1. 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

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

3. 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

4. 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

5. 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

6. 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 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

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