**3.1 Respiratory conditions**

Refugees arriving to Greece may be vulnerable to infectious diseases because of poor nutritional status, unsafe drinking water in their journeys, lack of vaccination, poor or overcrowded living conditions, and lack of immunity to endemic diseases [17]. These factors can occur in transit, or in the country of origin [17, 18]. Because of this host countries may have serious concerns about the spread of disease by refugees/migrants. While there is little evidence to indicate that refugees spread disease to local populations (EU/EEA), conclusive data is lacking. Work done by Rojek et al., evaluating prospective data from medical consultations on patients presenting with symptoms and signs of a syndrome that may have warranted inclusion in a syndromic surveillance system, showed that fewer than 5% of patients had a full set of vital signs documented [17]. Also, only 11% of patients with a possible syndrome were reported to the medical alert system. Such gaps indicate that refugee patients may not be asked for a medical history, or be given an appropriately complete physical examination. Consequently, the risk of infectious diseases in refugee populations and the chance of disease entry into local populations may be underestimated [17].

Respiratory infections are of great concern and are the most frequent problem [17]. Medecins Sans Frontieres (MSF) clinics at the point of entry into Greece and Serbia found that respiratory tract infections (RTI) occurred in 41% of refugees. Clinics at the Greek-Turkish border exhibited an RTI prevalence of 23% [19, 20]. Refugees in Turkey had 330,000 excess cases of RTI and 50,000 excess cases of diarrhea in 2015 [21].

The unprecedented cross border mobility of refugees/migrants and refugees lends to the dissemination of multi-drug resistant (MDR) pathogens across borders. MDR organisms are often carried by young men (wounded in combat or as innocent by-standers). These individuals often find their way into camps where conditions contribute to the spread of pathogens with antibiotic resistance [22]. Although available evidence is sparse, there are indications that refugees admitted to healthcare facilities frequently import MDRs [23].

In a recent report by Hermans et al. regarding the disease burden among those staying at the Lesbos, Greece refugee camp, no reported cases of tuberculosis were identified [24]. However, 15.3% of Syrian refugees screened in Berlin had potentially contagious diseases [25]. This suggests that refugees entering Greece may have had inadequate diagnostic work-ups either due to a lack of medical expertise or money to do the testing. With the ongoing Syria humanitarian crisis infectious disease will continue to emerge and reemerge [26].
