E p i d e m i o l o g i c s t u d y STDs and illegal immigration Immigration and clandestinity: new challenge/or STD Centre V. Padovese, T. Cimolino, G. Magaton Rizzi and G. Trevisan - S u m m a r y Migration patterns have changed during the last decades; in the past Italy, was characterized by mass emigration. Now Italy is taking over from Germany the role of Europe's main recipient of immigrants. Till 2001, the officially registered foreign population in Italy stood at 1.362.630. However, clandestine migrants pushed the real figure above 1.600.000. The analyses of residence permit data show that the immigrants are coming increasingly from East European countries, and that they are predominantly concentrated in the North of Italy. The new migratory flows from less developed countries imply many problems to the health assistance. "First aid centres" and "STD centres" offer the early assistance to the immigrants. The main problems are often the language and the immigrants' compliance; it is difficult for them to follow the therapeutic prescriptions, sometimes due to economic reasons only. As the consequence the relations between physicians and patients are not always satisfactory. One important characteristic that distinguishes contemporary immigration from the previous one is the significant presence of undocumented, or illegal, persons. The scarcity of sound information on undocumented immigrants makes the formulation and the implementation of an efficient policy, concerning this clandestine segment of the population, extremely difficult. We present the experience of STD centre of Trieste regarding these problems. KEY WORDS immigration, illegal, sexually transmitted diseases, STD centres Introduction In Italy, during the years, the role of STD centres underwent important changes. The STD centres were in the past organized as antivenereal centres. With the decrease of venereal diseases due to the campaigns of primary prevention, the improvement of diagnostic techniques and the antibiotic therapy, the historical role of these centres has been changed. The patients' typology has also been altered. In the '80, with the appearance of Acquired Immune Deficiency Syndrome, the interest of venereologists and specialists of infectious diseases has switched towards STDs again. Atypical manifestations of the classical STDs have been observed in these patients as a consequence of immunosuppression. Nowadays, the introduction of multiple drug therapy changed the diseases that have often assumed the characteristics of a chronic infection with extended course. The number of patients affected is also expected to increase. Beyond AIDS, the venere- Acta Dermatoven APA Vol 12, 2003, No 2 59 STD and illegal immigration E p i d e m i o l o g i c s t u d y ologist's attention is turned toward a new reality: the health problems of immigrants. Thus the doctors have again to treat venereal diseases, which were frequently observed in the past, as well as certain diseases, which used to be rare and that can be defined as "imported". During the last century migration patterns in Europe have been changed. It is possible to distinguish three main currents -flow of immigrants inside Europe, specially toward the more rich Northern countries; -transoceanic flow, especially to United States and Canada; -flow to and from ex-colonies. The technological progress and industrialization as well as the end of the colonial period, generated an imbalance between rich and poor countries. Such a development has modified characteristics and typology of the migration process. The increase of irregular and clandestine immigrants and the flow of refugees from Eastern Europe are some of the effects (1). Until the 60's, Italy has been characterized by a mass emigration, while now a mass immigration is observed, so Italy is taking over from Germany the role of European main recipient of immigrants from less developed countries. This increased immigrants' inflow to Italy has been observed since the 1970's, because of measures and restrictive policy adopted by the other European countries (1). Moreover, in Italy it is difficult to control the flow of immigrants due to the long coast. Analyses of data from residence permits show that the immigrants are coming increasingly from East European countries and from Africa, and that they are relatively concentrated in the Northern Italy. Till December 2001, the officially registered foreign population in Italy was estimated at 1.362.630 (2). According to the actual data and including the minors, we can assume the number of immigrants around 1.600.000, which corresponds to 2,8% of the total population. In the North-Eastern and in the North-Western Italy there are living even 24,2% and 32,7% respectively of the total number of immigrants. The presence in Northern Italy of 3-4 immigrants per each 100 000 inhabitants is related to better employment opportunities, while in the southern regions the immigrants are mostly refugees (2). From several collected data, we can conclude that the average immigrant is a young, strong, relatively educated male person, and in a good health condition. He risks getting ill either because of the dramatic traveling conditions or just after his arrival in Italy due to infectious diseases present in the host country. Psychological uneasiness, social degradation, nutritional and further problems are considerably influencing his health (3). On the national level the main disorders affecting the immigrants are dermatological (52%), respiratory (10,7%), digestive (9,2%), orthopedic and traumatic (8,6%), infectious (11%), neuropsychiatric (4%). Infec- tious diseases have increased in the last 2 years from the 7% at 11% totally, with an increase of HBV and HCV infections particularly. Furthermore, no data are available on the frequency of illnesses acquired in Italy, but infectious and parasitic diseases are frequently seen in immigrants, suggesting that their sanitary and housing conditions in their home country are generally poor (3). Materials and methods The problems arising are influenced by the great mobility of these people. On a public health level, complex issues, such as epidemiology, prevention, diagnosis, therapy and organization need to be considered. A "sentinel surveillance system" for the control of sexually transmitted diseases (STD) among foreigners was developed in Italy in 1991. The Italian National STD Surveillance System collects data on the incidence of certain STDs, reported by 47 sentinel STD clinics located throughout the country (4,5). The STD centre of Trieste is a part of this surveillance system. In 1999, the First aid centre for immigrants has been established in Trieste and it has become rapidly a public reference point for diagnosing, treatment, assistance and registration of clinical and epidemiological data regarding immigrants and homeless population. A total of 1734 immigrants were examined in two years (2000 and 2001) with the purpose to evaluate, from the statistical point of view, the provenience, sex, age, refugee status and pathologies that affect them, with a particular attention to dermatovenereological diseases. All immigrants affected by dermato-venereological pathologies were seen at our STD centre for a further evaluation and follow-up. Table 1. Most commonly diagnosed STDs in 7715 foreign immigrants: STD Sentinel Surveillance System, Italy, 1991-2001 (Modified from "MSTe immigrazione: la situazione nel 2002", Suligoi B) (6) Non specific cervical vaginitis (non-Gonococcal, non-Chlamydial) 22,3% Genital warts 15,8% Non specific Urethritis (non-Gonococcal, non-Chlamydial) 14,4% Syphilis latens 14,0% Gonococcal urethritis 9,2% Herpes genitalis 5,9% Chlamydia Trachomatis Urethritis 5,4% Syphilis I-II 3,5% Phthirius pubis 2,7% Chlamydia trachomatis cervical vaginitis 2,3% Trichomonas vaginalis cervical vaginitis 1,3% 60 -Acta Dermatoven APA Vol 12, 2003, No 2 E p i d e m i o l o g i c s t u d y STD and illegal immigration 350 300 250 -j 200 1b0 100 50 1 ll fk'Um-. <18 18-30 31-40 41-50 >50 □ total □ STP ■ irregular ■ regular Figure 1. Distribution of male immigrants by age and refugee status; STP: strangers temporary present (status not clear) 160 140 120 100 80 60 ' 40 ' 20 ' n-e _rn If i <18 18-30 31-40 41-50 >50 □ total □ STP ■ irregular ■ regular Results From January 1991 to December 2001, 68.000 new cases of sexually transmitted diseases were reported in Italy; of these 7715 were foreigners (11,4%), mainly Africans and Europeans. Among the foreigners, the most commonly diagnosed STDs were non-specific cervical vaginitis and urethritis (non-gonococcal, non-chlamy-dial) and genital warts (4). Table 1. From the total number of 1734 immigrants that had been screened during our study, 70% were males (1212) while 30% were females (522). Considering the age between 18 and 30 years, there is a distinct difference between both sexes (Figures 1, 2, 3). Figure 2. Distribution of female immigrants by age and refugee status; STP: strangers temporary present (status not clear) Regarding the immigrants' provenience, there is a prevalence of Europeans, in particular from Eastern Europe, and Africans (Figure 4). The main immigrants' pathologies observed in Trieste are: orthopedic and traumatic (23%), odontosto-matologic (18%), dermatologic (17%), digestive (15,5%), respiratory (15%) and otorinolaringological (5,9%), whereas infectious diseases represent only 0,4% of total visits. The rate of gynecological visits increased from 4,9% in 2000 to 13,4% in 2001, whereas the requests for uro-logical problems rose from 1,2% in 2000 to 2,4% in 2001. An estimation of dermatovenereological diseases in immigrants was obtained by processing data from the Figure 3. Distribution of immigrants by age m 1 1 1 -- □ 0-18 □ 19-30 131-40 «41-50 D>51 Figure 4. Immigrants by continental provenience 500 450 400 350 300 250 200 150 100 50 0 497 390 -23a 32C 89 ÉÉ— IS 2000 2001 U Africa □ Europe B Asia M America □ Australia Acta Dermatoven APA Vol 12, 2003, No 2 61 STD and illegal immigration E p i d e m i o l o g i c s t u d y STD centre and First-aid centre for immigrants in Trieste. The investigation revealed that parasitic diseases were diagnosed in 12,8%, secondary infected dermatitis in 35,5% and pruriginous symptoms in 28,8%, while the main STD problems ranked as follows: the non-specific cervical vaginitis amounted to 11,1%, non specific urethritis to 4%, genital warts to 3,5% and unrecognized syphilis to 3,1%. Discussion Nowadays, immigration represents one of the most complex contemporary phenomena faced by industrialized countries. The new migratory inflows from less developed countries imply many problems for the Health assistance system. There are great differences between migrants concerning the country of origin, the religion, faith and their social and cultural level. Besides various motivations (jobs, studies, family reunion), political asylum may complicate the situation. "First aid centres" and "STD centres" offer the early assistance to the immigrants. The extreme vulnerability of migrant this population, caused by the uprooting from their country of origin, poverty, risky jobs, and unemployment may lead into prostitution or various illegal activities. The above listed conditions contribute to the development of dermatologic and parasitic diseases, as well as of STDs related to precarious life conditions in the host country. While in Trieste dermatologic pathologies rep- R E FE R E N C E S - resent only 17% of total visits, data differ from those obtained for the whole country (52%). Perhaps the rapid movements of these persons are responsible for leaking evidence. The main problems are often the language, the poor immigrants' compliance, but also the economic reasons. So it is difficult for them to follow the therapeutic guide lines. As a consequence the relations between physicians and patients are not always satisfactory. One important characteristic that distinguishes contemporary immigration from the previous one is the presence of a significant number of undocumented or illegal immigrants. Immigration, the irregular one in particularly, remains a phenomenon strongly related to prostitution and to other illegal activities, induced by the criminal underground. The street prostitution has been deeply modified in the course of last years. Street sex workers come greatly from Africa and Eastern Europe. This is a socially alarming phenomenon concerning the STD propagation. In Trieste too, according to our data, this worrying activities take place. The diagrams on the immigrants' home countries show for Africa the prevalence of Senegalese's and Nigerians (Figure 2), for the Southern Americans the Columbians and Brazilians (Figure 3), and for Europe Serbs, Albanians from Kosovo, Rumanians and Albanians (Figure 4). It appears that in these migratory flows criminal activities of some specific aspects are involved. Coping with the above mentioned problems we often face situations that are difficult to manage, sometimes the multidisciplinary approach is required. 1. Leitner H. International migration and the politics of admission and exclusion in post war Europe. Political Geography 1995; 14 (3): 259-78. 2. Anticipazioni dossier statistico immigrazione Caritas 2002. CARITAS ITALIANA-FONDAZIONE MIGRANTES-CARITAS DI ROMA. www.caritasroma.it/immigrazione 3. Camoni L, Colucci A, Covre P, D'Agostini A, Frati R, Gallo P, Geraci S, Latini O, Luzi AM, Mayer R, Morrone A, Petrosillo N, Pino D, Rezza G. Immigration and health: the Italian National Focal Point experience. Ann. Ist Super Sanita 2000;36(4):479-90. 4. Suligoi B, Giuliani M and The Migration Medicine Study Group. Sexually transmitted diseases among foreigners in Italy. Epidemiol. Infect. 1997; 118:235-41. 5. Dal Conte I, Lucchini A, Contuzzi E, Di Perri G, Bingham J. Sexually transmitted infections in Italy: an overview. Int J STD AIDS 2001 Dec;12 (12):813-8 6. Suligoi B. MST e immigrazione: la situazione nel 2002. STD News n°17/Gennaio 2002. A U T H O R S ' Valeska Padovese, MD, Tang Matrei 17, 30020 Portogruaro (VE), Italy and ADDRESSES dept. of Dermatology and Venereology, Hospital of Cattinara, Trieste, Italy T. Cimolino, MD, dept. of Dermatology and Venereology, Hospital of Cattinara, Trieste, Italy Giovanni Magaton Rizzi, MD, dept. of Dermatology and Venereology, Hospital of Cattinara, Trieste, Italy Giusto Trevisan, MD, Professor and Chairman, dept. of Dermatology and Venereology, Hospital of Cattinara, Trieste, Italy 60 -Acta Dermatoven APA Vol 12, 2003, No 2