Refugee Health in

Côte des Neiges, 2018

Saint Mary’s Hospital

Family Medicine Centre Grand Rounds

August 29, 2018

Dr. Hannah Shenker MD CCFP

Dr. Ann Katrin Richter MD CCFP

CLSC Côte des Neiges

We have no conflict of interest to declare; We have

no affiliation, honoraria or monetary support from

an industry source.

Case Study 1 Amena

22 year old G3P2 presenting for prenatal care.

Born in Syria, had been living in a refugee camp in

Jordan x 5 years where she met her husband and

gave birth to 2 daughters.

Unilingual arabic

All 4 family members are government sponsored

refugees who arrived in Canada 3 months earlier

Living in an apartment in Villeray with support from

the Centre Sociale d’Aide aux Immigrants (CSAI)

Referred to PRAIDA for a voluntary refugee health

assessment

A Refugee health assessment (BSR) was performed at the CLSC Cote des Neiges by a nurse from PRAIDA

12 weeks pregnant

Iron deficiency

Vitamin D deficiency

OCD and PTSD

Contact dermatitis both hands due to repetitive hand washing

Hyperemesis gravidarum - mild

CBC and Hb electrophoresis normal

HIV, VDRL, HBV, HCV, Strongyloides all negative

Rubella immune, Varicella immune

CXR Normal

Referred to La Maison Bleue for interdisciplicary prenatal care and to RIVO for psychological services

Definitions Asylum seeker;

A person who requests protection from Canada upon

arrival in the country or during a temporary stay.

Under the United Nations’ Convention relating to the Status of Refugees, Canada grants asylum to certain

people on its territory who fear persecution or whose

lives would be in danger if they were to return to their

country of origin.

Canada’s Immigration and Refugee Board evaluates

each application and renders its decision on whether

or not to grant refugee status.

Definitions Refugee

A person who receives protection from Canada

Refugees selected abroad;

admitted to Canada after having spent many years in a refugee camp or because they were persecuted in their own country.

Upon arrival, they either receive assistance from the State, local NGO, or by a group or organization that has agreed to sponsor them.

Refugees recognized in Canada;

Recognized by the Immigration and Refugee Board after submitting an asylum application upon their arrival in Canada.

Definitions A Person without legal status

a tourist or temporary resident who has not renewed

his/her tourist visa or study permit, or whose work

permit has expired, and who has not left Canada

a person whose asylum application has been refused,

who has exhausted all possible recourse and who has

not obeyed a removal order

a person who has illegally crossed the border and has

not reported to the authorities

What are the steps involved in the

asylum application process?

Routine identity, health and security screening performed by the Canada Border Services Agency.

People are directed to temporary shelters.

The Québec government provides essential services to asylum seekers until the Immigration and Refugee Board (IRB) has rendered its decision on whether or not to grant refugee status.

If the IRB recognizes their refugee status, Québec issues a Certificat de sélection du Québec.

If a claim is rejected, individuals may be able to appeal the decision to the Refugee Appeal Division of the IRB

Statistics www.immigration-quebec.gouv.qc.ca

The top 5 birth countries of asylum seekers in

Québec in 2017

Haiti, Nigeria, USA, India, Saudi Arabia

On August 3, 2018 (Montreal):

56 new asylum seekers were provided with

accommodation

842 asylum seekers were being temporarily housed in

the Greater Montreal area

Statistics - cont

Asylum Claims Canada Québec

2016 23, 925 5,525

2017 49, 775 24,980

As of April 17, 2018, 14, 860 asylum seekers were living in Québec while waiting for their claim to be processed by the federal government.

Services offered to Asylum seekers while awaiting evaluation of their claim;

Temporary accommodation

Support to find permanent accommodation

Last resort financial assistance

Healthcare (Federal Interim Health Program)

Language classes

Access to school for minors

https://www.immigration-quebec.gouv.qc.ca/publications/en/divers/Guide-asylum-seekers.pdf

Health Screening of refugees and

asylum seekers performed by the

Canada Border Services Agency

Designed to assess a limited number of public health risks, not to provide preventative screening

Done within 12 months prior to arrival in Canada, or within 60 days of saylum claim in Canada

Physical exam by a designate physician

CXR (>11y)

VDRL (>15y)

UA (> 5y)

HIV (>15y or HIV +ve mother or recipient blood products)

Results are not necessarily linked with any f/u

Patient may not be aware of need for f/u

Results difficult to access as they are property of the government

Refugee Health Assessment Voluntary

Covered by the Interim federal health program

Offered in 14 cities across Québec

PRAIDA is designated service for the Island of Montreal

Well being assessment by a social worker

Health assessment by a nurse

History and physical exam

CBC, Hb electrophoresis, Vit D level

Screening for HIV, VDRL, Shisto, varicella IgG, HBV, HCV, TB

Referral for further assessment or treatment as necessary

Registration on GAMF

CMAJ, September 6, 2011, 183 (12)

Key points from the Canadian clinical

practice guideline for immigrant and

refugee health, 2011

Clinical preventive care should be informed by the person’s region or country of origin and migration history.

Forced migration, low income and limited proficiency in English or French increase the risk of a decline in health and should be considered in the assessment and delivery of preventive care.

Routinely offer:

Vaccination

measles, mumps, rubella, diphtheria, tetanus, pertussis, polio, VZV, hepatitis B, HPV

Screening for

hepatitis B and C, TB, HIV, intestinal parasites (strongyloides, schisto)

iron deficiency, dental pain, loss of vision, cervical cancer

Detecting and addressing the following conditions should be individualized to improve detection, adherence and treatment outcomes.

malaria, depression, PTSD, child maltreatment, intimate partner violence, diabetes mellitus, contraceptive needs, pregnancy

Pregnancy in the Refugee

Population Social Isolation, Depression, PTSD

associated with SGA infants and increased maternal morbidity

Sexual Abuse

Associated with unwanted pregnancies, psychological distress, STIs, PID, reproductive tract trauma, social rejection, infant abandonment or mistreatment

Infectious Diseases – Hep B, HIV, Syphilis, Zika

Hemoglobinopathies

Poor Nutritional Status

Workplace hazards

Female genital mutilation

Higher incidence of HTN Disorders of Pregnancy

Incorrect or incomplete obstetrical histories

Previous cesarien section with unclear indication, no OR report.

La Maison Bleue Centre de Perinatalité sociale

3 sites in Montreal (CDN, Park Ex, St Michel)

Interdisciplinary care of pregnant women and their

children living in contexts of social vulnerability

http://maisonbleue.info/

Case Study 2 Mme Diawara

46yo refugee claimant from Guinea referred to your

clinic from PRAIDA

Known for diabetes treated with glyburide

C/o insomnia and blurred vision

Has been in Canada for 3 weeks with her 2 young

grandchildren

Victim of persecution due to her role educating

and empowering women

Victim of physical and sexual assault

Daughter (mother of her grandchildren) was

imprisoned and has since disappeared

PHYSICAL HEALTH

Has not taken any medication in last 2 weeks

C/o polyuria and polydipsia

Random glycemia is 13.2

MENTAL HEALTH

C/O depressed mood and re-experiencing trauma

Poor overall functioning; difficulty caring for

grandchildren

Children are withdrawn and having nightmares

Making An Asylum Claim In

Canada Asylum claim made in Canada at port of entry or inland with

Immigration, Refugee and Citizenship Canada (IRCC) office

IRCC determines if an individual is eligible to make a claim

if eligible, claim is referred to the Refugee Protection Division of the Immigration and Refugee board of Canada for a hearing

if eligible, claimant has access to social assistance, education, emergency housing, and legal aid while a decision is pending

if decision of refugee claim is positive; person receives the protected person status and can apply for permanent residency

If an asylum claim is rejected by the Refugee Protection Division;

possible to appeal to the Refugee Appeal Division

if no right to appeal; may request the federal court to review the decision

if all appeals are exhausted, removal order becomes enforceable and person either leaves voluntarily or is deported

if eligible, prior to deportation a pre-removal risk assessment

persons who would not normally be eligible to become permanent residents of Canada may be able to apply on Humanitarian and Compassionate grounds

www.canada.ca/en/immigration-refugee-citizenship/services/refugees.html

PRAIDA Programme Regionale d’Acceuil et d’Integration des

Demandeurs d’Asile

located at 3725 St Denis, MOntreal

Mandated by the MSSS

Responds to the needs of individuals requesting refugee status in Quebec

Part of the Integrated Health and Social Services University Network for West-Central Montreal (CIUSSS West-Central Montreal).

PRAIDA’s mandate starts when a person who requests refugee status receives an official document from the Quebec Immigration Service identifying him or her as an asylum seeker.

www.ciusss-centreouestmtl.gouv.qc.ca

Services Provided By

PRAIDA Information regarding the immigration process

Assistance with emergency housing

Referral to organizations who can assist in search for more permanent housing

Aid with applications for social assistance

Assistance in obtaining a work permit

Contact information for immigration lawyers

Information about registering children for school

Nursing triage and resources for medical evaluations

Does an asylum seeker have

access to health and social

services?

YES

Any asylum seeker is eligible for health care and

social services free of charge.

Medical coverage by the Interim Federal Health

program via the Blue Cross – medavie insurance

company.

Interim Federal Health

Program (PFSI) Basic medical coverage

similar to health-care coverage from provincial or territorial health insurance plans

In-patient and out-patient hospital services by physicians and allied healthcare professionals

Pre and Post-natal care

Laboratory, diagnostic and ambulance services

Prescription drug coverage

similar to the coverage provinces and territories give to social assistance recipients

Prescription medications and other products listed on provincial/territorial public drug plan formularies

Supplemental coverage (similar to the coverage given to social assistance recipients by provincial and territorial governments)

limited vision and urgent dental care

home care and long-term care

services from allied health-care practitioners including clinical psychologists, psychotherapists, counselling therapists, occupational therapists, speech language therapists, physiotherapists

assistive devices, medical supplies and equipment, including:

orthopedic and prosthetic equipment

mobility aids

hearing aids

diabetic supplies

incontinence supplies

oxygen equipment

https://www.canada.ca/en/immigration-refugees-citizenship/services/refugees/help-within-canada/health-care/professionals.html

*health care providers who see asylum seekers may register with medavie blue cross for billing purposes.

Clinique pour Demandeurs

D’asile et Refugiés (CDAR)

clinic dedicated exclusively to the care of refugees

and asylum seekers

located in the CLSC CDN

team consists of

5 part time family doctors (equivalent to 1.2 full time

physician)

2 full time nurses

1 part time nurse practitioner

Services provided to refugees at CDAR

evaluation of medical needs screening BSR and

short term care

referral to specialists and to local support services

Registration on the GAMF

Services provided to asylum seekers at CDAR

medium term care for the most vulnerable asylum

seekers

Unstable chronic medical conditions

severe mental health conditions

Attestation letters describing scars and FGM

Referrals come to us through the PRAIDA triage RN

and lawyers in the community

PTSD in the Refugee

Population Most Canadian immigrants and refugees from countries

involved in war or significant social unrest have been exposed to traumatic events before migration

most (estimated at 80%) who experience traumatic events heal spontaneously after reaching safety

pushing for disclosure of traumatic events in well-functioning individuals may result in more harm than good

empathy, reassurance and advocacy are key elements of the recovery process

keep a high index of suspicion for mental health disorders; many patients present with somatic complaints

BACK TO MME DIAWARA

WHAT CAN WE DO FOR

HER?

Approach to the new Immigrant

and Refugee Claimant PMHx

Migration History

History of Trauma

Psychological evaluation/support network

Vaccination Hx

Lifestyle habits

Countries endemic for TB, Hep B

Exposure to health risks Living conditions – access to water, sanitation

Vectors of Dx – mosquitos, stagnant water

Basic Needs

refer to PRAIDA for

housing

immigration information

social assistance

school registration for her grandchildren

Medical Needs send to hospital or CLSC for immigration screening

labs and appropriate labs for her medical condition

send to local pharmacy for medication renewal

send to CLSC for diabetes teaching and follow up;

program cardiometabolique

refer to CLSC for vaccination and to enfance famille

Physical Exam vision and hearing screen

dental health

nutritional status, growth parameters

evidence of female genital mutilation

Laboratory work up and

Screening Tests CBC, ferritin, Hb electrophoresis

Creat, BUN

ALT

strongyloides, schistosomiasis (sub-saharan Africa)

VDRL, HIV, Hep B and C

G/C, Chlamydia if at risk

PPD

Usual screening as per gender, age group and risk factors:

PAP, Hba1c, ac glucose, lipids, mammogram, BMD

Mental Health Needs supportive counselling and self help care

referral to psychotherapy (RIVO resilience; reseau

d’intervention aupres des personnes ayant subi de

la violence organisee)

referral to CLSC GASMA for ongoing care or

psychiatry evaluation

medication for sleep and PTSD

Recommendations for

Mental Health Screening

depression; PHQ-9 screening if an integrated

treatment program is available

PTSD; no routine screening for exposure to

trauma; vigilance

child maltreatment; vigilance

intimate partner violence; vigilance

Questions?