Management of hepatitis A cases among refugees, asylum seekers and migrants in hosting facilities in Greece, 2017 1st World Congress on Μigration, Ethnicity, Race and Health, 17-19/5/2018, Edinburgh K. Mellou, Head of Foodborne Diseases Unit Department of Epidemiological Surveillance and Intervention Hellenic Centre for Disease Control and Prevention

The hepatitis A virus RNA virus Member of the Picornaviridae family, genus Hepatovirus. 

Hepatitis A Transmission through the fecal-oral route Adults: usually fever, fatigue, loss of appetite, nausea, vomiting, diarrhea, dark urine, abdominal pain, jaundice Children: usually asymptomatic or mild symptoms Severity: 10%–15% of symptomatic persons have prolonged or relapsing disease for up to 6 months Does not become chronic Case fatality between 0.1% and 0.3% It can cause liver failure and death in people with other liver diseases Symptomatic treatment - self limited disease IgG antibodies to HAV provide lifelong protection Vaccine preventable disease 1st World Congress on migration, ethnicity, race and health, 17-19/5/2018, Edinburgh

Incubation period – transmission period Average incubation period: 28 days (range: 15– 50 days) Transmission period: 2 weeks before the symptoms onset until 1 week after the symptoms or jaundice onset Newborns and young children: may last longer (up to 6 months) 1st World Congress on migration, ethnicity, race and health, 17-19/5/2018, Edinburgh

Hepatitis A and refugees population Overcrowding at hosting facilities Poor conditions / personal hygiene measures Most of adults immune due to prior infection Children: the main pool of susceptible population, non vaccinated, often asymptomatic disease 1st World Congress on migration, ethnicity, race and health, 17-19/5/2018, Edinburgh

Management of reported cases Any suspected Hepatitis A (HA) case is reported to HCDCP Public health action is taken – Protocol for the management of HA cases at refugee hosting facilities developed in early April 2016 as an adaptation of the ‘Hepatitis A management protocol for sporadic cases and outbreaks’ already available 1st World Congress on migration, ethnicity, race and health, 17-19/5/2018, Edinburgh

Management – basic pillars Conditions inside camps (sewage system, safe water, etc.) Personal hygiene measures Vaccination of close contacts within 14 days after their last contact with the case Mass vaccination 1st World Congress on migration, ethnicity, race and health, 17-19/5/2018, Edinburgh

Conditions and hygiene measures Measures for improvement of conditions (co-operation Ministry of Immigration, local public health authorities, etc.) Training of refugees (e.g. on thorough hand washing) Brochures and posters with instructions on personal hygiene translated into Arabic, Urdu and Farsi were distributed 1st World Congress on migration, ethnicity, race and health, 17-19/5/2018, Edinburgh

Recording of contacts Needs to be done quickly Close contacts Relatives Same tent Friends / travelers with the same boat Challenging – mobility of the population – lack of cultural mediators Lack of knowledge at the field / other priorities 1st World Congress on migration, ethnicity, race and health, 17-19/5/2018, Edinburgh

Background data In 2015 and first trimester of 2016, 15 and 10 cases respectively were reported among refugees travelling via Greece to other European countries In March 2016, northern borders of Greece closed Estimated refugee population 52,000 on 1 April; 62,700 by 31 December 1st World Congress on migration, ethnicity, race and health, 17-19/5/2018, Edinburgh

Reported cases in 2016 April to December 2016, 177 laboratory- confirmed symptomatic cases Subgenotype IB 1st World Congress on migration, ethnicity, race and health, 17-19/5/2018, Edinburgh

Number of notified cases of HA among refugees by week of symptoms onset (n=177), Greece, April - December, 2016 1st World Congress on migration, ethnicity, race and health, 17-19/5/2018, Edinburgh

Ring and mass vaccinations performed 1,681 refugees were vaccinated from April to December 2016 1,082 (64.4%) at five camps (mass vaccination) 599 during ring vaccination of 177 reported cases 1st World Congress on migration, ethnicity, race and health, 17-19/5/2018, Edinburgh

2017 situation and PHILOS personnel PHILOS program took over the co- ordination of public health action European Program – Emergency health response to migrant/refugee crisis - programme of the Greek Ministry of Health, and HCDCP funded by the Asylum, Migration and Integration Fund (AMIF) of EU’s DG Migration and Home Affairs

Activities of PHILOS personnel Assured notification of suspected cases Followed up suspected cases Recorded close contacts at the camp / camps Informed personnel on prevention measures Conducted vaccinations Recorded action and sent reports at HCDCP 1st World Congress on migration, ethnicity, race and health, 17-19/5/2018, Edinburgh

Cases of hepatitis A among refugees by week of symptom onset, Greece, January-December 2017 (n=26) 1st World Congress on migration, ethnicity, race and health, 17-19/5/2018, Edinburgh

Epidemiological characteristics Of the 26 cases: 16 males and 10 females Median age: 6 years old (min:2, max:33) 21 cases were children <15 years old 13 different locations: 9 hosting camps (21 cases) and 2 hotels (3 cases) and 2 apartments (2 cases) 6 cases were notified from southeastern Aegean (Dodecanese), 6 from northern Greece, 3 from south Greece, 4 from central Greece and 7 from northeastern Aegean 12 cases were from Syria, 5 from Kuwait and 4 from Iraq 22 cases were hospitalised 1st World Congress on migration, ethnicity, race and health, 17-19/5/2018, Edinburgh

Vaccination, 2017 146 persons were vaccinated 86 of them were the entire childhood population of one camp 1st World Congress on migration, ethnicity, race and health, 17-19/5/2018, Edinburgh

Conclusion HA is a public health problem among vulnerable populations, such as refugees living at hosting camps Early response is crucial for the prevention of large outbreaks Focus at living conditions, hygiene measures and vaccination of close contacts 1st World Congress on migration, ethnicity, race and health, 17-19/5/2018, Edinburgh

Thank you for your attention! 1st World Congress on migration, ethnicity, race and health, 17-19/5/2018, Edinburgh