Faculty/Presenter Disclosure

Transcription

1 Welcoming Immigrants & Refugees into Your Practice Presented by: Dr Rachel Talavlikar and Dr. Annalee Coakley Faculty/Presenter Disclosure Faculty/Presenter: Dr. Annalee Coakley Relationships with commercial interests: Grants/Research Support: Not Applicable Speakers Bureau/Honoraria: Not Applicable Consulting Fees: Not applicable Other: This presentation has received support from the Alberta College of Family Physicians in the form of a speaker fee and/or expenses. 1

2 ACFP 63 rd ASA Disclosure of Commercial Support This program has received financial support in the form of sponsorship from: Potential for conflict(s) of interest: Those speakers/faculty who have made COI disclosure are noted in the 63rd ASA Program and on the Salon A/B slide scroll. Mitigating Potential Bias ACFP: The ACFP s Sponsorship Guidelines apply to ASA Sponsorship. The ACFP abides by the College of Family Physicians of Canada s Understanding Mainpro+ Certification Guidelines, the Canadian Medical Association s Policy Guidelines for Physicians in Interactions With Industry and the Innovative Medicines Canada Code of Ethical Practices (2016). As a non profit organization, the ACFP complies with Canada Revenue Agency regulations. When deliberating acceptance of sponsorship, the ACFP considers and accepts sponsorship only from those whose products, services, policies, and values align with the ACFP vision, values, goals, and strategies priorities. ASA Planning Committee: Consideration was given by the 63 rd ASA Planning Committee to identify when Planning Committee members and speakers personal or professional interests may compete with or have actual, potential, or apparent influence over program content. Material/Learning Objectives and/or session description were developed and reviewed by a Planning Committee composed of experts/family physicians responsible for overseeing the program s needs assessment and subsequent content development to ensure accuracy and fair balance. The 63 rd ASA Planning Committee reviewed Sponsorship Agreements to identify any actual, potential or apparent influence over the program. Information/recommendations in the program are evidence and/or guidelines based, and opinions of the independent speakers will be identified as such. 2

3 Objectives Understand the difference between immigrants and refugees Understand the role of the Mosaic Refugee Health Clinic Understand common presentations in this population Understand the tropical presentations in this population Understand where to find support & resources within the community Discuss cultural competency when working with this population 5 Broad Context What is a migrant? What defines a refugee? What defines an immigrant? 6 3

4 Broad Context What is a refugee? 1951 Refugee Convention defines a refugee as someone who, owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, membership in 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. 7 What is an immigrant? A person who comes to live permanently in a foreign country Economic Classes: Federal skilled workers Quebec skilled workers Provincial nominees Entrepreneurs and self- employed persons Canadian experience class Federal skilled trades class Investors Start-up business class Caring for children and caring for people with high medical needs classes Immigrant Investor Venture Capital class Live-in caregivers in Canada Atlantic Immigration Pilot Programs Non Economic Classes: Members of the family class Adoptions Spouse or common-law partner in Canada class Humanitarian and compassionate consideration Protected persons Temporary resident permit holders 8 4

5 How many refugees How are many there refugees in the are there world? in the world? Sources: Census 2016, Statistics Canada and Calgary Economic Development 1 0 5

6 How many refugees are registered with the UNHCR? 17.2 million UNHCR, Key Facts and Figures, Which Agency is Responsible for Refugees? 1 2 6

7 UNHCR United Nations High Commission for Refugees The UNHCR is mandated to protect the rights and well-being of refugees worldwide The UNHCR ensures that refugees are provided with food, shelter, and potable water The UNHCR works to find a durable solution for refugees: 1. Repatriation 2. Local Integration 3. Resettlement 13 How are refugees classified? Nathan Denette, The Canadian Press, Justin Trudeau to Syrian refugee: Welcome Home, December 11, 2015,

8 Refugee Classification Convention Refugees Refugee Claimants Government Sponsored Refugees Privately Sponsored Refugees 15 Resettlement of Resettlement Refugees of Refugees Refugees registered with the UNHCR are Convention Refugees and are eligible for resettlement in a third country Convention refugees are divided into 2 classes: 1. Government Assisted Refugees (GARs) 2. Privately Sponsored Refugees (PSRs) 8

9 Refugee Resettlement: Refugee Claimants Refugee claimants come directly to Canada without registering with the UNHCR. Their claim is assessed by the Immigration Review Board (IRB). If accepted, they become permanent residents of Canada. If rejected, then they may have a chance to appeal the decision or may be removed from Canada. 17 Refugee Classification Convention Refugees Refugee Claimants Government Sponsored Refugees Privately Sponsored Refugees 18 9

10 Health Coverage for Convention Health Coverage Refugees for Convention Refugees All Convention Refugees are eligible for Provincial Health Care! Health Benefits for Convention Refugees All Convention Refugees have health benefits for 1 year through the Interim Federal Health Program (IFH) which is administered through Medavie Blue Cross 10

11 Health Benefits for Convention Convention Refugees Refugees IFH will cover essential medications, optometry services, and basic dental services Health Benefits for Refugee Claimants Health Benefits for Refugee Claimants IFH will cover health services, essential medications, optometry services, and basic dental services until the refugee claimant is accepted or deported 11

12 Health Benefits for Immigrants Once accepted as Permanent Residents are eligible to apply for Alberta Health Care on landing. Do not automatically receive any other benefits. If they have been sponsored are not able to apply for social assistance benefits for a set time frame (sponsors are liable in the meanwhile) 23 Where do Canada s refugees come from? Columbia Iraq Ethiopia Somalia Burma Syria Afghanistan Eritrea Congo Bhutan Sudan 24 12

13 Where do Calgary s refugees come from? Iraq Somalia Bhutan Eritrea Syria Ethiopia Afghanistan Burma Congo 25 The Numbers: 89,770: Refugees resettled as Permanent Residents in Canada from Jan October 2017 (IRCC, Facts and Figures 2017) 41,355: Refugee Claimants that came to Canada in 2017 (IRCC, Fact and Figures 2017) 11,960: Refugees resettled in Alberta as Permanent Residents from Jan October 2017 (IRCC, Facts and Figures 2017) 26 13

14 CCIS 27 What is it like to arrive in Calgary as a refugee? Documentary: 19 Days by Asha Siad

15 CCIS Services for Refugees Refugee Category GARs PSRs Refugee Claimants Services Provided Temporary Housing for 19 days at Margaret Chisholm Resettlement Centre (MCRC) Package of Resettlement Assistance Program Services Initial Needs Assessment Application for mandatory documents Referrals to community resources Employment Services Workshops and group sessions Referrals Assistance with work permit applications Employment services CCIS, Our Neighbours: Refugees in Calgary Enhancing Our Communities Immigrants 29.4% of Calgary s population are immigrants (Calgary Census, 2016) 30 15

16 Health Services Key Distinctions There are not generally specific health services for immigrants (although some clinics in the NE tailor their practice to this community). Many immigrants arrive in good health Will have had an immigration medical prior to arriving Are generally younger and often speak more English Often at risk for cardiovascular disease, obesity, diabetes, dyslipidemia, Hepatitis B&C (esp. when you look at top source countries). Are more often able to find a GP who speaks their language 31 What factors influence the health of refugees?

17 What factors influence the health of refugees? Post migration factors 33 What are conditions like in the countries of asylum? Access to education is a major challenge and many children have had their education disrupted Other challenges: access to health care, adequate housing, clean water, and employment

18 These conditions may lead to: Neglected chronic diseases Infections Dental problems Nutritional deficiencies Anemia Mental health problems 35 What barriers do newcomers face when accessing Canadian health care? Health Coverage Status Trust Language Education Cultural Beliefs concept of patient centered care System Barriers Interpretation services Fee-for-service model booked appt. times Provider beliefs, knowledge, cultural sensitivity and competence The role family plays in the care of patients 36 18

19 Health Services: Mosaic Refugee Health Clinic 37 Services Two registered nurses: Complex Case Managers Primary Care Physicians with DTM&H Visiting Specialists Dietitian Psychologists Social Workers Transition Coordinator Health Coordinator Support Staff 38 19

20 Goals of the MRHC Manage acute illnesses in newly arrived refugees Complete screening for infectious and chronic disease Stabilize chronic diseases Address and stabilize mental health problems Engage patients in preventative health care Teach patients to be independent navigators of the health system 39 What are refugees and immigrants screened for prior to coming to Canada? CXR to screen for active pulmonary TB > 11 yrs HIV > 15 yrs Syphilis (RPR) > 15 yrs U/A > 5 yrs Immigrants undergo a more complete medical 40 20

21 Initial Assessment at MRHC Orientation History Physical Order Screening Test Refer to Public Health for Vaccination Address contraceptive needs Advise to take vitamin D supplement Ensure Social Supports in place 41 What screening tests are recommended for most refugees and some immigrants? Hemoglobinopathy Screen (includes iron indices) HIV Serology Syphilis Serology Urine for G&C Hepatitis B Serology Hepatitis C Serology Strongyloides and Schistosoma Serology CBC Varicella IgG if >13 years of age Routine Age-Appropriate Screening Tests TST Stool for O&P and PCR if symptomatic 42 21

22 Common Presentations: Neglected Chronic Diseases Injuries and Physical Disabilities Chronic Pain Mental Health Issues: Depression, Anxiety, PTSD, Conversion Disorder, Somatic Symptoms Developmental Disabilities Dental Issues Iron Deficiency Anemia Infectious Diseases: LTBI, Latent Syphilis, Hep B 43 Injuries and Physical Disabilities Chronic pain secondary to injuries Physical disabilities and traumatic amputations IFH covers the cost of mobility devices (e.g. wheelchairs) Referrals to Physiatry or Amputee Clinic may be required 44 22

23 Resources for Amputees Clinics: Juvenile Amputee Clinic, ACH Tel: (403) Fax: (403) Adult Amputee Clinic, FMC Tel: (403) Fax: (403) Resources for Amputees Support Group: Alberta Amputee Sport and Recreation Association Tel: (403) Fax: (403)

24 Refugee Mental Health Issues The mental health issues that refugees present with may be: 1. Manifestations or exacerbations of pre-existing mental disorders 2. Precipitated by the war and displacement 3. Precipitated by the living conditions in the countries of refuge 47 Approach to Mental Health Issues Because mental health issues tend to improve with non-clinical interventions do not screen for mental health problems or PTSD. Focus on building a relationship with your patients in order to establish trust and rapport so that your patients can feel comfortable sharing their traumatic experiences and psychological symptoms. Remain alert to the possibility of mental health issues and address them as they present themselves. Refer to social work to address unmet social and material needs If you are investigating a patient, consider using the Refugee Health Screener 15 (RHS-15) as Tool for assessment 48 24

25 Mental Health Issues Mental health disorders often improve with an improvement in living conditions. Therefore, the best interventions are the non-clinical interventions: Safe environment Food security Educational opportunities Employment opportunities Social supports 49 Community Mental Health Resources Survivors of Torture Program (CCIS): (403) Ethos Program (CCIS): (403) For children aged 3-18 years and their families with a history of trauma and PTSD. Access Mental Health: (403) Distress Centre: (403) 266-HELP Mental Health Services through PCNs or your clinic 50 25

26 Potential Infectious Diseases Within the Refugee Population Hepatitis B, C H. Pylori Strongyloides Schistosomiasis Cutaneous Leishmaniasis Tinea GI Parasites Latent Syphilis Brucellosis Malaria Neurocystercicosis Typhoid Fever HIV Chagas Disease 51 Cutaneous Leishmaniasis Aleppo Boil Etiology: Leishmania major (85%) / tropica (15%) O/E: Non-healing Painless ulcer/plaque Classic = pizza rolled border and wet base Atypical appearance = more common Dx: Skin biopsy/scraping for PCR/culture (requires special media) Rx: Refer to Tropical Medicine Clinic at ACH or FMC 52 26

27 Cutaneous Leishmaniasis 53 Typhoid Fever Etiology: Salmonella typhi (+paratyphi) O/E: Fever NYD (majority of cases), No Diarrhea >50%, Rose spots Maculopapular rash (<10%) Dx: Blood Cultures x 2, Stool Bacterial C+S, Urine Bacterial C+S Rx: If well: Cipro 500mg PO BID x 14/7 (if susceptible) If Cipro Resistant call ID/send to ED If unwell: ED for IV Ceftriaxone 2g IV q24h 54 27

28 Parasitic Infections of the GI Tract What are the most common parasitic infections of the GI Tract: Giardia Amoebiasis Ascaris Hookworm Trichuris 55 Parasitic Infections of the GI Tract Why are they important? Can cause nutritional deficiencies (iron deficiency anemia, protein deficiency) Nutritional deficiencies can lead to poor growth and development Pregnant women and children are most vulnerable groups Can be spread to others (work, food handling, school) 1/3 of our patients are found to be infected 56 28

29 Giardia Transmission: Fecal oral spread ingestion of giadia cysts from contaminated food and water Symptoms: Asymptomatic or diarrhea Diagnosis: Stool of O&P and PCR Treatment: 1. No Rx is self-timing and therefore you may elect not to treat those who are asymptomatic 2. Metronidazole 250 mg po tid x 7 days 3. Because of resistance of to metronidazole in Africa and Asia, then may need to treat with Tinidazole 2g PO once for those patients who acquired Giardia in Africa or Asia (however, the patient needs to have failed metronidazole first before Health Canada will release Tinidazole). 57 Amoebiasis Amoebiasis 29

30 Amoebiasis Etiology: Entamoeba histolytica Symptoms: Asymptomatic, diarrhea, fulminant colitis, or liver abscess Diagnosis: Stool for O&P and PCR Treatment: Metronidazole 500 mg po tid x 7-10 days, followed by Paromomycin mg/kg/day po in 3 doses x 7 days 59 Strongyloides Etiology: Helminth infection with potential for auto-infection and dissemination. Hx: Often asymptomatic, abd pain, diarrhea O/E: Peri-anal rash Screening is recommended Labs: Strongyloides serology (include brief hx) Rx: Ivermectin 200 mcg/kg/day x 2 days (Form: 3mg tabs) Ivermectin is only available through the Special Access Program through Health Canada (SAP):

31 Larva Currens Larva Currens Why is Strongyloides important? If patients who are infected with Strongyloides become immunosuppressed then they can become acutely unwell with disseminated Strongyloides. Disseminated Strongyloides is a life threatening illness which presents with severe diarrhea, fever, jaundice, and shock. Therefore, SCREEN for it (use Prov Lab req) Especially if you are starting your refugee or immigrant patient on immunosuppresants

32 Schistosomiasis Helminth infection acquired from swimming or wading in snail infested fresh water Urinary schistosomiasis: Schistosoma hematobium Intestinal schistosomiasis: Schistosoma mansoni, Schistosoma japonicum Also known as Bilharzia 63 Schistosomiasis Schistosomiasis 32

33 Schistosomiasis 65 Schistosomiasis Schistosomiasis 33

34 Schistosomiasis: Why is it important? Intestinal schistosomiasis can lead to fibrosis of the intestines and liver Urinary schistosomiasis can lead to hematuria, fibrosis of the urinary tract, obstructive uropathy and renal failure. In rare cases the inflammation can result in bladder cancer (squamous cell carcinoma) 67 Treatment Treatment: Praziquantel 40 mg/kg divided bid x 1 day Coverage: Praziquantel is covered by IFH Praziquantel is not readily available at all pharmacies. The Mosaic Refugee Health Clinic recommends ordering praziquantel from Luke s Pharmacy in Bridgeland (Address: th Street NE; Tel: ( ) 68 34

35 Hepatitis B 2 billion infected in the world 360 million chronic carries A country considered endemic if >2% of the population infected Children of those parents born in countries with >8% infection rate should be screened (and are who will be eligible for vaccination by Public Health) 69 Global Impact Almost half of the world s population lives in an area with high HBV prevalence 2 billion with evidence of HBV infection 10 25% die of cirrhosis or liver cancer World population 6 billion million with chronic HBV WHO and CDC fact sheets, available at and

36 HBV Serologic Markers HBsAg General infection marker First serologic marker to appear Infection considered chronic if Persistent for > 6 months Anti-HBs (HBsAb) Recovery and/or immunity to HBV Detectable after immunity conferred by HBV vaccination Occasionally seen in chronic carriers HBeAg Indicates active replication of virus Absent in some mutations Anti-Hbe (HBeAb) Generally indicates virus has low levels replication Present in HBeAg negative Anti-HBc total (HBcAb total) Past exposure to HBV ALT abnormal if HBSAg positive and: >0.75% upper limit normal men >0.75% upper limit normal (women) 71 New Diagnosis of Hep B If a new diagnosis order: HBV DNA viral load, CBC, ALT, AST, GGT, ALP, Bili, INR, Alb, Cr, Fe, alpha 1 antitrypsin, ANA, SMA, AMA, IgG/A/M, HepBe antigen and anti-hepbe antigen Screen for Hep A/C, HIV Baseline Abdominal U/S for HCC screening Remember they are at risk for developing HCC without becoming Cirrhotic first! Viral hepatitis clinic at FMC and Satellite Clinics at East Calgary Health Centre 72 36

37 Hep B in Pregnancy Even if someone is an inactive carrier they are at risk for reactivation If initial diagnosis done in pregnancy must assess viral load and ALT status as well as other labs noted Depending on status may be started on treatment to decrease risk of transmission Consult if viral load >20000 or ALT>20 If low viral load will follow ALT q 3 months Baby will receive IVIG and immunization at birth CONSULT DR CARLA COFFIN - Hepatology 73 Thalassemias Genetically acquired abnormal structure of globin chain that form Hemoglobin Most common are Alpha/Beta Thal and Sickle Cell Often present as microcytic anemia Can be masked by iron deficiency Be sure to screen patients from endemic areas especially pre conception (samples can be marked as such) Can be at risk for iron overload 74 37

38 G6PD Deficiency On X Chromosome: males more severely affected Normal until exposed to oxidative stress Nitrofurantoin Primaquine Probenecid Sulfamethoxazole Advise medical alert bracelet or necklace 75 Tuberculosis Tuberculosis 38

39 Tuberculosis All refugees and immigrants from Africa and Asia require screening for TB 77 Why is screening for TB important? To prevent disease in the patient To prevent TB in our community 78 39

40 TB: How do we screen? 79 PPD Interpretation 80 40

41 TST reaction size and situations in which reaction is considered mm Considered positive if HIV AND the expected likelihood of TB infection is high (e.g., the client is from a population with a high prevalence of TB infection, is a close contact of an active, infectious case, or has an abnormal x-ray) 5 9 mm HIV infection Close contact of an active, infectious case Children suspected of having tuberculosis disease Abnormal chest x-ray with fibronodular disease Other immune suppression: TNF inhibitors, chemotherapy, dialysis Transplant candidates (if pre-transplant and relatively immune competent) > 10 mm All others including individuals who are anticipated to become immune suppressed as a result of treatments or medications yet to begin (e.g., TNF inhibitors, chemotherapy, radiation therapy, post-transplant rejection medications) 81 CXR 82 41

42 Quantiferon Test 83 Cultural Safety and Competency

43 Cultural Competency Values, norms, and traditions that affect how individuals of a particular group perceive, think, interact, behave, and make judgements about their world a set of congruent behaviors, attitudes and policies that come together in a system, agency or among professionals and enable that system, agency or professionals to work effectively in cross-cultural situations Quality of care and patient safety can be compromised when health-care providers do not respond to language and cultural preferences and differences University of Toronto Sick Kids 85 Cultural Fluency The ability for one to function within the norms and expectations of the culture in which they are living the ability to understand and participate fluently in a given culture 86 43

44 Culturally Competent Practice Screen for mental health, addictions, domestic violence Sensitivity around pelvic examination, family planning Support for nutritional deficiencies (esp. Iron) Expectations when providing (or not providing) medication prescriptions May only want to do certain things on specific days Understanding different cleansing practices, integrative health practices Recognizing the rituals especially around birth, marriage and death Patients will often say yes to please or because that s what they think you want to hear 87 English as a Second, Third or even Fourth Language Always use professional interpreter people mask their understanding Speak directly to the patient Listen to beliefs and request to be taught Use pictures and show equipment Often many words don t have same meaning e.g.: there is no word for something (no word for cancer in Hmong, no word for labour in Spanish) Be aware of the influence of hierarchy Use a teachback method and give bite sized chunks of information 88 44

45 Clinical Resources Evidence Based Checklist for Immigrants and Refugees: Evidence Based Screening Guidelines for Syrian Refugees: Refugee and Global Health e-learning: Caring for Kids New to Canada: 89 Clinical Resources Multicultural Mental Health Resource Centre: Refugee Health Resource:

46 Community Support Calgary Catholic Immigration Services: Mosaic PCN: MRHC Physician Support Hotline: Interpretive Services Language line is available at all AHS Facilities, CUPS, and The Alex In person interpretive services can be found at: 1. Immigrant Services Calgary: 1. Mayagwe:

47 Summary Both convention refugees and refugee claimants and immigrants are settling in Calgary in significant numbers; therefore, they will be your patients. Immigrants, Convention refugees are permanent residents of Canada; therefore, they are eligible for a PHN upon their arrival in Alberta. Refugee claimants are temporary residents of Canada; therefore, their health care if provided for by the Interim Federal Health Program. 93 Summary Refugees present most commonly with neglected chronic disease, traumatic injuries, infections, chronic pain, dental problems and mental health issues. Immigrants often arrive healthy but are at risk of developing chronic disease. Most mental health issues will resolve by addressing their social needs. The Mosaic Refugee Health Clinic aims to support refugees within their first 2 years in Canada. If you ever have any questions regarding refugee health, you can call the Mosaic Refugee Health Clinic hotline at

48 Questions? 48