Refugee Health in Pennsylvania

Jun Yang, Ph.D. Epidemiologist and State Refugee Health

Coordinator Division of Infectious Disease Epidemiology Bureau of Epidemiology PA Department of Health

August 17, 2017

2017 Annual Pennsylvania Refugee Consultation, Harrisburg, PA, August 16 - 17, 2017

Refugee Health Program (RHP)

Charlotte Fry State Refugee Coordinator

Jun Yang State Refugee Health Coordinator

Shakila Shah Refugee Health Promotion Coordinator

Susan Miller Refugee Health Social Worker

Mission of the RHP

• To ensure that refugees receive a comprehensive health and mental assessment after entry into the U.S.

• To identify and treat health conditions that could delay successful resettlement

Common Background of Refugees

Catastrophic events and displacement

Lack of food PoorOvercrowded Lack of clean environmental living water sanitation conditions

Lack of health care Insufficient vaccination

Unique refugee health challenges

Health Challenges among Refugees

Malnutrition: 28% among refugee children

Infectious/parasitic conditions Chickenpox outbreaks Splenomegaly among Congolese refugees

Mental health issues Higher suicide rates in Bhutanese refugees

Common mental health disorders Anxiety, depression, post-traumatic stress

disorder, and post-migration difficulties

Health Challenges among Refugees

Culture-related conditions Female genital mutilation/cutting

>200 million girls and women alive today have had FGM/C in 30 countries in Africa, the Middle East and Asia (WHO data)

Travel outside of U.S. to receive FGM/C

Domestic violence

Chronic conditions

Refugees Health Data Systems

• CDC Electronic Disease Notification (EDN) Web-based system launched in 2006 and has been

deployed to all states Notifies states when immigrants have notifiable

conditions or refugees arrive in their jurisdictions Provides medical information recorded on the

Department of State form

• PA eShare Web-based system launched in 2013 and has been

used by all contracted clinics Records medical information collected during

refugee health screening

Refugees Arrived in PA

2533 2634

3011 2898

2466

2818

2543

3541

0

500

1000

1500

2000

2500

3000

3500

4000

2009 2010 2011 2012 2013 2014 2015 2016

Year

Figure 1. Trends of Newly-Arriving Refugees in Pennsylvania, 2009 - 2016 (N=22,444)

Data source: CDC EDN

Refugees Arrived in PA

4584

2008

1266

1167

248

204

193

134

118

108

0 1000 2000 3000 4000 5000

Bhutan

Nepal

Iraq

Myanmar

Thailand

Ethiopia

Cuba

Sudan

Somalia

Malaysia

Figure 2. Ten countries of Origin with Most Newly Arriving Refugees in Pennsylvania, 2009 - 2012 (n=10,030)

Data source: CDC EDN

Refugees Arrived in PA

1736

1269

1207

997

995

935

714

317

259

243

0 500 1000 1500 2000

Bhutan

Nepal

Iraq

Myanmar

Syria

Congo

Somalia

Ukraine

Ethiopia

Cuba

Figure 3. Ten countries of Origin with Most Newly Arriving Refugees in Pennsylvania, 2013 - 2016 (n=8,672)

Data source: CDC EDN

Refugees Arrived in PA

4584

2008

1266

1167

248

204

193

134

118

108

0 1000 2000 3000 4000 5000

Bhutan

Nepal

Iraq

Myanmar

Thailand

Ethiopia

Cuba

Sudan

Somalia

Malaysia

Top Ten countries, 2009 - 2012

1736

1269

1207

997

995

935

714

317

259

243

0 500 1000 1500 2000

Bhutan

Nepal

Iraq

Myanmar

Syria

Congo

Somalia

Ukraine

Ethiopia

Cuba

Top Ten countries, 2013 - 2016

Data source: CDC EDN

0

50

70

Refugees Arrived in PA

Figure 4. Percent of Refugees Arriving in PA by Age Group, 2009 - 2016

60

30

40 <18 18-64 >64

20

10

2009 2010 2011 2012 2013 2014 2015 2016

Data source: CDC EDN

Refugee Health Conditions - TB

Figure 5. Percent of Any Pre-departure TB Conditions in Refugees Arriving in PA by Year, 2009 - 2016 (n=2,129, 9.5%)

14

12.3 12.1

2009 2010 2011 2012 2013 2014 2015 2016

Data source: CDC EDN

7.1 7.6

10.3

11.6

8.9

6.5

0

2

4

6

8

10

12

TB Incident in U.S., 2013 - 2015

• Approximately 3 cases per 100,000 persons

• Among foreign-born persons in U.S.: 15 cases per 100,000

Fiscal Federal Year 2015 – 2017 Health Screening Statistics

Figure 6. Number of Refugees Screened by Gender, 2015 – 2017 (n=2519 for 2015 – 2016; n=2110 for 2016 - 2017)

1400 1314

1071

1205

1039

0

200

400

600

800

1000

1200

Male Female

Year 2015 - 2016 Year 2016 - 2017

Note: For fiscal year 2016 – 2017, data were pulled for the period of October 1, 2016 – July 28, 2017

Data source: PA eShare

Fiscal Federal Year 2015 – 2017 Health Screening Statistics

Figure 7. Percent of Refugees with Parasitic Diseases by Screening, 2015 – 2017

20

18 17.2

6.6

0

2

4

6

8

10

12

14

16

Year 2015 - 2016 Year 2016 - 2017

Note: For fiscal year 2016 – 2017, data were pulled for the period of October 1, 2016 – July 28, 2017

Data source: PA eShare

60

Fiscal Federal Year 2015 – 2017 Health Screening Statistics

Figure 8. Percent of Major Referrals after Screening, 2015 – 2017

51 50 47 47

44

40 PCP Dental

30 Vision Health Dept

20 14 Mental

10 9810

2 2

0 Year 2015 - 2016 Year 2016 - 2017

Note: For fiscal year 2016 – 2017, data were pulled for the period of October 1, 2016 – July 28, 2017

Data source: PA eShare

Fiscal Federal Year 2015 – 2017 Health Screening Statistics

Figure 9. Results of Tuberculosis Testing and Subsequent Referral, 2015 – 2017

14 12.89

12

10 9.41

8 QuantiFERON+ 6.02 Skin Test>=10mm 5.69 6 5.02 TB Referral

4 2.78

2

0 Year 2015 - 2016 Year 2016 - 2017

Note: For fiscal year 2016 – 2017, data were pulled for the period of October 1, 2016 – July 28, 2017

Data source: PA eShare

Strategies to Improve Refugee Health

Sufficient funding: federal, state, other sources

Conduct epidemiologic studies and surveillance Refugee health surveys Targeted studies

Health education

Training

Increase collaboration

Strategies to Improve Refugee Health

Federal Agencies

State Agencies Resettlement Agencies

Healthcare Providers

Refugees Community Support

Other Partners

Available Refugee Health Resources in PA

Supports families with special medical needs children

Provides information on health care resources, respite care, advocacy, assistive technologies

Provides family support in overcoming challenges

Provides information about accessible and inclusive recreation and leisure

Special Kids

Network

Available Refugee Health Resources in PA

Refugee Health Promotion Grant

Training

Culturally Competent Health Education and Health Care

Serving LGBT Population

Mental Health First Aid Training

'tit' pennsylvania ., DEPARTMENT OF HUMAN SERVICES

4Jta pennsylvania • • DEPARTMENT OF HEALTH

Questions and Discussion

Contact Information

• Charlotte Fry charfry@pa.gov (717) 787-8608

• Jun Yang juyang@pa.gov 717-547-3486

• Shakila Shah shshah@pa.gov 717-346-1094

• Susan Miller sbowersmil@pa.gov 717-783-3901

http://www.refugeesinpa.org/

4Jta pennsylvania • • DEPARTMENT OF HEALTH

4Jta pennsylvania • • DEPARTMENT OF HEALTH

Definition of a Refugee

• Living outside their own country of nationality

• Unable or unwilling to return to that country because of persecution or a well-founded fear of persecution (based on race, religion, nationality, political opinion or membership in a particular social group)

Health Challenges among Refugees

Malnutrition – 2012 data

28% among refugee children

10% severe acute malnutrition (five times above the threshold)

44% of children < two years old are malnourished

18% of children < two years old have severe acute malnutrition

Data source: https://www.msf.org.za/stories-news/stories-and-news/south-sudan-new-msf-mortality­and-malnutrition-data-point-catastrophic

Health Challenges among Refugees

Infectious/Parasitic conditions

Chickenpox outbreaks Malaria – Splenomegaly among Congolese refugees

(under investigation)

Mental condition Higher suicide rates among Bhutanese refugees (2013 data) Common mental health disorders Anxiety Depression Post-traumatic stress disorder Post-migration difficulties (e.g., family conflict or

unemployment)

Fiscal Federal Year 2015 – 2017 Health Screening Statistics

Figure 9. Percent of Tuberculosis Diagnosis by Screening, 2015 – 2017

2.5

1.98 2

1.5 Active TB Latent TB

1 0.85 Healed TB

0.5

0.12 0.09 0.08 0.05 0

Year 2015 - 2016 Year 2016 - 2017

Note: For fiscal year 2016 – 2017, data were pulled for the period of October 1, 2016 – July 28, 2017

Data source: PA eShare