Clinical and Health Affairs
Initial Refugee Health Assessments: New Recommendations for Minnesota
By Susan Dicker, R.N., M.S.N., M.P.H., William M. Stauffer, M.D., M.S.P.H., DTM&H, Blain Mamo, M.P.H., Cindy Nelson, M.S.N., F.N.P.-BC, and Ann O'Fallon, R.N., M.A.
Historically, the purpose of medical screening of new refugees has been to identify acute conditions such as infections that can be effectively addressed with short-term therapy. More recently, screening of refugees who are new to Minnesota has included identifying conditions that require ongoing care. But regular screening for chronic conditions only makes sense when follow-up care can be provided. To address this issue, the Minnesota Department of Health’s Refugee Health Program, in conjunction with outside experts, reviewed its guidelines for medical screening of new refugees and revised its recommendations. In addition to recommending screening for infections and other acute conditions, the new guidelines call for screening for chronic conditions and repeat testing for diseases or conditions of long latency. The guidelines take into account the ability of the screening clinic to provide ongoing care or assure the patient’s transition to primary care.
The Minnesota Department of Health’s Refugee Health Program (RHP) has been coordinating the health screening of refugees entering Minnesota since the end of the Vietnam War. Under the Federal Refugee Act, Minnesota, like other states, offers refugees a health assessment within 90 days of their arrival. Refugees are required to have a physical exam overseas prior to their departure, which is designed to prevent persons with communicable diseases of public health significance from entering the country. The intent of the domestic exam is to eliminate health problems that might be barriers to successful resettlement and to protect the health of the population at large.1
The primary focus of the initial refugee health assessment (also referred to as the domestic health exam) has been screening for and treatment of infectious diseases such as tuberculosis, hepatitis B, and intestinal parasites. The initial assessment also has provided an opportunity to look for other health concerns, including those arising from war and trauma, and to introduce the refugee to the Western medical system.
Providers who perform health assessments in Minnesota follow the RHP guidelines, which are informed by recommendations from the Centers for Disease Control and Prevention (CDC), and the Office of Refugee Resettlement, as well as the expertise of infectious disease clinicians in Minnesota. In 2009, the RHP convened a group of infectious disease and refugee health experts to review its screening protocol in light of new national guidelines developed by the CDC’s Division of Global Migration and Quarantine and the Office of Refugee Resettlement’s Health Working Group. Following these discussions, the Minnesota workgroup recommended revising the state’s guidelines so that they more closely align with the CDC’s new refugee health guidelines.2
The state’s recommendations represent a new paradigm in medical screening of refugees. In addition to calling for screening for acute conditions, they promote screening for conditions that demand prolonged intervention such as heart disease and mental health problems, and they call for repeat screening for infectious diseases with long latency periods such as tuberculosis and intestinal parasites. This article summarizes the talks that led to the new guidelines, highlights some of the changes, and explains the rationale for the revisions.
Rethinking Screening: Discussion and Rationale
The workgroup’s discussions were framed by the following generally accepted criteria for population-based medical screening set by the World Health Organization:3
The condition should be an important health problem; The person should be in a latent or asymptomatic disease state; There should be a suitable test for the disease; The test should be acceptable to the population being screened; There should be an acceptable treatment and agreed-upon strategy for whom to treat and how to treat them; and The treatment should be cost-effective.
The workgroup also took into account factors that can impede follow-up care for refugees as they move into the broader community. They considered the fact that refugees may be unfamiliar with the concept of preventive care and that getting health care may be but one of many immediate and competing demands on refugees as they search for housing, jobs, and schools and learn a new language.4-6 The workgroup also noted that because there may be no one specified to follow up with patients after their initial health assessments, screening results may not find their way into the primary care system.
Finally, the workgroup discussed the screening process itself. Although the initial refugee health assessments are coordinated by the RHP in Minnesota, they are implemented at the county level by local public health units. Assessments can be done either at free-standing county public health clinics or at private clinics that work with local public health officials. The workgroup considered the strengths and weaknesses of each.
Members noted that public health clinics are able to accommodate large numbers of people and are located in places where refugees may be receiving other services. In addition, public health clinics often have staff who are bilingual or bicultural and who have experience working with refugees. Thus, they consistently offer high-quality assessments performed by professionals who have unique clinical expertise and who are culturally competent. But there is a drawback to conducting initial health assessments in public health clinics: the disconnect between screening and primary care. Even when refugees are referred to primary care providers in the community, they may not seek or receive care. When the screeners are not also the primary caregivers, laboratory tests and immunizations may be unnecessarily repeated and positive test results may not be acted upon, leading to more expense for the state and perhaps more health problems for the individual in the long term.
When the initial screening is done by a primary care provider in his or her clinic, it can mark the beginning of an ongoing relationship between that provider and the patient. For the screening to be successful, local public health experts need to educate the primary care provider about the recommended guidelines for the refugee health assessment as well as the cultural norms and health needs of the specific population. Issues that may challenge private providers who do refugee screenings include having to accommodate large families, working with interpreters, maintaining an up-to-date working knowledge of infectious diseases particular to a certain refugee population, understanding and addressing cross-cultural health needs, and maintaining the financial stability of their program.
The workgroup focused on the fact that refugee screening has evolved to include identification of conditions that demand ongoing therapy (eg, vitamin D deficiency and cardiovascular disease). It was noted that refugees typically have little to no access to medical care prior to coming to the United States, so many chronic conditions may never have been identified much less treated. And only those diseases considered to put the health of the public at risk are screened for prior to immigration. It was also noted that screening results for long-latency infections may be negative at arrival if the refugee was recently exposed but may later be positive. Finally, the workgroup decided that a medical screening should only be pursued if follow-up care for conditions that might be discovered can be provided.
To address these issues, the workgroup recommended that medical screening of new refugees take into account the capacity of the initial screening clinic to provide follow-up or ongoing care. In addition, the group recommended that refugees be tested for conditions that require prolonged intervention such as cardiovascular disease and certain cancers. And it advised repeat testing for infectious diseases or other conditions with long latency periods. The workgroup based its recommendations on the premise that the guidelines would be applied according to the screening site’s capacity to provide ongoing care or assure transition to primary care.
Changes in the Guidelines
There are three main components of an initial refugee health screening: The provider is to do a complete history, review of systems, and physical examination of the patient; assess for infectious diseases; and perform laboratory testing. The new recommendations distinguish between best practice in a public health setting and best practice in a primary care clinic.
It should be noted that the protocols for HIV, intestinal parasite, and lead screening have been updated to include the following: Testing for HIV infection in all new arrivals from endemic regions of the world, regardless of age, and testing of 13- to 64-year-olds from all other regions; Changes in application of recommended tests for screening for intestinal parasites; and Lead screening of children through 16 years of age. Otherwise, the recommendations for best practice in a public health clinic remain largely unchanged.
The recommendations for best practice in a primary care clinic now include screening for chronic conditions and repeat testing for diseases of long latency. Although infectious diseases continue to be a significant concern and can be readily addressed when identified, there is a growing recognition that chronic health disorders are common among refugees. Because of refugees’ prolonged lack of access to health care, these conditions may pose a long-term threat to the individual’s health.7-13
The new screening recommendations for prevention of chronic diseases are based on U.S. Preventive Services Task Force (USPSTF) guidelines for routine medical screening and include screening for hypertension, abdominal aortic aneurism, lipid disorders, renal disease, diabetes, cervical, breast, and colorectal cancer. In addition, physicians should maintain a high index of suspicion for a number of cancers when refugees present with hepatitis and H. pylori, or for thyroid cancer in refugees (typically Russian) who have a history of radiation exposure. In general, refugees are at a disproportionately increased risk for cancers that occur in the developing world such as those of the liver, esophagus, and stomach. Pap smears should be done for any woman older than 21 years of age or who is sexually active and has never been screened, as cervical cancer is the second most common cancer in the world.14 Many refugee women have never had a pelvic exam and may consider it invasive and unnecessary, so this should only be done once the provider and patient have established a trusting relationship.14,15
Sreening for growth, development, and malnutrition is now recommended. The experience of fleeing their homes, living in impoverished conditions, and having sustained infections contributes to refugees’ risk for chronic malnutrition.16-22 Also, providers should check vitamin D levels in both children and adults. Studies indicate significant vitamin D deficiency is common worldwide in children and adults, regardless of race or geographic location. Subclinical manifestation of vitamin D deficiency can be related to diseases of long latency such as osteoporosis, cancer, and autoimmune disorders.22-24
Also depression screening is now recommended for all adolescents and adults. Many refugees have suffered traumatic experiences including torture that can have long-term effects. Rates of post-traumatic stress disorder among refugees worldwide range from 30% to 60%.25-27 Most new refugees are unfamiliar with Western mental health services. Medical providers may be in the best position to help them access mental health care.
The new guidelines reiterate and stress the importance of follow up when infectious diseases of long latency are identified during screening. Completing therapy for latent TB infection can reduce the likelihood of the patient developing TB by up to 90%.28 The risk for progression to active TB is greatest in those with HIV infection.29 It is important to note that many refugees come from regions of the world where HIV is endemic and HIV and TB coinfection is prevalent. Also some parasitic infections can persist for years and, if left unchecked, lead to hyperinfection. People who are infected for many years are at risk for damage to their liver, intestines, lungs, and bladder.30,31 In addition to TB and HIV, hepatitis B (HBV) is endemic in many parts of the world, and screening results for HBV in Minnesota suggest a higher prevalence of infection among newly arrived refugees than among the general U.S. population.32,33 Untreated HBV can lead to chronic liver disease and even death.
Refugee resettlement is a federal humanitarian effort that enjoys bipartisan support. The United States is committed to giving refuge to persecuted individuals, and Minnesota has a proud tradition of welcoming refugees to our state. Over time, the state has seen doctors, nurses, teachers, lawyers, and politicians rise from the ranks of new generations of refugees. As new populations make Minnesota their home, it is important to ensure their health and the health of the public through comprehensive screening. MM
Susan Dicker is a refugee health nurse consultant for the Minnesota Department of Health’s Refugee Health Program; Blain Mamo is an epidemiologist with the program, and Ann O’Fallon is its refugee health coordinator. William Stauffer is an associate professor of infectious diseases and international medicine at the University of Minnesota and a member of the clinical faculty at Regions Hospital in St. Paul. He also serves as an advisor to the Centers for Disease Control and Prevention’s division of global health and migration. Cindy Nelson was a nurse practitioner at the Hennepin County Public Health Clinic at the time of this writing.
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