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Silvia Declich CNESPS/Istituto Superiore di Sanità - ISS (Italy)
ESCAIDE 2016: Plenary session on Migrant HealthStockholm, 28 November 2016
Experiences and challenges in monitoring migrant health
in migration centres and at community level
Outline
● Background● Monitoring migrant health at community level● Monitoring migrant health at migrant holding
level
Monitoring migrant health action points derived fro m the WHA Resolution on the Health of Migrants [2008]. Modified from: 20 10 World Health Organization (WHO) Global Consultation report “Healt h of migrants−the way forward”.
What are the numbers of migration in Europe?
Eurostat, 2015
19.8 million persons born in a non-EU
country
35.1 million people born in a foreign
country and living in an EU Member
State (6,9%)
High media attention
2006 - 2014
www.viewsoftheword.net
2015
581.319
153.872
Migrants by sea
Migrants by land
Migrant status and points of access to health care: the example of Italy
Intra EU mobility
Irregular migration
Regular migration
(Third Countries)
•Migrants with regular visa
•Refugees
•Asylum seekers
•Undocumented migrants (not stopped by IT authorities)
•Undocumented migrants (stopped by IT authorities)
Hosted temporarily in detention centres
Immigration Hosted temporarily in open (non secure) migration centres
Depending on their legal status, foreigners living in Italy may access health care and prevention• at community level (Min Health/NHS) or• at migration centre level (Min Interior).
Enter the community
Società Italiana di Medicina delle Migrazioni
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Regular migrants present: 5.420.000 (estimation Idos)
Migrants (including irregular): 5.800.000 (estimation Ismu)
Regular migrants resident: 5.015.000 (Istat)
Arrivals by sea 2014: 170.100 (MoI)
Arrivals by sea 2015: 153.842 (MoI)
Italy: migrants present in Italy and arrivals by se a1 Jan 2015 (x 1.000)
MONITORING MIGRANTHEALTH AT COMMUNITY LEVEL
Monitoring infectious diseases among migrant populations
Issues related to monitoring ID: ● diversity of data availability between countries and data
incompleteness for migrant related variables ● under/over/misreporting of cases of disease and
disalignment with appropriate denominators;● how to account for the diversity of migrant populations.
Knowing the occurrence of infectious disease in migrant populations is necessary to provide a response to individual and public health needs.
Limits and constraints
Diversity and limits in the definition of migrants in ID surveillance systems● ECDC�a migrant is
anybody “foreign-borne”
● Italy �different definitions among surveillance systems
Variable Variable Description
Advantages Disadvantages
Country of birth
Country of birth of patient
- Relatively easy to define- Available by age and sex in Eurostat data on migrants
-Includes host country nationals born abroad
-Provides no information about sub-groups and can mask important differences
-Second+ generationmigrants are notincluded in thisdefinition.
Country of nationality
Country where the patient is registered as citizen
- Relatively easy to define- Available by age and sex in Eurostat data on migrants
-Policies for granting nationality vary across countries
-Migrants and non-migrants can have more than one nationality
Limits and constrains
Limits and constraints - 2
Numerators/denominators can be affected by numerous biases:● (Un)documented immigrants tend to have limited access to
health care and preventive services, which can lead to under-diagnosis and under-reporting of disease � underestimation of disease occurrence
● Legislation influences both the accuracy and the availability of denominators: incompleteness of denominators tends to underestimate the “at risk” population � overestimation of disease occurrence
● Screening for asymptomatic diseases causes increased reporting �overestimation of disease occurrence when compared with routine data
Riccardo F, Giorgi Rossi P, Chiarenza A, Noori T, Declich S. Letter to the editor: Responding to a call for action - where are we now?. Euro Surveill. 2015;20(50)
Limits and constraints – 3
Migrants are considered one group not taking into account the diversity of migrant populations● Need for agreed and standardized variables able to
stratify this population on the basis of all dimensions that can influence the risk of, and vulnerability to, infectious diseases.
● Four data collection domains were identified, including the main factors used to describe infectious diseases risk and vulnerabilities among migrants a rapid desk review.
Riccardo F, Dente MG, Kärki T, Fabiani M, Napoli C, Chiarenza A, Giorgi Rossi P, Munoz CV, Noori T, Declich S. Towards a European Framework to Monitor Infectious Diseases among Migrant Populations: Design and Applicability. Int J Environ Res Public Health. 2015 Sep17;12(9):11640-61.
Multidimensional data collection framework: four da ta collection domains
How can we improve monitoring of ID at community level in order to acquire data that can be used to support decision making in public health?
● Routine infectious disease surveillance● Ad hoc studies on specific issues
Need for a multidimensional data collection frameworkthat could capture information on factors associated with increased risk to infectious diseases in migrant populations in the EU/EEA
Recommendations: to improve monitoring of ID at community level in order to acquire data that can b e used to support decision making in public health
● Propose agreed and standardized definitions of “migrants” both for numerators and denominators to use in ID surveillance and requirecomplete and reliable data matching those definitions
● Address limits in monitoring migrant health and ID at EU/EEA level by exploring with Member States the possibility of including or modifying relevant surveillance variables as per the data collection domains proposed
● Conduct consensus meetings in order to agree on a core set of indicators to collect comparable data, not available in surveillance, through concurrent national cross sectional surveys conducted in the EU/EEA.
● Support research finalized at addressing identified information gaps for the development of a Framework to monitor infectious diseases among migrant populations in the EU/EEA.
2.5 .Epidemiological surveillance capacities
need to be strehgthened to include migrant sensitive data...
Systems that collect data in respect of
migrant health also need to be reinforced so that outcome and
access issues may inform further planning
around appropriate target interventions….
MONITORING MIGRANTHEALTH AT MIGRANTHOLDING CENTRE LEVEL
Constraints and challenges
● Newly arrived migrants may be more vulnerable to ID for the conditions they experienced during their migration journey
● They may be subject to specific risks for ID in relation to their country of origin and countries visited during their migration
● Living conditions within closed or semi-closed communities could increase the risk of ID spread and expose migrants to ID
Constraints and challenges - 2
● Arrival of thousands people suffering harsh travelling conditions in very short time frame
● Fluid target population● Provisional centers fluidly opened and closed to
reflect accommodation needs● Formal and provisional hosting centers largely
independent from the NHS and related surveillance system
● Intense media attention
An ad hoc syndromic surveillance system for ID at hosting center level during a migration surge
● Syndromic surveillance is used in several uncertain and high profile situations
● Italy developed a syndromic surveillance system for ID at hosting center level during the 2011 Arab Spring
● Revised in 2014 to improve quality
Riccardo F, Napoli C, Declich S. et al. Syndromic surveillance of epidemic-prone diseases in response to an influx of migrants from North Africa to Italy, May to October 2011. Euro Surveill. 2011;16(46):pii=20016.
Napoli C, Riccardo F, Declich S et al. An early warning system based on syndromic surveillance to detect potential health emergencies among migrants: results of a two-year experience in Italy. Int J Environ. Res. Public Health 2014 Aug 20;11(8):8529-41
The Italian experience -1
• 13 syndromes
Migration Centre
Local Health Unit Region
Cnesps-ISS and MoH
Analysis
Data entry
Disseminationhttp://www.epicentro.iss.it/focus/sorveglianza/immigrati.asp
The Italian experience -2
• Aggregated data collection sheet
(numerator and denominator)
• Web based platform
The Italian experience -3
Methodology – statistical alerts and alarms
Expected incidence for each day based on the moving average of the previousseven days
Alert threshold calculated on the observed incidence (99% CI of the observedincidence).
OUTCOME DEFINITION ACTION
Statistical AlertBreach of the Alert threshold on one day.
Monitoring if threshold is breached the following day
Statistical AlarmBreach of the Alert threshold for two consecutive days for the same syndrome
Analysis stratified by reporting migration centre. If an alarm arises from a single migration centre, the CNESPS-ISS contacts the reporting health officer of the centre and ask for epidemiological validation.
Health EmergencyEpidemiological confirmationof statistical alarm
Outbreak control measuresimplemented
Results – population
• Mainly young adults
(May 2011-June 2013)
79% of the population under surveillance
composed by adolescents and young adults between
15 and 44 years.
11,47%
38,49%40,64%
9,40%
< 15 years
15-24 years
25-44 years
45+ years
Results – alarm thresholds(May 2011-June 2013)
•260 alerts and 20 statistical alarms
• No health emergencies: absence of major outbreaks
Syndrome No. of Cases (%) No. Alerts No. Alarms
1. Respiratory tract disease 3586 (49.0) 45 5
2. Suspected pulmonary tuberculosis 76 (1.0) 33 1
3. Bloody diarrhoea 108 (1.5) 31 1
4. Watery diarrhoea 1652 (22.6) 59 5
5. Fever and rash 18 (0.2) 10 0
6. Meningitis/encephalitis/encephalopathy/delirium 2 (0.0) 1 0
7. Lymphadenitis with fever 27 (0.4) 11 0
8. Botulism-like illness 0 - -
9. Sepsis or unexplained shock 0 - -
10. Haemorrhagic illness 0 - -
11. Acute jaundice 4 (0.1) 3 0
12. Parasite skin infection 1841 (25.2) 67 8
13. Unexplained death 0 - -
Total 7314 260 20
Results – Incidence trends• Overall low incidence for notified syndromes.
•No health emergencies: absence of major outbreaks
• Botulism-like illness, haemorrhagic illness, sepsis/unexplained shock and
unexplained death were never notified.
Incidence<0,5%
Recommendations: to improve monitoring for ID at hosting centre level during migration surges, in or der to acquire data that can be used to support decision making in public health
– Share protocols and experience among countries– Develop a common EU/EEA protocol to have
comparable data
Syndromic surveillance within migrant hosting centres
The ECDC Guidance
● Handbook to support MemberStates wishing to establishSyndromic surveillance in migrant reception/detentioncentres and other refugeesettings
● Based on the experience of experts in ECDC, Greece and Italy
http://ecdc.europa.eu/en/publications/Publications/syndromic-surveillance-migrant-centres-handbook.pdf
The CARE project pilot implementation
• Development, pilot and evaluation of a shared syndromicsurveillance system in migrant holding centres :• Greece, Italy� will implement in four hotspots until end
December 2016• Slovenia, Malta, Croatia, Portugal � will participate in a
simulation exercise (16-27 January 2017)
• Focus on Southern European countries
• Several activitiesincluding monitoringmigrant health
• A pre-defined objective• Aggregated data• Context-adapted syndromes
• Flexibility in syndrome definition alternatives• Possibility of adding a 14° syndrome only in some
countries
• Context-adapted data analysisapproaches• complementing common collection format
and data series-specific statistical methods
• Development and pilot of a shared syndromic surveillance web-based secure platform
How?
http://careformigrants.eu/communicable-diseases-monitoring/
https://www.iss.it/site/RMI/SyndromicSurveillance/
Pilot ongoing …
Thanks
to the team ISS/CNESPS (Antonino Bella, Flavia Riccardo, Christian Napoli, Cristina Giambi, Martina Del Manso, Maria Grazia Dente, Silvia Declich)
to the team of ASL di Reggio Emilia (Antonio Chiarenza, Paolo Giorgi Rossi, Paola Ballotari, Gabriele Romani e Annamaria Pezzarossi)
to the team of ECDC (Denis Coulombier, Jonathan Suk, Laura Espinosa, Teymur Noori)
to the Italian Ministry of Health and the Regions
to all of you for the attention!
