Migrant Health

Epidemiological Data in Greece

Hellenic Center for Disease Control and Prevention2012

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 2. experiences during migration, 3. access to health and labor4. factors relating to ethnicity and cultural practices5. 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

Factors that influence increases or decreases in infectious disease cases reported

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

2. Changes in migration patterns.3. Pre/post entry screening practices.4. Standard of living conditions in host country and associated risks of

onward transmission.5. Access to healthcare6. Level of case finding/diagnosis amongst different migrant groups 7. 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 infectedHIV infectedindividualsindividuals

SourcesSourcesReference labsReference labsHospitalsHospitals HCDCPHCDCP

Thessaloniki

Ioannina

Heraklion

Alexandroypolis

AtticaPatra

HIV cases by year of diagnosis

HIV- new cases by year of report and gender

Year of report SEX 2006 2007 2008 2009 2010 2011

M401

(80.52%)358

(83.64%)471

(84.26%)392

(83.58%)457

(86.88%)686

(85.43%)

F97

(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

MSM256

(51.41%)197

(46.03%)285

(50.98%)235

(50.11%)270

(51.33%)266

(33.13%)

IDUs16

(3.21%)9

(2.10%)9

(1.61%)10

(2.13%)14

(2.66%)190

(23.66%)

Hetero132

(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%)

Year of report

2006 2007 2008 2009 2010 2011

Hellenic387

(77.71%)318

(74.30%)431

(77.10%)337

(71.86%)384

(73.00%)573

(71.36%)

Non-native103

(20.68%)88

(20.56%)105

(18.78%)107

(22.81%)116

(22.05%)152

(18.93%)

Unknown8

(1.61%)22

(5.14%)23

(4.11%)25

(5.33%)26

(4.94%)78

(9.71%)

HIV- new cases by year of report and nationality

Number of HIV infected IDUs in 2011 by nationality and year of report

Year of report 2006 2007 2008 2009 2010 2011

Hellenic10

(62.50%)6

(66.67%)5

(55.56%)7

(70.00%)8

(57.14%)158

(83.15%)

Non-native6

(37.50%)3

(33.33%)4

(44.44%)3

(30.00%)6

(42.86%)32

(16.85%)

EUROPE AFRICA ASIA

Albania 2 Sudan 1Afghanistan 3

Belarus 1 Tunisia 1Armenia 1

Bulgaria 2 Georgia 7

Italy 1 Iraq 1Poland 2 Iran 5

Ukraine 1Kazakhstan 2Pakistan 1Bangladesh 1

Total9 2 21

Non-Native HIV infected IDUs in 2011 by nationality

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 2011Paraskevis 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 Non-natives

Total cases

% natives % non-natives

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 casesPilot project Andreas Syngros Hospital

Year Natives Non-natives

Total cases

% natives % non-natives

2003 74 27 101 73.27% 26.73%

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

Non-natives

Natives

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

75,4

65,4 66,4 64,461,9

56,653,3

23,5

28,531,8 33,4

37,4

43,446,7

1,16,1

1,8 2,3 0,7 0 00

10

20

30

40

50

60

70

80

2004 2005 2006 2007 2008 2009 2010

Year

(%)

rep

ort

ed c

ases

Non-native

Native

Unknown

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

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

73,374,174,973,4

68,766,666,4

15,5

14,21313,212,6

14,8

10,0 9,8

11,412,110,213,3

9,9

14,8

0

10

20

30

40

50

60

70

80

2004 2005 2006 2007 2008 2009 2010Year

(%)

Rep

ort

ed

cases

Pulmonary TB

Extrapulmonary TB

Both

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

18,3

20,4

25,8

8,1

16,2

10,0

0

5

10

15

20

25

30

Όχι Ναι Άγνωστο

Pulmonary cavity

(%)

Rep

ort

ed

cases

Natives

Non-natives

MDR TB Cases and NationalityGreece 2004-2010

3,2

1,9

0,4

1,3

2,82,5

3,93,4

5,86,3

4,6

2,7

0

2

4

6

8

2004 2005 2006 2007 2008 2009

Year

% r

es

ista

nc

e

Data:National Mycobacterial Reference Center, Sotiria General Hospital

Non-native

Greek

XDR TB Cases and NationalityGreece 2004-2010

1,3 1,3

0,81,0

0,40,6

1,1 1,1

0

0,5

1

1,5

2

2004 2005 2006 2007 2008 2009

Year

% r

esis

tanc

e

Non-Native

Greek

Data:National Mycobacterial Reference Center, Sotiria General Hospital

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 BConclusions

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’

Assessment visit to the Greek-Turkish border, ESCAIDE 2011 41

Background: Increased migration to the Greek-Turkish border

before 2009: 3,500

2009: 8,800

2010: > 47,000

2010: > 47,000

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

Tychero police station

Soufli 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 ProjectStaffing of the centres 7 physicians, 8 nurses, 5 psychologists, 3 social workers, 14

translators3 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

country of origin

Algeria

5.6%

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 INFORMATIONMantoux 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 Medical and Psychosocial Intervention in Populations with Limited Access to Health CareAccess 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: 7.619Females: 2.139Minors: 1.020 Most medical problems were related with:1. Upper and lower respiratory diseases2. Dermatological conditions relative to living conditions and habits

(scabies and other parasitic skin diseases, skin and wound infections, impetigo, soft tissue infections)

3. Epigastric pain and chronic diarrheal syndrome4. Rarely encountering chronic diseases

MOBILE HEALTH UNITS Most frequent mental disorders were:

1. Depression2. Phobias and Panic Attacks3. PTSD and other stress disorders Results from the infectious diseases testing are being

processed Preliminary results from 514 consenting individuals

Males: 449 (87,4%) HIV+: 29/514Females: 59 (11,5%) HIV+ IDU: 25/117 (21.4%)Non-native: 399 (77,6%) HIV+ non IDU: 4/397 (1%)IDUs: 117 (22,8%)

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