Editorial
Migration and chronic noncommunicable diseases: is the paradigm shifting? Francesco Castellia,b, Lina R. Tomasonic and Issa El Hamadd J Cardiovasc Med 2014, 15:693–695 a
Department of Clinical and Experimental Sciences, University of Brescia, University Division of Infectious Diseases, University of Brescia and Brescia Spedali Civili General Hospital, cUnit for Imported and Tropical Diseases and d Division of Infectious Diseases, Spedali Civili General Hospital, Brescia, Italy b
Correspondence to Francesco Castelli, MD, University Division of Infectious and Tropical Diseases, University of Brescia and Brescia Spedali Civili General Hospital, Piazza Spedali Civili, I-25123, Brescia, Italy E-mail: [email protected] Received 22 January 2014 Accepted 22 February 2014
The affiliations of all the authors of the present editorial contain either the word ‘infectious’ or ‘tropical’. Our affiliations indeed reflect our expertise as infectious disease specialists. The infectious disease specialists have traditionally been considered the experts in the field of migration medicine because it was thought that the large majority of the diseases affecting migrants had to be infectious or tropical (‘exotic’) in nature. Why then are we now writing a commentary on the article by Modesti et al.1 on cardiovascular health in migrants, published in this issue of Journal of Cardiovascular Medicine?1 Maybe the paradigm is shifting? Probably yes and we in Western countries are possibly witnessing the mirror of what is happening in many so-called low-middle income countries (LMICs). Of course, this does not mean that infectious diseases are no more relevant in the arena of migration medicine, but the picture is becoming more complex and multifaceted. Despite definitions of people living outside their place of birth being multiple, for the sake of simplicity, the term ‘migrant’ will be used here to define people born in LMICs residing in affluent countries of Europe and North America, usually to better their own and their family’s prospects of life.2 It is to be noted, however, that differences in cardiovascular risk exist even between different living settings (urban, rural and rural-to-urban migrants) even in the same LMIC, as recently demonstrated in Peru.3 According to the United Nations 2013 report,4 the total number of international migrants in mid-2013 overcame 231 million individuals, 59% of whom living in industrialized countries and the remaining 41% in southern countries (south-to-south migration). The health pattern of the latter population is probably to be considered separately. Their provenance is extremely diverse. Of the 72.4 million international migrants living in Europe, 8.9 million come from Africa, 18.6 million from Asia, 4.5 million from Latin America and 37.8 million from Europe itself. Italy is no 1558-2027 ß 2014 Italian Federation of Cardiology
exception and virtually all nationalities are represented among the 5 186 000 documented (and about 500 000 undocumented) migrants who were estimated to live in Italy at the end of 2012, even if more than one-third (35%) of migrants come from three countries: Romania, Albania and Morocco.5 The Global Burden of Disease Study6 offers some interesting information on the evolving pattern of disabilities and deaths [disability adjusted life years (DALYs)] worldwide, showing a general shift towards noncommunicable diseases at the global level. Three major drivers have led this change: first, population growth, particularly in developing countries, and ageing; second, better control of communicable diseases; and third, increasing proportion of chronic conditions leading to long disability periods.7 The increasing prevalence of chronic noncommunicable diseases, and cardiovascular diseases in particular, is also evident in LMICs and is thought to be due primarily to urbanization, globalization and the adoption of different life styles, with particular regard to reduced physical activity, smoking and the consumption of alcohol and of food with a high content of saturated fat and sugar.8 Although the trend is somehow general, important regional variations do exist and have been highlighted in the Global Burden of Diseases Study. On the one hand, if high blood pressure and ischemic heart attacks rank first as a risk factor and cause of DALY, respectively, in 2010, it is to be noted that HIV/AIDS ranked fifth (being 33rd in 1990) due to the impressive epidemic in developing countries and in particular in Africa. On the other hand, tobacco smoking is decreasing in the industrialized world, whereas it is on the rise in the developing world, especially East Asia. As a consequence, it has been estimated that as many as 85% of over 23 million deaths from cardiovascular diseases in 2030 will occur in LMICs.9 How do these regional figures and trends impact on migration medicine? What do migrants suffer from? The answer to this question is complex, resulting from a mix of various factors, the most important being the country of origin, country of destination, length of stay and, most importantly, socioeconomic status, as correctly pointed out by Modesti et al.1 These variables, when considered singularly, may lead to different and even conflicting results, and a lower overall (and cardiovascular-linked) mortality rate has been observed in migrants living in Denmark compared to an age- and sex-matched DOI:10.2459/JCM.0000000000000096
Copyright © Italian Federation of Cardiology. Unauthorized reproduction of this article is prohibited.
694 Journal of Cardiovascular Medicine 2014, Vol 15 No 9
Danish population.10 Other authors have also reported a lower prevalence of hypertension in migrants than in the native population, as it is the case for Bangladeshi subjects living in the United Kingdom, or Moroccan and Turkish individuals living in the Netherlands (reviewed in ref.2), highlighting the need for a comprehensive and standardized approach for data collection and analysis to obtain consistent results. However, the bulk of evidence points to a higher prevalence of cardiovascular risk factors and diseases, diabetes and kidney diseases in foreignborn populations in most Western countries. Along with that, a higher prevalence of some specific infectious conditions, both ubiquitous (tuberculosis, HIV/AIDS and hepatitis B)11,12 and more geographically limited (Chagas diseases, cysticercosis)13,14 have also been reported in migrant populations and should not be forgotten both for the health of the individual and public health purposes. The determinants of the rapid increase in noncommunicable diseases in migrants are complex and multifaceted. A large long-lasting prospective cohort study focusing on cardiovascular disorders (including diabetes), mental health and infectious diseases has recently been designed and will hopefully provide insights into the impact of ethnicity on health of European residents.15 As already mentioned, the burden of diseases in LMICs is rapidly changing with a shift, less marked in the African continent, towards noncommunicable diseases.6 As an example, the rate of hypertension is increasing in many developing countries as a result of urbanization, ageing of the population, changes in dietary habits, and persisting low access to quality prevention activities and care16 with poor control of the disease.17 The same is true for diabetes and other noncommunicable diseases, keeping in mind that the possible clinical spectrum of diseases in migrants, both communicable and noncommunicable, largely varies depending on the origin country. The precise role of genetics in determining health in a foreign environment is fascinating but still obscure. There is little doubt left that Afro-Americans tend to suffer more from cardiovascular diseases and diabetes than their native counterparts in the host countries, and this may be due to gene sequence variations.18,19 However, conflicting results do exist and this effect tends to become less evident with time and second- or third-generation migrants are less affected, suggesting that factors other than genetics may play an even more important role. Existing evidence demonstrates that many lifestyle habits, such as diet, change progressively after migration to industrialized countries, more so in young subjects and children, leading in general to an increase in energy and fat food, with lower intake of fibre, as reported in SouthAsian migrants living in Europe.20 Interestingly, in contrast, the protective effect on health of first-generation
migrants often referred to as ‘healthy migrant effect’ may also be lost with time as the culturally protective habits are progressively lost.21 More standardized studies are needed to assess the opposite evidence in a balanced manner. On the other hand, however, the attitude of adult firstgeneration migrants to modulate dietary habits in order to reduce the risk of cardiovascular disease has been reported to be constrained by different cultural factors including sex roles, body image, physical activity misconceptions, cultural priorities, cultural identity and explanatory model of disease.22 The level of reciprocal comprehension between the patient and the health worker is also often impaired by their respective cultural paradigms, leading to dramatic misunderstandings.23,24 Again, the clinical presentation and individual perception of various symptoms may be culture bound, delaying their correct interpretation by the physician. Language and cultural barriers may also prevent the complete fruition of preventive messages by the migrant population, and, conversely, the adoption of inclusive or exclusive health policies may favour of hinder access to care. Considering the impending public health problem posed by noncommunicable cardiovascular diseases, the more health policies are inclusive – also caring for undocumented migrants – the higher would be the benefit from the public health and even economic perspectives. This is, of course, even more true for communicable diseases. However, unfortunately, preventive activities in the migrant populations are often difficult with low response rates in particular in the lower socioeconomic strata.25–27 The Italian legislation, when properly implemented, is quite inclusive in this respect as individuals are in principle entitled, regardless of their legal status, to receive urgent and ‘essential’ care, to address also those conditions that, even not life-threatening in the immediate, may be so in the future. Cardiovascular diseases are a paradigm of such conditions. The article of Modesti et al. is timely and addresses an extremely important issue, that is the health of a stably growing proportion of the population in western countries. If originally mainly driven by infectious concerns (that still persist for specific marginalization-bound infections), a shift towards noncommunicable diseases is now observed, as a result of many concomitant factors. Western societies need to be prepared by the implementation of proper (scientific and cultural) training of health workers, proper scientific collation of sound data on such a complex phenomenon and inclusive preventive and curative health and social policies favouring both the individual and public health regardless of legal barriers.
References 1
Modesti PA, Bianchi S, Borghi C, et al. Cardiovascular health in migrants: current status and issues for prevention. A collaborative multidisciplinary task force report. J Cardiovasc Med 2014; 15:683–692.
Copyright © Italian Federation of Cardiology. Unauthorized reproduction of this article is prohibited.
Migration and chronic noncommunicable diseases Castelli et al. 695
2
3
4
5
6
7 8 9 10
11
12
13
14
Agyemang C, de-Graft Aikins A, Bhopal R. Ethnicity and cardiovascular health research: pushing the boundaries by including comparison populations in the countries of origin. Ethn Health 2012; 17:579–596. Miranda JJ, Gilman RH, Smeeth L. Differences in cardiovascular risk factors in rural, urban and rural-to-urban migrants in Peru. Heart 2011; 97: 787–796. United Nations. Trends in International Migrant Stock: the 2013 revision. http://esa.un.org/unmigration/TIMSA2013/migrantstocks2013. htm?mtotals. [Accessed 2 January 2014]. Centro Studi e Ricerche IDOS. Immigrazione. Dossier Statistico 2013. UNAR. Ufficio Nazionale contro le discriminazioni razziali, 2013. (IDOS Research and Study Center. Immigration. Statistical Report 2013. UNAR. National Office against racial discriminations). www. dossierimmigrazione.it. Murray CJL, Vos T, Lozano R, et al. Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Diseases Study. Lancet 2012; 380:2197–2223. Murray CJL, Phil D, Lopez AD. Measuring the global burden of diseases. N Engl J Med 2013; 369:448–457. Godfrey R, Julien M. Urbanisation and health. Clin Med 2005; 5:137–141. Mathers CD, Loncar D. Projections of global mortality and burden of diseases from 2002 to 2030. PLoS Med 2006; 3:2011–2030. Norredam M, Olsbjerg M, Petersen JH, et al. Inequalities in mortality among refugees and immigrants compared to native Danes: a historical prospective cohort study. BMC Public Health 2012; 12:757. McCarthy AE, Weld LH, Barnett ED, et al. Spectrum of illness in international migrants seen at GeoSentinel clinics in 1997–2009, Part 2: Migrants resettled internationally and evaluated for specific health concerns. Clin Infect Dis 2013; 56:925–933. Barnett ED, Weld LH, McCarthy AE, et al. Spectrum of illness in international migrants seen at GeoSentinel clinics in 1997–2009, Part 1: US-bound migrants evaluated by comprehensive protocol-based health assessment. Clin Infect Dis 2013; 56:913–924. Perez-Molina JA, Perez-Ayala A, Parola P, et al., EuroTravNet Network. EuroTravNet: imported Chagas disease in nine European countries, 2008 to 2009. Eurosurveillance 2011; 16:pii: 19966. Zammarchi L, Strohmeyer M, Bartalesi F, et al. Epidemiology and management of cysticercosis and Taenia solium taeniasis in Europe, systematic review 1990–2011. PLoS One 2013; 8:e69537.
15 16 17
18
19
20
21
22
23 24 25
26
27
Stronks K, Snjider MB, Peters RJG, et al. Unravelling the impact of ethnicity on health in Europe: the HELIUS study. BMC Public Health 2013; 13:402. Ibrahim MM, Damasceno A. Hypertension in developing countries. Lancet 2012; 380:611–619. Dzudie A, Kengne AP, Muna WFT, et al. Prevalence, awareness and control of hypertension in a self-selected sub-Saharan Africa urban population: a cross-sectional study. BMJ Open 2012; 2:pii: e001217. Neumeister A, Charney DS, Belfer I, et al. Sympathoneural and adrenomedullary functionional effects of alpha2C-adrenoreceptor gene polymorphism in healthy humans. Pharmacogenet Genomics 2005; 15:143–149. Palmer ND, Hester JM, An SS, et al. Resequencing and analysis of variation in the TCF7L2 gene in African Americans suggest that SNP rs7903146 is the causal diabetes susceptibility variant. Diabetes 2011; 60:662–668. Holmboe-Ottesen G, Wandel M. Changes in dietary habits after migration and consequences for health: a focus on South Asians in Europe. Food Nutr Res 2012; 56:56. Tarnutzer S, Bopp M, for the SNC study group. Healthy migrants but unhealthy offspring? A retrospective cohort study among Italians in Switzerland. BMC Public Health 2012; 12:1104; http:// www.biomedcentral.com/1471-2458/12/1104. [Accessed 2 January 2014]. Patel M, Phillips-caesar E, Boutin Foster C. Barriers to lifestyle behavioral changes in migrant south Asian populations. J Immigr Minor Health 2012; 14:774–785. El Hamad I, Scarcella C, Pezzoli MC, et al. Forty meals for a drop of blood. . .. J Trav Med 2009; 16:64–65. El Hamad I, Scarcella C, Pezzoli MC, et al. Dead blood under my skin. J Trav Med 2009; 16:284–285. Carvalho AC, Saleri N, El-Hamad I, et al. Completion of screening for latent tuberculosis infection among immigrants. Epidemiol Infect 2005; 133:179–185. Tomasoni LR, Sosta E, Beltrame A, et al. Antenatal screening for mother to child infections in immigrants and nationals: the case of toxoplasmosis in northern Italy. J Immigr Minor Health 2010; 12:834–840. Vlaar EMA, van Valkengoed IGM, Nierkens V, et al. Feasibility and effectiveness of a targeted diabetes prevention program for 18 to 60-yearold South Asian migrants. Design of the DH!AAN study. BMC Public Health 2012; 12:371.
Copyright © Italian Federation of Cardiology. Unauthorized reproduction of this article is prohibited.
Migration and chronic noncommunicable diseases: is the paradigm shifting? Francesco Castellia,b, Lina R. Tomasonic and Issa El Hamadd J Cardiovasc Med 2014, 15:693–695 a
Department of Clinical and Experimental Sciences, University of Brescia, University Division of Infectious Diseases, University of Brescia and Brescia Spedali Civili General Hospital, cUnit for Imported and Tropical Diseases and d Division of Infectious Diseases, Spedali Civili General Hospital, Brescia, Italy b
Correspondence to Francesco Castelli, MD, University Division of Infectious and Tropical Diseases, University of Brescia and Brescia Spedali Civili General Hospital, Piazza Spedali Civili, I-25123, Brescia, Italy E-mail: [email protected] Received 22 January 2014 Accepted 22 February 2014
The affiliations of all the authors of the present editorial contain either the word ‘infectious’ or ‘tropical’. Our affiliations indeed reflect our expertise as infectious disease specialists. The infectious disease specialists have traditionally been considered the experts in the field of migration medicine because it was thought that the large majority of the diseases affecting migrants had to be infectious or tropical (‘exotic’) in nature. Why then are we now writing a commentary on the article by Modesti et al.1 on cardiovascular health in migrants, published in this issue of Journal of Cardiovascular Medicine?1 Maybe the paradigm is shifting? Probably yes and we in Western countries are possibly witnessing the mirror of what is happening in many so-called low-middle income countries (LMICs). Of course, this does not mean that infectious diseases are no more relevant in the arena of migration medicine, but the picture is becoming more complex and multifaceted. Despite definitions of people living outside their place of birth being multiple, for the sake of simplicity, the term ‘migrant’ will be used here to define people born in LMICs residing in affluent countries of Europe and North America, usually to better their own and their family’s prospects of life.2 It is to be noted, however, that differences in cardiovascular risk exist even between different living settings (urban, rural and rural-to-urban migrants) even in the same LMIC, as recently demonstrated in Peru.3 According to the United Nations 2013 report,4 the total number of international migrants in mid-2013 overcame 231 million individuals, 59% of whom living in industrialized countries and the remaining 41% in southern countries (south-to-south migration). The health pattern of the latter population is probably to be considered separately. Their provenance is extremely diverse. Of the 72.4 million international migrants living in Europe, 8.9 million come from Africa, 18.6 million from Asia, 4.5 million from Latin America and 37.8 million from Europe itself. Italy is no 1558-2027 ß 2014 Italian Federation of Cardiology
exception and virtually all nationalities are represented among the 5 186 000 documented (and about 500 000 undocumented) migrants who were estimated to live in Italy at the end of 2012, even if more than one-third (35%) of migrants come from three countries: Romania, Albania and Morocco.5 The Global Burden of Disease Study6 offers some interesting information on the evolving pattern of disabilities and deaths [disability adjusted life years (DALYs)] worldwide, showing a general shift towards noncommunicable diseases at the global level. Three major drivers have led this change: first, population growth, particularly in developing countries, and ageing; second, better control of communicable diseases; and third, increasing proportion of chronic conditions leading to long disability periods.7 The increasing prevalence of chronic noncommunicable diseases, and cardiovascular diseases in particular, is also evident in LMICs and is thought to be due primarily to urbanization, globalization and the adoption of different life styles, with particular regard to reduced physical activity, smoking and the consumption of alcohol and of food with a high content of saturated fat and sugar.8 Although the trend is somehow general, important regional variations do exist and have been highlighted in the Global Burden of Diseases Study. On the one hand, if high blood pressure and ischemic heart attacks rank first as a risk factor and cause of DALY, respectively, in 2010, it is to be noted that HIV/AIDS ranked fifth (being 33rd in 1990) due to the impressive epidemic in developing countries and in particular in Africa. On the other hand, tobacco smoking is decreasing in the industrialized world, whereas it is on the rise in the developing world, especially East Asia. As a consequence, it has been estimated that as many as 85% of over 23 million deaths from cardiovascular diseases in 2030 will occur in LMICs.9 How do these regional figures and trends impact on migration medicine? What do migrants suffer from? The answer to this question is complex, resulting from a mix of various factors, the most important being the country of origin, country of destination, length of stay and, most importantly, socioeconomic status, as correctly pointed out by Modesti et al.1 These variables, when considered singularly, may lead to different and even conflicting results, and a lower overall (and cardiovascular-linked) mortality rate has been observed in migrants living in Denmark compared to an age- and sex-matched DOI:10.2459/JCM.0000000000000096
Copyright © Italian Federation of Cardiology. Unauthorized reproduction of this article is prohibited.
694 Journal of Cardiovascular Medicine 2014, Vol 15 No 9
Danish population.10 Other authors have also reported a lower prevalence of hypertension in migrants than in the native population, as it is the case for Bangladeshi subjects living in the United Kingdom, or Moroccan and Turkish individuals living in the Netherlands (reviewed in ref.2), highlighting the need for a comprehensive and standardized approach for data collection and analysis to obtain consistent results. However, the bulk of evidence points to a higher prevalence of cardiovascular risk factors and diseases, diabetes and kidney diseases in foreignborn populations in most Western countries. Along with that, a higher prevalence of some specific infectious conditions, both ubiquitous (tuberculosis, HIV/AIDS and hepatitis B)11,12 and more geographically limited (Chagas diseases, cysticercosis)13,14 have also been reported in migrant populations and should not be forgotten both for the health of the individual and public health purposes. The determinants of the rapid increase in noncommunicable diseases in migrants are complex and multifaceted. A large long-lasting prospective cohort study focusing on cardiovascular disorders (including diabetes), mental health and infectious diseases has recently been designed and will hopefully provide insights into the impact of ethnicity on health of European residents.15 As already mentioned, the burden of diseases in LMICs is rapidly changing with a shift, less marked in the African continent, towards noncommunicable diseases.6 As an example, the rate of hypertension is increasing in many developing countries as a result of urbanization, ageing of the population, changes in dietary habits, and persisting low access to quality prevention activities and care16 with poor control of the disease.17 The same is true for diabetes and other noncommunicable diseases, keeping in mind that the possible clinical spectrum of diseases in migrants, both communicable and noncommunicable, largely varies depending on the origin country. The precise role of genetics in determining health in a foreign environment is fascinating but still obscure. There is little doubt left that Afro-Americans tend to suffer more from cardiovascular diseases and diabetes than their native counterparts in the host countries, and this may be due to gene sequence variations.18,19 However, conflicting results do exist and this effect tends to become less evident with time and second- or third-generation migrants are less affected, suggesting that factors other than genetics may play an even more important role. Existing evidence demonstrates that many lifestyle habits, such as diet, change progressively after migration to industrialized countries, more so in young subjects and children, leading in general to an increase in energy and fat food, with lower intake of fibre, as reported in SouthAsian migrants living in Europe.20 Interestingly, in contrast, the protective effect on health of first-generation
migrants often referred to as ‘healthy migrant effect’ may also be lost with time as the culturally protective habits are progressively lost.21 More standardized studies are needed to assess the opposite evidence in a balanced manner. On the other hand, however, the attitude of adult firstgeneration migrants to modulate dietary habits in order to reduce the risk of cardiovascular disease has been reported to be constrained by different cultural factors including sex roles, body image, physical activity misconceptions, cultural priorities, cultural identity and explanatory model of disease.22 The level of reciprocal comprehension between the patient and the health worker is also often impaired by their respective cultural paradigms, leading to dramatic misunderstandings.23,24 Again, the clinical presentation and individual perception of various symptoms may be culture bound, delaying their correct interpretation by the physician. Language and cultural barriers may also prevent the complete fruition of preventive messages by the migrant population, and, conversely, the adoption of inclusive or exclusive health policies may favour of hinder access to care. Considering the impending public health problem posed by noncommunicable cardiovascular diseases, the more health policies are inclusive – also caring for undocumented migrants – the higher would be the benefit from the public health and even economic perspectives. This is, of course, even more true for communicable diseases. However, unfortunately, preventive activities in the migrant populations are often difficult with low response rates in particular in the lower socioeconomic strata.25–27 The Italian legislation, when properly implemented, is quite inclusive in this respect as individuals are in principle entitled, regardless of their legal status, to receive urgent and ‘essential’ care, to address also those conditions that, even not life-threatening in the immediate, may be so in the future. Cardiovascular diseases are a paradigm of such conditions. The article of Modesti et al. is timely and addresses an extremely important issue, that is the health of a stably growing proportion of the population in western countries. If originally mainly driven by infectious concerns (that still persist for specific marginalization-bound infections), a shift towards noncommunicable diseases is now observed, as a result of many concomitant factors. Western societies need to be prepared by the implementation of proper (scientific and cultural) training of health workers, proper scientific collation of sound data on such a complex phenomenon and inclusive preventive and curative health and social policies favouring both the individual and public health regardless of legal barriers.
References 1
Modesti PA, Bianchi S, Borghi C, et al. Cardiovascular health in migrants: current status and issues for prevention. A collaborative multidisciplinary task force report. J Cardiovasc Med 2014; 15:683–692.
Copyright © Italian Federation of Cardiology. Unauthorized reproduction of this article is prohibited.
Migration and chronic noncommunicable diseases Castelli et al. 695
2
3
4
5
6
7 8 9 10
11
12
13
14
Agyemang C, de-Graft Aikins A, Bhopal R. Ethnicity and cardiovascular health research: pushing the boundaries by including comparison populations in the countries of origin. Ethn Health 2012; 17:579–596. Miranda JJ, Gilman RH, Smeeth L. Differences in cardiovascular risk factors in rural, urban and rural-to-urban migrants in Peru. Heart 2011; 97: 787–796. United Nations. Trends in International Migrant Stock: the 2013 revision. http://esa.un.org/unmigration/TIMSA2013/migrantstocks2013. htm?mtotals. [Accessed 2 January 2014]. Centro Studi e Ricerche IDOS. Immigrazione. Dossier Statistico 2013. UNAR. Ufficio Nazionale contro le discriminazioni razziali, 2013. (IDOS Research and Study Center. Immigration. Statistical Report 2013. UNAR. National Office against racial discriminations). www. dossierimmigrazione.it. Murray CJL, Vos T, Lozano R, et al. Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Diseases Study. Lancet 2012; 380:2197–2223. Murray CJL, Phil D, Lopez AD. Measuring the global burden of diseases. N Engl J Med 2013; 369:448–457. Godfrey R, Julien M. Urbanisation and health. Clin Med 2005; 5:137–141. Mathers CD, Loncar D. Projections of global mortality and burden of diseases from 2002 to 2030. PLoS Med 2006; 3:2011–2030. Norredam M, Olsbjerg M, Petersen JH, et al. Inequalities in mortality among refugees and immigrants compared to native Danes: a historical prospective cohort study. BMC Public Health 2012; 12:757. McCarthy AE, Weld LH, Barnett ED, et al. Spectrum of illness in international migrants seen at GeoSentinel clinics in 1997–2009, Part 2: Migrants resettled internationally and evaluated for specific health concerns. Clin Infect Dis 2013; 56:925–933. Barnett ED, Weld LH, McCarthy AE, et al. Spectrum of illness in international migrants seen at GeoSentinel clinics in 1997–2009, Part 1: US-bound migrants evaluated by comprehensive protocol-based health assessment. Clin Infect Dis 2013; 56:913–924. Perez-Molina JA, Perez-Ayala A, Parola P, et al., EuroTravNet Network. EuroTravNet: imported Chagas disease in nine European countries, 2008 to 2009. Eurosurveillance 2011; 16:pii: 19966. Zammarchi L, Strohmeyer M, Bartalesi F, et al. Epidemiology and management of cysticercosis and Taenia solium taeniasis in Europe, systematic review 1990–2011. PLoS One 2013; 8:e69537.
15 16 17
18
19
20
21
22
23 24 25
26
27
Stronks K, Snjider MB, Peters RJG, et al. Unravelling the impact of ethnicity on health in Europe: the HELIUS study. BMC Public Health 2013; 13:402. Ibrahim MM, Damasceno A. Hypertension in developing countries. Lancet 2012; 380:611–619. Dzudie A, Kengne AP, Muna WFT, et al. Prevalence, awareness and control of hypertension in a self-selected sub-Saharan Africa urban population: a cross-sectional study. BMJ Open 2012; 2:pii: e001217. Neumeister A, Charney DS, Belfer I, et al. Sympathoneural and adrenomedullary functionional effects of alpha2C-adrenoreceptor gene polymorphism in healthy humans. Pharmacogenet Genomics 2005; 15:143–149. Palmer ND, Hester JM, An SS, et al. Resequencing and analysis of variation in the TCF7L2 gene in African Americans suggest that SNP rs7903146 is the causal diabetes susceptibility variant. Diabetes 2011; 60:662–668. Holmboe-Ottesen G, Wandel M. Changes in dietary habits after migration and consequences for health: a focus on South Asians in Europe. Food Nutr Res 2012; 56:56. Tarnutzer S, Bopp M, for the SNC study group. Healthy migrants but unhealthy offspring? A retrospective cohort study among Italians in Switzerland. BMC Public Health 2012; 12:1104; http:// www.biomedcentral.com/1471-2458/12/1104. [Accessed 2 January 2014]. Patel M, Phillips-caesar E, Boutin Foster C. Barriers to lifestyle behavioral changes in migrant south Asian populations. J Immigr Minor Health 2012; 14:774–785. El Hamad I, Scarcella C, Pezzoli MC, et al. Forty meals for a drop of blood. . .. J Trav Med 2009; 16:64–65. El Hamad I, Scarcella C, Pezzoli MC, et al. Dead blood under my skin. J Trav Med 2009; 16:284–285. Carvalho AC, Saleri N, El-Hamad I, et al. Completion of screening for latent tuberculosis infection among immigrants. Epidemiol Infect 2005; 133:179–185. Tomasoni LR, Sosta E, Beltrame A, et al. Antenatal screening for mother to child infections in immigrants and nationals: the case of toxoplasmosis in northern Italy. J Immigr Minor Health 2010; 12:834–840. Vlaar EMA, van Valkengoed IGM, Nierkens V, et al. Feasibility and effectiveness of a targeted diabetes prevention program for 18 to 60-yearold South Asian migrants. Design of the DH!AAN study. BMC Public Health 2012; 12:371.
Copyright © Italian Federation of Cardiology. Unauthorized reproduction of this article is prohibited.
