US Refugee Resettlement: Health lessons from an organized resettlement process

US Refugee Resettlement: Health lessons from an organized resettlement process William Stauffer Professor of Medicine & Pediatrics Infectious Diseases and International Medicine University of Minnesota

No financial disclosures If I discuss any off label uses of medications I will disclose to the audience Perspectives provided are my opinion only and are not given on behalf of the CDC.

Who am I?

Spatial Mobility of French Population, 1800-2000 Based on data from Grubler and Nakicenovic, 1991; Fig 7.18 in Cliff et al, 1998

Great-grandfather Grandfather Father Son

The Game Changer

Speed of Global Travel in Relation to World Population Growth Days to Circumnavigate ( ) the Globe 400 350 300 250 200 150 100 50 0 6 5 4 3 2 1 0 World Population in billions ( ) 1850 1900 1950 Year 2000 From: Murphy and Nathanson Sems. Virol. 5, 87, 1994

Estimated Annual International Arrivals Refugees 70 90,000 Includes ~12,000 adoptees Immigrants >1,000,000 International Travelers Foreign 60M/ U.S. 60M Source: U.S. Department of Homeland Security Slide courtesy of M. Cetron, DGMQ

Data from United Nations High Commissioner for Refugees (UNHCR): the UN Refugee Agency More than half of all refugees are < 18 years of age Source: http://www.unhcr.org/en-us/figures-at-a-glance.html, accessed 1/9/2017

Bureau of Population, Refugees, and Migration The Refugee Resettlement Process Persecution or fear of persecution Flight to country of first asylum Identified as a refugee by UNHCR or host country Identification of refugees who are eligible to be processed for U.S. resettlement Overseas processing, including Department of Homeland Security adjudication, medical screening and security background checks, cultural orientation, and sponsorship assurances Transportation to the U.S. Initial reception and placement in the U.S. Medium-term support through HHS funded services

Department of State Bureau of Population, Refugees, and Migration Office of Admissions - Refugee Processing Center Refugee Arrivals by Country Location Fiscal Year 2012 as of 30-September-2012 Cases: 27,125 Individuals: 58,238 Data extracted from the Worldwide Refugee Admissions Processing System (WRAPS). RPC/REPORT STATISTICIAN/MAP_ARRIVALSBYCOUNTRYLOCATION Page 1 of 4 Report Run Date: 1-October-2012

Department of State Bureau of Population, Refugees, and Migration Office of Admissions - Refugee Processing Center Refugee Arrivals by Country of Origin Fiscal Year 2012 as of 30-September-2012 Cases: 27,125 Individuals: 58,238 Data extracted from the Worldwide Refugee Admissions Processing System (WRAPS). RPC/REPORT STATISTICIAN/MAP_ARRIVALSBYCOUNTRYLOCATION Page 1 of 4 Report Run Date: 1-October-2012

Refugee resettlement, a model?

Division of Global Migration and Quarantine Immigrant, Refugee, and Migrant Health (IRMH) Branch Preventing Importation and Spread of Infectious Disease Through Immigrants & Refugees

Top 10 Countries of Nationality for FY16 US-Bound Refugees Total: 84,995 DRC 16279 Syria 12583 Burma 12294 Iraq 9838 Somalia 9032 84,995 Top 10 -red circle 35,189 = 49,806 Bhutan 5455 Iran 3736 Afghanistan 2743 Ukraine 2526 Eritrea 1924 Data Source: Worldwide Refugees Admissions Processing System (WRAPS) from U.S. Department of State

FY 2015 U.S. Refugee Arrivals by State Data source: Disease Notification Analysis (DNA) database based on Worldwide Refugee Admissions Processing System (WRAPS), U.S. Department of State

States of Initial Refugee Resettlement for FY2016 Number of Refugee Arrivals 0-500 500-1000 1001-1500 1501-2000 2001-2500 Nationality (only populations > 500 per state shown) Bhutan Burma DRC Iran Iraq Somalia Syria Ukraine Data Source: Worldwide Refugees Admissions Processing System (WRAPS) from U.S. Department of State

Mobility: time for health interventions? Refugee Camps Urban Centers Prevention, surveillance & Intervention opportunities Overseas Medical Exam Sites Quarantine Stations Resettlement Communities

U.S.-bound Refugees: Medical Evaluation Panel physicians (DoS) Required overseas medical examination ~2-6 mos State health dept ~1-3 mos Recommended domestic examination in US (DIFFERENT from overseas exam)

Current status of medical evaluation for U.S. bound refugees Overseas Pre-departure responses Medical Assessment Required for all refugees (and immigrants) Must be performed by designated Panel Physician Technical Instructions for medical exam published by CDC. Pre-departure presumptive treatment Increasing vaccination Post-arrival medical screening and evaluation New guidelines under development beginning in 2005. Post-arrival responses

Components of the Overseas Medical Exam Vaccine Administration Radiologic assessment for TB Syphilis testing

Healthy Resettlement Promotes Health Security: Overseas Tuberculosis Screening TB skin testing, Nepal Directly observed therapy for TB, Kenya TB cultures, Nepal

Tuberculosis Cases, United States, 1995-2014 18,000 100% No. of Cases 16,000 14,000 12,000 10,000 8,000 6,000 4,000 2014 TB rates: Total 2.96 per 100,000 US-born 1.2 per 100,000 Foreign-born 15.4 per 100,000 TB : 65% Foreign-born MDR TB: 88% Foreign-born 90% 80% 70% 60% 50% 40% 30% 20% Proportion Foreign-Born 2,000 10% 0 0% 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 U.S.-born Foreign-born % Foreign-born

TB Rates in Refugee Populations USRP, 2014 Screening Location Primary Populations Refugees Examined TB Cases Cases with Drug Resistance TB Rate per 100,000 Egypt Iraqi, Syrian, Somali, Sudanese 3,301* 0 0 0 Ethiopia Eritrean, Somali 7,511 14 0 186 Iraq Iraqi 13,480 1 0 7 Jordan Iraqi, Syrian 3,448* 0 0 0 Kenya Somali, Congolese 7,005 25 1 357 Malaysia Burmese 13,969 111 17 795 Nepal Bhutanese 7,653 50 0 653 Thailand Burmese 8,376 54 0 645 Turkey Iraqi, Syrian 5,367* 2 0 37 Uganda Congolese 2,940 6 2 204 *Primarily refugees, but may include small number of immigrant exams Preliminary data courtesy Ms. Michelle Russell

Effect of a Culture-Based Screening Algorithm on TB Incidence in US-Bound Immigrants and Refugees Number of Cases 2000 1600 1200 800 400 Smear-Based Algorithm 2002-2006 Culture-Based Algorithm 2007-2012 (implementation phase) Baseline US TB in FB < 1 year after arrival Overseas: Smear (-)/Culture (+) TB 0 Liu et al. Annals of Internal Medicine, 2015

Refugee Vaccination Program: Overview Up to 2012 - Many refugees arrived in U.S. with no vaccinations Reports of VPD s in newly arrived refugees Missed opportunity to vaccinate between overseas health exam & US arrival (4-6 months) Partnership between CDC, DOS, implemented by IOM End of 2012 began in 6 pilot countries: Malaysia, Nepal, Thailand, Ethiopia and Kenya, Uganda 2016 and beyond continuing to roll out globally with intentions of reaching 100% of USRP refugees 21 countries, covering 60% of all USRAP

Overseas Refugee Vaccination Program: Protecting against 11 Diseases Diphtheria Haemophilus influenzae type b Hepatitis B Measles Mumps Rotavirus Rubella Pertussis Polio Streptococcus pneumoniae (pneumococcal disease) Tetanus

Number of Refugees Vaccinated, CY* 2013-2016 2013 2014 2015 2016 Total # refugees vaccinated 29,464 42,058 41,693 102,246 215,461 > 700,000 doses of vaccines administered *CY: calendar year

Presumptive Treatment for Parasite Infections, Implementation by IOM, 2016 Region Coartem (malaria) Praziquantel (schistosomiasis) Albendazole (soiltransmitted helminths) Africa, Non- Loa Loa areas Africa, Loa Loa areas Ivermectin (strongyloides) Burundi, Ethiopia, Kenya, Rwanda, Uganda N/A Asia N/A N/A Nepal, Malaysia, Thailand Middle East N/A N/A Jordan, Iraq Latin America N/A N/A Future consideration Future consideration

Successful Overseas Interventions: Pre-departure Parasite Treatment Program > 64,648 U.S.-bound refugees treated in 2016

Estimated Program Costs & Outcomes Intestinal Parasites, Asian refugee cohort, n= 27,700 Maskery et al. Unpublished data, 2014. Prelim results, do not cite $7 $6 $5 $4 $3 $2 $1 $- Total cost (program + illness), million USD Domestic screen and treat Overseas MDA 8,000 7,000 6,000 5,000 4,000 3,000 2,000 1,000 0 Number with parasitic infections

Case Scenario 9 year old Liberian male refugee presents to Minnesota ED with fever three months after arrival to the U.S. PE significant for Afebrile, pallor Tachycardia with a flow murmur Protuberant abdomen, non-tender spleen into left pelvic gutter Laboratory WBC 4.3, Hgb 4.1, plt. 79

Diagnosis Scenario #4 9 year old afebrile Liberian with severe anemia The most likely diagnosis is? a. P. falciparum malaria b. P. ovale malaria c. P. malariae malaria d. P. vivax malaria e. P. knowlesi malaria

Diagnosis Scenario #4 9 year old afebrile Liberian with severe anemia The most likely diagnosis is? a. P. falciparum malaria b. P. ovale malaria c. P. malariae malaria d. P. vivax malaria e. P. knowlesi malaria

Pre-Departure Treatment 1999 Recommendation All SSA refugees Sulfadoxine-pyrimethamine (SP, Fansidar) 2005/2007 revision Artesunate combination therapy

% 10 9 8 7 6 5 4 3 2 1 0 Percentage of West African refugees in Hennepin County with malaria Pre-implementation Incremental implementation 1996 1997 1998 1999 2000 2001 2002 2003 2004 Year 1997 1998 1999 2000 2001 2002 2003 2004 Collinet-Adler et al. AJTMH 2007, 77(3):458-463.

Cases/1,000 Refugees 18 16 14 12 10 8 6 4 2 0 Results 15.5 Change: 79% (95% CI: 56%, 90%) 3.2 Change: 92% (95% CI: 66%, 98%) 1.3 May-July 07 SP July-Nov 07 Partially-Supervised AL Dec 07 Feb 08 Fully-Supervised AL SP: sulfadoxine-pyrimethamine (Fansidar); AL: artemether-lumefantrine (Coartem) Presumptive ACT adopted for U.S.-bound refugees from sub-saharan Africa

CDC s Electronic Disease Notification (EDN) System EDN Purpose: Capture overseas medical exam data EDN Users: Health Departments in all 50 States and D.C. >800 active users Notify state health departments Clinic-Level Users 18% TB Controllers 27% Capture domestic TB follow-up exam data Refugee Health Coord. 20% TB/Refugee Health Coord. 35%

BEFORE paper paper If no CDC presence at port of entry, CBP couriers to assigned CDC Quarantine EDN Medical forms are complete Immigrant arrives with paper forms CBP manually identifies and pulls record, reviews and transfers to CDC Add 1-7 Days CDC quarantine couriers paper forms to CDC HQ Forms manually entered into EDN, record is available to health department 1-6 months prior to arrival Day 1: Arrival Day 1 CBP misses some, which never get to CDC Day 2-5 (or 3-12) Day 5-7 (or 7-14) AFTER emedical & Pre-EDN database Medical forms are complete Immigrant arrives Pre-EDN Database CBP records arrival, record automatically transferred EDN Record is crossed referenced, automatically loaded into EDN and available to health departments 1-6 months prior to arrival Day 1: Arrival Day 1 Day 2

Domestic medical screening and evaluation

Areas being addressed in current guidelines Preventive Health Interventions History and physical examination Routine immunizations TB testing Counseling & Mental Health Nutrition Growth and Development Female Genital excision Mental Health Screening

Areas being addressed in current guidelines Laboratory Testing & Disease Specific Sections Overseas & domestic malaria Overseas & domestic Intestinal Parasites Hepatitis A-E General HIV Lead STI/syphilis Vitamin D

Future directions and Challenges Increase post-arrival surveillance Increase in population specific guidelines Flexibility--from reactive to pro-active. Shift from domestic to more predeparture screening and treatment Increased communication across systems (e.g. from overseas to postarrival clinicians). Begin to work with non-refugee immigrant populations.

Initiatives Increased pre-departure interventions Centers of Excellence Dissemination of best practices Guideline development/improvement Increased surveillance Improved medical education Train persons from communities to serve communities

Centers of Excellence in Refugee Health (2015-2020) q Surveillance/epidemiology of refugee populations Building a data repository for refugee health data from post-arrival screens Conducting clinical quality improvement evaluations on Hep B, LTBI, and chronic conditions in pediatric patients q Guideline Development and Revisions New Guidelines: Preventative Medicine, Women s Health, Pediatrics Revisions to Current CDC Guidelines: Mental Health, General, Hepatitis, Parasitics

Strengthening Surveillance for Diseases Among Newly-Arrived Immigrants and Refugees (2012-2017) Enhancing state or local refugee health surveillance systems by Automating processes Linking to other surveillance systems within a state Providing large dataset to describe refugee populations

Mobility: time for health interventions? Refugee Camps Urban Centers Prevention, surveillance & Intervention opportunities Overseas Medical Exam Sites Quarantine Stations Resettlement Communities

Cholera in New York City, 1892 Source Quarantine by Howard Markal

Death in a sailor s uniform holding the yellow quarantine flag knocking on the door of NYC during the 1898 yellow fever epidemic Frank Leslie s Illustrated Newspaper, Sept. 1878

Where do the real public health threats come from?

With 1 billion people crossing international borders each year, there is no where in the world from which we are remote and no one from whom we are disconnected. http://www.youtube.com/watch?v=g1l4gua8ary

Main Shipping Routes in the Eastern Pacific: 1936 World Waterways Network: 2008

World container ship traffic has doubled since 1997 Weather-Watch Ships at Sea: Tuesday, February 12, 2008, 1:00 PM (ships participating in a voluntary global weather watch system, of 40,000 ships at sea today)

Examples of emerging infections

Cultural Practices

Photo by Pat Walker MD, DTM & H

Photo Stacene Maroushek

Photo by Robert Levin, MD

Photo Stacene Maroushek

Providers in the 21 st century must be: Culturally competent Knowledgeable Ethnic differences in disease patterns. How geography plays a role Have you traveled? Where were you born? Have the basic attitudes, skills, and abilities to care for migrant populations.

In the future, human rights will be increasingly a universal criterion for designing ethical systems --Mahnaz Afkhami Global Health Program: www.globalhealth.umn.edu Monthly Tropical and Travel Medicine Seminar: stauf005@umn.edu