Lancet Infectious Diseases Jul 2017 Volume 17 Number 7 p673-780 e197-e234

Lancet Infectious Diseases
Jul 2017 Volume 17 Number 7 p673-780   e197-e234

Between the devil and the deep blue sea
The Lancet Infectious Diseases
Published: July 2017

An unprecedented number of people escaping conflict and poverty have migrated from Asia and Africa towards Europe in recent years. A report from the UN High Commissioner for Refugees estimated that in 2016 alone around 362 376 people crossed the Mediterranean Sea, risking their lives to reach Europe. These new arrivals were in addition to more than 1 million refugees and migrants who had crossed the Mediterranean Sea on makeshift boats in 2015. Because of their geographical location, Greece and Italy have been the countries facing a continuous influx of migrants, mainly people aiming to move to northern European nations. However, with the closure of the borders to migrants in several countries along the Balkan route, including the Greece–Macedonia border, Greece has become the place where migrants are stranded in refugees camps.

At the end of 2016, the population residing in the 51 existing hosting facilities in Greece was estimated to be around 62 700 people. Most refugees reaching Greece have come from Syria, Afghanistan, and Iraq. The situation in the refugee camps varies but overcrowding and poor hygienic conditions prevail, creating a favourable milieu for the spread of infectious diseases. Thus, it is not surprising that, as described in a Newsdesk report in this issue, a high number of cases of hepatitis A were reported in Greek hosting facilities for refugees in 2016. In total, 177 laboratory-confirmed symptomatic cases were reported; of these, 149 (84%) occurred in hosting camps, mostly among Syrian children younger than 15 years. All cases reported symptom onset after their entry into the country. As a consequence, 599 vaccinations (of 309 contacts aged 1–14 years and 290 contacts aged 15 or older) were done during ring vaccination of the 177 reported cases.

Hepatitis A is primarily transmitted through the faecal-oral route, either by person-to-person contact or by consumption of contaminated food or water. Although the disease is mainly asymptomatic in children, its severity increases with age with some adults experiencing acute liver failure, especially in the presence of underlying conditions. A Review in this journal describes the epidemiology of hepatitis A virus infection across Europe during the past 40 years, which shows that susceptibility to the disease in adults is increasing in large parts of Europe because of low endemicity. The emergence of hepatitis A in refugee camps in Greece shows that it is likely that migrants have similar susceptibility to the indigenous population for hepatitis A and that the conditions in which they are detained are extremely poor. Although the outbreak of hepatitis A was contained with interventions that included improving hygienic conditions and ring vaccination of contacts, the effort was complicated by some of the common challenges when dealing with migrants’ health such as tracking population mobility, identification of contacts, and lack of information on vaccination history.

The difficulty of collecting information on the health status of migrants results in a lack of consensus on the best approach for screening and vaccination in this vulnerable population. Although migrants are eligible for universal care in both Greece and Italy, the reality is that access to the local health services remains difficult in these populations, so data on their main health issues are limited. A recent study of migrants in Italy reported that health problems in this population vary depending on the phase of their journey. At arrival in the host country the main issues reported by migrants are physical and psychological traumas, unwanted pregnancies, and scabies. Yet, once migrants settle in a camp, tuberculosis, vaccine preventable diseases such as hepatitis A, and sexually-transmitted infections become the major problem.

Currently, a series of projects supported by the European Union’s Health Programme are aiming at developing a shared system for collection and transmission of health data that should reduce the risk of overtreatment and repetition of diagnostic tests. Better information would also facilitate the implementation of vaccination campaigns to close the gaps caused by migration, which in turn would reduce the chances that outbreaks such as the one described for hepatitis A could occur again.

Efforts to improve screening of the health needs of migrants should reflect a more inclusive attitude of the European Union towards migrants in the future. Migrants have not escaped from tragedy in their countries to meet disease and neglect in refugees camps. They deserve better.

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