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  1. Migrant Health Epidemiological Data in Greece Hellenic Center for Disease Control and Prevention 2012

  2. 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

  3. Migration and Health-key issues • Migrants may have more complex health needs than the native born population influenced by: • 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 • Mobility itselfdoesn’t cause ill health • Migration should be considered a social determinant of health

  4. Epidemiological data interpretation Factors that influence increases or decreases in infectious disease cases reported • 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

  5. Migration and Health-main global health issues • Tuberculosis • HIV/AIDS • STIs • Hepatitis B and C • Malaria • Enteric fevers • Chagas disease • Chronic diseases?

  6. 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


  8. 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

  9. HIV/AIDS Reporting System

  10. HIV cases by year of diagnosis

  11. HIV- new cases by year of report and gender +52.7%

  12. HIV cases by year of report and probable route of HIV transmission

  13. HIV- new cases by year of report and nationality

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

  15. Non-Native HIV infected IDUs in 2011 by nationality

  16. 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 2011 Paraskevis et al.: HIV-1 outbreak among injecting drug users in Greece,2011: a preliminary report, Euro Surveill. 2011;16(36):pii=19962

  17. STIs

  18. 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

  19. Sexually transmitted infections-STIs • Pilot program of enhanced epidemiologic surveillance for STIs “Andreas Syngros Dermatology and Venereal University Hospital, 2003-2009, sponsored by KEELPNO • 67.590visits for possible venereal disease • 3.288syphilis, gonorrhea, genital herpes and HIV diagnoses in total • 6.445diagnoses of HPV infection (condyloma acuminata)

  20. Primary Syphilis reported cases Pilot project Andreas Syngros Hospital

  21. Gonorrhea reported casesPilot project Andreas Syngros Hospital

  22. Tuberculosis

  23. Estimated Global Incidence of TB Data source: Global tuberculosis control 2011, World Health Organization

  24. Reported TB CasesGreece 2004-2010 Total Native Greeks Non-natives

  25. Distribution of Frequency in Reported TB Cases and Nationality in total of casesGreece 2004-2010 Natives Non-natives

  26. Distribution of Frequency in Reported TB Cases and Nationality, per year of reportingGreece 2004-2010 Native Non-native Unknown

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

  28. Frequency of Distribution of Reported TB Cases according to the Site of InfectionGreece 2004-2010 Pulmonary TB Extrapulmonary TB Both

  29. Frequency of Distribution of Reported TB Cases with Pulmonary Cavities, according to NationalityGreece 2004-2010 Natives Non-natives

  30. MDR TB Cases and NationalityGreece 2004-2010 Non-native Greek Data:National Mycobacterial Reference Center, Sotiria General Hospital

  31. XDR TB Cases and NationalityGreece 2004-2010 Greek Non-Native Data:National Mycobacterial Reference Center, Sotiria General Hospital

  32. 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

  33. 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

  34. total of 130 immigrants (81 men and 49 women), agedbetween 18 and 69 • hepatitis B virus surface antigen(HBsAg), the hepatitis B virus core antibody (anti-HBc) andthe 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

  35. Hepatitis B and C • HEPNET - GREECE (Hepatitis Network - Greece)for hepatitis B and C, is a multicenter nationwide retrospective-prospectivestudy, 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 ofchronic hepatitis B and C infection in Greece • 20 hepatology centers in Greece

  36. Hepatitis B • HEPNET study for chronic hepatitis B (Journal of Viral Hepatitis, 2008) evaluated the epidemiological features ofHBV infection in a sample of 3480 patients followed upduring 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

  37. The study populationconsisted of 3353 (93.4%) adultsat firstvisit 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

  38. Hepatitis B HEPNET study for chronic hepatitis B

  39. 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

  40. Migrant Health Care Project ‘Implementation of health care and psychosocial support activities for third-country nationalsthat may require international protection in the area of Evros-Greece’

  41. Background: Increased migration to the Greek-Turkish border 2010: > 47,000 before 2009: 3,500 2009: 8,800 2010: > 47,000 Assessment visit to the Greek-Turkish border, ESCAIDE 2011 41

  42. 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)

  43. Background: geographical locations Fylakio detention, screening centre Soufli police station Tychero police station Poros screening centre Feres police station Vena detention centre

  44. 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

  45. 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

  46. 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

  47. 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

  48. Migrant Health Care Project Demographical data Algeria 5.6% country of origin

  49. Migrant Health Care Project Demographical data Marital status

  50. 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