WHO-UNHCR-UNICEF joint technical guidance: general principles of vaccination of refugees, asylum-seekers and migrants in the WHO European Region

23-11-2015

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 must be addressed in a timely, effective manner. An effective response to the challenge will require strengthening national and regional health systems to ensure that all refugees and migrants have easy access to the health services they need. In doing so, the principles of equity, solidarity, human rights and dignity must be adhered to.

Risk for increased transmission of vaccine-preventable diseases 

The chronic health problems of refugees, asylum-seekers and migrants are generally similar to those of their host populations; however, the physical and psychological effects of fleeing their home countries and the long, arduous journeys they undertake increase their overall health risks. For example, mass population movement, lack of sufficient water and inadequate shelter and sanitation conditions increase the risks for 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 spread in the Region.

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

Furthermore, many residents and mobile individuals in the host countries of the Region remain susceptible. Many do not avail themselves of vaccination due to misconceptions about vaccines, complacency, poor awareness of the benefits of vaccines or religious or philosophical beliefs. Others do not have access to vaccination services because they do not have health insurance or are not registered with the health system. The recent outbreaks of measles in many European countries indicate that adolescents and young adults are particularly susceptible. 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 occur in the Region independently of refugee and migrant population movement. There is a continuing risk for a polio outbreak in the Region, as Bosnia and Herzegovina, Romania and Ukraine have repeatedly been identified by the Regional Certification Commission for Poliomyelitis Eradication as at high risk for transmission in the event of wild poliovirus importation, and an outbreak of circulating vaccine-derived poliovirus occurred in Ukraine in September. The rapid influx of large numbers of unvaccinated children would therefore only increase 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), 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, equitable access to health care services, including vaccines, irrespective of their legal status. Access to vaccines is indeed a specific objective in the WHO European Region, as outlined in the 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, the Convention on the Rights of the Child (12) and the United Nations Children's Fund (UNICEF) Core Commitments for Children in Humanitarian Action (13) call for equitable access of all children, adolescents and women to essential health services, with sustained coverage of preventive and curative interventions. These include timely immunization against vaccine-preventable diseases, particularly measles and polio.

The health systems in the countries receiving migrants are well equipped and experienced to diagnose and treat common infectious and noncommunicable diseases. They must be 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. Vaccines should be provided in an equitable manner with a systematic, sustainable, non-stigmatizing approach. As vaccination is a health intervention that requires a continuum of follow-up until the full schedule is completed, there must be cooperation among the countries of origin, of transit and of destination.

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

Recommendations for vaccination

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

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 cases, countries are urged to include refugees, asylum-seekers and migrants in any outbreak control measures taken, including vaccination. If the level of risk for serious disease transmission is considered high in an epidemiological risk assessment, countries may decide whether to vaccinate on the basis of the recommendations in the document Vaccination in acute humanitarian emergencies: a framework for decision making (14). Provision of measles-containing vaccines is further defined in Reducing measles mortality in emergencies, WHO–UNICEF joint statement (15), and provision of polio vaccines is discussed in Reducing risk of poliomyelitis outbreaks in emergencies, issued by the Global Polio Eradication Initiative (GPEI) (16).

The refugee crisis should incite all countries to review any immunity gaps in their populations and ensure tailored immunization services and strong communication and social mobilization in areas and groups that have suboptimal coverage. This will help countries fulfil 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 high population immunity against polio and mitigate the risk of importation and circulation of polioviruses, it is important that equitable access and administration of polio vaccines be given 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 (17) and provide access to the appropriate polio vaccine. 

Measles- and rubella-containing vaccines: As 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 of ongoing transmission in the Region and the 2015 measles and rubella elimination goal set for the Region, WHO supports closure of all immunity gaps, with activities such as national supplementary vaccination campaigns with measles- and rubella-containing vaccines. This is particularly important in countries where these diseases are still endemic and will contribute to 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 who are still susceptible to these diseases.

Strengthening communicable diseases surveillance systems 

Under the International Health Regulations (2005) (18), all countries should have effective disease surveillance and reporting systems, outbreak investigation ability and case management and response capacity. With this capacity, countries should also be able to perform quick, effective epidemiological risk assessments. WHO and the European Centre for Disease Prevention and Control (ECDC) have systems and capacity in place to support national disease surveillance.

References:

  1. Makówka A, Paradowska-Stankiewicz I, Szenborn L, Santibanez S, Mankerz A, Litwińska B. Measles outbreak among Roma people in Wrocław, Poland, 2012. Pol J Microbiol 2014;63(4):457–460
  2. Lemos C, Ramirez R, Ordobas M, Guibert DH, Sanz JC, Garcia L, et al. New features of rubella in Spain: the evidence of an outbreak. Euro Surveill 2004;9(4):pii=463
  3. Muscat M. Who gets measles in Europe? J Infect Dis 2011;204(Suppl 1):S353–S365
  4. WHO Epidemiological Brief No. 27 (October 2012). Copenhagen: World Health Organization Regional Office for Europe; 2012 
  5. Knol MJ, Urbanus AT, Swart EM, Mollema L, Ruijs WL, van Binnendijk RS, et al. Large ongoing measles outbreak in a religious community in the Netherlands since May 2013. Euro Surveill 2013;18(36):pii=20580
  6.  WHO EpiBrief, 2013, 3. Copenhagen: World Health Organization Regional Office for Europe; 2013:1–5
  7. Declaration from the International Conference on Primary Health Care, Alma-Ata, September 1978. Copenhagen: World Health Organization Regional Office for Europe; 1978
  8. Health 2020: the European policy, for health and well-being. Copenhagen: World Health Organization Regional Office for Europe; 2012
  9. Sixty-first World Health Assembly. WHA61.17. Health of migrants. Geneva: World Health Organization; 2008
  10. Convention and protocol relating to the status of refugees. Geneva: United Nations High Commissioner for Refugees; 2010 
  11. European vaccine action plan 2015–2020. Copenhagen: World Health Organization Regional Office for Europe; 2014
  12. Convention on the Rights of the Child. New York: United Nations; 1989
  13. Core commitments for children in humanitarian action. Geneva: UNICEF; 2010
  14. Vaccination in acute humanitarian emergencies: a framework for decision making. Geneva: World Health Organization; 2012
  15. Reducing measles mortality in emergencies, WHO-UNICEF Joint Statement. Geneva: World Health Organization; 2004 
  16. Reducing risk of poliomyelitis outbreaks in emergencies. Geneva: World Health Organization, Global Polio Eradication Initiative
  17. Responding to a poliovirus outbreak. Standard operating procedures for a new polio outbreak in a polio-free country. Geneva: World Health Organization; 2015
  18. International Health Regulations (2005). Second edition. Geneva: World Health Organization; 2008