Refugee Health in Pennsylvania Jun Yang, Ph.D. Epidemiologist and State Refugee Health Coordinator Division of Infectious Disease Epidemiology Bureau of Epidemiology PA Department of Health August 17, 2017 2017 Annual Pennsylvania Refugee Consultation, Harrisburg, PA, August 16-17, 2017
Refugee Health Program (RHP) Charlotte Fry State Refugee Coordinator Jun Yang State Refugee Health Coordinator Shakila Shah Refugee Health Promotion Coordinator Susan Miller Refugee Health Social Worker
Mission of the RHP To ensure that refugees receive a comprehensive health and mental assessment after entry into the U.S. To identify and treat health conditions that could delay successful resettlement
Common Background of Refugees Catastrophic events and displacement Overcrowded living conditions Lack of food Lack of clean water Poor environmental sanitation Lack of health care Insufficient vaccination Unique refugee health challenges
Health Challenges among Refugees Malnutrition: 28% among refugee children Infectious/parasitic conditions Chickenpox outbreaks Splenomegaly among Congolese refugees Mental health issues Higher suicide rates in Bhutanese refugees Common mental health disorders Anxiety, depression, post-traumatic stress disorder, and post-migration difficulties
Health Challenges among Refugees Culture-related conditions Female genital mutilation/cutting >200 million girls and women alive today have had FGM/C in 30 countries in Africa, the Middle East and Asia (WHO data) Travel outside of U.S. to receive FGM/C Domestic violence Chronic conditions
Refugees Health Data Systems CDC Electronic Disease Notification (EDN) Web-based system launched in 2006 and has been deployed to all states Notifies states when immigrants have notifiable conditions or refugees arrive in their jurisdictions Provides medical information recorded on the Department of State form PA eshare Web-based system launched in 2013 and has been used by all contracted clinics Records medical information collected during refugee health screening
Refugees Arrived in PA 4000 3500 Figure 1. Trends of Newly-Arriving Refugees in Pennsylvania, 2009-2016 (N=22,444) 3541 3000 2500 2533 2634 3011 2898 2466 2818 2543 2000 1500 1000 500 0 2009 2010 2011 2012 2013 2014 2015 2016 Year Data source: CDC EDN
Refugees Arrived in PA Figure 2. Ten countries of Origin with Most Newly Arriving Refugees in Pennsylvania, 2009-2012 (n=10,030) 0 1000 2000 3000 4000 5000 Bhutan 4584 Nepal 2008 Iraq Myanmar 1266 1167 Thailand Ethiopia Cuba Sudan Somalia Malaysia 248 204 193 134 118 108 Data source: CDC EDN
Refugees Arrived in PA Figure 3. Ten countries of Origin with Most Newly Arriving Refugees in Pennsylvania, 2013-2016 (n=8,672) 0 500 1000 1500 2000 Bhutan 1736 Nepal Iraq 1207 1269 Myanmar Syria Congo 935 997 995 Somalia 714 Ukraine Ethiopia Cuba 259 243 317 Data source: CDC EDN
Refugees Arrived in PA Top Ten countries, 2009-2012 0 1000 2000 3000 4000 5000 Top Ten countries, 2013-2016 0 500 1000 1500 2000 Bhutan 4584 Bhutan 1736 Nepal 2008 Nepal 1269 Iraq 1266 Iraq 1207 Myanmar 1167 Myanmar 997 Thailand 248 Syria 995 Ethiopia 204 Congo 935 Cuba 193 Somalia 714 Sudan 134 Ukraine 317 Somalia 118 Ethiopia 259 Malaysia 108 Cuba 243 Data source: CDC EDN
Refugees Arrived in PA 70 Figure 4. Percent of Refugees Arriving in PA by Age Group, 2009-2016 60 50 40 <18 30 18-64 >64 20 10 0 2009 2010 2011 2012 2013 2014 2015 2016 Data source: CDC EDN
Refugee Health Conditions - TB 14 12 10 Figure 5. Percent of Any Pre-departure TB Conditions in Refugees Arriving in PA by Year, 2009-2016 (n=2,129, 9.5%) 10.3 12.3 12.1 11.6 8.9 8 7.1 7.6 6.5 6 4 2 0 2009 2010 2011 2012 2013 2014 2015 2016 Data source: CDC EDN
TB Incident in U.S., 2013-2015 Approximately 3 cases per 100,000 persons Among foreign-born persons in U.S.: 15 cases per 100,000
Fiscal Federal Year 2015 2017 Health Screening Statistics 1400 1200 1000 Figure 6. Number of Refugees Screened by Gender, 2015 2017 (n=2519 for 2015 2016; n=2110 for 2016-2017) 1314 1205 1071 1039 800 600 Male Female 400 200 0 Year 2015-2016 Year 2016-2017 Note: For fiscal year 2016 2017, data were pulled for the period of October 1, 2016 July 28, 2017 Data source: PA eshare
Fiscal Federal Year 2015 2017 Health Screening Statistics 20 Figure 7. Percent of Refugees with Parasitic Diseases by Screening, 2015 2017 18 17.2 16 14 12 10 8 6 6.6 4 2 0 Year 2015-2016 Year 2016-2017 Note: For fiscal year 2016 2017, data were pulled for the period of October 1, 2016 July 28, 2017 Data source: PA eshare
Fiscal Federal Year 2015 2017 Health Screening Statistics 60 Figure 8. Percent of Major Referrals after Screening, 2015 2017 51 50 47 47 44 40 PCP 30 Dental Vision 20 10 14 8 10 9 Health Dept Mental 2 2 0 Year 2015-2016 Year 2016-2017 Note: For fiscal year 2016 2017, data were pulled for the period of October 1, 2016 July 28, 2017 Data source: PA eshare
Fiscal Federal Year 2015 2017 Health Screening Statistics 14 Figure 9. Results of Tuberculosis Testing and Subsequent Referral, 2015 2017 12.89 12 10 9.41 8 6 4 QuantiFERON+ 6.02 Skin Test>=10mm 2.78 5.69 5.02 TB Referral 2 0 Year 2015-2016 Year 2016-2017 Note: For fiscal year 2016 2017, data were pulled for the period of October 1, 2016 July 28, 2017 Data source: PA eshare
Strategies to Improve Refugee Health Sufficient funding: federal, state, other sources Conduct epidemiologic studies and surveillance Refugee health surveys Targeted studies Health education Training Increase collaboration
Strategies to Improve Refugee Health Federal Agencies Resettlement Agencies State Agencies Healthcare Providers Community Support Refugees Other Partners
Available Refugee Health Resources in PA Supports families with special medical needs children Provides information on health care resources, respite care, advocacy, assistive technologies Special Kids Network Provides family support in overcoming challenges Provides information about accessible and inclusive recreation and leisure
Available Refugee Health Resources in PA Refugee Health Promotion Grant Training Culturally Competent Health Education and Health Care Serving LGBT Population Mental Health First Aid Training
Questions and Discussion 'tit' pennsylvania., DEPARTMENT OF HUMAN SERVICES 4 Jta pennsylvania DEPARTMENT OF HEALTH
Contact Information Charlotte Fry charfry@pa.gov Jun Yang (717) 787-8608 juyang@pa.gov 717-547-3486 Shakila Shah shshah@pa.gov 717-346-1094 Susan Miller sbowersmil@pa.gov 717-783-3901 http://www.refugeesinpa.org/
4 Jta pennsylvania DEPARTMENT OF HEALTH
4 Jta pennsylvania DEPARTMENT OF HEALTH
Definition of a Refugee Living outside their own country of nationality Unable or unwilling to return to that country because of persecution or a well-founded fear of persecution (based on race, religion, nationality, political opinion or membership in a particular social group)
Health Challenges among Refugees Malnutrition 2012 data 28% among refugee children 10% severe acute malnutrition (five times above the threshold) 44% of children < two years old are malnourished 18% of children < two years old have severe acute malnutrition Data source: https://www.msf.org.za/stories-news/stories-and-news/south-sudan-new-msf-mortalityand-malnutrition-data-point-catastrophic
Health Challenges among Refugees Infectious/Parasitic conditions Chickenpox outbreaks Malaria Splenomegaly among Congolese refugees (under investigation) Mental condition Higher suicide rates among Bhutanese refugees (2013 data) Common mental health disorders Anxiety Depression Post-traumatic stress disorder Post-migration difficulties (e.g., family conflict or unemployment)
Fiscal Federal Year 2015 2017 Health Screening Statistics 2.5 Figure 9. Percent of Tuberculosis Diagnosis by Screening, 2015 2017 2 1.98 1.5 1 0.85 Active TB Latent TB Healed TB 0.5 0 0.12 0.09 0.08 0.05 Year 2015-2016 Year 2016-2017 Note: For fiscal year 2016 2017, data were pulled for the period of October 1, 2016 July 28, 2017 Data source: PA eshare