Refugee Health Issues. Deborah A. McMahan, MD Refugee Summit, 2016

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1 Refugee Health Issues Deborah A. McMahan, MD Refugee Summit, 2016

2 Agenda Conditions in the Camp Infectious Disease Issues Nutritional Issues Chronic Disease Issues Lifestyle Issues Mental Health Issues Dental Issues

3 Conditions in the Camp

4 Water Quality The late 19th and early 20th century saw rapid declines in mortality in industrialized countries. The introduction of chlorinated piped water supplies was a major contributor to this achievement. Water is also one of the main nutrients, along with fat, protein, carbohydrates and micronutrients, that the human body needs on daily basis Diarrhea, often the product of the consumption of poor quality water, is one of the main causes of morbidity that results in malnutrition.

Water Quality in Camps 1 water tap per 80 to 100 refugees Water Points < 200 m walking distance from dwellings in a safe/secure location A person drawing 80L of water from a well back to their home

5 Water Quality in Camps 1 water tap per 80 to 100 refugees Water Points < 200 m walking distance from dwellings in a safe/secure location A person drawing 80L of water from a well back to their home 200m away (often uphill from well) for all the family needs may use up to one sixth of their standard ration of 2,100 Kcal/day only on this task!

6 Sanitation Human feces contains a range of diseasecausing organisms, including viruses, bacteria and eggs or larvae of parasites. The microorganisms may enter the body through: contaminated food and water eating and cooking utensils and by contact with contaminated objects.

7 Sanitation Intestinal worm infections (hookworm, whipworm and others) are transmitted through contact with soil contaminated with feces and may spread rapidly where open defecation occurs and people are barefoot. These infections will contribute to anemia and malnutrition, and therefore also render people more susceptible to other diseases. Children are especially vulnerable to all the above infections.

10 Sanitation

11 Life in the Camps A study revealed that the youth considered their quality of life to be poor and limited due to confinement in the camps, the limited work opportunities, the aid dependency, the unclear future and the boredom and unhappiness they face.

12 Nutrition Their diet consists mainly of rice, beans and fish paste. Meat is rare and considered a precious commodity. Vegetables are also in short supply Lots of white rice. Poor drinking water quality.

13 Healthcare in the Camps Health care includes access to a short list of essential drugs (30 to 40 at most), which are chosen because of their affordability and effectiveness Some refugee camps have fully operational hospitals or highly developed clinics. A hospital or clinic usually serves a population of 200,000 (or one hospital per 10 refugee camps).

14 Infectious Disease Issues

15 Parasites

16 Parasites Because they are at high risk for parasitic infections refugees are treated for intestinal parasites with Albendazole It may not be effective in treating Giardia, or patients with a high parasitic load.

17 Symptoms Many infected persons have no symptoms. Among persons who do have symptoms, the most common are abdominal pain, diarrhea, and rash. Less commonly, nausea, vomiting, weight loss, cough, or breathing problems can result. Because the infection can persist, a person can have symptoms on and off for many years. We treat all relevant infections.

18 Helicobacter Pylori Helicobacter Pylori common in developing countries. Can lead to peptic ulcer disease Approximately 80% of refugees infected with H Pylori We test and treat all adults

19 Chronic Hepatitis B

20 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.

21 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. Hepatitis B surface antigen carrier rates in the tropics are 40 times greater than in the West. Genotype B and C are most common in Asia

22 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.

23 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. Hepatitis B and liver cancer constitute the greatest health disparity between Asian and white Americans.

24 Hepatitis B Long Term Consequences Cirrhosis is a potential long term complication Genotype C is associated with a higher risk of cirrhosis than genotype B The presence of other hepatotoxic factors such as alcohol ingestion, HCV co-infection can contribute to progression to cirrhosis. Once cirrhosis is established, individuals can decompensate over time.

25 Tuberculosis

26 TB Infection vs. TB Disease You can have small numbers of bacteria in your body (called TB infection or latent TB) or You can have a large number of TB bacteria in your body (called TB disease or active TB).

27 TB Infection vs. Active TB Disease 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

28 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 The incidence last year in Allen county was 70 per 100,000 Asian population MMWR; March 23, 2007 / 56(11);

29 Tuberculosis While the rate of TB infection among the Burmese is unknown, some estimates are that 40% of the Burmese population are infected with the TB bacteria. TB infection is not contagious but can lead to TB disease which is contagious MMWR; March 23, 2007 / 56(11);

30 Tuberculosis It is important for us to diagnose and treat latent TB as they have a minimum of a 10% chance of morphing into active TB at some point in the future Every year, half of our active cases are foreign born folks The problem is the average active TB patient infects 10 to 15 people before they are identified and treated. At any given time, we are treating 50 people for latent TB

31 HIV/AIDS

32 HIV/AIDS Burma is one of six countries also including India, China, Indonesia, Thailand and Vietnam that together account for more than 90 percent of the people living with HIV in Asia and the Pacific. Approximately 189,000 people in Burma are living with the virus, and an estimated 15,000 people died of AIDS-related illness in 2013 However, Burmese health experts said the real number of people with HIV/AIDS in the country could be higher than the figures suggest.

33 HIV/AIDS Risk factors include: 52 percent men who have sex with men 25 percent were intravenous drug users 23 percent were female sex workers. The figures also do not include children with HIV, who most often are passed the virus from their mother.

34 Local Case A family of four arrives in Fort Wayne Did not know they were infected with HIV Mother, Father and youngest child were all infected with HIV Mother died within weeks of arriving

35 Nutritional Issues

36 Vitamin D Deficiency and Anemia 90% are vitamin D deficient and require ongoing treatment Anemia In Southeast Asia, 48% of pregnant women (18 million) 46% of non-pregnant women (182 million) 66% of preschool children (115 million)

37 Chronic Disease Issues

38 Diabetes South Asians are known to have an increased predisposition for diabetes which has become an important health concern in the region. A significant epidemic of diabetes is present in the South Asian region with a rapid increase in prevalence over the last two decades.

39 Diabetes A significant epidemic of diabetes is present in the South Asian region with a rapid increase in prevalence over the last two decades In Myanmar, the prevalence of diabetes mellitus is increasing In the capital of Myanmar, overall prevalence of adult onset diabetes in is 11.8% (urban prevalence is 13.9% and rural prevalence is 7.3%).

40 Diabetes and Obesity A National Survey revealed associated risk factors for diabetes: the prevalence of smoking was 33.6% in males and 6.1% in females the prevalence of hypertension was 31% in males and 29.3% in females the prevalence of overweight was 21.85% in males and 23.07% in females the prevalence of obesity was 4.35 in males and 8.45 in females among the sample population.

41 Diabetes and Obesity Another study of 5000 people with diabetes and 3000 DM healthcare professionals across 13 countries showed that 40% of patients had poor psychological well-being, but only 10% of those received psychological care. It also stressed that the social support (support from family members, co-workers and friends) play a significant role in improving the patient's sense of well-being and management of their DM

42 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 primcare/case/hyperlipidemia/

43 Lifestyle Issues

44 Lifestyle Issues Over 30% of Burmese men smoke Studies estimate that about 20.5% of men drink alcohol Betel nut (Areca nut) chewing existed in Myanmar since ancient times and it was done by both the kings and ordinary people. About 51.4% of adult males chew bettlenut

45 Lifestyle Issues People who chew betel nut are 10 times more likely to have oral cancer than those who do not. About 90% of males with oral cancer in Myanmar had histories of habitual betel nut chewing. Betel nut chewing and smoking have a synergistic effect on oral cancer occurrence.

Lifestyle Issues -- Teens Among 13-15-year-old students in Myanmar, 15.

46 Lifestyle Issues -- Teens Among year-old students in Myanmar, 15.2% of boys and 2.0% of girls chew betel nut.

47 Lifestyle Issues -- Teens A study looking at 177 young Burmese workers aged years, revealed the following: 21.5% were current smokers 25.4% were alcohol drinkers, 36.7% were physically inactive

48 Mental Health Issues

49 Depression/Anxiety Trauma and torture often present as recurring physical ailments Prevalence rate of symptoms of depression is about 42% and anxiety is 41% in refugees in the camps Risk factors include: insufficient food, higher number of trauma events, previous mental illness, and landmine injuries.

50 Grief Many orphans Most have not grieved

51 Mental Health We screen all refugees Start by talking about sleep High prevalence of anxiety mixed with depression Respond well to SSRI and counseling

52 Pediatric Issues

53 Lead Poisoning Soil in the camps can contain high levels of lead Home remedies can also contain lead: Theneca Daw Tway

54 Lead Poisoning Can lead to problems with: Cognition Speech Issues Behavior Issues

55 Developmental Issues Refugee children are at high developmental risk due to dislocation and deprivation. Not many studies of prevalence Barriers to identification may include parents frame of reference Locally used Ages and Stages in small population and 7 of 19 screened needed intervention

56 School 7 year old Burmese boy Repeated kindergarten twice and having trouble (fights etc.) in first grade. Father works out of state, mother with multiple medical problems. Misses a lot of school

57 Issues Unable to do school work and was disruptive Mother does not understand what to do and does not understand the significance of his having trouble at school

58 What to Do? Have him undergo psych testing Many issues identified that impede his ability to learn Work with school and mother to request IEP Counseling

59 Dental Issues

60 Dental Issues Most refugees have never had any dental health care. Many chew beetle nuts (a stimulant similar to dipping snuff) Many face such conditions as gingivitis, calculus, tooth decay and periodontal disease

61 Summary

62 Summary Lived in difficult circumstances Many issues can be addressed Need a lot of health education Mental health issues can be addressed Worth giving them a good healthy start when they arrive here

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