Polio vaccination and stool screening of asylum seekers from Syria arriving in German reception centers, 2013/2014

What was implemented?

Nadine ZeitlmannESCAIDE 2014 – Session on Epidemiology and microbiology driving public health policy 07 November 2014

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• 90% of polio cases asymptomatic shedders• 1 in 200 infections: acute flaccid paralysis (AFP)

Background

Germany 2013•Dramatic increase of Syrian asylum seekers (11% from all applications)•Last endemic polio case: 1990•Polio vaccination routinely recommended for all asylum seekers (AS) in Germany

Syria•July 2013 – January 2014: Cluster of AFP (37 confirmed cases)•Most affected: children <2 yrs. with insufficient vaccination•Reason: vaccination coverage decrease from >90% to 68% (2012)

Source: Aylward, Lancet, Jan 2014

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In all asylum seeker reception

centers (RC)

RKI Recommendation (1 November 2013)

I. Obtain vaccination documentation from:

• all asylum seekers• staff of RCs

II. Vaccinate if immunization:

• undocumented• incomplete

1. Re-enforce existing routine vaccination recommendation

Vaccination against polio for all asylum seekers

2. Temporary recommendation:

(1 November 2013 - 18 April 2014)

Stool screening of Syrian children <3 yrs of age

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Aims

1. To what extend did RCs implement recommendations between

1 November 2013 and 31 January 2014 regarding:

• Percentage of AS with vaccination documents• Percentage of AS vaccinated• Percentage of stools submitted for screening• Overall implementation

2. Which factors inhibited or improved the implementation?

3. What can be learned and improved for future recommenations?

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Methods

04 March 2014 – 21 March 2014: Electronic questionnaire to health managers for 20 RCs in Germany

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Variables•Number of AS

− arriving in RCs

− with vaccination document

− vaccinated•Number of stool samples•Date of first vaccination•Daily occupancy•Hosting duration•Routine vaccination / stool screening •Obstacles•Self-rating overall implementation •Suggestions

Questionnaire

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For each RC: Percentage of arrived AS - vaccinated without document - with stools screened

Variables•Number of AS

− arriving in RCs

− with vaccination document

− vaccinated•Number of stool samples•Date of first vaccination•Daily occupancy•Hosting duration•Routine vaccination / stool screening •Obstacles•Self-rating overall implementation •Suggestions

Questionnaire

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Results

All twenty RCs responded

Overall number of AS in the study period

•Syrians < 3 years of age: 199

•Syrians other age groups: 4604

•AS with other country of origin: 29 034

Characteristics of RCs during the study period:

•Average daily occupancy: 594 AS (Range: 150 – 1900)

•Average hosting duration: 58 days (Range: 2.5 – 330)

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Results: Vaccination

Vaccination Documents•On average 90% of asylum seekers without vaccination documents

Offer and Implementation•All RCs offered vaccination for Syrians under 3 years of age•15 RCs for Syrians of other age groups•8 RCs for all AS•5 RCs for all AS and staff (as recommended!), no data on implementation

Syrian AS <3 yrs(n=20)

Syrian AS all age groups(n=15)

All AS(n=8)

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Results: Vaccination

Timeliness

•9 RCs implemented vaccination on day of recommendation or in advance (mean: 1.5 days)

Obstacles

•Main obstacles: – Staff shortages (11 RCs)– Language barriers (7 RCs) and – AS‘ indefinable vaccination status (7 RCs)

•3 RCs: no obstacles when implementing vaccination

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Results: Stool Screening

Implementation• 19 RCs implemented stool screening Syrians < 3 years of age

− 4 RCs managed to screen 100%

− 5 RCs screened 50-99% of AS

− 4 RCs screened <25% of AS

− 6 RCs missing data

Obstacles• 5 RCs: no obstacles when implementing stool screening

− 4 of them screen stools routinely (e.g. for parasites)

•Main obstacles

− Language barriers (10 RCs)

− Logistical challenges (8 RCs)

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Overall implementation and Suggestions

Self-rated overall implementation •Very well: 3 RCs•Well: 8 RCs•Not well: 9 RCs•Among small RCs (lower daily occupancy) a higher percentage (73%) rated implementation as well or very well than among larger RCs (27%)

Suggestions•5 RCs suggested multilingual information material for future recommendations

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Limitations

• Varying completeness of information

• Different stakeholders as survey participants

• Analyses of aggregated data

• No information on AS with incomplete vaccination

• No information on numbers of staff members vaccinated

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Conclusions

• German RCs implemented and offered polio vaccination and stool screening to a varying extent

• Large RCs reported a poorer overall feasability of recommendations

• RCs experience difficulty when obtaining AS‘ vaccination history and documents

• Staff shortages and language barriers hindered implementation

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Recommendations

In future recommendations•Tackle RCs‘ language barriers by providing or organizing multilingual information material (in progress!)

•Address need for preparedness for RCs‘ stakeholders to deal with staff shortages!

•Emphasize further, that if no vaccination document and history can be obtained, vaccination should be applied!

Encourage RCs to implement vaccination recommendations routinely and regardless international outbreak situations!