Update in Refugee and Immigrant Health

Comments

Transcription

Update in Refugee and Immigrant Health
Julie Caplow
May 5, 2017
Free Clinic Association of PA Conference
 Who is a refugee?
 Definitions and trends
 Services they are entitled to
 What do I do if a refugee walks into my clinic?
 Screenings recommendations
 Health profiles
 What can we do better in PA?
Forcibly
displaced
persons
Internally
displaced
persons
Asylum
seekers
A refugee is a person who owing
to a well-founded fear of being
persecuted for reasons of race,
religion, nationality,
membership of a particular
social group, or political
opinion, is outside the country of
his nationality, and is unable to or,
owing to such fear, is unwilling to
avail himself of the protection of
that country.
is unwilling to avail himself of the
-1951 Geneva Convention
Refugees
Forcibly
displaced
persons
65 million
Internally
displaced
persons
40 million
Durable solutions:
Asylum
seekers
3 million
Repatriation
Refugees
21 million
Local
integration
Resettlement
<1%
Gobal Trends, 2015 http://www.unhcr.org/576408cd7
Forcibly
displaced
persons
65 million
Internally
displaced
persons
40 million
Durable solutions:
Asylum
seekers
3 million
Repatriation
Refugees
50,000/yr
21 million
Local
integration
Resettlement
<1%
Gobal Trends, 2015 http://www.unhcr.org/576408cd7
REFUGEE ARRIVALS TO PA, OCT 2015- SEP 2016
Other
 3679 total arrivals between
SYRIA
UKRAINE
Oct 2015 and Sept 2016
AFGHANISTAN
IRAQ
BURMA
DEM REP OF
CONGO
CUBAN ENTRANT
SOMALIA
Pennsylvania Refugee Resettlement Program;
http://www.refugeesinpa.org/aboutus/demoandarrivalstats/index.htm
BHUTAN
 Coordinated by the PA Refugee Resettlement Program, with more than 30 partner
organizations
 Funded by US Department of Health and Human Services
 Each refugee gets paired with a caseworker for the first 3 months of arrival
 Services include:
 Housing
 Health screening
 Employment counseling and training
 English as a second language
 Citizenship preparation
 Domestic health screening performed within first 30 days of arrival
 10 “refugee clinics” exist in Philadelphia for this purpose
 8 months of insurance coverage under Refugee Medical
Assistance
 PA Medicaid equivalent
 Refugees are then eligible for ACA and Medicaid
 Do not have to wait 5 years as other legal immigrants do
Standard overseas and domestic screening
Performed in refugee camp prior to departure
 Purpose: “to identify certain disorders that could result in exclusion from
the United States under the provisions of the Immigration and Nationality
Act.”
 Communicable diseases (TB, syphilis, leprosy)
 Mental health disorders
 Substance abuse
 Criminal behavior
 “Public charge grounds”
 Also receive empiric treatment of common diseases e.g. intestinal
parasites
Source: www.cdc.gov/immigrantrefugeehealth
 Performed within 30 days of arrival
in the U.S.
 More extensive H&P
 Numerous screening tests and
immunizations
 Stabilization of any acute medical
issues
 Guidelines specific to country of
origin
Source: www.cdc.gov/immigrantrefugeehealth
Case comparison: Congolese and Syrian refugee
health needs
Who are they?
What are their health needs?
 DRC has been in conflict for nearly 2
decades
 1996 -1997 (First Congo War)
 1998 – 2003 (Second Congo War)
 2003- today: continued human rights abuses,
particularly against Congolese of Rwandan
origin
 Since 2013, more than 400,000
Congolese fled DRC
Health priorities per the CDC:
 Parasitic infections
 Malaria
 Mental health
 Sexual- and gender-based violence
https://www.cdc.gov/immigrantrefugeehealth/pdf/congolesehealth-profile.pdf
• Per CDC, Congelese should be
presumptively treated within 3 days of
departure from refugee camp
• If not, or if symptomatic, screen with thick
and thin smear
• Treatment:
• P. falciparum (90%): Atovaquone-proguanil
(Malarone) or artemether-lumefantrine (Coartem)
 Many are asymptomatic but can have long-term
consequences
 Schistosomiasis
 If untreated, can cause portal hypertension, cirrhosis, urinary
obstruction, bladder cancer
 Presumptive treatment with praziquantel recommended
 Strongyloides
 Can cause non-specific GI, skin, pulmonary symptoms;
 Hyperinfection syndrome if immunosuppressed
 If positive serology, treat with ivermectin
 Filaria (e.g. elephantiasis, loa loa, onchocerciasis)
 Test for these if patient has unexplained eosinophilia
 40% of Congolese women and 24% of men reported being victims of
sexual violence1
 Resulting high rates of emotional and physical trauma: PTSD, genital
fistulas, infertility, HIV/AIDS and other STIs
1 Johnson
K et al. Association of Sexual Violence and Human Rights Violations with Physical and Mental Health
in Territories of the Eastern Democratic Republic of the Congo. Journal of the American Medical Association
2010; Vol. 304. No. 5: 553-62
 <1% reported mental health issues in the pre-departure screening, but
close to half of adults met criteria for MDD and PTSD
 Group psychotherapy may be more effective than individual
psychotherapy
 Fuys, Andrew, and Sandra Vines. (2013) “Increasing Congolese Refugee Arrivals: Insights for Preparation.” Executive Summary. Washington
DC: Refugee Council USA. Print. February 15. Report from Associate Directors for International Programs and Resettlement and Integration,
Church World Service
 Bass JK, Annan J, Murray S et al. Controlled Trial of Psychotherapy for Congolese Survivors of Sexual Violence. N Engl J Med 2013;368:2182-
91.
• Very thorough TB screening
overseas  very few active
cases arrive to the U.S.
• However, nearly 1 in 3 have
latent TB
• High risk of reactivation TB
within first year of arrival
Who are they?
What are their health needs?
 Largest refugee crisis since
WWII
 Of a pre-war population of 22
million, half have been
displaced
 Strong education and health
systems prior to the conflict
CDC Health Priorities:
 Anemia
 Hypertension
 Diabetes
 Mental illness
Source: https://www.cdc.gov/immigrantrefugeehealth
 High prevalence of anemia in women and children, mostly iron
deficiency
 Approximately 5% of the Syrian population are carriers of beta
thalassemia trait
 Depression and anxiety very common
 Stigmatized in the Syrian community

International Medical Corps, Syria Crisis: Addressing Regional Mental Health Needs and Gaps in the Context of the Syria Crisis. 2015.
 Sirin, S.R. and L. Rogers-Sirin, The education and mental health needs of Syrian refugee children. 2015, Migration Policy Institute.
Congolese
Communicable
diseases
Syrians
Mental
Health
Noncommunicable
diseases
What can we do better in PA?
Case management by resettlement agency
3 months
Health screening and stabilization
1-4 months
Arrival to the U.S.
Healthcare coverage under Refugee Medical Assistance
8 months
1 year post-arrival
Survey of refugee patients 1 year after arrival:
Health Insurance Status
Need a PCP
16%
31%
53%
16%
Yes
84%
No
Unsure
Yes
No
Long-term health access among refugee patients: a needs assessment. Caplow J, Nguyen L, Obidowski J, Barden-Maja A.
Poster presentation, Penn Health Equity Week. April 6. 2017.
 Language is the most commonly
identified barrier to refugee care
 Refugees may speak obscure dialects
– difficult to obtain skilled interpreters
 Visits are time-consuming
Primary care clinics with language services,
courtesy of Penn ServiceLink
 Examples:
 Lack of perceived need for preventive health
 Alternative medicines and beliefs
 Stigmatization of certain health disorders
 Lack of awareness of patient confidentiality
 Mental health services
 Difficult to access in Philadelphia
 Overwhelming need for dental and eye exams
 Women’s health visits
 Increased PAP completion with in-person female interpreters
 Latent TB treatment
 Much improved adherence rates with pharmacy directed treatment monitoring program
(40% 94% completion rates!)
 Carter KL, Gabrellas AD, Shah S, Garland JM. Improved latent tuberculosis therapy completion rates in refugee patients through use of a
clinical pharmacist. Int J Tuberc Lung Dis. 2017 Apr 1;21(4):432-437.
 The flow of refugees worldwide is at an all-time high
 Refugees undergo health screening before and after travel, and have 8
months of insurance coverage via RMA
 Refugee health priorities vary vastly depending on their origin
 The CDC website is an excellent resource!
 Current areas of need:
 Long-term insurance coverage and primary care
 Interpretation services
 Mental health, GYN, dental and vision care
 Expand network of primary care providers for refugees in PA
 Educate about refugee health needs
 Increase availability of interpreter services
 Contact your local resettlement agencies!
 Partner with mental health, GYN, optometry and dental providers
 Streamline insurance renewal process after RMA expires
 UN Refugee Agency: http://www.unhcr.org
 CDC: http://www.cdc.gov/immigrantrefugeehealth
 PA Refugee Resettlement Program: http://www.refugeesinpa.org
 Philadelphia Refugee Health Collaborative: http://philarefugeehealth.org/
 Aba Barden, Carol McLaughlin and Kim Carter
 HIAS
 Penn refugee clinic attendings, residents and student volunteers
 Free Clinic Association of PA
Test
CBC with diff
Quantiferon
Gold
Hepatitis B sAg,
sAb, cAb
Whom to test
Everyone
Everyone
HIV
RPR
Urine
GC/chlamydia
Everyone
Everyone
Everyone
VZV serology
(IgG)
Everyone
Strongyloides
Ab
Malaria smear
Everyone, unless pretreated with Ivermectin
Everyone
If from Sub-Saharan Africa or h/o malaria or positive
symptom screen; not required if pretreated within 3
days of departure
Schistosoma Ab African and Middle Eastern patients, unless
pretreated with praziquantel
B12
Nepali patients
Urine Hcg
All women of child-bearing age
MMR serologies Pregnant women only
CMP, A1c,
Lipids, Hep C
Ab
As per US guidelines and provider discretion
Immunization
Tdap
Whom to immunize
Everyone - even if already received
tetanus
MMR
Everyone EXCEPT pregnant women
VZV
Visit #2: Those whom are non-immune,
EXCEPT pregnant women
Hep B series
Visit #2: Those whom are non-immune
Influenza
Everyone during flu season
HPV
All men and non-pregnant women <26
years
Pneumococcal As per US guidelines
(23 and 13
valent)
Meningococcal Everyone up to age 19 or going to
college/military
Polio
Ages 18-25 if attending public school
https://www.cdc.gov/immigrantrefugeehealth/guid
elines/domestic/domestic-guidelines.html

Similar documents