Germany: Migration dynamics - present situation, achievement and major challenges Alexandra Sarah Lang, MSE Department for Infectious Disease Epidemiology Surveillance Unit
The Robert Koch Institute s key functions Detect Evaluate Act 1200 employees (~450 researchers) Identification/evaluation Communication/Cooperation Epidemiological intelligence Consultation/Recommendation Research Publications 2
Background and current situation in Germany 3
Different public health levels in Germany National level State level District level Federal Ministry of / Robert Koch Institute State health authority (1 per state) Local health authority (1 per district) Note: Due to federal organization no direct jurisdiction of national level, only advice/support of the state/local level possible! 4
Uniform legal framework for distribution and health regulations for asylum seekers The Asylum Law (AsylG): 45: Distribution of asylum seekers to federal states based on "Königstein" formula (footing on tax revenue and population size) 62: Newly arrived asylum seekers obtain initial medical examination The Asylum Seekers Benefits Law (AsylbLG): 4: Only treatment of acute diseases and pains as well as obstetrical care and vaccinations free of charge The Infectious Disease Protection Law (IfSG): 36: Medical certificate prooving there are no indications for severe communicable disesases upon arrival or otherwise obligation to tolerate medical examination 5
Legal obligation for inital medical examination On federal level: Mass screening for contagious infectious diseases Prior to mass accommodation Screening for tuberculosis School/ Nursery entry health examination for children Additionally in some federal states: Blood testing (e. g. hepatitis) Stool screening (e.g. parasites) High variability in 16 federal states in regard to Number of asylum seekers Scope of initial medical examination Implementation of screening exams Provision of medical care 6
Annual Number of asylum applications since since 1953 1980 - Military coup in Turkey 1992 War in former Yugoslavia Source: Federal Office for Migration and Refugees, as of Juli 2018 2015/16 War in Syria, Balkan migration 7
Asylum applicants in Germany (first time applications) by country of origin 2015-2017, absolute numbers Source: Federal Office for Migration and Refugees 8
Factors with impact on the health situation of refugees War trauma Source: faz.net Insecure drinking water Source: Augsburger Allgemeine Mass accommodation No privacy Living in confined spaces Source: tagesschau.de Source: Kölner Stadtanzeiger 9
Consequences for the health of refugees General poor health Mental health problems Special risk to be affected by infectious diseases 10
Cases of notifiable infectious diseases among asylum seekers (September 2015 - September 2017) Top 10* Category Number of cases Tuberculosis 3,418 Chicken pox 2,829 Hepatitis B 1,931 Influenza 811 Rotavirus-Gastroenteritis 543 Norovirus-Gastroenteritis 507 Hepatitis C 498 Giardiasis 263 Hepatitis A 252 Campylobacter 156 * Influenced by screening activities for selected diseases Similar as in general population: Respiratory, gastrointestinal and vaccine-preventable diseases most frequent 11
TB Epidemiology in Germany, 2002-2017 All Cases 2017: 5,486 2016: 5,949 2015: 5,834 Children only 2017: 238 2016: 228 2015: 192 September 27, 2018 WHO Summer School on Refugee and Migrant
Achievements and good practice 13
Adjustment of infectious diseases notification system Additional information in notification system since 9/2015-2017 Asylum seeker? Country of birth? Date of entry? Living in mass accommodation? Until December 2017: Notification data were published in monthly reports www.rki.de/asyl Ad hoc-adjustment of notification system: Collection of additional variables for HBV and HCV since 2017 Country of Birth Nationality Year of entry 14
Surveillance-Tool for syndromic data collection and analysis in mass accommodations for refugees Assistance in early detection of infectious disease outbreaks (high risk due to poor living conditions) Raising of awareness for infectious diseases from public health perspective 15
Guidance at national level For communicable and non-communicable diseases: Technical documents, recommendations and guidelines Risk assessments Screening Hygiene measures Outbreak control 16
Development of new strategies to include migrant populations in health surveys: The IMIRA-project To improve the inclusion of migrant populations into health monitoring Identification of relevant concepts and indicators To evaluate the usability of additonal data sources for health reporting To integrate migrant health into regular health reporting To extend networking and collaborations with important national and international stakeholders 17
Example for best practice: The programme With Migrants for Migrants Intercultural in Germany (MiMi) (I) Aims: Level unequal long-term health opportunities Increase of health literacy and empowerment Promoting individual responsibility for health and health awareness Methods: Culturally sensitive interventions in health promotion and prevention, provision of health-related information Training of migrants to be intercultural mediators and experts in relevant health issues Training of health professionals to improve awareness and knowledge of migrant communities and migrants health issues 18
Example for best practice: The programme With Migrants for Migrants Intercultural in Germany (MiMi) (II) Outcomes: Training of >1,000 migrants >32.000 migrants reached by information campaigns Subject of europe-wide Case Study of the WHO Culture- and language-specific concepts guarentee high-quality and costeffective health care Information material in many languages to guide health decisions 19
Major challenges for Public Services 20
Major Challenge 1: Uncertainty Initial lack of reliable information on health status of refugees/impact of migration dynamics on health system Difficult for routine surveillance and monitoring instruments to capture refugees health status Screening procedures varied over region and time Impact on the number of reported/recorded cases Screening artefacts No easy comparison possible from state to state Dissimilar facts made clear and concise communication difficult 21
Major challenge 2: Language and cultural barriers Caution and reluctance of many refugees when communicating with public health authorities Translation capacities not available at short notice or to the necessary extent Severe exhaustion or psychological trauma due to flight conditions, war and crisis Difficult social and living conditions before, during and also after flight increased vulnerability to many health risks 22
Major challenge 3: Anxieties and worries in the population Partly irrational fears Different risk perception: Travel to/from high-incidence-countries associated with higher possibility of transmission of some infectious diseases Public health authorities were asked to enforce health measures on refugees (entry screening etc.) Argueing for evidence- and science-based measures especially difficult in times of crises with high media attention and reluctance to listen 23
Conclusion (I) Data show: Refugees in Germany more at risk themselves rather than posing a risk to the general population! Good access to health care is most relevant Germany s local public health authorities contributed tremdendous work in handling a large number of refugees in a short period of time Despite difficulties and communication challenges: Positive experience of social coherence and much civil engagement 24
Thank you for your attention! Questions? 25