Practical Tips for Refugee Health in Primary Care. Live from Penn State Hershey!
Develop your approach to refugee health in the primary care setting. We discuss important considerations for primary care of the refugee patient with Dr. Tanuja Devaraj (Penn State), an internist with expertise in migration health. We review barriers to primary care, how to take a migration history, and common health concerns that occur in this patient population. We also discuss strategies for screening for trauma and mental health issues, which are common among patients who have gone through migration.
Writer: Tanuja Devaraj MD and Paul Williams MD, FACP
Infographic: Emi Okamoto MD
Cover Art: Paul Williams MD, FACP
Hosts: Stuart Brigham MD; Matthew Watto MD, FACP; Paul Williams MD, FACP
Editor: Clair Morgan of Nodderly.com (audio), Emi Okamoto MD (written)
Guest: Tanuja Devaraj MD
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15:08 The overseas medical examination (prior to arrival in the US)
17:28 The initial domestic medical examination, primary care visit; Vaccinations; Initial lab testing
21:54 Barriers to refugee health
26:12 Taking a migration history
29:25 Who’s paying for refugee care?
31:08 Mental health and the refugee population
34:20 Screening and addressing past trauma, torture
40:14 Recap; Quick discussion of parasitic infections
45:08 Audience questions: Visits with multiple family members; Additional resources available for refugee health
Refugee Health – Pearls
A refugee is one who has fled their country due to persecution, war, or threat of violence and gained legal protection to enter a host country. An asylee has fled their country and arrives at the host country to seek legal protection. A migrant is anyone who has migrated for educational, economic, or family opportunities.
Refugees will have undergone a visa medical exam and a domestic screening exam before their initial primary care visit. There may be years between these screening exams and an initial primary care visit.
There are guidelines for the initial domestic visits, but variability in their implementation. These are mostly for public health reasons, and focus on screening for infectious diseases.
Prior medical records are often difficult to obtain. Check titers before empirically immunizing for hepatitis B and varicella (expert opinion).
It is important to be mindful of cultural and systematic barriers to refugee health. The use of appropriate interpreter services is highly recommended.
The migration history is the most important part of the social history at the initial primary care visit.
Have a low threshold to screen for chronic illnesses such as diabetes and dyslipidemia, which can present at younger ages.
Mental health issues such as PTSD, anxiety, and depression are very common among refugees, and there are multiple validated tools to screen for these diagnoses.
All refugees should be screened for trauma, and there are several validated tools for this as well.
Refugee Health – In-Depth Show Notes
Refugee: Anyone who has fled their country due to persecution, war, or violence. A refugee is granted refugee status once they have fled to a neighboring country, where upon they are afforded legal protection. Refugee status is ostensibly temporary, and lasts until the party is assimilated into their host country or a third country.
Asylee: Someone who has fled (similar to a refugee) to a host country without prior permission and then applies for legal protection.
Migrant: Anyone who migrates for educational, economic, or family opportunities.
Refugee population from Bhutan
In the 1990s, forced to leave Bhutan and flee to refugee camps in Nepal
Many have come to larger cities like Philadelphia to resettle
PA has largest Bhutanese population
Health care prior to resettlement often provided by UN and host country
Initial Health Screenings
6 months prior to migrating, a visa medical examination is performed
There are specific guidelines from the United States regarding these examinations
This is a generalized exam, focusing on ruling out obvious illness that might prove to be a barrier to migration
These exams typically do not screen for latent tuberculosis or chronic diseases
The visa examination focuses on items like infectious diseases and decompensated mental illness
Most refugees from high-risk areas are given empiric albendazole prior to resettlement
Initial domestic medical examination
Occur upon relocation to the United States
Often done in Department of Health clinics
These exams differ from an initial primary care visit
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Dr. Devaraj reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures.
Devaraj T, Williams PN, Brigham SK, Okamoto E, Watto MF. “#196 LIVE! Refugee Health with Tanuja Devaraj MD”. The Curbsiders Internal Medicine Podcast. http://thecurbsiders.com/episode-list February 24, 2020.