Evidence-Based Care of Your Immigrant & Refugee

PatientsFamily Medicine Grand Rounds

Schulich School of Medicine & DentistryApril 5, 2014

Natalie Lovesey, MD, CCFPFamily Physician, Southdale Family Medical Centre

London, Ontario, Canada

Presentation OverviewDefinitions

Key resource – CCIRH guidelines & online checklists

London’s refugee populations

Infectious diseases

Mental Health & PTSD

Eosinophilia & Intestinal parasites

Throughout: Resources in London & Where to get help

Immigrant & Refugee Health - Definitions

Immigrant: one who has taken up permanent residency in another country

Refugee: one who has been forced to flee his or her country because of persecution, war, or violence. A refugee has a well-founded fear of persecution for reasons of race, religion, nationality, political opinion or membership in a particular social group

This presentation will focus on refugees, but many things are applicable to recently-arrived immigrants

Immigrant Health Status ‘Healthy Migrant’ phenomenon – immigrants often

healthier than native-born population upon arrival Health indices become similar to native-born population after

~5 years

Subgroups of immigrants are at increased risk of disease-specific mortality; for example: Southeast Asians from stroke ( [OR] 1.46, 95% [CI] 1.00–1.91)

Caribbeans from diabetes mellitus (OR 1.67, 95% CI 1.03–

2.32) and infectious diseases Immigrant men from liver cancer (OR 4.89, 95% CI 3.29–6.49)

Many health needs the same as native-born; but some may differ and require increased awareness

Refugee Health StatusHigher risk of past trauma, violence, and harsh

living conditions

Health varies greatly depending on their particular circumstances (access to health care, living conditions, social status, etc.)

At risk for decline in health status after arrival

Health Coverage for Refugees & Immigrants

Coverage: New Immigrants

3 month wait time for permanent residents in Ontario, Quebec, BC, Nunavut and the Yukon

Quebec has variable wait time and has exceptions for pregnant women, infectious diseases, domestic violence, etc.

Vestige of pre-Medicare days when private insurance plans typically had a 3 month wait

Non-evidence based? ON does not specifically outline its rationale for the waitPresumably thought to be cost-effective, but is it?

Coverage: Refugees Gov’t-assisted refugees: ‘expanded health care coverage’ – ie. Hasn’t changed

from previous Similar to coverage for those on provincial assistance

Privately sponsored refugees and refugee claimants who are not from designated countries of origin (DCOs),2 – ‘health care coverage’ Includes coverage for hospital, physician, laboratory, and diagnostic services.

Medications and vaccines are generally not covered, unless they are needed to prevent or treat a disease that poses a risk to public health or public safety—for example, medications for HIV or tuberculosis.

Refugee claimaints from DCOs (countries deemed by CIC to be ‘safe’ and therefore should not produce refugees”; rejected refugee claimaints; refugees whose claim has been suspended ‘public health care coverage’ – coverage for services only if they are required to

diagnose, prevent or treat a disease posing a risk to public health or to diagnose or treat a condition of public safety concern (such as HIV or TB): hospital services, services of a doctor or registered nurse licensed in Canada, laboratory and diagnostic services, and medication and vaccines. This coverage is very limited.

Coverage & Cuts“Refugee health - Providing the best possible

care in the face of crippling cuts” – Sheikh, Rashid, Berger et al., Canadian Family Physician, June 2013

Article is an excellent reference for different classes of coverage

It IS confusing, and an arduous process to find out what/who is covered.

Doctors for Refugee Care Report

“Children and pregnant women are being turned away from clinics despite having valid coverage.8 Patients are being asked to pay up front of their visits despite having coverage. E–mails obtained from the CMAJ revealed that only 9 out of 33 walk-in clinics in Ottawa, Ont, were accepting refugees as patients, and in those cases in which refugees were seen, they were charged fees of up to $60.9 Refugees are being harmed by confusion almost as much as by the cuts themselves.”

Ontario Temporary Health Program

Launched Jan. 1, 2014 in response to IFH cuts

Goal “ to provide access to essential and urgent health care, as well as medications coverage to refugee claimants living in Ontario, regardless of the status of their claim or the country they are from.”

Also administered by Mediavie Blue Cross

Claims submitted first for processing to Medavie Blue Cross through the IFHP. If the claim is rejected for services beyond Public Health and Public Safety coverage under IFHP, it can be sent to the OTHP for consideration of payment.

Tips When Providing CareNot clear which clinical presentations justify an

investigation to rule out an infection by a transmissible organism, even if the eventual diagnosis is not a notifiable disease.

Therefore, when calling the Blue Cross, it is important to highlight that the visit is to investigate a possible communicable disease—for example, evaluating a cough in order to rule out tuberculosis.

Refugees in London

Current Refugee Health Clinic Model in London, ONPartnership with Cross Cultural Learner Centre

and London Intercommunity Health Centre

Came into being from Dr. Bhayana’s refugee health experience & Newcomer Health Project (started 2008)

Always looking to expand roster of family doctors accepting refugee patientsAcademic centres are ideal!

Populations in London, ON: Iraqi refugees

Many Iraqi refugees arrived as GARs in the past few years

Many had reasonable access to health care

Many exposed to past violence

Common health issues: Hypertension and cardiac diseasePost-Traumatic Stress DisorderDepressionMSK issues related to past trauma

Iraqi refugees56% have experienced torture (Willard, Rabin & Lawless,

2013) 24.3% primary; 31.4% secondary

Torture survivors more likely to report physical and mental symptoms.

Torture and cumulative trauma are the strongest predictors of post-traumatic stress disorder and are associated with chronic physical and mental health problems.

Most individuals with a history of trauma recover (~80%), but those with PTSD can remain symptomatic for years

Bhutanese RefugeesBhutanese refugees of ethnic Nepali descent – living

in UN-run camps in Nepal since the early 1990s

In 2007, 108 000 Bhutanese refugees living in the camps

Canada plans to resettle up to 6500 refugees in total (2007-present)

Common health issues: Anemia Vitamin B12 deficiency Mental health issues

Bhutanese RefugeesSince 2009: at least 16 suicides among the

49,010 Bhutanese refugees resettled to the United States.

Factors: social isolation, substance abuse, domestic violence, depression, and resettlement issues

Some refugees may have been tortured prior to fleeing Bhutan. Men are more likely to report having been tortured than women, but tortured women are more likely to report mental health conditions than tortured men.

Refugee patients in your office: where to start

Refugee patients in your office: where to start

Interpreters can be arranged through Across Languages

Use a certified interpreter Beware Google translate!Beware family members as translators!Beware other staff as translators!

What’s been done already? Canadian Immigration Exam (more in a moment)Usually TB screening, through the Health Unit.Sometimes immunizations through the Health Unit.

Canadian Immigration Exam

Done in country of origin or after approval of asylum seekers

Purpose is two fold – considers cost to health care system (‘excessive demand’) and public health safety for Canadian society

Includes health history, exam with vision and hearing

Review of CXR (11 yrs and older)

Urinalysis (5 yrs and older) - dipstick for glc, blood, protein

HIV - added Jan. 2002 Since 1991, HIV has not been considered to pose a public safety risk,

so immigration applicants may be denied if they are determined to place an ‘excessive demand’ on the health care system; refugees, protected persons & family class immigrants are exempt from the ‘excessive demand’ consideration.

Where to start: HistoryCountry of birth, migration history

Time spent in camp? Conditions?

Languages spoken and/or written

Education, occupation (past/present)

Housing situation

Family members – any in other countries?

EAL Level? Attending classes?

Where to start?Canadian Collaboration for Immigrant & Refugee

Health Guidelines – CMAJ 2011

Online checklist based on country of origin

http://www.ccirhken.ca/

Infectious Diseases

Tuberculosis: CCIRH Risk of reactivation increased in refugees

Children: Screen those < 20 yrs from countries with a high incidence of TB (> 15 per 100 000 population) as soon as possible after their arrival in Canada with a TST, and recommend treatment for latent tuberculosis infection if results are positive, after ruling out active TB.

Adults: Screen refugees aged 20-50 yo from countries with a high incidence of tuberculosis ASAP after their arrival in Canada with a TST. Screen all other adult immigrants who have risk factors that increase the risk of active with TST, and recommend treatment for latent tuberculosis infection if results are positive, after ruling out active TB.

Basically, all areas except N. America, W. Europe, Australia, NZ.

TB screening tests TB skin test (TST) and Interferon-Gamma Release Assay (IGRA)

TST: Sensitivity 70-80%, specificity 97% EXCEPT in BCG-vaccinated individual – only 60% spec. Likelihood of false pos TST with BCG dec’s with time; less likely if vaccinated <age 2

IGRA: Sensitivity 70-80%; specificity 99% - lower in kids; more indeterminate results

Both TST & IGRA especially challenging for kids <10

Dr. Chris Greenaway (ID, Montreal) thinks IGRA superior in BCG-vaccinated adult, otherwise, use caution.

IGRA available in London at Gamma Dynacare Pall Mall. Cost to patient $100.

Vaccine-Preventable Diseases

Immigrant/Refugee children & adults more likely to have received immunization against Measles Diphtheria Pertussis Tetanus Polio BCG (TB)

Less likely to have received Mumps Rubella Varicella H. influenzae S. pneumo

Vaccine-Preventable Diseases

Seroprevalence studies: Measles immunity >95% Mumps immunity 80-92% Rubella 80-85% Td 50-60% in 20-30 yo’s, less with increasing age

Immigrants over-represented in Rubella outbreaks, and most cases of congenital rubella syndrome and neonatal tetanus have been in babies of foreign-born mothers (in US/Can.)

Immigrants not over-represented in past mumps or measles outbreaks

Vaccine-Preventable Diseases

CCIRH: All (adults and children) without written records should be given a primary immunization (catch-up) schedule

NACI: All without records should be given a primary immunization seriesAdults – primary series of Td (1st Tdap), and polio,

and MMR if born after 1970 & no hx of measles OR seroneg for mumps or rubella

There are no systemic catch-up programs in place for adults, or for some vaccines (eg. varicella)

Vaccine-Preventable Diseases

Best approach for children WITH records is challengingStudies of discordance between records and

immunity. False records? Cold chain issues? Host factors?

Most conservative: repeat seriesAlternative: screen/test and vaccinate

MMR VaccineEffectiveness

Measles: close to 100% protection after 2 dosesMumps: 64% after 1 dose; 79% after 2 dosesRubella: >95% protection after 1 dose

Adverse effectsFever 5%Febrile seizure 0.3%Benign ITP <0.01%Parotitis rareArthritis up to 25% of postpubertal women; higher in

never-vax than in prev-vax. (occurs within 2 weeks)

VaricellaOccurs at older ages in tropical countries

~age 15 vs. temperate or cold countries age 5

~30% of adolescents & adults from tropical countries are susceptible

CCIRH: Vaccinate all children <13yo with varicella vaccine

Screen all >13 with serology and vaccinate if susceptible

Hepatitis B Prevalence of Hep B in refugees and new immigrants is 3%, vs.

0.5% of Canadian-born

CCIRH: Screen those from areas where seroprevalence ≥2% with Hep B sAg, sAb and cAb

Everywhere except United States, Canada, western and northern Europe, Australia, New Zealand (consider other RFs)

Refer if sAg positive

Vaccinate if susceptible

1-2%/year rate of household transmission to children in 1st decade of life if family member positive VACCINATE young children of parents from areas of high Hep B EVEN

if parents negative &/or child born here – extended family members may be positive.

Hepatitis CCCIRH: Screen those from areas where

seroprevalence ≥3%; refer if positive

MalariaCCIRH: Do not routinely screen, but be alert

especially for those from Sub-Saharan Africa

Mental Health

Depression: CCIRH Rate of depression in immigrants are slightly lower

than general population, rising over time to be similar to the gen pop

Rate of depression in refugees is similar to the general population

CCIRH: If an integrated treatment program is available, screen adults for depression using a systematic clinical inquiry or validated patient health questionnaire (PHQ-9 or equivalent). Link suspected cases of depression with an integrated treatment program and case management or mental health care. (QOE: moderate)

PTSD Screening: CCIRHDo not conduct routine screening for exposure

to traumatic events, because pushing for disclosure of traumatic events in well-functioning individuals may result in more harm than good. Be alert for signs and symptoms of post-traumatic stress disorder, especially in the context of unexplained somatic symptoms, sleep disorders or mental health disorders such as depression or panic disorder, and perform clinical assessment as needed to address functional impairment. (QOE: low)

PTSD Primary Care PTSD Screen

In your life, have you ever had any experience that was so frightening, horrible, or upsetting that, in the past month, you*

1. Have had nightmares about it or thought about it when you did not want to?

2. Tried hard not to think about it or went out of your way to avoid situations that reminded you of it?

3. Were constantly on guard, watchful, or easily startled?

4. Felt numb or detached from others, activities, or your surroundings?

PTSDPTSD more likely than any other mental health

disease to present with somatic symptoms

Can result in avoidance behaviour, INCLUDING avoiding associating physical symptoms with past trauma.

PTSD Management Core of healing is re-building trust – Dr. Mara Rabin, Utah

Don’t discount the importance of a regular, trusting relationship with you.

Don’t press for details of trauma Very individualized

Practice family-centered care; trauma-informed care

Try to value methods of recovery and resilience, rather than overly pathologizing

Highlight non-pharmacologic management Exercise prescriptions, OHIP-covered physiotherapy, social

contact

PTSD Management First line: psychotherapy

Pharmacologic treament (guidelines differ) 1st line – paroxetine with augmentation (bupropion, mirtazapine) 2nd line – sertraline, venlafaxine

Sleep/nightmares Prazosin 1 mg po qhs, titrate up by 1-2 mg every few days until

effective dose reached. Avg dose 3 mg. Range 1-10 mg. Monitor for orthostatic hypotension. (Level A)

Clonidine 0.2-0.6 mg in divided doses. (Level C) Monitor for orthostatic hypotension.

Benzodiazepines can INCREASE flashbacks

Dr. Cronkright, Syracus, NY: amitriptyline first line for PTSD-assoc back pain

Trauma-Informed CareTrauma: an event that overwhelms an

individual’s capacity to cope

PTSD can result from the trauma, but not inevitably

Key principles of trauma-informed care:Trauma awarenessEmphasis on safety and trustOpportunity for choice, collaboration and

connectionStrengths-based and skill building

What might this mean in a Family Medicine office?

Awareness that many of our patients (refugee and otherwise) are trauma victims

Awareness that ‘simple’ tasks like filling out forms, or taking a medical history, may be difficult for some patients

Sensitivity to physical examination

Reassurance of continuity of care

Reminding patients that they can refuse exams/procedures

London ResourcesMuslim Family Resource Centre for Social

Support & IntegrationArabic and English-speaking psychologistsNon-religious, culturally sensitive, family-centered

model

Family Services Thames ValleyMultilingual counsellors

London Intercommunity Health Centre - Women of the World – several support groups including Iraqi

Eosinophilia & Parasites

Eosinophilia Usually defined as >450 absolute EO/L (ie 0.45)

Mild – up to 1500 Severe >3000 – refer urgently (ID/Heme/Allergy-Immunology)

“Worms, wheezes, and weird diseases”

Most common causes in refugees: Ascariasis, filarial infections, hookworm, schistosomiasis,

strongyloides, trichuriasis, toxocariasis

Hx: past living conditions? Soil/water exposure? GI symptoms? Rashes? Hematuria? ROS.

Workup: Repeat CBC, LFTs, stool O&P x 3, u/a, urine O&P (sample put in stool O&P bottle), CXR

EosinophiliaAsymptomatic, stool negative: serology for

strongyloides, schistosomiasis, filariasis, toxocariasis

Empiric anti-helminth treatment recommended for populations at high risk of parasites (eg. Southasian) – single-dose ivermectin/albendazole/mebendazole 100 mg po bid x 3d or 500 mg x 1

Wait 2/12 before repeating CBC

Fail to find cause in about 50%

Symptomatic: organ-specific workup; refer

EosinophiliaNegative stool O&P doesn’t rule out infection

Non-pathogenic parasites in stool: shows you past exposure to contaminated water

Children more likely to have EOphilia and to have multiple concurrent infections

Pregnant women – EO counts go down during pregnant, lowest at delivery – repeat postpartum

ParasitesMost self-resolve within months-years after

arrival in Canada without treatment

Two deserve special mention because they may persist for decades sub-clinically, and can result in significant morbidity and mortalityStrongyloidesSchistosomiasis

StrongyloidiasisCaused by nematode Strongyloides stercoralis

30-100 million people worldwide

Endemic in Africa, Asia, Southeast Asia, Central & South America

Human infection occurs from the nematode infiltrating intact skin, most often bare feet on soil

>10% Iraqi refugees positive

69% of Bhutanese refugees positive

Census data 2001: 77.5% of immigrants to Canada 1991-2001 were from Strongy-endemic countries

StrongyloidiasisMost people develop an asymptomatic, chronic GI tract

infection

Unusual features of its biology can lead to autoinfection, disease persistence, and hyperinfection syndrome in the setting of impaired cellular immunity Hyperinfection has high mortality rate, 70% Common trigger is systemic steroid treatment

Case series of 10 patients with disseminated infection in Toronto 2002 (CMAJ) 4/10 had systemic steroid use; 3/10 had HTLV-1 infection Can cause secondary Gram negative sepsis as nematode

passes through GI wall

StrongyloidesCCIRH Recommendation:

Strongyloides - Screen refugees newly arriving from Southeast Asia and Africa with serologic tests for Strongyloides, and treat, if positive, with ivermectin (first-line therapy) or albendazole (if there are contraindications to ivermectin).

How to test: Serology (100% sensitivity, 88% specificity) Public health req – S06 – “strongyloides serology”

If indeterminate or positive: treat

Complete Health Canada request form

How to Order Strongyloides Treatment

Health Canada Special Access Programme Form for ivermectin (non-licensed)

Available online – Google above

You will be sent medication; call patient in to discuss how to take. Need weight of patient.

3 mg tabs - dose is 200 micrograms/kilogram/day x 2 days; repeat in 2 weeks

ask for number of tabs needed

Word of Caution African countries considered endemic for Loa loa

(presumptive ivermectin should not be used for Strongyloides)

AngolaCameroonCentral Africa RepublicChadRepublic of CongoDemocratic Republic of the CongoEquatorial GuineaGabonNigeriaSouth Sudan

Probably best to refer to ID in this case.

Schistosomiasis>200 million people infected worldwide

Second only to malaria in terms of disease burden from parasitic illness

AKA “bilharzia”

Disease caused by parasitic worms Schistosoma mansoni, S. haematobium, and S. japonicum; less commonly, S. mekongi and S. intercalatum.

Schistosomiasis Geographic Distribution

Schistosomiasis Symptoms

Early – can be asymptomatic

Can have rash within days

Can have fever, chills, cough, myalgias within 1-2 months

When adult worms are present, the eggs that are produced usually travel to the intestine, liver or bladder, causing inflammation or scarring. Children who are repeatedly infected can develop anemia, malnutrition, and learning difficulties. After years of infection, the parasite can also damage the liver, intestine, lungs, and bladder. Rarely, eggs are found in the brain or spinal cord and can cause seizures, paralysis, or spinal cord inflammation.

Long term – bladder cancer, infertility, other

Symptoms of schistosomiasis are caused by the body's reaction to the eggs produced by worms, not by the worms themselves.

Schistosomiasis Treatment

Schistosomiasis – Post-Treatment

CCIRH: Serologic testing after treatment for schistosomiasis is not recommended, as the antibodies tend to persist over time.

All treated individuals should be followed prospectively for clinical signs or symptoms of persistent infection and to ensure that eosinophil counts remain within or return to normal limits within six months of receiving effective treatment.

Should patients have persistent symptoms and/or eosinophilia after six months, should be pursued.

Other conditions

Type II DiabetesCCIRH: Screen immigrants and refugees >age

35 from high risk groups South AsianLatin AmericanAfrican

Iron deficiency anemiaCCIRH: Screen women of reproductive age with

serum hemoglobin

“VFR” Travel – Visiting Friends & Relatives

Travelers returning to their country of origin to visit family & friends, especially those traveling from a developed to a developing country

Often at greater risk of illness because of several factors May believe they are immune to diseases present in country of origin Less likely to consult pre-departure travel clinics; take malaria prophylaxis More likely to visit remote areas and be exposed to local infection risks May be cost barriers to recommended travel immunizations and malaria

prophylaxis Barriers or unawareness of travel medicine clinics Lack of adequate screening and immunization care in country of settlement Travel may be last-minute, eg. attending a family member’s funeral May travel during pregnancy; with small infants and children

Ask about upcoming travel plans; let patients know about the Travel Clinics; give presumptive advice about illness eg. management of diarrhea in young children; be on alert especially with fever in returning travelers

Practice Management Tips

Practice Management TipsUse certified interpreters – Across Languages

Can be used to convey information to patients eg. asking them to follow up

Book longer time for visits

Have patience – you won’t cover everything in one visit. Have them book follow up before they leave your office.

If newly arrived, plan regular visits every 1-3 months.

When referring, consider hospital-based specialists – may be easier to arrange interpreters and for patients to arrange transportation

Practice Management TipsAsk for help – refer ID/other; email colleagues &

specialists; connect with online listserv, etc.

Excellent conference every June – Toronto/RochesterNorth American Refugee Health Conference

ResourcesCaring for Kids New to Canada – Canadian

Pediatric Society – kidsnewtocanada.ca

Sick Kids – aboutkidshealth.ca – multilingual patient handouts

ccihrken.ca

AcknowledgementsDr. Bhooma Bhayana

Dr. Sherin Husein

Canadian Collaboration for Refugee & Immigrant Health

Refugee patients

Questions?