Serving Refugee & Immigrant Patients What every local provider and navigator should know

Transcription

1 Serving Refugee & Immigrant Patients What every local provider and navigator should know Deborah A. McMahan, MD Health Commissioner November 20, 2017

2 Agenda Important Health Issues Important Mental Health Issues Observations Along the Way Boy Are We Blessed

3 Important Health Issues

4 Screening in Allen County All refugees are screened for: Relevant infectious diseases Chronic health conditions Nutritional deficiencies Mental Health Issues

5 Tuberculosis

6 Latent TB Around someone with TB disease and inhale bacteria Immune system contains infection so bacteria do not grow and become dormant No symptoms Not contagious Positive TST or IGRA Normal chest x-ray Can be treated to prevent TB disease in future

7 TB Disease or Active TB Has been exposed to another person with TB disease may have been years prior Immune system can no longer contain bacteria Symptomatic Abnormal chest x-ray Usually have positive TST or IGRA May be contagious 50% mortality if not treated

8 TB Infection vs. Active TB Infection Active Contagious No Yes Symptoms No Yes Positive ppd Yes Yes Abnormal x-ray No Maybe People with TB infection do not pose a risk to others

9 Tuberculosis Overview Two Forms of TB Active Tuberculosis Latent Tuberculosis (TB Infection)

10 TB Symptoms Cough Fever Night sweats Weight loss Chest pain

11 Tuberculosis While the rate of TB infection among the Burmese is unknown, some estimates are that 40% of the Burmese population have latent TB While latent TB is not contagious but it can lead to TB disease which is contagious. Once the average person develops TB disease, they infect 10 to 15 other people before they are diagnosed and treated. MMWR; March 23, 2007 / 56(11);

12 Tuberculosis The estimated incidence of tuberculosis (TB) cases in 2006 in the United States was 4.6 cases per 100,000 population The estimated incidence of tuberculosis in the general population in Thailand is 141 cases per 100,000 MMWR; March 23, 2007 / 56(11);

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14 Allen County TB Disease Allen County TB Cases ( )

15 New Treatment for Latent TB Old treatment was daily Rifampin for 4 months self administered New treatment INH/Priftin weekly for 12 weeks via directly observed treatment 100% compliance!!!!

16 New Concerns Refugees who were allegedly treated for latent TB have developed active TB --- seriously question compliance Secondary refugees have moved here before being treated for latent TB then develop active TB here Contagious TB while working in factories

17 Large Scale Screen and Treat Three Burmese refugees with contagious TB at three different factories Tested all foreign born to pick up exposed but also secondary refugees who had not been treated Mass treatment at facilities with new regimen -- so we are sure they have been treated

18 Pediatric Active TB Worldwide, there are at least 1 million cases of TB among children less than 15 years of age each year. In the US 9,582 cases of TB were reported in 2013, of which 5% cases were among children less than 15 years of age. In high TB burden settings outside of the United States, children account for 15 20% of TB cases. In 2016 we had five children with active TB in ages ranging from 1 year to 13 years old 28% of our cases.

19 Signs and Symptoms in Children Cough Feelings of sickness or weakness, lethargy, and/or reduced playfulness Weight loss or failure to thrive Fever Night sweats Children are much less likely to be contagious

20 Diagnosing Pediatric Active TB Confirming the diagnosis with sputum can be challenging because: It is difficult to collect sputum specimens from infants and young children; and The laboratory tests used to find TB in sputum are less likely to have a positive result in children; because children are more likely to have a smaller number of bacteria.

21 Treatment of Active Pediatric TB In children less than 4 years of age, treatment for active TB should be started as soon as the diagnosis is suspected. The regimens recommended for adults are also the regimens of choice for infants, children, and adolescents with tuberculosis, with the exception that ethambutol is not used routinely in children (unless there are cavitary lesions or suspected INH resistance). Always use DOT

22 Pediatric Case Allen County Twelve month old Burmese refugee Several month history of cough and night sweats without fever. Father had active TB in camp but before she was born Positive TST Chest x-ray with right middle lobe infiltrate r/o TB Gastric TB culture neg Empiric treatment One month after 3 drug regimen cough and night sweats resolved

23 Pediatric Case Allen County Four year old Burmese refugee Several month history of night sweats without cough or fever. Father had active TB in camp when she was infant Positive TST Chest x-ray normal Gastric TB culture neg Consultation with ID empiric treatment One month after 3 drug regimen night sweats resolved

24 Pediatric Case Allen County Thirteen year old from the Philippines Contact to an active case of TB Initial TST was negative Developed productive cough that resolved in one week We obtained three sputum samples (just to be thorough) which were smear negative Four weeks after symptoms resolved, cultures grew TB TST now positive Was treated for six months with standard regimen

25 Chronic Hepatitis B

26 Hepatitis B As many as 1 in 10 Asians and foreign-born Asian Americans is living with chronic HBV infection, compared to 1 in 1000 in the non-asian U.S. population. Although Asian Americans make up only 4% of the U.S. population, they account for over half of the estimated 1.25 million individuals with chronic HBV infection. Most of them acquire this infection at birth.

27 Chronic Hepatitis B While we do not know the exact prevalence of Hepatitis B in the Burmese population, research has shown that the Burmese typically have about 15% rates of chronic hepatitis B infection. Persons from Southeast Asia are also at high risk of perinatal transmission as perinatal transmission is common. Reuse of needles and syringes for medical and vaccination use also contributes

28 Chronic Hepatitis B Adults 90% will get rid of the virus and recover without any problems; 10% will develop chronic hepatitis B. Young Children 40% will get rid of the virus and recover without problems; 60% will develop a chronic hepatitis B infection. Infants 90% will become chronically infected; only 10% will be able to get rid of the virus.

29 Hepatitis B Long Term Consequences Liver cancer caused by chronic HBV infection is the second leading cause of cancer death for Asian men living in the United States. Liver cancer incidence is up to 9 times higher in Asian American men than in their white counterparts. Hepatitis B and liver cancer constitute the greatest health disparity between Asian and white Americans.

30 Hepatitis B Long Term Treatment Chronic hepatitis B is not curable, but it is treatable. The goal of therapy is to reduce the risk of complications by reducing hepatitis B viral load and the loss of HBeAg (either with or without detection of anti-hbe) while improving liver enzyme levels. Many experts anticipate that medications to cure hepatitis B virus (HBV) will be available, perhaps as early as a few years from now.

31 Parasites

32 Parasites Due to their living conditions, the refugees are often at high risk for parasitic infections. Commonly see Giardia and Helicobacter pylori or just eosinophilia We treat all of these infections

33 Chronic Health Issues

34 Diabetes Asians have a strong ethnic and genetic predisposition for diabetes and have lower thresholds for the environmental risk factors. As a result, they develop diabetes at a younger age and at a lower body mass index and waist circumference when compared with the Western population. A significant epidemic of diabetes is present in the South Asian region with a rapid increase in prevalence over the last two decades.

35 Diabetes A study published in 2012 revealed that higher consumption of white rice is associated with a significantly increased risk of type 2 diabetes, especially in Asian (Chinese and Japanese) populations. Each additional daily serving of white rice may increase the risk of Type 2 diabetes by 10% Those who ate the highest amounts of white rice had a 27% higher risk of diabetes than those who ate the least, and the risk was most pronounced in Asian people.

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37 Prediabetes Prediabetes prevalence is also higher than that of diabetes in many of the Asian countries Pre-diabetes is a condition in which blood glucose levels are higher than normal, but not high enough to be classified as full-blown diabetes. Those with pre-diabetes are at increased risk of developing type 2 diabetes within a decade unless they adopt a healthier lifestyle that includes weight loss and more physical activity.

38 Complications Asian diabetic patients have a high risk of developing long term diabetic complications because they develop the disease earlier. Nearly 30% of type 2 diabetic patients in Asian countries have retinopathy. The prevalence of diabetic end stage renal disease is also higher than among the white populations. The prevalence of neuropathy and foot complications are also high among the Asian patients

39 Heart Disease South Asians have a higher CHD risk in this population, which may be related in part to a higher prevalence of the metabolic syndrome, insulin resistance, and hyperlipidemia clerkships/primcare/case/hyperlipidemia /

40 TB and Diabetes Diabetes triples a person s risk of developing tuberculosis. The likelihood that a person with TB will die, or that they will get TB again after they have been successfully treated for it, is also significantly higher among people with diabetes. Research also shows that among people who are being treated for TB, those with diabetes remain contagious longer than those who do not have diabetes.

41 Risk of Progression to Disease TB Infection No risk factors TB Disease (10% lifetime risk) TB Infection And Diabetes TB Disease (30% lifetime risk) TB Infection And HIV TB Disease (7 10% per year Remains latent Remains latent Remains latent

42 TB Risk Factors; Texas

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44 Important Mental Health Issues

45 Refugees and Mental Health High rates of mental health problems in refugees have been shown to be related to the complex interaction between pre- and post-migration experiences. Refugees experience high rates of pre-migration trauma and loss, and experience multiple traumas over a prolonged and anxiety

46 Burmese and Mental Health Burmese refugees being resettled to the United States are likely to have some level of mental health problems. Within Myanmar, many are subjected to torture by the Burmese Army, including: forced labor; stress positions; beatings; burning; sexual assault, rape; electric shock; sleep deprivation; and, solitary confinement Alcoholism also may be common among resettled Burmese refugees, especially men

47 Refugees and Mental Health Across diverse refugee populations, pre-migration trauma consistently predicts symptoms of PTSD, depression and anxiety Other pre-migration factors that predicted poorer outcomes were identified in a meta-analysis including: older age, female sex, rural background, higher education, and higher socio-economic status. udy_in_karenni_refugee_camp.pdf

48 Refugees and Mental Health Higher rates of PTSD, anxiety and depression were found in people who reported higher rates of postmigration living difficulties Prevalence rate of symptoms of depression is about 42% and anxiety is 41% in refugees udy_in_karenni_refugee_camp.pdf

49 Family Challenges One of the biggest obstacles refugees and immigrant parents report is raising their children in a new, unfamiliar culture. Parents often find that their children are quickly Americanized, which may be at odds with their own culture. When kids pick up English much faster than their parents it throws off the parent-child dynamic, and kids use this to their advantage.

50 Family Challenges Immigrant parents bring with them their original cultural models of the successful parent and how to rear a child properly. Then when they migrate to a new culture, they find that other parents, teachers and professionals, may possess different images of the successful parent and different strategies for childrearing. This is tough

51 Family Challenges In the process of migration, parents can have extended periods of potentially damaging separation from their children. When family separations have been protracted, attachment difficulties have been noted as children miss their known caregivers and withdraw from estranged biological parents upon reunification.

52 Family Challenges Resulting parental disappointment, stress, and depression are common as are difficulties in reestablishing relationships with and authority over children. The ambivalence and guilt experienced by parents who separate from their children during migration is justified because children who are separated from their parents are more likely to report depressive symptoms than children who have not been separated.

53 Case Middle aged Burmese mother brings two children in for evaluation and treatment of latent TB. Family had been recently reunited after prolonged separation. Physical fight in exam room Mother hit child because frustrated by his adopting local youth culture CPS

54 Observations Along the Way

55 Medical Interpreters Being cheap with interpreters is expensive Need to explain complex diseases and how to manage them Children should not be doing this And your sign language is probably not that great

56 Families Need Help When otoscopes are used as instruments of discipline it is a sign we are not doing enough to help families adjust Purdue University Group

57 Medical Home If anyone needed a medical home, this population does

58 Pay Me Now or Pay Me Later Prevention is always cheaper and always the correct answer on a pop quiz

59 Boy Are We Blessed

60 Need I Say More?

61 Easy Access to Clean Water

62 Easy Access to Vaccines

63 We Can Attend a PTA Meeting and Know What is Going On

64 Easy Access to Good Medical Care

65 Summary

66 Summary Refugees may have significant infectious and chronic health issues that required good public health and medical care Families will likely have issues with adjustment to new styles of parenting and other family issues Mental illness is common