#196 LIVE! Refugee Health with Tanuja Devaraj MD

February 24, 2020 | By Paul Williams

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.

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Credits

Producer: Paul Williams MD, FACP

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

Sponsor

ACP’s Medical Knowledge Self Assessment Program, MKSAP 18. MKSAP provides the latest and most comprehensive educational content needed by internists today. It’s THE internal medicine go-to resource for continuous learning and Board preparation. Visit http://www.acponline.org/mksapcurbsiders to place your order!

Time Stamps

• 00:00 Sponsor -ACP’s MKSAP 18 http://www.acponline.org/mksapcurbsiders 
• 00:15 Intro, disclaimer, guest bio
• 02:08 Guest one-liner, book recommendations, career advice
• 07:12 Picks of the Week*: Full Catastrophe Living – Jon Kabat-Zinn (book); Exit West: A novel – Mohsin Hamid; Ad Astra (film); Snuff – Terry Pratchett (book)
• 09:36 Sponsor -ACP’s MKSAP 18 http://www.acponline.org/mksapcurbsiders 
• 10:30 Defining terms refugee, asylee, migrant
• 12:08 Bhutan and The Buthanese refugee population
• 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
• 47:50 Outro

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

Definitions

• 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.

Butanese refugees

• Refugee population from Bhutan
• In the 1990s, forced to leave Bhutan and flee to refugee camps in Nepal
• Predominantly Hindu
• 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
  • The CDC has specific guidelines for these examinations
    • Focused on protection of public health
    • Usually include screening for latent or active TB, HIV, hepatitis B, syphilis, gonorrhea, and possible lab screenings for chronic illness
    • There is sometimes variability in implementation of these guidelines
    • Most patients have gotten TDaP and MMR prior to this examination
• Routine primary care visit
  • Can sometimes occur years after the initial domestic screening history
    • Due to cultural perceptions of health and barriers to access
  • General screening measures include a CBC (for nutritional status) and obtaining vaccination history
    • Check Hep B and varicella titers prior to empirically immunizing (expert opinion)
    • Check for strongyloides serologies (IgG) if from endemic area (expert opinion; more at the CDC website)
  • Chronic illnesses can present at younger age
    • Diabetes and hypertension specifically
      • Rates in native countries often very high
      • Can be exacerbated by globalization
    • Have a low threshold for screening Hgb A1c and lipid panel even in younger patients
    • Screen aggressively for hepatitis B and C

Obtaining a Migration History

• Key component of social history
• CDC and UNHCR are helpful resources for background information, and Global Burden of Disease visualization can give more country-specific health information
• Important questions to consider:
  • When did they migrate and how long had they lived in the refugee camps?
    • What was life like there?
    • What was their access to education, food, and healthcare?
  • What was their migration to the U.S. like?
    • Who is in the household?
    • What barriers did they encounter during migration?
  • What has their adjustment process been like?
    • What has been difficult and what is going well?
  • What has your healthcare been like?
    • What medications are you taking?
    • What have you taken in the past?
    • When was the last time you saw a doctor?

Potential Barriers to Care

Language

• Interpreter services are variable, but highly recommended

Culture

• There is often little concept of primary or preventive care
  • The perception may be that physician visits are for acute illness only
• It is sometimes difficult to overcome cultural perceptions of certain illnesses

Navigation of the healthcare system

Limited access to insurance

• There is initial coverage by Refugee Medical Assistance for 8 months after arrival
  • This is often followed by a lapse in care
• Application for further medical assistance is often burdensome and state-dependent

More Barriers

• Obtaining prior records is often challenging
• Access to mental health support can be difficult

Mental health concerns among refugees

• One of the most common medical problems seen in the primary care setting
• Can includes anxiety, adjustment disorder, depression, and PTSD
• PTSD and depression rates may be as high as 30% in the refugee population (Kronick, 2018)
  • Suicide is twice as common than among U.S. born population
• Migration is intrinsically stressful and traumatic
• Older patients may have greater difficulty assimilating
• Manifestations of mental health issues are often somatic (Aragona, 2010)
  • Can include chronic pain and gastrointestinal symptoms

Evaluation for trauma

All refugees should be screened for trauma

• There is a 2-question screening tool that is useful (CDC recommended):
  • Have you ever experienced trauma or violence in the former country you resided in?
  • If you did, would you like to talk about it? 

Other validated tools:

• Harvard Trauma Questionnaire
• Hopkins Symptom Checklist
  • Validated in refugee populations for different cultures and languages
• PCL 5
  • Useful for diagnosis of PTSD
• GAD-7 and PHQ-9 are useful for evaluation for anxiety and depression, respectively
• There may be initial resistance to discussion
  • Establish relationship and address specific concerns, and re-visit if necessary (expert opinion)

Goal

Listeners will develop an approach for the management of the refugee patient in the primary care setting.

Learning objectives

After listening to this episode listeners will…  

1. Describe the differences between refugees, asylees, and migrants.
2. Recognize the exposure to healthcare and health screenings that have occurred prior to the initial primary care visit.
3. Be able to obtain a thorough and relevant migration history.
4. Navigate the potential barriers that can arise during the refugee primary care visit.
5. Demonstrate the ability to screen for trauma and common mental health concerns in the refugee population.

Links*

1. Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain, and Illness – Jon Kabat-Zinn
2. Exit West: A novel – Mohsin Hamid
3. Ad Astra 
4. Snuff – Terry Pratchett

*The Curbsiders participates in the Amazon Services LLC Associates Program, an affiliate advertising program designed to provide a means for sites to earn advertising commissions by linking to Amazon. Simply put, if you click on our Amazon.com links and buy something we earn a (very) small commission, yet you don’t pay any extra.

References

1. CDC Guidelines for the domestic screening examination: [https://www.cdc.gov/immigrantrefugeehealth/guidelines/domestic/domestic-guidelines.html]
2. CDC background on Bhutanese refugees: [https://www.cdc.gov/immigrantrefugeehealth/pdf/bhutanese-health-profile.pdf]
3. Crosby S. Primary Care Management of Non–English-Speaking Refugees Who Have Experienced Trauma: A Clinical Review.  JAMA 2013. [https://www.ncbi.nlm.nih.gov/pubmed/23925622]
4. Terasaki G et al. Care of Adult Refugees with Chronic Conditions.  Medicine Clinics of North America 2015. https://www.ncbi.nlm.nih.gov/pubmed/26320045
5. Kronich R.  Mental Health of Refugees and Asylum Seekers: Assessment and Intervention. Can J Psychiatry. 2018. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5912300/]
6. Aragona et al. The relationship between somatization and posttraumatic symptoms among immigrants receiving primary care services. J Trauma Stress. 2010. [https://www.ncbi.nlm.nih.gov/pubmed/?term=20931663]

Disclosures

Dr. Devaraj reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures. 

Citation

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.