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More than 10 months after the first case of COVID-19 in Africa was detected (in Egypt on February 14), prevalence and mortality are still relatively low and, although there are many hypotheses, the reasons remain unclear (1–3). Reduced virulence of SARS-CoV-2 in Africa, genetic or trained immunity, and young population (3, 4) are among the main reasons being evaluated.

Background International literature suggests that disadvantaged groups are at higher risk of morbidity and mortality from SARS-CoV-2 infection due to poorer living/working conditions and barriers to healthcare access. Yet, to date, there is no evidence of this disproportionate impact on non-national individuals, including economic migrants, short-term travellers and refugees. Methods We analyzed data from the Italian surveillance system of all COVID-19 laboratory-confirmed cases tested positive from the beginning of the outbreak (20th of February) to the 19th of July 2020. We used multilevel negative-binomial regression models to compare the case fatality and the rate of admission to hospital and intensive care unit (ICU) between Italian and non-Italian nationals. The analysis was adjusted for differences in demographic characteristics, pre-existing comorbidities, and period of diagnosis. Results We analyzed 213 180 COVID-19 cases, including 15 974 (7.5%) non-Italian nationals. We found that, compared to Italian cases, non-Italian cases were diagnosed at a later date and were more likely to be hospitalized {[adjusted rate ratio (ARR)=1.39, 95% confidence interval (CI): 1.33–1.44]} and admitted to ICU (ARR=1.19, 95% CI: 1.07–1.32), with differences being more pronounced in those coming from countries with lower human development index (HDI). We also observed an increased risk of death in non-Italian cases from low-HDI countries (ARR=1.32, 95% CI: 1.01–1.75). Conclusions A delayed diagnosis in non-Italian cases could explain their worse outcomes compared to Italian cases. Ensuring early access to diagnosis and treatment to non-Italians could facilitate the control of SARS-CoV-2 transmission and improve health outcomes in all people living in Italy, regardless of nationality.

Background The Universal Health Coverage (UHC) proposes that an ideal health system must be able to extend the health coverage to the whole population (universality), to guarantee all the necessary services (globality) and to do it without additional direct costs for the people (free of charge). The achievement of the UHC represents the target 3.8 of the Sustainable Developed Goals. The World Health Organization and the World Bank have developed an index to monitor the UHC (an algorithm that contains 16 indicators of essential health services), while for financial protection they rely on the incidence of catastrophic expenditure on health (percentage of families in which the living expenses for health without reimbursement exceed the10% of consumption). Objectives To strengthen the Italian operators' knowledge about the accessibility to health services in Italy and in countries around the world utilizing the UHC index and the incidence of catastrophic expenditure. Results The National Center for Global Health of the Italian National Institute of Health (ISS) collected the documents and the data already produced and validated by the international scientific community. ISS in collaboration with the Department of Public Health and Infectious Disease of Sapienza University of Rome developed a workshop training program to bring the UHC concepts at national level in a simplified manner. This was developed in order to encourage a reflection and to strengthen the understanding of the complexity of the UHC. The framework and the program of the workshop will be presented during the conference. Conclusions Studying the UHC means focusing on the inequalities in health care. To increase the sensibility of professionals may be a resource to promote the health coverage for all in the national territory. Key messages Encouraging the discussion between professionals is possible to understand the complexity of the UHC. The achievement of the UHC may happen only through the improving of the knowledge about it.

Background. One Health is receiving attention for arbovirus infection prevention and control and for defining national “intersectoral” priorities. Increasing awareness of intersectoral priorities through multisectorial risk assessments (MRA) is promising, where data are not systematically shared between sectors. Towards this aim, the MediLabSecure project organized three MRA exercises (hereby called exercises): one on West Nile virus, one on Crimean–Congo haemorrhagic fever, and one on Rift Valley fever, assessing the added value of this approach. Methods. The exercises relied on RA methodologies of international organisations. Country representatives of the human and animal virology, medical entomology, and public health sectors (hereby called “sectors”) involved in the surveillance of vector-borne diseases participated in the exercises. Background documentation was provided before each exercise, and a guide was developed for the facilitators. All three exercises included technical and methodological presentations and a guided RA directed at bringing into play the different sectors involved. To assess the added value of the approach, each participant was asked to rank the level of perceived benefit of the multisectoral collaboration for each “risk question” included in the exercises. Results. In total, 195 participants from 19 non-EU countries in the Mediterranean and Black Sea regions took part in the exercises. The participants assessed the multisectoral approach as valuable in analysing comprehensively the situation by having access to information and knowledge provided by each of the sectors involved. Sharing of information and discussion facilitated reaching a consensus on the level of risk in each country. Conclusions. Increasing awareness of intersectoral priorities, including cross-border ones, through MRA is relevant to reduce gaps due to unavailability of shared data and information. Given that six out of the ten threats to global health listed by WHO are occurring at the human-animal-environmental interfaces, comprehensive regional RA with a One Health approach made by national authorities can be a relevant added value for the global health security.

Background Migrants represent a potential vulnerable group and adequate health protection, including vaccine preventable diseases prevention, should be ensured. The aim of this survey was to map national immunization policies and practices targeting asylum seekers, refugees and irregular migrants in EU/EEA countries. Methods A web-based cross-sectional survey was conducted in 28 EU and 2 EEA countries within the ECDC funded Vaccine European New Integrated Collaboration Effort (VENICE) Project in the period January-April 2018. Results All countries but one completed the survey and 28 countries offer vaccination to migrants. A national regulation/legal framework supporting migrant immunization is available in most countries. This is specifically established for migrants' health services for 5, part of the National Immunization Programme (NIP) for 15 and both for 3 countries. All the vaccinations included in the NIP appropriate for age are offered to children/adolescents in 27 countries and to adults in 13. In 15 countries offering only certain vaccinations to adults, priority is given to DT, MMR and polio. Vaccinations are mainly given at holding/community level and only 5 countries vaccinate at entry level. A vaccination card is delivered in 23/28 countries to children/adolescents and 24/28 to adults. Recording of individual data vary highly: for children/adolescents and adults, respectively, 15 and 12 countries use an electronic database, 5 and 4 use only paper registry, 2 and 3 use both electronic and paper registries, while 6 and 9 countries do not record information at all. Individual and aggregated data are not made available from the sites where vaccinations are delivered to other local or national institutions in 13 and 15 countries. Conclusions Although policies about immunization of migrants are available in most of EU/EEA countries, there are important differences as to their objectives and implementation, especially methods of recording and transmitting data. Key messages Given the survey results and the migrants’ mobility, it is important to share data within and across countries to better respond to migrants' immunization needs. Strengthening partnerships between countries of origin, transit and destination, and sharing documentation may ensure the completion of vaccination series and avoid unnecessary revaccinations.

Emerging and re-emerging infectious diseases and zoonoses indicate the importance of the One Health (OH) approach for early warning. At present, even when surveillance data are available, they are infrequently timeously shared between the health sectors. In the context of the MediLabSecure (MLS) Project, we investigated the collection of a set of surveillance indicators able to provide data for the implementation of integrated early warning systems in the 22 MLS countries of the Mediterranean, Black Sea and Sahel regions. We used an online questionnaire (covering vector, human, and animal sectors), focusing on seven relevant arboviruses, that was submitted to 110 officially appointed experts. Results showed that West Nile virus was perceived as the most relevant zoonotic pathogen, while Dengue virus was the most relevant non-zoonotic pathogen in the study area. Data collection of early warning indicators is in place at a different level for all the investigated pathogens and in almost all the MLS Countries. Further assessments on the reliability of the collection in place and on the feasibility of piloting an integrated early warning system for arbovirus could verify if integrated early warning really represents the Achilles’ heel of OH.

Countries around the Mediterranean Sea share epidemiologic characteristics and public health problems. From 2007 to 2013, a Mediterranean collaborating framework called the EpiSouth Network was established to share knowledge and develop joint activities. Under the coordination of the Italian National Public Health Institute (ISS), this network implemented 2 projects, the first focused on communicable disease surveillance and training and the second on strengthening preparedness for common health threats and biosecurity risks. After the first 3 years of activity, the network included public health institutes, ministries of health, and laboratories of 27 countries in southern Europe, the Balkans, North Africa, and the Middle East. The network worked in collaboration with and with the support of the European Commission, the European Centre for Disease Prevention and Control, the World Health Organization, and the Italian Ministry of Health. This article provides an overview of the key strategic approaches an...

BackgroundThe Mediterranean Basin is historically a hotspot for trade, transport, and migration. As a result, countries surrounding the Mediterranean Sea share common public health threats. Among them are vector-borne diseases, and in particular, mosquito-borne viral diseases are prime candidates as (re)emerging diseases and are likely to spread across the area. Improving preparedness and response capacities to these threats at the regional level is therefore a major issue. The implementation of entomological surveillance is, in particular, of utmost importance. Guidance in designing entomological surveillance systems is critical, and these systems may pursue different specific objectives depending on the disease. The purpose of the proposed review is to draw up guidelines for designing effective and sustainable entomological surveillance systems in order to improve preparedness and response. However, we make it clear that there is no universal surveillance system, so the thinking behind harmonisation is to define evidence-based standards in order to promote best practises, identify the most appropriate surveillance activities, and optimise the use of resources. Such guidance is aimed at policymakers and diverse stakeholders and is intended to be used as a framework for the implementation of entomological surveillance programmes. It will also be useful to collaborate and share information with health professionals involved in other areas of disease surveillance. Medical entomologists and vector control professionals will be able to refer to this report to advocate for tailored entomological surveillance strategies. The main threats targeted in this review are the vectors of dengue virus, chikungunya virus, Zika virus, West Nile virus, and Rift Valley fever virus. The vectors of all these arboviruses are mosquitoes.MethodsCurrent knowledge on vector surveillance in the Mediterranean area is reviewed. The analysis was carried out by a collaboration of the medical entomology experts in the region, all of whom belong to the MediLabSecure network, which is currently funded by the European Union and represents an international effort encompassing 19 countries in the Mediterranean and Black Sea region.FindingsRobust surveillance systems are required to address the globalisation of emerging arboviruses. The prevention and management of mosquito-borne viral diseases must be addressed in the prism of a One Health strategy that includes entomological surveillance as an integral part of the policy. Entomological surveillance systems should be designed according to the entomological and epidemiological context and must have well-defined objectives in order to effect a tailored and graduated response. We therefore rely on different scenarios according to different entomological and epidemiological contexts and set out detailed objectives of surveillance. The development of multidisciplinary networks involving both academics and public authorities will provide resources to address these health challenges by promoting good practises in surveillance (identification of surveillance aims, design of surveillance systems, data collection, dissemination of surveillance results, evaluation of surveillance activities) and through the sharing of effective knowledge and information. These networks will also contribute to capacity building and stronger collaborations between sectors at both the local and regional levels. Finally, concrete guidance is offered on the vector of the main arbovirus based on the current situation in the area.

Migrant centres, as other institutions hosting closed or semi-open communities, may face specific challenges in preventing and controlling communicable disease transmission, particularly during times of large sudden influx. However, there is dearth of evidence on how to prioritise investments in aspects such as human resources, medicines and vaccines, sanitation and disinfection, and physical infrastructures to prevent/control communicable disease outbreaks. We analysed frequent drivers of communicable disease transmission/issues for outbreak management in institutions hosting closed or semi-open communities, including migrant centres, and reviewed existing assessment tools to guide the development of a European Centre for Disease Prevention and Control (ECDC) checklist tool to strengthen preparedness against communicable disease outbreaks in migrant centres. Among articles/reports focusing specifically on migrant centres, outbreaks through multiple types of disease transmission were described as possible/occurred. Human resources and physical infrastructure were the dimensions most frequently identified as crucial for preventing and mitigating outbreaks. This review also recognised a lack of common agreed standards to guide and assess preparedness activities in migrant centres, thereby underscoring the need for a capacity-oriented ECDC preparedness checklist tool.

International audience; In the context of One Health, there is presently an effort to integrate surveillance of human, animal, entomological, and environmental sectors. This aims to strengthen the prevention of, and preparedness against, arbovirus infections, also in the light of environmental and climate changes that could increase the risk of transmission. However, criteria to define integrated surveillance, and to compare different systems, still need to be identified and tested. We conducted a scoping review to identify and examine surveillance systems for West Nile virus (WNV), chikungunya virus (CHKV), dengue virus (DENV), and Rift Valley fever virus (RVFV), which involve human, animal, entomological, and environmental sectors. We analyzed findings using a conceptual framework we developed for this purpose. The review highlights that the criteria proposed in the conceptual framework to describe integrated surveillance are consistently reported in the context of studies and programs related to integrated surveillance of the selected arboviral diseases. These criteria can facilitate the identification and description of operationalized One Health surveillance.

We conducted a scoping review of literature to improve our understanding of the accuracy of infectious disease monitoring in migrants in the Europe. We searched PubMed for papers relevant to the topic including: case reports, observational and experimental studies, reviews, guidelines or policy documents; published after 1994. We identified 532 papers, 27 of which were included in the review. Legislation and right to access health care influence both the accuracy of rates and risk measures under estimating the at risk population, i.e., the denominator. Furthermore, the number of reported cases, i.e., the numerator, may also include cases not accounted for in the denominator. Both biases lead to an overestimated disease occurrence. Restriction to healthcare access and low responsiveness may cause under-detection of cases, however a quantification of this phenomenon has not been produced. On the contrary, screening for asymptomatic diseases increases ascertainment leading to increased detection of cases. Incompleteness of denominator data underestimates the at-risk population. In conclusion, most studies show a lower probability of under-reporting infectious diseases in migrants compared with native populations.

The unprecedented flow of migrants over the last three years places Italy in front of new issues regarding medical care from the rescue phase up to the integration into the national health services, including preventive actions. We used online questionnaires to investigate the Italian national and regional policies for immunization offer targeting asylum seekers, refugees, irregular migrants and unaccompanied minors. Another questionnaire was used to assess how these policies are translated into practice in migrant reception centres and community health services. Questionnaires were filled out at the national level, in 14 out of 21 Regions/Autonomous Provinces, and in 36 community health services and 28 migrant reception centres. Almost all responders stated that all vaccinations included in the National Immunization Plan are offered to migrant children and adolescents. The situation concerning adults is fragmented, with most of the Regions and local centres offering more vaccines than the national offer—which include polio, tetanus and measles–mumps-rubella. Data on immunized immigrants is archived at the regional/local level with different methods and not available at the national level. Further efforts to ensure consistency in vaccine provision and adequate mechanisms of exchanging data are needed to guarantee a complete vaccination offer and avoid unnecessary health actions, including unnecessary re-vaccination.

There are limitations in our capacity to interpret point estimates and trends of infectious diseases occurring among diverse migrant populations living in the European Union/European Economic Area (EU/EEA). The aim of this study was to design a data collection framework that could capture information on factors associated with increased risk to infectious diseases in migrant populations in the EU/EEA. The authors defined factors associated with increased risk according to a multi-dimensional framework and performed a systematic literature review in order to identify whether those factors well reflected the reported risk factors for infectious disease in these populations. Following this, the feasibility of applying this framework to relevant available EU/EEA data sources was assessed. The proposed multidimensional framework is well suited to capture the complexity and concurrence of these risk factors and in principle applicable in the EU/EEA. The authors conclude that adopting a multi-dimensional framework to monitor infectious diseases could favor the disaggregated collection and analysis of migrant health data.

Screening is one possible tool for monitoring infectious diseases among migrants. However, there is limited information on screening programmes targeted for newly arrived migrants in EU/EEA countries. Our aim was to investigate the implementation, practices and usefulness of these programmes. We conducted a survey among country experts from EU/EEA countries and Switzerland, asking whether their countries had implemented screening programmes. We also estimated the association between the implementation of these programmes and the rate of asylum-seekers in the population. Of the countries, 16 (59%) had implemented screening programmes and 15 (56%) had national guidelines. The rate of asylum-seekers was associated with implementation of screening programmes (p = 0.014). Screening was performed most often for tuberculosis, most commonly on holding level, and was targeted to specific migrant groups in over half of the countries performing screening. Twenty-five of all the country experts (96%) considered screening among migrants useful, and 24 (92%) would welcome EU level guidelines for screening. The implementation of screening programmes varied, and the practices were different among countries. Our survey suggests, that establishing EU level guidelines for screening would be useful, although they would have to take into account differences between individual countries.

Background: In sub-Saharan Africa, co-infection with HIV and malaria is probably very common. Although an interaction between the two infections is biologically plausible, it has not been investigated thoroughly. Objectives: To evaluate the association firstly between co-infection with HIV and malaria parasites and the occurrence of acute fever, and secondly between HIV infection and clinical malaria, defined as the presence of acute fever and malaria parasites. Methods: A hospital-based case‐control study was conducted in Gulu District (northern Uganda), an area endemic for malaria and with a high HIV prevalence. HIV testing and malaria parasite quantification were performed on 167 consecutive adult outpatients with acute fever and no signs or symptoms of localized infection, and on 134 consecutive adult in-patients without fever who were admitted for non-HIV-related trauma or elective surgery. Results: No significant association with acute fever was observed for single infection with either malaria parasites [adjusted odds ratio (AOR), 1.75; 95% confidence interval (CI), 0.73‐4.21] or HIV (AOR, 1.01; 95% CI, 0.51‐2.03), whereas a significant association was observed for co-infection (AOR, 9.75; 95% CI, 1.19‐80.00). An association was found between HIV infection and clinical malaria (AOR, 2.34; 95% CI, 0.89‐6.17); the association became statistically significant when the definition of clinical malaria included a cut-off for parasite density (50 th percentile; i.e., 586 parasites/Il; AOR, 3.61; 95% CI, 1.04‐12.52). Conclusions: Despite the limited statistical power, the results of our study show an association between HIV infection and clinical malaria; if confirmed, this finding could be important for public health in sub-Saharan Africa.

Countries bordering the Mediterranean are part of a major migration system. The aim of this study is to assess the main access barriers to immunization of mobile populations in the region and propose an action based framework to decrease health access inequalities. A survey on formal and informal barriers to immunization among mobile communities was conducted among public health officials formally appointed as focal points of the EpiSouth Network by 26 Mediterranean countries. Twenty-two completed the questionnaire. Thirteen countries reported at least one vaccine preventable disease (VPD) outbreak occurring among mobile populations since 2006 even though their legal entitlement to immunization is mostly equivalent to the general population's. Informal barriers, particularly lack of information and lack of trust in authorities, and disaggregation of data collection are the major issues still to be addressed. Mediterranean countries need to fill the gap in immunization coverage among pockets of susceptible individuals in order to prevent VPD outbreaks. Having for the most part ensured free entitlement, introducing more migrant friendly approaches, increasing information availability among mobile communities, building trust in public health services and disaggregating data collection to monitor and evaluate service performance among mobile groups are key aspects to address in the region.

A retrospective analysis of the discharge records of 186,131 inpatients admitted to six Ugandan hospitals during 1992-1998 was performed to describe the disease patterns and trends among the population of Northern Uganda. In all hospitals, malaria was the leading cause of admission and the frequency of admissions for malaria showed the greatest increase. Other conditions, such as malnutrition and injuries, mainly increased in the sites affected by civil conflict and massive population displacement. Tuberculosis accounted for the highest burden on hospital services (approximately one-fourth of the total bed-days), though it showed a stable trend over time. A stable trend was also observed for acquired immunodeficiency syndrome (AIDS), which is in contrast to the hypothesis that AIDS patients have displaced other patients in recent years. In conclusion, preventable and/or treatable communicable diseases, mainly those related to poverty and poor hygiene, represent the leading causes of admission and death, reflecting the socioeconomic disruption in Northern Uganda.

During the period 1996-99 the prevalence of HIV-1 increased among pregnant women living in the rural areas of Gulu district (North Uganda). This trend could be partly explained by the violent recrudescence of civil strife since 1996 which caused a dramatic reduction in activities of health education and massive population displacement to protected camps. Screening and services for the prevention and control of HIV-1 should be promoted among displaced people. (authors)

Background The tender TRAIN4M&H (Provision of training for first-line health professionals and law enforcement officers working at local level with migrants and refugees, and training of trainers- contract 20167204), funded by the EC-DG SANTE under the 3rd EU HP, intended to conduct training programme in all EU/EEA countries for health professionals, law enforcement officers an social workers in front-line countries and coach trainers in the others. Objectives Training was aimed at reinforcing skills, improving understanding and positive attitudes, and promoting a holistic approach in the work with migrants. The boundaries set by the tender included a short training duration; exclusive use of pre-existing and validated training materials; different professional targets. Italian National Health Institute and Sapienza University of Rome designed the training programme. Criteria for content selection and methodological choices were submitted for consultation to an inter-professional Expert Group in two steps. Results Given the limited training timeframe, the delivery of specialised content could not be the focus of this training. It was decided therefore to transform the target requirement into added value, by mixing the target groups into multi-professional classes. This bring a diversity of understandings into the classroom and enhance communication between sectors. The training included also topics such as “context of migration” and “intercultural competences” to create common ground for multi-professional exchange. Similarly, the need to adapt to different EU/EEA contexts argued for a modular structure where Units are selected by the Local Trainer based on a training needs assessment questionnaire sent to trainees beforehand. All materials are on EU Health Policy Platform's Agora (webgate.ec.europa.eu/hpf/). Conclusions Training on migrants' health is a complex process, requiring the engagement of learners from their previous experiences and an interdisciplinary approach. Key messages Inter-professional training programme can be used for the adult trainings especially in case of a cross-sectoral topic as migrants’ health is. Inter-professional training is a strategy that can guide coherently content design, outcome identification and the choice of evaluations tools.

Following civil unrest in North Africa early in 2011, there was a large influx of migrants in Italy. A syndromic surveillance system was set up in April to monitor the health of this migrant population and respond rapidly to any health emergency. In the first six months, the system produced 67 alerts across all syndromes monitored and four alarms. There were no health emergencies, however, indicating that this migration flow was not associated with an increased risk of communicable disease transmission in Italy.