Metro Refugee Health Task Force

Metro Refugee Health Task Force Refugee Health Program Update Kailey Nelson, MPH Epidemiologist, MDH Blain Mamo, MPH Interim Refugee Health Coordinator, MDH Laura Doggett, MPH Refugee Outreach Coordinator, MDH September 3, 2013 Refugee Health Program, Minnesota Department of Health

Background

Dept. of Homeland Security 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 Refugee Health Program, Minnesota Department of Health

Who is a refugee? Foreign-born resident who: is not a United States citizen cannot return to his or her country of origin because of a well-founded fear of persecution due to race, religion, nationality, political opinion, or membership in a particular social group Refugee status is generally given: prior to entering the United States by the State Department or U.S Citizenship and Immigration Services (USCIS) Refugee Health Program, Minnesota Department of Health

Who is an asylee? Foreign-born resident who: is not a United States citizen cannot return to his or her country of origin because of a well-founded fear of persecution due to race, religion, nationality, political opinion, or membership in a particular social group Asylee status is generally given: after entering the United States by the State Department or U.S. Citizenship and Immigration and Services (USCIS) 6/20/00

Worldwide Statistics, 2012 Total forcibly displaced Total internally displaced persons Total refugees New refugee and asylum seekers 45.2 million 28.8 million 15.4 million 1.1 million Total resettled 88,600 UNHCR Global Trends 2012, United Nations Higher Commissioner for Refugees

Principal Sources of Refugees 2012 1. Afghanistan 2,585,600 2. Somalia 1,136,100 3. Iraq 746,400 4. Syria 728,500 5. Sudan 569,200 6. Dem. Rep of Congo 509,400 7. Myanmar (Burma) 415,300 8. Colombia 394,100 9. Vietnam 336,900 10. Eritrea 285,100 Source: UNHCR Global Trends 2012, United Nations Higher Commissioner for Refugees

Main Countries of Refugee Resettlement, 2012 1. United States 66,289 2. Canada 9,624 3. Australia 5,937 4. Sweden 1,873 5. Norway 1,228 6. United Kingdom 1,039 7. New Zealand 781 8. Finland 731 9. Denmark 476 10. All Others* 600 Total N=88,578 *Includes the Germany, Spain, France, Brazil, Ireland, Portugal, Philippines, Iceland, Uruguay, Argentina, Chile, Hungary, and Liechtenstein Source: UNHCR Global Trends 2012, United Nations Higher Commissioner for Refugees

Top U.S. States for Refugee* Resettlement FY 2012 1. Texas 5,907 2. California 5,183 3. Michigan 3,600 4. New York 3,528 5. Pennsylvania 2,813 6. Georgia 2,516 7. Florida 2,249 8. Ohio 2,246 9. Arizona 2,242 10. Washington 2,161 13. Minnesota 1,733 Total admitted 58,236 * Numbers include Amerasian, Asylees (Derivatives), Entrants/Parolees and Primary Refugee arrivals Source: U.S. Office of Refugee Resettlement

Minnesota Refugee Arrivals 2012

Top 6 MN Counties of Primary Refugee Resettlement 2012 1. Ramsey 1,196 2. Hennepin 559 3. Stearns 118 4. Olmsted 95 5. Anoka 69 6. Clay 38 7. Total 2,264 Refugee Health Program, Minnesota Department of Health

Kittson Marshall Roseau Lake of the Woods Koochiching 2012 Primary Refugee Arrivals To Minnesota (N=2,264) Beltrami St. Louis Polk Pennington Cook Red Lake Clear Water Itasca Lake Norman Mahnomen Hubbard Cass Clay Becker Aitkin Wilkin Ottertail Grant Douglas Wadena Todd Morrison Crow Wing Mille Lacs Kanabec Carlton Pine Number of Refugee Arrivals By Initial County Of Resettlement 0 Traverse Big Stone Chippewa Lac Qui Parle Yellow Medicine Lincoln Stevens Swift Lyon Pope Renville Redwood Stearns Kandiyohi Brown Meeker Sibley McLeod Nicollet Benton Wright Sherburne Carver Le Sueur Scott Isanti Hennepin Anoka 71 Rice Ramsey Dakota Chisago Washington Goodhue Wabasha 1-10 11-30 31-50 51-100 101 500 501-1,500 Pipestone Murray Cottonwood Watonwan Blue Earth Waseca Steele Dodge Olmsted Winona Rock Nobles Jackson Martin Faribault Freeborn Mower Fillmore Houston

Refugee Arrivals to MN by Region of World 1979-2012 Number of arrivals 8000 7000 6000 5000 4000 3000 2000 1000 0 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Southeast Asia Sub-Saharan Africa Eastern Europe FSU Middle East/North Africa Other Refugee Health Program, Minnesota Department of Health

Primary Refugee Arrivals, Minnesota 2012 Refugee Health Program, Minnesota Department of Health N=2,264 Other includes Belarus, Cameroon, China, DR Congo, Cuba, Eritrea, Guatemala, Indonesia, Iran, Ivory Coast, Kenya, Laos/Hmong, Liberia, Mexico, Moldova, Nepal, Russia, Sudan, Tanzania, and Ukraine

Country of Origin by County of Resettlement, 2012 900 400 800 700 300 600 Burma Somalia Somalia Ethiopia 500 200 Bhutan Bhutan 400 Ethiopia Iraq 300 200 Iraq Other 100 Other 100 0 0 Hennepin Ramsey N=1,195 N=558 120 40 100 80 60 40 20 Somalia Iraq 30 20 10 Somalia Iraq Bhutan Burma Sudan 0 Stearns 0 N=118 Olmsted N=95 Refugee Health Program, Minnesota Department of Health

Primary Refugee Arrival by Month, Minnesota, 2005-2012 Number of Arrivals 2000 1800 1600 1400 1200 1000 800 600 400 200 0 Jan Feb Mar Apr May Jun Jul Month 2005 2006 2007 2008 2009 2010 2011 2012 Refugee Health Program, Minnesota Department of Health Aug Sep Oct Nov Dec

Minnesota Refugee Health Assessment 2012

Refugee Health Screening in MN Exam w/in the first 90 days of arrival Public health clinics and private providers Goal:...to control communicable disease among, and resulting from, the arrival of new refugees through: health assessment treatment referral

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

Refugee Health Assessment Pink Form

Primary Refugee Arrivals Screened Minnesota, 2002-2012* 8000 7000 7351 7009 6801 Number of Arrivals 6000 5000 4000 3000 2000 1000 1032 963 890 2403 2242 2118 94% 97% 5326 5355 5108 4990 4893 4710 98% 98% 92% 99% 97% 2867 2740 2320 2264 2697 2241 1891 2201 2220 1839 2075 1205 2867 98% 1827 1200 1167 1152 1169 99% 99% 94% 0 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Arrivals Eligible for Screening *Ineligible if moved out of state or to an unknown destination, unable to locate or died before screening Screened *2012 data are preliminary Refugee Health Program, Minnesota Department of Health

Health Status of New Refugees, Minnesota, 2012* Health status upon arrival No of refugees No(%) with infection screened among screened TB infection** 2,033 (98%) 452 (22%) Hepatitis B infection*** 2,057 (99%) 115 (6%) Parasitic Infection**** 2,002 (96%) 264 (13%) Sexually Transmitted 1,992 (96%) 25 (1%) Infections (STIs)***** Malaria Infection 114 (5%) 2 (2%) Lead****** 751 (94%) 10 (1%) Hemoglobin 2,048 (99%) 424 (21%) Total screened: N=2,075 (94% of 2,201 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 ****** Children <17 years old (N=800 RHAs) Refugee Health Program, Minnesota Department of Health

Refugee Health Program, Minnesota Department of Health Tuberculosis Infection* Among Refugees By Region Of Origin, Minnesota, 2012 N=2,033 screened Overall TB Infection 452/2,033 22% Sub-Saharan Africa 265/899 29% SE/East Asia 162/918 18% Latin America/Caribbean 0/4 0% North Africa/Middle East 22/168 13% Europe 3/44 7% 0% 10% 20% 30% 40% 50% *Diagnosis of Latent TB infection (N=445) or Suspect/Active TB disease (N=7); Data are preliminary

Intestinal Parasitic Infection* Among Refugees by Region of Origin, Minnesota, 2012 N=2,002 screened Overall Parasitic Infection Rate Sub-Saharan Africa 264/2,002 99/896 11% 13% SE/East Asia 148/928 16% Latin America/Caribbean 0/4 0% North Africa/Middle East 16/130 12% Europe 1/44 2% 0% 5% 10% 15% 20% 25% 30% * At least one stool parasite found (including nonpathogenic); Data are preliminary

Hepatitis B* infection Among Refugees by Region of Origin, Minnesota, 2012 N=2,057 screened Overall Hepatitis B Infection Rate Sub-Saharan Africa 7% 8% 115/2,057 48/908 SE/East Asia 8% 66/932 Latin America/Caribbean 0% 0/4 North Africa/Middle East 1% 1/169 Europe 0% 0/44 * +HBsAg; Data are preliminary Refugee Health Program, Minnesota Department of Health 0% 5% 10% 15% 20%

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

Refugee Arrivals 2013* *1/1/2012 8/15/2012

Primary Refugee Arrivals, Minnesota 1/1/2013-8/15/2013* Bhutan, 88 (6%) Ethiopia, 35 (2%) All Others, 69 (5%) Iraq, 90 (6%) Burma, 610 (42%) N=1,459 Somalia, 567 (39%) Other includes Afghanistan, Belarus, Cambodia, Cameroon, China, Congo, Cuba, Eritrea, Kenya, Liberia, Mexico, Moldova, Sudan, Ukraine, and Vietnam *Data are preliminary Refugee Health Program, Minnesota Department of Health

Top 6 MN Counties of Primary Refugee Resettlement 2013* 1. Ramsey 787 2. Hennepin 277 3. Stearns 135 4. Olmsted 74 5. Anoka 61 6. All Others 125 Total 1,459 *1/1/2013-8/15/2013 Data are preliminary Refugee Health Program, Minnesota Department of Health

Country of Origin by County of Resettlement, 2013* 500 450 400 350 300 250 200 150 100 50 0 Ramsey N=787 Burma Somalia Bhutan Other 200 180 160 140 120 100 80 60 40 20 0 Hennepin Somalia Bhutan Iraq Ethiopia Other N=277 80 40 60 40 20 Somalia Iraq Other 30 20 10 Somalia Iraq Ethiopia Burma Sudan Eritrea 0 0 Stearns N=135 Olmsted N=74 *1/1/2012-8/15/2013; Data are preliminary Refugee Health Program, Minnesota Department of Health

Health Status of New Refugees, Minnesota, 2013* Health status upon arrival No of refugees No(%) with infection screened among screened TB infection** 479 (90%) 82 (17%) Hepatitis B infection*** 528 (99%) 30 (6%) Parasitic Infection**** 512 (97%) 41 (8%) Sexually Transmitted 430 (67%) 1 (<1%) Infections (STIs)***** Malaria Infection 26 (5%) 0 (0%) Lead****** 190 (92%) 0 (0%) Hemoglobin 527 (99%) 105 (20%) Total screened: N=530 (47% of 1130 eligible refugees) * For refugees arriving into the US from 1/1/2013 through 6/30/2013 (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 ****** Children <17 years old (N=207 RHAs) Refugee Health Program, Minnesota Department of Health

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 Arrivals to Minnesota 2012 Jan - Aug 2013 Total notifications: 312 Total notifications: 350

Secondary Refugee Arrivals to Minnesota 2012 Jan - Aug 2013 Total notifications: 312 Total notifications: 350 Outcome No. (%) Screened in MN 123 (39%) Completed screening in primary state Completed screening in primary state, needs f/u 139 (45%) 7 (2%) Not screened/pending 43 (14%) Outcome No. (%) Screened in MN 129 (37%) Completed screening in primary state Completed screening in primary state, needs f/u 76 (22%) 5 (1%) Not screened/pending 140 (40%)

Refugee Program Initiatives and Projects 2013

CDC Hepatitis B Linkage to Care Project

Hepatitis B Linkage to Care Funded by CDC beginning October 2012; renewed for an additional year, through September 2014 Goal: Enhance hepatitis B testing, follow-up, and linkage to care for newly arrived primary and secondary refugees in Hennepin and Ramsey Counties Key Objectives: 100% of HBV screening results for new refugees reported to RHP. At least 90% of HBV+ refugees referred to care and 75% present for care

Hepatitis B Linkage to Care Linkage to Care Outcomes Refugees for whom HBV screening results have been reported to RHP since October 2012 959 Newly identified HBV-positive individuals 77 (8%) Successfully linked to care (attended follow-up) 56 Linkage to care in progress 16 Lost to follow-up 5

Hepatitis B Linkage to Care Paw s Success Stories: A middle-aged female patient was referred by screening clinic to GI specialist. Despite transportation assistance, she missed appointment. Clinic reported that she was confused about process. Paw called her, provided education, arranged taxi. Patient has attended two follow-up appointments and calls Paw to check in about next steps. A young man had missed his specialist appointment. When Paw called, he said he didn t think follow-up care was important. She provided education, and he attended the appointment she made for him.

Refugees with Acute or Chronic Health Conditions Complex Cases

Complex Cases Increased number of medically complex cases arriving nationally and in MN Resettlement workers are not familiar with medical terminology, impact of disease, or health-related resources Resettlement workers are not given extra time or $$ for taking on cases with high needs for medical case management

Complex Case Criteria Arrival with medical issues beyond scope of routine health screening Need expedited access to health services On medications for condition Severe or multiple conditions Pregnant Need to assure connection and follow through with health-related services in order to resettle successfully

Data entry to score, write care plans, monitor & update cases, and to provide summary data Complex Case Process Referral by resettlement agency or MDH MDH RHP program mgr. or nurse reviews & scores each case based on complexity & urgency of needs MSW coordinates the development of care plan Consider unique needs of each case, and routine process in expedited way for appropriate referrals MSW meets with resettlement case management staff who implement care plans

Complex Cases 2012 Health Condition n % Avg # Objectives Avg # Days Care Plan Open Avg Level of Severity % Completed Plan Cardiology/HTN 45 28% 3.7 76.1 2.4 89% Pregnancy 25 15% 5.2 73.1 1.9 100% Mental Health 20 12% 6.2 80.8 2.6 90% Developmental Delay 14 9% 7.8 99.4 3.7 93% Seizure Disorder 12 7% 6.5 89.7 3.2 100% Asthma 11 7% 3.9 78.9 2.6 82% Physical Disability 11 7% 6.4 104.1 3.4 82% Diabetes 10 6% 4.4 84.8 2.5 80% Other 69 43% 6.1 73.3 2.5 97% Total 162 100% 6.1 76.3 2.5 93% Includes alcoholism, hematology, OBGYN, ENT, cancer, dental, kidney, migraines, malnutrition, gastroenterology, vision, hearing, infectious disease, COPD, thyroid Sum of health conditions > total due to multiple conditions per case (30% of cases had more than one condition) Note: 264 complex case referred in 2012; 102 determined to be ineligible

Complex Case - Best Practices Pre-arrival arrangements Refer early; equipment at airport; make appointments Documentation / Communication Determine eligibility; create care plan; weekly updates; calls & emails ongoing; case completion Assure medication supply upon arrival Determine # of meds and supply Expedite health screening or primary care visit Expedite MA Apply within 3 days, request rush Release of information for MDH Complete day after arrival at VOLAG initial meeting

Complex Case - Best Practices cont d Establish Primary care Every complex case - link to ongoing care PMAP compatible with primary care Deliberate choice avoid the default Access Emergency Services Communicate w/ primary care Assure other specialty/specific referrals adaptive equipment, cognitive or physical assessment, county services, mental health, PCA or home nursing, specialist, surgery Achieve independent access to care Ability to access primary & urgent care and refill prescriptions independent of VOLAG

Case Study - 2 members of the same family 40 year old man - unspecified mental retardation dependent on others for daily needs 58 year old woman - deaf, mute, developmental delays, incontinence, cardiomegaly - need full-time care giver US ties are a nephew and his wife, who will be responsible for clients care Notified pre-arrival & scheduled appointments for diagnostic assessments; to occur approximately 1 mo. after arrival Release of information enabled diagnostic assessments to go directly to Ramsey Co. adult disability coordinator who referred for home nursing and PCA assessment. The nephew and his wife now work as PCAs, and clients have a county disability case manager Expedited screening and primary care appointments arranged by VOLAG case manager & local public health to quickly address health & medical equipment needs & additional referrals to specialists PMAP enrollment form to change plan sent to Co. from VOLAG there was a delay in appointments 2 nd mo. post-arrival due to PMAP plan default incompatible with clinic VOLAG linked family to legal services to establish guardianship for these clients

Refugee Health Program Community Outreach

Refugee Health Directories

Highlights RHP projects and events Refugee Health Data Update Provider Update LPH/VOLAG Spotlight Community Outreach Update Community Spotlight Upcoming Events Over 500 subscribers from around the world! Refugee Health Quarterly

Diverse Media Project Refugee Health Program 2013

Diverse Media Project PURPOSE: To provide information about immunizations to diverse communities through local media PROGRAMS: Refugee Health, Immunizations and Immunizations, Tuberculosis and International Health (ITIH) Communications OUTCOME: Health messages include an advertisement (image, text and a call to action) and an article about the particular topic or a public service announcement (PSA) for radio programming

Diverse Media Project AUDIENCES: African American, Cambodian, Ethiopian (Amharic and Oromo), Filipino, Hmong, Latino (Spanish), Liberian (and other West African communities), Native American, Somali, and Vietnamese. KEY MESSAGES: Flu, measles/international travel, childhood immunizations, adolescent immunizations, hepatitis, pertussis/tdap, and adult immunizations CURRENT TIMELINE: August 15, 2013- June 30, 2014 Previous Timeline(s): July15, 2012 June 30, 2013; January 1, 2012- June 30, 2012 (pilot phase)

Diverse Media Project International Travel, Amharic, 2013 Infant Immunizations, 2013

Diverse Media Project Hepatitis B, Hmong, 2013

Diverse Media Project Flu, Somali, 2012-2014 Pertussis, Spanish, 2012

Community Health Education Project PURPOSE: To develop and deliver health education to refugee communities focused on infectious diseases, chronic/acute diseases and preventive health while increasing community capacity to conduct health education programs and strengthening partnerships with the Minnesota Department of Health (MDH).

CHE Project

CHE Project Formats could include: presentations, radio or TV shows, health fair, articles

Health Orientation Project Assess current health orientation at resettlement agencies, clinics and local public health Transportation Health Insurance Medication Interpreters Primary Care Emergency Care Urgent Care

Health Orientation Project Health Orientation Workgroup Collaboration of resettlement agencies, clinics and local public health Adapt/develop toolkit to ensure standard and comprehensive health orientation Ensure orientation is implemented and evaluated

Minnesota Refugee Health Program Phone: 651-201-5414 or 1-877-676-5414 Web site: www.health.state.mn.us/refugee Address: Minnesota Department of Health Refugee Health Program 625 Robert St N PO Box 64975 St. Paul, MN 55164-0975 Refugee Health Program, Minnesota Department of Health