Transcript Διαφάνεια 1

Migrant Health
Epidemiological Data in Greece
Hellenic Center for Disease Control and Prevention
2012
Migration and Health-key issues
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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
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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.
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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
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Tuberculosis
HIV/AIDS
STIs
Hepatitis B and C
Malaria
Enteric fevers
Chagas disease
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Chronic diseases?
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Hellenic Centre for Disease Control
and Prevention
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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
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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
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Steady increase in the reported numbers of new HIV cases during the
last decade, both in native and non-native individuals
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1/3 of new cases yearly occur in MSM
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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MOBILE HEALTH UNITS
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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
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10.778 medical examinations
Males: 7.619
Females: 2.139
Minors: 1.020
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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
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Most frequent mental disorders were:
1.
2.
3.
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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
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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