Refugee Health Screening and the NM Department of Health

1. Refugee Health Screening and the NM Department of Health Refugee Health Program, Southeast Heights Public Health Office

2. Refugee Health Program in US/NM • What is a Refugee and how do they get to the US?

3. Refugee Defined • Refugee is defined as a person who has been forced to leave their country in order to escape war, persecution or natural disaster Libyian refugees fleeing 2011

4. UNHCR • The Office of the United Nations High Commissioner for Refugees was established on December 14, 1950 by the United Nations General Assembly. The agency is mandated to lead and co-ordinate international action to protect refugees and resolve refugee problems worldwide. Its primary purpose is to safeguard the rights and well-being of refugees. It strives to ensure that everyone can exercise the right to seek asylum and find safe refuge in another State, with the option to return home voluntarily OR to resettle in a third country.

5. How does a refugee get to Albuquerque? • Group of people are declared a refugee by UNHCR • US Federal government decides how many refugees will be accepted into the country for that given year • Waiting list (prioritized due to need not projected/perceived success in accepting country) • Health Screening in home country • Trip to Resettlement nation • Assisted by resettlement agency • Refugee Health Screening • Can move to the state of their choice (don’t have to stay in state of arrival, but may have to pay their own way to new state)

6. 1estimate re: “stateless people” www.trust.org

7. Who get resettled first? • Resettlement of refugees is viewed as a humanitarian effort, not an effort to import workers or those most “suited to be successful”. • The sicker, more vulnerable a refugee is, the better their chances of resettlement • This translates into sicker, more fragile, needy refugees presenting themselves in our communities

8. Refugee groups recently resettled in NM • Vietnamese (most resettlement 1970s) • Laos, Cambodian (1970s-80s) • Iraqi • Cuban • African (Somali, Congo, Sierra Leon, Sudan) • Bhutanese • Burmese

9. Refugee Health History in NM • Catholic Charities has been the primary resettlement agency for settling Federally sponsored refugees since the 1970s • Other church groups have sponsored and supported fragile populations, Catholic Charities is the only group that currently coordinates resettlement with Federal and HSD funds

10. Refugee is another word for resilient

11. The Refugee Health Screening • Begins abroad (except for some Cuban Entrants) • The screening abroad includes • Screening for TB (Chest X Ray) • Physical Examination with notation of gross musculoskeletal abnormalities, skin conditions • May note other long-standing health issues (may miss completely) • RPR for Syphilis in refugees over age 18 • May include HIV (not required since 2010) • May include vaccines (NOT REQUIRED)

12. Refugee Health Screening here in the US • Goal is to complete within 30 days of resettlement, may go 60 days • Is conducted at the SE Heights Public Health office on Zuni in the International District • Typically 2-3 weeks after arrival • Completed as a family unit, with immediate follow-up at Public Health (1 week) and referral to UNM SE Heights Family Health or provider of choice • Have an established network with UNM SE Heights

13. Why do we do the refugee health screening? • The purpose of the domestic refugee health screening is to ensure that refugees receive treatment and care for conditions of public health significance, and that such conditions do not prevent successful resettlement in the United States (U.S.). • Most refugees are eligible for Medicaid during the first eight months after arrival to the U.S.

14. Assessment • Tests conducted as part of the refugee health screen • CBC • Assessing for signs of infection, possible viral or parasitic infections, blood disorders • Non-specific • Results forwarded to Primary care MDs; helpful to draw while drawing other tests-hopefully saves the pt. a poke • CMP: baseline liver function, important before starting INH

15. Tests continued • Hepatitis B profile: Antigen, Antibodies, Core Antibodies, Anti-Hep B IgM • Will vaccinate or refer based on results either to PCP or will consult with DOH Hepatitis Program • We do not routinely screen for Hep C unless pts disclose risk factors

16. TB Testing • This is one of the most important pieces of the Refugee Health Screen • Latent TB infections are very common in our refugee populations • Come from endemic countries • Poor access to treatment abroad so it is more easily spread than TB is the US • Cramped living conditions • Overall compromised health status increasing the risk of latent case breaking down; increased spread

17. TB in the refugee camp • Most refugees know that they cannot come to the US with Active TB • Some will buy just enough TB meds on the black market to clear their smears • Leads to medication resistance • Stress of moving can cause further breakdown and worsening disease • Occasional incorrect cultures overseas (will diagnose it as non-TB when it is in fact TB)

18. The 22 countries shown on the map accounts for 80% of the tuberculosis cases in the world

19. How do we test for TB at the Public Health Office? • ADULTS = IGRA testing: Brand we use is Quantiferon • Blood Test used to aid in diagnosing Latent TB and TB Disease • IGRAs measure immune reactivity to Mycobacterium tuberculosis • Does NOT interact with BCG! • Routinely drawn over age 18 • TST on children

20. Advantages to IGRA testing • Single Patient Visit • Results in 72 hours (usually a week with DOH) • BCG DOES NOT CAUSE A FALSE POSITIVE • OTHER MYCOBACTERIUMS DO NOT CAUSE A FALSE POSITIVE • Is more specific • Will not cause the pain and scarring of a skin test

21. IGRA • Disadvantages • Blood must be processed (incubated) within 8-16 hrs of collection • Errors in collection/processing • Limited data on use of IGRAs to predict progress to active TB • Limited data on use in special populations i.e. children, recent contacts, immuno-compromised • Test may be expensive

22. IF you think your client is a refugee… • DON’T DO A TB SKIN TEST WITHOUT TALKING TO US FIRST! • Unnecessary • You may get a false positive result (BCG) • Puts the pt through unnecessary pain and potential scarring

23. HIV testing • No longer routinely done abroad prior to travel to US since 2010 • Is routinely done as part of the Refugee Health Screening but pt.s can decline (oral test) • If + refer to NM AIDS Services and the Truman St. Clinic (UNM) • Only 1 positive in 2011, and pt. had already had a + test in home country

24. Other STDs • Syphilis: MSM or victims of human trafficking: RPR if not documented from home country • Gonhorrhea/Chlamydia testing: Young adults, not previously tested, disclose multiple partners or symptoms

25. Refugee Children • Baseline lead level • Pilot here showed minimal elevated lead levels • Other cities have seen high lead levels in children from Asia (Nepali, Burmese) • Use Car batteries for cooking/heat • Baseline to see if elevated lead comes from sub-standard housing (older apartments, east coast) • Hbg/Hct, referral to WIC if under age 5, referral to supplemental food program (ECHO/commodities) if over age 5 • CBC for adolescents age 16 and up

26. Parasites….how we treat • Albendazole (Albenza) 400 mg PO single dose to all refugees 2 years of age and up • CDC recommends Albenza, Ivermectin and Praziquantel (AFRICA) together • Albenza alone doesn’t cover all parasites but covers many • effective against: roundworms, tapeworms, and flukes • Currently discussing addition of more specific parasitic serological testing, possibly more meds

27. Parasites, continued • If a refugee complains of GI symptoms, consider stool samples as these are not done as part of their refugee health screen • When sending note on specimen OVERSEAS TRAVEL or local laboratories will not complete all of the necessary testing

28. Mental Health Issues and Referrals • Many refugees come with horrific trauma stories and have suffered human rights violations • Are dealing with grief, fear, and many other emotions • Functional Assessment during Refugee Health Screen • Referral to Amber Gray MPH, MA, LPCC, ADTR, NCC who has set up a mental health provider network

29. Immunization and the Refugee Population • Immunization status varies greatly depending on home country • Many foreign countries have good vaccine campaigns but lack of documentation • Asian and African: may have some vaccines prior to travel but may have missed all childhood vaccines depending on their access to medical care

30. BONUS QUESTION • Name the 4 countries that still have endemic Polio Virus

31. Polio Endemic Countries • INDIA • NIGERIA • PAKISTAN • AFGHANISTAN

32. Measles 2011 • Current widespread Measles outbreak in Ethiopian Somali Refugee camp (08/06/2011) • 47 cases, 3 deaths, hundreds of suspected cases and more deaths expected • Poor immunization rates in Somalia coupled with Famine and crowding living conditions are accelerating this outbreak • MMR temperature sensitive (Live) • We continue to resettle Somalis in Albuquerque • VACCINATE! VACCINATE! VACCINATE!

33. Refugee Healthcare access • Can get on UNM Cares if they are unable to get a job with insurance (rare) after their Medicaid expires but do not always know how to obtain services • Refugees often have issues navigating healthcare system • Women can obtain family planning services at the public health dept.

34. Questions • Department of Health • SE Heights Public Health Office • 505-841-8928 • 7525 Zuni Ave SE Albuquerque NM 87108