Vaccination policies of immigrants in the EU/EEA Member States–the measles immunization example

Vaccination policies of immigrants in the EU/EEA Member States–the measles immunization example Abstract Background In 2015–16, the European Union/European Economic Area Member States (EU/EEA MSs) experienced an unprecedented volume and rate of migration, posing serious challenges to existing national immunization systems and strategies and raising the questions of where, when and who to vaccinate. We assessed existing strategies for vaccinating immigrant populations in the EU/EEA using measles as an example of the most important vaccine-preventable diseases. Methods In this cross-sectional study, conducted from March to May 2016, an electronic questionnaire was sent to the Heads of National Immunization Technical Advisory Groups (NITAGs) or equivalent policy-making bodies in each of the 31 EU/EEA Member States. Responses were entered into a structured database and validated by survey responders for final analysis. Results Validated responses from all 31 EU/EEA NITAGs or equivalents showed that there is no common measles immunization policy for European immigrants. Policies vary widely from no policy at all (9 of 31, 29%) to vaccination of all comers (2 of 31, 6%), or vaccination of selected cohorts based on vaccination history (17 of 31, 55%) or serum antibody analysis (2 of 31, 6%). Further, the operational responsibilities for immigrant vaccination and documentation methods are not unified within the EU/EEA region. Conclusions With some notable exceptions immunization policies to contain spread of infectious diseases through migration are either non-existent or vary widely between countries in the EU/EEA. With freedom of movement within the EU/EEA there ought to be harmonization and a common EU/EEA vaccination strategy to replace national policies for immigrant populations. Introduction In the last 2 years, Europe has witnessed an unprecedented volume of migration, with over 7 million people migrating between countries inside the European Union and European Economic Area (EU/EEA) where almost 2 million people have arrived from outside Europe, including over 600 000 children.1,2 This has posed serious strains on the healthcare systems in the receiving countries, particularly with respect to immunization. Immigrants from outside or citizens moving between EU countries might fall through the very diverse European immunization systems such that they are not adequately vaccinated in either their home or host countries. While infants may receive their routine immunizations in the first 2–3 months of life on the assumption that mothers and new-borns will be ‘static’ for some months after the birth, there is no guarantee that children will receive recommended primary or booster vaccinations later in life. One prime example is measles vaccination, which is not normally administered before 9-months of age. Numbers of measles cases and deaths are at an all-time low, with elimination in some parts of the world, but the disease continues to be a major global public health issue, afflicting millions of people and causing an estimated 15 deaths every hour, despite the availability of highly effective and affordable vaccines.3,4 Europe is still some way from achieving its elimination goal, with regular measles outbreaks such as the one that started in Romania in February 2016 and continues with high intensity in 2017.5 Situations like this pose a potential risk of repeated exportation to other countries and continuous transmission in areas where vaccination coverage is suboptimal. Most recent measles outbreaks in the EU/EEA are linked to migration with four identified sources of measles importation from outside and five from inside the EU/EEA causing a total of 3969 infections and 1 death in 2015.6 EU measles elimination, first envisaged for 2010 and now reset for 2020,7,8 will always be hindered when some children have never been immunized or are incompletely immunized. Immigration adds to the complexity and challenges to achieving this goal. Existing EU legislation states that human immunization policy is a Member State competency,9 but individual National Immunization Technical Advisory Groups (NITAGs) face their own challenges to ensure high vaccine coverage levels. Comparisons of migrant health provisions across the EU/EEA are challenging; there is no consensus of the definition of ‘an immigrant’, as such classifications are determined by national legislative, administrative and policy factors and the terms vary considerably in the EU/EEA.10 We surveyed current policies for immigrant immunization in the 31 EU/EEA Member States with measles as an example disease, using an electronic questionnaire sent to each representative NITAG. Methods Study design This cross-sectional study, undertaken between March 7th and May 12th 2016, used a standardized, semi-structured electronic questionnaire sent to senior immunization policy stakeholders of each of the 31 EU/EEA Member States (Supplementary table). Liechtenstein was not included as the country does not have its own NITAG but has a representative member at the Swiss EKIF (Eidgenössische Kommission für Impffragen-Switzerland), adopting their recommendations without further assessment. We identified stakeholders by web searches using the Vaccine European New Integrated Collaboration Effort gatekeeper‘s list, country specific NITAG members lists (where available) and European Centre for Disease Prevention and Control (ECDC) and World Health Organization resources. Answers from completed surveys were entered into a database and specific country profiles created using a reader-friendly design closely following the defined five domains of the questionnaire. These were returned to the 31 Member States responders for validation to ensure that we did not introduce any errors through our interpretation. In some countries (Spain, Sweden, Luxembourg, Romania, Switzerland, France, Germany, Norway, Portugal) teams of professionals working at National Institutes of Public Health, NITAGs or Ministries of Health, worked on the original questionnaire and evaluated their country profiles, but the validation was given by one nominee who in most of the cases was the head of the respective department, institution or NITAG chair. The same approach was used in previous work on immunization policies or NITAG practices and characteristics in the EU/EEA Member States that presents data which was validated by one nominated contact person in most of the countries.11,12 Data collection The survey collected data on immigrant immunization policies in general, with specific questions on underlying measles epidemiology and routine measles vaccination policies, as well as operational practices and goals of NITAGs or equivalent decision-making committees. We defined an immigrant as ‘a person who comes to live permanently in a foreign country’ so including European citizens moving between countries within the EU/EEA. This definition was sent to all participants in an invitation email together with the survey link and the general description of the study. The standardized questionnaire solicited specific information in five domains: Immunization strategies for immigrants using measles as example: description of existing strategies, methods currently used to determine the measles vaccination and immune status of immigrants, measles vaccination assessment of immigrants. This manuscript presents data from this specific domain. Baseline measles epidemiology/vaccination: size of birth cohort, vaccination coverage for first (MCV1) and second (MCV2) measles vaccinations, the schedule within country immunization program diversity, vaccine type and intentions to introduce a different measles containing vaccine, measles catch-up campaigns in the last 5 years and reasons for conducting them, surveillance and monitoring methods for measles, and incentives given to healthcare providers to achieve measles immunization targets. Vaccines: measles vaccine supply and potential shortages due to provision of measles vaccinations to immigrants. Operational goals and implementation of measles immunization: description of operational goals and implementation methods, published references, government websites or others in place to ensure adequate communication of these goals and implementation methods. NITAG specific: NITAG name in country language and English, website and current roles and responsibilities of the existing EU/EEA NITAGs or equivalent decision making committees. Data handling and analysis The questionnaire, developed in English using Google forms® and available to all participating countries, was completed by the selected participants and saved automatically in Google Drive®. Data from validated country profiles were imported into Excel® and analysed quantitatively and descriptively to obtain aggregated results which describe key characteristics of measles vaccination policies in EU/EEA. Results Competent immunization policy representatives from all 31 (100%) EU/EEA Member States responded to and validated the questionnaire (Supplementary table); 23 countries provided comments during the validation and their country profiles were adjusted accordingly, and 8 countries validated without adjustments. There is a large diversity in strategies for measles vaccination of immigrants across the 31 EU/EEA Member States (figure 1). Nine (Bulgaria, France, Hungary, Poland, Portugal, Slovakia, Slovenia, Spain and Switzerland) do not have any country level immigrant measles vaccination policy while strategies of the other 22 can be classified by taking into consideration parameters like age, immunization status and what constitutes an immigrant. Figure 1 View largeDownload slide EU/EEA Measles vaccination policies for immigrants Figure 1 View largeDownload slide EU/EEA Measles vaccination policies for immigrants Two countries vaccinate all immigrants regardless of age or vaccination status; Lithuania, where all immigrants are mandatorily vaccinated against measles. The UK, where without a reliable vaccination history, immigrants are assumed to be unimmunized. Two doses of MMR are given irrespective of history of measles, mumps or rubella infection and/or age. Six countries vaccinate immigrants after assessing their immunization status regardless of age: Cyprus: vaccination is performed after evaluation of vaccination records by specific healthcare providers assigned for immigrants or public healthcare providers. Austria and Estonia: unimmunized immigrants are vaccinated according to the national immunization schedule. Status is determined by any healthcare provider (Austria) or two healthcare providers after evaluating the vaccination records (Estonia). Norway: all immigrants receive MMR if they were not previously vaccinated or have had the disease. Specific healthcare providers assigned for immigrants or public healthcare providers evaluate immunization status in a medical screening visit for new arrivals by analysing vaccination records and self-reported history of previous measles disease or vaccination without written documentation. Luxembourg: immigrants are vaccinated if unimmunized and after a medical screening visit; immunization records are evaluated by the Public Health service under the responsibility of the Ministry of Health. Iceland: after determining immunization status by specific healthcare providers assigned for immigrants using existing vaccination records unimmunized immigrants are vaccinated according to the national schedule. Two countries vaccinate immigrants depending on age and immunization status assessment: Malta: immigrants under 18 years are vaccinated with MMR if they are deemed unimmunized after the country or regional office for vaccination has assessed the status from the existing immunization records. Sweden: all immigrant children 0–18 years are offered all vaccines included in the Swedish National Immunization Program, including MMR. Non-immune adults are also recommended MMR but must pay the cost. Immigrant immunization status is assessed by specific or public healthcare providers after evaluating vaccination records and/or self-reported vaccination status or previous disease. MMR is given only if they are unvaccinated or lack clear documentation. Three countries vaccinate specific immigrant populations, namely asylum seekers, regardless of the age, after assessing their immunization status: Croatia: only asylum seekers are vaccinated against measles if they do not have documented evidence of earlier vaccination. Evaluation is performed by a specifically assigned healthcare provider in a medical screening visit and on the basis of existing vaccination records, self-reported previous vaccination or disease. Other immigrants are not vaccinated. Belgium: only asylum seekers and refugees receive measles vaccine if unvaccinated. Latvia: only asylum seekers and refugees are immunized after evaluation of vaccination records during a medical assessment by a specific healthcare provider. Six countries vaccinate specific immigrants based on age and immunization status: Greece: vaccinates all refugees between 12 months to 15 years of age with one dose of MMR, after assessing immunization status based on self-reported vaccinations without written documentation. Other immigrants are not vaccinated. The Czech Republic only vaccinates asylum seekers younger than 18 years after a specific health care provider evaluates vaccination records. Finland: only unimmunized refugees, asylum seekers and foreign students are offered MMR vaccination. Any healthcare provider can assess the status based on existing vaccination records or self-reported previous vaccinations or disease. Germany: The Robert Koch Institute issued a concept note for the vaccination of asylum seekers early after their arrival, priority being given to close gaps in measles immunization. In case of missing vaccination records, adults born after 1970 should also be vaccinated. Assessment of immunization status can be performed by any healthcare provider by evaluating existing vaccination records. Denmark: a medical examination, performed by public healthcare providers, including assessment of immunization status (vaccination records, self-reported vaccinations without written documentation or self-reported previous disease) is offered to all asylum seekers in special centres where they must live while their application is being processed. All migrant children receive MMR, administered in these asylum centres, in accordance with the Danish immunization program. The Netherlands: children of asylum seekers (0–19 years) are immunized after assessment of vaccination status by a public healthcare provider or the country or regional office for vaccination based on evaluation of vaccination records. Reliability of self-reported vaccination status is also considered and judged by the healthcare provider. Special situations existed in three countries: Romania: existing policies for refugees, immigrants and asylum seekers included in the Romanian national vaccination program, apply only in the context of particular epidemiological situations or in case of international public health emergencies. These policies refer to provision of measles immunization recommendations to this population. Ireland: most immigrants are under care of a GP (General Practitioner) who should assess vaccination status after evaluating existing records and taking into consideration also self-reported doses of vaccine or previous disease. The public health system formally assesses asylum seekers, recommending and providing vaccination if required. Without documented MMR vaccination the recommendation is they should be vaccinated; Italy: the only country that requires legal immigrants to have a medical examination in their country of origin, before arriving in Italy. For other immigrants (including illegal immigrants arriving by sea), there is no a standard national measles vaccination policy. Regional approaches vary, and may include serologic evaluation, dissemination of leaflets in different languages, active calls for immigrants and for other difficult to reach populations. Different methodologies are used to assess immigrants’ measles vaccination or immune status across EU/EEA countries (figure 2), with one or more different methods used. In 25 of 31 (81%) Member States immunization status of immigrants is based on assessing the vaccination records during medical screening visits for new arrivals or during later checks. In 10 of 31 (32%) countries, this assessment is based on self-reported measles vaccination status with no written documentation, self-reported measles disease or vaccination in seven (23%) countries, and by serologic evaluation of immigrants performed prior to immunization in two (6%) countries (Italy and Spain). Figure 2 View largeDownload slide Methods used for assessing measles vaccination and/or immune status of an immigrant in EU/EEA Figure 2 View largeDownload slide Methods used for assessing measles vaccination and/or immune status of an immigrant in EU/EEA Responsibility for assessing immigrants measles vaccination status varies considerably among the EU/EEA countries (figure 3). In 16 (52%) Member States, specific healthcare providers are assigned for immigrants and in 10 (32%) public healthcare providers are responsible vaccinating immigrants. In nine countries (29%) any healthcare provider can assess measles vaccination status in immigrants, while two (6%) countries (Malta and The Netherlands) have national or regional offices for immigrant vaccination. No EU/EEA Member State provides measles immunization services for immigrants at, or locally to consulates or embassies where visas are issued. Figure 3 View largeDownload slide Responsibility for measles vaccination assessment of immigrants in EU/EEA Figure 3 View largeDownload slide Responsibility for measles vaccination assessment of immigrants in EU/EEA In four (13%) countries (France, Greece, Ireland and Slovenia), this responsibility is not defined although it will be defined in France in the future. In Ireland, public healthcare providers have a clear responsibility to assess measles immunization, but only for asylum seekers being screened. Legal immigrants to the country must discuss vaccination with their own GP. Measles immunization schedules currently being used in EU/EEA Measles vaccination schedules are set at the national level in 30 of the 31 EU/EEA countries. In Germany 15 of the 16 federal states have a common recommendation, the exception being Saxony where a regional committee recommends MCV2 at age 5+ years. Across the EU/EEA region there are eight different recommended vaccination schedules for MCV1 which we clustered into three categories (figure 4), mainly differing in age at first dose and age window for vaccination. The minimum age for measles vaccination in the EU/EEA is 11 months in Austria and Germany which are following a common schedule, 11–14 months of age, while 23 countries start their measles immunization schedules at 12–15 months of age. Denmark, Hungary and Norway recommend MCV1 be given at 15 months exactly, Slovakia gives MCV1 between 14–17 months of age, and Iceland and Sweden give MCV1 only at 18 months. Figure 4 View largeDownload slide Measles vaccination schedules in EU/EEA Figure 4 View largeDownload slide Measles vaccination schedules in EU/EEA Age ranges for the second dose of measles vaccine are wider, with 16 different recommendations starting as early as 15 months, before the first dose has been given in some countries and as late as 13 years of age (figure 4). MCV2 recommendations are clustered as follows: 15–24 months of age (6/31, 19%), 3–6 years of age (6/31, 19%), 5–10 years of age (13/31, 42%) and above 10 years of age (6/31, 19%). Discussion We researched measles vaccination policies for immigrants into Europe because of three concerns which could amplify each other: the current wave of immigration which poses a potential communicable disease risk, the increase in EU/EEA measles cases and exportations inside and outside of the region, and the status of harmonization of EU/EEA vaccination schedules. We prepared a detailed and representative inventory of current policies and measles immunization strategies for immigrants from all 31 EU/EEA Member States (excluding Liechtenstein). The unprecedented volume and the speed of migration Europe experienced in 2015–16, with almost 2 million external immigrants arriving and over 7 million migrating within the region,1,13 poses serious challenges to the existing immunization systems to decide when, where and whom to vaccinate. Definitions of what constitutes an immigrant, a migrant, refugee or asylum seeker differ widely across the EU/EEA Member States, complicating the analysis and comparison of policies. Different definitions have significant consequences for data in terms of numbers of migrants and the analysis of the impact of migration on the epidemiology of different infectious diseases.14 Migration is a pan-European phenomenon, but immigration health policies are still national, reflected in the wide diversity in strategies for immigrant measles vaccination across Member States. Only Lithuania and the UK vaccinate all immigrants regardless of their age, origin or vaccination status. The low risk of serious or severe adverse events due to measles vaccination in individuals who have had measles or have been vaccinated previously15 makes this a very pragmatic, safe and probably cost-effective approach that could serve as a model for the rest of Europe. Those countries or regions which only vaccinate after resource- and time-consuming serological testing for measles, risk that results are only available when the immigrant has already have moved on. Most EU/EEA measles outbreaks in 2015–17 were linked to migration.16 This situation is exacerbated by lack of EU/EEA strategies to address the politically sensitive issue of harmonization of vaccination schedules and immunization policies of immigrants, and the methods used for assessing measles immunization status in immigrants. While measles vaccination of immigrants from outside the EU/EAA is a first country of entry border issue, for which clear vaccination policies should be in place, internal migration across Member States poses a different problem. Without harmonization of measles vaccination policies a child migrating from one European country to another could easily fall through the cracks and not be vaccinated because of being too young in the exit country and too old in the destination country. There are some limitations to this study. First, the process of identifying appropriate stakeholders to answer the questionnaire in each country was difficult and also time consuming. Secondly, although additional explanatory information was provided, respondents may have interpreted the term immigrant somewhat differently. Thirdly, the questionnaire was quite lengthy and time consuming, covering five different domains. These limitations were anticipated before the survey was sent. We carefully screened and analysed available resources to create a complete and reliable list of responders to our survey and a communication plan was implemented from the beginning with reminders, follow-up emails and clear clarifications and scheduled phone calls with some responders. Acknowledgements The authors acknowledge the contribution of Prof. Dr. Sue Ann Costa Clemens who participated in the initial design of the survey and provided important guidance during the study; Prof. Dr. Emanuele Montomoli as a representative of the University of Siena-Medical School for all the support provided during the development of the study; Prof. Dr. Heinz Josef Schmitt for his timely suggestions that helped establishing the goals of this research; Dr. Steffen Glismann for important guidance and contribution; Dr. Giovanni della Cioppa for his advice and support; Keith Veitch for editorial advice, and finally and most especially all the survey respondents for taking the time to complete the questionnaire, to validate their countries profiles and reply to our follow-up questions. This work has been orally presented at the 15th Conference of the International Travel Society on 15th of May 2017 in Barcelona, Spain. Funding No honoraria, grants or other form of payment were provided to authors during research or the development of this manuscript to which both MAB and RC contributed equally. Conflicts of interest: None declared. Key points To the best of our knowledge, this is the first research presenting and analysing the vaccination strategies for immigrants in all EU/EEA Member States. The results show a great diversity and discrepancy in strategies for measles vaccination of immigrants in EU/EEA as also a great variety of vaccination schedules currently used across the Region, with little if no sign of harmonization. We show that in the EU/EEA region, where measles vaccination coverage is suboptimal, migration plays a very important role in outbreaks and further complicating the goal of measles elimination in all EU by 2020. Migrant immunization policies in Europe are not harmonized at all which leads to the fact that especially migrant children fall thru the cracks of the system where in one country they are too young to be immunized and when arriving in the destination country they are too old. Common efforts toward vaccination of migrants rather than establishing national policies, guidelines and different recommendations on the basis of different categories and definitions of immigrants, are needed in order to achieve the goal of elimination. Disclaimers This research was conducted by MAB as thesis in the Executive Master Program in Vaccinology and Pharmaceutical Clinical Development at the University of Medicine in Siena, Italy. RC was supervisor for MAB’s master thesis. The corresponding author had full access to all the data in the study and had final responsibility for the decision to submit for publication. No honoraria, grants or other form of payment were provided to authors. MAB and RC declare no competing interests. Supplementary data Supplementary data are available at EURPUB online. References 1 Semenza JC, Carrillo-Santisteve P, Zeller H, et al.   Public health needs of migrants, refugees and asylum seekers in Europe, 2015: infectious disease aspects. Eur J Public Health  2016; 26: 1– 2. Google Scholar CrossRef Search ADS PubMed  2 Statistical office of the European Union. Statistics Explained [Internet]. Statistical office of the European Union Official website. 2016 [cited 2016 Dec 29]. Available at: http://ec.europa.eu/eurostat/statistics-explained/index.php/Main_Page. 3 World Health Organisation. WHO | Measles | Fact sheet [Internet]. World Health Organization. World Health Organization; 2016 [cited 2016 May 5]. Available at: http://www.who.int/mediacentre/factsheets/fs286/en/. 4 Centers for Disease Control and Prevention. Vaccines: VPD-VAC/Measles/FAQ Disease & Vaccine [Internet]. Centers for Disease Control and Prevention official website. 2015 [cited 2016 May 6]. Available at: http://www.cdc.gov/vaccines/vpd-vac/measles/faqs-dis-vac-risks.html. 5 ECDC. Ongoing Outbreak of Measles in Romania, Risk of Spread and Epidemiological Situation in EU/EEA Countries Main Conclusions and Options for Response. 2017;(March). Available at: http://ecdc.europa.eu/en/publications. 6 European Centre for Disease Prevention and Control. Measles and Rubella Monitoring Reports. [cited 2016 May 19]. Available at: http://ecdc.europa.eu/en/publications/surveillance_reports/vpd/Pages/emmo.aspx. 7 The Regional Office for Europe of the World Health Organization. Renewed Commitment to Measles and Rubella Elimination and Prevention of Congenital Rubella Syndrome in the WHO European Region by 2015 Regional Committee for Europe. WHO Reg Off Eur Publ. 2010; 6(July): 1. 8 The Regional Office for Europe of the World Health Organization. European Vaccine Action Plan 2015–2020 . WHO Reg Off Eur Publ, 2014. 9 Tsolova S. The treaty of Lisbon and public health in the EU [Internet], Vol. 20. Eur J Pub Health  2010; 20: 475. Google Scholar CrossRef Search ADS   10 International Organization for Migration. European Research on Migration and Health [Internet]. International Organization for Migration official website. [cited 2016 Jul 22]. Available at: http://www.migrant-health-europe.org/files/Research on Migrant Health_Background Paper.pdf. 11 European Centre for Disease Prevention and Control. Current Practices in Immunisation Policymaking in European Countries . Stockholm: ECDC, 2015. 12 Takla A, Wichmann O, Carrillo-Santisteve P, et al.   Characteristics and practices of national immunisation technical advisory groups in Europe and potential for collaboration, April 2014. Euro Surveill  2015; 20:pii: 21049. 13 Statistical office of the European Union. Statistics Explained [Internet]. Statistical office of the European Union Official website. 2016. Available at: http://ec.europa.eu/eurostat/statistics-explained/index.php/Main_Page (29 August 2017, date last accessed). 14 Anderson B, Scott B. Who Counts as a Migrant? Definitions and their Consequences—Migration Observatory—The Migration Observatory. Available at: http://www.migrationobservatory.ox.ac.uk/resources/briefings/who-counts-as-a-migrant-definitions-and-their-consequences/#kp1 (29 August 2017, date last accessed). 15 McLean HQ, Fiebelkorn AP, Temte JL, Wallace GS. Centers for Disease Control and Prevention. Prevention of measles, rubella, congenital rubella syndrome, and mumps, 2013: summary recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep  2013; 62(RR-04): 1– 34. 16 European Centre for Disease Prevention and Control. Monthly Epidemiological Updates on Measles Surveillance Data. Available at: http://ecdc.europa.eu/en/publications/surveillance_reports/vpd/Pages/emmo.aspx (29 August 2017, date last accessed). © The Author 2017. 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Vaccination policies of immigrants in the EU/EEA Member States–the measles immunization example

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Abstract

Abstract Background In 2015–16, the European Union/European Economic Area Member States (EU/EEA MSs) experienced an unprecedented volume and rate of migration, posing serious challenges to existing national immunization systems and strategies and raising the questions of where, when and who to vaccinate. We assessed existing strategies for vaccinating immigrant populations in the EU/EEA using measles as an example of the most important vaccine-preventable diseases. Methods In this cross-sectional study, conducted from March to May 2016, an electronic questionnaire was sent to the Heads of National Immunization Technical Advisory Groups (NITAGs) or equivalent policy-making bodies in each of the 31 EU/EEA Member States. Responses were entered into a structured database and validated by survey responders for final analysis. Results Validated responses from all 31 EU/EEA NITAGs or equivalents showed that there is no common measles immunization policy for European immigrants. Policies vary widely from no policy at all (9 of 31, 29%) to vaccination of all comers (2 of 31, 6%), or vaccination of selected cohorts based on vaccination history (17 of 31, 55%) or serum antibody analysis (2 of 31, 6%). Further, the operational responsibilities for immigrant vaccination and documentation methods are not unified within the EU/EEA region. Conclusions With some notable exceptions immunization policies to contain spread of infectious diseases through migration are either non-existent or vary widely between countries in the EU/EEA. With freedom of movement within the EU/EEA there ought to be harmonization and a common EU/EEA vaccination strategy to replace national policies for immigrant populations. Introduction In the last 2 years, Europe has witnessed an unprecedented volume of migration, with over 7 million people migrating between countries inside the European Union and European Economic Area (EU/EEA) where almost 2 million people have arrived from outside Europe, including over 600 000 children.1,2 This has posed serious strains on the healthcare systems in the receiving countries, particularly with respect to immunization. Immigrants from outside or citizens moving between EU countries might fall through the very diverse European immunization systems such that they are not adequately vaccinated in either their home or host countries. While infants may receive their routine immunizations in the first 2–3 months of life on the assumption that mothers and new-borns will be ‘static’ for some months after the birth, there is no guarantee that children will receive recommended primary or booster vaccinations later in life. One prime example is measles vaccination, which is not normally administered before 9-months of age. Numbers of measles cases and deaths are at an all-time low, with elimination in some parts of the world, but the disease continues to be a major global public health issue, afflicting millions of people and causing an estimated 15 deaths every hour, despite the availability of highly effective and affordable vaccines.3,4 Europe is still some way from achieving its elimination goal, with regular measles outbreaks such as the one that started in Romania in February 2016 and continues with high intensity in 2017.5 Situations like this pose a potential risk of repeated exportation to other countries and continuous transmission in areas where vaccination coverage is suboptimal. Most recent measles outbreaks in the EU/EEA are linked to migration with four identified sources of measles importation from outside and five from inside the EU/EEA causing a total of 3969 infections and 1 death in 2015.6 EU measles elimination, first envisaged for 2010 and now reset for 2020,7,8 will always be hindered when some children have never been immunized or are incompletely immunized. Immigration adds to the complexity and challenges to achieving this goal. Existing EU legislation states that human immunization policy is a Member State competency,9 but individual National Immunization Technical Advisory Groups (NITAGs) face their own challenges to ensure high vaccine coverage levels. Comparisons of migrant health provisions across the EU/EEA are challenging; there is no consensus of the definition of ‘an immigrant’, as such classifications are determined by national legislative, administrative and policy factors and the terms vary considerably in the EU/EEA.10 We surveyed current policies for immigrant immunization in the 31 EU/EEA Member States with measles as an example disease, using an electronic questionnaire sent to each representative NITAG. Methods Study design This cross-sectional study, undertaken between March 7th and May 12th 2016, used a standardized, semi-structured electronic questionnaire sent to senior immunization policy stakeholders of each of the 31 EU/EEA Member States (Supplementary table). Liechtenstein was not included as the country does not have its own NITAG but has a representative member at the Swiss EKIF (Eidgenössische Kommission für Impffragen-Switzerland), adopting their recommendations without further assessment. We identified stakeholders by web searches using the Vaccine European New Integrated Collaboration Effort gatekeeper‘s list, country specific NITAG members lists (where available) and European Centre for Disease Prevention and Control (ECDC) and World Health Organization resources. Answers from completed surveys were entered into a database and specific country profiles created using a reader-friendly design closely following the defined five domains of the questionnaire. These were returned to the 31 Member States responders for validation to ensure that we did not introduce any errors through our interpretation. In some countries (Spain, Sweden, Luxembourg, Romania, Switzerland, France, Germany, Norway, Portugal) teams of professionals working at National Institutes of Public Health, NITAGs or Ministries of Health, worked on the original questionnaire and evaluated their country profiles, but the validation was given by one nominee who in most of the cases was the head of the respective department, institution or NITAG chair. The same approach was used in previous work on immunization policies or NITAG practices and characteristics in the EU/EEA Member States that presents data which was validated by one nominated contact person in most of the countries.11,12 Data collection The survey collected data on immigrant immunization policies in general, with specific questions on underlying measles epidemiology and routine measles vaccination policies, as well as operational practices and goals of NITAGs or equivalent decision-making committees. We defined an immigrant as ‘a person who comes to live permanently in a foreign country’ so including European citizens moving between countries within the EU/EEA. This definition was sent to all participants in an invitation email together with the survey link and the general description of the study. The standardized questionnaire solicited specific information in five domains: Immunization strategies for immigrants using measles as example: description of existing strategies, methods currently used to determine the measles vaccination and immune status of immigrants, measles vaccination assessment of immigrants. This manuscript presents data from this specific domain. Baseline measles epidemiology/vaccination: size of birth cohort, vaccination coverage for first (MCV1) and second (MCV2) measles vaccinations, the schedule within country immunization program diversity, vaccine type and intentions to introduce a different measles containing vaccine, measles catch-up campaigns in the last 5 years and reasons for conducting them, surveillance and monitoring methods for measles, and incentives given to healthcare providers to achieve measles immunization targets. Vaccines: measles vaccine supply and potential shortages due to provision of measles vaccinations to immigrants. Operational goals and implementation of measles immunization: description of operational goals and implementation methods, published references, government websites or others in place to ensure adequate communication of these goals and implementation methods. NITAG specific: NITAG name in country language and English, website and current roles and responsibilities of the existing EU/EEA NITAGs or equivalent decision making committees. Data handling and analysis The questionnaire, developed in English using Google forms® and available to all participating countries, was completed by the selected participants and saved automatically in Google Drive®. Data from validated country profiles were imported into Excel® and analysed quantitatively and descriptively to obtain aggregated results which describe key characteristics of measles vaccination policies in EU/EEA. Results Competent immunization policy representatives from all 31 (100%) EU/EEA Member States responded to and validated the questionnaire (Supplementary table); 23 countries provided comments during the validation and their country profiles were adjusted accordingly, and 8 countries validated without adjustments. There is a large diversity in strategies for measles vaccination of immigrants across the 31 EU/EEA Member States (figure 1). Nine (Bulgaria, France, Hungary, Poland, Portugal, Slovakia, Slovenia, Spain and Switzerland) do not have any country level immigrant measles vaccination policy while strategies of the other 22 can be classified by taking into consideration parameters like age, immunization status and what constitutes an immigrant. Figure 1 View largeDownload slide EU/EEA Measles vaccination policies for immigrants Figure 1 View largeDownload slide EU/EEA Measles vaccination policies for immigrants Two countries vaccinate all immigrants regardless of age or vaccination status; Lithuania, where all immigrants are mandatorily vaccinated against measles. The UK, where without a reliable vaccination history, immigrants are assumed to be unimmunized. Two doses of MMR are given irrespective of history of measles, mumps or rubella infection and/or age. Six countries vaccinate immigrants after assessing their immunization status regardless of age: Cyprus: vaccination is performed after evaluation of vaccination records by specific healthcare providers assigned for immigrants or public healthcare providers. Austria and Estonia: unimmunized immigrants are vaccinated according to the national immunization schedule. Status is determined by any healthcare provider (Austria) or two healthcare providers after evaluating the vaccination records (Estonia). Norway: all immigrants receive MMR if they were not previously vaccinated or have had the disease. Specific healthcare providers assigned for immigrants or public healthcare providers evaluate immunization status in a medical screening visit for new arrivals by analysing vaccination records and self-reported history of previous measles disease or vaccination without written documentation. Luxembourg: immigrants are vaccinated if unimmunized and after a medical screening visit; immunization records are evaluated by the Public Health service under the responsibility of the Ministry of Health. Iceland: after determining immunization status by specific healthcare providers assigned for immigrants using existing vaccination records unimmunized immigrants are vaccinated according to the national schedule. Two countries vaccinate immigrants depending on age and immunization status assessment: Malta: immigrants under 18 years are vaccinated with MMR if they are deemed unimmunized after the country or regional office for vaccination has assessed the status from the existing immunization records. Sweden: all immigrant children 0–18 years are offered all vaccines included in the Swedish National Immunization Program, including MMR. Non-immune adults are also recommended MMR but must pay the cost. Immigrant immunization status is assessed by specific or public healthcare providers after evaluating vaccination records and/or self-reported vaccination status or previous disease. MMR is given only if they are unvaccinated or lack clear documentation. Three countries vaccinate specific immigrant populations, namely asylum seekers, regardless of the age, after assessing their immunization status: Croatia: only asylum seekers are vaccinated against measles if they do not have documented evidence of earlier vaccination. Evaluation is performed by a specifically assigned healthcare provider in a medical screening visit and on the basis of existing vaccination records, self-reported previous vaccination or disease. Other immigrants are not vaccinated. Belgium: only asylum seekers and refugees receive measles vaccine if unvaccinated. Latvia: only asylum seekers and refugees are immunized after evaluation of vaccination records during a medical assessment by a specific healthcare provider. Six countries vaccinate specific immigrants based on age and immunization status: Greece: vaccinates all refugees between 12 months to 15 years of age with one dose of MMR, after assessing immunization status based on self-reported vaccinations without written documentation. Other immigrants are not vaccinated. The Czech Republic only vaccinates asylum seekers younger than 18 years after a specific health care provider evaluates vaccination records. Finland: only unimmunized refugees, asylum seekers and foreign students are offered MMR vaccination. Any healthcare provider can assess the status based on existing vaccination records or self-reported previous vaccinations or disease. Germany: The Robert Koch Institute issued a concept note for the vaccination of asylum seekers early after their arrival, priority being given to close gaps in measles immunization. In case of missing vaccination records, adults born after 1970 should also be vaccinated. Assessment of immunization status can be performed by any healthcare provider by evaluating existing vaccination records. Denmark: a medical examination, performed by public healthcare providers, including assessment of immunization status (vaccination records, self-reported vaccinations without written documentation or self-reported previous disease) is offered to all asylum seekers in special centres where they must live while their application is being processed. All migrant children receive MMR, administered in these asylum centres, in accordance with the Danish immunization program. The Netherlands: children of asylum seekers (0–19 years) are immunized after assessment of vaccination status by a public healthcare provider or the country or regional office for vaccination based on evaluation of vaccination records. Reliability of self-reported vaccination status is also considered and judged by the healthcare provider. Special situations existed in three countries: Romania: existing policies for refugees, immigrants and asylum seekers included in the Romanian national vaccination program, apply only in the context of particular epidemiological situations or in case of international public health emergencies. These policies refer to provision of measles immunization recommendations to this population. Ireland: most immigrants are under care of a GP (General Practitioner) who should assess vaccination status after evaluating existing records and taking into consideration also self-reported doses of vaccine or previous disease. The public health system formally assesses asylum seekers, recommending and providing vaccination if required. Without documented MMR vaccination the recommendation is they should be vaccinated; Italy: the only country that requires legal immigrants to have a medical examination in their country of origin, before arriving in Italy. For other immigrants (including illegal immigrants arriving by sea), there is no a standard national measles vaccination policy. Regional approaches vary, and may include serologic evaluation, dissemination of leaflets in different languages, active calls for immigrants and for other difficult to reach populations. Different methodologies are used to assess immigrants’ measles vaccination or immune status across EU/EEA countries (figure 2), with one or more different methods used. In 25 of 31 (81%) Member States immunization status of immigrants is based on assessing the vaccination records during medical screening visits for new arrivals or during later checks. In 10 of 31 (32%) countries, this assessment is based on self-reported measles vaccination status with no written documentation, self-reported measles disease or vaccination in seven (23%) countries, and by serologic evaluation of immigrants performed prior to immunization in two (6%) countries (Italy and Spain). Figure 2 View largeDownload slide Methods used for assessing measles vaccination and/or immune status of an immigrant in EU/EEA Figure 2 View largeDownload slide Methods used for assessing measles vaccination and/or immune status of an immigrant in EU/EEA Responsibility for assessing immigrants measles vaccination status varies considerably among the EU/EEA countries (figure 3). In 16 (52%) Member States, specific healthcare providers are assigned for immigrants and in 10 (32%) public healthcare providers are responsible vaccinating immigrants. In nine countries (29%) any healthcare provider can assess measles vaccination status in immigrants, while two (6%) countries (Malta and The Netherlands) have national or regional offices for immigrant vaccination. No EU/EEA Member State provides measles immunization services for immigrants at, or locally to consulates or embassies where visas are issued. Figure 3 View largeDownload slide Responsibility for measles vaccination assessment of immigrants in EU/EEA Figure 3 View largeDownload slide Responsibility for measles vaccination assessment of immigrants in EU/EEA In four (13%) countries (France, Greece, Ireland and Slovenia), this responsibility is not defined although it will be defined in France in the future. In Ireland, public healthcare providers have a clear responsibility to assess measles immunization, but only for asylum seekers being screened. Legal immigrants to the country must discuss vaccination with their own GP. Measles immunization schedules currently being used in EU/EEA Measles vaccination schedules are set at the national level in 30 of the 31 EU/EEA countries. In Germany 15 of the 16 federal states have a common recommendation, the exception being Saxony where a regional committee recommends MCV2 at age 5+ years. Across the EU/EEA region there are eight different recommended vaccination schedules for MCV1 which we clustered into three categories (figure 4), mainly differing in age at first dose and age window for vaccination. The minimum age for measles vaccination in the EU/EEA is 11 months in Austria and Germany which are following a common schedule, 11–14 months of age, while 23 countries start their measles immunization schedules at 12–15 months of age. Denmark, Hungary and Norway recommend MCV1 be given at 15 months exactly, Slovakia gives MCV1 between 14–17 months of age, and Iceland and Sweden give MCV1 only at 18 months. Figure 4 View largeDownload slide Measles vaccination schedules in EU/EEA Figure 4 View largeDownload slide Measles vaccination schedules in EU/EEA Age ranges for the second dose of measles vaccine are wider, with 16 different recommendations starting as early as 15 months, before the first dose has been given in some countries and as late as 13 years of age (figure 4). MCV2 recommendations are clustered as follows: 15–24 months of age (6/31, 19%), 3–6 years of age (6/31, 19%), 5–10 years of age (13/31, 42%) and above 10 years of age (6/31, 19%). Discussion We researched measles vaccination policies for immigrants into Europe because of three concerns which could amplify each other: the current wave of immigration which poses a potential communicable disease risk, the increase in EU/EEA measles cases and exportations inside and outside of the region, and the status of harmonization of EU/EEA vaccination schedules. We prepared a detailed and representative inventory of current policies and measles immunization strategies for immigrants from all 31 EU/EEA Member States (excluding Liechtenstein). The unprecedented volume and the speed of migration Europe experienced in 2015–16, with almost 2 million external immigrants arriving and over 7 million migrating within the region,1,13 poses serious challenges to the existing immunization systems to decide when, where and whom to vaccinate. Definitions of what constitutes an immigrant, a migrant, refugee or asylum seeker differ widely across the EU/EEA Member States, complicating the analysis and comparison of policies. Different definitions have significant consequences for data in terms of numbers of migrants and the analysis of the impact of migration on the epidemiology of different infectious diseases.14 Migration is a pan-European phenomenon, but immigration health policies are still national, reflected in the wide diversity in strategies for immigrant measles vaccination across Member States. Only Lithuania and the UK vaccinate all immigrants regardless of their age, origin or vaccination status. The low risk of serious or severe adverse events due to measles vaccination in individuals who have had measles or have been vaccinated previously15 makes this a very pragmatic, safe and probably cost-effective approach that could serve as a model for the rest of Europe. Those countries or regions which only vaccinate after resource- and time-consuming serological testing for measles, risk that results are only available when the immigrant has already have moved on. Most EU/EEA measles outbreaks in 2015–17 were linked to migration.16 This situation is exacerbated by lack of EU/EEA strategies to address the politically sensitive issue of harmonization of vaccination schedules and immunization policies of immigrants, and the methods used for assessing measles immunization status in immigrants. While measles vaccination of immigrants from outside the EU/EAA is a first country of entry border issue, for which clear vaccination policies should be in place, internal migration across Member States poses a different problem. Without harmonization of measles vaccination policies a child migrating from one European country to another could easily fall through the cracks and not be vaccinated because of being too young in the exit country and too old in the destination country. There are some limitations to this study. First, the process of identifying appropriate stakeholders to answer the questionnaire in each country was difficult and also time consuming. Secondly, although additional explanatory information was provided, respondents may have interpreted the term immigrant somewhat differently. Thirdly, the questionnaire was quite lengthy and time consuming, covering five different domains. These limitations were anticipated before the survey was sent. We carefully screened and analysed available resources to create a complete and reliable list of responders to our survey and a communication plan was implemented from the beginning with reminders, follow-up emails and clear clarifications and scheduled phone calls with some responders. Acknowledgements The authors acknowledge the contribution of Prof. Dr. Sue Ann Costa Clemens who participated in the initial design of the survey and provided important guidance during the study; Prof. Dr. Emanuele Montomoli as a representative of the University of Siena-Medical School for all the support provided during the development of the study; Prof. Dr. Heinz Josef Schmitt for his timely suggestions that helped establishing the goals of this research; Dr. Steffen Glismann for important guidance and contribution; Dr. Giovanni della Cioppa for his advice and support; Keith Veitch for editorial advice, and finally and most especially all the survey respondents for taking the time to complete the questionnaire, to validate their countries profiles and reply to our follow-up questions. This work has been orally presented at the 15th Conference of the International Travel Society on 15th of May 2017 in Barcelona, Spain. Funding No honoraria, grants or other form of payment were provided to authors during research or the development of this manuscript to which both MAB and RC contributed equally. Conflicts of interest: None declared. Key points To the best of our knowledge, this is the first research presenting and analysing the vaccination strategies for immigrants in all EU/EEA Member States. The results show a great diversity and discrepancy in strategies for measles vaccination of immigrants in EU/EEA as also a great variety of vaccination schedules currently used across the Region, with little if no sign of harmonization. We show that in the EU/EEA region, where measles vaccination coverage is suboptimal, migration plays a very important role in outbreaks and further complicating the goal of measles elimination in all EU by 2020. Migrant immunization policies in Europe are not harmonized at all which leads to the fact that especially migrant children fall thru the cracks of the system where in one country they are too young to be immunized and when arriving in the destination country they are too old. Common efforts toward vaccination of migrants rather than establishing national policies, guidelines and different recommendations on the basis of different categories and definitions of immigrants, are needed in order to achieve the goal of elimination. Disclaimers This research was conducted by MAB as thesis in the Executive Master Program in Vaccinology and Pharmaceutical Clinical Development at the University of Medicine in Siena, Italy. RC was supervisor for MAB’s master thesis. The corresponding author had full access to all the data in the study and had final responsibility for the decision to submit for publication. No honoraria, grants or other form of payment were provided to authors. MAB and RC declare no competing interests. Supplementary data Supplementary data are available at EURPUB online. References 1 Semenza JC, Carrillo-Santisteve P, Zeller H, et al.   Public health needs of migrants, refugees and asylum seekers in Europe, 2015: infectious disease aspects. Eur J Public Health  2016; 26: 1– 2. Google Scholar CrossRef Search ADS PubMed  2 Statistical office of the European Union. Statistics Explained [Internet]. Statistical office of the European Union Official website. 2016 [cited 2016 Dec 29]. Available at: http://ec.europa.eu/eurostat/statistics-explained/index.php/Main_Page. 3 World Health Organisation. WHO | Measles | Fact sheet [Internet]. World Health Organization. World Health Organization; 2016 [cited 2016 May 5]. Available at: http://www.who.int/mediacentre/factsheets/fs286/en/. 4 Centers for Disease Control and Prevention. Vaccines: VPD-VAC/Measles/FAQ Disease & Vaccine [Internet]. Centers for Disease Control and Prevention official website. 2015 [cited 2016 May 6]. Available at: http://www.cdc.gov/vaccines/vpd-vac/measles/faqs-dis-vac-risks.html. 5 ECDC. Ongoing Outbreak of Measles in Romania, Risk of Spread and Epidemiological Situation in EU/EEA Countries Main Conclusions and Options for Response. 2017;(March). Available at: http://ecdc.europa.eu/en/publications. 6 European Centre for Disease Prevention and Control. Measles and Rubella Monitoring Reports. [cited 2016 May 19]. Available at: http://ecdc.europa.eu/en/publications/surveillance_reports/vpd/Pages/emmo.aspx. 7 The Regional Office for Europe of the World Health Organization. Renewed Commitment to Measles and Rubella Elimination and Prevention of Congenital Rubella Syndrome in the WHO European Region by 2015 Regional Committee for Europe. WHO Reg Off Eur Publ. 2010; 6(July): 1. 8 The Regional Office for Europe of the World Health Organization. European Vaccine Action Plan 2015–2020 . WHO Reg Off Eur Publ, 2014. 9 Tsolova S. The treaty of Lisbon and public health in the EU [Internet], Vol. 20. Eur J Pub Health  2010; 20: 475. Google Scholar CrossRef Search ADS   10 International Organization for Migration. European Research on Migration and Health [Internet]. International Organization for Migration official website. [cited 2016 Jul 22]. Available at: http://www.migrant-health-europe.org/files/Research on Migrant Health_Background Paper.pdf. 11 European Centre for Disease Prevention and Control. Current Practices in Immunisation Policymaking in European Countries . Stockholm: ECDC, 2015. 12 Takla A, Wichmann O, Carrillo-Santisteve P, et al.   Characteristics and practices of national immunisation technical advisory groups in Europe and potential for collaboration, April 2014. Euro Surveill  2015; 20:pii: 21049. 13 Statistical office of the European Union. Statistics Explained [Internet]. Statistical office of the European Union Official website. 2016. Available at: http://ec.europa.eu/eurostat/statistics-explained/index.php/Main_Page (29 August 2017, date last accessed). 14 Anderson B, Scott B. Who Counts as a Migrant? Definitions and their Consequences—Migration Observatory—The Migration Observatory. Available at: http://www.migrationobservatory.ox.ac.uk/resources/briefings/who-counts-as-a-migrant-definitions-and-their-consequences/#kp1 (29 August 2017, date last accessed). 15 McLean HQ, Fiebelkorn AP, Temte JL, Wallace GS. Centers for Disease Control and Prevention. Prevention of measles, rubella, congenital rubella syndrome, and mumps, 2013: summary recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep  2013; 62(RR-04): 1– 34. 16 European Centre for Disease Prevention and Control. Monthly Epidemiological Updates on Measles Surveillance Data. Available at: http://ecdc.europa.eu/en/publications/surveillance_reports/vpd/Pages/emmo.aspx (29 August 2017, date last accessed). © The Author 2017. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

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The European Journal of Public HealthOxford University Press

Published: Nov 9, 2017

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