Public health needs of migrants, refugees and asylum seekers in Europe, 2015: Infectious disease aspects

In the first 10 months of 2015 the total number of asylum applications to the European Asylum Support Office (EASO) recorded by European Union (EU) countries exceeded the 1 million mark, an unprecedented level since the establishment of the EU. Syria has been the most common country of origin of asylum applications, followed by Afghanistan and Iraq. 1 However, these figures do not take unregistered migrants into account: in the same time period, 500 000 undocumented border crossing detections were recorded on the EU’s external borders, according to Frontex. 2 In the light of these developments, the European Centre for Disease Prevention and Control (ECDC) assessed the public health needs of migrants or individuals that are applying for asylum or refugee status, through: (i) interviews with 14 experts from Member States and Non-Governmental Organizations with first-hand experience working with migrant populations (7–11 August 2015); (ii) a non-systematic review of available evidence (peer-reviewed publications and relevant ECDC risk assessments); and (c) an expert meeting on the prevention of infectious diseases among newly arrived migrants in the EU and European Economic Area (EEA) (12–13 November 2015). 3–5 A recurrent theme across all the expert consultations conducted by ECDC was the need to establish a reception system for newly arrived migrants. In primary reception centres, a health assessment should be carried out immediately upon arrival. Equipping these reception areas with primary care and public health services facilitates screening, vaccination and treatment (if required) of individuals free of charge. The organisers of reception areas should consider adequately stocking them with rapid tests (e.g. for malaria) and providing instant treatment and care to patients. Such rapid interventions are the best course of action to detect and prevent onwards spread of cases of infectious disease, through the identification and management of infectious diseases with potential for transmission. Interviewees emphasised the importance of adequate housing conditions for newly arrived migrants. The interaction of a number of factors, such as poor access to healthcare, low educational attainment, inadequate nutrition and poor personal and food hygiene contribute to a vulnerabilities to infections. This is further complicated in the absence of environmental sanitation and safe water supplies. Thus, ensuring adequate water supply, sanitation and hygiene can be seen as part of a cohesive strategy to prevent the spread of infectious diseases in these settings. Avoiding or minimizing crowded living conditions in reception and detention centres can avoid or reduce transmission of diseases such as respiratory infections, gastroenteritis, louse-borne relapsing fever, trench fever, typhus, scabies and other vector-, air-(meningococcal disease) and food-borne diseases within the host country. Experts also stressed that integration into the national healthcare system, and society at large, should be accelerated, not only to prevent exacerbation of existing health problems, but also to mitigate the risks of outbreaks. Screening can be defined as the systematic practice of medical examination, involving laboratory or other diagnostic testing, to search for and identify cases of a specific infectious disease in a target population. Although most newly arrived migrants are healthy, expert consultations pointed out the importance of screening for infectious diseases according to countries of origin, since prevalence rates differ considerably. Monitoring the infectious disease burden in these populations can identify infected individuals in need of treatment. Moreover, early detection and rapid medical intervention can potentially mitigate the risks of further onward transmission within migrant communities as well as in the destination country. According to a recent survey in EU/EEA countries, screening for infectious diseases among migrants is currently directed predominantly towards tuberculosis (TB). TB screening can be performed at different time points upon migrating to a new country (i.e. upon arrival in a country or post-arrival). However, there are a number of key factors to take into account when deciding whether to implement TB disease screening in a setting of irregular migrants such as the options for treatment supervision and outcome monitoring. Other diseases for which some EU/EEA Member States currently screen, and which could be considered, include hepatitis B, hepatitis C, HIV, sexually transmitted diseases, vaccine-preventable diseases, cholera, malaria, helminths, intestinal protozoa and Chagas disease. Screening should always be based on an assessment of the most likely exposures and health needs of the target population, and connected to a process of diagnosis and treatment. The experts suggested alternative measures to routine surveillance, which may be difficult to apply to mobile migrant groups. Systems, such as syndromic surveillance protocols, could be designed to generate alerts and initiate a timely public health response in contained settings such as migrant reception and detention centres. Syndromic surveillance should complement, and not substitute, the mandatory infectious disease notification system. Conditions to consider include: respiratory tract disease, suspected pulmonary TB, bloody diarrhoea, watery diarrhoea, fever and rash, meningitis/encephalitis or encephalopathy/delirium, lymphadenitis with fever, botulism-like illness, sepsis or unexplained shock, haemorrhagic illness, acute jaundice, parasite skin infection, unexplained death. However, a general health screening should be done regardless of the presence of symptoms. Specific vaccination strategies are often necessary for displaced populations and refugees in order to protect both children and adults from infectious diseases, prevent spread of infection due to crowded conditions and ensure continuity of childhood immunisation schedules that may well have been disrupted in source countries. In addition, attention also should be paid to healthcare workers’ immunisation status for their own protection, as they can play an important role in introducing highly contagious infectious diseases into vulnerable populations or can transmit infections prevalent among migrants into the host country. Vaccinations to consider among migrants include: measles, poliomyelitis, meningococcal disease, and diphtheria/tetanus/pertussis. For measles, immunisation, preferentially with MMR vaccine, consideration should be given to prioritising children up to 15-years old. Poliomyelitis vaccination should be considered for children and adults coming from countries currently exporting poliovirus such as Afghanistan and Pakistan, infected countries, such as Nigeria and Somalia, or countries which remain vulnerable to international spread, including Cameroon, Equatorial Guinea, Ethiopia, Iraq, Israel and Syria. Vaccination for meningococcal disease should be conducted preferably with vaccines against meningococcal serogroups A, C, W-135 and Y; or, if a country does not use the quadrivalent vaccines, with vaccines against serogroups A and/or C. Finally, a review of individuals’ vaccination status should be considered for both adults and children and vaccination with diphtheria-tetanus-pertussis be offered in accordance with national guidelines. Experts also emphasized the usefulness of a system to track migrants from their first point of entry to primary and secondary reception centres and their eventual final destination. Such a follow-up system would be essential to ensure follow up of primary vaccination courses and boosters (e.g. tetanus and diphtheria toxoid boosters), treatment supervision and outcome monitoring (e.g. TB), access to medication (e.g. HIV). Experts interviewed spoke of the importance of health education and health promotion that can be provided through sessions and other outreach activities to the migrant populations and their community leaders. These interventions should be tailored linguistically and culturally to the target populations and ideally involve the target population in the design, implementation and evaluation of the programme. The role of cultural mediators should be stressed as vital for this type of activity (although they are needed for all contacts and communication). Health promotion can also help emphasise the positive aspects of health assessments, such as that screening, immunization and treatment of infectious diseases can be beneficial and promote a healthy productive life in the host country. Over the longer-term, there is a need for Europe-wide, evidence-based guidance on prevention and assessment of infectious diseases among migrants, both to ensure a consistent approach across the EU/EEA and to support Member States that currently do not have guidance in this area. Such guidance should uphold the principle of ensuring that assessment is always linked to adequately resourced follow-up treatment and care, provide recommendations on what conditions to assess and what not to assess, and assist countries to set priorities and make the best use of available resources. Migrants do not pose a significant health threat to the citizens of the EU. There is no evidence or expert opinion that suggests that migrants increase the risk of infectious disease epidemics in the host population in Europe. However, many newly arrived migrants in Europe are vulnerable to infection, and thus prevention and assessment of infectious diseases among newly arrived migrants is essential to identify and address their health needs. Ensuring adequate shelter, sanitation and water supplies, providing access to vaccinations and medical care, and paying particular attention to the most vulnerable, such as children and the elderly are important priorities to ensure that migrants’ health needs are addressed. Key points Reception centres/systems for newly arrived migrants in order to assure health assessments immediately upon arrival Adequate shelter to avoid crowding and ensuring and good sanitation and hygiene to minimise infection risks Health education and health promotion emphasising the benefits of screening, immunisation and other measures Screening for communicable diseases according to countries of origin and countries transited during migration External experts were interviewed between 7 and 11 August 2015: Anders Tegnell (Folkhalsomyndigheten, Sweden), Andreas Gildorf (Unit for Surveillance, Robert Koch Institute), Peter Kreidl (Ministry of Health, Austria), Agoritsa Baka (Hellenic Centre for Disease Control and Prevention, Greece), Flavia Riccardo (Istituto Superiore di Sanità, Italy), Nuria Serre (Drassanes-Hospital, Barcelona, Spain), Israel Molina (Drassanes-Hospital, Barcelona, Spain), Chiara Baruzzi and Efstathios Kyrousis (Médecins sans Frontières, Greece), Marianne van der Sande (National Institute for Public Health and the Environment, the Netherlands), Federica Zamatto and Stefano di Carlo (Médecins sans Frontières, Italy), Kevin Pottie (University of Ottawa, Canada), Tim Cooper (EASO). Conflicts of interest : None declared.

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