Health risks from recent migrations to Europe Zdravstveni rizici od nedavnih migracija ka Evropi

Throughout the history, as well as today, migrations appear as health problem if they are massive, sudden and with an independent flow 1. In the last several years Europe met a large influx of migrants. Even before recent wave of mass migrations, 3.8 million migrants entered European Union (EU) in 2014 and 1.9 million from them was not from European countries. In 2015, however, 1.5 million more migrants arrived 2, and during the first nine months of 2015 over 600,000 applications for asylum were filed in the EU 3. The main causes of modern massive migrations to Europe are: demographic explosion in Africa and in the Middle East, long-lasting wars and growing possibility of social engineering. At the same time, birth rates and population in Europe – the wealthiest and best governed continent – are in decline. Above all, migrations to Europe are highly facilitated by the fact that Europe shares the sea with Africa and the Middle East, while the European countries share common borders. One of the effects of the increase and escalation of international migrations is that it certainly intensifies the process of globalization 1, 2. Despite the fact that birth rates in Africa is the highest on the world, most migrants come from the Middle East because wars were always more important reason for migrations than demographic explosion, and the number of interstate and internal wars and activities of terrorist organizations in the same area is increasing in the last several decades. They come mostly from Syria, but also from Afghanistan, Eritrea, Iraq, Pakistan, Somalia and other warturned countries from this parts of the world. With the first wave of migrants emerged also the concern in Europe whether they will bring disease and death to the domestic population. This concern created various fears in Europe and opened numerous questions which, if answered, could help to determine health condition of the migrants and the health risk they pose for domestic population of the countries through which they are travelling or where they are staying. Key questions, under the conditions of increased panic in some, above all Central European states, were mostly related to concerns about European population health, but not about health of the migrants: Are refugees carriers of contagious diseases and what is the percentage of those with infectious diseases in the migrant population? Do migrants pose a health risk for domestic population in terms of possible epidemic outbreaks? To which extent? Which new diseases do they bring? Are migrants carriers of microbes (viruses and bacteria) causing diseases typical (or atypical) for the region where they come from? In this article both the level of health risk presented by the migrants to domestic populations of the EU and Serbia as well as the level of risks presented to the various migrant groups as they mingle together are discussed.


Introduction
Throughout the history, as well as today, migrations appear as health problem if they are massive, sudden and with an independent flow 1 . In the last several years Europe met a large influx of migrants. Even before recent wave of mass migrations, 3.8 million migrants entered European Union (EU) in 2014 and 1.9 million from them was not from European countries. In 2015, however, 1.5 million more migrants arrived 2 , and during the first nine months of 2015 over 600,000 applications for asylum were filed in the EU 3 .
The main causes of modern massive migrations to Europe are: demographic explosion in Africa and in the Middle East, long-lasting wars and growing possibility of social engineering. At the same time, birth rates and population in Europe -the wealthiest and best governed continent -are in decline. Above all, migrations to Europe are highly facilitated by the fact that Europe shares the sea with Africa and the Middle East, while the European countries share common borders. One of the effects of the increase and escalation of international migrations is that it certainly intensifies the process of globalization 1,2 .
Despite the fact that birth rates in Africa is the highest on the world, most migrants come from the Middle East because wars were always more important reason for migrations than demographic explosion, and the number of interstate and internal wars and activities of terrorist organizations in the same area is increasing in the last several decades. They come mostly from Syria, but also from Afghanistan, Eritrea, Iraq, Pakistan, Somalia and other warturned countries from this parts of the world.
With the first wave of migrants emerged also the concern in Europe whether they will bring disease and death to the domestic population. This concern created various fears in Europe and opened numerous questions which, if answered, could help to determine health condition of the migrants and the health risk they pose for domestic population of the countries through which they are travelling or where they are staying. Key questions, under the conditions of increased panic in some, above all Central European states, were mostly related to concerns about European population health, but not about health of the migrants: Are refugees carriers of contagious diseases and what is the percentage of those with infectious diseases in the migrant population? Do migrants pose a health risk for domestic population in terms of possible epidemic outbreaks? To which extent? Which new diseases do they bring? Are migrants carriers of microbes (viruses and bacteria) causing diseases typical (or atypical) for the region where they come from? In this article both the level of health risk presented by the migrants to domestic populations of the EU and Serbia as well as the level of risks presented to the various migrant groups as they mingle together are discussed.

Migrations as the health risk for Europe
The first reaction of the EU institutions was slow and not very effective. It showed that, in the last decade, Europe was not well prepared to meet the huge challenge brought by uncontrolled migrations. As a result, many political and other anomalies arose in many European countries regarding the issue of mass migrations 4 . Aside from the late reactions of the European health institutions, they ultimately paid special attention to security challenges posed by migrants 5 . Therefore, the European countries mostly paid attention to the increased danger of terrorism, rape and other crimes 6 . They paid little attention to unsuccessful integration of migrants and even less attention to screening the migrants and identifying those aspects which might present possible public health risks for Europe.
Health risks related to sudden mass migrations, which are still going on, albeit with less intensity, can be divided into two periods: intensive fluctuations of migrants throughout a series of European countries including Serbia, and the current period when migrants, willingly or unwillingly, stay in one of the European countries for longer periods.
Thus, during the first period from 2015 to 2016, is characterized by the most intense migration movements, the health risk consisted not only of the possibility of epidemic outbreaks and spreading of contagions among domestic population, but also of the lack of complete and reliable insight into the health conditions in migrant groups. Reasons for this lie in enormous numbers of migrants and the speed which they proceeded with across Europe without being restricted by many states.
In the beginning, the screening process showed that migrants reported their health condition as being good. One can logically assume that if they were ill they would not undertake such a long and perilous journey. But, the fact is that the migrants came from countries plagued by war, disease and poverty and where health practicies are low, vaccinations and other forms of immunological protection are irregular and infrequent even in times of peace. It is also the fact that they traveled to their destinations staying in unsanitary, overcrowded accommodations, often without access to fresh water or health care. In the beginning of these migrations many countries did not provide sanitary or safe health accomodation, nor sufficient health services. Inadequate sanitation, suboptimal hygiene, and unsafe water and food can increase the risks of outbreaks of water and foodborne diseases such as salmonellosis, hepatitis A virus infection and cholera. The highest percentage of foreigners in need of medical help came from Africa or the Middle East. Many did not report their health issues from the fear of being deported. However, due to the harsh conditions and the very long travel, there were significant chance that they would become ill, or that some hidden disease would manifest itself and become intense. Additionally, migration itself can impair both mental and physical health 5 .
Health risk was additionally increased by the fact that there were numerous illegal crossings over the borders. It is impossible to control the health conditions of those migrants who entered the country illegally and avoided registration and accommodations in the Migrant Centers, often living in unsanitary conditions.
During the second period, which still lasts, health risk stemming from unsanitary living conditions and lack of health care among migrants is significantly reduced, while levels of risk due to their more extensive contact with local population increase.
By examining health condition of migrants during both periods carried out by European states, affected by migrations, the World Health Organization (WHO) and other international organizations, shown that the fear of epidemic outbreaks, mass contagion of domestic population with infectious diseases or its exposure to rare and endemic diseases was unfounded. Migrants were mostly ill with seasonal respiratory infections and digestion problems, as well as with dermatological diseases (scabies) and feet injuries to the degree consistent with the conditions of their long travel and poor accommodation. Relatively high levels of post-traumatic stress diagnosis and depression 6 were also found as expected.
Migration has been mostly talked about as a driver of infectious diseases to European countries, particularly in those which receive migrants from places with high prevalence of infectious diseases 7 . National Surveillance Systems of European countries demonstrated higher incidence and prevalence rates of certain infectious diseases among migrants, such as human immunodeficiency virus (HIV) infections, tuberculosis and hepatitis. Pulmonary tuberculosis was one of the main foci for migrant health assessment (MHA) process. But the evidence from epidemiological studies indicates that the risk of transmission from migrants to the general population was relatively low, approximately as one decade before 8 . Possibility of contagion with new strains of viruses and bacteria dangerous for European population, has not been confirmed so far. Just the opposite, there is a growing evidence that migrants from countries with high prevalence of HIV are at much higher risk of acquiring HIV after arrival in the EU 9 . More than one-third of all newly diagnosed HIV cases in 2015 in the EU were among migrants 10 . Migrants account for more than half of all newly diagnosed HIV cases in 10 EU countries and in some of them (Sweden, Luxembourg) the rate is over 70% (Figure 1). Higher rates of acquired immunodeficiency syndrome (AIDS) deaths in migrants can, at least in part, be attributed to the high frequency of late diagnosis (e.g. diagnosis with an AIDS defining illness) 11 . HIV testing rates among migrants are low. This reflects the existence of many different barriers, not only the lack of knowledge of other cultures and backgrounds, but, also, the lack of testing and cure, fear of the disease and death, the fear of discrimination in the community as well as fear of deportation 12 .
Lately, health and safety/security experts in the EU are more interested in mental health of the migrants considering that certain percentage of terrorist and extremist attacks in the EU and the USA over the last few years were perpetrated by persons of migrant origin having mental health issues. Some of data suggest that almost two-third of asylum seekers may meet the diagnostic criteria for post traumatic stress disorder (PTSD) 13 . 600-1,000 migrants entered Serbia daily. The number of sylum seekers, originally small, increased each yearand it stood at 30,000 in 2015 14 .

Migrations as the health risk for Serbia
Medical triage is availabe at the point of entry to Serbia. There, the primary concern dealt with is the health status of the asylum seekers, as such. However, despite the fact that medical staff in some asylum centers in Serbia is available 24h per day, migrants do not ltake enough advantage of this opportunity.
Data obtained from systematic health monitoring of asylum centers show that 68,802 health hazards were observed during the period from June 1, 2015 to January 10, 2016. Respiratory diseases dominated among migrants with increasing incidence in cold months, and there were 45% respiratory infections, 8% injuries, 5% intestinal infections with diarrhea, and 4% without diarrhea. They also reported 15 births, 6 abortions and 2 sudden deaths. Thus far there have not been any reports of unexpected communicative diseases, but they are always possible 14 . The number of health issues showing growing incidence peeked in late October and early November but stabilized in the winter. During the analyzed period, 71,327 medical examinations were conducted on migrant patients with predominance of curative treatments (94%) 15 . So far, no cases of plague were reported nor there were any reports on the Middle East respiratory syndrome coronavirus, both represented serious concern 16 . In this respect, situation in Serbia is almost completely consistent with the findings in other Europeans countries along the migration route.
The asylum centers in Serbia are unrestricted centersmigrants can freely move not only from centers to town but also from town to town as well.
During the measles epidemic this winter (2018) in Serbia there were 12 deaths. It represents 1/3 of the number of deaths from smallpox (36) in the year 1972 in former Yugoslavia, which at that time had population three times larger than the population of Serbia today 16 . There were rumors connecting the last outbreak of measles in Serbia with the migrants, but there is no evidence confirming this claim.
Among the many problems facing Serbia today, there is also difficulty with vaccines and related supplies arriving slowly and often times late. For example, during the recent flood crisis, vaccines for hepatitis A were requested, but they arrived one year later 14 .
In response to the recent large influxes of migrants arriving in Serbia, the Ministry of Health requested that the WHO conduct a joint assessment and review of the Serbian health system's capability to manage large and sudden groups of migrants 17 . To that end, in April 2015, the WHO Regional Office for Europe started the project Public Health Aspects of Migration in Europe (PHAME), aiming to strengthen capability and adequate management of the public health challenges (including the health of migrants) related to the issue of large influx of migrants 14 .
The migrant population coming in Europe is relatively healthy and doesn't present a significant health hazard for locals. There is no evidence or expert opinion that suggests that migrants increase the risk of epidemics caused by infectious disease in the host population of Europe 18 .

Conclusion
Health risk from migration in Europe was not excessive in any period. Nevertheless, certain health risk still exist for domestic population as well as for the migrants themselves. That is primarily due to the fact that migrants legally residing in a country routinely avoid medical examinations and poor personal hygiene among some migrant, even when they are provided with accommodations that meet the necessary sanitary requirements. Therefore, today, health risks related to the migrants in Europe are higher for the migrants themselves than for the domestic populations. Although health risk related to migrants as a threat to public health, it is not high in Europe, it is still listed in official European documents as an important security challenge due to constant illegal influx of new migrants. There is also an ever present chance of revived and increased migrant flow caused by the real possibility of revival of old war conflicts as well as the eruption of the new ones in the Middle East and in Africa.
Thus, preventing measures remain mandatory in all EU countries, as well as in other countries along the migrations` route including Serbia.