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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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
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
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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.
Comments
February 25, 2020, 9:39pm Mary Theresa Forbes writes:
I am glad that Dr. Tanuja Devaraj disregarded the negative comment and continued with her career. Unfortunately, this happens too often. Everyone's talents are different. I appreciate the work that she is doing. I found this episode delightful and very informative.
Thank you,
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Comments
I am glad that Dr. Tanuja Devaraj disregarded the negative comment and continued with her career. Unfortunately, this happens too often. Everyone's talents are different. I appreciate the work that she is doing. I found this episode delightful and very informative. Thank you,