Vaccinations in migrants and refugees: a challenge for European health systems. A systematic review of current scientific evidence

Children on the move in Europe: a narrative review of the evidence on the health risks, health needs and health policy for asylum seeking, refugee and undocumented children

BACKGROUND

Europe has experienced a marked increase in the number of children on the move. The evidence on the health risks and needs of migrant children is primarily from North America and Australia.

OBJECTIVE

To summarise the literature and identify the major knowledge gaps on the health risks and needs of asylum seeking, refugee and undocumented children in Europe in the early period after arrival, and the ways in which European health policies respond to these risks and needs.

DESIGN

Literature searches were undertaken in PubMed and EMBASE for studies on migrant child health in Europe from 1 January 2007 to 8 August 2017. The database searches were complemented by hand searches for peer-reviewed papers and grey literature reports.

RESULTS

The health needs of children on the move in Europe are highly heterogeneous and depend on the conditions before travel, during the journey and after arrival in the country of destination. Although the bulk of the recent evidence from Europe is on communicable diseases, the major health risks for this group are in the domain of mental health, where evidence regarding effective interventions is scarce. Health policies across EU and EES member states vary widely, and children on the move in Europe continue to face structural, financial, language and cultural barriers in access to care that affect child healthcare and outcomes.

CONCLUSIONS

Asylum seeking, refugee and undocumented children in Europe have significant health risks and needs that differ from children in the local population. Major knowledge gaps were identified regarding interventions and policies to treat and to promote the health and well-being of children on the move.

National approaches to the vaccination of recently arrived migrants in Europe: A comparative policy analysis across 32 European countries

BACKGROUND

Migrants may be underimmunised and at higher risk of vaccine-preventable diseases, yet there has been no comprehensive examination of what policies are currently implemented across Europe targeting child and adult migrants. We analysed vaccination policies for migrants in 32 EU/EEA countries and Switzerland.

METHODS

Using framework analysis, we did a comparative analysis of national policies and guidelines pertaining to vaccination in recently arrived migrants through a systematic guideline and literature review and by approaching national experts.

RESULTS

Six (18.8%) of 32 countries had comprehensive policies specific to the vaccination of migrants (two focused only on child migrants, four on both adults and children). Nineteen (59.4%) countries applied their national vaccination schedule for migrant vaccinations, predominantly focusing on children; and five (15.6%) countries had circulated additional migrant-specific resources to relevant health-care providers. In six (18.8%) countries, policies on migrant vaccination focused on outbreak-specific vaccines only. In ten (31.3%) countries, policies focused on priority vaccinations, with polio being the vaccine most commonly administered and heterogeneity noted in vaccines recommended to adults, adolescents, and children. Eighteen (56.3%) countries recommended that an individual should be considered as unvaccinated where vaccination records were missing, and vaccines re-administered. Nine (28.1%) countries reported that specific vaccinations were mandatory.

CONCLUSION

There is considerable variation in policies across Europe regarding approaches to vaccination in adult and child migrants, and a lack of clarity on optimum ways forward, what vaccines to offer, with a need for robust research in this area. More emphasis must be placed on ensuring migrant-specific guidance is disseminated to front-line healthcare professionals to improve vaccine delivery and uptake in diverse migration populations across the region.

The UCL-Lancet Commission on Migration and Health: the health of a world on the move

With one billion people on the move or having moved in 2018, migration is a global reality, which has also become a political lightning rod. Although estimates indicate that the majority of global migration occurs within low-income and middle-income countries (LMICs), the most prominent dialogue focuses almost exclusively on migration from LMICs to high-income countries (HICs). Nowadays, populist discourse demonises the very same individuals who uphold economies, bolster social services, and contribute to health services in both origin and destination locations. Those in positions of political and economic power continue to restrict or publicly condemn migration to promote their own interests. Meanwhile nationalist movements assert so-called cultural sovereignty by delineating an us versus them rhetoric, creating a moral emergency.

In response to these issues, the UCL-Lancet Commission on Migration and Health was convened to articulate evidence-based approaches to inform public discourse and policy. The Commission undertook analyses and consulted widely, with diverse international evidence and expertise spanning sociology, politics, public health science, law, humanitarianism, and anthropology. The result of this work is a report that aims to be a call to action for civil society, health leaders, academics, and policy makers to maximise the benefits and reduce the costs of migration on health locally and globally. The outputs of our work relate to five overarching goals that we thread throughout the report.

First, we provide the latest evidence on migration and health outcomes. This evidence challenges common myths and highlights the diversity, dynamics, and benefits of modern migration and how it relates to population and individual health. Migrants generally contribute more to the wealth of host societies than they cost. Our Article shows that international migrants in HICs have, on average, lower mortality than the host country population. However, increased morbidity was found for some conditions and among certain subgroups of migrants, (eg, increased rates of mental illness in victims of trafficking and people fleeing conflict) and in populations left behind in the location of origin. Currently, in 2018, the full range of migrants’ health needs are difficult to assess because of poor quality data. We know very little, for example, about the health of undocumented migrants, people with disabilities, or lesbian, gay, bisexual, transsexual, or intersex (LGBTI) individuals who migrate or who are unable to move.

Second, we examine multisector determinants of health and consider the implication of the current sector-siloed approaches. The health of people who migrate depends greatly on structural and political factors that determine the impetus for migration, the conditions of their journey, and their destination. Discrimination, gender inequalities, and exclusion from health and social services repeatedly emerge as negative health influences for migrants that require cross-sector responses.

Third, we critically review key challenges to healthy migration. Population mobility provides economic, social, and cultural dividends for those who migrate and their host communities. Furthermore, the right to the highest attainable standard of health, regardless of location or migration status, is enshrined in numerous human rights instruments. However, national sovereignty concerns overshadow these benefits and legal norms. Attention to migration focuses largely on security concerns. When there is conjoining of the words health and migration, it is either focused on small subsets of society and policy, or negatively construed. International agreements, such as the UN Global Compact for Migration and the UN Global Compact on Refugees, represent an opportunity to ensure that international solidarity, unity of intent, and our shared humanity triumphs over nationalist and exclusionary policies, leading to concrete actions to protect the health of migrants.

Fourth, we examine equity in access to health and health services and offer evidence-based solutions to improve the health of migrants. Migrants should be explicitly included in universal health coverage commitments. Ultimately, the cost of failing to be health-inclusive could be more expensive to national economies, health security, and global health than the modest investments required.

Finally, we look ahead to outline how our evidence can contribute to synergistic and equitable health, social, and economic policies, and feasible strategies to inform and inspire action by migrants, policy makers, and civil society. We conclude that migration should be treated as a central feature of 21st century health and development. Commitments to the health of migrating populations should be considered across all Sustainable Development Goals (SDGs) and in the implementation of the Global Compact for Migration and Global Compact on Refugees. This Commission offers recommendations that view population mobility as an asset to global health by showing the meaning and reality of good health for all. We present four key messages that provide a focus for future action.

Low uptake of nasal influenza vaccine in Polish and other ethnic minority children in Edinburgh, Scotland

Failure to vaccinate is well-recognised in Europe as a contributing factor to outbreaks of infectious diseases. Low immunisation rates are often associated with religious, social and ethnic minorities, including refugees or migrant groups. Polish people form Scotland's newest and largest migrant group. They have moved to Scotland since 2004, joining established ethnic minorities from China, the Indian subcontinent and Africa. Scotland has had a seasonal influenza nasal vaccination programme for all primary school children since 2013. We investigated three primary schools in Edinburgh, which had reported low influenza vaccination uptake rates in 2016 and 2017 and found that these schools contained many pupils from ethnic minorities, the majority of whom were Polish. Pupils were categorized as one of three ethnic groupings: White British, Polish and Other Identified Ethnic Minority (OIEM). We ascertained ethnicity using NHS and Education Department information sources and name recognition. We examined vaccine acceptance, declination and non-return of consent forms. In 2017, nasal influenza vaccine uptake was 70.7% (65.2-75.6%, p < 0.001) in White British, 60.9% (53.9-67.6%%, p < 0.001) in other identified ethnic minorities and 25.0% (20.9-29.6%, p > 0.001) in Polish children. White British children were more likely to return completed forms (78.9%) than other groups (OIEM 68.2% and Polish 61.8%). 36.8% of Polish families completed a consent form declining vaccination compared to 6.2% of White British families. These findings demonstrate that significant differences exist in nasal influenza vaccination uptake rates, which have important implications for the trans-national study of vaccine hesitancy. Further qualitative work and an investigation of uptake rates of other childhood immunisations in Polish and other migrant groups is required to assess differences in uptake and behaviours.

Migration and health: A retrospective study about the prevalence of HBV, HIV, HCV, tuberculosis and syphilis infections amongst newly arrived migrants screened at the Infectious Diseases Unit of Modena, Italy

INTRODUCTION

Aim of the study is to evaluate the prevalence of HBV, HIV, HCV, tuberculosis and syphilis infection among immigrants assigned to the immigrant centre of the province of Modena.

METHODS

At the time of arrival all immigrant were tested for: HBsAg, HBsAb, HBcAb, Ag p24/HIVAb, HCVAb, RPR, TPPA, Mantoux test (>10mm diameter of induration was considered to be positive), Chest X-rays. In case of positive samples, second level tests were performed (HbeAg, HBeAb, HDVAb, and baseline management and treatment of the infection detected).

RESULTS

A total of 304 immigrant people were enrolled in the study. HBsAg positivity was 12.2%, HCVAb 3.3%, HIVAb 1.6%, TPPA+RPR positivity in the 0.7%; 10.2% had a positive Mantoux test; 5.6% had Chest X-rays positive for signs of infection and 6 patients had an active tuberculosis. 83.8% HBsAg were HBeAb positive/HBeAg negative. HDVAb resulted positive in 1 patient (2.7%). Previous HBV infection was detected in 28.6% of cases, isolated HBcAb in 2.3%; 5.6% of patients resulted to be positive to HbsAb alone (probable vaccinated).

CONCLUSION

Our study confirms the high prevalence of HBsAg positivity and latent tuberculosis among immigrants, underlying the importance of screening for infections in this special population.

Divergent approaches in the vaccination of recently arrived migrants to Europe: a survey of national experts from 32 countries, 2017

BackgroundMigrants within the European Union and European Economic Area (EU/EEA) may be underimmunised and lack documentation on previous vaccinations. We investigated approaches to vaccination in recently arrived adult and child migrants, and guideline availability and implementation. Methods: Between March and May 2017, a national vaccination expert from every EU/EEA country and Switzerland completed an electronic questionnaire. We used descriptive analyses to calculate percentages, and framework analysis to synthesise free-text responses. Results: We approached 32 countries (response rate 100%). Although 28 experts reported vaccination guidance at national level, specific guidelines for recently arrived migrants were only available in six countries and not consistently implemented. Twenty-three countries administered vaccinations during on-arrival health checks. Most experts recommended multiple vaccination opportunities be made available: at point of entry (n = 13) or at holding level (reception centres, migrant camps, detention centres) (n = 21). In 30 countries, child migrants without evidence of previous vaccination were re-vaccinated according to the national schedule. Diphtheria-pertussis-tetanus and polio vaccinations were given to migrant children in all countries, measles-mumps-rubella (MMR) in 31 countries, hepatitis B vaccination in 25. Low levels of catch-up vaccination were reported in adult migrants, with only 13 countries offering MMR and 10 countries charging fees. Conclusion: Existing guidance is often not migrant-specific and may not be applied in practice; clarification is needed on which vaccines should be given. Strategies are needed specifically for catch-up vaccination in adult migrants. Vaccinations should be offered in multiple settings, free of charge, with sufficient guidance and training provided to front-line healthcare professionals.

Interventions to Improve Vaccination Uptake and Cost Effectiveness of Vaccination Strategies in Newly Arrived Migrants in the EU/EEA: A Systematic Review

Newly arrived migrants to the EU/EEA (arrival within the past five years), as well as other migrant groups in the region, might be under-immunised and lack documentation of previous vaccinations, putting them at increased risk of vaccine-preventable diseases circulating in Europe. We therefore performed a systematic review conforming to PRISMA guidelines (PROSPERO CRD42016045798) to explore: (i) interventions that improve vaccine uptake among migrants; and (ii) cost-effectiveness of vaccination strategies among this population. We searched MEDLINE, Embase, CINAHL, and Cochrane Database of Systematic Reviews (CDSR) between 1 January 2006 to 18 June 2018. We included three primary intervention studies performed in the EU/EEA or high-income countries and one cost effectiveness study relevant to vaccinations in migrants. Intervention studies showed small but promising impact only on vaccine uptake with social mobilization/community outreach, planned vaccination programs and education campaigns. Targeting migrants for catch-up vaccination is cost effective for presumptive vaccination for diphtheria, tetanus, and polio, and there was no evidence of benefit of carrying out pre-vaccination serological testing. The cost-effectiveness is sensitive to the seroprevalence and adherence to vaccinations of the migrant. We conclude that scarce but direct EU/EEA data suggest social mobilization, vaccine programs, and education campaigns are promising strategies for migrants, but more research is needed. Research should also study cost effectiveness of strategies. Vaccination of migrants should continue to be a public heath priority in EU/EEA.

Migrant and refugee populations: a public health and policy perspective on a continuing global crisis

The 2015-2017 global migratory crisis saw unprecedented numbers of people on the move and tremendous diversity in terms of age, gender and medical requirements. This article focuses on key emerging public health issues around migrant populations and their interactions with host populations. Basic needs and rights of migrants and refugees are not always respected in regard to article 25 of the Universal Declaration of Human Rights and article 23 of the Refugee Convention. These are populations with varying degrees of vulnerability and needs in terms of protection, security, rights, and access to healthcare. Their health status, initially conditioned by the situation at the point of origin, is often jeopardised by adverse conditions along migratory paths and in intermediate and final destination countries. Due to their condition, forcibly displaced migrants and refugees face a triple burden of non-communicable diseases, infectious diseases, and mental health issues. There are specific challenges regarding chronic infectious and neglected tropical diseases, for which awareness in host countries is imperative. Health risks in terms of susceptibility to, and dissemination of, infectious diseases are not unidirectional. The response, including the humanitarian effort, whose aim is to guarantee access to basic needs (food, water and sanitation, healthcare), is gripped with numerous challenges. Evaluation of current policy shows insufficiency regarding the provision of basic needs to migrant populations, even in the countries that do the most. Governments around the world need to rise to the occasion and adopt policies that guarantee universal health coverage, for migrants and refugees, as well as host populations, in accordance with the UN Sustainable Development Goals. An expert consultation was carried out in the form of a pre-conference workshop during the 4th International Conference on Prevention and Infection Control (ICPIC) in Geneva, Switzerland, on 20 June 2017, the United Nations World Refugee Day.

Impact of the Refugee Crisis on the Greek Healthcare System: A Long Road to Ithaca

Greece is the country of "Xenios Zeus", the Ancient Greek god of foreigners and hospitality; however, it is also the main point of entry to Europe. Since the beginning of 2014, 1,112,332 refugees crossed the borders of Greece. Overall, 33,677 children and adolescent refugees sought asylum in Greece from 2013 to 2017, while 57,042 refugees are currently being hosted. The rapid entry of refugees into Greece raised the critical issue of health policy. The Greek National Health Service (NHS) faces many challenges. Adequate economic and human support is essential if this situation is to be managed successfully. However, Greece still bears the burden of the economic downturn since 2009. In fact, the crisis led to shortages in crucial equipment, and unmet health needs for both locals and refugees. The NHS deals with traumatic experiences, as well as cultural and linguistic differences. Overcrowded reception centers and hotspots are highly demanding and are associated with severe disease burden. This highlights the importance of guidelines for medical screening, healthcare provision, and a well-managed transition to definitive medical facilities. Furthermore, non-governmental organizations make an essential contribution by ensuring appropriate support to refugee minors, especially when they experience poor access to the NHS.

Immunization and technology among newcomers: A needs assessment survey for a vaccine-tracking app

Objectives: Newcomers experience unique challenges with respect to vaccination. These challenges are compounded by the need to navigate complex vaccination catch-up schedules upon arrival in their new home countries. Our group has pioneered the development of CANImmunize, a free, bilingual, pan-Canadian digital application designed to empower individuals to manage their vaccination records. To inform how a vaccine tracking app such as CANImmunize might be tailored to meet the unique needs of newcomers, this study sought to determine commonly spoken languages, technology use, and current methods of vaccine tracking among recent newcomers to Canada.

Methods: Government-assisted refugees attending a health clinic in Ottawa, Canada were invited to complete a 17-question needs assessment survey. The survey captured data on household demographics, spoken languages, country of origin, technology use and methods used to track vaccination history.

Results: 50 newcomers completed the needs assessment survey. Arabic was the predominant language spoken by surveyed individuals. Although 92% of participants owned a smartphone, the majority did not actively use digital health applications. 18 (36%) participants reported being vaccinated before arriving in Canada. 27 (54%) participants were parents, 23 of whom reported that their children were vaccinated prior to arrival in Canada. 38 (76%) participants indicated that they would use a vaccine tracking app such as CANImmunize if it were translated into their primary language of communication.

Conclusions: The results of our study indicate that mobile technology may be a useful tool to help newcomer families stay on track with provincial and territorial immunization schedules.

Bibliometric analysis of global migration health research in peer-reviewed literature (2000-2016)

BACKGROUND

The health of migrants has become an important issue in global health and foreign policy. Assessing the current status of research activity and identifying gaps in global migration health (GMH) is an important step in mapping the evidence-base and on advocating health needs of migrants and mobile populations. The aim of this study was to analyze globally published peer-reviewed literature in GMH.

METHODS

A bibliometric analysis methodology was used. The Scopus database was used to retrieve documents in peer-reviewed journals in GMH for the study period from 2000 to 2016. A group of experts in GMH developed the needed keywords and validated the final search strategy.

RESULTS

The number of retrieved documents was 21,457. Approximately one third (6878; 32.1%) of the retrieved documents were published in the last three years of the study period. In total, 5451 (25.4%) documents were about refugees and asylum seekers, while 1328 (6.2%) were about migrant workers, 440 (2.1%) were about international students, 679 (3.2%) were about victims of human trafficking/smuggling, 26 (0.1%) were about patients' mobility across international borders, and the remaining documents were about unspecified categories of migrants. The majority of the retrieved documents (10,086; 47.0%) were in psychosocial and mental health domain, while 2945 (13.7%) documents were in infectious diseases, 6819 (31.8%) documents were in health policy and systems, 2759 (12.8%) documents were in maternal and reproductive health, and 1918 (8.9%) were in non-communicable diseases. The contribution of authors and institutions in Asian countries, Latin America, Africa, Middle East, and Eastern European countries was low. Literature in GMH represents the perspectives of high-income migrant destination countries.

CONCLUSION

Our heat map of research output shows that despite the ever-growing prominence of human mobility across the globe, and Sustainable Development Goals of leaving no one behind, research output on migrants' health is not consistent with the global migration pattern. A stronger evidence base is needed to enable authorities to make evidence-informed decisions on migration health policy and practice. Research collaboration and networks should be encouraged to prioritize research in GMH.

Use of health services among international migrant children - a systematic review

BACKGROUND

Migrant children have specific health needs, and may face difficulties in accessing health care, but not enough is known about their health service use. This study aims to describe patterns of use of health services of international migrant children and differences to respective native populations.

METHODS

Electronic databases PubMed and Web of Science, references of identified publications, and websites of relevant international agencies were searched. We included observational studies published between 2006 and 2016 that reported use of formal health services by migrant children (0-18 years), including first and second generation migrants. Data on study characteristics, study theme, main outcome and study quality were extracted.

RESULTS

One hundred seven full texts were included in the review. Of the studies that reported comparable outcomes, half (50%) indicated less use of healthcare by migrants compared with non-migrants; 25% reported no difference, 18% reported greater use, and 7% did not report this outcome. There was variation by theme, so that the proportion of conclusions "less use" was most common in the categories "general access to care", "primary care" and "oral health", whereas in the use of emergency rooms or hospitalisations, the most common conclusion was "greater use".

CONCLUSIONS

Migrant children appear to use different types of healthcare services less than native populations, with the exception of emergency and hospital services.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO systematic review registration number: CRD42016039876 .

Immunization Offer Targeting Migrants: Policies and Practices in Italy

The unprecedented flow of migrants over the last three years places Italy in front of new issues regarding medical care from the rescue phase up to the integration into the national health services, including preventive actions. We used online questionnaires to investigate the Italian national and regional policies for immunization offer targeting asylum seekers, refugees, irregular migrants and unaccompanied minors. Another questionnaire was used to assess how these policies are translated into practice in migrant reception centres and community health services. Questionnaires were filled out at the national level, in 14 out of 21 Regions/Autonomous Provinces, and in 36 community health services and 28 migrant reception centres. Almost all responders stated that all vaccinations included in the National Immunization Plan are offered to migrant children and adolescents. The situation concerning adults is fragmented, with most of the Regions and local centres offering more vaccines than the national offer—which include polio, tetanus and measles–mumps-rubella. Data on immunized immigrants is archived at the regional/local level with different methods and not available at the national level. Further efforts to ensure consistency in vaccine provision and adequate mechanisms of exchanging data are needed to guarantee a complete vaccination offer and avoid unnecessary health actions, including unnecessary re-vaccination.

Missed hepatitis b/c or syphilis diagnosis among Kurdish, Russian, and Somali origin migrants in Finland: linking a population-based survey to the national infectious disease register

BACKGROUND

Migrants are considered a key population at risk for sexually transmitted and blood-borne diseases in Europe. Prevalence data to support the design of infectious diseases screening protocols are scarce. We aimed to estimate the prevalence of hepatitis B and C, human immunodefiency virus (HIV) infection and syphilis in specific migrant groups in Finland and to assess risk factors for missed diagnosis.

METHODS

A random sample of 3000 Kurdish, Russian, or Somali origin migrants in Finland was invited to a migrant population-based health interview and examination survey during 2010-2012. Participants in the health examination were offered screening for hepatitis B and C, HIV and syphilis. Notification prevalence in the National Infectious Diseases Register (NIDR) was compared between participants and non-participants to assess non-participation. Missed diagnosis was defined as test-positive case in the survey without previous notification in NIDR. Inverse probability weighting was used to correct for non-participation.

RESULTS

Altogether 1000 migrants were screened for infectious diseases. No difference in the notification prevalence among participants and non-participants was observed. Seroprevalence of hepatitis B surface antigen (HBsAg) was 2.3%, hepatitis C antibodies 1.7%, and Treponema pallidum antibodies 1.3%. No cases of HIV were identified. Of all test-positive cases, 61% (34/56) had no previous notification in NIDR. 48% of HBsAg, 62.5% of anti-HCV and 84.6% of anti-Trpa positive cases had been missed. Among the Somali population (n = 261), prevalence of missed hepatitis B diagnosis was 3.0%. Of the 324 Russian migrants, 3.0% had not been previously diagnosed with hepatitis C and 2.4% had a missed syphilis diagnosis. In multivariable regression model missed diagnosis was associated with migrant origin, living alone, poor self-perceived health, daily smoking, and previous diagnosis of another blood-borne infection.

CONCLUSIONS

More than half of chronic hepatitis and syphilis diagnoses had been missed among migrants in Finland. Undiagnosed hepatitis B among Somali migrants implies post-migration transmission that could be prevented by enhanced screening and vaccinations. Rate of missed diagnoses among Russian migrants supports implementation of targeted hepatitis and syphilis screening upon arrival and also in later health care contacts. Coverage and up-take of current screening among migrants should be evaluated.

Paediatric Virology and its interaction between basic science and clinical practice (Review)

The 3rd Workshop on Paediatric Virology, which took place on October 7th, 2017 in Athens, Greece, highlighted the role of breast feeding in the prevention of viral infections during the first years of life. Moreover, it focused on the long-term outcomes of respiratory syncytial virus and rhinovirus infections in prematurely born infants and emphasised the necessity for the development of relevant preventative strategies. Other topics that were covered included the vaccination policy in relation to the migration crisis, mother‑to‑child transmission of hepatitis B and C viruses, vaccination against human papilloma viruses in boys and advances on intranasal live‑attenuated vaccination against influenza. Emphasis was also given to the role of probiotics in the management of viral infections in childhood, the potential association between viral infections and the pathogenesis of asthma, fetal and neonatal brain imaging and the paediatric intensive care of children with central nervous system viral infections. Moreover, an interesting overview of the viral causes of perinatal mortality in ancient Greece was given, where recent archaeological findings from the Athenian Agora's bone well were presented. Finally, different continuing medical educational options in Paediatric Virology were analysed and evaluated. The present review provides an update of the key topics discussed during the workshop.

National immunization strategies targeting migrants in six European countries

Over the last three years an unprecedented flow of migrants arrived in Europe. There is evidence that vaccine preventable diseases have caused outbreaks in migrant holding centres. These outbreaks can be favored by a combination of factors including low immunization coverage, bad conditions that migrants face during their exhausting journey and overcrowding within holding facilities. In 2017, we conducted an online survey in Croatia, Greece, Italy, Malta, Portugal and Slovenia to explore the national immunization strategies targeting irregular migrants, refugees and asylum seekers. All countries stated that a national regulation supporting vaccination offer to migrants is available. Croatia, Italy, Portugal and Slovenia offer to migrant children and adolescents all vaccinations included in the National Immunization Plan; Greece and Malta offer only certain vaccinations, including those against diphtheria-tetanus-pertussis, poliomyelitis and measles-mumps-rubella. Croatia, Italy, Malta and Portugal also extend the vaccination offer to adults. All countries deliver vaccinations in holding centres and/or community health services, no one delivers vaccinations at entry site. Operating procedures that guarantee the migrants' access to vaccination at the community level are available only in Portugal. Data on administered vaccines is available at the national level in four countries: individual data in Malta and Croatia, aggregated data in Greece and Portugal. Data on vaccination uptake among migrants is available at national level only in Malta. Concluding, although diversified, strategies for migrant vaccination are in place in all the surveyed countries and generally in line with WHO and ECDC indications. Development of procedures to keep track of migrants' immunization data across countries, development of strategies to facilitate and monitor migrants' access to vaccinations at the community level and collection of data on vaccination uptake among migrants should be promoted to meet existing gaps.

Barriers to immunization among newcomers: A systematic review

INTRODUCTION

Currently, there is a lack of comprehensive evidence exploring vaccine decision-making among newcomers. We conducted a systematic review of qualitative studies aimed at identifying factors that influence newcomers' decision-making with regards to vaccination.

METHODS

We conducted a search of MEDLINE, EMBASE, CINAHL and Cochrane Central. To be included, studies needed to employ a qualitative methodology and address newcomer attitudes, beliefs, and/or perceptions regarding vaccination. Two independent reviewers screened the articles for relevant information and applied a content analysis methodology to code the identified barriers.

RESULTS

Twenty-one studies were included in this review, and four types of barriers were identified: cultural factors, knowledge barriers, insufficient access to healthcare, and vaccine hesitancy. Insufficient knowledge about vaccination and the virus being prevented and concerns about safety were the most commonly reported barriers. A sub-analysis of barriers specific to HPV indicated that cultural beliefs about sexuality and incomplete knowledge about the role of HPV in the development of cervical cancer are major barriers to vaccine uptake.

CONCLUSION

Strategies to improve vaccination uptake in newcomers should consider focusing on the barriers identified in this review while taking into account the unique opportunities for promoting uptake within newcomer populations.

Bibliometric analysis of medicine - related publications on refugees, asylum-seekers, and internally displaced people: 2000 - 2015

BACKGROUND

Wars and violent domestic conflicts have forced millions of people to move outside their homes. Meeting the basic health needs of those people requires an understanding of research activity and research output on this topic. The objective of this study was to shed light on the quantity and impact of medicine - related publications on refugees, asylum seekers and internally displaced people (IDP).

METHOD

Scopus database was used to retrieve required data. Specifically, the number of publications, top productive countries and institutions, highly cited articles, citation analysis, international collaboration, and journals involved in publishing articles on refugees, asylum seekers and IDP were reviewed and analyzed. The time span for the study was set from year 2000 to 2015.

RESULTS

Two thousands five hundred and thirty publications were retrieved. The h-index of retrieved articles was 64. A steep rise in number of publications was noticed after 2011. Top productive countries were the United States of America, Australia and the United Kingdom. The American public health institute (Centers for Disease Control and Prevention) and the United Nations refugee agency were among the top active organizations on this topic. Active journals in publishing on health of refugees, asylum seekers and IDP were those on mental health, psychology, public health and general medicine. Publications on Somali, Afghani, Iraqi, and Syrian refugees received a significant share of medicine-related publications. Analysis of publications based on region showed that publications on refugees from Middle East is rising sharply and is approaching those on African refugees.

CONCLUSION

Bibliometric analysis reveals that research publications on refugees have been increasing in a dramatic way and articles are being published in journals with high impact factor and international reputation, not only in general medicine and public health, but also mental health and psychology journals. Analysis of publications related to refugees can be helpful to international health agencies and governments not only to document the psychological trauma of fled people, but also to identify best mental health programs to face the consequences of wars and aggression that led to this refugee crisis.