Authors: Ruegba Bekibele, MBBS; Lily Rubenstein, BSN, PHN; Sheyanga Beecher, CNP, MPH; Stacene Maroushek MD, PhD, MPH
INTRODUCTION
The Minnesota Department of Health Refugee Health Program (MDHRHP) aims to protect and promote the health of newcomer populations in Minnesota. The program assists in coordinating Refugee Health Assessments, supports new arrivals to Minnesota with complex medical needs, trains and supports providers in best practices and analyzes, summarizes, and shares data on newcomer health in Minnesota.
Newcomer populations often have unique clinical needs across the continuum of care. Knowing the steps of medical assessment and intervention before and after the resettlement process are key to being able to provide effective and efficient healthcare.
CASE EXAMPLE
A 10-year-old Afghani girl is brought in by her family for a routine well child check at the pediatric clinic. This visit was coordinated by the local public health agency and medical records have been made available prior to the visit. With the aid of a Pashto interpreter, the provider is able to determine that the family moved to the United States two months ago under the refugee resettlement program. The family shares their records of the overseas medical exam and immunization history paperwork.
A detailed review of systems is positive only for intermittent abdominal pain. After briefly reviewing the family’s diet, the mom shares the family has been eating more processed foods and packaged meals since arriving in Minnesota. The patient is straining with bowel movements which have been more infrequent than previously. The mother also mentions that the patient was found to have “low blood level” during the patient’s pre-departure screening at the refugee camp in Pakistan. The patient has no other past medical or surgical history. She has no known history of allergies.
Mom also says that the family has been stressed by the recent loss of patient’s paternal grandma who died of tuberculosis (TB) in Kabul last year. Family history is otherwise unremarkable. The patient lives with her parents and five siblings in temporary housing provided by the refugee resettlement program. The family has health insurance coverage under Medical Assistance. The patient and her siblings are enrolled in school. Transportation still remains a concern.
Vital signs: Temp 99.8, HR 107, RR 18, BP 96/54. The patient is tracking along the 15th percentile for weight and 20th percentile for height. Physical examination is remarkable for conjunctival and palmar pallor suggesting mild anemia and multiple carious teeth.
The provider orders a complete blood count with differential, lead test, and interferon gamma release assay (IGRA) TB blood test, Hepatitis A, Hepatitis B and HIV. Review of the patient’s immunization history paperwork and the CDC Childhood and Adolescent Immunization schedule indicates that the patient is due for Human Papilloma Virus (HPV) vaccine and Varicella vaccines for which the family consents. The provider review ways to increase fiber in the new diet and prescribes a course of polyethylene glycol laxative powder. The provider also counsels the family on dental hygiene. A dental referral is placed and the social worker is consulted to help co-ordinate transportation and provide the family with resources for housing. A two-week follow up visit is scheduled.
At the follow-up visit the doctor reviews the results of investigations with the patient’s caregiver. The CBC was remarkable for anemia with hemoglobin of 10g/dl, RDW 17%, MCV 65fL and RBC within normal range. Lead, IGRA TB blood test, Hepatitis A, Hepatitis B, and HIV were all negative. At this follow up visit, the patient initiates the Hepatitis A and B vaccine series and is started on a multi-vitamin with iron. Mother reports the patient is having softer stools and less abdominal pain. She also notes that they have an upcoming appointment with the dental clinic in 2-months’ time. The patient is discharged home with plans to follow up. The provider completes the Refugee Health Assessment Form (https://www.health.state.mn.us/communities/rih/hcp/assesfrm.pdf) and sends it directly to the local public health contact.
In three months, the patient is brought in by her mother for her follow up appointment. Mom has no new concerns. A review of the growth chart reveals that the patient is now tracking along the 25th percentile for weight and remains at the 15th percentile for height. A repeat CBC and IGRA TB blood test are normal. The patient no longer has abdominal pain. When asked about patient’s mental health and how the family is coping with paternal grandmother’s loss, Mom says the patient is seeing her school counselor. The family still lives in a temporary housing and relies on public transport. Dad is working on getting a job. Mom says they would like to establish care with this provider. The provider reaches out to the social worker to help with community resources for jobs and transportation needs. The social worker gets in touch with the family’s case worker at the local resettlement agency and discusses the families need and plan to address social determinant of health needs in more detail.
DISCUSSION
Immigration and visa status can have implications for one’s health as it determines benefits eligibility and the health care a newcomer may have received prior to and after arrival to the United States. MDHRHP works with arrivals who are eligible to receive Office of Refugee Resettlement benefits, including (but not limited to) refugees, Asylees, Special Immigrant Visa holders, Certified Victims of Human Trafficking, and certain humanitarian parolee groups. This article focuses on two of the largest populations currently served by the MDHRHP, refugees and those with humanitarian parole.
A refugee is someone who has experienced past persecution or has a well-founded fear of persecution on account of their race, religion, nationality, membership in a particular social group, or political opinion.
Humanitarian parole is a temporary status which gives individuals permission to be in the US legally for urgent humanitarian reasons. There are currently programs for those from Ukraine, Haiti, Cuba, Nicaragua, and Venezuela to seek humanitarian parole1,2.
Of note, asking one’s immigration status during a health care exam is not recommended as doing so may cause undue anxiety. However, one can ask about any overseas health screening as a surrogate because it is important to determine whether a patient has received any previous health exams.
Health Care Assessments Before and After Resettlement
Overseas Medical Exam
Those with refugee status receive an Overseas Medical Exam (OME) within six months of departure by a Panel Physician who is selected by the US Embassy and performs OME according to CDC recommendations3. The OME consists of several components including a medical history and physical examination and assessment for diseases of public health significance including Tuberculosis. However, Hepatitis B and HIV screening may not be included. Patients also receive some immunizations that are age-appropriate according to ACIP guidelines and protect against outbreak prone diseases or diseases that have been, or are in the process of being eliminated in the US4. Immunizations depend on availability in the country of departure which may vary. Consequently, refugee arrivals may not have received all ACIP-recommended immunizations at the time of arrival.
Within 1-2 weeks of departure, an abbreviated medical exam is performed (Pre-Departure Medical Exam). At this time, individuals may receive additional lab testing such as a COVID-19 and/or pregnancy test, additional immunizations, and presumptive treatment for parasitic infections5 and malaria6 if clinically appropriate.
The Refugee Health Assessment and Linkage to Primary Care
Thirty to ninety days after arrival in Minnesota, refugee arrivals receive an optional, but strongly recommended, comprehensive health assessment7 coordinated by MDHRHP and local public health agency in the county of residence. This visit is performed by physicians, PAs, and NPs who have been trained by the MDHRHP and consists of a history and physical, infectious disease, lead, and mental health screening, immunizations, and referral to ongoing primary care or specialty care as needed. Results are returned to the MDHRHP and monitored for trends. Aggregate results are shared to state and national partners.
Some Refugee Health Assessments are performed by primary care providers, and some are performed at more specialized clinics such as a city public health clinic. Newcomers may opt to stay with their assessment provider for ongoing primary care or move to a different provider or clinic. Those that receive their assessment at a public health clinic without ongoing primary care services will be referred to an alternate clinic.
Humanitarian parole health requirements
Those with humanitarian parole generally do not receive an OME. They may or may not be eligible to receive a Refugee Health Assessment depending on whether they have been granted Office of Refugee Resettlement benefits. For questions on which populations currently qualify, please reach out to MDHRHP. Several humanitarian parolee groups have health requirements set by the US Citizenship and Immigration Services office. These include, one measles, one polio, and one COVID-19 vaccine prior to departure, and completion of the COVID-19 series and an IGRA test within 90 days of arrival.
Medical records
Newcomers are provided with a copy of their Overseas Medical Exam records. The MDHRHP is also provided with a copy of these exams from the CDC and share them with the Refugee Health Assessment provider. These records hold lab results, immunizations, and history and physical results. A profile in the Minnesota Immunization Information Connection (MIIC) is established once these records are received, generally within 1-2 weeks after arrival. If a newcomer has not received an OME and not received care elsewhere, there may not be a MIIC profile.
Humanitarian parolees may have a copy of their immunization records and IGRA test results, or may be able to provide information on where domestic health care occurred. This information is not routinely collected by the MDHRHP.
For domestic records, determine where the Refugee Health Assessment occurred and request medical records per routine clinic processes. If the patient cannot remember where the RHA took place, please contact MDHRHP.
In addition to refugees, asylees, special immigrant visa holders, certified victims of human trafficking, and certain humanitarian parolee groups, there are other populations of foreign-born children, including unauthorized immigrants without any history of health screenings or immunization records. These patients also seek care in primary care clinics for routine well child checks and require thoughtful assessment and assistance navigating complicated healthcare needs. For additional information, please refer to Screening and Healthcare of Immigrant Children8 and the American Academy of Pediatrics toolkit on serving immigrant children https://downloads.aap.org/AAP/PDF/cocp_toolkit_full.pdf
Works Cited
- US Citizenship and Immigration Services. (2023, July 12). Process for Cubans, Haitians, Nicaraguans, and Venezuelans. https://www.uscis.gov/CHNV
- US Citizenship and Immigration Services. (2023, July 12). Uniting for Ukraine. https://www.uscis.gov/ukraine
- Centers for Disease Control and Prevention. (2019, October 16). Immigrant, refugee and migrant health, Panel physicians. https://www.cdc.gov/immigrantrefugeehealth/panel-physicians/introduction-background.html.
- Centers for Disease Control and Prevention. (2023, May 12). Immigrant, refugee and migrant health, Panel physicians on vaccines. https://www.cdc.gov/immigrantrefugeehealth/panel-physicians/vaccinations.html#:~:text=The%20panel%20physician%20must%20counsel,the%20vaccines%20they%20are%20using.
- Centers for Disease Control and Prevention. (2021, March 16). Presumptive treatment and screening for strongyloidiasis, infections caused by other soil-transmitted helminths, and schistosomiasis among newly arrived refugees. https://www.cdc.gov/immigrantrefugeehealth/guidelines/domestic/intestinal-parasites-domestic.html.
- Centers for Disease Control and Prevention. (2019, September 13). Presumptive treatment of P. falciparum Malaria in refugees relocating from sub-Saharan Africa to the United States. https://www.cdc.gov/immigrantrefugeehealth/guidelines/domestic/malaria-guidelines-domestic.html
- Minnesota Department of Health. (2023, March 3). Minnesota Domestic Refugee Health Screening Guidance. https://www.health.state.mn.us/communities/rih/guide/index.html.
- Maroushek, SR. Screening and Healthcare of Immigrant Children, In: Nelson Textbook of Pediatrics, 20th Edition. Editors: Robert Kliegman, Richard Behrman, Hal Jenson, and Bonita Stanton. Elsevier Press, Philadelphia, PA, (2015).
