.[30] These diseases gain entry to the central nervous system through various modes, such as peripheral nerves or neural tissues, resulting in an array of neurological impairments that influence cognitive processes, bearing significant consequences if left unchecked.

Seizures and tremors are particularly noteworthy among the observed neurological symptoms due to their immediate cognitive implications. These symptoms disrupt attention, memory, and overall cognitive functioning. For instance, African trypanosomiasis, caused by Trypanosoma parasites, can lead to seizures and tremors, creating substantial challenges for affected children in maintaining focus and retaining information during educational pursuits.

NCI-NTDs can also result in hearing loss and blindness, further compounding the cognitive difficulties faced by migrant children. Hearing and vision are vital sensory pathways for cognitive development, and impairments in these areas can hinder the acquisition of knowledge, communication, and social interaction.

Some NCI-NTDs are associated with learning disabilities and early dementia and, in some cases, are linked to early Parkinsonism.[31] Conditions like neurocysticercosis can result in significant cognitive deficits over time. Moreover, migrant children affected by these diseases may encounter substantial obstacles in their educational journey, including memory deficits, attention difficulties, and learning challenges, which can significantly impact their academic progress.

White matter involvement in NCI-NTDs can lead to disruptions in neural connectivity, further exacerbating cognitive impairments. This aspect is particularly relevant in conditions like neurologic melioidosis, where the central nervous system is directly affected, potentially resulting in white matter abnormalities that affect cognitive processes.

The cognitive impairments associated with these neurological assaults encompass memory deficits, attention difficulties, learning challenges, and problems with decision-making and problem-solving. Furthermore, these deficits extend beyond academic performance and hinder the development of crucial social skills. Migrant children may find it challenging to engage in social interactions, form friendships, and participate fully in classroom activities. The stigma associated with cognitive challenges can exacerbate feelings of isolation and impact their overall well-being. Therefore, comprehensive interventions addressing the neurological and cognitive aspects of NCI-NTDs are crucial to promoting cognitive development in migrant children and ensuring their overall well-being on their unique journeys.

3.     Educational and Social Implications of Cognitive Impairment

Migrants who enter host countries often navigate a journey that involves moving across regions, cities, and towns and eventually integrating into various communities. However, the integration process has challenges, especially in identifying causal factors that could impact cognitive development.[32] As families settle into urban, suburban, or rural areas, the chances of recognizing potential parasitic infections or other factors contributing to cognitive impairment may diminish.[33] The bustling dynamics of larger cities or the close-knit fabric of smaller communities can inadvertently obscure health concerns, particularly when these concerns are not immediately visible.[34]

Nevertheless, the potential for missed diagnoses and delayed interventions looms large, as migrant families navigating complex transitions may not always have access to adequate healthcare resources.[35] Consequently, these children’s educational and social pathways intersect with the challenge of identifying and addressing cognitive impairment. Collaborative efforts among healthcare providers, educators, and community leaders are vital to ensuring that the educational journey of migrant children is coupled with holistic health surveillance, enabling timely interventions, and ultimately fostering their cognitive potential.

Educational systems commonly utilize standardized assessments to gauge students’ learning abilities and identify potential challenges.[36] However, cognitive impairment due to NCI-NTDs can confound these assessments, leading to inaccurate evaluations of a child’s academic potential. Migrant children grappling with the effects of these diseases might score lower than expected on cognitive tests, which can result in their placement in learning deficiency categories. A study by Pabalan et al. demonstrated that untreated Soil-Transmitted Helminth (STH) infections are associated with impairments in areas like working memory, learning, and reaction time.[37] This research indicates that cognitive deficits resulting from untreated STH infections can confound academic assessments, leading to misclassification and the placement of affected children in learning deficiency categories.

Migrant children, already navigating the complexities of adjusting to new cultural and linguistic environments, may experience heightened feelings of inadequacy and social isolation when they struggle academically. Moreover, the social integration of migrant children is intertwined with their educational experiences. Impaired cognitive function can hinder the development of crucial social skills, making it challenging for these children to form relationships and participate fully in classroom activities. The stigma associated with cognitive challenges might result in exclusion or marginalization by peers, compounding feelings of isolation and affecting overall well-being.

The misconceptions surrounding cognitive impairments resulting from NCI-NTDs underscore the importance of raising awareness among educators and school personnel. Educational institutions should be equipped with the knowledge to recognize the potential impact of these diseases on cognitive abilities. Instead of viewing academic struggles as mere learning deficiencies, educators need to adopt a more holistic perspective that considers underlying health factors, including the possibility of NCI-NTDs.

4.     Anemia and Language Delays as Indicators

To effectively identify NCI-NTDs in migrant children, a nuanced approach is essential. Currently, in the United States, there is a lack of specific guidance regarding the screening and management of NCI-NTDs in migrants. Though general health screening does exist to some extent, they do not delve into the details of how NCI-NTDs are screened for, diagnosed, or managed in these populations.[38] This limitation highlights the need for more comprehensive and targeted research and guidelines regarding identifying and managing NCI-NTDs in migrant populations, especially those who may lack consistent access to healthcare services due to their migration status. It underscores the importance of addressing this gap in knowledge and healthcare provision to ensure the well-being of vulnerable migrant communities.

In addition, this approach should consider the migrants’ journey and the possibility of disease manifestations. Training and guidelines should be designed to encompass all individuals who interact with these children, including social workers, nutritionists, nurse practitioners, educators, and local health departments.

Critical indicators that warrant further evaluation as simple markers include anemia and language delays, which can provide insights into underlying NCI-NTDs and their cognitive implications. These indicators act as valuable signposts throughout the migration journey, guiding healthcare providers and educators toward a more accurate understanding of the child’s health and developmental requirements.

4.1.      Anemia as a Multifaceted Indicator

Anemia serves as a multifaceted indicator signaling the presence of NCI-NTDs. Migrant children from endemic regions might have encountered parasitic infections like hookworm or schistosomiasis, known to cause chronic anemia. The connection between anemia and cognitive impairment is well-established; iron deficiency affects neural function and cognitive development. Therefore, migrant children presenting with anemia should prompt comprehensive evaluation, considering the potential role of NCI-NTDs and associated cognitive challenges. Recognizing anemia’s significance early on is crucial for timely intervention and support, as iron supplementation and treatment for parasitic infections can address both anemia and cognitive issues.

4.2.     Language Delays Indicating NCI-NTDs

Language development is a pivotal milestone in a child’s cognitive journey, and language delays can indicate underlying NCI-NTDs. These delays are attributed to various NCI-NTDs, including those impacting the central nervous system. Manifesting as difficulties in language understanding and expression, these delays affect educational and social interactions. Children experiencing language delays not only face communication struggles but also encounter hindered cognitive growth. Recognizing language delays as potential NCI-NTD indicators is essential for timely intervention and support.

Table 4 offers an overview of different types of language delays, shedding light on their potential causes or risk factors, their impact on language and communication skills, the average age of onset, and whether specific factors like infections, nutritional deficiencies, neurological conditions, environmental influences, or genetic and developmental factors could contribute to these delays.

This categorization of language delays encompasses expressive language delay, receptive language delay, mixed expressive-receptive language delay, phonological delay, speech sound disorder, auditory processing disorder, and specific language impairment (SLI). Importantly, it underscores how these language delays can affect individuals, from impairing their comprehension and expression to influencing their overall communication skills. The average age at which these delays manifest could also aid in early identification and intervention.

Recognizing language delays as potential NCI-NTD indicators can be a vital step in offering timely intervention and support, ultimately fostering the cognitive development and well-being of these young newcomers. Notably, the information presented in Table 4 illustrates that identifying these speech and language delays does not require extensive laboratory tests or specialized equipment. Instead, these delays can be observed and flagged at all staff levels or junctions along the host country settlement pathway. Furthermore, developing a coordinated guideline that can be referenced at all staffing levels and stages of their journey might provide valuable assistance.

However, the challenges faced by migrant children, as highlighted in a 2022 Washington Post article by Valerie Strauss, underscore the critical importance of recognizing potential neurocognitive impairments such as language delays.[40] These young migrants, often arriving with limited resources and support, turn to schools as a primary source of assistance. However, the intricate nature of the immigration system and unclear resource allocation can complicate their educational journey, making it essential to identify subtle indicators like language delays early on. The educational system’s bureaucratic nature, combined with the scarcity of adequate resources and support, poses significant obstacles to providing the necessary help to these youth. Moreover, the presence of an anti-immigrant climate further exacerbates their challenges, as it can deter them from seeking assistance for issues like language delays. To address these complexities effectively, a coordinated and compassionate approach is essential, one that ensures proper resource allocation, mental health care, and staffing within school systems.

4.3.     Migration Pathways and Indicator Significance

Migrant children’s diverse migration pathways, spanning regions with varying disease burdens, emphasize the importance of using anemia and language delays as indicators. Children from non-endemic areas, suddenly exposed to NCI-NTDs through migration, might exhibit these indicators without fully grasping their significance. Recognizing that the responsibility for early detection and support extends beyond educators and healthcare providers is essential.

In this comprehensive and community-oriented approach, various stakeholders play vital roles in ensuring the well-being of migrant children. This collaborative effort encompasses not only educators and healthcare providers but also social workers, community health workers, host families, and a broad spectrum of individuals and organizations within host communities. Each of these stakeholders can contribute to the early detection and support of migrant children at risk of NCI-NTDs.

Social workers, for instance, often advocate for children’s welfare, and their expertise in identifying signs of developmental or health-related issues can be invaluable. With their deep understanding of the local community and cultural nuances, community health workers can bridge the gap between healthcare services and migrant families, facilitating access to healthcare and early screenings. Host families, as nurturing and supportive environments, are well-positioned to observe and report any concerning developments in a child’s health or behavior.

In this collective effort, community members, educators, healthcare providers, and support networks all share the common goal of ensuring that migrant children receive the necessary care and intervention when needed. By involving multidisciplinary stakeholders and fostering a sense of community responsibility, the chances of early detection, timely intervention, and improved outcomes for migrant children with potential NCI-NTDs are significantly enhanced. This collaborative approach underscores the importance of addressing the unique health challenges faced by migrant children and promoting their overall well-being as they integrate into new communities.

5.     Recognizing the Significance of Early Detection through Comprehensive Screening and Collaborative Efforts

Incorporating anemia and language delays into screening protocols offers a practical yet robust approach to the early identification of NCI-NTDs in migrant children. Notably, these indicators are noninvasive and can easily be observed by those who come in contact with these children—be it educators, social workers, community health workers, or host families. This broadens the net for early detection and makes the process more inclusive and accessible, even in settings where specialized healthcare services are scarce.

Early detection mitigates immediate health concerns and safeguards the long-term well-being and successful integration of these children into new host countries. Failure to act upon these indicators could have detrimental effects on both their health and their ability to assimilate into new environments. Therefore, a comprehensive screening process at various contact points during their migration journey is imperative.

Understanding the interconnected challenges of migration, health, and education enables us to provide a more holistic form of care. In this multifaceted approach, the emphasis is not just on treating health symptoms but also on supporting the broader developmental and psychosocial needs of migrant children affected by NCI-NTDs. By engaging in early and collaborative intervention, we lay a cornerstone in the healthcare provision for these children, ensuring that health challenges tied to their unique migratory journeys are promptly and effectively addressed.

6.     Conclusion

Neglected tropical diseases (NTDs), specifically NCI-NTDs, extend beyond isolated infections. They can progressively deteriorate over time, often going unnoticed until they reach irreversible stages, leading to cognitive decline and disability. While screenings for these conditions are technically mandated, the urgency of migration surges and the complexities of resettlement in new host countries can lead to these crucial evaluations being bypassed or delayed. This exposes vulnerable migrant children to increased risks, emphasizing the ethical imperative for comprehensive screenings as these young individuals integrate into new communities.[41]

Given these circumstances, there is a compelling need to expand the scope of responsibility for early detection and intervention. This involves training a wide array of individuals—including nurses, educators, nutritionists, rural physicians, and host families—to recognize noninvasive visual cues, such as signs of anemia and language delays, which can serve as early indicators of NCI-NTDs. Doing so adds another layer of vigilance and maximizes the chances that these conditions will be identified even in scenarios where formal screenings may be missed.

Prioritizing the educational well-being of these children becomes paramount. School districts may be unprepared to identify these manifestations and erroneously attribute them solely to emotional issues or learning disabilities. This underscores the importance of raising awareness within educational institutions regarding the potential long-term effects of NTDs on cognitive development and the necessity for early identification and support.

The intricate interplay between neglected tropical diseases and the cognitive and developmental pathways of migrant children illuminates a stark reality—the persistent existence of substantial unmet medical needs within these vulnerable populations and the long-term repercussions of delayed or missed diagnoses. These challenges extend beyond immediate physical discomfort, shaping the intricate pathways of their cognitive and developmental trajectories.

In recognition of these multi-dimensional challenges, advocacy for a recalibration of our approach to healthcare and education is urgent. As we navigate the complex convergence of NTDs, migration, health, language, and cognitive development, our efforts should be guided by empathy, collaboration, and an unwavering commitment to fostering the holistic well-being of migrant children affected by NTDs.

In essence, this work underscores the urgent need for a transformative shift in how the health and educational needs of migrant children are addressed.[42] By acknowledging the importance of early detection and intervention in their cognitive and developmental paths, we lay the foundation for equitable opportunities, ensuring that every child, regardless of their starting point or ultimate destination, can thrive and reach their maximum potential.

Conflict of Interest

The authors declare no conflict of interest.

Acknowledgment

I acknowledge all the support from my supervising professors, Prof. Victor Eneojo ADAMU and Prof. Laurent CLEENEWERCK

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[1] Peter J. Hotez, Forgotten People, Forgotten Diseases: The Neglected Tropical Diseases and Their Impact on Global Health and Development, 1st ed. (Washington DC: ASM Press, 2008), 5.

[2] Ibid.

[3] Nathaly Aya Pastrana et al., “The Process of Building the Priority of Neglected Tropical Diseases: A Global Policy Analysis,” PLOS Neglected Tropical Diseases 14, no. 8 (August 12, 2020): e0008498, https://doi.org/10.1371/journal.pntd.0008498.

[4] Aaron L. Berkowitz et al., “Neurologic Manifestations of the Neglected Tropical Diseases,” Journal of the Neurological Sciences 349, no. 1 (February 15, 2015): 20–32, https://doi.org/10.1016/j.jns.2015.01.001.

[5] Hotez, Forgotten People, Forgotten Diseases: The Neglected Tropical Diseases and Their Impact on Global Health and Development, 7.

[6] Berkowitz et al., “Neurologic Manifestations of the Neglected Tropical Diseases.”

[7] Monty Lyman et al., “Neuroinflammation: The Role and Consequences,” Neuroscience Research 79 (February 1, 2014): 1–12, https://doi.org/10.1016/j.neures.2013.10.004.

[8] Lyman et al.

[9] Hotez, Forgotten People, Forgotten Diseases: The Neglected Tropical Diseases and Their Impact on Global Health and Development, 7.

[10] Camila M. Chaparro and Parminder S. Suchdev, “Anemia Epidemiology, Pathophysiology, and Etiology in Low- and Middle-Income Countries,” Annals of the New York Academy of Sciences 1450, no. 1 (2019): 15–31, https://doi.org/10.1111/nyas.14092.

[11] Chaparro and Suchdev.

[12] Hotez, Forgotten People, Forgotten Diseases: The Neglected Tropical Diseases and Their Impact on Global Health and Development, 22.

[13] Alhassan O. Ghodeif and Hanish Jain, “Hookworm,” in StatPearls (Treasure Island (FL): StatPearls Publishing, 2023), http://www.ncbi.nlm.nih.gov/books/NBK546648/.

[14] Hotez, Forgotten People, Forgotten Diseases: The Neglected Tropical Diseases and Their Impact on Global Health and Development, 134.

[15] Hotez, 139.

[16] Peter J. Hotez and David H. Molyneux, “Tropical Anemia: One of Africa’s Great Killers and a Rationale for Linking Malaria and Neglected Tropical Disease Control to Achieve a Common Goal,” PLOS Neglected Tropical Diseases 2, no. 7 (July 30, 2008): e270, https://doi.org/10.1371/journal.pntd.0000270.

[17] Hotez and Molyneux.

[18] Pamela Rosa-Gonçalves, Flávia Lima Ribeiro-Gomes, and Cláudio Tadeu Daniel-Ribeiro, “Malaria Related Neurocognitive Deficits and Behavioral Alterations,” Frontiers in Cellular and Infection Microbiology 12 (February 22, 2022): 829413, https://doi.org/10.3389/fcimb.2022.829413.

[19] Chaparro and Suchdev, “Anemia Epidemiology, Pathophysiology, and Etiology in Low- and Middle-Income Countries.”

[20] Ibid.

[21] Ibid.

[22] John De Pasquale, “Soil-Transmitted Helminths in Schoolchildren in Grand Bois Haiti: A Prevalence Study,” Public Health Theses, April 1, 2007, https://doi.org/10.57709/1125759.

[23] Chaparro and Suchdev, “Anemia Epidemiology, Pathophysiology, and Etiology in Low- and Middle-Income Countries.”

[24] Ibid.

[25] Ibid.

[26] Berkowitz et al., “Neurologic Manifestations of the Neglected Tropical Diseases.”

[27] Ibid.

[28] Ibid.

[29] Ibid.

[30] Hotez, Forgotten People, Forgotten Diseases: The Neglected Tropical Diseases and Their Impact on Global Health and Development, 117.

[31] Berkowitz et al., “Neurologic Manifestations of the Neglected Tropical Diseases.”

[32] Avinash K. Shetty, “Infectious Diseases among Refugee Children,” Children 6, no. 12 (November 27, 2019): 129, https://doi.org/10.3390/children6120129.

[33] Elena Riza et al., “Community-Based Healthcare for Migrants and Refugees: A Scoping Literature Review of Best Practices,” Healthcare 8, no. 2 (April 28, 2020): 115, https://doi.org/10.3390/healthcare8020115.

[34] COUNCIL ON COMMUNITY PEDIATRICS et al., “Providing Care for Immigrant, Migrant, and Border Children,” Pediatrics 131, no. 6 (June 1, 2013): e2028–34, https://doi.org/10.1542/peds.2013-1099.

[35] Claire Mock-Muñoz de Luna et al., “Towards More Equitable Education: Meeting Health and Wellbeing Needs of Newly Arrived Migrant and Refugee Children—Perspectives from Educators in Denmark and Sweden,” International Journal of Qualitative Studies on Health and Well-Being 15, no. Suppl 2: 1773207, accessed September 6, 2023, https://doi.org/10.1080/17482631.2020.1773207.

[36] Jason M. Lodge et al., “Understanding Difficulties and Resulting Confusion in Learning: An Integrative Review,” Frontiers in Education 3 (2018), https://www.frontiersin.org/articles/10.3389/feduc.2018.00049.

[37] Noel Pabalan et al., “Soil-Transmitted Helminth Infection, Loss of Education and Cognitive Impairment in School-Aged Children: A Systematic Review and Meta-Analysis,” PLOS Neglected Tropical Diseases 12, no. 1 (January 12, 2018): e0005523, https://doi.org/10.1371/journal.pntd.0005523.

[38] Douglas W. MacPherson and Brian D. Gushulak, “Health Screening in Immigrants, Refugees, and International Adoptees,” The Travel and Tropical Medicine Manual, 2017, 260–70, https://doi.org/10.1016/B978-0-323-37506-1.00019-2.

[39] CLAUDIO O. TOPPELBERG and THEODORE SHAPIRO, “Language Disorders: A 10-Year Research Update Review,” Journal of the American Academy of Child and Adolescent Psychiatry 39, no. 2 (February 2000): 143–52, https://doi.org/10.1097/00004583-200002000-00011.

[40] Valerie Strauss, “Perspective | Challenges That Young Immigrants Face with U.S. Public Schools,” Washington Post, October 12, 2022, https://www.washingtonpost.com/education/2022/10/12/challenges-immigrants-face-public-schools/.

[41] Adarsh Kohli, Samita Sharma, and Susanta K. Padhy, “Specific Learning Disabilities: Issues That Remain Unanswered,” Indian Journal of Psychological Medicine 40, no. 5 (2018): 399–405, https://doi.org/10.4103/IJPSYM.IJPSYM_86_18.

[42] {Citation}