GUIDANCE ON THE. by author. screening and vaccination of MIGRANTS in Europe. Sally Hargreaves PhD FRCPE. Imperial College London, UK

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1 GUIDANCE ON THE screening and vaccination of MIGRANTS in Europe Sally Hargreaves PhD FRCPE Imperial College London, UK

2 Migration in Europe Major demographical shifts in recent years in terms of internal and external migration Migrants may come from countries where health and vaccination systems have broken down or are inadequate They may face disparities in access to care, poverty, exclusion This has implications for European health systems 2

3 Settlement countries Camps/Detention North Africa Where, when, who, and how best to screen and vaccinate? Transit countries (Southern EU, Balkans etc) First arrival countries (Turkey, Italy, Greece, etc)

4 We need to consider other aspects of migration in Europe 35.1million EU migrants in Europe living outside of their country of birth >>recent large multi-country measles outbreak is involving mobile EU economic migrants moving east to west Migrants who travel to visit friends and relatives >>80% of UK s malaria cases were in this group elibrary Distribution of measles cases by country, EU/EEA 1 Jan-31 December 2017 Source: ECDCESCMID Labour migration

5 ECDC risk assessments ECDC threat assessment for the EU Twenty-seven confirmed cases of louse-borne relapsing fever (LBRF) were diagnosed in EU countries and Switzerland between July and October These cases, diagnosed among refugees from countries of the Horn of Africa are not unexpected as the disease is present in north-eastern Africa. The information available indicates that most of the 27 cases are likely to have been exposed to body lice infestations and louse-borne relapsing fever during their journey to Europe. Symptoms of the three cases reported in Sicily occurred shortly after entry, suggesting an infection with Borrelia recurrentis near to the time they arrived in Italy. The transmission of Borrelia recurrentis to the eight cases reported in Germany is likely to have taken place towards the end of their journey in Libya or upon arrival in Italy. The Netherlands reported cases of LBRF with onset in late spring These cases used the same migration route through Libya as the German cases, favouring the hypothesis of transmission of LBRF in the countries traversed before arriving in Europe. In Turin, however, the two affected individuals were living in Italy since 2011 and they denied recent travel to endemic regions. Therefore they are likely to have become infected while being housed in the same overcrowded facility as the newly arrived infected cases. This points to the possibility of locally acquired transmission of LBRF among migrants within the EU. Suggested citation: European Centre for Disease Prevention and Control. Louse-borne relapsing fever in the EU 17 November Stockholm: ECDC; European Centre for Disease Prevention and Control, Stockholm, 2015 RAPID RISK ASSESSMENT Louse-borne relapsing fever in the EU 17 November 2015 An increase of refugees from LBRF-endemic areas has been observed in the EU since 2014, indicating that similar importation of cases and subsequent secondary transmission could occur in EU/EEA countries. These events highlight the importance of early detection and notification, for timely implementation of public health measures in order to reduce the risk of outbreaks. Furthermore, LBRF should be considered in differential diagnosis of malaria and as a potential cause of fever, particularly if recurrent, among refugees using the East African and Central Mediterranean routes. Body lice infestation is linked to low socioeconomic status, over-crowding and poor personal hygiene. Refugees are vulnerable to body lice infestation due to challenging living conditions during migration, and after entry into the EU due to crowded conditions in temporary shelters. People in close contact with migrants hosting body lice infected with Borrelia recurrentis are at risk of being exposed to the disease. Once in the EU, there is a risk of spread from infected individuals infested with body lice to the homeless or other vulnerable population groups sharing the same living environment, in particular temporary housing in crowded environments. The risk of infection for relief workers involved in refugee care is extremely low when appropriate hygiene measures such as wearing gloves during medical examination are observed. Body lice can transmit other diseases (e.g. epidemic typhus and trench fever), and delousing is an effective way to control transmission of louse-borne pathogens. ECDC threat assessment for the EU The scale of the current influx of refugees is inevitably putting pressure on public health systems in frontline receiving countries. Refugees do not currently represent a threat to Europe with respect to communicable diseases, but they are a priority group for communicable disease prevention and control efforts because they are more vulnerable. The risk to refugees arriving in Europe of contracting communicable diseases has increased due to the current overcrowding at reception facilities, resulting in compromised hygiene and sanitation arrangements. While the risk of mosquito-borne diseases has been reduced as a result of the approaching winter, the risk of other diseases whose spread is facilitated by overcrowding and lower temperatures has increased as a result of greater numbers of refugees likely to be gathering in close proximity to seek shelter from the cold weather. It is therefore expected that the incidence of respiratory and gastrointestinal conditions will increase in the coming months. Recent weeks have seen reports of emerging outbreaks of communicable diseases affecting the refugee population. Of particular concern is the emergence of 27 cases of louse-borne relapsing fever (LBRF) in different locations along the route followed by the refugees arriving in Italy. The probable transmission of LBRF among refugee communities in the EU indicates that more cases may be seen in the near future, unless appropriate hygiene measures are implemented rapidly. Low coverage for some vaccines, along with low immunity for some diseases, may result in susceptible refugees developing diseases such as measles and chickenpox (varicella), given the high incidence of these in some areas of the EU. The risk to European residents of being affected by outbreaks occurring among refugee populations remains extremely low since the compromised hygiene, overcrowding and limited access to clean water responsible for their transmission are specific to the reception facilities in which they are occurring. Conclusions and options for response There are no indications that the number of people seeking refuge in Europe will decrease over the coming months, and the winter season will make the situation harder for those already living in precarious conditions across Europe. The basic information that would allow an adequate assessment of the situation is currently not available. The exact number of refugees is unknown, and assessment is hampered because refugees may avoid registration for fear of being sent back and because they move through different European countries. While the risk of mosquito-borne diseases has been reduced as a result of the autumn and approaching winter, the risk to refugees of diseases whose spread is facilitated by overcrowding and lower temperatures has increased. Options for reducing the risk of cases and outbreaks of communicable diseases and to improve the management of preventive and curative health services for refugees and migrants appear below. Suggested citation: European Centre for Disease Prevention and Control. Communicable disease risks associated with the movement of refugees in Europe during the winter season 10 November 2015, Stockholm: ECDC; European Centre for Disease Prevention and Control, Stockholm, 2015 RAPID RISK ASSESSMENT Communicable disease risks associated with the movement of refugees in Europe during the winter season 10 November

6 ECDC risk assessments Communicable disease risks associated with the movement of refugees in Europe during the winter season ECDC threat assessment for the EU ECDC threat assessment for the EU The risk to refugees has increased due to The scale of the current influx of refugees is inevitably putting pressure on public health systems frontline receiving Twenty-seven confirmed cases of louse-borne relapsing fever (LBRF) were diagnosed in EU countries and countries. Switzerland between July and October These cases, diagnosed among refugees from countries of the Refugees do not currently represent a threat to Europe with respect to communicable diseases, but they are a priority Horn of Africa are not unexpected as the disease is present in north-eastern Africa. group for communicable disease prevention and control efforts because they are more vulnerable. The risk to The information available indicates that most of the 27 cases are likely to have overcrowding been exposed to body lice at reception refugees arriving in Europe of contracting facilities, communicable diseases has increased due to the current overcrowding resulting at in infestations and louse-borne relapsing fever during their journey to Europe. Symptoms of the three cases facilities, resulting in compromised hygiene and sanitation arrangements. While the risk of mosquito-borne reported in Sicily occurred shortly after entry, suggesting an infection with Borrelia recurrentis near to the time diseases has been reduced as a result of the approaching winter, the risk of other diseases whose spread is facilitated they arrived in Italy. The transmission of Borrelia recurrentis to the eight cases reported Germany is likely to by overcrowding and lower temperatures has increased as a result of greater numbers of refugees likely to be have taken place towards the end of their journey in Libya or upon arrival Italy. The Netherlands reported gathering in close proximity to seek shelter from the cold weather. It is therefore expected that the incidence of cases of LBRF with onset in late spring These cases used the same migration route through Libya as the respiratory and gastrointestinal conditions will increase in the coming months. German cases, favouring the hypothesis of transmission of LBRF in the countries traversed before arriving in Recent weeks have seen reports of emerging outbreaks of communicable diseases affecting the refugee population. Europe. poor hygiene and sanitation Of particular concern is the emergence of 27 cases arrangements of louse-borne relapsing fever (LBRF) in different locations along In Turin, however, the two affected individuals were living in Italy since 2011 and they denied recent travel to the route followed by the refugees arriving in Italy. The probable transmission of LBRF among refugee communities endemic regions. Therefore they are likely to have become infected while being housed in the same in the EU indicates that more cases may be seen in the near future, unless appropriate hygiene measures are overcrowded facility as the newly arrived infected cases. This points to the possibility of locally acquired implemented rapidly. transmission of LBRF among migrants within the EU. Low coverage for some vaccines, along with low immunity for some diseases, may result in susceptible refugees An increase of refugees from LBRF-endemic areas has been observed in the EU since 2014, indicating that developing diseases such as measles and chickenpox (varicella), given the high incidence of these in some areas of similar importation of cases and subsequent secondary transmission could occur in EU/EEA countries. the EU. These events highlight the importance of early detection and notification, for timely implementation of public health measures in order to reduce the risk of outbreaks. Furthermore, LBRF should be considered in differential diagnosis of malaria and as a potential cause of fever, particularly if recurrent, among refugees using the East African and Central Mediterranean routes. Body lice infestation is linked to low socioeconomic status, over-crowding and poor personal hygiene. Refugees are vulnerable to body lice infestation due to challenging living conditions during migration, and after entry into the EU due to crowded conditions in temporary shelters. People in close contact with migrants hosting body lice infected with Borrelia recurrentis are at risk of being exposed to the disease. Once in the EU, there is a risk of spread from infected individuals infested with body lice to the homeless or other vulnerable population groups sharing the same living environment, in particular temporary housing in crowded environments. The risk of infection for relief workers involved in refugee care is extremely low when appropriate hygiene measures such as wearing gloves during medical examination are observed. Body lice can transmit other diseases (e.g. epidemic typhus and trench fever), and delousing is an effective way to control transmission of louse-borne pathogens. Suggested citation: European Centre for Disease Prevention and Control. Louse-borne relapsing fever in the EU 17 November Stockholm: ECDC; European Centre for Disease Prevention and Control, Stockholm, 2015 RAPID RISK ASSESSMENT Louse-borne relapsing fever in the EU 17 November 2015 ECDC threat assessment: Newly arrived migrants and refugees do not represent a threat to Europe with respect to RAPID RISK ASSESSMENT communicable diseases The risk to European residents of being affected by outbreaks occurring among refugee populations remains extremely low since the compromised hygiene, overcrowding and limited access to clean water responsible for their transmission are specific to the reception facilities in which they are occurring. Conclusions and options for response There are no indications that the number of people seeking refuge in Europe will decrease over the coming months, and the winter season will make the situation harder for those already living in precarious conditions across Europe. The basic information that would allow an adequate assessment of the situation is currently not available. The exact number of refugees is unknown, and assessment is hampered because refugees may avoid registration for fear of being sent back and because they move through different European countries. While the risk of mosquito-borne diseases has been reduced as a result of the autumn and approaching winter, the risk to refugees of diseases whose spread is facilitated by overcrowding and lower temperatures has increased. Options for reducing the risk of cases and outbreaks of communicable diseases and to improve the management of preventive and curative health services for refugees and migrants appear below. Suggested citation: European Centre for Disease Prevention and Control. Communicable disease risks associated with the movement of refugees in Europe during the winter season 10 November 2015, Stockholm: ECDC; European Centre for Disease Prevention and Control, Stockholm, November

7 Lancet-UCL Commission on migration and health Due to report in 2018 Aim: generate new data and renewed dialogue around the impact of migration on health Lack of data/guidance, making policy making difficult Focus is on refugees, but what about everyone else? How does the Universal Health Coverage agenda apply to migrants in Europe?: Why is it that thousands of migrants in Europe only have access to emergency health care through the emergency room? What is an acceptable level of health care that should be offered on arrival, and subsequently? Universal health coverage (UHC) means that all people and communities can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship.

8 Lancet-UCL Commission on migration and health Aldridge R, et al (UCL). Summary of random effects meta-analysis of Standardised Mortality Ratios for international migrants by ICD-10 disease category (Unpublished data; Prospero CRD ) Systematic review and meta-analysis on mortality outcomes in international migrants globally: 316 studies Overall mortality advantage to international migration across almost all the ICD-10 disease categories when migrants compared to host population Migration can be healthy Increased mortality: infectious diseases

9 Why are migrants disproportionately affected by infectious diseases? Country of origin: higher burden of disease Transit experience (camps/detention facilities) Socio-demographic factors: poverty and destitution Discrimination, racism, xenophobia Inequities in access to screening, vaccination, treatment Low levels of adherence and treatment completion

10 Various approaches to screening migrants in the EU/EEA Source: Karki T, et al. Environ Res Pub Hlth 2014 Focus is on: Active TB (recently expanding into latent TB in migrant screening programmes) On or soon after arrival Asylum seekers/refugees 10

11 Proportion HIV diagnoses among migrants in the EU/EEA 2015 (n= ) HIV is an important New diagnoses in people originating from countries with generalised HIV epidemics New diagnoses in people originating from other countries 37% * Migrants are all persons born outside of the country in which the diagnosis was made. Data presented here are among cases with known region of origin; There were no cases reported among migrants in Hungary or Liechtenstein. Source: Teymur Noori, ECDC, Sweden consideration for migrants in Europe >>migrants face a disproportionate burden Huge regional variations

12 Where do migrants acquire HIV infection (before or after arrival to EU?) Refugees/asylum seekers only Source: Rice BD, Elford J, Yin Z et al (2012). A new method to assign country of HIV infection among heterosexuals born abroad and diagnosed with HIV in the UK. AIDS 26 (15): Historically migrant population in Europe likely acquired HIV infection in home country This has shifted in recent years and there is now ongoing HIV acquisition and transmission postmigration to Europe among certain migrant groups 12

13 Where do migrants acquire HIV infection (before or after arrival to EU?) Refugees/asylum seekers only Why is this important? Screening newly arrived migrants at point of entry is not enough Some sub-populations of migrants are at-risk for HIV acquisition many years after arrival to the EU >>same applies to TB (reactivation 3-4 years after arrival) Countries should develop and deliver targeted primary HIV prevention programmes to migrant populations at risk Including for those visiting friends and relatives Source: Rice BD, Elford J, Yin Z et al (2012). A new method to assign country of HIV infection among heterosexuals born abroad and diagnosed with HIV in the UK. AIDS 26 (15):

14 Availability of ART for undocumented migrants, 2016 Source: ECDC. From Dublin to Rome: ten years of responding to HIV in Europe and Central Asia: Stockholm, ECDC; ,286 patients at NGO clinics across 14 European countries>>>securing access to basic health care is a great challenge 55% reported having no healthcare coverage Source: ECDC. HIV and migrants. Monitoring implementation of the Dublin Declaration on Partnership to Fight HIV/AIDS in Europe and Central Asia: 2017 progress report Stockholm: ECDC; 2017.

15 Foreign-born population (%) and proportion from HBV-endemic countries (prevalence of < 2%) Source: ECDC. Epidemiological assessment of hepatitis B and C among migrants in the EU/EEA. Stockholm: ECDC; Hep B: over half of all cases imported In the UK, around 14% of the population is foreign born, or whom nearly 60% come from an intermediate or high endemic country for Hep B Consider internal migrants: Italian, Polish, and Romanian migrants contributed relatively high numbers of HBV and HCV cases in this ECDC dataset 15

16 y r Foreign-born population (%) and proportion from HBV-endemic countries (prevalence of < 2%) a r b i L r e ho D t I u M a C y b S E Many countries have screening guidelines, but they are Hep B: over half of all not cases imported implemented well in migrant populations In the UK, around 14% of the population is Cross-sectional study exploring UK General Practitioner foreign born, or whom nearly 60% come from an intermediate or high endemic testing practices for hep B country for Hep B Screening delivered to only 9627 (12%) of 82,561 migrants in Consider internal migrants: Italian, Polish, whom testing was recommended in UK national guidelines and Romanian migrants contributed >>>lack of knowledge and lack of resources citedhigh by numbers clinicians relatively of HBV and HCV cases in this ECDC dataset as key barriers Source: ECDC. Epidemiological assessment of hepatitis B and C among migrants in the EU/EEA. Stockholm: ECDC;

17 < 1% EU/EEA TB: steady decline, but increasing in migrants 26.8% of TB cases occurred in persons of foreign origin (range %) 1 to 9.9% 10 to 39.9% 40 to 74.9% 75% Not reporting 17 Assessing the burden of key infectious diseases affecting migrant populations in the EU/EEA Of the 29 reporting countries, 24 countries reported on country of birth. Austria and Greece report and Belgium, Hungary and Poland did not report case-based data to TESSy on country of birth or c submitted aggregated data to WHO. Of the total cases for which case-based data were rep 24.3% ( cases) were classified as foreign origin or migrant, 60% ( cases) as native ( cases) as unknown 29 (Figure 4.2). Figure 4.2 Percentage of TB cases reported in the EU/EEA Member States by migration Belgium Hungary Poland Bulgaria Romania Slovakia Lithuania Latvia Portugal Czech Republic Estonia Slovenia TOTAL Spain Finland Ireland Germany Austria Greece France Italy Luxemburg Denmark United Kingdom Iceland Netherlands Malta Cyprus Norway Sweden 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Migrant Native Unknown In 11 of 29 countries providing data on origin of cases, the percentage of foreign origin cases was in 2010 (Table 4.1). Sweden, Norway and Cyprus reported the highest percentages of migrant cas TB notifications. In contrast, in the five high-priority countries (Bulgaria, Estonia, Latvia, Lithuania T

18 Latent TB in migrants to the EU/EEA Most active TB in migrants in EU is due to reactivation of latent TB acquired in country of origin The effectiveness of latent TB screening is currently limited by: large pool of migrants with infection, poorly predictive tests, long treatment, and a weak care cascade Data from this systematic review found that only 14% of migrants who needed treatment ultimately completed it: drop-out at every stage of the screening and treatment pathway >>shown in other studies 18

19 Latent TB in migrants to the EU/EEA Most active TB in migrants is a result of reactivation of latent TB acquired in country of origin Data are limited but the most cost-effective approach may be targeting young migrants from high TB incidence countries Why is this important? We need targeted programmes focusing on high uptake and treatment completion Adapted to the specific and unique needs of migrants Robust research needed to assess what works to improve outcomes >>latent TB completion rates were 83% in migrants in a Swedish study, associated with interpreter-assisted appointments throughout therapy [O Olsson et al J Infect Dis 2018] Latent TB screening is currently limited by: large pool of migrants with infection, poorly predictive tests, long treatment, and a weak care cascade Only 14.3% of migrants who needed treatment ultimately completed it: drop-out at every stage 19

20 MDR-TB in migrants in the EU/EEA MDR-TB is more prevalent among migrants Austria/Netherlands/Norway most MDR-TB cases are in migrants; Eastern European countries MDR-TB is in the host population Low detection and inadequate treatment of MDR-TB are major drivers of the European epidemic

21 Guidelines, strategies, action plans ROADMAP TO IMPLEMENT THE TUBERCULOSIS ACTION PLAN FOR THE WHO EUROPEAN REGION Towards ending tuberculosis and multidrug-resistant tuberculosis 21

22 The Wolfheze Consensus Guidelines established by WHO and others for a minimum package of cross-border TB control and care in the WHO European Region Focus on improving cross-border collaboration for screening and care along the entire migration trajectory and minimum standards Calls for latent TB and drug-resistant TB to be incorporated into migrant screening as part of a basic package of care, and calls for action at all levels Service delivery provision should be: -Free of charge for the patient; -Culturally competent; -Respectful of patient rights; -Designed through participatory consultative approaches involving patient organisations and migrant communities 22

23 Vaccine-preventable diseases in migrants Migration is associated with increased risk of vaccine-preventable diseases Data suggest migrants are an underimmunised group in Europe (eg. Rubella, tetanus, MMR) and have been associated with epidemics of vaccine-preventable diseases Some dominant migrant-sending countries to Europe have low immunisation coverage (Syria: 50% measles, rubella, polio; 40% diptheria, tetanus, pertussis) Migrants may also present with uncertain status and a lack of documents regarding previous vaccination: unclear as to what approach to take 23

24 Specific nationalities and adolescent/adult migrants may be particularly affected Country of origin N (%) immunised to national OR (95% CI) schedule Syria 731 (52%) 1 Afghanistan 102 (7%) 0.50 ( ) Eritrea 55 (4%) 0.53 ( ) Iran 99 (7%) 0.61 ( ) Iraq 89 (6%) 0.94 ( ) Russia 114 (8%) 0.58 ( ) Somalia 80 (6%) 1.48 ( ) Stateless Palestinians 150 (11%) 1.50 ( ) Age-group years 441 (31%) years 410 (29%) 1.79 ( ) 0-5 years 569 (40%) ( ) ageescmid Table: Regression analysis of asylum-seeking children considered vaccinated according to the Danish national schedule by country of origin and Nakken CS et al. Vaccination status and needs of asylum-seeking children in Denmark: a retrospective database analysis. Public Health 2018; DOI: /j.puhe asylum-seeking children and adolescents: 33% not immunised according to Danish national schedule 22% not immunised for MMR Afghan and Eritrean least likely to be vaccinated 48% of those aged years were unvaccinated/unknown elibrary 24

25 Ensuring high levels of vaccine coverage is a key priority for Europe through the European Vaccine Action Plan (target: >95% coverage of MMR) It is acknowledged that consistently high levels of migration to the Region, alongside low national uptake, may pose challenges to achieving this

26 ECDC guidelines Children follow national schedule Recommends MMR, DTP, polio to be readministered all adult migrants with uncertain vaccination status Other vaccinations (eg Hep B, influenza, Varicella) given depending on living conditions, season, epidemiological situation ECDC. Infectious diseases of specific relevance to newly-arrived migrants in the EU/EEA 19 November ECDC: Stockholm;

27 ..migrants should be vaccinated according to immunisation schedule of country in which they intend to stay for more than a week, with priority given to MMR and polio vaccines, and that refugees and asylum seekers should have non-discriminatory, equitable access to vaccination irrespective of their legal status WHO-UNHCR-UNICEF joint technical guidance (2015)

28 ESGITM Working Group on Vaccination in Migrants Set up in 2017 to explore approaches to vaccination in adult and child migrants across Europe Questionnaire survey of experts Experts identified through ESCMID/ESGITM networks (May 2017) 12-point electronic questionnaire 32 countries (100% response rate) Policy analysis Collated policies on vaccination of migrants across EU/EEA via ESCMID/ESGITM networks, literature search of key databases and grey literature (eg. MoH websites) Guided by Bardach s health policy framework ESCMID Study Group for Infections in Travellers and Migrants ESGITM arch_projects/study_groups/t ravel_and_migration/ 28

29 Vaccination guidelines and approaches vary widely Refugees/asylum seekers only Recently arrived migrants All migrants including undocumented migrants Germany: In Germany implementation of guidelines is an issue of federal states and finally the local authorities. It depends on local number of staff, number of refugees, available resources and systems. Only 6 (19%) of 32 countries had migrantspecific guidelines on vaccination: focused on refugees Guidelines poorly implemented in practice, according to experts, with few examples of incountry initiatives targeting migrants Interestingly, 10 (31.3%) of 32 countries reported charging certain newly arrived migrants for vaccinations 29

30 Number of Responding Countries Lack of clarity regarding approaches to catch-up vaccinations in adolescents and adults and what vaccinations to offer Refugees/asylum seekers only Children Adults Focus is very much on children for catchup vaccinations to align them with the national schedule Excludes adults and adolescents: less than half of all reporting countries offered DTP (16 of 31 countries), polio (12 of 32), MMR (12 of 32) to adults. Estonia: The completeness of adult migrant vaccination depends on the health care provider if they consider vaccination as a priority. 30

31 Number of Responding Countries Lack of clarity regarding approach to catch-up in adolescents and adults and what vaccinations to give Refugees/asylum seekers only Experts we approached recommended Focus ismultiple very much on children for catch- offered vaccinations to adult/child to align them with the opportunities for vaccination beup migrants post arrival national schedule Excludes adults and adolescents: less 81% countries requested EU guidance on vaccination Children implementation in migrants; than half of all reporting countries offered Adults and for vaccination to be better promoted in migrants DTP (16 of 31 countries), polio (12 of 32), MMR (12 of 32) to adults. Other vaccines less frequently reported Estonia: The completeness of adult migrant vaccination depends on the health care provider if they consider vaccination as a priority. 31

32 Would European guidance on screening and vaccination for infectious diseases among migrants be useful?

33 Evidence-based guidance for prevention of infectious diseases among newly arrived migrants in the EU/EEA Due to be published later this year Collect and synthesise the scientific evidence and existing European/international guidelines on screening and prevention for infectious diseases among migrants, taking into account the: Individual and public health benefits Limitations and ethical considerations Screening, vaccination, and treatment options Implementation considerations Cost-effectiveness Target audience: - National and sub-national policy makers in EU/EEA Member States; - Health practitioners; - NGOs/patient organisations

34 ECDC Scientific Panel Angel Kunchev Bulgaria Gabrielle Jones France Andreas Gilsdorf Germany Agoritsa Baka Greece Apostoles Veizis - Greece Lelia Thornton Ireland Cliona M Cheallaigh - Ireland Silvia Declich Italy Francesco Castelli - Italy Pierluigi Lopalco - Italy Michael Vonk Netherlands Maria van den Muijsenbergh Netherlands Irene Veldhuijzen Netherlands Maria Axelsson Sweden Sonia Dias Portugal Henrique Barros Portugal Manuel Carballo Spain Katherine Russell United Kingdom Dominik Zenner United Kingdom Manish Pareek United Kingdom Rebecca Hall United Kingdom OBSERVERS Isabel de la Mata European Commission Olga Gorbacheva IOM Joao Pires WHO Regional Office for Europe Ludovica Banfi EU Fundamental Rights Agency The work has involved 21 ECDC-appointed experts in public health, infection, and migration, an advisory board, observers (including the IOM) and multiple experts in each disease area The project is being coordinated by Teymor Noori, migrant health lead at the ECDC; research is being led by Kevin Pottie and team at University of Ottowa

35 Priority conditions identified and systematic reviews commissioned on effectiveness and cost-effectiveness of screening in each disease area Active TB Hepatitis C Intestinal parasites Schistosomiasis Strongyloidiasis Latent TB Hepatitis B Routine vaccinations Measles Mumps Rubella Hib Diphtheria Polio Tetanus Pertussis HIV

36 Approach Researchers used GRADE-based synthesis and evidence-to-decision tables to assess all the evidence and produce the guidelines Guideline development has proved extremely challenging in part due to low quality evidence in this area Reports available from: 1 st Scientific panel meeting (Nov 2015) 2 nd Scientific panel meeting (Oct 2016)

37 Added value of this guidance All infections/vaccination in one place Cross referencing all existing guidance A key focus is on implementation issues in migrant populations, and how best to deliver screening and vaccination programmes considering their unique needs Country Australia Canada Effectiveness Costeffectiveness Certainty of evidence (GRADE) Low to moderate certainty for effectivenes s FACE Survey* All guidelines recommend assessing the immunisation record of the migrants and not pursuing serology testing. There is very little data on the costeffectiveness of vaccination strategies in migrant populations. According to the ad-hoc scientific panel, immunisatio n against VPDs among Moderate migrants in Vaccination is to be Serological testing certainty of the EU/EEA offered according to was less cost evidence for is: the national effective than How and who to vaccinate cost immunization presumptive -of Assess availability of immunization records; effectivenes and plan guidelines of the host immunisation of moderatehigh to high vaccination based on age. s country. internationally adopted children. priority Social Provide mobilization catch-up immunisation so people from refugee-like and backgrounds outreach are immunised - acceptable Pre-departure equivalent to an Australianborn person of the same vaccination age. of programmes - feasible appeared Full catch-up to be if records refugee are not was available costsaving rubella and - cost- associated Measles, with mumps the and most significant decreased vaccine effective increases Vaccinate all adult immigrants preventable without immunization records - highly vaccination using one rates. dose of measles mumps rubella diseases (61)3). vaccine. equitable Diphtheria, pertussis, tetanus and polio HiB Vaccinate all adult immigrants without immunization records using a primary series of tetanus, diphtheria and inactivated polio vaccine (three doses), the first of which should include a cellular pertussis vaccine. Table 2: International guideline VPD recommendations in migrants Strength of Recommenda tion Strong recommendation Children/adolesce nts Conditional recommendation for adults Implementation considerations All migrant children/adolescents should be vaccinated according to the host countries vaccine schedules to address health equity concerns. Migrant adults without prior vaccination records should be vaccinated in accordance with the host country vaccine schedule. In humanitarian scenarios offer diphtheria, tetanus, haemophilus influenzae type B and polio vaccines at entry and detainment phases. Table 1: Evidence synthesis and guidance for VPDs in migrants 37

38 Implementation is key Facilitators Migrant involvement Outreach Service provider management well-trained and dedicated screening staff culturally sensitive and appropriate services trust and respect for the judgement of staff interviews conducted by a health care worker in a migrant's native language support patient involvement in delivery increasing migrant community ownership and collaborations awareness-raising in migrant communities around health access and disease prior to screening testing in user-friendly outreach settings (e.g. general health check approach and promotion, anonymous testing approach); efficient testing, communication of results and referrals clear patient pathways Focus on minimizing drop-out and ensuring adherence/treatment completion strong coordination 38

39 United Kingdom: Migrant Health Guide 39

40 Conclusions Although most migrants are healthy, we need to consider multiple infections and vaccination needs targeting key nationalities and particular migrant sub-groups Tailor and target testing/screening programmes so as to diagnose early and reduce the proportion of people living with undiagnosed infectious disease Expand focus away from refugees/asylum seekers to the wider group of migrants circulating in Europe Ensure linkage to care and screening/treatment completion There are clear clinical, public health, and human rights arguments for promoting access to an acceptable level of free health care to migrants 40

41 Acknowledgements Prof Jon Friedland ICL Dr Laura Nellums ICL Dr Teymur Noori, ECDC Kieran Rustage ICL Dr Robert Aldridge UCL Prof Ymkje Stienstra Univ of Groningen Sofanne J Ravensbergen Univ of Groningen Members of the European Society for Clinical Microbiology and Infectious Diseases Study Group for Infections in Travellers and Migrants (ESGITM) Working Group on Vaccination in Migrants Nick J Beeching, Francesco Castelli, Marie Norredam, Hakan Leblebicioglu, Hakan Erdem, Manuel Carballo, Christoph Lange, Delia Goletti, Christian Wejse, Resat Ozaras, Rogelio Lopez-Velez, Athanassios Tsakris, Eskild Petersen, Rok Civljak, Patrica Schlagenhauf, Nicolas Vignier, with the support of the Executive Committee and Membership of ESGITM ( s.hargreaves@imperial.ac.uk