Migrant Health

Epidemiological Data in Greece

Hellenic Center for Disease Control and Prevention 2012

Migration and Health-key issues

   Migration is a global phenomenon 3% of the world’s population resides permanently or temporarily outside their country of origin (World Bank, 2009) Economic development and labor, urbanization, climate change, war and ethnic conflict are the main drivers

Migration and Health-key issues

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  Migrants may have more complex health needs than the native born population influenced by: the burden of disease and living conditions in their country of origin experiences during migration, access to health and labor factors relating to ethnicity and cultural practices burden of diseases in the country of reception Mobility itself doesn’t cause ill health Migration should be considered a social determinant of health

Epidemiological data interpretation

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Factors that influence increases or decreases in infectious disease cases reported

Changes in the epidemiology of an infectious disease in a migrant’s country of origin.

Changes in migration patterns.

Pre/post entry screening practices.

Standard of living conditions in host country and associated risks of onward transmission.

Access to healthcare Level of case finding/diagnosis amongst different migrant groups Reporting practices and changes to surveillance systems

Migration and Health-main global health issues

       Tuberculosis HIV/AIDS STIs Hepatitis B and C Malaria Enteric fevers Chagas disease  Chronic diseases?

Hellenic Centre for Disease Control and Prevention

  Greek public health agency Major operating component of the Ministry of Health HCDCP works with partners to:  monitor health     detect and investigate health problems support research implement prevention strategies advocate sound public health policies

HIV/AIDS

HIV/AIDS reporting system

• • • • • • • Initiation of AIDS reporting: 1984 Initiation of HIV reporting: 1998 First AIDS diagnosis: 1981 Number of reported HIV+ cases: 11,340 Number of AIDS diagnoses: 3,235 Number of deaths: 2,152 HIV+ patients under treatment: 5,500

HIV/AIDS Reporting System

HIV infected individuals Ioannina Thessaloniki Patra Attica Alexandroypolis Heraklion Sources

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Reference labs

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Hospitals

HCDCP

HIV cases by year of diagnosis

70 60 50 40 30 20 10 00 5.4

1998 3.6

2002 4.8

2005 5.3

2008 6.1

31/10/2011 Year of diagnosis

HIV- new cases by year of report and gender

Year of report SEX M F 2006 2007 2008 2009 2010 2011 401 (80.52%) 358 (83.64%) 471 (84.26%) 392 (83.58%) 457 (86.88%) 686 (85.43%) 97 (19.48%) 70 (16.36%) 88 (15.74%) 77 (16.42%) 69 (13.12%) 117 (14.57%) Total 498 428 559 469 526 803 +52.7%

HIV cases by year of report and probable route of HIV transmission

Year of report (10 months) 2006 2007 2008 2009 2010 2011 MSM 256 (51.41%) 197 (46.03%) 285 (50.98%) 235 (50.11%) 270 (51.33%) 266 (33.13%) IDUs 16 (3.21%) 9 (2.10%) 9 (1.61%) 10 (2.13%) 14 (2.66%) 190 (23.66%) Hetero 132 (26.51%) 97 (22.66%) 122 (21.82%) 75 (15.99%) 90 (17.11%) 108 (13.45%) Unknown 88 (17.67%) 123 (28.74%) 138 (24.69%) 147 (31.34%) 150 (28.52%) 236 (29.39%)

HIV- new cases by year of report and nationality

Year of report 2006 2007 2008 2009 2010 2011 Hellenic 387 (77.71%) 318 (74.30%) 431 (77.10%) 337 (71.86%) 384 (73.00%) 573 (71.36%) Non-native Unknown 103 (20.68%) 88 (20.56%) 8 (1.61%) 22 (5.14%) 105 (18.78%) 23 (4.11%) 107 (22.81%) 116 (22.05%) 152 (18.93%) 25 (5.33%) 26 (4.94%) 78 (9.71%)

Number of HIV infected IDUs in 2011 by nationality and year of report 2006 Year of report 2007 2008 2009 2010 2011 Hellenic 10 (62.50%) Non-native 6 (37.50%) 6 (66.67%) 3 (33.33%) 5 (55.56%) 4 (44.44%) 7 (70.00%) 3 (30.00%) 8 (57.14%) 6 (42.86%) 158 (83.15%) 32 (16.85%)

Non-Native HIV infected IDUs in 2011 by nationality EUROPE

Albania 2 Belarus 1 Bulgaria 2 Italy 1 Poland 2 Ukraine 1

9 AFRICA

Sudan 1 Tunisia 1

Total 2 ASIA

Afghanistan 3 Armenia 1 Georgia 7 Iraq 1 Iran 5 Kazakhstan 2 Pakistan 1 Bangladesh 1

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Conclusions: HIV/AIDS Greece

 Steady increase in the reported numbers of new HIV cases during the last decade, both in native and non-native individuals  1/3 of new cases yearly occur in MSM  HIV outbreak among IDUs in 2011 Paraskevis et al.: HIV-1 outbreak among injecting drug users in Greece,2011: a preliminary report, Euro Surveill. 2011;16(36):pii=19962

STIs

Sexually transmitted infections-STIs

      The epidemiological surveillance of STIs is a task of KEELPNO’s office for HIV/AIDS and STIs. The new surveillance system for STIs established in 2009 collects actively data (case-based and aggregated) on cases of gonorrhoea, syphilis, chlamydia and LGV.

Data is collected from clinicians/hospitals/laboratories in public and private sector. Notification is mandatory by law EU-2008 case definitions are used.

Significant underreporting from the private health sector

Sexually transmitted infections-STIs

 Pilot program of enhanced epidemiologic surveillance for STIs “Andreas Syngros Dermatology and Venereal University Hospital, 2003-2009, sponsored by KEELPNO  67.590 visits for possible venereal disease  3.288 syphilis, gonorrhea, genital herpes and HIV diagnoses in total  6.445 diagnoses of HPV infection (condyloma acuminata)

Primary Syphilis reported cases Pilot project Andreas Syngros Hospital

Year Natives 2003 2005 2006 2007 2008 2009 90 114 96 155 119 140 Non natives 26 25 44 42 36 34 Total cases 116 139 141 197 155 174 % natives % non natives 77.59% 22.41% 82.01% 17.99% 68.57 % 78.68 % 31.43% 21.32% 76.77 % 80.46 % 23.23% 19.54%

Year 2003 2004 2005 2006 2007 2008 2009

Gonorrhea reported cases Pilot project Andreas Syngros Hospital

74 144 94 76 73 112 122 Natives 17 19 44 45 Non natives 27 26 10 Total cases 101 170 104 93 92 156 167 % natives % non natives 73.27% 26.73% 84.71% 90.38% 15.29% 9.62% 81.72% 79.35% 71.79% 73.05% 18.28% 20.65% 28.21% 26.95%

Tuberculosis

Estimated Global Incidence of TB

Data source: Global tuberculosis control 2011, World Health Organization

Reported TB Cases Greece 2004-2010 Total Native Greeks Non-natives

Distribution of Frequency in Reported TB Cases and Nationality in total of cases Greece 2004-2010

Natives

64,1% Έλληνες Αλλοδαποί Άγνωστο

Non natives

34,0% 1,9%

Distribution of Frequency in Reported TB Cases and Nationality, per year of reporting Greece 2004-2010

30 20 10 0 80 70 60 50 40 75,4 23,5 1,1 2004 65,4 28,5 6,1 2005 66,4 Native 64,4 Non-native 31,8 33,4 1,8 2006 2,3 2007

Year

61,9 37,4 56,6 43,4 53,3 46,7 0,7 2008 Unknown 0 2009 0 2010

Age Distribution of Reported TB cases and Nationality Greece 2004-2010

50 40 30 20 10 0

Frequency of Distribution of Reported TB Cases according to the Site of Infection Greece 2004-2010

80 73,4 74,9 74,1 73,3 68,7 66,4 66,6 70 Pulmonary TB 60 14,8 10,0 14,8 9,9 13,3 12,6 10,2 13,2 12,1 13 Extrapulmonary TB 11,4 15,5 14,2 9,8 Both 2004 2005 2006 2007

Year

2008 2009 2010

Frequency of Distribution of Reported TB Cases with Pulmonary Cavities, according to Nationality Greece 2004-2010

30 25 20 15 10 5 0 Natives 25,8 Non-natives 10,0 20,4 16,2 18,3 Όχι Ναι

Pulmonary cavity

8,1 Άγνωστο

MDR TB Cases and Nationality Greece 2004-2010

8 6 4 Greek 2,5 2 Non native 3,9 2,8 3,4 0 2004 2005 5,8 6,3 1,3 0,4 2006

Year

2007

Data:National Mycobacterial Reference Center, Sotiria General Hospital

3,2 2,7 2008 1,9 4,6 2009

XDR TB Cases and Nationality Greece 2004-2010

2 1,5 1 0,5 Greek 1,3 1,1 Non Native 0,4 0,6 1,3 0 2004 2005 2006

Year

2007

Data:National Mycobacterial Reference Center, Sotiria General Hospital

0,8 1,1 1,0 2008 2009

Tuberculosis- issues to consider in the present and future

      Underreporting Review of current reporting form and reporting system Surveillance of MTB resistance Surveillance of the disease/therapy outcome Implementation of the National Action Plan for Tuberculosis Network of coordinators for the assessment of the implementation of the National Action Plan in peripheral level

Hepatitis B and C

   Greece has been traditionally considered as a region of intermediate endemicity for HBV infection and estimated prevalence rates for HBsAg range from 3-5 % reaching 24% in certain rural areas. First community based study in the general population of Greece, with a methodological approach based on multi-staged random sampling, was by Prof. Gogos et al. in EurJ Epidem 2003 Rates: 2.1% rate of chronic HBV carriers, 0.5% antibodies to HCV

    total of 130 immigrants (81 men and 49 women), aged between 18 and 69 hepatitis B virus surface antigen (HBsAg), the hepatitis B virus core antibody (anti-HBc) and the hepatitis C virus antibody (anti-HCV) were detected with ELISA method the prevalence of HBsAg and anti-HBc was extremely high (15.4 % and 53.1 %, respectively), similar to that reported in countries of high endemicity for HBV infection The prevalence of anti-HCV in the population of non-natives was relatively low (2.3 %) and no differences among various nationalities were found

Hepatitis B and C

 HEPNET - GREECE (Hepatitis Network - Greece) for hepatitis B and C, is a multicenter nationwide retrospective-prospective study, initiated in 2003  sponsored by the Greek government, approved and conducted through the Hellenic Center for Disease Control and Prevention  Evaluation of the epidemiology and course of chronic hepatitis B and C infection in Greece  20 hepatology centers in Greece

Hepatitis B

   HEPNET study for chronic hepatitis B (Journal of Viral Hepatitis, 2008) evaluated the epidemiological features of HBV infection in a sample of 3480 patients followed up during the years 1997–2006 Baseline demographics, clinical and virological characteristics at their initial presentation at a hepatology centre Evaluation of the characteristics of the disease amongst immigrants and Greek patients

Hepatitis B

     The study population consisted of 3353 (93.4%) adults at first visit and 127 (3.6%) children The majority of non-natives were born in Albania (71.0%) followed by Eastern European (19.4%) and Asian countries (3.2%) The majority of patients was of male gender, with an average age of 45 years, born in urban areas Immigrants were more frequently born in rural areas, were younger and with lower BMI compared to Greeks Adult immigrants had more frequently positive HBeAg compared to the Greek adults (10.6% vs 6.7%, P = 0.003

Hepatitis B HEPNET study for chronic hepatitis B

HEPNET study for chronic hepatitis B Conclusions

     Immigrants represented a considerable proportion (18.6%) of the total study population (and 56.6% of the children) They were of younger age both at first visit (30.3 ± 14.2) and at first diagnosis of infection (28.4 ± 13.7) Although aware of their disease before their first visit to the centre, did not seek medical advice due to ignorance about the seriousness of their disease Patients from Albania were found to be the core immigrant population (13.7% out of 18.6%) Most of adult natives and immigrants had similarly no known source of infection with intrafamilial spread accounting for 16.7% and 18.7% of the HBV transmission routes

Migrant Health Care Project ‘Implementation of health care and psychosocial support activities for third-country nationals that may require international protection in the area of Evros-Greece’

Background: Increased migration to the Greek-Turkish border

before 2009: 3,500 2009: 8,800 2010: > 47,000 Assessment visit to the Greek-Turkish border, ESCAIDE 2011 41

Background: Detention and Health Care

  Greek law: persons without valid entry papers are detained in closed centres until ID verification Prior to March 2011, health care was provided by  local medical doctors  NGO’s  Hellenic Centre for Disease Control and Prevention (KEELPNO)

Background: geographical locations

Fylakio detention, screening centre Soufli police station Tychero police station

Poros

screening centre

Feres

police station

Vena

detention centre

Migrant Health Care Project

  Migrant Health Care (MHC) project became operational in March 2011 funded by the European Union (EU) (80%) and by the Greek national authorities (20%)

AIM OF THE PROJECT

  providing medical and psychosocial support to detained migrants protecting public health through vaccination and screening of the newcomers

Migrant Health Care Project

Staffing of the centres

 7 physicians, 8 nurses, 5 psychologists, 3 social workers, 14 translators 3 administrative staff ,3 drivers and 2 technical laboratory assistance

Entry assessment

 Medical file (medical history and clinical examination)   Testing for tuberculosis, blood cell count, Haemorragic fever, stool samples if diarrhea Psychosocial evaluation

Vaccination

 Children (< 18 y.): diphtheria, tetanus, pertussis, polio, measles, mumps, rubella  Adults: diphtheria, tetanus, polio

Early warning system

        Surveillance of migrants, including an early warning component, had been set up Surveillance network composed of the medical staff in the centres, doctors from the hospital and the project manager and the HCDCP Telephone reporting daily Systematic documentation of health conditions is done after release of migrants Alert notification was reported to be done by the medical staff in the detention centres via telephone to the project manager and once a day in a regular basis No outbreaks of communicable diseases had been reported during the visit Most migrants were reported to be healthy individuals During the period of risk assessment, through screening two MDR TB patients from Georgia were diagnosed

Migrant Health Care Project

Demographical data

 Time period: March-July 2011 (5 months)  6 stations and detention centers in Evros National Border  6899 immigrants were screened in total  6278 (91%) were male and 621 (9%) were female, 258 minors  Average age: males: 25.31, females: 44

Migrant Health Care Project

Demographical data

Algeria 5.6%

country of origin

Migrant Health Care Project

Demographical data

Marital status

MEDICAL INFORMATION

        Almost 4000 sought medical advice during their detention and 100 were hospitalized 7% of women were pregnant 23% of cases had upper or lower respiratory tract infections 18% musculoskeletal pain 10% headache 9% epigastric pain 8% skin rash and dermatological conditions 2% presented with gastroenteritis

MEDICAL INFORMATION

Mantoux testing  1132 Mantoux tests were performed from which 88 (7.8%) were positive Vaccinations   adults migrants were vaccinated against Poliomyelitis children against Diphteria, Tetanus, Pertussis and Poliomyelitis and against Measles, Mumps and Rubella Psychosocial evaluation Referrals

MEDICAL INFORMATION Haemorrhagic fever testing

 Of the 521 samples none was found + for IgM antibodies for Crimean-Congo H. Fever  Two had IgM+ and IgG+ antibodies for Dengue  One had IgM+ and IgG+ for WNV  One had IgM+ and IgG+ for Chickungunya virus

CONCLUSIONS

     Most of the migrants arriving were in a healthy status No outbreaks of communicable diseases were recorded in detention centers There was an unexpectedly high percentage of pregnancies and a substantial number unaccompanied minors, both of which are vulnerability factors The percentage of positive Mantoux among screened migrants' shows that TB screening should be permanent on a daily basis Practitioners should be aware that Heamorragic fever should be considered when migrants with arthralgia and fever seek for medical assistance in primary health care facilities

MOBILE HEALTH UNITS

Medical and Psychosocial Intervention in Populations with Limited Access to Health Care

MOBILE HEALTH UNITS

  Pilot Program (November-December 2010) revealed the need for further interventions The program reaches vulnerable population groups such as immigrants/refugees, shelterless individuals, IDUs, illegal prostitutes and victims of trafficking, unattended minors

AIMS AND PURPOSES

 Amelioration of the health of these populations and protection of public health   Epidemiological surveillance of certain communicable diseases with a focus on early diagnosis Implementation of health promotion activities and disease prevention strategies

MOBILE HEALTH UNITS

      4 units working 7 days/week 1 physician, 1 nurse, 1 psychologist/social worker, 1 administrative employee,1 driver, 1 translator/cultural mediator where needed Medical intervention protocol (triage, medical history and clinical examination) Testing for HIV/AIDS, HBV upon consent, malaria Referral of emergencies, special care, gynecological /obstetrics Psychosocial history and psychological evaluation is carried out when appropriate

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10.778 medical examinations Males: 7.619

Females: 2.139

Minors: 1.020

Most medical problems were related with: Upper and lower respiratory diseases Dermatological conditions relative to living conditions and habits (scabies and other parasitic skin diseases, skin and wound infections, impetigo, soft tissue infections) Epigastric pain and chronic diarrheal syndrome Rarely encountering chronic diseases

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Most frequent mental disorders were: Depression Phobias and Panic Attacks PTSD and other stress disorders  Results from the infectious diseases testing are being processed  Preliminary results from 514 consenting individuals Males: 449 (87,4%) Females: 59 (11,5%) Non-native: 399 (77,6%) IDUs: 117 (22,8%) HIV+: 29/514 HIV+ IDU: 25/117 (21.4%) HIV+ non IDU: 4/397 (1%)

Key messages

     Migration is a global phenomenon and a social determinant of health In general, migrant populations are in a good physical condition (“the healthy migrant effect”) upon arrival to host countries Undocumented migrants are special populations subjected to various health threats Significant underreporting occurs for most communicable diseases, especially in these groups for plenty of reasons (fear of illegal status, limited access to health care, language and cultural barriers, fear of the loss of employment) We need to strengthen surveillance systems in order to make prompt interventions and communicate to health professionals the special issues of migrant health