The Syrian refugees crisis brings challenges to the health authorities in Europe: hepatitis A virus is a case in point

Public health consequences after ten years of the Syrian crisis: a literature review

Ten years of the Syrian war had a devastating effect on Syrian lives, including millions of refugees and displaced people, enormous destruction in the infrastructure, and the worst economic crisis Syria has ever faced. The health sector was hit hard by this war, up to 50% of the health facilities have been destroyed and up to 70% of the healthcare providers fled the country seeking safety, which increased the workload and mental pressure for the remaining medical staff. Five databases were searched and 438 articles were included according to the inclusion criteria, the articles were divided into categories according to the topic of the article.

Through this review, the current health status of the Syrian population living inside Syria, whether under governmental or opposition control, was reviewed, and also, the health status of the Syrian refugees was examined according to each host country. Public health indicators were used to summarize and categorize the information. This research reviewed mental health, children and maternal health, oral health, non-communicable diseases, infectious diseases, occupational health, and the effect of the COVID − 19 pandemic on the Syrian healthcare system. The results of the review are irritating, as still after ten years of war and millions of refugees there is an enormous need for healthcare services, and international organization has failed to respond to those needs. The review ended with the current and future challenges facing the healthcare system, and suggestions about rebuilding the healthcare system.

Through this review, the major consequences of the Syrian war on the health of the Syrian population have been reviewed and highlighted. Considerable challenges will face the future of health in Syria which require the collaboration of the health authorities to respond to the growing needs of the Syrian population. This article draws an overview about how the Syrian war affected health sector for Syrian population inside and outside Syria after ten years of war which makes it an important reference for future researchers to get the main highlight of the health sector during the Syrian crisis.

Hepatitis A virus age-specific seroprevalence after the implementation of a Toddlers' Vaccination in Turkey: Shifting susceptibility to adolescents

Aim:

In Turkey, improvements in sanitation and the implementation of a vaccination program resulted in reduced rates of childhood exposure to hepatitis A virus. The incidence of symptoms and the complications of the disease are known to be increased in later ages. We aimed to describe changes in the seroprevalence of hepatitis A virus from the pre-vaccine era (2012) to the post-vaccine era (2018) in different age groups.

Material and Methods:

Levels of anti-hepatitis A virus immunoglobulin (Ig)-G of patients with no chronic disease and who were admitted to our hospital between 2013–2018 were obtained retrospectively from a single children’s hospital database system.

Results:

A total of 3238 subjects were enrolled in the study (2820 children, 418 adults). The overall percentage of seropositivity was 60.5% in group 1 (age ≤2 years), 57.9% in group 2 (age 2–6 years), 31.2% in group 3 (age 7–11 years), 32.7% in group 4 (age 12–18 years), 44.6% in group 5 (age 19–24 years), and 73.9% in group 6 (age >25 years). Between 2013–2018, the increase in the number of seropositive individuals in group 2 (p<0.01), and the decrease in groups 3 and 4 were statistically significant from 2013 to 2018 (p=0.028, p<0.01).

Conclusion:

According to the data of this single-center children’s hospital in Turkey, hepatitis A virus seropositivity increases significantly in the preschool age group, but decreases in school-age children and adolescents after vaccination.

Epidemiology of hepatitis A in Greece in the last decade: management of reported cases and outbreaks and lessons learned

Hepatitis A is a mandatory notifiable disease in Greece. Here, we present the epidemiological data for 2009-2018 and the results of outbreak investigations performed, and discuss future public health priorities.Overall, 1193 cases were reported; 320 migrants/refugees, 240 Roma, 112 travellers and 521 from the general population. The median age of the affected general population (37 years) had an increasing trend (from 30.8 years in 2009 to 40.5 in 2018, P < 0.001) and was significantly higher than that among Roma and migrants (7 and 8 years, respectively, P < 0.001). Twenty-two cases (2.2%) were unvaccinated patients with a chronic liver disease. Fifty clusters with 2-12 cases each were recorded; 44 were attributed to person-to-person transmission and six to food consumption. Three outbreaks accounting for 32.3% of the total number of recorded cases were identified; in 2013 among Roma (112 cases), in 2016 among refugees (188 cases) and in 2017 among men having sex with men (96 cases; 33 of them (34.4%) HIV-positive). The epidemiological data depict that improving living conditions and vaccination coverage of deprived populations, and informing adults on the disease focusing at faecal-oral transmission during sexual intercourse and travel should be the future public health priorities.

Immunization Against Hepatitis A in Migrant Children: Three Vaccination Strategies, A Retrospective Study

BACKGROUND

Hepatitis A is endemic in many countries. Swiss guidelines recommend vaccinating patients native from endemic areas. In Geneva's Children's hospital, migrant children are screened and vaccinated if seronegative. Because hepatitis A's prevalence is decreasing worldwide, more children are seronegative at arrival, highlighting the need for immunization in medical centers and refugee camps and questioning the benefits of systematic serology. Other Swiss hospitals vaccinate regardless of serostatus. This study's aim is to assess migrant children's immunity according to origin and age, and the cost-effectiveness of different immunization strategies.

METHODS

We retrospectively analyzed 329 children's serostatus (1-16 years of age) between 2012 and 2015, using enzyme-linked fluorescent assay method. Serology and vaccine costs were based on local prices. Groups were compared with χ test and the age-seropositivity relationship was studied with linear regression.

RESULTS

The predominant regions were the Eastern Mediterranean and European Regions with mostly negative serologies (71% and 83%) and the African Region with mostly positive serologies (79%). Immunity varied depending on birth country. Regardless of region, seropositivity increased with age (P < 0.001). The most cost-effective vaccination strategy was an individualized approach based on age and origin, reducing costs by 2% compared with serology-guided immunization and by 17% compared with systematic vaccination.

CONCLUSIONS

Many migrant children >5 years old are seronegative and at risk of clinical infection. They need to be immunized. New guidelines according to age and origin should be defined to reduce immunization costs. We recommend systematic vaccination for patients <5 years old or native from low endemicity areas (≤25.7% of seropositivity). For the others, we propose serology-based vaccination.

Infectious disease profiles of Syrian and Eritrean migrants presenting in Europe: A systematic review

BACKGROUND

In the past decade, a large influx of migrants presented in Europe. Their country of origin was mainly either Syria or Eritrea. Public health institutions in host countries in Europe are challenged to screen and care for migrant populations with regard to infectious diseases.

METHODS

We performed a systematic literature review (according to PRISMA guidelines) to define the infectious disease profile of migrants originating in Syria and Eritrea.

RESULTS

The search resulted in 825 papers of possible relevance for infectious diseases in migrants from Syria, of which, after screening, we included 35 in the systematic review. A further 265 papers of possible relevance for infectious diseases in Eritrean migrants were screened, of which we included 27 in the systematic review. In migrants from Syria, leishmaniasis was the most frequently reported infectious disease. In addition, colonisation with drug resistant, Gram-negativ bacteria was reported. In the Eritrean migrants the infectious disease most described in the selected papers was louse-borne relapsing fever. Other frequently reported infectious diseases were scabies and Plasmodium vivax malaria.

CONCLUSION

Our systematic analysis defines the profiles of infectious diseases for migrants from Syria and Eritrea and serves as an evidence base for public health screening and care of presenting migrants.

The epidemiology of Norovirus in the Middle East and North Africa (MENA) region: a systematic review

Norovirus (NoV) is considered the second leading cause of viral acute gastroenteritis (AGE). To our knowledge, there are no systematic reviews assessing the role of NoV in AGE in the Middle East and North Africa (MENA) region. Consequently, we conducted an extensive systematic literature review on articles studying NoV in the 24 countries of the MENA region during the past 15 years (2000-2015). The methods and reporting were set according to the 2015 PRISMA-P and based on the elements from the international prospective register of systematic reviews (PROSPERO). We retrieved 38 studies meeting our predefined inclusion criteria and were used to extract full data. Studies reporting on NoV were conducted in 15 out of the 24 countries of the region. The reported NoV infection rates in MENA countries ranged between 0.82% and 36.84%. The majority of studies were clinical observational studies assessing NoV rates mainly among children. Participants were recruited from in- and outpatient clinics. NoV infection was reported all year round with with peaks observed mainly during cold months. GII.4 was the predominant genotype detected in stool of participants as reported by 16 out of 25 studies (64%). Overall, there is an increasing recognition of NoV as an important causative agent of AGE across all age groups in the MENA region. Further studies are needed to assess the national and the regional burden of NoV among different age groups, its molecular diversity and seasonal variability.

Hepatitis A virus infections and outbreaks in asylum seekers arriving to Germany, September 2015 to March 2016

From September 2015 to March 2016, hepatitis A notifications in Germany increased by 45% to 699 cases compared to 482 cases in the same period of the previous year. Children aged five to nine years were predominantly affected (22% of all cases in this period). We hypothesized that this increase could be explained by the marked influx of asylum seekers in this time period. We analysed national surveillance data and estimated the number of imported and autochthonous hepatitis A cases in asylum seekers. We also investigated molecular signatures of hepatitis A viruses sampled from asylum seekers to identify chains of transmission. We found that 40% (278 cases) of all 699 hepatitis A cases notified between September 2015 and March 2016 in Germany concerned asylum seekers. Most infections were acquired abroad, but at least 24% accounted for autochthonous infections. Among asylum seekers, children aged five to nine years were overrepresented with 97 of 278 (35%) notified cases. The analysed hepatitis A virus sequences were primarily subgenotype IB strains and clustered with previously isolated samples from the Middle East, Turkey, Pakistan and East Africa. Except one transmission from an asymptomatic child to a nursery nurse working in a mass accommodation, we are not aware of infection chains involving asylum seekers and German residents. We conclude that asylum-seeking children and adolescents are susceptible to hepatitis A virus infections, particularly children aged five to nine years. Measures to prevent secondary infections in asylum seekers such as extended hygiene measures and post-exposure prophylaxis seem advisable.