Practicing Global Health in the US Immigrant and Refugee Health Care Janine Young, MD, FAAP October 20, 2016
No financial or other relevant disclosures
US News and World Report, 9/11/15
UNHCR, Ethiopia, 2012
Source: CBS News, 7/7/2014
UN definition of refugee 1951 Convention A refugee.is someone who is unable or unwilling to return to their country of origin owing to a well founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group, or political opinion. United Nations High Commissioner for Refugees, http://www.unhcr.org/3b66c2aa10.html
US Annual Refugee Admissions FY 1980 2016 US Dept of State data http://www.migrationpolicy.org/article/refugeesand asylees united states, Accessed 10/13/16
Refugee Admissions 1975 9/30/2016 http://www.wrapsnet.org/reports/admissio Arrivals/tabid/211/Default.aspx, Accessed 10/13/16
Refugee Arrivals by Nationality Fiscal year 2016
Country of origin, refugee arrivals 2013 2015 http://www.migrationpolicy.org/article/refugees and asylees united states, Accessed 10/13/16
US Arrivals, FY2016 85,000 Refugees US State Dept, http://www.pewresearch.org/fact tank/2016/10/05/u sadmits record number of muslim refugees in 2016/, Accessed 10/13/16
110,000 refugees Top 5 Countries of Origin Democratic Republic of the Congo Syria Burma Iraq Somalia US Refugee Arrivals FY 2017 Top 5 U.S. States welcoming refugees California Texas New York Michigan Ohio Colorado projected 2500 Photo: UNHCR, 2006 http://www.state.gov/r/pa/prs/ps/2016/10 /262776.htm, Accessed 10/13/16
US Arrival of Refugees by State FY2006 2015 http://www.state.gov/r/pa/pl/249076.htm, Accessed 4/27/16
Adera is a 6year old who is seeing you for a refugee screening exam 1 month after arrival in the US. Her family is from Somalia but she was born in Hagadera, a refugee camp in Kenya, and has lived there since birth. Photo credit: http://blogs.worldbank.org/voices/category/countries /somalia
http://storymaps.esri.com/stories/2013/refugeecamps/?wt.mc_id=emailcampaignh15201
The Economist, 5/28/16
Refugee Overseas State Department Exam
TST or IGRA 2 14 yrs CXR >15 yrs VDRL >15 yrs, No HIV testing since 2010 PMH checklist PE Minimal vaccines Presumptive treatment for STH, strongyloidiasis, and if from SSA schistosomiasis and p. falciparum malaria Photo credit CDC Domestic Screening Guidelines, 5/30/15
History: Home birth in Somalia DOB: 1/1/2010???, 6 sibs Staple foods: flour, rice, beans, vegetables. No access to milk, meat, eggs No schooling No known health issues, although overseas records state chronic malnutrition and history of malaria. FH: None known
Physical Exam Vital Signs: Wt 15 kg, Ht 103 cm BMI 15, 10 th percentile HR 90, RR 18, BP 80/60 Thin fine hair, yellowish Neck no goiter, no generalized LAN Cor: rrr, vibratory systolic murmur best heard at mid L sternal border, 2+FP Pulm: cta Abd: s ntnd, no HSM Back: wnl
CDC PHIL, Image 4096
CDC PHIL, Image 3756
CDC Public Health Image Library, 6621
CDC PHIL 6900
Physical Exam, Con t You explain that standard of care is to do a headto toe exam, including full skin evaluation as well as a GU exam, yearly, at well child checks and ask the mother and child permission to do so. You explain that normally, no one touches private parts and that you are a physician and are checking to make sure everything is normal. Adera lies down in frog leg position with a drape covering her abdomen. The mother is standing beside her. Findings are
Reproduced, with permission from UW Medicine/Harborview Medical Center for Sexual Assault & Traumatic Stress
Global Prevalence of FGM/C
FGM/C Complications Infection, bleeding, sepsis, death immediate complications Recurrent UTIs/pyelonephritis Cysts Keloids Abscesses Hematocolpos/dysmenorhea Dysfunctional voiding Dyspareunia Complications during/post childbirth increased C section rate, post partum hemorrhage, increased infant resuscitation rates Infertility?HIV, hep B, C? WHO 2006 and Nour N, FGC, Reviews in Obs and Gyn, Vol 1, 3, 2008
What testing do you want to do?
CO Standing Labs at 4 Screening Sites Teens Child 13 mo 12 yrs Infant 0 12 mo TSH, Free T4 (13mo 3 yrs) Newborn screen Cbc/diff Lead IGRA TST (<2 yrs), IGRA (>2 yrs) TST Hep B panel sag, sab,cab Hep C Ab HIV 4 th gen Syphilis EIA If risk factors or mother s results not available Urine GC/Chlam PCR If risk factors Non standing labs Strongyloides IgG Schistosoma IgG (SSA) Malaria thin/thick and MRDT (SSA) O and P x 3
UIC=urinary iodine concentration Lancet Diabetes & Endocrinology Zimmermann, M et al March 31, 2015. Volume 3, Issue 4. Pages 286 295.
Results CBC/diff: hgb 8.0, MCV 56, RDW 25, plts 600, absolute eos 650 TSH: 10 (normal: 0.5 5.0) Free T4: 2.0 (0.5 1.9) Lead: 12 Hep B s Ag, sab, c Ab negative Hep C Ab negative HIV negative QFT negative Syphilis not done (mom negative)
Outcome 1 month follow up: TSH 6, free T4 2 CBC/diff: hgb 10, mcv 65, rdw 18, plts 450, abs eos 500 Lead 9 Weight increased 1 kg, still low height In school kindergarten and learning English
Summary When seeing an immigrant, ask questions! How long have you been in the US? How did you get to the US? (e.g. coyote, direct flight, through many countries, etc) Determine legal status (e.g. refugee, student VISA, asylee, undocumented immigrant) Always consider vertical transmission (no pre natal screening in most resource poor areas of developing countries), newborn screening labs, environmental exposure risks, and infectious diseases endemic to then region when deciding approach to work up
Resources CDC Domestic Refugee Screening Guidelines http://www.cdc.gov/immigrantrefugeehealth/guidelines/domestic/do mestic guidelines.html AAP Immigrant Toolkit https://www.aap.org/en us/about the aap/committees Councils Sections/Council on Community Pediatrics/Pages/Section 1 Clinical Care.aspx?nfstatus=401&nftoken=00000000 0000 0000 0000 000000000000&nfstatusdescription=ERROR%3a+No+local+token CDC Catch up Immunization Schedule https://www.cdc.gov/vaccines/schedules/downloads/child/0 18yrschild combined schedule.pdf#page=3