Christos Hadjichristodoulou Professor of Hygiene and Epidemiology Faculty of Medicine, University of Thessaly, Greece Seminar “ Population Movements and Public Health ”

African ship transferred slaves, designed by Thomas Clarkson

The slave deck of the ship “WILDFIRE”, Key West, Florida, 30 April 1860 Source: HARPER'S WEEKLY [JUNE 2, 1860]

Ellis Island

Migration in the European Union (EU) Over the last few decades: The overall migration direction changed. The EU region became more of a receiver than an exporter of people. The migrants are carrying with them: Their language and culture Their hygiene standards and lifestyle Their DNA (chronic diseases) Possibly communicable diseases Rapid global migration has a potential for any disease to be spread further and faster than was previously possible.

Major Migration Flows: 21 st century

Immigrant transportation to Greece

Different risks according to the immigrants wave  1989: First immigrant wave Albania (56%) Bulgaria (5%) Romania (3%) Georgia (3%) Ukraine (3%) Poland (3%)  1999: Second immigrant wave Pakistan Bangladesh India Philippines China  2015: Third immigrant wave Syria Pakistan Afghanistan Number of refuges and immigrants in Greece: ???

Apprehended undocumented immigrants, Greece SOURCE: Hellenic Police, *:9 months Apprehended undocumented immigrants Supporters of undocumented immigrants

Immigrants from malaria endemic countries*, Evrotas, Greece, *Pakistan, Afghanistan, Bangladesh

Reported malaria cases by year of onset and case classification, Greece, Year of symptom onset Imported casesLocally acquired cases* Total GreeceEvrotasGreeceEvrotas * All P. vivax cases

Geographic distribution of malaria cases (imported and locally acquired) in Greece focusing on Evrotas, Laconia

Actions and results to control malaria in Greece

Targeted activities of the HCDCP and MALWEST project for malaria 1. Active surveillance for human cases Focus investigation for every local case Active case detection Fever screening Mass screening (RDT, micro, PCR) 2. Mosquito surveillance 3. Training seminars for laboratory doctors and healthcare professionals 4. Information campaigns for the public 5. Molecular epidemiology 6. Mass drug administration (MDA) to immigrants, bed net distribution and indoor residual spraying (IRS)  Laconia Municipality

State of the art for malaria surveillance and control Systematic review of the current knowledge on malaria with an emphasis on Europe and Greece  Malaria manual Contents: ◦ Epidemiology of malaria in Europe and Greece ◦ Re-emergence of malaria ◦ Clinical manifestations and diagnosis ◦ Treatment and prevention ◦ Surveillance and risk assessment ◦ Mosquito control

State of the art for malaria surveillance and control

Study on presence, seasonal variation and spatial distribution of mosquitoes Additional actions Enhanced mosquito surveillance in Evrotas, Laconia and Marathon, Attica Study on mosquitoes overwintering in Evrotas Municipality Systematic comparison study on mosquito-trap National mosquito surveillance (funded by HCDCP) 2012 Focused mosquito surveillance in the high risk areas 2013

Results of mosquito surveillance in Evrotas, Laconia Mosquito species captured with traps Anophelinae  Anopheles sacharovi (Favre 1903)  Anopheles claviger s.s. (Meigen 1804) Culicinae  Culex pipiens s.l.  Culex territans (Walker 1856)  Culex tritaeniorynchus Giles, 1901  Aedes albopictus (Skuse 1895)  Culiseta longiareolata (Marcquart 1838)  Culiseta annulata (Schrank 1776)  Culiseta subochrea (Edwards 1921)  Ochlerotatus caspius (Pallas 1771)  Ochlerotatus dentritus (Halidey 1833)  Coquilletidia richiardii (Ficalbi 1889) Type of sampleSamplings Collected specimens Larvae & pupae Trap collections Resting adults963 Hunan bait collections 12 Total

Results of mosquito surveillance in Marathonas & Schinias area, Attica Total number of samples: 985 Mosquito species captured by traps Anophelinae  Anopheles sacharovi (Favre 1903)  Anopheles claviger s.s. (Meigen 1804)  Anopheles hyrcanus (Pallas 1771)  Anopheles algeriensis Theobald 1903 Culicinae  Culex pipiens s.l.  Culex tritaeniorynchus Giles, 1901  Culiseta longiareolata (Marcquart 1838)  Culiseta annulata (Schrank 1776)  Ochlerotatus detritus (Halidey 1833)

Malaria seroepidemiological study Target ◦ Antibody response assessment in Greeks and immigrants residing in areas with local malaria transmission Sampling ◦ 2012 – Pilot study:  19 Greeks  19 immigrants ◦ 2012 – Seroepidemiological study  248 asymptomatic Greeks  721 asymptomatic immigrants Methods ◦ ELISA ◦ IFAT

Results of pilot study:  Greeks: 10.5 %  Immigrants: 15.7 % Results of seroepidemiological study Results of malaria seroepidemiological study Country of origin Place of Residence LaconiaAttica Screening (n=1019) Greeks (n=298)Greece Positive results0/298 (0%) Immigrants (n=721) Pakistan73667 Afghanistan55 India77 Positive results 85/721 (11.78%)

Active surveillance for human cases Focus investigation for every local case Active case detection (ACD) Fever screening ◦ Regular house visits – Evrotas municipality Mass screening (RDT, micro, PCR) ◦ Evrotas municipality (Lakonia Regional Unit) ◦ Marathon municipality (East Attica Regional Unit) ◦ Points of entry Plasmodium genotyping

Results of active case detection 2012 ◦ Total fever screenings (every 15 days): ◦ 861 malaria tests (RDT, micro, PCR)  422 malaria tests for symptoms compatible with malaria  439 malaria tests in the context of focus investigation  17/27 malaria cases detected through ACD, of which 15 were immigrants from endemic countries 2013 ◦ Total fever screenings (every 7 days): ◦ 290 malaria tests (RDT, micro, PCR) 2014 ◦ Total fever screenings (every 7 days): ◦ 196 malaria tests (RDT, micro, PCR)

Evaluation of diagnostic tools used during active case detection  Diagnostic tools:  Rapid diagnostic tests (RDT)  Microscopy  PCR  955 samples examined by all diagnostic tools  Results PCR PositiveNegativeTotal RDT Positive430 Negative Total Microscopy PositiveNegativeTotal RDT Positive37643 Negative Total Sensitivity: 95.6% (95% C.I.: ) Specificity: 100% (95% C.I.: ) PPV: 100% (95% C.I.: ) K value : (95% C.I.: ) Sensitivity: 97.3% (95% C.I.: ) Specificity: 99.4% (95% C.I.: ) PPV: 86.1% (95% C.I.: ) K value : (95% C.I.: )

Results of Plasmodium genotyping Plasmodium genotyping in Filia, Karditsa (2012) Plasmodium genotyping in Evrotas Municipality, Laconia ( )

Results of Plasmodium genotyping

Training seminars - E-learning platform

Locally-acquired malaria cases by week of symptom onset, Evrotas, 2011 (n=33*) and 2012 (n=10) Decision for mass drug administration * Two cases with symptom onset in 2012 and one case with unknown week of onset are not included

Mass Drug Administration to immigrants Target population:  Immigrants from malaria endemic countries (not cases, not received Rx in 2012) G6PD testing Signed consent form with support of mediators Treatment course:  Chloroquine x 3 days (to cover cases of low parasitemia)  Primaquine x 14 days (target hypnozoites) Duration:  June – December 2013 and immigrants received treatment course in 2013 and 2014

Monthly distribution (number and percentage) of the completed regimens in 1,094 immigrants in 2013 and 2014 in Evrotas, Greece

Eligible immigrants in site (n=1270) Assessed for G6PD levels (n=1253) Excluded (n=75) # -Left the area of Evrotas Excluded (n=25) -G6PD moderate/severe deficiency (n=22) -Declined to participate (n=3) Excluded (n=17) -Cases of 2012 Lost to follow-up (MDA started but not completed due to departure from Evrotas) (n=49)* Lost to follow-up (MDA started but unknown if completed) (n=9) † MDA prematurely terminated due to side effect (n=1) Received malaria preventive therapy with DOT (n=950) Duration: 14 days Received malaria preventive therapy with SOT – phone call (n=144) Duration: 14 days) INITIATION OF MDA (n=1153) # Immigrants consented to participate and were tested for G6PD levels but left the area before initiation of MDA. * Field team was not informed and thus unable to continue with SOT. † Field team was informed, and the remainder of the regimen pills was provided to each immigrant but there was no confirmation that the course was completed (not answering phone calls). Follow-up at least 6 months Zero malaria cases and relapses No late side effects MDA flow chart during the years 2013 and 2014 in the area of Evrotas, Greece

Characteristics of the target immigrant population at Evrotas (n=1094), for 2013 and 2014 Immigrants characteristicsNumberPercentage Male gender % AgeRange (median: 28.5) N/A Country of originPakistan95287% Bangladesh585.3% Afghanistan756.8% India30.3% Iran10.1% Unknown50.5% Education (mean years in school)6.9N/A Duration of stay in Greece (months, median)38.3N/A

Reported adverse events associated to chloroquine and primaquine administration (n=1094), for 2013 and 2014 Side effect/SymptomChloroquine95% C.I.Primaquine95% C.I. No of events Dizziness143 (13.1%) Headache141 (12.9%) Diarrhoea50 (4.6%) Abdominal pain*76 (6.9%) (7.8%) Nausea/vomiting*67 (6.1%) (6.1%) Muscular weakness11 (1.0%) Sleep disturbance18 (1.6%) Skin rash13 (1.2%) Vision disorders7 (0.6%) Photosensitivity2 (0.2%) Anorexia*2 (0.2%) (0.5%) Hemolytic anaemia0 1 (0.1%)0-0.6

Reported malaria cases by year of onset and case classification, Evrotas and other regions in Greece, EvrotasOther regions in Greece Year of symptom onset Locally acquiredImportedLocally acquiredImported

Long Lasting Insecticide treated Nets -LLINs May – October 2013: ◦ 550 LLINs distributed to residences of immigrants from endemic countries ◦ 441 LLINs for 700 individuals from 19 to 31 May

Indoor residual spraying, IRS  IRS supervision  2012: two round IRS (July and September) with 81% coverage of immigrants’ residences  2013: two round IRS (June and October)  Evaluation over time of the residual activity of IRS  Every 30 days for 5 months

Malaria cases in 2015 and prediction for : ◦ A total of 60 laboratory confirmed cases of malaria were reported. ◦ 54 cases were imported and 6 P. vivax malaria cases as introduced locally acquired. ◦ Areas of introduced locally acquired cases: Evrotas, Marathonas, Larissa, Trikala, Thiva Conclusions 1.The same vulnerable regions as the previous years. 2.Evrotas Municipality is a very high risk area and Marathon is just below Evrotas Malaria is going to continue being a serious public health problem in Greece.

We should take control measures for immigrants but do not forget that Greece is famous for the Greek word “PHILOXENIA” that means hospitality! In Greece we are covering the vital needs of immigrants… …even through our austerity!