Date Published: March 18, 2018
Publisher: The American Society of Tropical Medicine and Hygiene
Author(s): Tarissa Mitchell, Deborah Lee, Michelle Weinberg, Christina Phares, Nicola James, Kittisak Amornpaisarnloet, Lalita Aumpipat, Gretchen Cooley, Anita Davies, Valerie Daw Tin Shwe, Vasil Gajdadziev, Olga Gorbacheva, Chutharat Khwan-Niam, Alexander Klosovsky, Waritorn Madilokkowit, Diana Martin, Naing Zaw Htun Myint, Thi Ngoc Yen Nguyen, Thomas B. Nutman, Elise M. O’Connell, Luis Ortega, Sugunya Prayadsab, Chetdanai Srimanee, Wasant Supakunatom, Vattanachai Vesessmith, William M. Stauffer.
With an unprecedented number of displaced persons worldwide, strategies for improving the health of migrating populations are critical. United States–bound refugees undergo a required overseas medical examination to identify inadmissible conditions (e.g., tuberculosis) 2–6 months before resettlement, but it is limited in scope and may miss important, preventable infectious, chronic, or nutritional causes of morbidity. We sought to evaluate the feasibility and health impact of diagnosis and management of such conditions before travel. We offered voluntary testing for intestinal parasites, anemia, and hepatitis B virus infection, to U.S.-bound refugees from three Thailand–Burma border camps. Treatment and preventive measures (e.g., anemia and parasite treatment, vaccination) were initiated before resettlement. United States refugee health partners received overseas results and provided post-arrival medical examination findings. During July 9, 2012 to November 29, 2013, 2,004 refugees aged 0.5–89 years enrolled. Among 463 participants screened for seven intestinal parasites overseas and after arrival, helminthic infections decreased from 67% to 12%. Among 118 with positive Strongyloides-specific antibody responses, the median fluorescent intensity decreased by an average of 81% after treatment. The prevalence of moderate-to-severe anemia (hemoglobin < 10 g/dL) was halved from 14% at baseline to 7% at departure (McNemar P = 0.001). All 191 (10%) hepatitis B–infected participants received counseling and evaluation; uninfected participants were offered vaccination. This evaluation demonstrates that targeted screening, treatment, and prevention services can be conducted during the migration process to improve the health of refugees before resettlement. With more than 250 million migrants globally, this model may offer insights into healthier migration strategies.
Worldwide, an unprecedented 65 million people—approximately 1% of the world’s population—are forcibly displaced.1 Since 1975, the United States has resettled more than three million refugees, with 85,000 arriving in 2016.2 United States–bound refugees have three organized health encounters during resettlement: 1) required initial overseas examination, performed 2–6 months before travel to detect and treat “inadmissible” public health conditions (primarily tuberculosis [TB]). The required elements of this examination include medical history (including history of mental health or substance abuse issues), complete physical examination, evaluation for TB either by tuberculin skin test or chest X-ray (depending on age), laboratory testing for gonorrhea and syphilis, and screening for other communicable diseases of public health concern when applicable3; 2) predeparture examinations for fitness-to-travel and presumptive treatment of soil-transmitted helminths (STH) and Strongyloides, usually conducted 3–5 days pretravel by physicians from the International Organization for Migration (IOM)4; and 3) voluntary domestic medical examinations, performed by U.S. state or local health departments within 90 days after arrival.4 The Centers for Disease Control and Prevention (CDC) provides recommendations for domestic examination, but implementation varies by state.
During the initial overseas medical examination, we offered voluntary testing and management for anemia, hepatitis B virus (HBV) infection, and intestinal parasites to a convenience sample of U.S.-bound refugees aged ≥ 6 months living in three camps on the Thailand–Burma border. These conditions were chosen because of their known high prevalence in this region6–8 and the potential to improve travel fitness or prevent disease by early screening or intervention. The 6-month age cutoff was chosen because physiologic anemia can occur in younger infants.9 Written consent was obtained from participants ≥ 15 years of age and parents or guardians of those < 15 years old (during the overseas medical examination process, refugees ≥ 15 years old are considered adults). Blood and stool samples were collected during the three examinations previously described (Supplemental Figure 1). Initial and predeparture time points were defined by dates of first and last examinations overseas, respectively, as repeat medical examinations were required for participants who did not depart within 6 months of the initial examination. Participants with identified medical conditions underwent management and evaluation based on clinical judgment and algorithms (Supplemental Figures 2–4, Supplemental Table 1). To facilitate follow-up, results were communicated to U.S. state refugee health programs directly via secure fax. States sent available, domestic examination results to CDC. We offered enrollment to all 3,419 U.S.-bound refugees having initial medical examinations during July 9, 2012 to November 29, 2013 and enrolled 57% (2,004) (Table 1). Among participants, 42% (848) were < 18 years old and 52% (1,038) were male (Table 1). Complete or partial results were available for all participants at initial, 89% (1,794) at predeparture, and 39% (777) at domestic examinations. Median time between initial and predeparture time points was 167 days (interquartile range [IQR]: 135–326; min–max: 33–1,013), and 35 days between predeparture and domestic examinations (IQR: 27–50; min–max: 11–393). This evaluation demonstrated that selected public health services, including intestinal parasite treatment, are logistically feasible and can improve health for refugees in the 2- to 6-month overseas resettlement processing window. Source: http://doi.org/10.4269/ajtmh.17-0725