WHO-UNHCR-UNICEF Joint Statement on general principles on vaccination of refugees, asylum-seekers and migrants in the WHO European Region November 2015

30.11.2015 14:44

 

Those most at risk of acquiring vaccine-preventable diseases are young children who have not yet been vaccinated because vaccination programmes in their home countries have been interrupted by civil unrest and war

Background  
The unprecedented influx of refugees, asylum seekers and migrants to countries of the World Health Organization (WHO) European Region poses a public health challenge that needs to be addressed in a timely and effective manner. An effective response to this challenge will require strengthening of national and regional health systems to ensure that all refugees and migrants have easy access to the needed health services. In dealing with such a challenge, the principles of equity, solidarity, human rights and dignity must be adhered to.

Risk of increased transmission of vaccine-preventable diseases   
Chronic health problems suffered by refuges, asylum seekers and migrants are generally similar to those of host populations. However, the physical and psychological burden that comes with fleeing their home countries and the long arduous journeys being undertaken increase overall health risks. For example, factors such as mass population movement, water shortage, and inadequate shelter and sanitation conditions increase the risk of acquiring communicable diseases.  Children are especially prone to acute conditions, such as respiratory diseases, diarrhoea and skin infections. Respiratory illnesses are expected to increase in the winter months as respiratory syncytial virus and seasonal influenza become widespread in the Region.

Most refugees and migrants arriving in Europe are coming from Middle Eastern countries where vaccines are widely accepted and coverage has been historically high. Those most at risk of acquiring vaccine-preventable diseases are young children who have not yet been vaccinated because vaccination programmes in their home countries have been interrupted by civil unrest and war.

On the other hand, there are many residents and mobile individuals in host countries of the Region that remain susceptible. Many are not availing themselves of vaccination due to misconceptions about vaccines, complacency, low awareness of benefits of vaccines and religious or philosophical beliefs. Others do not have access to vaccination services due to lack of health insurance or registration with the health system. Recent outbreaks of measles in many European countries have highlighted adolescents and young adults as a particularly susceptible group. In addition, in recent years, measles and rubella outbreaks have disproportionately affected particular groups such as Roma in Poland,[1] immigrants in Spain,[2] anthroposophic communities in German-speaking countries[3], and Sweden[4]and orthodox Protestant communities in the Netherlands.[5],[6]

Most outbreaks of vaccine-preventable diseases such as measles, rubella and pertussis continue to occur in the Region independent of refugee and migrant population movement. The risk of a polio outbreak also continues in the Region, since Bosnia and Herzegovina, Romania and Ukraine have in recent years been repeatedly identified by the Regional Certification Commission for Poliomyelitis Eradication as being at high-risk for transmission in the event of wild poliovirus importation and a cVDPV outbreak started in Ukraine in September. The rapid influx of large numbers of unvaccinated children therefore only increases existing immunity gaps.

Provision of health services and vaccines  
In line with the Alma‑Ata declaration on universal health coverage (1978),[7] Health 2020 (the European policy for health and well-being),[8] the World Health Assembly resolution WHA61.17 on migrants' health,[9] and the 1951 Refugee Convention[10] all state that refugees and asylum seekers should have non-discriminatory and equitable access to health care services, including vaccines, irrespective of their legal status.  Access to vaccines is indeed a specific objective for the WHO European Region as outlined in European Vaccine Action Plan 2015-2020,[11] which was endorsed by all 53 Member States. The plan proposes that all countries in the Region ensure that immunization policies are non-discriminatory and that the services are fully inclusive and user-friendly. In addition, United Nations Children’s Fund (UNICEF) Core Commitments for Children in Humanitarian Action calls for ensuring equitable access of all children, adolescents and women to essential health services with sustained coverage of preventive and curative interventions.[12] These also include timely immunization against vaccine-preventable diseases, particularly against measles and polio.

Health systems in the countries receiving migrants are well equipped and experienced to diagnose and treat common infectious and noncommunicable diseases. We must ensure that they are adequately prepared and organized to provide support to refugees, asylum-seekers and migrants while at the same time ensuring the health of the resident population. The provision of vaccines should be carried out in an equitable manner with a systematic, sustainable and non-stigmatizing approach. Since immunization is a health intervention requiring a continuum of follow-up until the full schedule is completed, this requires cooperation among the countries of origin, transit and destination.

We applaud the many countries, such as those on the frontline of large-scale migration, that have been vaccinating refugees, asylum-seekers, and migrants regardless of country of origin and according to their routine vaccination schedules.

Recommendations for vaccination   
The current influx of refugees, asylum-seekers and migrants is not only unprecedented in scale but also in speed of movement. This poses particular challenges in deciding when and where to vaccinate. The situation is compounded further by the fact that many vaccines require consecutive doses in timed intervals. Access to the full immunization schedule through follow up vaccinations is therefore difficult to ensure while people are on the move. However, refugees, asylum-seekers and migrants should be vaccinated without unnecessary delay according to the national immunization schedules of the country where they are envisioned to reside for more than a week. Measles/mumps/rubella (MMR) and polio vaccines should be prioritized.  Governments should consider providing each vaccinee or child’s caregiver with documentation of the vaccinations given. This will help avoid unnecessary vaccination.

Vaccination of refugees, asylum-seekers and migrants is not recommended at border crossings unless there is an outbreak of a vaccine-preventable disease in the host or transit country. In such a case, countries are urged to include refugees, asylum-seekers and migrants in any outbreak control measures taken (including vaccination). If the level of risk of serious disease transmission is considered high based on epidemiological risk assessment, countries may decide whether or not to vaccinate based on recommendations in the document “Vaccination in acute humanitarian emergencies: a framework for decision making”.[13] Provision of measles-containing vaccines is further defined in “Reducing measles mortality in emergencies, WHO-UNICEF Joint Statement”[14] and provision of polio vaccines is discussed in “Reducing risk of poliomyelitis outbreaks in emergencies” issued by the Global Polio Eradication Initiative (GPEI).[15]

The refugee crisis calls for all countries to review existing immunity gaps in their populations, and to address areas and groups with suboptimal coverage through tailored immunization services, strong communication and social mobilization. This will help countries fulfill their shared responsibility to attain the goals of global polio eradication and regional measles and rubella elimination.

Recommendations on specific vaccines   
Polio vaccines: In light of the current high level of population immunity against polio and the specificities in the organization and provision of primary health care services in European countries, supplementary polio immunization campaigns for preventive purposes are not considered essential. However, to maintain this high population immunity against polio, and mitigate the risk of importation and circulation of polioviruses, we emphasize the importance of equitable access and administration of polio vaccines to all individuals and population groups in accordance with current national routine immunization schedules for children and adults.

National stockpiling of oral polio vaccines in anticipation of a possible polio outbreak is not recommended. The GPEI will manage polio outbreaks in accordance with the latest standard operating procedures[16]and provide access to the appropriate polio vaccine.

Measles- and rubella-containing vaccines:  
Given that some countries of the Region are still considered endemic for measles and rubella, refugees and migrants should be vaccinated against these diseases as a priority and in line with national vaccination schedules. In view ongoing transmission of measles and rubella in the Region and the 2015 measles and rubella elimination goal set for the Region, WHO supports the closure of all immunity gaps in the population with activities such national supplementary immunization campaigns with measles- and rubella-containing vaccines. This is particularly important in countries where these diseases are still endemic. Such an activity would certainly contribute toward reaching the goal of eliminating these diseases from the Region.

Protection of health care workers   
In line with WHO recommendations, most countries of the WHO European Region recommend seasonal influenza vaccination for health care workers. Vaccination against hepatitis B, measles and rubella is also recommended to those that are still susceptible to these diseases.

Strengthening communicable diseases surveillance systems   
Under the International Health Regulations (2005)[17] all countries should have effective disease surveillance and reporting systems, outbreak investigation ability, and case management and response capacity. In line with these capacities, countries should also be able to perform quick and effective epidemiological risk assessments. WHO and the European Union’s Centre for Disease Prevention and Control (ECDC) have systems and capacities in place to support national disease surveillance efforts.

References


[1]  Makówka A, Paradowska-Stankiewicz I, Szenborn L et al. Measles outbreak among Roma people in Wrocław, Poland, 2012. Pol J Microbiol. 2014;63(4):457-60.

[2]Lemos C, Ramirez R, Ordobas M, et al. New features of rubella in Spain: the evidence of an outbreak. Euro Surveill 2004; 9(4):pii=463. Available at:

www.eurosurveillance.org/ViewArticle.aspx?ArticleId=463

[3] Muscat M. Who gets measles in Europe? J Infect Dis 2011; 204(suppl 1):S353-365. 

[4]World Health Organization Regional Office for Europe. WHO Epidemiological Brief No. 27 (October 2012).

Available at: www.euro.who.int/__data/assets/pdf_file/0011/177653/EpiBrief-Issue-27-v-3.pdf 

[5] Knol MJ, Urbanus AT, Swart EM, et al. Large ongoing measles outbreak in a religious community in the Netherlands since May 2013. Euro Surveill 2013; 18(36):pii=20580. Available at: www.eurosurveillance.org/ViewArticle.aspx?ArticleId=20580

[6]World Health Organization Regional Office for Europe. WHO EpiBrief, 2013, 3:1–5

Available at: www.euro.who.int/__data/assets/pdf_file/0003/214833/EpiBrief-Issue-3,-2013.pdf

[7] World Health Organization Regional Office for Europe. Declaration from the International Conference on Primary Health Care, Alma-Ata, September 1978. Available at: http://www.euro.who.int/__data/assets/pdf_file/0009/113877/E93944.pdf

[8] World Health Organization Regional Office for Europe. Health 2020: the European policy, for health and well-being. Website:  http://www.euro.who.int/en/health-topics/health-policy/health-2020-the-european-policy-for-health-and-well-being/about-health-2020

[9] World Health Organization.   Sixty-first world health assembly.  WHA61.17 . Health of migrants 2008. http://apps.who.int/gb/ebwha/pdf_files/A61/A61_R17-en.pdf 

[10] United Nations High Commissioner for Refugees. 2010. Convention and protocol correlating to the status of refugees. Available at: http://www.unhcr.org/3b66c2aa10.html

[11] World Health Organization Regional Office for Europe. 2014. European vaccine Action Plan 2015-2020. Available at: http://www.euro.who.int/__data/assets/pdf_file/0007/255679/WHO_EVAP_UK_v30_WEBx.pdf?ua=1

[12] UNICEF Core Commitments for Children in Humanitarian Action. Available at: http://www.unicefinemergencies.com/downloads/eresource/docs/1/2010-CCC-FinaI.pdf

[13] World Health Organization. Vaccination in acute humanitarian emergencies: a framework for decision making. Available at:

http://www.who.int/immunization/sage/meetings/2012/november/FinalFraft_FrmwrkDocument_SWGVHE_23OctFullWEBVERSION.pdf

[14] Reducing measles mortality in emergencies, WHO-UNICEF Joint Statement. Available at: http://www.who.int/immunization/diseases/WHO_UNICEF_Measles_Emergencies.pdf

[15] Reducing risk of poliomyelitis outbreaks in emergencies, Global Polio Eradication Initiative. Available at: http://www.polioeradication.org/Portals/0/Document/Resources/Polio_in_Emergencies.pdf

[16] World Health Organization. Responding to a poliovirus outbreak. Standard Operating Procedures for a new polio outbreak in a polio-free country. Available at: http://www.polioeradication.org/Portals/0/Document/Resources/PolioEradicators/1a.PolioOutbreakGuideline20150220.pdf                                                                  

[17] World Health Organization.  International Health Regulations (2005) Second edition.

Available at: http://www.who.int/ihr/publications/9789241596664/en/

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