Patricia F Walker, MD, DTM&H

1. HealthPartners Center for International HealthCare Delivery Model Healthcare in the Global Village: Serving Refugees in IndianaSeptember 24-25, 2009 Patricia F Walker, MD, DTM&H Associate Professor, Div of Infectious Disease and International Medicine Dept of Internal Medicine, University of Minnesota Medical Director, HealthPartners Center for International Health and Travel Medicine Clinics

2. HealthPartnersCenter for International HealthCare Delivery Model: • Hire bilingual/ bicultural staff at all levels • Only use professionally trained medical interpreters • Hire providers with expertise in refugee health care • Provide multidisciplinary care

3. HealthPartnersCenter for International HealthCare Delivery Model: • Hire bilingual/ bicultural staff at all levels

4. HealthPartnersCenter for International HealthCare Delivery Model: 2. Only use professionally trained medical interpreters

5. HealthPartnersCenter for International HealthCare Delivery Model: 3.Hire providers with expertise in refugee health care

6. HealthPartnersCenter for International HealthCare Delivery Model: 4. Provide multidisciplinary care Internal Medicine Psychiatry and Psychology Co-located with Pediatrics Clinic Social Worker/Case Management staff Dietician/Diabetes educators Pharmacist

7. Best Practices in New Arrival Screening

8. Best practice:Medical Screening of new arrivals 1. General history & physical examination 2. Immunization status 3. Tuberculosis screening 4. Laboratory testing 5. Vision and hearing evaluation 6. Dentistry referral 7. Psychological assessment/referral as needed

9. Best Practice: Medical History Ask the patient’s life story • Pre flight: Country of origin and reason for escape Life and employment before immigration Medical problems or stress in home country • Path to host country: Time spent in refugee camps/location Physical separation from loved ones • Losses of family/friends and reasons for death Adams, KM et al, BMJ 328 26 June 2004

10. Best practice: Medical history • History of disease or exposure: TB, malaria, parasites, hepatitis, STD’s • Directed ROS: fever, night sweats, wt loss cough, hemoptysis diarrhea, visible parasites in stool jaundice • Vaccine status: ask for records • Traditional medicines and substance use • Reproductive history/genital surgery/hx of UTI’s • Trauma history Adams, KM et al, BMJ 328 26 June2004

11. Best Practice: Physical exam of refugees/migrants Keep an open mind…: • Patient affect • Vision and hearing screen • Skin (pallor, tinea, nodules/macules) • Adenopathy • Chronic hearing and dental problems • Murmurs • Hepatosplenomegaly • Evidence of neuropathy • Evidence of injury/disability • Cultural practices/FGM

12. Courtesy of Bill Stauffer, MD

13. Best Practice:Tuberculosis screening for new arrivals PPD > 6 weeks old CXR if: Positive PPD Those with symptoms of TB disease Use of Quantiferon Gold blood testing for patients with (+) PPDs who decline INH Set up an LTBI clinic run by nursing staff if you do not refer patients to your health department

14. Best Practice: Laboratory screening • CBC with differential • Serum chemistries • HBsAg, Hep B surface Ab, anti HBc • VDRL or RPR, HIV • Blood lead level if < 6 years old • Stool O&P x 2-3 (am specimens, different days) • Urinalysis • Screening for vaccine preventable diseases

15. Use best practice order sets – whether paper or electronic NEW ARRIVAL SCREENING (Right Click to begin documentation)        SUBJECTIVE PT NAME is a 57 yr female here for New Arrival Health Screening. Pt here with: {COMPANION:7598}.Allergies: SOCIAL HISTORY Birth Place: {COUNTRY OF ORIGIN:19012}Year left country of origin: ***Other countries lived in/where: ***Date US arrival: ***{ADULT/CHILD:7650}Religion: {RELIGIONS:7597}Years of formal education: {Numbers 1-10:10013}English skills: {EXCELLENT/POOR:7595}Occupation: *** Review of Systems{ROS:16340 OBJECTIVE Physical Exam:General: {general appearance:7555}Skin: {SKIN EXAM:101::"Skin color, texture, turgor normal. No rashes or lesions."}, {EXTREMITY EXAM:5109::"extremities, peripheral pulses and reflexes normal"}, {nails:5758}HEENT: {ENT EXAM:5032::"ENT exam normal, no neck nodes or sinus tenderness"}Respiratory: {LUNG EXAM:401}Cardiovascular: {HEART EXAM:501}Breasts: {BREAST EXAM:5056::"not performed"}Gastrointestinal: {ABDOMEN:26529::"soft, without masses, distention or organomegaly","bowel sounds intact"}Genitourinary: {FEMALE/MALE:7599}Musculoskeletal: {MUSCULOSKELETAL EXAM:803}Endocrine: Thyroid exam: {thyroid:5702}Neurological: {NEURO EXAM:901::"Gait normal. Reflexes normal and symmetric. Sensation grossly intact."}Ano-Recto: ASSESSMENT New Arrival Health Screening. Healthy appearing {CHILD:7647}*** PLAN Referral to: {new arrival referrals:7664}Orders for: ***Follow up: {REFUGEE FOLLOW UP:7730}***

16. US screening pitfalls • Screening is voluntary; new arrivals may not be seen in timely fashion, or not be seen at all • Quality and thoroughness of health assessment varies, particularly with private clinics • Providers unfamiliar with management of results of screening (+ PPD, eosinophilia, Hepatitis B carriers) • Reporting back to State Health Departments is incomplete • Sharing of data nationally is incomplete (Electronic disease notification will address this)

17. eSHARE: electronic system for the health assessment of refugees Web based system for collecting domestic screening results eSHARE tools: • Promotional materials • User Guide and Data Dictionary • User Agreement • Implementations Models and Protocols • Training Curriculum and Demo Site

18. US screening results, selected refugee and immigrant populations • Positive TST 10.1-70% • HBsAg (+) 4-15% • Anemia 6.6-24% • Eosinophilia 17-28% • Intestinal parasites 21-75% Source: Seybolt L, Barnett, ED, Stauffer, W. (2007). US Medical Screening for Immigrants and Refugees. In P.F. Walker and E. D. Barnett (Ed.), Immigrant Medicine (pp.135-150). Elsevier.

19. Best practices:Country/ethnic specific cancer screening • Liver cancer Hepatitis B • Cervical cancer Human papilloma virus • Gastric cancer Helicobacter pylori

20. Best practices:Hepatitis B in refugees and immigrants • High prevalence: 3 - 19% or higher • Educate carriers regarding transmission • Check Hep A status in Hep B carriers and offer Hep A immunization if not immune • Screen family members for Hepatitis B and offer immunization

21. Best practices:Hepatocellular carcinoma screening • 3rd most common cause of cancer related deaths in world: 550K/year • A vaccine preventable cancer • Population specific cancer screening: AFP as tumor marker q 6 mo. RUQ US q 6-12 mo.

22. Best practice:Use check lists* as much as possible! • If patient’s HBsAg is positive, have the lab automatically reflex to testing: • Viral load • HepBeAg • HepBeAb • Hep A antibody screen • Then obtain US and send to hepatologist (Recommended reading: Better by Atul Gawande, MD)

23. Best practice: Match the cancer screening to the population served!Cervical cancer in immigrants • 87 yo Vietnamese patient of mine presented with vaginal bleeding. US arrival in 1985 (age 64). • Husband had died during war, not sexually active, refused pelvic/pap. • Dx: Stage 3 cervical cancer

24. Best practice:Effective educational programs • Address cross cultural beliefs (cancer is not treatable; if I have no symptoms, I have no health problem; I am not sexually active now, and not at risk). • Utilize female providers. • Develop ethnic specific educational materials (Currently completing a 3 minute Spanish and Somali video for use in exam room) • Offer HPV vaccine to younger women.

25. Best Practice: Consult available resources Refugee health guidelines: www.cdc.gov/yellowbook/RefugeeGuidelines www.ccirh.uottawa.ca Translated educational materials for the VFR traveler: www.tropical.umn.edu The LEARN model 13 min video on how to conduct an effective interview across cultures List of excellent migrant health resources: CDC Yellow Book 2010, chapter 9 (Stauffer)