National immunization strategies targeting migrants in six European countries

Strengthening life-course immunisation in migrant populations: access, equity, and inclusion

Adult and adolescent migrants worldwide, and those arriving in Europe, are an under-immunised group for routine vaccinations due to missed childhood vaccines and doses in their countries of origin, and their subsequent marginalisation from health and vaccination systems. Declining population-level coverage for routine vaccines across Europe, which has accelerated post-pandemic, places these and other under-immunised populations at even greater risk of vaccine-preventable diseases. However, despite clear guidelines around the importance of delivering 'catch-up' vaccination throughout the life-course, migrants are rarely effectively incorporated into routine vaccination programmes on arrival to Europe. These populations have subsequently been involved in outbreaks, including measles and diphtheria, and are missing opportunities to receive more recently introduced vaccines such as HPV to align them with European vaccine schedules. WHO's new Immunization Agenda 2030 places a renewed emphasis on equitable access to vaccine systems and integrating catch-up vaccination for missed vaccines and doses throughout the life-course. In addition, lessons learned and innovations from the COVID-19 pandemic merit further consideration in the design and delivery of more inclusive vaccination programmes. We describe current gaps in policy and practice around life-course vaccination in migrant populations, key factors that drive low vaccine uptake and coverage, and explore the benefits of participatory approaches to designing and delivering interventions with impacted communities, to define new strategies to advance vaccine equity across the Region.

Understanding the health system barriers and enablers to childhood MMR and HPV vaccination among disadvantaged, minority or underserved populations in middle- and high-income countries: a systematic review

BACKGROUND

Child vaccinations are among the most effective public health interventions. However, wide gaps in child vaccination remain among different groups with uptake in most minorities or ethnic communities in Europe substantially lower compared to the general population. A systematic review was conducted to understand health system barriers and enablers to measles, mumps and rubella (MMR) and human papilloma virus (HPV) child vaccination among disadvantaged, minority populations in middle- and high-income countries.

METHODS

We searched Medline, Cochrane, CINAHL, ProQuest and EMBASE for articles published from 2010 to 2021. Following title and abstract screening, full texts were assessed for relevance. Study quality was appraised using Critical Appraisal Skills Program checklists. Data extraction and analysis were performed. Health system barriers and enablers to vaccination were mapped to the World Health Organization health system building blocks.

RESULTS

A total of 1658 search results were identified from five databases and 24 from reference lists. After removing duplicates, 1556 titles were screened and 496 were eligible. Eighty-six full texts were assessed for eligibility, 28 articles met all inclusion criteria. Factors that affected MMR and HPV vaccination among disadvantaged populations included service delivery (limited time, geographic distance, lack of culturally appropriate translated materials, difficulties navigating healthcare system), healthcare workforce (language and poor communication skills), financial costs and feelings of discrimination.

CONCLUSION

Policymakers must consider health system barriers to vaccination faced by disadvantaged, minority populations while recognizing specific cultural contexts of each population. To ensure maximum policy impact, approaches to encourage vaccinations should be tailored to the unique population's needs. A one-size-fits-all approach is not effective.

Scoping Review on Barriers and Challenges to Pediatric Immunization Uptake among Migrants: Health Inequalities in Italy, 2003 to Mid-2023

In the aftermath of the COVID-19 pandemic, asylum seekers, refugees, and foreign-born migrants are more likely to suffer from physical, mental, and socioeconomic consequences owing to their existing vulnerabilities and worsening conditions in refugee camps around the world. In this scenario, the education of migrants and newcomers about immunization is critical to achieving health equity worldwide. Globally, it is unclear whether government vaccination policies are prioritizing the health information needs of migrants. We searched for studies investigating the vaccination uptake of migrant children settled in Italy that were published between January 2003 and 25 June 2023. Following Arksey and O'Malley's five-stage method for scoping reviews, all potentially relevant literature published in English was retrieved from SciSearch, Medline, and Embase. This search resulted in 88 research articles, 25 of which met our inclusion criteria. Our findings indicate unequal access to vaccination due to a lack of available information in the native language of the immigrants' country of origin, vaccine safety concerns or lack of awareness, logistical difficulties, and fear of legal consequences. The findings strongly encourage further government and political discourse to ensure migrants have fair, equitable, ethical, and timely access to essential medicines.

Access to Vaccination for Newly Arrived Migrants: Developing a General Conceptual Framework for Understanding How to Improve Vaccination Coverage in European Countries

Objectives: Access to vaccination for newly arrived migrants (NAMs) is a relevant concern that requires urgent attention in EU/EEA countries. This study aimed to develop a General Conceptual Framework (GCF) for understanding how to improve vaccination coverage for NAMs, by characterizing and critically analyzing system barriers and possible strategies to increase vaccination. Methods: A theoretical conceptualization of the GCF was hypothesized based on conceptual hubs in the immunization process. Barriers and solutions were identified through a non-systematic desktop literature review and qualitative research. The GCF guided the activities and facilitated the integration of results, thereby enriching the GCF with content. Results: The study explores the vaccination of NAMs and proposes strategies to overcome barriers in their vaccination process. It introduces a framework called GCF, which consists of five interconnected steps: entitlement, reachability, adherence, achievement, and evaluation of vaccination. The study also presents barriers and solutions identified through literature review and qualitative research, along with strategies to enhance professionals' knowledge, improve reachability, promote adherence, achieve vaccination coverage, and evaluate interventions. The study concludes by recommending strategies such as proximity, provider training, a migrant-sensitive approach, and data collection to improve vaccination outcomes for NAMs. Conclusion: Ensuring equitable access to healthcare services, including vaccination, is crucial not only from a humanitarian perspective but also for the overall public health of these countries.

The impact of migration-related characteristics on the risk of TORCH infections among women of childbearing age: a population-based study in southern China

BACKGROUND

TORCH infections are the most common prenatal infections causing congenital malformation and infant mortality, especially in developing countries. Migrant women might be vulnerable to TORCH infections, but little is known about the association between migration-related characteristics and TORCH infection risk. This study aimed to investigate the impact of migrant status, migration distance, and the spouse's migrant status on the TORCH epidemic among women of childbearing age.

METHODS

Based on the National Free Preconception Health Examination Project, we analyzed a representative dataset of TORCH infections among women of childbearing age (15-49 years old) in Guangdong Province of China (2014-2019, n = 2,451,297). The past and/or recent infection status of TORCH infections (Toxoplasma gondii [TOX], Cytomegalovirus [CMV], and Rubella virus [RV]) were identified. Demographic and migration-related characteristics were collected. We thoroughly assessed the prevalence of TORCH infections in both migrant and native women and estimated adjusted odd ratios (aOR) for migration-related characteristics using multivariable logistic regression after adjusting the other sociodemographic factors.

RESULTS

Among all 2,451,297 participants, 443,725 (18.1%) were migrant women. Migrant women presented a lower risk of past TOX infection (aOR: 0.89, 0.88-0.91) suggesting a healthy migrant effect (HME), but a higher risk of recent TOX infection (aOR: 1.88, 1.77-1.99), past CMV infection (aOR: 1.26, 1.25-1.28) and RV infection in natural ways (aOR: 1.05, 1.04-1.06). Compared with intra-provincial migrants, inter-provincial migrants had a lower past TOX infection (aOR: 0.88, 0.85-0.91), but a higher risk of recent TOX infection (aOR: 1.16, 1.05-1.27) and RV infection (aOR: 1.33, 1.31-1.36). In addition, having a migrant spouse was associated with a higher risk for all types of infection.

CONCLUSION

This study reported the association of migrant status and migration distance with TORCH infections, although the significance and directionality of these associations varied between pathogens. The spouse's migrant status further amplified the infection risk for all types of pathogens. Our findings suggested interventions for preventing the spread of CMV and RV infection and new acquisition of TOX infection for migrants in southern China, to narrow the native-migrant health inequity and decrease the incidence of prenatal infections and related adverse outcomes.

Suboptimal Serologic Immunity Against Poliomyelitis Among New Migrant Children in Greece Calls for Organized Action

BACKGROUND

Migration-flows pose the risk of poliovirus reintroduction from endemic countries to Greece. This study aims to evaluate serologic-immunity/vaccination against poliomyelitis in newly-arriving migrant children.

METHODS

Demographic-immunisation data and blood-serum were obtained from migrants 1-14years-old, referred to a hospital-clinic in Athens-Greece within three months from arrival. Immunity to polioviruses-1-3 was determined by serum-neutralizing-antibodies(WHO guidelines). Titers ≥ 1:8 were considered positive.

RESULTS

From 9/2010 to 9/2013, 274 children(150 refugees/124 immigrants), mean age 7.1years-old, were enrolled. Only 57(20.8%) of them presented with vaccination-records. Children originated mainly from Asia(n = 198), Eastern Europe(n = 28), Middle East(n = 24) and Africa(n = 24) with 160(58.4%) from polio-endemic-countries(Afghanistan-112(40.8%), Pakistan-24(8.8%) and India-24(8.8%)). Seropositivity against polio-1-2&3 was 84.3%, 86.1% and 74.5%, respectively. Immigrants, had higher seroprotective rates against polioviruses-1-2&3 than refugees(polio-1:p = 0.002;polio-2:p = 0.004,polio-3:p < 0.001). Seronegativity to 1PVs-2PVs and all three polio serotypes was found in 37(13.5%),12 (4.4%), and 30 children(10.9%) respectively. Increasing number of vaccine-doses, and younger-age, were positively-associated with seropositivity.

DISCUSSION

A remarkable fraction of newly-arrived migrant-children were seronegative to one or more polioviruses.

Country immunization policies for refugees across 20 low-middle income and 20 high-income countries

In 2020, 26 million refugees resettled in a new country-fleeing their homes due to conflict and persecution. Due to low immunization coverage and underlying health conditions, refugees commonly face an increased risk of contracting vaccine-preventable diseases. We collected and analyzed existing routine immunization policies for refugees across 20 low- and middle-income countries (LMICs) and 20 high-income countries (HICs), each with the highest number of refugees per 1000 residents. Primary and secondary data sources were used to collect policy evidence. Across 20 LMICs, 13 countries specified standing nationwide routine immunization policies for refugees, while 14 out of the 20 HICs included refugees in their national routine immunization programs. LMICs and HICs should include refugees in their national routine immunization policies and provide accessible and affordable immunizations. Such efforts would reduce vaccine-preventable diseases and protect the health of refugee populations-especially during the COVID-19 pandemic.

Measles Vaccination and Outbreaks in Croatia from 2001 to 2019; A Comparative Study to Other European Countries

Due to the current burden of COVID-19 on public health institutions, increased migration and seasonal touristic traveling, there is an increased risk of epidemic outbreaks of measles, mumps and rubella (MMR). The aim of the present study was to analyze the epidemiological data on MMR immunization coverage and the number of measles cases in 2001−2019 in Croatia and a number of European countries. Results revealed a decreasing trend in vaccination in 2001−2019 throughout Europe. However, Croatia and Hungary still have the highest primary and revaccination coverage, compared to other analyzed countries. The highest number of measles cases was in 2017 in Romania. There was no significant correlation between the percentage of primary vaccination and the number of measles cases (r = −0.0528, p = 0.672), but there was a significant negative correlation between the percentage of revaccination and the number of measles cases (r = −0.445, p < 0.0001). In conclusion, the results of the present study emphasize the necessity to perform a full protocol of vaccination to reach appropriate protection from potential epidemic outbreaks. Furthermore, in the light of present migrations, documenting the migrants’ flow and facilitating vaccination as needed is of utmost importance to prevent future epidemics.

What the reproductive number R0 can and cannot tell us about COVID-19 dynamics

The reproductive number R (or R0, the initial reproductive number in an immune-naïve population) has long been successfully used to predict the likelihood of pathogen invasion, to gauge the potential severity of an epidemic, and to set policy around interventions. However, often ignored complexities have generated confusion around use of the metric. This is particularly apparent with the emergent pandemic virus SARS-CoV-2, the causative agent of COVID-19. We address some misconceptions about the predictive ability of the reproductive number, focusing on how it changes over time, varies over space, and relates to epidemic size by referencing the mathematical definition of R and examples from the current pandemic. We hope that a better appreciation of the uses, nuances, and limitations of R and R0 facilitates a better understanding of epidemic spread, epidemic severity, and the effects of interventions in the context of SARS-CoV-2.

Immunisation of migrants in EU/EEA countries: Policies and practices

In recent years various EU/EEA countries have experienced an influx of migrants from low and middle-income countries. In 2018, the "Vaccine European New Integrated Collaboration Effort (VENICE)" survey group conducted a survey among 30 EU/EEA countries to investigate immunisation policies and practices targeting irregular migrants, refugees and asylum seekers (later called "migrants" in this report). Twenty-nine countries participated in the survey. Twenty-eight countries reported having national policies targeting children/adolescent and adult migrants, however vaccinations offered to adult migrants are limited to specific conditions in seven countries. All the vaccinations included in the National Immunisation Programme (NIP) are offered to children/adolescents in 27/28 countries and to adults in 13/28 countries. In the 15 countries offering only certain vaccinations to adults, priority is given to diphtheria-tetanus, measles-mumps-rubella and polio vaccinations. Information about the vaccines given to child/adolescent migrants is recorded in 22 countries and to adult migrants in 19 countries with a large variation in recording methods found across countries. Individual and aggregated data are reportedly not shared with other centres/institutions in 13 and 15 countries, respectively. Twenty countries reported not collecting data on vaccination uptake among migrants; only three countries have these data at the national level. Procedures to guarantee migrants' access to vaccinations at the community level are available in 13 countries. In conclusion, although diversified, strategies for migrant vaccination are in place in all countries except for one, and the strategies are generally in line with international recommendations. Efforts are needed to strengthen partnerships and implement initiatives across countries of origin, transit and destination to develop and better share documentation in order to guarantee a completion of vaccination series and to avoid unnecessary re-vaccination. Development of migrant-friendly strategies to facilitate migrants' access to vaccination and collection of vaccination uptake data among migrants is needed to meet existing gaps.

Determinants of Tetanus Vaccination among Adult Immigrants: Findings from the Portuguese National Health Survey 2014

Vaccination is an effective strategy to prevent tetanus, and in Portugal this service is provided free of charge. Despite this, immigrants reported lower tetanus vaccination coverage than did Portuguese natives. The objective of this study was to identify sociodemographic, migration-related, and access-to-care factors associated with tetanus vaccination coverage among adult immigrants, using data from the Portuguese National Health Survey 2014. For the sample of 1277 immigrants aged ≥18 years, we estimated self-reported tetanus vaccination within the preceding 10 years and its determinants using complex samples logistic regression. The overall self-reported tetanus vaccination coverage was 79.5% (95% CI: 75.8-82.8). Age (adjusted odd ratio (aOR) per 1 year age increase = 0.97, 95% CI: 0.95-0.99), higher household income per adult (aOR = 0.42, 95% CI: 0.19-0.96), having Portuguese citizenship (aOR = 2.30, 95% CI: 1.25-4.24), having private health insurance (aOR = 1.99, 95% CI: 1.06-3.71), and contact with family/general physician in the last 12 months (aOR = 1.59, 95% CI: 1.01-2.51) were associated with self-reported tetanus vaccination coverage among adult immigrants. We also found significant disparities in coverage between regions of residence. This study identified several determinants associated with self-reported tetanus vaccination coverage among adult immigrants in Portugal. These findings may help policymakers to design specific interventions to increase tetanus vaccination coverage among this population.

Infectious diseases at different stages of migration: an expert review

BACKGROUND

Human migration is increasing in magnitude and scope. The majority of migrants arriving in high-income countries originate from countries with a high prevalence of infectious diseases. The risk and burden of infectious diseases are not equally distributed among migrant groups and vary with migration stage.

METHODS

A broad literature review was conducted on the drivers for infectious diseases and associated health outcomes among migrants across different stages of migration. The aim was to provide practitioners with an overview of the key infectious disease risks at each stage to guide health promotion strategies.

RESULTS

A complex interaction of factors leads to infectious diseases and associated poor health outcomes among migrants. The most important drivers are the epidemiology of infectious diseases in their countries of origin, the circumstances and conditions of the migration journey and barriers accessing healthcare post-arrival. During the recent large waves of forced migration into Europe, the primary health concerns on arrival were psychological, traumatic and chronic non-communicable diseases. In the early settlement period, crowded and unhygienic living conditions in reception camps facilitated outbreaks of respiratory, gastrointestinal, skin infections and vaccine preventable diseases. After re-settlement, undetected and untreated latent infections due to tuberculosis, viral hepatitis, HIV, chronic helminthiasis and Chagas' disease led to poor health outcomes. Migrants are disproportionally affected by preventable travel-related diseases such as malaria, typhoid and hepatitis due to poor uptake of pre-travel prophylaxis and vaccination. Infectious diseases among migrants can be decreased at all migration stages with health promotion strategies adapted to their specific needs and delivered in a linguistically and culturally sensitive manner.

CONCLUSIONS

Tailored health promotion and screening approaches and accessible and responsive health systems, regardless of legal status, will be needed at all migration stages to limit the burden and transmission of infectious diseases in the migrant 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.

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.