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Perception of Occupational Risks and Practices of Self-protection from Infectious Diseases Among Workers in Contact with International Migrants at Hungary’s Border

Objective: The purpose of the present study was to investigate employees’ self-assessments of their occupational risks and health awareness as well as their perception of preventive methods. We also aimed to collect data on employees’ perception of some selected alarming signs and symptoms that may encourage them to take further actions (such as separation and calling an ambulance). Participants and methods: Between April and June 2013, an anonymous questionnaire survey was conducted with the participation of 70 employees working with migrants (both health-care and non-health-care staff) in 10 Hungarian settlements: 4 border crossing points along the eastern Schengen borderline, 3 asylum detention centers and 3 reception centers. Results: Our results demonstrated an increased perception of certain biological and mental health hazards at work among those working with migrants: 63.7% of the health-care workers and even 37.3% of the non-health-care staff come into contact with human secretions (feces, urine, saliva) “frequently” or “sometimes”. Self-assessed awareness of the signs and symptoms of infectious diseases was poor: only 12.8% of participants evaluated their awareness as “good” or “very good”. Threat of verbal violence may be considered a common mental risk at work for participants: 35% “sometimes” or “frequently” and 5% “always” face verbal violence during their work. The most commonly used preventive measures against infectious diseases included the use of gloves, masks and disinfectants; these were generally available to 70 to 80% of the workers and properly applied. Conclusions: Our results indicate considerable deficiencies in the participants’ preparedness in respect to their occupational health-related issues. Since it is essential for those having daily physical contact with migrants during their work to be properly informed about the occupational health hazards and consequences that may be associated with international migration, their training programs urgently require further development. More comprehensive knowledge may improve the preventive attitudes of employees, and conscious application of preventive measures may contribute to better public and occupation health safety.


Introduction
Between 2008-2010, an international research project was conducted along the Hungarian, Slovakian and Polish Schengen borders. The Increasing Public Health Safety Alongside the European Union's (EU) New Eastern European Borderline (PHBLM) [1][2][3] project was performed by the International Organization for Migration (IOM) in cooperation with the University of Pecs and was cofinanced by the European Commission and the Hungarian Ministry of Health. The 36-month-long project aimed to • assess the magnitude and nature of the current health/ public health hazards in border management posed by migration along the new Schengen borders of an enlarged European Union; • analyze and document the current public health practice regarding border management in the EU countries forming the new eastern Schengen border; • promote the human rights-based provision of appropriate and adequate health care to migrants and occupa-tional health assistance to border management personnel through training, minimum public health standards, and structural changes; • improve public health security along the entire external border of the enlarged EU.
In the year immediately following the inclusion of Hungary in the Schengen Area, according to the data of the Schengen Information System (SIS), the number of migrants trying to enter the country illegally dramatically increased, with 41% of the cases along the Ukrainian border, 67% of which involved migrants from Pakistan.
International migration is still a rapidly growing phenomenon, and it affected Hungary in 2013 more critically than ever before. It is estimated that in 2011, there were nearly 50 million (48.9 million) foreign-born residents in the EU (accounting for 9.7% of the total population) 4) . Approximately two-thirds of these residents (32.4 million) were born outside the EU, with the majority arriving from distant geographical areas (such as Pakistan, Afghanistan, Syria and different North and Central African countries, like Somalia). Since a significant percentage of migrants will work in agriculture, their border crossing-related health/public health conditions are of crucial importance. Health protection and disease prevention should have started already at that stage in order to prevent those serious health conditions-likely not unique-already explored by the Occupational Health Department of University of Milan San Paolo Hospital Unit 5) . There is proven evidence that a migrant population could have a significant effect on the incidence of communicable and vaccine-preventable diseases (VPDs) in the host population. High notification rates of measles have been reported in Europe between 2010 and 2013. A clear relation has been shown between the incidence of measles and measles vaccine coverage. The most affected Western European countries, like the UK, Germany, France, Italy, and Spain, have considerable migrant populations as well. During the last few years, more and more reports have been published on public health impacts of immigrant populations on the health-care indicators in the European Union (EU) [6][7][8] .
In the United Kingdom (UK), where the migrant population comprised almost 12% of the population in 2010, the migrant population comprises individuals from all over the world. The greatest burden of communicable diseases has been reported among this non-UK born population, namely 73% of TB cases and almost 60% of newly diagnosed cases of HIV, and 80% of hepatitis B-infected UK blood donors were born abroad 6) . Not only the first-generation immigrants but also the second generation could have an important role in the epidemiological phenomenon. In the Netherlands, infections caused by the hepatitis A virus (HAV) have shown a seasonal peak incidence in autumn due to import of HAV by young immigrant travelers returning from visits in Turkey and Morocco and secondary cases among their siblings and schoolmates 7) . These general population level data have an even more important relevance when we consider the economic interest of introduction of a "healthy" migrant workforce into the European Union's workforce market, especially in the field of agriculture. These data underline the importance of sufficient health-and public health-related knowledge, attitudes and practices of the officials and personnel already at border-crossing points and reception centers.
However, Hungary, which has the longest eastern and southern-eastern borders in the Schengen Area, is particularly attractive for migrants, who would like to enter the Schengen Area illegally (bypassing all the official procedures like visa issuance and border control and arriving usually without an identity card or any other documents), since, in the case of crossing successfully the so called "green border" of Hungary, they may get into any part of the EU's Schengen countries without any further border control. In 2013**, a comprehensive national research project was conducted aiming to reassess the awareness of the perceived health risks and attitudes towards prevention of both healthcare workers (HCWs) and non-health-care workers (non-HCWs, mainly border police employees) at three different types of facilities: border crossing points (BCPs) along the Schengen borderline as well as at certain long-term facilities for migrants, such as asylum detention centers (ADCs) and reception centers (RCs).
The investigations presented in this study were meant to identify the employees' self-assessments of their occupational risks and health awareness as well as their perception of preventive methods in order to provide a reliable basis for designing future training programs and health promotion interventions as well as to inform policy makers about the present deficiencies of the occupational health of employees working directly with migrants.

Methods and Study Population
From April to September 2013, a survey was conducted regarding the self-assessments of occupational health risks of employees in 10 Hungarian settlements, including 4 BCPs along the eastern and southern-eastern Schengen borders in Hungary: at least one BCP beside each of the three Schengen neighbor countries of Hungary, the Ukraine, Romania and Serbia (those with the largest yearly crossing traffic). Employees of the three ADCs nearest to the Schengen border were selected as the second target group, while the third target group consisted of staff members working at three existing Hungarian RCs. The only inclusion criterion was that the employees-during their work-had to have direct, daily physical contact with international migrants. At the ADCs and RCs, both HCWs (e.g., paramedics, health service assistants) and non-HCWs (e.g., social workers, immigration officers, frontier guards, and jailers at the ADCs) were also enrolled in the study. The total number of participants was 70; two-third of the participants (70.0%) were males, and a great majority (84.3%) were non-HCWs. The survey instrument was a self-administered, anonymous questionnaire with 43 items. The questions inquired about demographic data, awareness of biological, environmental and psychological occupational health hazards, applied methods of prevention, and their health awareness. The questionnaire applied was a semistructured, standardized questionnaire based on the survey instrument used during the previously mentioned PHBLM project 2) . As a first step, the director of the selected institution was personally contacted and informed about the aims of the research. In the case that they consented, a contact person was assigned who was the local person responsible for further assistance in the survey. These local contacts were personally informed about the research in detail, and the anonymous questionnaire sheets and the informed consent forms were given to them. Each participant of the questionnaire survey was informed about the purposes and the non-compulsory nature of the research by these local contact persons within a few days, and in the case that they agreed, they signed an informed consent form, which was collected in an envelope. Following this, participants filled out the anonymous questionnaires, which were collected in a separate envelope and sent back to the survey organizers. Participation was on a voluntary basis and without remuneration. Depending on the total number of employees of the institution, 6-10 questionnaires were distributed to each site, and altogether, 90 sheets were distributed to the 10 sites. We received back altogether 70 properly completed questionnaires from 9 out of the 10 visited sites, and so the total response rate was 78% (70/90). Unfortunately, we did not get back any of the 10 questionnaires left at one of the institutions; however, we made several efforts (emails, phone-calls) to ask for their cooperation.

Data analysis
The data were analyzed using the Statistical Package for the Social Sciences (SPSS) for Windows, Version 21.0. Basic descriptive statistics and frequency calculations were performed on all variables. Bivariate relationships between nominal variables (gender, type, and site of occupation) were assessed using χ² tests and Fischer's exact test. All tests of significance were two-tailed, and significance was set at the 5% level. These variables were chosen to be tested for potential relations between participants' awareness of and attitudes towards their occupational health risks and the type and site of occupation. Ordinal variables were compared using the Mann-Whitney test and Kruskal test.
All investigations were approved by the national Office of Immigration and Nationality (OIN) and the Directorate-General of the Police Department of the National Police Law-enforcement (nr.: 29000/20165-2/2012/Ált.).

Characteristics of the study population
Of the 70 employees surveyed, 49 (70%) were males and 21 (30%) were females. The vast majority of respondents were non-HCWs, while 15.7% were HCWs. Table 1 shows the sociodemographic characteristics of the study population.

Self-assessment of exposure to chemical, biological and mental health hazards
Of the selected biological and environmental health hazards (Table 2), both "dust/pollution" and the "environment of the border-land" were noted as significant perceived risks more by males and non-HCWs working at the BCPs, while females and HCWs at ADCs and at the RCs may be affected significantly more by contact with human samples (e.g., blood). Odor was mostly disturbing at the RCs. One in five respondents reported that they may have contact with human secretion (feces, urine, saliva) "frequently or always" during their work, and the majority of them (9/13) were non-HCWs. Environmental risks of the borderline affected the males, younger age-groups, and particularly the employees of the BCPs. Of the psychological risks, "being eyewitness of traumatic events" was also reported significantly more by the BCP staff. Otherwise, age, educational level, and the residential area did not show correlation with participants' exposure to occupational risks.

Assessment of participants' awareness of infectious diseases
Participants were asked to assess their own level of health awareness concerning the communicable diseases that are common and dangerous worldwide, their signs and symptoms, methods of spread, and measures for prevention (Table 3). Generally, females and HCWs estimated their knowledge better (Figures 1-4).
Participants' awareness of the methods of transmission of some contagious diseases was examined objectively as well. Eight infectious diseases and some possible methods of transmission were listed, and the participants were asked to choose the correct answer ( Figure 5). As expected, the HCWs performed the best in this test, with nearly half of them (45.5%) choosing the correct answer for 51-75% of the questions. Only one in every five non-HCW (20.3%) obtained a better result than 75% concerning the transmission of infectious diseases. These latter results did not reach the level of significance.

Assessment of the risk of being infected with certain contagious diseases
Participants were also asked to assess the risk of being infected with a list of selected (8) contagious diseases (Table   4). Generally, the BCP staff assessed a higher risk of catching an infectious disease (15-30%).
The highest assessed risks were reported for catching hepatitis B, TB, and diarrhea (50%<) among BCP staff (high or outstanding risk). The possibility of being infected with scabies, as health hazard, was also emphasized by those working at the RCs (62%). Participants estimated the lowest risk (appr. 12%) for catching syphilis and malaria. Preventive measures applied Table 5 shows the frequency of respondents' use of preventive measures against infectious diseases in the case of suspicion of exposure to an infectious patient. Washing hands, use of disinfectants, and wearing rubber gloves were reported as the most commonly applied methods (95.7%, 81.4%, 71.4%, respectively). It is the HCWs' responsibility to direct and/or to take a suspicious patient to the hospital and to inform the local public health authorities about a confirmed infection, and they reported significantly more consequent use of protective tools. Non-HCWs are not likely to inform public health authorities in the case of suspicion of an infectious disease. Asking a superior's guidance is more common among the non-HCWs (police staff) working at ADCs, while HCWs more frequently ask for a doctor's guidance when coming into contact with a likely infectious migrant. Separation of the questionable migrant is the typical action at the ADCs, while other locations are not likely to use this important preventive measure. Age, educational level, and residential area generally did not show an individual effect on the preventive methods applied.

Evaluation of the severity of some alarming signs and symptoms
Participants assessed the severity of some selected signs and symptoms and the importance of taking further actions (e.g., separation) (Table 6, Figure 6). Loss of consciousness and jaundice were reported as the most alarming signs (55%) that require further measures, and this was especially indicated by HCWs (90%). Vomiting, pain in the chest or abdomen, catatonia, and rashes were estimated as also being very alarming for 20-30% of respondents. Rashes and vomiting seemed significantly more alarming for the non-HCWs.

Discussion
The results presented in this study may confirm that employees at the front lines of receiving and working with migrants may face an increased occupational risk of certain biological and chemical health hazards, such as having a direct contact with human secretions (e.g., blood, feces, urine, saliva) or working continuously in polluted and/or odorous environments. Those working in long-term facilities, such as asylum detention centers, or at reception centers, where immigrants may spend a longer period of time (even one year) while their applications for recognition as refugees are under consideration, may also face significant mental health hazards, such as being eyewitness to traumatic events, and they have to deal with the daily threat of verbal (or even physical) violence. On the other hand, our results proved that the vast majority of the non-HCWs (80%<) and even more than half of the HCWs (paramedics, health service as-sistants) do not have a sufficient awareness of the methods of transmission of infectious diseases, and this may contribute to a lower level of understanding of the risks of infectious diseases and their consequences. Our study population also assessed their own levels of awareness as insufficient (average or below) concerning the signs and symptoms and method of spread of infectious diseases that are common worldwide and half of the study population demonstrated an "average" self-assessed awareness of the most common preventive measures against contagious diseases.
The increased presence of certain occupational health hazards on one side and the demonstrated low level of appropriate knowledge on the health impact of assisting migrants on the other side have a three-fold unfavorable impact: • They hinder care staff in practicing and mediating the required level of health protection and disease prevention when assisting migrants while in camps, although these things should have started already at this stage, to prepare them with respect to how to prevent health hazards they may face in their future workplaces, especially in the field of agriculture. • Not being aware of their own occupation-related increased health risks, they are not likely to consider seriously the necessary preventive measures, thereby increasing the hazards for their own, their colleagues' and their families' health. • The care staff's inappropriate levels of knowledge-and consequently their practices as well-about their occupation-related health risks may have serious implications also for the public health conditions of the general population, inducing epidemic outbreaks as well.
Our survey also highlighted that the relationship between the non-HCW staff working at the borders and the local public health authorities is poor. Even in the case of migrants suspected of having an infectious disease, they are not likely to contact the responsible public health officials. This brings into the discussion how much the implementation of the WHO International Health Regulations 9) has been completed. It was due to be completed by 2012. Naturally, it should already have been incorporated into the basic training of the border guard staff.
The conflict of human rights aspects and public health security measures is reflected well in the fact that even in the case of contagious diseases, separation of the possible source of spreading the infection is not considered a priority as a preventive measure by of most of the border personnel. This conflict has to be discussed well in training, even in the training for the HCW staff.
Furthermore, our results may also indicate that there are considerable gaps in the training program for those working with migrants concerning the health-related aspects of Contact with chemicals Never   Awareness of the methods of spread of the most common infectious diseases Very weak N= number of respondents. If p < 0.05, the statistical probability that the given finding may have occurred by chance is less than 5%.
international migration that should be urgently addressed given the dramatically increased inflow of international migrants arriving from distant geographical areas that was observed in Hungary during 2013. Limitations of the present study include the lack of a con-trol group; however, this study primarily focused on comparison of the awareness of the risks of employees who may have direct contact with migrants at different facilities, such as BCPs, ADCs, and RCs. It would have been interesting to compare their answers with those of the general population.   Despite these limitations, to the best of our knowledge, the present study revealed the self-assessed health awareness of staff working with migrants for the first time in a country in the Central and Eastern European region. In addition, we compared our findings also by age, gender, education level, and residential area as well as by the type (health-care vs.        N= number of respondents, BCP= border crossing point, ADC= asylum detention center, RC= reception center, NR= no response. If p < 0.05, the statistical probability that the given finding may have occurred by chance is less than 5%. non-health-care occupation) and site of occupation (BCP vs. ADC vs. RCs).
In conclusion, the results presented in this study give an insight into the employees' self-assessments of their occupational risks and health awareness as well as about their perception of preventive methods at three different facilities dealing with migrants: BCPs, ADCs, and RCs. Our results confirm that there may be significant gaps in the health awareness of these employees, and this may have serious three-fold occupational and public health implications: occupational health hazards of the care staff, health implications of the introduction of a "migrant workforce" into the European workforce market, and at host countries' population level, such as the reemergence of certain VPDs. Our findings may indicate considerable deficiencies in the training programs for these workers, which certainly require urgent further development, since it is essential that this population be properly informed about the health hazards and consequences associated with international migration. More comprehensive knowledge may improve the preventive attitude of employees, and conscious application of preventive measures may contribute to better public and occupation health safety. Thus, well-designed, properly conducted educational programs and the incorporation of health aspects into undergraduate training for staff focusing on raising awareness about the health risks of international migration would be of crucial importance for public health. Finally, our findings also draw attention to the fact that occupational health in relation to international migration-the health hazards of daily (physical) contact with those arriving from distant geographical areas-has not received enough attention to date, neither from the side of the health policy makers nor from the side of the health-care providers, and further studies with a longer duration and multiple follow-up points are needed to investigate the long-term outcomes of newly developed educational programs in order to highlight their value and effectiveness in prevention. This may have a longterm benefit on the smooth and successful introduction of a migrant workforce into the European workforce market.

Conflict of interest:
The authors declare that they have no conflicts of interest.

* The Schengen Convention is an agreement among some
European states that allows for the abolition of systematic border controls between the participating countries. It also includes provisions on common policy concerning the temporary entry of people (including the Schengen Visa), the harmonization of external border controls, and cross-border police and judicial co-operation. ** This research was realized in the frames of TÁMOP 4.2.4. A/2-11-1-2012-0001 "National Excellence Program -Elaborating and operating an inland student and researcher personal support system convergence program." The project was subsidized by the European Union and co-financed by the European Social Fund.