migrant health: best practices & travel medicine

Migrant Health: Best

Practices & Travel Medicine

William Stauffer

University of Minnesota CISTM Quebec, Canada

May 26, 2015

• Financial disclosure (Critical Measures: Cultural Health Care Education) • If we discuss any off label uses of medications we will disclose to the audience

Objectives

•  Important health issues in migrant populations •  Important screening tests & health

interventions to promote migrant health •  Important opportunities to promote health in

the pre-travel setting

•  Hopefully have fun…

Thanks to Chris Greenaway innovative topic that I struggle with but never thought of as a presentation topic.

Humans and mobility •  Human migration has occurred as long as humans have

been on the planet – first left Africa ~60 million years ago •  UK is home to the most diverse community in the world •  There are at least 1,000 French-born people living in each

of 83 different countries •  The number of immigrants living in Spain grew ~8 fold

between 1990-2013 •  The POOREST countries have the LEAST number of

emigrants •  84% of UAE population is foreign born

Humans and mobility •  More than 200 million people live outside their

country of birth •  3% of the world’s population •  5th most populated country in the world

•  In US: •  ~13% of population 1st generation FB •  Estimated 45,790,000 were born outside the US •  Miami >60%, NYC >30%

•  Almost uniformly most vulnerable and disenfranchised in health systems

11Source: Population Action International 1994

Migrating Populations, 1960-1975

22

•• 2000: 175 million; >4x increase from 1975 2000: 175 million; >4x increase from 1975

•• 2050: 230 million2050: 230 million

Sources: Population Action International 1994, International Org anization for Migration, 2003

Migrating Populations, 1990 -2000

Guidelines for migrant health screening

•  United States •  CDC (refugee & international adoptee) •  AAP (in process for all migrants & international adoptee)

•  Canada •  CMAJ—Canadian Collaboration for Immigrant and

Refugee Health (2011)

•  Australia •  Refugee

•  UK •  Migrant Health Assessment Sub-committee of HPSC

Scientific Advisory (2015)

•  Europe •  Call for development

Common components

•  History & physical •  Routine blood & urine testing

•  CBC with diff, renal fxn, pregnancy

•  Tuberculosis •  Chronic or regulatory infections

•  HIV, syphilis, GC/Chlamydia, hep C

•  Parasitic testing •  Stool, focus on strongyloides & schistosomiasis

•  Misc (e.g. Toxins, vitamins) •  Lead, B12

•  Vaccine recommendations, including testing for active hepatitis B

Also disease specific guidelines

•  Common diseases/infections •  Hepatitis B •  HIV •  Hepatitis C •  TB •  Lead •  Chronic non-communicable diseases (e.g. HTN, Diabetes,

lipids) •  Cancers (breast, colon, prostate)

•  Health Prevention Guidelines •  Vaccination •  Dental •  Vision •  Hearing

Why Screen?

•  Public Health and/or Regulatory (not necessarily the same)

•  Patient Centered Care •  Tenants of Screening

How, when and why can pre-travel visit overlap with screening & preventive measures in migrants?

•  Point of Contact: frequently disenfranchised population with limited health care access

•  Travel providers may be more educated and aware

of certain diseases, particularly infections, that affect migrants (disease disparity)

•  A travel provider cares about preventing

morbidity and mortality and has the opportunity by definition—this is an added opportunity

Hang with me ☺

•  Case based examples (5 cases) •  A bit of “read my mind” & show and tell •  Please, at the conclusion, question, add or

subtract…

Case #1

33 yo female of Korean descent (adopted age 4 years), traveling to India (Mangalore) for 1 month for wedding (marrying an Indian gentlemen). •  Past Medical History

•  Had an ASD repaired as a child •  Seasonal allergies

•  Meds •  Intranasal steroid prn

Case #1

33 yo female of Korean descent (adopted age 4 years), traveling to India (Mangalore) for 1 month for wedding (marrying an Indian gentlemen). •  Immunizations

•  Tdp UTD •  Polio UTD •  HPV completed •  Hep B UTD •  MMR UTD •  Hep A none •  VZV—had chicken pox as child

Case #1

33 yo female of Korean descent (adopted age 4 years), traveling to India (Mangalore) for 1 month for wedding (marrying an Indian gentlemen).

•  Where is your opportunity? •  Immunizations


Highlight Case

19 y/o Vietnamese male presents to the ED with 2 months wt loss, low grade fevers, swelling of the abdomen.

• Exam

•  cachectic male with protuberant abdomen and the liver is > 10 cm below the costal margin with multiple palpable, non-tender nodules. In addition there is a fluid wave and he has pitting lower extremity edema.

Highlight Case

•  Laboratory WBC: 9 Hgb: 9.8 (MCV 68) Plt.: 130 ESR: 88 ALT: 599

Diagnostic lab test returns

Alpha-fetoprotein 889

Highlight Case

•  Laboratory WBC: 9 Hgb: 9.8 (MCV 68) Plt.: 130 ESR: 88 ALT: 599

Diagnostic lab test returns Alpha-fetoprotein 589

Alpha-fetoprotein 889

19 y.o. Vietnamese male with abdominal pain,

increased alpha-fetoprotein

The most likely etiology of this hepatocarcinoma is:

a.  Hepatitis B b.  Aflotoxin c.  Hepatitis C d.  Schistosomiasis

Hepatocellular carcinoma

•  4th most common cause of cancer related deaths in world: 610K/year

•  A vaccine preventable cancer •  Treatment available •  Population specific cancer screening

Hepatitis B

•  CDC recommends testing for:

•  Individuals born in areas where prevalence of HBsAg is ≥ 2%, regardless of immunization status in country of origin

•  US-born persons not immunized during infancy born to

parents in regions with prevalence of HBsAg ≥ 8%

Weinbaum CM et al. MMWR. 2008; 57(RR08);1-20.

Geographic distribution of hepatitis B, 2009

Hep B

•  ~240 million infected worldwide, 1.2 million in US •  15-25% lead to severe liver disease and/or cancer •  FYI: Asia pacific islanders make up <5% of total

US population, account for more than 50% of chronic infections.

Hepatitis B infection Among Refugees by Region of Origin, Minnesota, 2013

0%

1%

0%

8%

5%

6%

0% 5% 10% 15% 20%

Europe

North Africa/Middle East

Latin America/Caribbean

SE/East Asia

Sub-Saharan Africa

Overall Hepatitis BInfection Rate

Refugee Health Program, Minnesota Department of Health

N=2,050 screened

122/2,050

43/897

77/990

0/8

2/152

0/3

Case #1


•  Where is your opportunity? •  What do you want to do with her immunizations?


Case #1


•  Where is your opportunity? •  What do you want to do with her immunizations?

•  Anti-B surface antibody positive •  Anti-B core antibody negative •  Hepatitis B surface antigen positive •  Hepatitis A antibody positive

Case #1 Main Point

•  Always consider hepatitis B infection, even if documented vaccination (but no documented testing)

Case #2

58 yo Hmong male traveling to Chang Mai Thailand for 3 weeks to VFR. •  PMHx

•  Glaucoma •  Uric acid kidney stones •  Chronic renal failure, has met with transplant team •  LTBI (treated with 9 months INH)

•  Meds •  Aspirin •  Lisinopril •  Topical steroids

•  Social History •  Moved as refugee to US in 1993 •  Five children, 8 grandchildren

Case #2

58 yo Hmong male traveling to Chang Mai Thailand for 3 weeks to VFR. •  Immunizations

•  Tdp UTD •  Polio UTD •  Hep B UTD (neg HBsAg) •  MMR UTD •  Hep A immune by serology •  VZV—immune by serology

Case #2

58 yo Hmong male traveling to Chang Mai Thailand for 3 weeks to VFR. •  Where is your opportunity?

Highlight Case

•  One week prior •  55 year old Hmong m presented with

wheezing & SOB. •  He was placed on prednisone for

“asthma”.

•  Today, presents w/ fever, rash, confusion & abdominal pain.

•  Quickly develops septic shock, E. coli bacteremia & dies.

•  Had moved to Minnesota > 15 years prior from Thailand.

Photo provided by Charles Cartwright, PhD

55 y.o. Hmong male with SOB/Wheezing

Most likely diagnosis is? a.  Urosepsis b.  Ruptured viscous c.  Strongyloidiasis d.  Melioidosis

Pt. Age Ethnicity Time in US

Outcome

1 42 Cambodia 6 mo Recovery 2 24 Hmong 3 yrs Recovery 3 34 Hmong >5 yr Recovery 4 52 Vietnamese >5yr Recovery 5 46 Hmong 8 yrs Death

6 69 Hmong 4 yrs Death

7 72 Laotian 7 yrs Death

8 49 Vietnamese >5yrs Recovery 9 34 Hmong 4 yrs Death

Newberry AM, CHEST 2005;128(5):3681-4.

Newberry AM, CHEST 2005;128(5):3681-4.

Strongyloides stercoralis disseminated/hyperinfection Syndrome

• More than 100 million people infected with strongyloides worldwide.

•  10 cases of disseminated strongyloides in 7 months in Toronto1

•  151 cases of strongyloides (not disseminated) •  if not diagnosed at time of arrival mean time to

diagnosis was 61 months2

1Lim S. CMAJ 2004;171(5): 479-84 2 Boulware DR, Stauffer WM et al. Am J Med 2007;120(60):545;e1-8

Strongyloides in migrants

•  Strongyloides •  East Africa 11%, Cambodian 42% (Australia)1 •  Lao refugees, 20% positive 12 years after arrival2 •  Burmese and Liberian, over 65% seropositive from migrant

serum bank3

1. Caruana SR, et al. J Travel Med. 2006;13:233-239

2. 3de Silva S, Saykao P, Kelly H, et al. Epidemiol Infect 2002:128(3):439-44. 3. Unpublished research data.

Case #2

•  Test vs. presumptively treat Case #2 Main Point •  Consider strongyloides (do no harm) especially in

high risk migrants who have a likelihood of receiving immunosuppression.

Case #3

•  16 yo Somali female brought by “uncle” to travel to Kenya for 3 months over the summer. •  PMHx

•  No significant

•  Meds •  None

•  Social History •  Family moved to US when she was 4 years of age from

Dadaab. Lives with extended family in “Little Mogadishu” in an apartment with 8 other individuals.

Case #3

•  16 yo Somali female brought by “uncle” to travel 2 Kenya for 3 months over the summer. •  Immunizations/Preventive measures

•  All routine immunizations are UTD •  Had new arrival screening at 4 years of age

•  What opportunity do you see?

Case #3

•  TB screening •  IGRA positive (CXR negative)

•  Scheduled for latent TB treatment

25%

9%

0%

18%

30%

22%

0% 10% 20% 30% 40% 50%

Europe

North Africa/Middle East

Latin America/Caribbean

SE/East Asia

Sub-Saharan Africa

Overall TB Infection

2/8

173/986

N=2,033 screened

*Diagnosis of Latent TB infection (N=446) or Suspect/Active TB disease (N=9)

Refugee Health Program, Minnesota Department of Health

Tuberculosis Infection* Among Refugees By Region Of Origin, Minnesota, 2013

266/886

455/2,033

14/150

0/3

Case #3

•  TB screening •  IGRA positive (CXR negative)

•  Scheduled for latent TB treatment

Red Flag: Wearing headphones, Hijab, says “I am not going”…

Case #3

•  Red Flag: Guesses?

Case #3

•  Female Genital Mutilation

Case #3 Main Point

•  Pre-travel visit is opportunity to identify those at risk of being infected with TB as well as assessing risk and appropriate follow-up after travel.

Case #4

43 yo Congolese female going to Rwanda (outside Kigali) for 9 day trip for funeral—leaving in 5 days. •  PMHx

•  Malaria


•  Social History •  Moved to U.S. 2 years ago to join family (through lottery)

from Rwanda •  4 children, three grandchildren

Case #4

43 yo Congolese female going to Rwanda (outside Kigali) for 9 day trip for funeral. •  Immunizations

•  Tdp had 2 recorded •  Polio has 2 recorded •  Hep B none •  MMR UTD •  Hep A none •  VZV – no vaccine

Case #4

43 yo Congolese female going to Rwanda (outside Kigali) for 9 day trip for funeral. •  What are your opportunities?

Case #4

43 yo Congolese female going to Rwanda (outside Kigali) for 9 day trip for funeral. •  What are your opportunities?

•  Tetanus, diphtheria, pertussis had 2 recorded •  Polio has 2 recorded •  Hep B none •  MMR UTD •  Hep A none •  VZV – no vaccine

Case #4

43 yo Congolese female going to Rwanda (outside Kigali) for 9 day trip for funeral. •  What do you want to do with her immunizations?

•  Boost Tetanus, diphtheria, pertussis & polio (could do select serologies)

•  Anti-B surface antibody negative •  Anti-B core antibody positive •  Hepatitis B surface antigen negative •  Hepatitis A antibody positive •  VZV antibody negative

VZV

•  Mean age of developing disease is 10-15 years in tropical countries (some countries a large percentage of those >35 years are susceptible)

•  Opportunity to vaccinate, especially adolescents1

1Greenaway C, et al. Epidemiol infect 2014;142(8):1695-707

Case #4

•  43 yo Congolese female going to Rwanda (outside Kigali) for 9 day trip for funeral. •  Other Opportunities?

•  Hint: in 2010 the US stopped requiring mandatory testing prior to immigration.

Case #4


• HIV antibody positive, confirmed with PCR

Case #4


• HIV antibody positive, confirmed with PCR

• Rate in Congolese refugees in Rwanda ~3%

HIV Screening

•  CDC •  Basically opt-out, everyone should be tested; annual

testing in high risk persons (MMWR Sept 22, 2006;55(14);1-17.

•  Canada •  Individual requesting •  S/S of infection •  Illness associated with “weakened immune system or a

diagnosis of TB” •  Unprotected intercourse or use of shared drug equipment

with a partner whose HIV status is known to be positive •  Pregnant or planning pragnancy •  Victims of sexual assualt

Case #4

•  43 yo Congolese female going to Rwanda (outside Kigali) for 9 day trip for funeral. •  Even More Opportunities?

Highlight Case

20 yo Somali female presenting with acute abdominal pain, anorexia & fever •  <24 hours, no stool •  No sign PMHx, No Meds •  Social history: moved from Kenya (refugee) 14

months prior to presentation

Highlight Case

20 yo Somali female presenting with acute abdominal pain, anorexia & fever •  Examination

•  RRQ tenderness with sigs of peritoneal irritation (rebound, positive R leg lift)

•  Laboratory •  WBC: 18,000 (N88, L11, E1) •  Hgb 12.4 (MCV nl) •  CRP 14 (nl<0.9) •  Abdominal flat plat (decreased air RLQ)

Case CT: fat stranding, edema of appendix

Case: Abdominal pain, fever

Prevalence of Schistosoma among African Refugees, 1993-2004

•  289/291 (99.3%) Schistosoma cases identified among sub-Saharan Africans

•  Prevalence = 2.4% among African refugees

• Central Africans 6/51 (11.8%) • West Africans 130/2358 (5.5%) • East Africans 153/9445 (1.6%)

•  Schistosomiasis •  Somali, over 80% seropositive from migrant serum bank1 •  Increasing case series and reports on complications after

arrival in the U.S. •  Complications reported due to excessive invasive testing

1.  Unpublished research data.

2.  Summer AP, et al. Hematuria in children. Clin Pediatr 2006;45():177-81.

Parasitic infections in migrants

•  CDC Lost Boys (Sudanese) Reunion Study (n=464)1

•  49% tested positive for strongyloidiasis by serology •  44% tested positive for Schistosomiasis mansoni or

hematobium •  22% seropositive for Both

•  69% were seropositive for Either

1 Posey DL, et al. Clin Infect Dis 2007;45(10):1210-5.

Case #4

•  43 yo Congolese female going to Rwanda (outside Kigali) for 9 day trip for funeral. •  What about strongyloides? •  Do you want to presumptively treat?

Case #4 Main Points

•  Usually multiple opportunities •  Consider HIV testing if appropriate •  Consider other chronic infections with high

prevalence (e.g. schistosomiasis) •  Be aware of Loa loa and risk of presumptively

using ivermectin for strongyloides

Case #5

37 yo Pakistani male planning a 2 week trip to Panama City for business. •  PMHx

•  Asthma and hospitalized for pneumonia 2 years ago (ID saw and had presumptive treatment for strongyloides and serology came back positive)

•  Tested for LTBI and negative 2 years ago •  HIV documented negative


•  Social history •  Moved to US in 1997 with family as immigrant. Has 3

children, married.

Case #5

37 yo Pakistani male planning a 2 week trip to Panama City for business. •  Imminizations

•  Tdp UTD •  Polio UTD •  Hep B UTD (Hep B Antigen negative) •  MMR UTD •  Hep A immune by serology •  VZV—immune by serology

Case #5

37 yo Pakistani male planning a 2 week trip to Panama City for business. •  Opportunity?

Case #5

37 yo Pakistani male planning a 2 week trip to Panama City for business. •  Opportunity? HINT

Case #5

37 yo Pakistani male planning a 2 week trip to Panama City for business. •  Opportunity?

•  Hepatitis C antibody positive, PCR confirmed

Hepatitis C

•  Estimated 170 million cases worldwide, 3.2 million in the US.

•  Certain populations with very high rates •  E.g. Bolivia, Cameroon, Central Republic of Africa, Chad,

China, DRC, Egypt, Guinea, Mongolia, Pakistan, Rwanda, Thailand, Vietnam.

•  Of every 100 persons infected with HCV •  75-85% will develop chronic infection •  60-70 will go on to develop chronic liver disease •  5-20 will develop cirrhosis over a period of 20-30 yrs •  1-5 will die from consequences (HCC or cirrhosis)

Case #5 Main Point

•  Consider Hep C in higher risk populations

Conclusion

•  Disease prevalence varies by population •  The Pre-travel visit represents an opportunity to

screen for chronic infections which have substantial morbidly and mortality •  Hepatitis B •  Strongyloides •  HIV •  TB •  Other Chronic Infections/conditions

•  Hep C •  Schistosomiasis

•  Offers opportunity to up date routine vaccines and to establish care for chronic diseases/infections

migrant health: best practices & travel medicine

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