Module 2 – 4 Infectious diseases

4 Infectious diseases

Recently the most comprehensive document regarding infectious diseases in refugees and other migrants is the ECDC Technical Document: Infectious diseases of specific relevance to newly-arrived migrants in the EU/EEA dated 19th November 2015. [http://ecdc.europa.eu/en/publications/Publications/Infectious-diseases-of-specific-relevance-to-newly-arrived-migrants-in-EU-EEA.pdf]

“Migrant populations entering the EU/EEA, and particularly children, are at risk of developing infectious diseases in the same way as other EU populations, and in some cases may be more vulnerable. It is important, therefore, that they should benefit from the same level of protection as indigenous populations with regard to infectious diseases, including those which can be prevented by routine vaccinations. In addition, these populations may be subject to specific risks of infectious diseases in relation to their country of origin, countries visited during their journey as migrants and the conditions they experienced during migration. (ECDC, 2015)“

“The risk for EU/EEA countries of infectious disease outbreaks as a consequence of the current influx of migrants is extremely low. Although the likelihood that the specific infectious disease risks highlighted in this document will occur among migrants is low, or in some cases very low, they should still be considered, to ensure that they are recognised and treated in a timely manner, or prevented by immunisation when indicated. They do not represent a significant risk for EU/EEA populations. (ECDC, 2015)”

Table: Infectious diseases to consider according to country of origin (ECDC, technical document, 2015)

 

Infectious diseases to consider in overcrowded settings:

 “Poor living conditions, crowded shelters, detention centres and refugee camps may increase the risk of lice and/or fleas spreading and in rare cases these lice or fleas can carry  diseases (e.g. louse borne diseases  such as relapsing fever due to Borrelia recurrentis, trench fever due to Bartonella quintana, epidemic typhus due to Rickettsia prowazekii, and murine typhus), as well as the spread of mites (scabies).

In recent months, 27 cases of relapsing fever have been reported in the Netherlands, Germany, Finland and Belgium among migrants and refugees from Somalia, Eritrea, and Ethiopia. The latter mainly used the East African route for their journey and contracted the diseases during travel or early upon arrival into EU countries. Meningococcal disease outbreaks have been associated with overcrowding in refugee settings. Sharing dormitories, poor hygiene, and limited access to medical care have been reported as contributing factors. The meningococcal carriage rate has been shown to be higher among individuals in overcrowded settings and most cases are acquired through exposure to asymptomatic carriers. Meningococcal disease is usually reported in children, but is still a leading cause of both meningitis and sepsis in adolescents, young adults and adults, particularly in densely-populated settings such as refugee camps.

In addition, overcrowding has been associated with increased transmission of measles, varicella and influenza. (ECDC, 2015)”

 

Differential diagnosis to consider during clinical diagnosis:

Screening of refugee/migrant population for certain conditions is part of the prevention and control strategy for some countries, and should therefore be considered in accordance with national guidelines.

In addition, to the more common diseases seen among resident EU populations, specific infectious diseases should be considered for differential diagnosis depending on the symptoms presented by refugees and other migrants during medical examination.

Table: Differential diagnosis to consider during clinical diagnosis (ECDC, technical document, 2015)

 

4.1 Specific infectious diseases

A detailed description of specific infectious diseases can be found in the two documents of the ECDC which were published in 2014:

ECDC: Technical Report: Assessing the burden of key infectious diseases affecting migrant populations in the EU/EEA [http://ecdc.europa.eu/en/publications/Publications/assessing-burden-disease-migrant-populations.pdf]

ECDC: Technical Report: Migrant health: Background note to the ‘ECDC Report on migration and infectious diseases in the EU’ [http://ecdc.europa.eu/en/publications/publications/0907_ter_migrant_health_background_note.pdf]

4.1.1 Tuberculosis

“The percentage of TB cases in migrants has increased from 10% in 2000 to 25% in 2010. Many migrant develop TB as a consequence of their socio-economic status in the host countries. Material deprivation appears to be a far greater determinant than the country of origin. Migrants who arrive with a history of TB may be at risk of reactivate TB infection because of overcrowded and poorly ventilated living conditions, homelessness and inadequate nutrition. (ECDC. Report on migration and infectious diseases in the EU, 2014)”

 

 

4.1.2 HIV/AIDS

This sub-chapter is taken from MEM-TP (2016) EU training on health services for migrants and ethnic minorities

Key principles in the ECDC guidance on HIV testing include ensuring that HIV testing is voluntary and confidential and that informed consent is given. It is also recommended that access to treatment, care and prevention services is ensured for those who test positive. It is specified that this should apply to all individuals at risk of or infected with HIV, including irregular migrants.

Despite this, migrants in many settings across Europe face legal, administrative, cultural and linguistic barriers to accessing HIV testing

Data submitted to ECDC for Dublin Declaration reporting show that although many EU/EEA countries identify migrants as an important sub-population in their national response to HIV, few have adequate surveillance systems in place related to HIV among migrants

(ECDC. Report on migration and infectious diseases in the EU, 2014)

Consider the following in a migrant patient with HIV:

  • “Unusual” subtypes: Subtype D.
  • Universal infections, e.g. Tuberculosis.
  • Endemic infections, e.g. Malaria.
  • Hepatotoxicity: Side effects to antiretroviral and medical treatment for TB.
  • Immune reconstitution syndrome.
  • Metabolopathies: Glucose 6 Phosphate Dehydrogenase deficit

4.1.3  Vral Hepatitis

This sub-chapter is taken from MEM-TP (2016) EU training on health services for migrants and ethnic minorities

  • Hepatitis A is mainly transmitted through contaminated food and water, but infection can also occur through injecting drug use and sexual contact.
  • There is little evidence to indicate that hepatitis A in Europe is associated with migration
  • The World Health Organization estimates that worldwide, 3.0% of the population have been infected with hepatitis C virus and that more than 150 million people have chronic infection.
  • Over 350 000 people are reported to die each year as a result of HCV-related liver diseases.
  • The three countries most affected are Egypt, Pakistan and China, with estimated HCV prevalences of 22%, 4.8% and 3.2%, respectively.
  • In Europe, HCV prevalence is low and is estimated to range from 0.1‒5.6% among the general population. The highest prevalences are in southern and eastern European countries.

 

Here are some useful resources regarding hepatitis B and C among refugees and migrants:

4.1.4 Sexual Transmitted diseases

This sub-chapter is taken from MEM-TP (2016) EU training on health services for migrants and ethnic minorities

Gonohrroea

Available data are limited and partly contradictory. It is therefore difficult to draw clear conclusions about gonorrhoea in migrants in the EU/EEA. Available data, however, show little difference in gonorrhoea rates between migrants and non-migrants. Data suggest that there are marked differences between migrants and non-migrants with respect to mode of transmission of gonorrhoea and the percentage of gonorrhea cases among sex workers.

Syphillis

Data from hospital-based studies suggest that migrants from some regions, for example, those from South America and the Caribbean in Spain and from eastern Europe in the Czech Republic, may be at higher risk of syphilis infection, while data from STI clinics in London, United Kingdom, suggested that men from some eastern European countries were more likely to be diagnosed with syphilis.

Male latex condoms, when used consistently and correctly, are highly effective in reducing the transmission of HIV and other sexually transmitted infections, including gonorrhoea, chlamydial infection and trichomoniasis.

 

4.2        Possible uncommon infectious diseases in refugees and other newly arrived migrants in Austria

„Contrary to the widely held believe there exists no systematic relationship between migration and the introduction of infectious diseases.“ (WHO Europa)

Refugees/migrants/asylum seekers often have a reduced general health condition due to the physical and psychological stress that came with the flight. That can increase their vulnerability to infectious disease. Additionally, the housing situation can increase their susceptibility for infections. In most cases refugees/migrants/asylum seekers are affected by common diseases, which are also common in the local population, such as:

  • Urinary tract infection
  • Upper respiratory tract infection
  • Gastroenteritis, etc.

Furthermore, in refugee/asylum seeker housing facilities an increased occurrence of easily transmittable disease can happen such as:

  • Measles
  • Varicella
  • Influenza or
  • Scabies

Additionally it has to be considered, that refugees/migrants/asylum seekers often lack a sufficient immunization and diseases can occur against which people living in Austria for a longer period of time are mostly protected, such as

  • Polio
  • Diphtheria
  • Hepatitis B or

The prevalence of these diseases varies in the various countries of origins of refugees/migrants/asylum seekers. For example, Polio is still endemic in Afghanistan and Pakistan, whereas prevalence in Syria was until 2015 comparable with that in Europe.

 

Links on immunization monitoring:

The European Centre for Disease Prevention and Control (ECDC) gives an overview on which infectious diseases should be taken into consideration in refugees/migrants/asylum seekers according to the country of origin [Link to sub-chapter 2.4.1]

ECDC Technical Document, Infectious diseases of specific relevance to newly-arrived migrants in the EU/EEA [http://ecdc.europa.eu/en/publications/Publications/Infectious-diseases-of-specific-relevance-to-newly-arrived-migrants-in-EU-EEA.pdf]

In some rare cases, infectious diseases emerge in refugee/migrant/asylum seeker populations, which are endemic in their country of origin or which were acquired during the flight, and which normally, do not occur in Austria.

Some of these infectious diseases require acute treatment. These include:

  • Malaria
  • Lice relapsing fever
  • Lassa fever
  • Crimean Congo fever
  • Typhus (salmonella)
  • Visceral leishmaniosis
  • Typhoid fever (rickettsia)
  • Amoebic liver abscess
  • Leptospirosis
  • Meningitis
  • Tuberculous meningitis
  • Other bacterial meningitis

Please find further information on incubation period, symptoms, transmission route and occurrence on the website of the Austrian Ministry of Health, especially in the publication by the Austrian Society for infectious diseases and tropical medicine on acute disease requiring treatment and uncommon infectious diseases for Austria which can occur in refugee/migrant/asylum seeker populations.  [http://www.bmg.gv.at/cms/home/attachments/4/8/2/CH1465/CMS1444117620344/infektiologie_asylsuchende_v2_10_2015.pdf]

Helpful links and references

For the Austrian context:

Austrian Ministry of Health, Frequently Asked Questions on Flight Movements and Health [http://www.bmg.gv.at/home/Startseite/aktuelle_Meldungen/Haeufig_gestellte_Fragen_zu_Fluechtlingsbewegung_und_Gesundheit]

Austrian Agency for Food Safety, Infectious Diseases: Refugees Present No Relevant Risk

[www.ages.at/themen/ages-schwerpunkte/infektionskrankheiten/]

For the international context:

World Health Organization Europe – Frequently asked questions on migration and health available in German

[http://www.euro.who.int/de/health-topics/health-determinants/migration-and-health/migrant-health-in-the-european-region/migration-and-health-key-issues]

and in English [http://www.euro.who.int/en/health-topics/health-determinants/migration-and-health/migrant-health-in-the-european-region/migration-and-health-key-issues]