Minnesota Department of Health

Minnesota Department of Health

The Refugee Act of 1980 The Refugee Act of 1980 created The Federal Refugee Resettlement Program [Office of Refugee Resettlement at Dept of Human and Health Services] to provide for the effective resettlement of refugees and to assist them to achieve economic self-sufficiency as quickly as possible after arrival in the United States. Availed funds for medical screening and initial medical treatment under subsection (b)(5), (ii) for services for refugees under subsection (c)(1)

Infectious Disease Epidemiology, Prevention and Control

Refugee and International Health Program Staff International Health Coordinator LEP Communications Planner International Health Planner Student Workers (x3) Interns (x2) Refugee Health Coordinator Refugee Health Nurse Consultant Refugee Health Systems Coordinator (MSW) Refugee Health Epidemiologist

Refugee and International Health Program Vision Optimal health for refugees and immigrants achieved through innovative leadership and strong partnerships

Mission Statements Refugee Health Program International Health Program Promote and enhance the health and wellbeing of refugees Advance effective community health practices with refugees, immigrants, and LEP persons

Refugee and International Health Program Guiding Principles Community Engagement: Working collaboratively with our communities on issues affecting their well-being Empowering Partnerships: Strengthening and maintaining relationships with key partners over time through mutually beneficial capacity-building Data-informed Action: Analyzing and acting on health surveillance data and data gathered from our communities to effect positive change for the people we serve Cultural and Linguistic Best Practices: Ensuring that our messaging and programming are culturally reflective and linguistically appropriate Health Equity: Achieving the conditions in which all people have the opportunity to attain their highest possible level of health

Minnesota Refugee & International Health Program Functions Coordinate health screenings for refugees Analyze data, summarize and share results Research studies Identify health disparities Develop health education programs & materials Train health professionals Strengthen partnerships

U.S. Government Definitions U.S.A. U.S. Citizen Non-Citizen (Foreign-born) Immigrant Non-Immigrant LPR LTR authorized employment undocumented individual student visitor on business tourist Persons fleeing from persecution refugee asylee Parolee/ entrant victim of trafficking Refugee Health Program, Minnesota Department of Health

Refugee Admissions Ceilings for FY2015 Latin America/Cari bbean, 4,000 Europe and Central Asia, 1,000 Unallocated, 2,000 Near East/South Asia, 33,000 YEAR REFUGEE ADMISSIONS CEILING FY TOTAL ADMITTED INTO U.S. 2002 36,500 27,119 2003 70,000 28,423 2004 70,000 52,873 2005 70,000 53,813 East Asia, 13,000 2006 70,000 41,279 2007 70,000 48,282 2008 80,000 60,191 Africa, 17,000 2009 80,000 74,654 2010 80,000 73,311 2011 80,000 56,424 2012 76,000 58,236 Source: US Department of State Ceiling: 70,000 2013 70,000 69,930 2014 70,000 69,987 2015 70,000 51,530

Top U.S. States for Refugee* Resettlement FY 2014 1. Texas 7,210 2. California 6,111 3. New York 4,079 4. Michigan 4,006 5. Florida 3,519 6. Arizona 2,964 7. Ohio 2,811 8. Pennsylvania 2,743 9. Georgia 2,694 10. Illinois 2,578 13. Minnesota 2,232 Total admitted 69,987 * Numbers include Amerasian, Asylees (Derivatives), Entrants/Parolees and Primary Refugee arrivals Source: Refugee Processing Center/WRAPS

Refugee Arrivals to MN by Region of World 1979-2014 Number of arrivals 8000 7000 6000 5000 4000 3000 2000 1000 0 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 2005 2007 2009 2011 2013 Southeast Asia Sub-Saharan Africa Eastern Europe FSU Middle East/North Africa Other Refugee Health Program, Minnesota Department of Health

Types of Medical Exams Overseas Visa Medical Examination United States Public Health Service Domestic Refugee Health Assessment Minnesota Department of Health Adjustment of Status Medical Examination from temporary to permanent resident needed to obtain a green card Immigration and Naturalization Services Refugee Health Program, Minnesota Department of Health

Refugee Benefits Health screening exam within 90 days of arrival Almost all newly arrived refugees are eligible for Refugee Medical Assistance Mandated 3 months of casework through assigned resettlement agency; each family has a case manager Time-limited public cash benefits distributed through the resettlement agency; must comply with work participation expectations Refugee Health Program, Minnesota Department of Health

Refugee Health Partners County Services VOLAGs Health Care Provider MDH Local Health Dept. 5/2010

Outline of Exam Components Health History Physical Exam Immunization review and update TB screening Hep B screening Screening for Intestinal Parasites CBC with differential Lead Screening STI risk assessment and screening per provider discretion Assessment for Dental, Vision, WIC etc.

Refugee Health Assessment Information Flow Quarantine Station/CDC/EDN Local Health Dept. Screens Forwards to primary provider Primary provider screens Screening form completed & returned Refugee Health Program, Minnesota Department of Health

What is eshare? web-based application developed for collecting demographic and domestic health screening results to conduct disease surveillance. - secure, remote data entry - summary reporting tool

Minnesota Refugee Health Data and Statistics 2014

Number of arrivals Refugee Arrivals to MN by Region of World 1979-2014 8000 7000 6000 5000 4000 3000 2000 1000 0 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 2005 2007 2009 2011 2013 Southeast Asia Sub-Saharan Africa Eastern Europe FSU Middle East/North Africa Other Refugee Health Program, Minnesota Department of Health

Primary Refugee Arrivals, Minnesota 2014 Ethiopia, 70 (3%) Bhutan, 77 (3%) All Others*, 172 (7%) Iraq, 191 (8%) N=2,475 Burma, 838 (34%) Somalia, 1127 (45%) Other includes Afghanistan, Belarus, Cambodia, Cameroon, Cuba, DR Congo, Ecuador, El Salvador, Eritrea, the Gambia, Honduras, Iran, Kenya, Liberia, Moldova, Nepal, Russia, Rwanda, Sierra Leone, Sri Lanka, Sudan, Tanzania, Ukraine, and West Bank Refugee Health Program, Minnesota Department of Health

Kittson Marshall Roseau Lake of the Woods Koochiching 2014 Primary Refugee Arrival To Minnesota (N=2,475) Beltrami St. Louis Polk Pennington Cook Red Lake Clear Water Itasca Lake Norman Mahnomen Hubbard Cass Clay Becker Aitkin Wilkin Otter Tail Grant Douglas Wadena Todd Morrison Crow Wing Mille Lacs Kanabec Carlton Pine Number of Refugees Arrival By Initial County Of Resettlement 0 Traverse Big Stone Lac Qui Parle Yellow Medicine Lincoln Stevens Swift Lyon Pope Chippewa Renville Redwood Stearns Kandiyohi Brown Meeker Sibley McLeod Nicollet Benton Wright Sherburne Carver Le Sueur 71 Anoka Washing- Hennepin Ram-tosey Scott Isanti Rice Dakota Chisago Goodhue Wabasha 1-10 11-30 31-100 101-250 251 500 501 1,500 Pipestone Murray Cottonwood Watonwan Blue Earth Waseca Steele Dodge Olmsted Winona Rock Nobles Jackson Martin Faribault Freeborn Mower Fillmore Houston

Top MN Counties of Primary Refugee Resettlement 2014 1. Ramsey 1,277 2. Hennepin 455 3. Stearns 275 4. Anoka 155 5. Olmsted 136 6. All Others 177 Total 2,475 Refugee Health Program, Minnesota Department of Health

Country of Origin by County of Resettlement, 2014 900 800 700 600 500 400 300 200 100 0 Ramsey N=1,277 Burma Somalia Bhutan Iraq Ethiopia Other 400 300 200 100 0 Hennepin N=455 Somalia Iraq Bhutan Ethiopia Other 100 250 200 150 100 50 Somalia Iraq Kenya 80 60 40 20 Iraq Somalia Afghanistan Other 0 Stearns 0 N=275 Anoka N=155 Refugee Health Program, Minnesota Department of Health

Primary Refugee Arrivals Screened Minnesota, 2003-2014* 8000 7000 7351 7009 6801 Number of Arrivals 6000 5000 4000 3000 2000 1000 0 2403 2242 2118 94% 5326 5355 5108 4893 4990 4710 97% 98% 98% 2867 2740 2259 2141 2320 2475 2697 1893 2200 2109 2241 24282410 2220 1845 2172 2082 1265 1830 98% 1205 1167 1200 1152 1169 99%* 99% 99% 99% 97% 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014* 99% 99% Arrivals Eligible for Screening Screened *Ineligible if moved out of state or to an unknown destination, unable to locate or died before screening Refugee Health Program, Minnesota Department of Health *2014 data are preliminary

Primary Refugees Reasons for No Screening, Minnesota, 2014 Contact Failed, 7% Screened Elsewhere, No Results, 2% Pending, 2% Refused Screening, 5% Unable to Locate, Incorrect Address*, 50% Moved Out of State*, 34% *Ineligible for the refugee health assessment Refugee Health Program, Minnesota Department of Health N=56 *Counted as ineligible for screening

Refugee Screening Rates by Exam Type Minnesota, 2014* Health Screening Rate Tuberculosis (TB) Hepatitis B Intestinal Parasites Lead (<17 yrs old) STIs** 99% 96% 98% 91% 97% 98% 2,419/2,428 2,332/2,419 2,378/2,419 2,212/2,419 1,000/1,036 2,363/2,419 Malaria 9% 206/2,419 0% 20% 40% 60% 80% 100% Refugee Health Program, Minnesota Department of Health *Some screening results pending **Screened for at least one type of STI

Health Status of New Refugees, Minnesota 2014* Health status upon No of refugees No (%) with arrival screened infection TB infection** 2,332 (96%) 484 (21%) Hepatitis B infection*** 2,378 (98%) 123 (5%) Parasitic Infection**** 2,212 (91%) 331 (15%) Sexually Transmitted 2,363 (98%) 19 (1%) Infections (STIs)***** Malaria Infection 206 (9%) 0 (0%) Lead****** 1,000 (97%) 71 (7%) Hemoglobin 2,354 (98%) 502 (21%) *Total screened: N=2,419 (>99% of 2,428 eligible refugees); data are preliminary ** Persons with LTBI (>= 10mm induration or IGRA+, normal CXR) or suspect/active TB disease *** Positive for Hepatitis B surface antigen (HBsAg) **** Positive for at least one intestinal parasite infection ***** Positive for at least one STI (tested for syphilis, HIV, chlamydia or gonorrhea) ****** Children <17 years old (N=1,036 screened); lead level 5 µg/dl Refugee Health Program, Minnesota Department of Health

Health Status of New Refugees, Minnesota Immunization Status, 2002 2014* % with Evidence of Immunizations 100 90 80 70 60 50 40 30 20 10 0 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014* Overseas Domestic Year Refugee Health Program, Minnesota Department of Health Refugee Health Program, Minnesota Department of Health *2014 data are preliminary

Primary Refugee Arrivals, Minnesota Jan June 2015 Afghanistan, 23 (3%) Ukraine, 19 (2%) All Others*, 82 (8%) Ethiopia, 28 (3%) N=990 Iraq, 52 (5%) Burma, 310 (31%) Somalia, 476 (48%) Other includes Belarus, Bhutan, Congo, DR Congo, Eritrea, Ethiopia, Iran, Liberia, Mexico, Moldova, Russia, Sudan, Syria, and Vietnam Refugee Health Program, Minnesota Department of Health

Kittson Marshall Roseau Lake of the Woods Koochiching Jan-June 2015 Primary Refugee Arrival To Minnesota (N=990) Beltrami St. Louis Polk Pennington Cook Red Lake Clear Water Itasca Lake Norman Mahnomen Hubbard Cass Clay Becker Aitkin Wilkin Otter Tail Grant Douglas Wadena Todd Morrison Crow Wing Mille Lacs Kanabec Carlton Pine Number of Refugees Arrival By Initial County Of Resettlement 0 Traverse Big Stone Lac Qui Parle Yellow Medicine Lincoln Stevens Swift Lyon Pope Chippewa Renville Redwood Stearns Kandiyohi Brown Meeker Sibley McLeod Nicollet Benton Wright Sherburne Carver Le Sueur 71 Anoka Washing- Hennepin Ram-tosey Scott Isanti Rice Dakota Chisago Goodhue Wabasha 1-10 11-20 31-40 41-100 101 300 301 500 Pipestone Murray Cottonwood Watonwan Blue Earth Waseca Steele Dodge Olmsted Winona Rock Nobles Jackson Martin Faribault Freeborn Mower Fillmore Houston

Languages* Used by Primary Refugee Arrivals to Minnesota, January 2004-June 2013 N=24,344 *Language used during the domestic refugee health assessment, which generally occurs within 90 days of US arrival. Language is only available for refugees wh a refugee health assessment and used an interpreter. **Other includes Acholi, Afar, Anuak, Bali, Bari, Bassan, Bhutanese, Burmese, Chin, Chinese, Dinka, Farsi, French, Fula, Ghanaian, Gio, Gola, Haitian Creole, I Italian, Karenni, Kayah, Khmer, Kono, Krahn, Kuranko, Kurdish, Liberian, Madi, Mandinka, Mandino, Mano, Mende, Moldova, Mon, Nepali, Nuer, Oromo, Pashto Russian, Sarpo, Sign Language, Spanish, Sudanese, Swahili, Thai, Tibetan, Tigre, Tigrigna, Togolese, Ukrainian, and Vietnemese

Secondary Refugees 2014 2015* *Secondary notifications through June 30, 2015. 2015 data are preliminary

Secondary Refugees Who is a secondary refugee? Secondary refugees are individuals who initially settle in a state other than Minnesota but soon migrate to live in Minnesota. This migration can occur within days, weeks, months or a year of a refugee s arrival to the U.S. Who notifies MDH of the arrival of a secondary refugee? MDH is most often notified of a secondary refugee s arrival into Minnesota from Local Public Health or a clinic. However, in some instances, the primary state may notify MDH that the refugee has moved to Minnesota.

Secondary Refugee Work Flow LPH or Clinic Notified of Secondary Refugee Arrival Fax Notification Form to MDH Refugee Health Program (RHP) MDH RHP Requests Overseas Records and Screening History from Primary State Secondary refugee eligible for screening MDH RHP Forwards Overseas Records and Screening History to LPH Secondary refugee ineligible for screening Refugee Health Assessment Completed LPH Faxes/Mails Pink Form to MDH RHP No further assistance required

Secondary Refugee Arrival Notifications to Minnesota, 2014 Iraq, 26 (3%) Burma, 13 (1%) All Others, 13 (2%) N=841 Somalia, 789 (94%)

Kittson Marshall Roseau Lake of the Woods Koochiching 2014 Secondary Refugee Arrival Notifications To Minnesota (N=841) Beltrami St. Louis Polk Pennington Cook Red Lake Clear Water Itasca Lake Norman Mahnomen Hubbard Cass Clay Becker Aitkin Wilkin Otter Tail Grant Douglas Wadena Todd Morrison Crow Wing Mille Lacs Kanabec Carlton Pine Number of Refugees Arrival By Initial County Of Resettlement 0 Traverse Big Stone Lac Qui Parle Yellow Medicine Lincoln Stevens Swift Lyon Pope Chippewa Renville Redwood Stearns Kandiyohi Brown Meeker Sibley McLeod Nicollet Benton Wright Sherburne Carver Le Sueur 71 Anoka Washing- Hennepin Ram-tosey Scott Isanti Rice Dakota Chisago Goodhue Wabasha 1-10 11-20 21-40 41-100 101 300 >301 Pipestone Murray Cottonwood Watonwan Blue Earth Waseca Steele Dodge Olmsted Winona Rock Nobles Jackson Martin Faribault Freeborn Mower Fillmore Houston

Secondary Refugee Arrivals to Minnesota 2014 Total notifications: 841 Outcome No. (%) Eligible and Screened in MN Completed screening in primary state Completed screening in primary state, needs LTBI f/u 332 (39%) 320 (38%) 8 (2%) Not screened/pending 181 (22%) Refugee Health Program, Minnesota Department of Health

Secondary Refugee Notifications to MDH by Initial State of Resettlement, 2014 1. Texas 81 (10%) 2. Georgia 73 (9%) 3. New York 71 (8%) 4. Arizona 56 (7%) 5. Connecticut 56 (7%) 6. Missouri 53 (6%) 7. Massachusetts 46 (5%) 8. North Carolina 42 (5%) 9. Colorado 40 (5%) 10. Pennsylvania 35 (4%) 11. All Others 288 (34%) 12. Total 841 (100%) Refugee Health Program, Minnesota Department of Health

Secondary Refugee Arrival Notifications to Minnesota, January to June 2015 Burma, 33 (6%) All Others, 18 (3%) N=581 Somalia, 530 (91%)

Kittson Marshall Roseau Lake of the Woods Koochiching Jan June 2015 Secondary Refugee Arrival Notifications To Minnesota (N=581) Beltrami St. Louis Polk Pennington Cook Red Lake Clear Water Itasca Lake Norman Mahnomen Hubbard Cass Clay Becker Aitkin Wilkin Otter Tail Grant Douglas Wadena Todd Morrison Crow Wing Mille Lacs Kanabec Carlton Pine Number of Refugees Arrival By Initial County Of Resettlement 0 Traverse Big Stone Lac Qui Parle Yellow Medicine Lincoln Stevens Swift Lyon Pope Chippewa Renville Redwood Stearns Kandiyohi Brown Meeker Sibley McLeod Nicollet Benton Wright Sherburne Carver Le Sueur 71 Anoka Washing- Hennepin Ram-tosey Scott Isanti Rice Dakota Chisago Goodhue Wabasha 1-10 11-20 21-40 41-100 101 200 >201 Pipestone Murray Cottonwood Watonwan Blue Earth Waseca Steele Dodge Olmsted Winona Rock Nobles Jackson Martin Faribault Freeborn Mower Fillmore Houston

Medically Complex Cases Increased number of medically complex cases arriving nationally and in MN HTN DM Pregnancy Mental Health Asthma Physical Disability Seizure disorder Developmental Delay Resettlement workers are not familiar with medical terminology or impact of disease Social Work position housed at MDH assists all resettlement agencies with complex cases Program implications Implementing mental health component to routine screening Expanding resources/partners

Complex Cases by Health Condition, 2014 Condition N % Cardiology/HTN 102 24% Blind/Vision 37 9% Mental Health 37 9% Pregnancy 35 8% Asthma 27 6% Diabetes 19 5% Orthopedics 18 4% Deaf/Hearing 17 4% Physical Disability 16 4% Developmental Delay 14 3% Gastroenterology 10 2% Other 90 21% Total 422 100% Includes Infectious disease, kidney, thyroid, hematology, ENT, immunology, pulmonary, migraines, malnutrition, seizure disorder, COPD, OB/GYN Sum of health conditions > total, due to multiple conditions per case (34% of cases had more than one condition; N=100/293)

CURRENT PROJECTS

Health Education: Refugees Community Health Education (CHE) Project Partner with refugee- and immigrant-led community organizations Activities include radio and TV shows, presentations, fairs, etc. Variety of topics covered: HIV, hepatitis B, nutrition, flu, etc. Refugee Health Orientation Standardize messages: resettlement agencies, clinics, community organizations Other Health Education Activities Health curriculum for English language learners Community events: health and resource fairs Hmong Health Care Professionals Coalition Karen Organization of Minnesota Southside Center Adult Education

Diverse Media & Health Promotion RIH works with over 20 diverse media vendors Print, Radio, and Online Vendors often publish an accompanying health article for free when an ad is purchased

Diverse Media Example: Autism Goal: Reach Somali audiences to increase awareness of signs of Autism and why to act early Included: Programs on Somali TV Online ads with video links Print ads with article on Autism

Other Projects Mental Health Screening Piloting addition of screening questions in key clinics Normalize mental health as being part of general health Emergency Network to Reach LEP Populations Building a more robust network of key people connected to LEP communities across MN CDC Projects

Other Projects (cont.) LEP Communications Project Building capacity within and externally Language Data Workgroup MDH LEP Communications Website In Planning phase Will be getting input from a variety of stakeholders Resources: LEP data, Cultural Profiles, Diverse Media examples, Spotlight on Partners What could help your work?

Ayurvedic Medicine Project Several recent cases of lead poisoning in South Asian children residing in MN Sources found to be Ayurvedic medicines/remedies that were either purchased in India or sent from there RIH partnering with: MDH Lead/Healthy Homes South Asian CBOs including AshaUSA and SEWA-AIFW Several Ayurvedic Practitioners Created informational brochure in English and 5 major South Asian Languages Huthasani for eczema Gripe Water

Ayurvedic Medicine Project (cont.) Partnered with AshaUSA to survey the South Asian community for better understanding of use in MN Interviewing and planned messaging for providers Surveyed and discussed Ayurvedic medicine at India Fest, 8/15/2015

Interpreter Registry Project Tasked by MN legislature to: carry out extensive informationgathering with all stakeholders Create report and proposed legislation

Other Initiatives Publications www.health.state.mn.us/refugee Directories, Provider and Partner Information, Material for Refugee Education Annual Forum Metro Refugee Health Task Force Workgroups, collaborations and coalitions Quarterly newsletter

For More Information Website: www.health.state.mn.us/refugee Phone: 651-201-5414 or 1-877-676-5414