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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 Migrants may have more complex health needs than the native born population influenced by: 1. 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 2. 3. 4. 5. Mobility itself doesn’t cause ill health Migration should be considered a social determinant of health Epidemiological data interpretation Factors that influence increases or decreases in infectious disease cases reported 1. 2. 3. 4. 5. 6. 7. 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 Alexandroypolis Thessaloniki Ioannina Patra Attica Heraklion Sources Reference labs Hospitals HCDCP HIV cases by year of diagnosis 70 60 6.1 31/10/2011 5.4 4.8 1998 2005 50 40 30 3.6 2002 20 10 00 Year of diagnosis 5.3 2008 HIV- new cases by year of report and gender Year of report SEX 2006 2007 2008 2009 2010 2011 M 401 358 471 392 457 686 (80.52%) (83.64%) (84.26%) (83.58%) (86.88%) (85.43%) F 97 70 88 77 69 117 (19.48%) (16.36%) (15.74%) (16.42%) (13.12%) (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) MSM IDUs Hetero 2006 2007 2008 2009 256 197 285 235 16 9 9 10 2010 2011 266 270 (51.41%) (46.03%) (50.98%) (50.11%) (51.33%) (33.13%) (3.21%) (2.10%) (1.61%) (2.13%) 132 97 122 75 88 123 138 14 190 (2.66%) (23.66%) 108 90 (26.51%) (22.66%) (21.82%) (15.99%) (17.11%) (13.45%) 236 147 150 Unknown (17.67%) (28.74%) (24.69%) (31.34%) (28.52%) (29.39%) HIV- new cases by year of report and nationality Year of report 2006 2007 2008 2009 2010 2011 Hellenic 387 (77.71%) 318 431 337 384 573 (74.30%) (77.10%) (71.86%) (73.00%) (71.36%) Non-native 103 88 105 107 116 152 (20.68%) (20.56%) (18.78%) (22.81%) (22.05%) (18.93%) Unknown 8 (1.61%) 22 (5.14%) 23 (4.11%) 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 10 6 5 7 8 158 Hellenic (62.50%) (66.67%) (55.56%) (70.00%) (57.14%) (83.15%) 6 3 4 3 6 32 Non-native (37.50%) (33.33%) (44.44%) (30.00%) (42.86%) (16.85%) Non-Native HIV infected IDUs in 2011 by nationality EUROPE AFRICA ASIA Albania 2 Sudan 1 Afghanistan 3 Belarus 1 Tunisia 1 Armenia 1 Bulgaria 2 Georgia 7 Italy 1 Iraq 1 Poland 2 Iran 5 Ukraine 1 Kazakhstan 2 Pakistan 1 Bangladesh 1 Total 9 2 21 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 Nonnatives Total cases % natives % nonnatives 2003 90 26 116 77.59% 22.41% 2005 114 25 139 82.01% 17.99% 2006 96 44 141 68.57 % 31.43% 2007 155 42 197 78.68 % 21.32% 2008 119 36 155 76.77 % 23.23% 2009 140 34 174 80.46 % 19.54% Gonorrhea reported cases Pilot project Andreas Syngros Hospital Year Natives 74 Nonnatives 27 Total cases 101 % natives % nonnatives 73.27% 26.73% 2003 2004 144 26 170 84.71% 15.29% 2005 94 10 104 90.38% 9.62% 2006 76 17 93 81.72% 18.28% 2007 73 19 92 79.35% 20.65% 2008 112 44 156 71.79% 28.21% 2009 122 45 167 73.05% 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 Έλληνες 64.1% Αλλοδαποί Άγνωστο Nonnatives 34.0% 1.9% Distribution of Frequency in Reported TB Cases and Nationality, per year of reporting Greece 2004-2010 80 Native 75,4 65,4 70 66,4 64,4 61,9 (%) reported cases 60 56,6 50 Non-native 46,7 37,4 40 30 43,4 53,3 28,5 31,8 33,4 23,5 20 Unknown 10 1,1 6,1 1,8 2,3 0,7 0 0 2006 2007 2008 2009 2010 0 2004 2005 Year Age Distribution of Reported TB cases and Nationality Greece 2004-2010 Frequency of Distribution of Reported TB Cases according to the Site of Infection Greece 2004-2010 80 70 73,4 66,4 66,6 74,9 74,1 73,3 68,7 Pulmonary TB (%) Reported cases 60 50 40 30 20 Extrapulmonary TB 14,8 13,3 10,0 9,9 12,6 2004 2005 14,8 10 10,2 12,1 11,4 15,5 13,2 13 14,2 9,8 2007 2008 2009 2010 0 2006 Year Both Frequency of Distribution of Reported TB Cases with Pulmonary Cavities, according to Nationality Greece 2004-2010 30 Natives 25,8 (%) Reported cases 25 20,4 20 18,3 16,2 15 10 Non-natives 10,0 8,1 5 0 Όχι Ναι Pulmonary cavity Άγνωστο MDR TB Cases and Nationality Greece 2004-2010 8 % resistance 6 6,3 5,8 Nonnative 4,6 3,9 4 Greek2,5 2,8 3,4 3,2 2,7 1,9 2 1,3 0,4 0 2004 2005 2006 2007 Year Data:National Mycobacterial Reference Center, Sotiria General Hospital 2008 2009 XDR TB Cases and Nationality Greece 2004-2010 2 % resistance 1,5 1,3 Greek 1 0,6 0,5 1,3 1,1 1,1 NonNative 1,0 0,8 0,4 0 2004 2005 2006 2007 Year Data:National Mycobacterial Reference Center, Sotiria General Hospital 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 MOBILE HEALTH UNITS 10.778 medical examinations Males: 7.619 Females: 2.139 Minors: 1.020 Most medical problems were related with: 1. 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 2. 3. 4. MOBILE HEALTH UNITS Most frequent mental disorders were: 1. 2. 3. 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