Chancroid – a rare disease in Europe. Would recent migration flows change the

epidemiology in the EU/EEA? Otilia Mardh, Ninnie Abrahamsson, Andrew Amato-Gauci

European Centre for Disease Prevention and Control

30th IUSTI European Congress 2016, September 15-17, Budapest

Chancroid – a rare sexually transmitted infection?

Worldwide

• Decline in global incidence (WHO, Global STI strategy, 2016)

• Still prevalent in resource-poor settings in countries from Africa, Asia; among CSW and their clients (Lewis, 2014)

• Risk factor for HIV-transmission in sub-Saharan Africa

EU/EEA

• not mandatorily notifiable

• not reported to The European Surveillance System

Refugees movements to EU/EEA

• >1 million Mediterranean sea arrivals in 2015 (UNHCR1), 291 773 in 2016

• Majority originate from:

• Syria 43%, Afghanistan 23%, Iraq 14%;

• Pakistan, Iran, Nigeria, Gambia, Senegal, Guinea, Mali ; each <3%

• ECDC STI surveillance data: 11% of gonorrhoea and 7.3% of syphilis cases in 2010 were among migrants (ECDC report, 2014)

• Multiple barriers for migrants to access sexual health services (ICRH report, 2011)

• Undocumented migrants are at higher risk to acquire sexually transmitted infections and less likely to access sexual health services (Sebo P, 2011)

1 United Nations High Commissioner for Refugees

Objectives

• Describe current epidemiology of chancroid in the EU/EEA

• Describe burden of infection in countries of origin of newly arrived migrants, in order to identify needs for clinical awareness and sexual health services

Methods

• Literature review

• PubMed® and Embase®, January 2016

• studies reporting prevalence, proportions of positive patients, surveillance reports

• search strategies combined “chancroid” (OR “ulcus molle” OR “Haemophilus ducreyi”) with epidemiology and case reports concepts

• publications from 2000 onwards

• no language restrictions

• UNHCR for refugees statistics

8 studies from 6 EU/EEA countries7 case reports from 6 countries

9 studies from 3 of the top 10 countries of origin

http://data.unhcr.org/mediterranean/regional.php

Results

Chancroid epidemiology in EU/EEA Prevalence studies, surveillance reports

NA –denominator data not available , *syphilis, gonorrhoea, chancroid and LGV, N/A = Information not available/reported

8 studies, 6 countries

References: Zakoucka et al. 2004, Hope-Rapp et al. 2010, Kyriakis et al. 2003, Giuliani et al. 2004, Bruisten et al. 2001, O’Farrell & Lazaro 2014, Dufaur et al. 2015, Rayment et al. 2013

Chancroid epidemiology in EU/EEACase reports

*contact with CSW in the country of travelling

References:Henry et al. 2009, Marasovic et al. 2000, Knudsen et al. 2010, Knudsen et al. 2010, Holst et al. 2007, Fouéré et al.2015, Canhoto et al. 2012, Barnes et al. 2014

7 cases, 6 countries

A sporadic case in UK, 2014

• 22y/o M

• No history of a contact with a non-UK resident

• Painful penile ulcers

• Syphilis, HSV, LGV, chlamydia, gonorrhoea and HIV – negative!

• Self diagnosed!

• No other cases identified through contact tracing

GTI= genitourinary tract infections; IF, COAG = Direct immunofluorescence, coagglutination

Chancroid epidemiology in the top ten countries of origin of newly arrived migrants* in EU/EEA

* Mediterranean sea arrivals, Jan-March 2016

Pakistan

Senegal

Nigeria

9 studies, 3 countries

References:Maan et al. 2011, Bhutto et al. , Sami & Baloch 2005, Razvi et al. 2014, Rehan 2003, Awolade et al. 2012, Fayemiwo et al. 2011, Fatiregun & Afolabi Bamgboye 2004, Totten et al. 2000

Conclusions: EU/EEA

• Low numbers of chancroid cases in Europe• No cases reported after 2000 in Greece, Italy, Netherlands and Croatia,

after 2010 in Belgium and Denmark • Most recent cases (sporadic) in UK, 2014 and France, 2015• 4 cases associated with travel to North Africa, 2009; Guinea, 2000;

Pakistan, 2010; Madagascar, 2015• 2 sporadic cases with no travel history (UK, 2014; Portugal,2012) • Higher prevalence among foreign-borns in Italy, Greece (before 2000)

Sporadic occurrence of chancroid cannot be excluded. Clinical awareness is advised in patients with a history of travel and sexual contact with persons in high-risk groups.

Conclusions: refugees and migrants

• No studies from Syria, Afghanistan, Iraq (80% of refugees)

• Studies from Pakistan, Nigeria and Senegal (low % of migrants influx)

• Most recent chancroid reports from Pakistan, 2014; Nigeria, 2003; Senegal, 1992;

• Reports from patients in high-risk groups, patients with co-infections, FSW and clients

Appropriate access to sexual health services will maintain or improve the sexual health of newly arrived migrants.

Thank you!