Measles outbreak in an asylum-seekers' shelter in Germany: comparison of the implemented with a hypothetical containment strategy

Effect of the Promulgation of the New Migrant's Employment Law on Migrant Insurance Coverage in Thailand: An Interrupted Time Series Analysis, 2016-2018

This study explores the effect of the recently enacted Foreigners’ Working Management Emergency Decree, 2017 on migrant insurance coverage between January 2016 and December 2018. We employed an interrupted time series (ITS) model to estimate the level and trend changes of the number of migrants enrolled in Social Health Insurance (SHI) for formal workers and the Health Insurance Card Scheme (HICS) for other migrants. Before the Decree’s implementation, SHI covered roughly a third of the total migrants holding work permits, while HICS covered over half of migrants in the country. We found that the new employment law contributed to a rise in the volume of SHI members and a decline in the HICS members in the long run, which might be partly due to a switch from the HICS members in the formal sector to the SHI, as originally intended by the law. In addition to the law effect, some coincided political force from international trade partners and supranational organizations might also contribute to the progress in protecting the rights of migrant workers. The long-term monitoring of migrant insurance coverage and a mapping against the changes in migrant-related laws and contexts are recommended.

Migration and outbreaks of vaccine-preventable disease in Europe: a systematic review

Migrant populations are one of several underimmunised groups in the EU or European Economic Area (EU/EEA), yet little is known about their involvement in outbreaks of vaccine-preventable diseases. This information is vital to develop targeted strategies to improve the health of diverse migrant communities. We did a systematic review (PROSPERO CRD42019157473; Jan 1, 2000, to May 22, 2020) adhering to PRISMA guidelines, to identify studies on vaccine-preventable disease outbreaks (measles, mumps, rubella, diphtheria, pertussis, polio, hepatitis A, varicella, Neisseria meningitidis, and Haemophilus influenzae) involving migrants residing in the EU/EEA and Switzerland. We identified 45 studies, reporting on 47 distinct vaccine-preventable disease outbreaks across 13 countries. Most reported outbreaks involving migrants were of measles (n=24; 6496 cases), followed by varicella (n=11; 505 cases), hepatitis A (n=7; 1356 cases), rubella (n=3; 487 cases), and mumps (n=2; 293 cases). 19 (40%) outbreaks, predominantly varicella and measles, were reported in temporary refugee camps or shelters. Of 11 varicella outbreaks, nine (82%) were associated with adult migrants. Half of measles outbreaks (n=11) were associated with migrants from eastern European countries. In conclusion, migrants are involved in vaccine-preventable disease outbreaks in Europe, with adult and child refugees residing in shelters or temporary camps at particular risk, alongside specific nationality groups. Vulnerability varies by disease, setting, and demographics, highlighting the importance of tailoring catch-up vaccination interventions to specific groups in order to meet regional and global vaccination targets as recommended by the new Immunisation Agenda 2030 framework for action. A better understanding of vaccine access and intent in migrant groups and a greater focus on co-designing interventions is urgently needed, with direct implications for COVID-19 vaccine delivery.

Interventions to reduce the burden of vaccine-preventable diseases among migrants and refugees worldwide: A scoping review of published literature, 2006-2018

BACKGROUND

Disparities in vaccine-preventable disease (VPD) burden and immunisation coverage between migrants and refugees and their host populations have been described in numerous countries worldwide. Effective strategies are required to reduce the health disparities and immunisation inequities experienced by migrants and refugees.

METHODS

Using Arksey and O'Malley's framework, we conducted a scoping review to identify available literature on interventions aimed at reducing VPD burden among migrants and refugees worldwide. We searched for relevant empirical, peer-reviewed literature published in English between 2006 and 2018 using MEDLINE, Ovid EMBASE, CINAHL, Sociological Abstracts, and Web of Science databases. Relevant information from the studies, including intervention type, details and outcomes, were charted in Microsoft Excel and results were summarised using a descriptive analytical method.

RESULTS

Seventy studies met the inclusion criteria. The number of published studies increased over the years. The majority of studies were conducted in high-income countries. More studies were conducted among migrants (not including refugees) (n = 48, 66%) than specifically among refugees (n = 25, 34%). Interventions were implemented in a variety of settings, including health care (n = 31, 42%), community (n = 29, 39%), off-shore (n = 7, 9%), national (n = 4, 5%), school (n = 2, 3%), and workplace (n = 1, 1%). Studies reported interventions focused at the individual (to facilitate uptake of health services) (n = 4, 5%), community (to raise awareness) (n = 25, 34%), provider (to offer health services) (n = 12, 16%) and/or system (to increase compliance with recommendations) (n = 33, 45%) level. To be effective, interventions were designed to overcome commonly identified barriers to accessing services related to language, culture, distance and cost. Engagement with community members and organisations was an effective way to co-design interventions that address migrants' specific needs.

CONCLUSIONS

Studies emphasised the importance of interventions that address the heterogeneity within and between migrant and refugee populations. Considerable variation in practice remains, therefore more evaluation of interventions is needed to inform policy and programme decision-making.

Using a mobile application to detect health needs among children and adolescents who are newly arrived migrants in Europe

BACKGROUND

Unprecedented numbers of migrants have arrived in Europe, including children and adolescents. Little is known about their unique health needs. Prospective data collection has been sparse. Mobile applications may help to facilitate global health surveillance.

METHODS

A pre-validated survey instrument was converted into a mobile application covering self-reported exposures and disruptions of healthcare before/during migration, communicable and non-communicable diseases. Participation was voluntary, anonymous and confidential.

RESULTS

Data were obtained from 405 migrant children and adolescents in Berlin, Germany, between 7 October 2015 and 15 March 2016 (median age 19 years, range: 1-24; 80.7% males) with the majority from Syria (62.5%), Afghanistan (9.1%) and Iraq (8.2%). In total, 55% were without family, 64% registered asylum-seekers with access to healthcare; 54% had seen a doctor since arrival, with colds or respiratory complaints (37.5 and 13.6%), followed by pain (26.7%) gastrointestinal (12.4%) and skin problems (11.1%). Underlying conditions were reported in 15.6%, predominantly asthma. Overall, 73% reported being up-to date on immunizations, but only 22% held a vaccination record with 46.4% having lost it during migration.

CONCLUSIONS

The lack of medical and immunization records among newly arrived migrants provides a challenge to healthcare systems. Mobile applications offer rapid screening tools in times of crisis, helping stakeholders with timely information.

Healthcare is not universal if undocumented migrants are excluded

Helena Legido-Quigley and colleagues examine the barriers that migrants face in accessing healthcare and argue they are counterproductive for host countries

[Health examination of asylum seekers: A nationwide analysis of state policies in Germany : § 62 of the asylum law]

BACKGROUND

A health examination of newly arrived asylum seekers, aimed at detecting infectious diseases and preventing disease outbreaks in accommodation facilities, is mandated by national law in all German states. Due to the decentralized German federal system, different state policies are in place and lead to substantial variation in the content and implementation of the health examination.

OBJECTIVES

To compare health examination policies in the 16 German states with a focus on conducted tests, preventive measures and the general procedure.

METHODS

A comparative content analysis of policy documents addressing the health examination was conducted. Relevant documents were identified through a nationwide search (conducted June-October 2015) through public sources, inquiries at responsible authorities and interviews with representatives of public health services.

RESULTS

In the study period, relevant policy documents for 13 states were identified, of which eight were administrative decrees of the responsible state ministries. Policies differed strongly with respect to the content of the health examination and the selection of compulsory screening measures. We identified three main groups: (A) states with compulsory screening limited to measures enshrined in federal law, (B) states with extended tuberculosis screening for children and pregnant women, and (C) states with extended mandatory screening measures for further infectious diseases beyond tuberculosis. Considerable differences were also found with regard to the implementation of the examinations, and the purchasing and re-imbursement policies.

CONCLUSIONS

The stark heterogeneity in health examination policies between the states cannot be rationally explained from a public health perspective. The indication for certain measures remains unclear. A broad discussion of the medical necessity of screening tests, combined with further systematic analyses, is necessary in order to develop nationwide evidence-based recommendations and decision-making tools for the conduct of health examinations of asylum seekers.

Microbiological screenings for infection control in unaccompanied minor refugees: the German Armed Forces Medical Service's experience

BACKGROUND

The German Military Medical Service contributed to the medical screening of unaccompanied minor refugees (UMRs) coming to Germany in 2014 and 2015. In this study, a broad range of diagnostic procedures was applied to identify microorganisms with clinical or public health significance. Previously, those tests had only been used to screen soldiers returning from tropical deployments. This instance is the first time the approach has been studied in a humanitarian context.

METHODS

The offered screenings included blood cell counts, hepatitis B serology and microscopy of the stool to look for protozoa and worm eggs as well as PCR from stool samples targeting pathogenic bacteria, protozoa and helminths. If individuals refused certain assessments, their decision to do so was accepted. A total of 219 apparently healthy male UMRs coming from Afghanistan, Egypt, Somalia, Eritrea, Syria, Ghana, Guinea, Iran, Algeria, Iraq, Benin, Gambia, Libya, Morocco, Pakistan, and Palestine were assessed. All UMRs who were examined at the study department were included in the assessment.

RESULTS

We detected decreasing frequencies of pathogens that included diarrhoea-associated bacteria [Campylobacter (C.) jejuni, enteropathogenic Escherichia (E.) coli (EPEC), enterotoxic E. coli (ETEC), enteroaggregative E. coli (EAEC), enteroinvasive E. coli (EIEC)/Shigella spp.), Giardia (G.) duodenalis, helminths (comprising Schistosoma spp., Hymenolepis (H.) nana, Strongyloides (S.) stercoralis] as well as hepatitis B virus. Pathogenic microorganisms dominated the samples by far. While G. duodenalis was detected in 11.4% of the assessed UMRs, the incidence of newly identified cases in the German population was 4.5 cases per 100,000 inhabitants.

CONCLUSIONS

We conclude that the applied in-house PCR screening systems, which have proven to be useful for screening military returnees from tropical deployments, can also be used for health assessment of immigrants from the respective sites. Apparently healthy UMRs may be enterically colonized with a broad variety of pathogenic and apathogenic microorganisms. Increased colonization rates, as shown for G. duodenalis, can pose a hygiene problem in centralized homes for asylum seekers.

[Systematic review and evidence mapping of empirical studies on health status and medical care among refugees and asylum seekers in Germany (1990-2014)]

BACKGROUND

Owing to a lack of routine statistics on the health status and medical care of asylum seekers, empirical studies play a major role in the mapping of these aspects.

OBJECTIVES

The aim of this review is to provide a comprehensive overview of the research landscape in this area, synthesizing knowledge from empirical studies and identifying evidence gaps.

METHODS

A three-tiered search strategy included searching for empirical studies in national/international databases and on the internet, screening reference lists, and contacting experts. Studies meeting predefined inclusion criteria were thematically organized and described in a narrative synthesis.

RESULTS

The searches generated 1,190 hits; 52 articles met the inclusion criteria. Of these, 41 were quantitative studies (78.9 %), 10 qualitative (19.2 %), and 1 was a review (1.9 %). A total of 30 primary articles (58.9 %) analyzed mental health aspects, followed by infectious diseases (n = 12, 23.5 %). Qualitative studies, mainly ethnographies and case studies, explored mental health and social determinants of health, providing evidence for the impact of living conditions on health and medical care. Few studies analyzed chronic diseases (n = 3) or childhood illnesses (n = 6). No studies analyzed the health needs or medical care of asylum-seeking women during pregnancy and child birth. In 62.7 % of the primary studies, a single sampling point was used to recruit asylum seekers. Nationwide external validity was given in two quantitative studies.

CONCLUSION

The priority research areas identified are chronic diseases and childhood and maternal health. The divergency and heterogeneity of the studies hamper a comprehensive and comparable acquisition of knowledgeand emphasize the  need for collaborative research to close the existing evidence gaps.

[Infectious disease outbreaks in centralized homes for asylum seekers in Germany from 2004-2014]

BACKGROUND

Migration and imported infections are changing the distribution of infectious diseases in Europe. However little is known about the extent of transmission of imported diseases within Europe. Asylum seekers are of increasing importance for infectious disease epidemiology and can be particularly vulnerable for infections and disease progression due to stressful conditions of migration and incomplete vaccination status.

OBJECTIVES

The aim is to analyse transmission of infectious diseases in centralized homes for asylum seekers in national infectious disease surveillance data to identify relevant infectious diseases and possible public health measures to reduce transmission.

METHODS

German national notification data was systematically analysed from 2004 to 2014 for outbreaks reported to have occurred within centralized homes for asylum seekers followed by descriptive analysis of outbreak- and case-characteristics.

RESULTS

From 2004 to 2014 the number of outbreaks in centralized homes for asylum seekers per year increased, a total of 119 outbreaks with 615 cases were reported. Cases in these outbreaks were caused by chicken pox (30 %), measles (20 %), scabies (19 %), rota-virus-gastroenteritis (8 %) and others (each <5 %). Of 119 outbreaks, two outbreaks of measles in centralized homes were connected to outbreaks outside the centralized homes. For 210 of 311 cases in 2014 the place of infection was reported, 87 % of those with known place of infection were infected in Germany.

CONCLUSIONS

Infectious disease outbreaks in centralized homes for asylum seekers are reported increasingly often in Germany. Chicken pox, measles and scabies were the most frequent outbreak causing diseases. Spread of such outbreaks outside centralized homes for asylum seekers was rare and infectious diseases are mainly acquired in Germany. The majority of outbreaks in centralized homes for asylum seekers would be preventable with vaccinations at arrival and appropriate hygiene measures.

Immunity against vaccine-preventable diseases in Finnish pediatric healthcare workers in 2015

Healthcare workers (HCWs) pose a risk to themselves and their patients if not protected against vaccine-preventable diseases. Alarmingly, lacking immunity has been reported in several studies. We assessed the immunity against vaccine-preventable diseases in 157 pediatric HCWs in Helsinki Children's Hospital. The HCWs enrolled answered a questionnaire and gave a serum sample. Antibodies were measured with EIA against MMR-diseases, tetanus and diphtheria toxins, Hepatitis B (HBV), Hepatitis A (HAV), varicella zoster and pertussis toxin. Neutralizing antibodies against poliovirus 1, 2 and 3 were measured. All of the HCWs had antibodies against tetanus and 89.8% against diphtheria. All had measurable levels of polio antibodies to all three polioviruses. 41% had suboptimal levels of antibodies against at least one of the antigens tested: MMR-viruses, diphtheria, HBV or polio. Measles, mumps and rubella antibodies were detectable in 81.5%, 89.2% and 93%, respectively. Only one HCW had no varicella-antibodies. Hepatitis B surface antibodies (HBsAb) were detected in 89.8% of the nurses. 67.5% had HAV-antibodies. A poor correlation between detected antibody levels and reported vaccination history was noticed, indicating a need for a universal record system for registering the vaccines given to each individual.

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

The decline of immunization rates in countries of origin of migrants and refugees, along with risky conditions during the journey to Europe, may threaten migrants' health. We performed a systematic review of the scientific literature in order to assess the frequency of vaccine preventable diseases, and vaccination coverage among migrants and refugees in Europe. To this end, Medline and Cochrane databases were considered. After the screening and the selection process, 58 papers were included in the review. We focused on the following vaccine-preventable diseases: hepatitis B, measles, rubella, mumps, tetanus, poliomyelitis, pertussis, diphtheria, meningitis, and varicella. The results were presented as a qualitative synthesis. In summary, several studies highlighted that migrants and refugees have lower immunization rates compared to European-born individuals. Firstly, this is due to low vaccination coverage in the country of origin. Then, several problems may limit migrants' access to vaccination in Europe: (i) migrants are used to move around the continent, and many vaccines require multiple doses at regular times; (ii) information on the immunization status of migrants is often lacking; (iii) hosting countries face severe economic crises; (iv) migrants often refuse registration with medical authorities for fear of legal consequences and (v) the lack of coordination among public health authorities of neighboring countries may determine either duplications or lack of vaccine administration. Possible strategies to overcome these problems include tailoring immunization services on the specific needs of the target population, developing strong communication campaigns, developing vaccination registers, and promoting collaboration among public health authorities of European Countries.

Measles, mumps, rubella, and varicella seroprevalence in refugees in Germany in 2015

PURPOSE

The current extent of migration poses emerging socio-economic and humanitarian challenges. Little is known on vaccination rates in migrants entering Europe, and the implementation of guidelines for serological testing and vaccination of refugees are pending.

METHODS

We conducted seroprevalence analyses for measles, mumps, rubella and varicella (MMRV) in 678 refugees coming to Germany during the current crisis.

RESULTS

The mean age of refugees was 28.8±11.4 years, and 76.1 % of subjects were male. Overall, IgG seronegativity was 7.4 % (95 % CI 5.5-9.6) for measles, 10.2 % (95 % CI 8.0-12.5) for mumps, 2.2 % (95 % CI 1.2-3.4) for rubella, and 3.3 % (95 % CI 1.9-4.9) for varicella. Seropositivity rates were age-dependent with considerably low values in children. For example, overall MMR immunity was 90.9 % (95 % CI 88.8-93.1), but only 73.1 % of minor aged refugees displayed complete seroprevalence against all three diseases, and only 68.9 % of children and adolescents were completely MMRV immune.

CONCLUSION

Our initial data set suggests overall satisfactory MMRV immunity in adult migrants coming to Europe, but the observed low MMRV seroprevalences in refugee children support thorough and prompt vaccination of young migrants entering Europe. Taken together, our data set underlines the urgent need to implement and validate vaccination guidelines for refugee care in the current crisis.

Systematic Review of Health Economic Analyses of Measles and Rubella Immunization Interventions

Economic analyses for vaccine-preventable diseases provide important insights about the value of prevention. We reviewed the literature to identify all of the peer-reviewed, published economic analyses of interventions related to measles and rubella immunization options to assess the different types of analyses performed and characterize key insights. We searched PubMed, the Science Citation Index, and references from relevant articles for studies in English and found 67 analyses that reported primary data and quantitative estimates of benefit-cost or cost-effectiveness analyses for measles and/or rubella immunization interventions. We removed studies that we characterized as cost-minimization analyses from this sample because they generally provide insights that focused on more optimal strategies to achieve the same health outcome. The 67 analyses we included demonstrate the large economic benefits associated with preventing measles and rubella infections using vaccines and the benefit of combining measles and rubella antigens into a formulation that saves the costs associated with injecting the vaccines separately. Despite the importance of population immunity and dynamic viral transmission, most of the analyses used static models to estimate cases prevented and characterize benefits, although the use of dynamic models continues to increase. Many of the analyses focused on characterizing the most significant adverse outcomes (e.g., mortality for measles, congenital rubella syndrome for rubella) and/or only direct costs, and the most complete analyses present data from high-income countries.

Seroprevalence of Antibodies against Measles, Rubella and Varicella among Asylum Seekers Arriving in Lower Saxony, Germany, November 2014-October 2015

The number of asylum seekers arriving in Germany has increased rapidly since 2014 and cases of vaccine-preventable diseases at reception centres were reported. Asylum seekers 12 years and older arriving in Lower Saxony were serologically screened for antibodies against measles, rubella and varicella between November 2014 and October 2015. We calculated the seroprevalence from the screening data by disease, country of origin and age group and compared them to literature-based herd immunity thresholds in order to identify immunisation gaps. In total, 23,647 specimens were included in our study. Although the vast majority of asylum seekers tested positive for antibodies against measles, rubella and varicella, the seroprevalences were not sufficient to ensure herd immunity. The seroprevalences varied substantially between countries of origin and increased with age. Immunisation of asylum seekers against measles, rubella and varicella is needed and the detailed information on seroprevalences among subgroups of asylum seekers can be used for targeted immunisations at reception centres.

Towards a European Framework to Monitor Infectious Diseases among Migrant Populations: Design and Applicability

There are limitations in our capacity to interpret point estimates and trends of infectious diseases occurring among diverse migrant populations living in the European Union/European Economic Area (EU/EEA). The aim of this study was to design a data collection framework that could capture information on factors associated with increased risk to infectious diseases in migrant populations in the EU/EEA. The authors defined factors associated with increased risk according to a multi-dimensional framework and performed a systematic literature review in order to identify whether those factors well reflected the reported risk factors for infectious disease in these populations. Following this, the feasibility of applying this framework to relevant available EU/EEA data sources was assessed. The proposed multidimensional framework is well suited to capture the complexity and concurrence of these risk factors and in principle applicable in the EU/EEA. The authors conclude that adopting a multi-dimensional framework to monitor infectious diseases could favor the disaggregated collection and analysis of migrant health data.

Effect of Restricting Access to Health Care on Health Expenditures among Asylum-Seekers and Refugees: A Quasi-Experimental Study in Germany, 1994-2013

Background

Access to health care for asylum-seekers and refugees (AS&R) in Germany is initially restricted before regular access is granted, allegedly leading to delayed care and increasing costs of care. We analyse the effects of (a) restricted access; and (b) two major policy reforms (1997, 2007) on incident health expenditures for AS&R in 1994-2013.

Methods and Findings

We used annual, nation-wide, aggregate data of the German Federal Statistics Office (1994-2013) to compare incident health expenditures among AS&R with restricted access (exposed) to AS&R with regular access (unexposed). We calculated incidence rate differences (∆IR_t) and rate ratios (IRR_t), as well as attributable fractions among the exposed (AFe) and the total population (AFp). The effects of between-group differences in need, and of policy reforms, on differences in per capita expenditures were assessed in (segmented) linear regression models. The exposed and unexposed groups comprised 4.16 and 1.53 million person-years. Per capita expenditures (1994–2013) were higher in the group with restricted access in absolute (∆IR_t = 375.80 Euros [375.77; 375.89]) and relative terms (IRR = 1.39). The AFe was 28.07% and the AFp 22.21%. Between-group differences in mean age and in the type of accommodation were the main independent predictors of between-group expenditure differences. Need variables explained 50-75% of the variation in between-group differences over time. The 1997 policy reform significantly increased ∆IR_t adjusted for secular trends and between-group differences in age (by 600.0 Euros [212.6; 986.2]) and sex (by 867.0 Euros [390.9; 1342.5]). The 2007 policy reform had no such effect.

Conclusion

The cost of excluding AS&R from health care appears ultimately higher than granting regular access to care. Excess expenditures attributable to the restriction were substantial and could not be completely explained by differences in need. An evidence-informed discourse on access to health care for AS&R in Germany is needed; it urgently requires high-quality, individual-level data.

[Vaccination coverage against measles and sero-epidemiology of measles-specific IgG antibodies in German children and adolescents]

BACKGROUND

Measles is a vaccine-preventable disease that could be eliminated by global vaccination strategies with two-dose measles vaccination. The World Health Organization (WHO) European Region aims at achieving measles elimination by 2015. Target control is mainly based on verification of 95 % vaccination coverage. In Germany, target verification cannot be based on data from centrally collected registers on vaccination and seroprevalence of measles-specific antibodies.

OBJECTIVE

This paper provides an overview of measles vaccination coverage and the timeliness of measles vaccination in birth cohorts 1989-2008. In addition, factors associated with vaccination gaps are described.

METHODS

Primary data on vaccination coverage (annual school entrance health examination) and on vaccination coverage and immune status (population-based German Health Interview and Examination Survey for Children and Adolescents - KiGGS) and secondary data (insurance refund claim data) are described and discussed.

RESULTS AND CONCLUSION

The measles immunization coverage (two doses) obtained in the 2010 school entrance examinations was 91.5 %. The range was 87.6-95.3 % between Federal States. Regional differences were even more pronounced between districts. The timeliness of the two-dose measles immunization increased from 41 % (birth cohorts 2001/2002) to 66 % (birth cohorts 2006/2008). Despite progress in recent years, measles vaccination coverage is still inadequate in adolescents, young adults, and young children. The German Standing Committee on Vaccination (STIKO) recommends a combined MMR vaccination of adults who were born after 1970 and who were not fully vaccinated against measles during childhood. Successful implementation of this recommendation is crucial just as it is important to step up efforts to improve the timeliness of measles vaccination in young children. Regional vaccination gaps and susceptible clusters defined by age or sociodemographic parameters are of particular importance to the epidemiology of measles disease. Knowledge of the factors associated with nonimmunization should be used to tailor vaccination strategies.