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Refugee Health

Gain insights on caring for resettled refugees, common medical conditions, and overcoming healthcare barriers. Understand the PCP's role, refugee journey, and necessary screenings.

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Refugee Health

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  1. Refugee Health A General Pediatrician’s Perspective Jennifer Garcia, M.D Assistant Professor General Pediatrics YCHC September 12, 2018

  2. Objectives • Recognize the various steps refugee families take on their journey to the U.S. • Expand knowledge of the PCP’s role in caring for recently resettled refugees • Review medical conditions commonly encountered in recently resettled refugees • Discuss challenges in caring for refugee families and how to decrease barriers to accessing health care

  3. Where are our patients from?

  4. October 2016 to September 2017 Total of 51,392

  5. October 2017 to Current Total of 16,230

  6. Top 10 languagesU.S. fiscal year 2018 • Nepali • Swahili* • Karen • Spanish • Somali • Arabic* • Burmese • Armenian • Farsi • Chaldean • *Sango

  7. https://youtu.be/xpG3jLGGkvc

  8. Overview of a refugee’s journey

  9. Refugee flees home

  10. Temporary asylum in refugee camp

  11. UNHCR interview to determine if granted refugee status

  12. 3 durable solutions: • Voluntary repatriation to home country • Integrate into country of asylum • Resettlement in 3rd country (<1%) • Legal and physical protection needs • Survivors of violence and torture • Medical needs • Women-at-risk • Family reunification • Children and adolescents • Elderly refugees • Lack of local integration prospects

  13. If decision is resettlement in US Interview by CIS- qualify as refugee under U.S. law and is “eligible”?

  14. A refugee’s journey • Eligible Overseas Resettlement Support Center • Interviews applicant • Prepares paperwork for CIS • Arranges medical exam, background/security check • Names and addresses of relatives • Work history/job skill • Special education or medical needs

  15. A refugee’s journey • International Organization for Migration (IOM) arranges transport (must repay) • IOM provides cultural orientation (~15 hrs) • Important aspects of life in US • Problem-solving skills • Establish realistic expectations • Can vary by location

  16. ★

  17. A refugee’s journey • Volunteer agencies (VOLAGs) accept refugees in city of resettlement • Welcome at airport • Arrange housing, furniture, basic household supplies • Cultural orientation • Refer to social services and employment • Albuquerque VOLAG: • Lutheran Family Services

  18. Overseas and domestic health screening

  19. Overseas Medical Exam • Physical exam • Screen for Class A or B conditions • Initiate some vaccines • Tuberculosis, Hep B screening +/- STIs • Anti-parasitics, Anti-malarial given depending on country of origin

  20. Recommended domestic screening by age

  21. What is our role as the pcp?

  22. PCP follow-up of domestic screening • Review lab results • Ensure recommended anti-parasitics given • Ensure recommended anti-malarial given • Vaccine catch-up • Multivitamin for 6 mos-6 yrs old • Schedule repeat lead level in 6 months if < 6yo

  23. Recommended pre-departure anti-parasitic medications

  24. Soil transmitted helminths Ascaris Hookworm Whipworm

  25. Soil transmitted helminths • Pre-departure treatment: Albendazole • All countries, age >1 yo • Mostly asymptomatic • Heavy parasite burden: abdominal pain, diarrhea, blood in stool, rectal prolapse, obstruction

  26. Strongyloides

  27. Strongyloides • Pre-departure treatment: Ivermectin • Contraindicated if from Loa Loa endemic country in SSA or <15 kg • Contact with contaminated soil • Usually asymptomatic • Can auto-infect and last decades, • Hyperinfection syndrome if become immunosuppressed, fatality rate 50%! • If symptoms present- abdominal pain, diarrhea, Loefflers syndrome (acute transient pneumonitis), Larva currens (urticarial rash)

  28. Schistosomiasis

  29. Schistosomiasis • Pre-departure treatment: Praziquantel • SSA, ≥5 yrs old • Host snail lives in freshwater • Acute infection: rash, fever, HA, myalgia, respiratory sx, eosinophilia and HSM • Chronic infection: inflammation due to eggs lodged in organ vessels • blood in stool, bowel wall ulceration, liver fibrosis, portal hypertension, dysuria, hematuria, renal failure, increased risk of bladder cancer

  30. What if none or incomplete treatment overseas? • Screen (stool or serum) OR treat presumptively* • Caution! if from Loa Loa endemic country (Loaiasis=African eye worm) • Do not treat strongyloides presumptively with Ivermectin. • Use high dose Albendazole instead

  31. Malaria

  32. Recommended pre-departure anti-malarial medication • Coartem (Artemether-lumefantrine) • Fixed combination tablet • Available in most refugee camps • Wide therapeutic window • Minimal side effects • Given as DOT 3 days before departure • Contraindicated if <5kg, pregnant, lactating

  33. What if no treatment overseas? • Give presumptive treatment OR screen • Tx: Coartem or Malarone • Screen: 3 separate thick-and-thin blood smears taken at 12-24 hour intervals

  34. Malaria symptoms • Initial: High fever, chills, rigor, sweats, HA • Progression: N, V, D, cough, tachypnea, arthralgia, myalgia, HSM, abdominal and back pain • Severe illness: anemia, thrombocytopenia, pallor and jaundice

  35. What are we seeing in clinic?

  36. Eosinophilia • Abs Eo count >400 • Complete or incomplete pre-departure tx? • Timing of CBC after anti-parasitics? • If persistent 6 months after treatment, look for other causes

  37. Elevated lead level • Exposures in country of origin • Malnutrition and iron deficiency cause increased risk of elevated BLL • Continued exposure to lead after arrival in US

  38. Elevated lead level • *Typically seeing elevated BLL of 5-14 mcg/dL • Try to identify any ongoing exposures • Check for iron deficiency (CBC, ferritin, CRP) • Nutrition counseling (Ca, Fe, Vit C, Fiber) • Developmental screening/EI referral • Repeat test (timing based on initial level)

  39. Neutropenia • ANC <1500 • *Typically seeing mild to moderate neutropenia • Possible race and ethnic variability • “normal” ANC slightly lower in Yemenite Jews, Ethiopians, certain Arabs • West Africa: Duffy Ag-Receptor chemokine gene (DARC) null • Benign familial/ethnic neutropenia: Yemenite Jews, South African, West Indian, Arab Jordanian

  40. Neutropenia • Acquired • Post-infectious • Nutritional: Vitamin B12, folate, copper deficiencies • Hypersplenism: hepatitis, malaria • Immune disorders • Bone marrow disorders • Congenital • Shwachman Diamond, Chediak-Higashi, cyclic neutropenia

  41. Neutropenia: Vitamin B12 and folate deficiency • CBC: Hb, MCV, WBC +/- Plt, Retic, Hypersegmented neutrophils • B12 deficiency • Decreased intake animal products • Decreased absorption- Crohn’s, pancreatic insufficiency, bacterial overgrowth, tapeworm • Folate deficiency • Lack of fresh vegetables & fortified grains • Lack of routine folate supplementation

  42. Anemia • Iron deficiency- MCV, RDW, RBC • Lead toxicity- NL/MCV, NL/RDW, RBC • Thalassemia • Sickle cell • G6PD

  43. Thalassemias HbA

  44. Alpha Thalassemias • Silent carrier-1 gene defect • Trait- 2 gene defect • Microcytosis, mild or no anemia • Suspect if negeval for IDA and normal Hb electrophoresis • HbH disease- 3 gene defect so only 4 beta chains • Microcytosis, chronic hemolysis, splenomegaly • Hydropsfetalis- 4 gene defect

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