Refugee Health

1. Refugee Health Julie Caplow May 5, 2017 Free Clinic Association of PA Conference

3. Agenda • 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?

4. Global trends

5. 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 Terminology

6. Let’s add some numbers Durable solutions: Gobal Trends, 2015 http://www.unhcr.org/576408cd7

7. Let’s add some numbers 50,000/yr Durable solutions: Gobal Trends, 2015 http://www.unhcr.org/576408cd7

8. Refugees in Pennsylvania • 3679 total arrivals between Oct 2015 and Sept 2016 Pennsylvania Refugee Resettlement Program; http://www.refugeesinpa.org/aboutus/demoandarrivalstats/index.htm

9. Refugee Services in PA • 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

10. Healthcare access • 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

11. Health screening Standard overseas and domestic screening

12. Overseas health 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

13. Domestic health screening • 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

14. Health Profiles Case comparison: Congolese and Syrian refugee health needs

15. Congolese Refugees • Who are they? • What are their health needs?

16. Congolese Refugees • 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

17. Congolese Refugees: Health Profile Health priorities per the CDC: • Parasitic infections • Malaria • Mental health • Sexual- and gender-based violence https://www.cdc.gov/immigrantrefugeehealth/pdf/congolese-health-profile.pdf

18. Malaria • 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)

19. Other parasitic infections • 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, loaloa, onchocerciasis) • Test for these if patient has unexplained eosinophilia

20. Sexual and Gender-Based Violence • 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

21. Mental Health • <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.

22. Tuberculosis • 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

23. Syrian Refugees • Who are they? • What are their health needs?

24. Syrian Refugee Crisis • 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

25. Syrian Refugees: Health Profile CDC Health Priorities: • Anemia • Hypertension • Diabetes • Mental illness Source: https://www.cdc.gov/immigrantrefugeehealth

26. Chronic disease prevalence

27. Anemias • High prevalence of anemia in women and children, mostly iron deficiency • Approximately 5% of the Syrian population are carriers of beta thalassemia trait

28. Mental Health • 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.

29. Congolese vs. Syrian Refugee Health Priorities Congolese Syrians Mental Health Non-communicable diseases Communicable diseases

30. Remaining challenges What can we do better in PA?

31. Long-term healthcare access Case management by resettlement agency 3 months Health screening and stabilization 1-4 months Healthcare coverage under Refugee Medical Assistance 8 months 1 year post-arrival Arrival to the U.S.

32. Long-term healthcare access Survey of refugee patients 1 year after arrival: 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.

33. Language barriers • 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

34. Cultural barriers • Examples: • Lack of perceived need for preventive health • Alternative medicines and beliefs • Stigmatization of certain health disorders • Lack of awareness of patient confidentiality

35. Other lessons from Penn Refugee Clinic • 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.

36. Take-away points • 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

37. Call to Action • 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

38. Resources • 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/

39. Thank you! • Aba Barden, Carol McLaughlin and Kim Carter • HIAS • Penn refugee clinic attendings, residents and student volunteers • Free Clinic Association of PA

40. Domestic screening & immunizations summary https://www.cdc.gov/immigrantrefugeehealth/guidelines/domestic/domestic-guidelines.html