1. Enhanced malaria diagnosis capacity in camps hosting migrants/ refugees in Greece, 2009-2017
Agis Terzidis
Paediatrician, Vice president of Hellenic Center for Disease Control & Prevention (HCDCP), Special advisor to the Minister of Health

2. Malaria in Greece 1974: malaria-free
: imported cases/year
74% of imported cases were migrants
: imported cases/year
83% of imported cases were migrants
Recent malaria crisis: vast migrants/ refugees influx in Greece
 20-35% of population originated from malaria endemic countries
Greece was declared free from malaria in 1974, following an intense control program ( ). Since then, several ( cases) imported cases were reported annually to KEELPNO referring to patients infected abroad (returning travelers or migrants from malaria endemic countries).
Recent migration crisis led to a vast migrants/refugees influx to Greece, with 20-35% of the refugee/migrant population hosted in camps originated from malaria-endemic countries.
Since 2015, an increase of the malaria imported cases was recorded among migrants originating from malaria endemic countries, representing 83% (241/290) of the imported cases in Among the 241 cases in migrants from endemic countries, 85% (204/241) originated from the Indian subcontinent.

3. Imported malaria cases by place of infection, Greece, 2015-2017
83% (241/290) of imported cases: migrants/ refugees
84% (201/241) of migrants patients: P.vivax malaria
23% (n=55) of migrants patients: hosted in camps/ hotspots
Place of infection
2015
2016
2017
Total
Indian subcontinent
57 (88%)
80 (88%)
67 (80%)
204 (85%)
Africa
8 (12%)
11 (12%)
18 (20%)
37 (15%) 65 91 85
241
Among the 241 cases in migrants from endemic countries, 85% (204/241) originated from the Indian subcontinent.

4. Locally acquired P.vivax cases
Malaria in Greece,
: locally acquired malaria cases
Year
Imported cases
Locally acquired P.vivax cases
2009 44 7
2010 40 4
2011 54 42
2012 73 20
2013 22 3
2014 38
2015 79 8
2016
111 6
2017
100
Additionally, since 2009 a number of locally acquired P. vivax malaria cases have been recorded in various areas of the country (i.e., among patients without travel history to a malaria endemic country), mainly as sporadic introduced cases but also in clusters (in ), in areas combining vectors with imported cases. Most areas where locally acquired cases were recorded over the last years were rural close to wetlands with high number of persons from endemic countries.

5. Activities for the management of malaria in Greece, 2011 - 2017
Multi-sectoral National Committee - Working Groups on VBDs
Action Plan for the Management of Malaria (MoH, HCDCP)
1. Risk assessment
2. Enhanced malaria surveillance
3. Enhanced laboratory diagnosis
4. Case management - Standardization of treatment
5. Communication
6. Blood safety measures
7. Vector surveillance and control
Following the occurrence of cases, the KEELPNO developed an Action Plan for the Management of malaria, which included a series of activities such as:
Enhanced malaria surveillance to early detect cases
Enhancing laboratory diagnosis of malaria
Standardization of the malaria treatment
Increase awareness among health professionals for the diagnosis of malaria
Communication to the public on malaria and personal protection measures against mosquitoes
Communication with national and international public health stakeholders
Blood safety measures
Vector surveillance and control activities

6. Activities for the management of malaria in Greece, 2011 - 2017
Multi-sectoral National Committee - Working Groups on VBDs
Action Plan for the Management of Malaria (MoH, HCDCP)
1. Risk assessment
2. Enhanced malaria surveillance
3. Enhanced laboratory diagnosis
4. Case management - Standardization of treatment
5. Communication
6. Blood safety measures
7. Vector surveillance and control
Since 2012, KEELPNO has developed and continuously implements an Action Plan for the Management of Malaria. In addition, during summer 2015 the “National Action Plan for the Management of Malaria” of the Ministry of Health was published. According to these, a series of activities are implemented nationwide for the prevention and management of malaria, with the collaboration of national, regional and local authorities. These activities for the management of malaria include (in short):
risk assessment for the re-emergence of malaria,
enhanced malaria surveillance and intervention activities (case finding, case investigation, active case detection, environmental and vector investigation),
enhancing laboratory diagnosis of malaria
case management - standardization of the malaria treatment
communication activities to the public, health professionals and local stakeholders/ public health authorities
designation of affected areas - blood safety and haemovigilance measures
vector control activities - entomological surveillance.
Since 2012, Hellenic Center for Disease Control & Prevention (HCDCP) distributed Rapid Diagnostic Tests (RDTs) for malaria to healthcare facilities in areas with migrant populations, to strengthen local diagnostic capacity, aiming at timely diagnosis of imported cases.

7. Activities for the management of malaria in Greece, 2015 - 2017
Multi-sectoral National Committee - Working Groups on VBDs
Action Plan for the Management of Malaria (MoH, HCDCP)
1. Risk assessment
2. Enhanced malaria surveillance
3. Enhanced laboratory diagnosis
4. Case management - Standardization of treatment
5. Communication
6. Blood safety measures
7. Vector surveillance and control
8. Prevention activities in camps hosting migrants/ refugees
Since 2012, KEELPNO has developed and continuously implements an Action Plan for the Management of Malaria. In addition, during summer 2015 the “National Action Plan for the Management of Malaria” of the Ministry of Health was published. According to these, a series of activities are implemented nationwide for the prevention and management of malaria, with the collaboration of national, regional and local authorities. These activities for the management of malaria include (in short):
risk assessment for the re-emergence of malaria,
enhanced malaria surveillance and intervention activities (case finding, case investigation, active case detection, environmental and vector investigation),
enhancing laboratory diagnosis of malaria
case management - standardization of the malaria treatment
communication activities to the public, health professionals and local stakeholders/ public health authorities
designation of affected areas - blood safety and haemovigilance measures
vector control activities - entomological surveillance.
Since 2012, Hellenic Center for Disease Control & Prevention (HCDCP) distributed Rapid Diagnostic Tests (RDTs) for malaria to healthcare facilities in areas with migrant populations, to strengthen local diagnostic capacity, aiming at timely diagnosis of imported cases.

8. Malaria prevention activities in camps hosting migrants/ refugees, Greece, 2016-2017
Risk assessment (vector, environment, demographics) for each camp
Enhanced surveillance - laboratory diagnosis capacity
Support hospitals in case management (diagnosis, treatment)
Personal protection against mosquitoes
Intensifying vector surveillance and control
Camps location, MoH Circular (>6km from large Anopheles breeding sites or population from non-endemic countries)
Since 2016, RDTs were further distributed to healthcare facilities in camps hosting refugees/migrants, and nearby hospitals, and awareness was raised among health professionals for testing suspected cases.
Local, regional and tertiary hospitals in Greece are facing increased number of referrals that concern refugees and migrants.
Given that some facilities have limited experience in diagnosing malaria through microscopy (the malaria diagnosis gold standard), the distribution, availability and use of RDTs aims at strengthening local malaria laboratory diagnostic capacity, in order to early detect malaria cases. The early detection of malaria cases enables the prompt management and treatment of individual patients and decreases the transmission period of each case contributing to the prevention of ongoing local transmission.

9. Enhanced laboratory malaria diagnosis capacity in camps hosting migrants/ refugees, Greece,
Distribution of Malaria RDTs (P.f/ Pan) in healthcare facilities providing health care to migrants/ refugees (POCs): - camps hosting migrants/ refugees, and - nearby healthcare facilities (hospitals and health centers)
Raised awareness among health professionals for testing suspected cases (letters, PHILOS personnel): - case definition of suspected cases - protocol on the management of suspected cases - guidelines on the use of RDTs (training of PHILOS personnel) - algorithm for case managing in negative and positive results
Monthly recording of the used RDTs (Jun - Dec 2017)
Since 2012, KEELPNO has distributed RDTs for malaria to hospitals and health centers in areas with recently recorded local malaria transmission, and in areas with large populations of immigrants from endemic countries (i.e., large urban centers, in refugee/migrant camps, reception centers and the nearby Health Units), to strengthen local diagnostic capacity, aiming at prompt diagnosis and treatment of malaria cases.
Since 2016, RDTs were further distributed to healthcare facilities in camps hosting refugees/migrants, and nearby hospitals, and awareness was raised among health professionals for testing suspected cases. Since 2017, this intervention was supported by programme “PHILOS–Emergency health response to refugee crisis” of the Greek Ministry of Health, implemented by HCDCP funded by Asylum, Migration and Integration Fund of EU’s DG Migration and Home Affairs.
Written information was provided when delivering the RDTs, including case definition of suspected cases and cases under investigation, protocol and guidelines on the use of RDTs, algorithm for managing the negative and the positive RDT results, and recording of the used RDTs. One contact person in each camp and each healthcare facility was defined to receive and be in charge of the storage and use of the RDTs. Recording forms for the used RDTs were also provided, with the request of monthly recording of the used RDTs.

10. Malaria RDTs (P.f/ Pan) distribution in camps hosting migrants/ refugees, Greece, 2016-2017
1,825 malaria RDTs were distributed to 58 camps
1,780 malaria RDTs were distributed to 77 nearby health units
Total RDTs supply, (n=5,800):
- Programme “PHILOS–Emergency health response to refugee crisis” (n=2,500)
- KEELPNO (n=1,800)
- MSF donation to KEELPNO (n=1,500)
Since 2012, KEELPNO has distributed RDTs for malaria to hospitals and health centers in areas with recently recorded local malaria transmission, and in areas with large populations of immigrants from endemic countries (i.e., large urban centers, in refugee/migrant camps, reception centers and the nearby Health Units), to strengthen local diagnostic capacity, aiming at prompt diagnosis and treatment of malaria cases.
Since 2016, RDTs were further distributed to healthcare facilities in camps hosting refugees/migrants, and nearby hospitals, and awareness was raised among health professionals for testing suspected cases. Since 2017, this intervention was supported by programme “PHILOS–Emergency health response to refugee crisis” of the Greek Ministry of Health, implemented by HCDCP funded by Asylum, Migration and Integration Fund of EU’s DG Migration and Home Affairs. In June-September 2017, the number of RDTs used in camps was regularly recorded.

11. Malaria RDTs distribution in camps hosting migrants/ refugees, Greece, 2016-2017
KEELPNO sent 5,083 RDTs to 218 healthcare (HC) facilities, including
3,605 RDTs to 135 HC facilities - POCs for migrants/ refugees: - 1,675 RDTs to 54 (100%) camps - 1,780 RDTs to 77 (100%) nearby HC facilities RDTs to 4 migrants’ detention centers
Since 2012, KEELPNO has distributed RDTs for malaria to hospitals and health centers in areas with recently recorded local malaria transmission, and in areas with large populations of immigrants from endemic countries (i.e., large urban centers, in refugee/migrant camps, reception centers and the nearby Health Units), to strengthen local diagnostic capacity, aiming at prompt diagnosis and treatment of malaria cases.
Since 2016, RDTs were further distributed to healthcare facilities in camps hosting refugees/migrants, and nearby hospitals, and awareness was raised among health professionals for testing suspected cases. Since 2017, this intervention was supported by programme “PHILOS–Emergency health response to refugee crisis” of the Greek Ministry of Health, implemented by HCDCP funded by Asylum, Migration and Integration Fund of EU’s DG Migration and Home Affairs.
Written information was provided when delivering the RDTs, including case definition of suspected cases and cases under investigation, protocol and guidelines on the use of RDTs, algorithm for managing the negative and the positive RDT results, and recording of the used RDTs. One contact person in each camp and each healthcare facility was defined to receive and be in charge of the storage and use of the RDTs. Recording forms for the used RDTs were also provided, with the request of monthly recording of the used RDTs.

12. Recording of malaria RDTs use in camps hosting migrants/ refugees, Greece, 2017
Systematic recording of the RDTs use, June – December 2017
In 35 (100%) camps with medical services and PHILOS personnel, where 1,150 RDTs were distributed: RDTs in 28 camps in the mainland RDTs in 7 camps on the islands
RDTs use recording: - at least once: from 28/35 (80%) camps (all 28 camps in the mainland) - at least once a month: from 12/35 (34%) camps
RDTs’ use was recorded at least once from a total of 28 (80%) camps; from all 28 (100%) camps in the mainland. In 2017, no recording of the RDTs use was provided from the seven camps located in the six Aegean islands-hotspots, which were supported by the PHILOS program in autumn 2017.
A total of 94 “Initial recording forms” were sent from these 28 camps, from March to December The number of camps per number of RDTs’ use recordings is presented in the Table 1. The median number of the recordings of the RDTs’ use (number of “Initial recording forms” sent) among these 28 camps was 3 (0-7).

13. Malaria RDTs use in camps hosting migrants/ refugees, Greece, 2016 - 2017
5% (39/800) RDTs were used in 39% (11/28) camps
28 imported malaria cases were diagnosed among migrants/ refugees living in camps: in in 2017
RDTs contributed to diagnosis in 96% (n=27) of these cases (in POCs in camps or nearby HC facilities)
5% (39/800) RDTs were used in 39% (11/28) camps (from the 28 camps where RDTs use was recorded at least once).
RDTs’ use was recorded at least once from a total of 28 (80%) camps; from all 28 (100%) camps in the mainland. In 2017, no recording of the RDTs use was provided from the seven camps located in the six Aegean islands-hotspots, which were supported by the PHILOS program in autumn 2017.
A total of 39 (5%) RDTs in 11 (39%) camps were recorded to have been used out of the 800 RDTs distributed to the 28 camps in the mainland (with at least one recording of the RDTs’ use) in , including 17 RDTs used in 2017.
A total of 94 “Initial recording forms” were sent from these 28 camps, from March to December The number of camps per number of RDTs’ use recordings is presented in the Table 1. The median number of the recordings of the RDTs’ use (number of “Initial recording forms” sent) among these 28 camps was 3 (0-7).

14. Conclusions – Challenges
Malaria RDTs: contributed to prompt diagnosis of imported cases in areas hosting migrants/ refugees
Challenges: - high turn-over of health professionals (training, raise awareness) - recording of RDTs use - resources
The high turn-over of the health professionals/ institutions/ agencies/ NGOs providing primary health care in POCs in refugee/migrant camps produces constrains in updating the RDTs contact persons, the recording of the RDTs’ use and the training of the health professionals.
The relatively small reported number of RDTs used since July 2017 in the refugee/migrants camps (in the mainland) cannot be easily assessed, i.e., if this is due to the actual small number of the malaria suspected cases among migrants in the mainland’s camps or to limited awareness and under investigation of suspected cases leading to under diagnosis (or the contribution of each factor to the limited number of the used RDTs).

15. Conclusions – Recommendations
Timely malaria diagnosis: pivotal for personal health benefit, and prevention of local transmission
In all areas hosting migrants from malaria endemic countries:
Local malaria diagnosis capacity should be enhanced
Malaria RDTs: valuable tool in the field, should be available
Raise awareness among health professionals (for prompt detection and testing of suspected cases): pivotal, should be enhanced
The high turn-over of the health professionals/ institutions/ agencies/ NGOs providing primary health care in POCs in refugee/migrant camps produces constrains in updating the RDTs contact persons, the recording of the RDTs’ use and the training of the health professionals.
The relatively small reported number of RDTs used since July 2017 in the refugee/migrants camps (in the mainland) cannot be easily assessed, i.e., if this is due to the actual small number of the malaria suspected cases among migrants in the mainland’s camps or to limited awareness and under investigation of suspected cases leading to under diagnosis (or the contribution of each factor to the limited number of the used RDTs).

16. Thank you

17. Imported malaria cases, Greece, 2015-2017
83% (241/290) of imported cases: migrants
23% (55/241) of migrants patients: hosted in camps/ hotspots (in 96% (53/55) of these cases: RDTs contributed to the diagnosis)
Place of infection of migrants
2015
2016
2017
Total migrants patients
Indian sub-continent
57 (88%)
80 (88%)
67 (80%)
204 (85%)
Africa
8 (12%)
11 (12%)
18 (20%)
37 (15%)
Total 65 91 85
241
Βασικοί άξονες δράσης:
Εκτίμηση κινδύνου
Επιδημιολογική επιτήρηση
Εργαστηριακή διάγνωση
Αντιμετώπιση – Διαχείριση κρουσμάτων
Επικοινωνία
Μέτρα για την ασφάλεια του αίματος
Επιτήρηση και έλεγχος διαβιβαστών