Presentation given by Dr. Silvia Declich during the ESCAIDE 2016 plenary session on migrant health on 29 November 2016 in Stockholm, Sweden

1. Silvia Declich
CNESPS/Istituto Superiore di Sanità - ISS (Italy)
ESCAIDE 2016: Plenary session on Migrant Health
Stockholm, 28 November 2016
Experiences and challenges in
monitoring migrant health
in migration centres and at community level

2. Outline
● Background
● Monitoring migrant health at community level
● Monitoring migrant health at migrant holding
level

3. Monitoring migrant health action points derived from the WHA Resolution
on the Health of Migrants [2008]. Modified from: 2010 World Health
Organization (WHO) Global Consultation report “Health of migrants−the
way forward”.

4. What are the numbers of migration in
Europe?
Eurostat, 2015
19.8 million persons
born in a non-EU
country
35.1 million people
born in a foreign
country and living in
an EU Member
State (6,9%)

5. High media attention

6. 2006 - 2014
www.viewsoftheword.net
2015
581.319
153.872
Migrants by sea

7. Migrants by land

8. Migrant status and points of access to health care:
the example of Italy
Intra EU
mobility
Irregular
migration
Regular
migration
(Third
Countries)
•Migrants with
regular visa
•Refugees
•Asylum seekers
•Undocumented
migrants (not
stopped by IT
authorities)
•Undocumented
migrants (stopped
by IT authorities)
Hosted temporarily in
detention centres
Immigration Hosted temporarily in
open (non secure)
migration centres
Depending on their legal status, foreigners
living in Italy may access health care and
prevention
• at community level (Min Health/NHS) or
• at migration centre level (Min Interior).
Enter the
community

9. Società Italiana di Medicina delle Migrazioni
NostraelaborazionesustimeIdos,datiMinisteroInternoeIOM,2015-SIMM
Regular migrants present: 5.420.000 (estimation Idos)
Migrants (including irregular): 5.800.000 (estimation Ismu)
Regular migrants resident: 5.015.000 (Istat)
Arrivals by sea 2014: 170.100 (MoI)
Arrivals by sea 2015: 153.842 (MoI)
Italy: migrants present in Italy and arrivals by sea
1 Jan 2015 (x 1.000)

10. MONITORING MIGRANT
HEALTH AT COMMUNITY
LEVEL

11. Monitoring infectious diseases among
migrant populations
Issues related to monitoring ID:
● diversity of data availability between countries and data
incompleteness for migrant related variables
● under/over/misreporting of cases of disease and
disalignment with appropriate denominators;
● how to account for the diversity of migrant populations.
Knowing the occurrence of infectious disease in migrant
populations is necessary to provide a response to individual
and public health needs.

12. Limits and constraints
Diversity and limits in
the definition of
migrants in ID
surveillance systems
● ECDC a migrant is
anybody “foreign-
borne”
● Italy different
definitions among
surveillance systems
Variable Variable
Description
Advantages Disadvantages
Country of
birth
Country of birth
of patient
- Relatively easy
to define
- Available by
age and sex in
Eurostat data on
migrants
-Includes host
country nationals
born abroad
-Provides no
information about
sub-groups and can
mask important
differences
-Second+ generation
migrants are not
included in this
definition.
Country of
nationality
Country where
the patient is
registered as
citizen
- Relatively easy
to define
- Available by
age and sex in
Eurostat data on
migrants
-Policies for granting
nationality vary
across countries
-Migrants and non-
migrants can have
more than one
nationality

13. Limits and constrains

14. Limits and constraints - 2
Numerators/denominators can be affected by
numerous biases:
● (Un)documented immigrants tend to have limited access to
health care and preventive services, which can lead to under-
diagnosis and under-reporting of disease underestimation
of disease occurrence
● Legislation influences both the accuracy and the availability
of denominators: incompleteness of denominators tends to
underestimate the “at risk” population overestimation of
disease occurrence
● Screening for asymptomatic diseases causes increased
reporting overestimation of disease occurrence when
compared with routine data
Riccardo F, Giorgi Rossi P, Chiarenza A, Noori T, Declich S. Letter to the editor: Responding to a call for action - where are we now?.
Euro Surveill. 2015;20(50)

15. Limits and constraints – 3
Migrants are considered one group not taking into
account the diversity of migrant populations
● Need for agreed and standardized variables able to
stratify this population on the basis of all dimensions that
can influence the risk of, and vulnerability to, infectious
diseases.
● Four data collection domains were identified, including the
main factors used to describe infectious diseases risk and
vulnerabilities among migrants a rapid desk review.

16. Riccardo F, Dente MG, Kärki T, Fabiani M, Napoli C, Chiarenza A, Giorgi Rossi P, Munoz CV, Noori T, Declich S. Towards a European
Framework to Monitor Infectious Diseases among Migrant Populations: Design and Applicability. Int J Environ Res Public Health. 2015 Sep
17;12(9):11640-61.
Multidimensional data collection framework: four data collection domains

17. How can we improve monitoring of ID at
community level in order to acquire data that
can be used to support decision making in
public health?
● Routine infectious disease surveillance
● Ad hoc studies on specific issues
Need for a multidimensional data collection framework
that could capture information on factors associated with
increased risk to infectious diseases in migrant populations in
the EU/EEA

18. Recommendations: to improve monitoring of ID at
community level in order to acquire data that can be used to
support decision making in public health
● Propose agreed and standardized definitions of “migrants” both for
numerators and denominators to use in ID surveillance and require
complete and reliable data matching those definitions
● Address limits in monitoring migrant health and ID at EU/EEA level by
exploring with Member States the possibility of including or modifying
relevant surveillance variables as per the data collection domains
proposed
● Conduct consensus meetings in order to agree on a core set of
indicators to collect comparable data, not available in surveillance,
through concurrent national cross sectional surveys conducted in the
EU/EEA.
● Support research finalized at addressing identified information gaps
for the development of a Framework to monitor infectious diseases
among migrant populations in the EU/EEA.

19. 2.5 .Epidemiological
surveillance capacities
need to be
strehgthened to
include migrant
sensitive data...
Systems that collect
data in respect of
migrant health also
need to be reinforced
so that outcome and
access issues may
inform further planning
around appropriate
target interventions….

20. MONITORING MIGRANT
HEALTH AT MIGRANT
HOLDING CENTRE LEVEL

21. Constraints and challenges
● Newly arrived migrants may be more vulnerable
to ID for the conditions they experienced during
their migration journey
● They may be subject to specific risks for ID in
relation to their country of origin and countries
visited during their migration
● Living conditions within closed or semi-closed
communities could increase the risk of ID spread
and expose migrants to ID

22. Constraints and challenges - 2
● Arrival of thousands people suffering harsh
travelling conditions in very short time frame
● Fluid target population
● Provisional centers fluidly opened and closed to
reflect accommodation needs
● Formal and provisional hosting centers largely
independent from the NHS and related
surveillance system
● Intense media attention

23. An ad hoc syndromic surveillance
system for ID at hosting center level
during a migration surge
● Syndromic surveillance is used in several
uncertain and high profile situations
● Italy developed a syndromic surveillance system
for ID at hosting center level during the 2011
Arab Spring
● Revised in 2014 to improve quality
Riccardo F, Napoli C, Declich S. et al. Syndromic surveillance of epidemic-prone diseases in response to an influx of migrants from North
Africa to Italy, May to October 2011. Euro Surveill. 2011;16(46):pii=20016.
Napoli C, Riccardo F, Declich S et al. An early warning system based on syndromic surveillance to detect potential health emergencies
among migrants: results of a two-year experience in Italy. Int J Environ. Res. Public Health 2014 Aug 20;11(8):8529-41

24. The Italian experience -1
• 13 syndromes

25. Migration
Centre
Local Health Unit Region
Cnesps-ISS and MoH
Analysis
Data entry
Dissemination
http://www.epicentro.iss.it/focus/sorveglianza/immigrati.asp
The Italian experience -2

26. • Aggregated data collection sheet
(numerator and denominator)
• Web based platform
The Italian experience -3

27. Methodology – statistical alerts and alarms
Expected incidence for each day based on the moving average of the previous
seven days
Alert threshold calculated on the observed incidence (99% CI of the observed
incidence).
OUTCOME DEFINITION ACTION
Statistical Alert
Breach of the Alert threshold
on one day.
Monitoring if threshold is
breached the following day
Statistical Alarm
Breach of the Alert threshold
for two consecutive days for
the same syndrome
Analysis stratified by reporting
migration centre.
If an alarm arises from a single
migration centre, the
CNESPS-ISS contacts the
reporting health officer of the
centre and ask for
epidemiological validation.
Health Emergency
Epidemiological confirmation
of statistical alarm
Outbreak control measures
implemented

28. Results – population
• Mainly young adults
(May 2011-June 2013)
79% of the population
under surveillance
composed by adolescents
and young adults between
15 and 44 years.
11,47%
38,49%
40,64%
9,40%
< 15 years
15-24 years
25-44 years
45+ years

29. Results – alarm thresholds
(May 2011-June 2013)
•260 alerts and 20 statistical alarms
• No health emergencies: absence of major outbreaks
Syndrome No. of Cases (%) No. Alerts No. Alarms
1. Respiratory tract disease 3586 (49.0) 45 5
2. Suspected pulmonary tuberculosis 76 (1.0) 33 1
3. Bloody diarrhoea 108 (1.5) 31 1
4. Watery diarrhoea 1652 (22.6) 59 5
5. Fever and rash 18 (0.2) 10 0
6. Meningitis/encephalitis/encephalopathy/delirium 2 (0.0) 1 0
7. Lymphadenitis with fever 27 (0.4) 11 0
8. Botulism-like illness 0 - -
9. Sepsis or unexplained shock 0 - -
10. Haemorrhagic illness 0 - -
11. Acute jaundice 4 (0.1) 3 0
12. Parasite skin infection 1841 (25.2) 67 8
13. Unexplained death 0 - -
Total 7314 260 20

30. Results – Incidence trends
• Overall low incidence for notified syndromes.
•No health emergencies: absence of major outbreaks
• Botulism-like illness, haemorrhagic illness, sepsis/unexplained shock and
unexplained death were never notified.
Incidence
<0,5%

31. Recommendations: to improve monitoring for ID at
hosting centre level during migration surges, in order to acquire
data that can be used to support decision making in public health
– Share protocols and experience among countries
– Develop a common EU/EEA protocol to have
comparable data
Syndromic surveillance within migrant hosting centres

32. The ECDC Guidance
● Handbook to support Member
States wishing to establish
Syndromic surveillance in
migrant reception/detention
centres and other refugee
settings
● Based on the experience of
experts in ECDC, Greece and
Italy
http://ecdc.europa.eu/en/publications/Publications/syndromic-surveillance-migrant-centres-handbook.pdf

33. The CARE project pilot implementation
• Development, pilot and evaluation of a shared syndromic
surveillance system in migrant holding centres:
• Greece, Italy will implement in four hotspots until end
December 2016
• Slovenia, Malta, Croatia, Portugal will participate in a
simulation exercise (16-27 January 2017)
• Focus on Southern
European countries
• Several activities
including monitoring
migrant health

34. • A pre-defined objective
• Aggregated data
• Context-adapted syndromes
• Flexibility in syndrome definition alternatives
• Possibility of adding a 14° syndrome only in some
countries
• Context-adapted data analysis
approaches
• complementing common collection format
and data series-specific statistical methods
• Development and pilot of a shared
syndromic surveillance web-based
secure platform
How?
http://careformigrants.eu/communicable-diseases-monitoring/

35. https://www.iss.it/site/RMI/SyndromicSurveillance/
Pilot ongoing …

36. Thanks
to the team ISS/CNESPS (Antonino Bella, Flavia Riccardo, Christian
Napoli, Cristina Giambi, Martina Del Manso, Maria Grazia Dente, Silvia
Declich)
to the team of ASL di Reggio Emilia (Antonio Chiarenza, Paolo Giorgi
Rossi, Paola Ballotari, Gabriele Romani e Annamaria Pezzarossi)
to the team of ECDC (Denis Coulombier, Jonathan Suk, Laura Espinosa,
Teymur Noori)
to the Italian Ministry of Health and the Regions
to all of you for the attention!
silvia.declich@iss.it