Chancroid, a rare sexually transmitted infection in Europe, may see changing epidemiology due to recent migration flows. A literature review found few reported chancroid cases in Europe since 2000, with most being sporadic or associated with travel. Studies from top countries of origin for migrants like Pakistan, Nigeria and Senegal show chancroid prevalence among high-risk groups. While data is limited on chancroid in Syria, Afghanistan and Iraq, appropriate access to sexual health services could benefit migrant sexual health. Clinical awareness remains advised for travelers reporting risk factors.

1. Chancroid – a rare disease in Europe.
Would recent migration flows change the
epidemiology in the EU/EEA?
Otilia Mardh, Ninnie Abrahamsson, Andrew Amato-Gauci
European Centre for Disease Prevention and Control
30th IUSTI European Congress 2016, September 15-17, Budapest

2. Chancroid – a rare sexually transmitted infection?
Worldwide
• Decline in global incidence (WHO, Global STI strategy, 2016)
• Still prevalent in resource-poor settings in countries from Africa, Asia; among
CSW and their clients (Lewis, 2014)
• Risk factor for HIV-transmission in sub-Saharan Africa
EU/EEA
• not mandatorily notifiable
• not reported to The European Surveillance System

3. Refugees movements to EU/EEA
• >1 million Mediterranean sea arrivals in 2015 (UNHCR1), 291 773 in 2016
• Majority originate from:
• Syria 43%, Afghanistan 23%, Iraq 14%;
• Pakistan, Iran, Nigeria, Gambia, Senegal, Guinea, Mali ; each <3%
• ECDC STI surveillance data: 11% of gonorrhoea and 7.3% of syphilis cases in
2010 were among migrants (ECDC report, 2014)
• Multiple barriers for migrants to access sexual health services (ICRH report,
2011)
• Undocumented migrants are at higher risk to acquire sexually transmitted
infections and less likely to access sexual health services (Sebo P, 2011)
1 United Nations High Commissioner for Refugees

4. Objectives
• Describe current epidemiology of chancroid in the EU/EEA
• Describe burden of infection in countries of origin of newly arrived
migrants, in order to identify needs for clinical awareness and sexual
health services

5. Methods
• Literature review
• PubMed® and Embase®, January 2016
• studies reporting prevalence, proportions of
positive patients, surveillance reports
• search strategies combined “chancroid” (OR
“ulcus molle” OR “Haemophilus ducreyi”)
with epidemiology and case reports
concepts
• publications from 2000 onwards
• no language restrictions
• UNHCR for refugees statistics
8 studies from 6
EU/EEA countries
7 case reports
from 6 countries
9 studies from 3
of the top 10
countries of
origin
http://data.unhcr.org/mediterranean/regional.php

6. Results

7. Chancroid epidemiology in EU/EEA
Prevalence studies, surveillance reports
NA –denominator data not available , *syphilis, gonorrhoea, chancroid and LGV, N/A = Information not available/reported
8 studies, 6 countries
References:
Zakoucka et al. 2004, Hope-Rapp et al. 2010, Kyriakis et al. 2003, Giuliani et al. 2004, Bruisten et al. 2001, O’Farrell &
Lazaro 2014, Dufaur et al. 2015, Rayment et al. 2013

8. Chancroid epidemiology in EU/EEA
Case reports
*contact with CSW in the country of travelling
References:
Henry et al. 2009, Marasovic et al. 2000, Knudsen et al. 2010, Knudsen et al. 2010, Holst et al. 2007, Fouéré et al.
2015, Canhoto et al. 2012, Barnes et al. 2014
7 cases, 6 countries

9. A sporadic case in UK, 2014
• 22y/o M
• No history of a contact with a non-UK
resident
• Painful penile ulcers
• Syphilis, HSV, LGV, chlamydia, gonorrhoea and
HIV – negative!
• Self diagnosed!
• No other cases identified through contact
tracing

10. GTI= genitourinary tract infections; IF, COAG = Direct immunofluorescence, coagglutination
Chancroid epidemiology in the top ten countries of origin of
newly arrived migrants* in EU/EEA
* Mediterranean sea arrivals, Jan-March 2016
Pakistan
Senegal
Nigeria
9 studies, 3 countries
References:
Maan et al. 2011, Bhutto et al. , Sami & Baloch 2005, Razvi et al.
2014, Rehan 2003, Awolade et al. 2012, Fayemiwo et al. 2011,
Fatiregun & Afolabi Bamgboye 2004, Totten et al. 2000

11. Conclusions: EU/EEA
• Low numbers of chancroid cases in Europe
• No cases reported after 2000 in Greece, Italy, Netherlands and Croatia,
after 2010 in Belgium and Denmark
• Most recent cases (sporadic) in UK, 2014 and France, 2015
• 4 cases associated with travel to North Africa, 2009; Guinea, 2000;
Pakistan, 2010; Madagascar, 2015
• 2 sporadic cases with no travel history (UK, 2014; Portugal,2012)
• Higher prevalence among foreign-borns in Italy, Greece (before 2000)
Sporadic occurrence of chancroid cannot be excluded.
Clinical awareness is advised in patients with a history of travel and sexual contact
with persons in high-risk groups.

12. Conclusions: refugees and migrants
• No studies from Syria, Afghanistan, Iraq (80% of refugees)
• Studies from Pakistan, Nigeria and Senegal (low % of migrants influx)
• Most recent chancroid reports from Pakistan, 2014; Nigeria, 2003; Senegal, 1992;
• Reports from patients in high-risk groups, patients with co-infections, FSW and
clients
Appropriate access to sexual health services will maintain or improve the sexual
health of newly arrived migrants.

13. Thank you!