Migrant Health: Best Practices & Travel Medicine

Transcription

1 Migrant Health: Best Practices & Travel Medicine William Stauffer University of Minnesota CISTM Quebec, Canada May 26, 2015

2 Financial disclosure (Critical Measures: Cultural Health Care Education) If we discuss any off label uses of medications we will disclose to the audience

3 Objectives Important health issues in migrant populations Important screening tests & health interventions to promote migrant health Important opportunities to promote health in the pre-travel setting Hopefully have fun Thanks to Chris Greenaway innovative topic that I struggle with but never thought of as a presentation topic.

4 Humans and mobility Human migration has occurred as long as humans have been on the planet first left Africa ~60 million years ago UK is home to the most diverse community in the world There are at least 1,000 French-born people living in each of 83 different countries The number of immigrants living in Spain grew ~8 fold between The POOREST countries have the LEAST number of emigrants 84% of UAE population is foreign born

5 Humans and mobility More than 200 million people live outside their country of birth 3% of the world s population 5 th most populated country in the world In US: ~13% of population 1st generation FB Estimated 45,790,000 were born outside the US Miami >60%, NYC >30% Almost uniformly most vulnerable and disenfranchised in health systems

6 Migrating Populations, Source: Population Action International 1994

7 Migrating Populations, : 175 million; >4x increase from 1975

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9 Guidelines for migrant health screening United States CDC (refugee & international adoptee) AAP (in process for all migrants & international adoptee) Canada CMAJ Canadian Collaboration for Immigrant and Refugee Health (2011) Australia Refugee UK Migrant Health Assessment Sub-committee of HPSC Scientific Advisory (2015) Europe Call for development

10 Common components History & physical Routine blood & urine testing CBC with diff, renal fxn, pregnancy Tuberculosis Chronic or regulatory infections HIV, syphilis, GC/Chlamydia, hep C Parasitic testing Stool, focus on strongyloides & schistosomiasis Misc (e.g. Toxins, vitamins) Lead, B12 Vaccine recommendations, including testing for active hepatitis B

11 Also disease specific guidelines Common diseases/infections Hepatitis B HIV Hepatitis C TB Lead Chronic non-communicable diseases (e.g. HTN, Diabetes, lipids) Cancers (breast, colon, prostate) Health Prevention Guidelines Vaccination Dental Vision Hearing

12 Why Screen? Public Health and/or Regulatory (not necessarily the same) Patient Centered Care Tenants of Screening

13 How, when and why can pre-travel visit overlap with screening & preventive measures in migrants? Point of Contact: frequently disenfranchised population with limited health care access Travel providers may be more educated and aware of certain diseases, particularly infections, that affect migrants (disease disparity) A travel provider cares about preventing morbidity and mortality and has the opportunity by definition this is an added opportunity

14 Hang with me Case based examples (5 cases) A bit of read my mind & show and tell Please, at the conclusion, question, add or subtract

15 Case #1 33 yo female of Korean descent (adopted age 4 years), traveling to India (Mangalore) for 1 month for wedding (marrying an Indian gentlemen). Past Medical History Had an ASD repaired as a child Seasonal allergies Meds Intranasal steroid prn

16 Case #1 33 yo female of Korean descent (adopted age 4 years), traveling to India (Mangalore) for 1 month for wedding (marrying an Indian gentlemen). Immunizations Tdp UTD Polio UTD HPV completed Hep B UTD MMR UTD Hep A none VZV had chicken pox as child

17 Case #1 33 yo female of Korean descent (adopted age 4 years), traveling to India (Mangalore) for 1 month for wedding (marrying an Indian gentlemen). Where is your opportunity? Immunizations Tdp UTD Polio UTD HPV completed Hep B UTD MMR UTD Hep A none VZV had chicken pox as child

18 Highlight Case 19 y/o Vietnamese male presents to the ED with 2 months wt loss, low grade fevers, swelling of the abdomen. Exam cachectic male with protuberant abdomen and the liver is > 10 cm below the costal margin with multiple palpable, non-tender nodules. In addition there is a fluid wave and he has pitting lower extremity edema.

19 Highlight Case Laboratory WBC: 9 Hgb: 9.8 (MCV 68) Plt.: 130 ESR: 88 ALT: 599 Diagnostic lab test returns Alpha-fetoprotein 889

20 Highlight Case Laboratory WBC: 9 Hgb: 9.8 (MCV 68) Plt.: 130 ESR: 88 ALT: 599 Diagnostic lab test returns Alpha-fetoprotein 589 Alpha-fetoprotein 889

21 19 y.o. Vietnamese male with abdominal pain, increased alpha-fetoprotein The most likely etiology of this hepatocarcinoma is: a. Hepatitis B b. Aflotoxin c. Hepatitis C d. Schistosomiasis

22 19 y.o. Vietnamese male with abdominal pain, increased alpha-fetoprotein The most likely etiology of this hepatocarcinoma is: a. Hepatitis B b. Aflotoxin c. Hepatitis C d. Schistosomiasis

23 Hepatocellular carcinoma 4th most common cause of cancer related deaths in world: 610K/year A vaccine preventable cancer Treatment available Population specific cancer screening

24 Hepatitis B CDC recommends testing for: Individuals born in areas where prevalence of HBsAg is 2%, regardless of immunization status in country of origin US-born persons not immunized during infancy born to parents in regions with prevalence of HBsAg 8% Weinbaum CM et al. MMWR. 2008; 57(RR08);1-20.

25 Geographic distribution of hepatitis B, 2009

26 Hep B ~240 million infected worldwide, 1.2 million in US 15-25% lead to severe liver disease and/or cancer FYI: Asia pacific islanders make up <5% of total US population, account for more than 50% of chronic infections.

27 Hepatitis B infection Among Refugees by Region of Origin, Minnesota, 2013 N=2,050 screened Overall Hepatitis B Infection Rate Sub-Saharan Africa 6% 5% 122/2,050 43/897 SE/East Asia 8% 77/990 Latin America/Caribbean 0% 0/3 North Africa/Middle East 1% 2/152 Europe 0% 0/8 0% 5% 10% 15% 20% Refugee Health Program, Minnesota Department of Health

28 Case #1 33 yo female of Korean descent (adopted age 4 years), traveling to India (Mangalore) for 1 month for wedding (marrying an Indian gentlemen). Where is your opportunity? What do you want to do with her immunizations? Tdp UTD Polio UTD HPV completed Hep B UTD MMR UTD Hep A none VZV had chicken pox as child

29 Case #1 33 yo female of Korean descent (adopted age 4 years), traveling to India (Mangalore) for 1 month for wedding (marrying an Indian gentlemen). Where is your opportunity? What do you want to do with her immunizations? Anti-B surface antibody positive Anti-B core antibody negative Hepatitis B surface antigen positive Hepatitis A antibody positive

30 Case #1 Main Point Always consider hepatitis B infection, even if documented vaccination (but no documented testing)

31 Case #2 58 yo Hmong male traveling to Chang Mai Thailand for 3 weeks to VFR. PMHx Glaucoma Uric acid kidney stones Chronic renal failure, has met with transplant team LTBI (treated with 9 months INH) Meds Aspirin Lisinopril Topical steroids Social History Moved as refugee to US in 1993 Five children, 8 grandchildren

32 Case #2 58 yo Hmong male traveling to Chang Mai Thailand for 3 weeks to VFR. Immunizations Tdp UTD Polio UTD Hep B UTD (neg HBsAg) MMR UTD Hep A immune by serology VZV immune by serology

33 Case #2 58 yo Hmong male traveling to Chang Mai Thailand for 3 weeks to VFR. Where is your opportunity?

34 Highlight Case One week prior 55 year old Hmong m presented with wheezing & SOB. He was placed on prednisone for asthma. Today, presents w/ fever, rash, confusion & abdominal pain. Quickly develops septic shock, E. coli bacteremia & dies. Had moved to Minnesota > 15 years prior from Thailand.

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36 Photo provided by Charles Cartwright, PhD

37 55 y.o. Hmong male with SOB/Wheezing Most likely diagnosis is? a. Urosepsis b. Ruptured viscous c. Strongyloidiasis d. Melioidosis

38 55 y.o. Hmong male with SOB/Wheezing Most likely diagnosis is? a. Urosepsis b. Ruptured viscous c. Strongyloidiasis d. Melioidosis

39 Pt. Age Ethnicity Time in US Outcome 1 42 Cambodia 6 mo Recovery 2 24 Hmong 3 yrs Recovery 3 34 Hmong >5 yr Recovery 4 52 Vietnamese >5yr Recovery 5 46 Hmong 8 yrs Death 6 69 Hmong 4 yrs Death 7 72 Laotian 7 yrs Death 8 49 Vietnamese >5yrs Recovery 9 34 Hmong 4 yrs Death Newberry AM, CHEST 2005;128(5): Newberry AM, CHEST 2005;128(5):

40 Pt. Age Ethnicity Time in US Outcome 1 42 Cambodia 6 mo Recovery 2 24 Hmong 3 yrs Recovery 3 34 Hmong >5 yr Recovery 4 52 Vietnamese >5yr Recovery 5 46 Hmong 8 yrs Death 6 69 Hmong 4 yrs Death 7 72 Laotian 7 yrs Death 8 49 Vietnamese >5yrs Recovery 9 34 Hmong 4 yrs Death Newberry AM, CHEST 2005;128(5): Newberry AM, CHEST 2005;128(5):

41 Strongyloides stercoralis disseminated/hyperinfection Syndrome More than 100 million people infected with strongyloides worldwide. 10 cases of disseminated strongyloides in 7 months in Toronto cases of strongyloides (not disseminated) if not diagnosed at time of arrival mean time to diagnosis was 61 months 2 1 Lim S. CMAJ 2004;171(5): Boulware DR, Stauffer WM et al. Am J Med 2007;120(60):545;e1-8

42 Strongyloides in migrants Strongyloides East Africa 11%, Cambodian 42% (Australia) 1 Lao refugees, 20% positive 12 years after arrival 2 Burmese and Liberian, over 65% seropositive from migrant serum bank 3 1. Caruana SR, et al. J Travel Med. 2006;13: de Silva S, Saykao P, Kelly H, et al. Epidemiol Infect 2002:128(3): Unpublished research data.

43 Case #2 Test vs. presumptively treat Case #2 Main Point Consider strongyloides (do no harm) especially in high risk migrants who have a likelihood of receiving immunosuppression.

44 Case #3 16 yo Somali female brought by uncle to travel to Kenya for 3 months over the summer. PMHx No significant Meds None Social History Family moved to US when she was 4 years of age from Dadaab. Lives with extended family in Little Mogadishu in an apartment with 8 other individuals.

45 Case #3 16 yo Somali female brought by uncle to travel 2 Kenya for 3 months over the summer. Immunizations/Preventive measures All routine immunizations are UTD Had new arrival screening at 4 years of age What opportunity do you see?

46 Case #3 TB screening IGRA positive (CXR negative) Scheduled for latent TB treatment

47 Refugee Health Program, Minnesota Department of Health Tuberculosis Infection* Among Refugees By Region Of Origin, Minnesota, 2013 N=2,033 screened Overall TB Infection 22% 455/2,033 Sub-Saharan Africa 30% 266/886 SE/East Asia 18% 173/986 Latin America/Caribbean 0% 0/3 North Africa/Middle East 9% 14/150 Europe 25% 2/8 0% 10% 20% 30% 40% 50% *Diagnosis of Latent TB infection (N=446) or Suspect/Active TB disease (N=9)

48 Case #3 TB screening IGRA positive (CXR negative) Scheduled for latent TB treatment Red Flag: Wearing headphones, Hijab, says I am not going

49 Red Flag: Guesses? Case #3

50 Case #3 Female Genital Mutilation

51 Case #3 Main Point Pre-travel visit is opportunity to identify those at risk of being infected with TB as well as assessing risk and appropriate follow-up after travel.

52 Case #4 43 yo Congolese female going to Rwanda (outside Kigali) for 9 day trip for funeral leaving in 5 days. PMHx Malaria Meds None Social History Moved to U.S. 2 years ago to join family (through lottery) from Rwanda 4 children, three grandchildren

53 Case #4 43 yo Congolese female going to Rwanda (outside Kigali) for 9 day trip for funeral. Immunizations Tdp had 2 recorded Polio has 2 recorded Hep B none MMR UTD Hep A none VZV no vaccine

54 Case #4 43 yo Congolese female going to Rwanda (outside Kigali) for 9 day trip for funeral. What are your opportunities?

55 Case #4 43 yo Congolese female going to Rwanda (outside Kigali) for 9 day trip for funeral. What are your opportunities? Tetanus, diphtheria, pertussis had 2 recorded Polio has 2 recorded Hep B none MMR UTD Hep A none VZV no vaccine

56 Case #4 43 yo Congolese female going to Rwanda (outside Kigali) for 9 day trip for funeral. What do you want to do with her immunizations? Boost Tetanus, diphtheria, pertussis & polio (could do select serologies) Anti-B surface antibody negative Anti-B core antibody positive Hepatitis B surface antigen negative Hepatitis A antibody positive VZV antibody negative

57 VZV Mean age of developing disease is years in tropical countries (some countries a large percentage of those >35 years are susceptible) Opportunity to vaccinate, especially adolescents 1 1 Greenaway C, et al. Epidemiol infect 2014;142(8):

58 Case #4 43 yo Congolese female going to Rwanda (outside Kigali) for 9 day trip for funeral. Other Opportunities? Hint: in 2010 the US stopped requiring mandatory testing prior to immigration.

59 Case #4 43 yo Congolese female going to Rwanda (outside Kigali) for 9 day trip for funeral. Other Opportunities? HIV antibody positive, confirmed with PCR

60 Case #4 43 yo Congolese female going to Rwanda (outside Kigali) for 9 day trip for funeral. Other Opportunities? HIV antibody positive, confirmed with PCR Rate in Congolese refugees in Rwanda ~3%

61 HIV Screening CDC Basically opt-out, everyone should be tested; annual testing in high risk persons (MMWR Sept 22, 2006;55(14);1-17. Canada Individual requesting S/S of infection Illness associated with weakened immune system or a diagnosis of TB Unprotected intercourse or use of shared drug equipment with a partner whose HIV status is known to be positive Pregnant or planning pragnancy Victims of sexual assualt

62 Case #4 43 yo Congolese female going to Rwanda (outside Kigali) for 9 day trip for funeral. Even More Opportunities?

63 Highlight Case 20 yo Somali female presenting with acute abdominal pain, anorexia & fever <24 hours, no stool No sign PMHx, No Meds Social history: moved from Kenya (refugee) 14 months prior to presentation

64 Highlight Case 20 yo Somali female presenting with acute abdominal pain, anorexia & fever Examination RRQ tenderness with sigs of peritoneal irritation (rebound, positive R leg lift) Laboratory WBC: 18,000 (N88, L11, E1) Hgb 12.4 (MCV nl) CRP 14 (nl<0.9) Abdominal flat plat (decreased air RLQ)

65 Case CT: fat stranding, edema of appendix

66 Case: Abdominal pain, fever

67 Prevalence of Schistosoma among African Refugees, /291 (99.3%) Schistosoma cases identified among sub-saharan Africans Prevalence = 2.4% among African refugees Central Africans 6/51 (11.8%) West Africans 130/2358 (5.5%) East Africans 153/9445 (1.6%)

68 Schistosomiasis Somali, over 80% seropositive from migrant serum bank 1 Increasing case series and reports on complications after arrival in the U.S. Complications reported due to excessive invasive testing 1. Unpublished research data. 2. Summer AP, et al. Hematuria in children. Clin Pediatr 2006;45():

69 Parasitic infections in migrants CDC Lost Boys (Sudanese) Reunion Study (n=464) 1 49% tested positive for strongyloidiasis by serology 44% tested positive for Schistosomiasis mansoni or hematobium 22% seropositive for Both 69% were seropositive for Either 1 Posey DL, et al. Clin Infect Dis 2007;45(10):

70 Case #4 43 yo Congolese female going to Rwanda (outside Kigali) for 9 day trip for funeral. What about strongyloides? Do you want to presumptively treat?

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72 Case #4 Main Points Usually multiple opportunities Consider HIV testing if appropriate Consider other chronic infections with high prevalence (e.g. schistosomiasis) Be aware of Loa loa and risk of presumptively using ivermectin for strongyloides

73 Case #5 37 yo Pakistani male planning a 2 week trip to Panama City for business. PMHx Asthma and hospitalized for pneumonia 2 years ago (ID saw and had presumptive treatment for strongyloides and serology came back positive) Tested for LTBI and negative 2 years ago HIV documented negative Meds None Social history Moved to US in 1997 with family as immigrant. Has 3 children, married.

74 Case #5 37 yo Pakistani male planning a 2 week trip to Panama City for business. Imminizations Tdp UTD Polio UTD Hep B UTD (Hep B Antigen negative) MMR UTD Hep A immune by serology VZV immune by serology

75 Case #5 37 yo Pakistani male planning a 2 week trip to Panama City for business. Opportunity?

76 Case #5 37 yo Pakistani male planning a 2 week trip to Panama City for business. Opportunity? HINT

77 Case #5 37 yo Pakistani male planning a 2 week trip to Panama City for business. Opportunity? Hepatitis C antibody positive, PCR confirmed

78 Hepatitis C Estimated 170 million cases worldwide, 3.2 million in the US. Certain populations with very high rates E.g. Bolivia, Cameroon, Central Republic of Africa, Chad, China, DRC, Egypt, Guinea, Mongolia, Pakistan, Rwanda, Thailand, Vietnam. Of every 100 persons infected with HCV 75-85% will develop chronic infection will go on to develop chronic liver disease 5-20 will develop cirrhosis over a period of yrs 1-5 will die from consequences (HCC or cirrhosis)

79 Case #5 Main Point Consider Hep C in higher risk populations

80 Conclusion Disease prevalence varies by population The Pre-travel visit represents an opportunity to screen for chronic infections which have substantial morbidly and mortality Hepatitis B Strongyloides HIV TB Other Chronic Infections/conditions Hep C Schistosomiasis Offers opportunity to up date routine vaccines and to establish care for chronic diseases/infections