Abstracts from the Annual Regional Epidemiologists’ Meeting,Kiev, June 2011

  Published: 14.08.12 Updated: 14.08.2012 15:22:52

Migrant Health in Poland

Michał Czerwinski, Iwona Paradowska-Stankiewicz
National Institute of Public Health – National Institute of Hygiene, Poland

Citation: Czerwinski M, Paradowska-Stankiewicz I. Migrant Health in Poland. EpiNorth 2011; 12: 83-4.

Due to geography, migrants from Eastern Europe and Asia often consider Poland as a gateway into the European Union (EU) with the majority of migrants merely passing through the boarders. According to Eurostat (2010), Poland has currently one of the lowest numbers of foreigners (less than 1%) living and working within its borders in comparison to other European countries. Short-term labour migration continues to dominate, particularly seasonal work of up to 3 months. However, after Poland’s inclusion in the EU, a new trend of long-term migration has emerged. While the numbers are still small, there is clearly a growing influx of people primarily from neighbouring countries including Ukraine, Belarus, and Russia who intend to stay in Poland for longer periods of time. Recent changes in trends and predominant types of migration to Poland have been investigated. Official statistics often fail to capture the true influx of migrants.

Migrant public health accessibility

There are challenges associated with integrating migrants into public health services. To date much attention has focused on ‘risk groups’ such as refugees (mostly Chechens) and travellers (Roma community).
Migrants, particularly from non-EU countries, often have to overcome many barriers when attempting to access health services in Poland. One of the biggest barriers is that public health care is mainly provided to insured migrants with regulated status. Aside from legal issues, additional challenges include language barriers, cultural differences and other individual factors such as fear of job loss, saving money etc. The issue of health among immigrants in Poland is somewhat neglected and to date not many studies have investigated this problem. More efforts are needed to effectively integrate migrants into the Polish health care system.

Consequences to susceptible populations
A recent measles outbreak in Poland among Roma travellers provides an example of the consequences of having a large susceptible (unvaccinated) population. Of 214 measles cases reported during 2008 and 2009 in Poland, 79% of cases were among the Roma community with very low measles vaccination coverage. Furthermore, a study recently conducted in refugee centres indicated that similar ‘pockets’ of susceptible population may also be found among Chechen children living in Polish refugee centres who are immunized too late or not at all.
Migration of populations may also contribute to the transmission of tuberculosis, particularly multidrug-resistant tuberculosis, and HIV/STI infections. In Poland, these problems have not been broadly investigated to date. However, there is increasing evidence that there is a high proportion of multidrug-resistant tuberculosis among foreign-born cases.

More research is essential to ensure that the health needs of different groups of migrants are better understood, to plan interventions and develop recommendations.

Role of the Laboratory Network in Implementing the Measles Elimination Programme in Ukraine
I. Demchishina
Virology and AIDS Laboratory, State Institution “Central Sanitary-Epidemiological Station of the Ministry of Health of Ukraine”

Citation: Demchishina I. Role of the Laboratory Network in Implementing the Measles Elimination Programme in Ukraine. EpiNorth 2011; 12: 84-5.

Ukraine takes an active part in the international programme targeted at eliminating measles globally. The existing laboratory network, including all countries of the post-Soviet era, enables the timely detection of all suspected measles cases among patients with exanthema (rash). One major goal of WHO is to establish a network of up-to-date professional diagnostic laboratories complying with the highest quality requirements and functioning in accordance with standard protocols in order to provide the most complete and accurate data from laboratory analyses. The laboratories operate pursuant to WHO guidelines and participate in the annual process of research results external assessment, a professional evaluation conducted by WHO control desks. The National Laboratory of Ukraine has shown very good problem solving performance (of 98.0 – 100%) for many years.
The laboratory network now focuses not only on surveillance over measles virus circulation, including laboratory diagnostics of the infection and molecular identification of virus strains, but also monitoring of specific immunity in various age groups of the population. The latter task is essential for identification of risk groups and for documenting the efficiency of immunization.
With the current limited control over measles and rubella, laboratories are mainly involved in monitoring the results of vaccination campaigns, confirmation of sporadic suspected cases, investigation of outbreaks and, if necessary, serological surveys among the population. Measles and rubella elimination requires extended epidemiological surveillance with differential laboratory diagnostics, fingerprinting of virus isolates and identification of cases imported from endemic territories.
In light of WHO guidelines, the laboratory network in the countries of the Commonwealth of Independent States faces the following challenges:
– to provide effective exchange of data on the current incidence of measles and rubella and on results of diagnostic tests;
– to support rapid exchange of data on measles incidence in boundary regions;
– to organize collection and timely delivery of clinical samples (identification and characterization of isolates);
– to implement a unified protocol for collection, storage and transport of clinical samples;
– to integrate data on rubella and congenital rubella syndrome (CRS) within the measles laboratory network in order to control the disease;
– to test and re-test health care professionals;
– to hold a seminar on active epidemiological surveillance over measles and CRS;

– to bring the national laboratories in full compliance with accreditation requirements.
Pursuant to the Order of the Ministry of Health as of 2003, there are three laboratories in Ukraine, Kiev, Donetsk, and Odessa that are involved in investigations related to measles and rubella.
The National Laboratory of Ukraine specializes in laboratory diagnostics of measles and rubella and collaborates with WHO regional reference laboratories, including WHO Reference Centre for the European Region for Measles and Rubella in Luxembourg. Joint investigations devoted to further testing of samples collected in Ukraine that are negative for both measles and rubella, but in which parvoviruses B19 may be found, are planned.

Implementation of the Measles Elimination Programme in the Russian Federation

N. Frolova
Federal Service for Surveillance on Consumer Rights Protection and Human Well-Being (Rospotrebnadzor), Moscow, Russia

Citation: Frolova N. Implementation of the Measles Elimination Programme in the Russian Federation. EpiNorth 2011; 12: 86-7.

The Measles Elimination Programme (hereafter referred to as the Programme) in the Russian Federation was approved by Order No. 270 of the Ministry of Health on 19.08.2002. The Programme is targeted at the elimination of measles in the Russian Federation by 2007 and further certification of areas in the Russian Federation as free of endemic measles by 2010.
The first stage of the Programme was planned to be implemented in 2002-2004. The goal was to stabilize measles incidence at the sporadic level in all regions of the country. The purpose of the second stage (2005-2007) was to prevent measles cases and to eliminate endogenous measles. At the third stage (2008-2010), the administrative territories of the Russian Federation were to be certified as areas free of endemic measles and the results achieved were to be maintained.
The following conditions were defined as vital for elimination of measles:
- Coverage of the population by immunization against measles should be no less than 95% of the total population subject to immunization; the risk groups should be detected in a timely manner and additional immunization campaigns should be conducted for such groups;
- All cases of measles need to be timely identified and confirmed by results of laboratory tests;
- Molecular typing of measles strains is to be performed.
Since 1986, when the new national vaccination Programme was introduced, all children in the country have been vaccinated against measles twice (at the age of 12 months and 6 years). Before 1986, children were immunized against measles only once. In general, the country had reached and maintained high levels of measles immunization coverage among children (> 95%) even before the Programme was implemented.
Mass vaccination of children against measles, booster vaccination before they start school as well as additional immunization campaigns conducted in risk areas and among representatives of risk groups contributed to a steady decline of measles incidence in Russia. As a result, the general incidence rate in Russia during the 1990s was as low as 3.0-5.0 cases per 100,000 population. The average rate was 933.2 per 100,000 population during the pre-vaccination period. In some regions the epidemic process of measles has been interrupted for quite a long time as a result of vaccination.
The Programme initiated immunization of adults aged 18 to 35 years who had not had measles or had not been vaccinated. People who failed to produce any documentation of prior immunization against measles were also vaccinated. In 2004-2007, 3.2 million people aged 18-35 received the measles vaccine. In 2007, the national vaccination Programme was expanded to include adults aged 18-35 who had never had measles or been vaccinated or with no record of previous vaccination. During 2008-2009, in accordance with the vaccination Programme, 2.45 million adults aged 18-35 years were immunized.
The herd immunity of the population in each administrative territory of the Russian Federation is regularly estimated by means of serological investigations of specific immunity of vaccinated people in indicator age groups.
With measles incidence at sporadic levels, active measures are taken in accordance with WHO guidelines to detect cases among patients with exanthema and fever. Examination of these patients revealed 45 cases of measles in 2006, 14 cases in 2007, 5 cases in 2008 and 15 cases in 2009.
The Programme in the Russian Federation also includes establishing a laboratory network for measles control. The laboratory network consists of 10 regional centres for measles and rubella surveillance. The centres conduct diagnostic tests for laboratory confirmation of measles cases. The network of regional centres is regulated by the National Research and Policy Centre for Surveillance over Measles and Rubella, which is responsible for isolation and molecular investigations of measles and rubella viruses. The Centre also oversees the activity of regional centres. The share of measles cases confirmed by laboratory tests increased from 46.8% in 2003 to 93.6% in 2007. In 2008 all cases of measles registered in the country were confirmed by laboratory tests.
The Programme has made an impact on the characteristics of the epidemic process of measles infection. In 2007 the measles incidence rate was 0.11 per 100,000 population; in 2008, 2009 and 2010 the rates were 0.02, 0.07 and 0.09 per 100,000 population, respectively.
Since 2007, measles virus type D6, which used to be endemic for Russia, has not been detected in the country. All cases of the disease registered since 2007 have been either imported or associated with other imported cases, and the results have been confirmed by epidemiological investigations and laboratory tests.
By 2010 the Russian Federation achieved results corresponding to the measles elimination criteria defined by WHO. In 2010-2011 certification of administrative territories of the Russian Federation as areas free of endemic measles started.
At present, the major goals are: maintenance of high measles vaccination coverage of children and adults aged 18 to 35 years; work with risk groups; support for preparedness at health institutions to timely detect measles infection and immunize all contacts.

Experiences with influenza post pandemic
B.G. Iversen,
Department of Infectious Disease Epidemiology, Norwegian Institute of Public Health

Citation: Iversen BG. Experiences with influenza post pandemic. EpiNorth 2011; 12: 88-9.

After the influenza pandemic of 2009, it is important to assess our performance and learn from our experiences in order to improve our preparedness plans. At the Norwegian Institute of Public Health (NIPH) one of our conclusions was to improve national surveillance, particularly surveillance of severe hospital cases and mortality. We also need to strengthen the vaccine distribution system and have better legal flexibility. Our pandemic plan needs to be more flexible and dynamic, and less medical textbook-like.

WHO appointed an International Health Regulations (IHR) Review Committee with a mandate to assess the functioning of the IHR (2005) in relation to the current pandemic and other public health events. Specifically, the Committee reviewed the scope, appropriateness, effectiveness, and responsiveness of global actions as well as the role of WHO and identified lessons learned. One conclusion was that the IHR helped make the world better prepared to cope with public health emergencies and recommended that WHO accelerate the implementation of core capacities required by the IHR; to enhance the WHO Event Information Site and to reinforce evidence-based decisions on international travel and trade.

Another conclusion was that WHO performed well in many ways during the pandemic, confronted systemic difficulties and demonstrated some shortcomings. The Committee found no evidence of malfeasance. The virus characterisation and making of the vaccine seed strain was rapid. Important critical points were that there was no good assessment of severity, the phase structure was unnecessarily complex and that WHO kept the names of the emergency committee members secret. However, there was no evidence that WHO overstated the seriousness of the pandemic, declared a false pandemic, eliminated severity from the definition or served the industry. To better prepare the world to respond to a new pandemic, all countries should implement the core public health capacities stated in the IHR. Global preparedness can be advanced through research, reliance on a multisectoral approach, strengthened health care delivery systems, economic development in low and middle-income countries and improved health status. The report was approved at World Health Assembly in May 2011 and WHO was asked by member states to follow up the recommendations and report in 2013.

Migrants’ Health in Europe
M.-J. Peiro
Migration Health Unit, International Organization for Migration (IOM), Belgium

Citation: Peiro M-J. Migrants’ Health in Europe. EpiNorth 2011; 12: 90-1.

Modern migration often is characterized by hardship and social exclusion during travel and upon arrival, conditions that often negatively affect the health of migrants. Migration is thus a social determinant of health (SDH). The provision of appropriate health care for all types of migrants is a humanitarian obligation. It is also necessary to address public health concerns for countries of transit and destination, concerns that increase with mobility and greater diversity of health profiles including infectious and vaccine-preventable diseases. Adequate primary care is the most efficient and cost effective strategy to improve migrants’ health.
Data provided in the ECDC Background Note to the Report on Migration and Infectious Diseases suggest that migrant populations in the EU, especially those from high disease prevalence countries, are “disproportionately affected by TB, HIV, Hepatitis A and B”. However, the risk of spread to host communities is low. Poorer SDH increase the risk of contracting infectious diseases, while lack of access to healthcare acts as a barrier to prevention, diagnosis and treatment. This warrants national responses including fostering migrants’ access to health care, active case finding and targeted vaccination and health promotion programmes. The EU placed migrant health on its agenda in 2007 with the Council Conclusions on the Health of Migrants) and is publishing via ECDC a series of reports on migration and key infectious diseases, notably HIV. In most EU countries, lack of comprehensive data on migration and infectious diseases is apparent and data collection is not standardised. A first step is therefore to improve surveillance among migrant groups and in a concerted way at the regional level, with common understandings and definitions to allow for data comparability (ECDC/IOM report on ‘HIV Data Comparability’).
The International Organization for Migration (IOM) has also stressed migrant health, and related legal obligations with regard to health care, as a priority in its Member States and key stakeholders notably in the IOM/EU/Portugal 2009 EU-Level Consultation on Migration Health and the WHO/IOM 2010 Global Consultation on Migrant Health (‘Health of Migrants – The Way Forward’ Report). More concretely, IOM implements health assessments for migrants (250,000 examinations/year, including treatment, vaccination, extensive counselling and data analysis); runs centres providing medical and other support to vulnerable migrants; and provides capacity building and technical support for governments in the area of health and migration/mobility including pandemic preparedness. For example, a 3-year IOM programme funded by the European Commission studied health conditions and preparedness along the new EU eastern borders and found that there were no standardized health examinations for migrants or systematized data collection and that there were important gaps in training and in referral systems, as well as key barriers to health care access. As an initial response, the IOM programme developed guidelines for public health and detention, a migrant health electronic database template as well as training modules for health professionals and border guards.
The policy response to migrant health concerns should link human rights, public health, as well as individual and community security and wellbeing. An effective response will include standardized regional protocols for migrant health protection, and improved and more comparable data.

Epidemiological surveillance of influenza in Latvia
J. Perevoščikovs
Epidemiological Safety and Public Health Department, State Agency “Infectology Center of Latvia” (LIC)

Citation: Perevoščikovs J. Epidemiological surveillance of influenza in Latvia. EpiNorth 2011; 12: 92-3.

Epidemiological surveillance and control of influenza are based on the Cabinet Regulations No. 941 “Regulations Regarding Influenza Control Measures” adopted 21 November 2006 that define the sentinel surveillance system, requirements for investigation of cases with acute respiratory infections (ARI), and preparedness and response plans in health care institutions. During the 2009/10 season 58 – 61 primary health care physicians, 11 hospitals, 37 schools and 40 kindergartens participated in the influenza monitoring system, covering 4.8% - 5.1% of the population in Latvia. Health care practitioners involved in the monitoring provided data on cases of influenza-like illness, other ARI and pneumonia by completing and sending a special form to LIC regional epidemiologists once a week. Requirements for virological investigation were the followings:
• A cluster of influenza-like illness in the period between epidemics;
• ARI with complications in a patient admitted to hospital;
• Influenza with complications in a person vaccinated against influenza with the vaccine recommended by WHO for one particular epidemic season;
• The death of a patient with ARI symptoms;
• A person with ARI symptoms during a period of pandemic threat who has visited a country (territory) affected by possible pandemic virus or has been in contact with a person possibly infected with the pandemic strain.
The influenza epidemic of 2010/11 was moderate in terms of average intensity and length. Circulation of influenza B virus resulted in a somewhat prolonged epidemic in comparison with the previous epidemic. The incidence in all age groups except 0-4 years was higher than in 2009/10 and children in the age group 5 –14 years were more affected as in the previous season. Incidence in the age group 0 - 4 years decreased by 28%. Circulation of two influenza viruses was observed: virus A(H1N1) - 48.7% cases (maximum in age group 50 –59 years) and influenza B virus - 51.3% cases (maximum in age group 10 – 19 years). In comparison with the 2009/10 season the number of pneumonia cases increased in all age groups, especially among 5 –14 year old children. The severity of the A(H1N1) influenza epidemic probably increased: while morbidity related to A(H1N1) decreased considerably (by 40%) the number of lethal cases associated with A(H1N1) decreased by only 23%. Similar health risk factors for lethal cases associated with laboratory-confirmed influenza were observed during the 2009/10 season although the proportion of lethal cases in patients without chronic diseases was lower than in the previous season (10% in 2010/11 and 31% in 2009/10).

Revealing Infectious Diseases Among Migrants in Leningrad Oblast

E.A. Mikhaylova
Directorate of the Federal Service for Surveillance on Consumer Rights Protection and Human Well-Being in Leningrad oblast, St. Petersburg, Russia

Citation: Mikhaylova E.A. Revealing Infectious Diseases Among Migrants in Leningrad Oblast. EpiNorth 2011; 12: 94.

In accordance with legislation of the Russian Federation (the Federal Law on Legal Status of Foreign Citizens in the Russian Federation), all foreign citizens entering the country temporarily under non-visa conditions for a period over 3 months must provide medical documents to the migration services indicating that they are not drug addicts and do not have any infectious diseases. The infectious diseases which are considered to be hazardous for the public are HIV infection, tuberculosis and sexually transmitted infections (syphilis, Lymphogranuloma venereum and chancroid). The documents must be provided within 30 days from the date of application for a part-time resident permit in the country.
Since 2007, 87 patients with HIV infection and 221 patients with tuberculosis have been actively detected in Leningrad oblast. Results of comparative analysis indicate that the frequency of tuberculosis among migrants is 1.5-2 times higher than among the resident population. In contrast, HIV infection is 3-5 times more frequent among permanent residents of Leningrad oblast than among migrants.
If any infections are diagnosed among stateless persons during their medical examination, free-of-charge counter-epidemic measures are always taken in the focus of the infection. These patients are offered treatment in specialized hospitals, either at the expense of their employers or at their own expense. If a patient declines the course of treatment or defaults, the Directorate prepares documents to revoke further residence of the foreign citizen or stateless person in the Russian Federation.
Foreign citizens and stateless people coming to Leningrad oblast are also subject to mandatory vaccination against poliomyelitis and measles. Vaccination is in accordance with the currently implemented programmes for the elimination of measles and maintenance of the Leningrad oblast as poliomyelitis-free area.