Access to health and how to do it inclusively Prof. Francesco - PowerPoint PPT Presentation

Access to health and how to do it inclusively Prof. Francesco Castelli – University of Brescia with the support of the Departments n. 3 and n. 9 of the General Directorate for Health Prevention, Italian Ministry of Health

257.7 M in 2017 3.4% in 2017 https://www.iom.int/

Central America Route Southeast Asian Route SOURCES: Missing Migrants Project, IOM SOURCES: Missing Migrants Project, IOM https://migrationdataportal.org/?i=stock_abs_&t=2017 Mediterranean sea Route SOURCES: Missing Migrants Project, IOM; UNHCR; i-Map; Regional Mixed Migration Secretariat

Fig. 1. International migrants by region of residence, 2015 Million 80 70 60 50 40 30 20 10 0 Africa Asia Europe Latin America Nortern America Oceania and the Carribean Source: UN DESA, 2015. www.un.org/en/development/desa/population/migration/data/estimates2/estimates15.shtml, modified

Complex drivers of migration: macro-, meso- and micro-factors Micro Individual characteristics Political •Age, sex, ethnicity •Conflict, insecurity •Education, wealth •Discrimination •Marital status •Persecution •Religion, language Migrate Environmental Demographic • Exposure to hazard •Population density Final •Population structure • Food/water security Macro •Diseases prevalence decision • Energy security • Land productivity Stay Social Economic Obstacles/facilitators •Job opportunities • Seeking education •Political/legal framework •Income • Family obligations •Social networks/diasporic links •Producer/consumer •Cost of moving prices •Technology Meso Source: Foresight: Migration and Global Environmental Change (2011) Final Project Report The Government Office for Science, London, modified

Objectives of the talk • Review the Italian response to the migrant surge over the past few years • Describe the Italian model of provision of health care to new migrants

Previous refugee crises in Italy Brindisi, 1991 Lampedusa, 2011

https://frontex.europa.eu/along-eu-borders/migratory-map/

The Dublin Treaty • The Dublin III Regulation (No. 604/2013) was approved in June 2013, replacing the Dublin II Regulation, and applies to all member states except Denmark. It came into force on 19 July 2013. It is based on the same principle as the previous two i.e. that the first Member State where finger prints are stored or an asylum claim is lodged is responsible for a person's asylum claim. • In July 2017, the European Court of Justice upheld the Dublin Regulation declaring it still stands despite the high influx of 2015, giving EU member states the right to deport migrants to the first country of entry to the EU.

Migrants’ relocation to other European Countries Done (as at April 2018) Pledged From Italy From Greece ISPI Fact Checking - Migrazioni 2018

Current migrant crisis: 2014-2018 15.6% 8.3% 8.2% 7.6% 7.0% 6.1% 6.1% https://data2.unhcr.org/en/situations/mediterranean/location/5205

Migrants landed in Italy (January to August) 2016 to 2018 1. Change in italian policy towards migrants 2. Degradating political situation in Lybia Italian Ministry of Interior, data at 31° August 2018

Unaccompanied childrern Italian Ministry of Interior, data at 31° August 2018

Asylum request Expulsion Repatriation In 7 days

2014: the first contingency plan in Sicily

Contingency plan in Sicily: medical triage On board (NGOs, Italian Navy Ships) 1 2 1) Mandatory Medical report Prior to landing (USMAF: maritime, air and border health office) 2) Authorization for landing http://pti.regione.sicilia.it/portal/page/portal/PIR_PORTALE/PIR_LaStrutturaRegionale/PIR_AssessoratoSalute/PIR_Pi anocontingenzasanitarioregionalemigranti/piano%20contingenza%20A4-2017_Definitivo.pdf

Standard Operating procedures applicable to Italian Hotspots http://www.libertaciviliimmigrazione.dlci.interno.gov.it/sites/default/files/allegati/hotspots_sops_-_english_version.pdf

DATA COLLECTION: 17 screening (YES/NO) with free text note pad if items, with questions and answers Disease/Pathology Breathing Apparatus GUIDED SCREENING Digestive System Cardiovascular System Central Nervous System Skeletal System Urogenital System Endocrine System Psychological Illnesses YES

DATA ACCURACY IMPROVEMENT

Contingency plan in Sicily: medical triage On board (NGOs, Italian Navy Ships) 1 2 1) Mandatory Medical report Prior to landing (USMAF: maritime, air and border health office) 2) Authorization for landing 3 3) At the port (Local Health Service, IRC: Italian Red Cross) 4 4) Transfer (hospital or reception centres) http://pti.regione.sicilia.it/portal/page/portal/PIR_PORTALE/PIR_LaStrutturaRegionale/PIR_AssessoratoSalute/PIR_Pi anocontingenzasanitarioregionalemigranti/piano%20contingenza%20A4-2017_Definitivo.pdf

Standard Operating procedures applicable to Italian Hotspots http://www.libertaciviliimmigrazione.dlci.interno.gov.it/sites/default/files/allegati/hotspots_sops_-_english_version.pdf

Medical screening at landing AUGUST 2013 – DECEMBER 2017 Numero Scabies 43.800 Obstetric-ginaecological problems 4.210 Hospital admission 2.865 Traumas and wounds 1.771 Dispneas of unknown origin 929 Fever of unknown origin 719 Ortopedical conditions 500 Dermatological conditions 469 Infections 442 Dehydration 418 Pediatric illnesses 144 Neurological conditions 86 Surgiucal emergencies 67 Other 63 TOTALE 56.483 Attività di sorveglianza sanitaria sui flussi migratori, Ufficio 3, DG Prevenzione Sanitaria, dati al 31/12/2017

Death in the sea Dead bodies found on boats PERIOD N. bodies 10th August 2013 –31st December 2017 1.035 Attività di sorveglianza sanitaria sui flussi migratori, Ufficio 3, DG Prevenzione Sanitaria, dati al 31/12/2017

The arrival by sea

Regional relocation of migrants in Italy Tot.: 155.619 Italian Ministry of Interior, data at 31° August 2018

Asylum request Asylum request: Refugee status International protection Humanitarian permits Expulsion Repatriation In 7 days

Syndromic survaillance in (first) reception centres Circolare Misteriale n. DGPRE.V/8636 7th April 2011

Syndromic survaillance in hotspots/hubs Aimed at ensuring uniform and timely epidemiological surveillance: notification to be sent within 24 hours (10:00 A.M. of the day after the evaluation) This syndromic surveillance system complements, but does not substitute for, the existing mandatory infectious disease notification system A total of 13 syndromes were defined as potentially indicative of infectious diseases and/or unusual adverse health events The surveillance system started operating on 11 April 2011 Circolare Misteriale n. DGPRE.V/8636 7th April 2011

Syndromes A Lasting more than 3 weeks but less than one month B Cases presenting with primary gastrointestinal bleeding, for example due to an ulcer, should be excluded C Cases do acute leukaemia should be excluded Ministry’s Circular n. DGPRE.V/8636 7th April 2011 Riccardo F, et al.Euro Surveill. 2011;16(46):pii=20016.

Syndromic survaillance: working principles • For each syndrome, the Observed Daily Incidence (ODI) is calculated by dividing the n. of daily cases observed in the reporting immigration centres by the n. of migrants present that same day • The moving average of the previous 7 days incidence is used to define each syndromes’ Expected Daily Incidence (EDI). • The EDI of each syndrome is measured against a threshold set at 99% confidence interval (99% CI) of the ODI using a Poisson distribution • A statistical alert is automatically triggered when the EDI fells outside this threshold. Statistical alerts are considered valid only when the EDI fells below the ODI ( i.e. , when the observed incidence was higher than expected). A statistical alarm is issued whenever valid statistical alerts are • triggered on the same syndrome for at least two consecutive days Napoli C et al. Int. J. Environ. Res. Public Health 2014, 11 , 8529-8541; doi:10.3390/ijerph110808529

Asylum request Expulsion Refugee status: ~ 7% International protection: ~ 15% Humanitarian permits: ~ 25% Repatriation In 7 days CAS = Centri di Accoglienza Straordinaria Centres for Extraordinary Hospitality SPRAR = Sistema di Protezione per Richiedenti Asilo e Rifugiati Protection System for Refugees and Asylum Seekers

Guidelines for migrant health in reception facilities • A progressive approach according to the specific stage of reception: initial evaluation on arrival, followed by a medical examination in the first reception facility, and a full taking in charge of the individual and their pathologies at the second reception level. • Consider both communicable and non communicable diseases, as well as non pathological conditions (pregnancy) and vaccination • Infectious diseases evaluated: tuberculosis, malaria, hepatitis B and C, HIV, sexually transmitted diseases, intestinal parasites http://www.salute.gov.it/imgs/C_17_pubblicazioni_2624_allegato.pdf