Primary Care for Refugees



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Over the past decade, at least 600,000 refugees from more than 60 different countries have been resettled in the United States. The personal history of a refugee is often marked by physical and emotional trauma. Although refugees come from many different countries and cultures, their shared pattern of experiences allows for some generalizations to be made about their health care needs and challenges. Before being accepted for resettlement in the United States, all refugees must pass an overseas medical screening examination, the purpose of which is to identify conditions that could result in ineligibility for admission to the United States. Primary care physicians have the opportunity to care for members of this unique population once they resettle. Refugees present to primary care physicians with a variety of health problems, including musculoskeletal and pain issues, mental and social health problems, infectious diseases, and longstanding undiagnosed chronic illnesses. Important infectious diseases to consider in the symptomatic patient include tuberculosis, parasites, and malaria. Health maintenance and immunizations should also be addressed. Language barriers, cross-cultural medicine issues, and low levels of health literacy provide additional challenges to caring for this population. The purpose of this article is to provide primary care physicians with a guide to some of the common issues that arise when caring for refugee patients.

Throughout history, persons have been forced to flee their homes because of war, famine, or persecution. In 1951, in an effort to protect European refugees in the aftermath of World War II, the United Nations developed an official definition of “refugee,” which has since been called the Geneva convention. A 1967 United Nations Protocol removed the geographic and time boundaries from the original definition. Today, the United Nations defines a refugee as anyone who:

…owing to well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion, is outside the country of his nationality and is unable or, owing to such fear, is unwilling to avail himself of the protection of that country.1

Over the past decade, at least 600,000 refugees from more than 60 different countries have been resettled in the United States.2  Table 1 lists the top 10 countries of origin for refugees arriving in the United States from 2000 to 2009, and Table 2 shows the distribution of those refugees resettled in each state or territory.2

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation Evidence rating References

Physicians should focus on addressing refugees' postmigration resettlement challenges (e.g., housing, employment, social isolation) rather than directing therapies at healing past traumas.

C

10, 13, 14, 18

Refugees presenting with abdominal symptoms, hematuria, or failure to thrive should be assessed for parasites.

C

19, 21

Refugees from malaria-endemic areas presenting with fatigue, pallor, hematologic abnormalities, and possibly an enlarged spleen should be evaluated for malaria.

C

19

Physicians who accept federal payers should provide language translation services for refugees who need them, as required by federal law.

C

23


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.xml.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

View Table

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation Evidence rating References

Physicians should focus on addressing refugees' postmigration resettlement challenges (e.g., housing, employment, social isolation) rather than directing therapies at healing past traumas.

C

10, 13, 14, 18

Refugees presenting with abdominal symptoms, hematuria, or failure to thrive should be assessed for parasites.

C

19, 21

Refugees from malaria-endemic areas presenting with fatigue, pallor, hematologic abnormalities, and possibly an enlarged spleen should be evaluated for malaria.

C

19

Physicians who accept federal payers should provide language translation services for refugees who need them, as required by federal law.

C

23


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.xml.

Table 1.

Top 10 Countries of Origin for Refugees Resettled in the United States from 2000 to 2009

Country Number of refugees

Cuba

119,129

Former Soviet Union

87,621

Somalia

60,003

Former Yugoslavia

46,868

Burma

46,235

Iraq

40,868

Iran

38,140

Liberia

26,046

Sudan

21,985

Vietnam

20,274


Information from reference 2.

Table 1.   Top 10 Countries of Origin for Refugees Resettled in the United States from 2000 to 2009

View Table

Table 1.

Top 10 Countries of Origin for Refugees Resettled in the United States from 2000 to 2009

Country Number of refugees

Cuba

119,129

Former Soviet Union

87,621

Somalia

60,003

Former Yugoslavia

46,868

Burma

46,235

Iraq

40,868

Iran

38,140

Liberia

26,046

Sudan

21,985

Vietnam

20,274


Information from reference 2.

Table 2.

Top Three Refugee Countries of Origin by U.S. State or Territory

State/territory Refugees resettled, 2000 to 2009 Top three countries of origin

Florida

108,261

Cuba, Haiti, former Yugoslavia

California

75,167

Iran, former Soviet Union, Iraq

Texas

39,494

Burma, Cuba, Somalia

New York

38,785

Former Soviet Union, Burma, Liberia

Minnesota

31,458

Somalia, Laos, Ethiopia

Washington

29,412

Former Soviet Union, Somalia, Burma

Arizona

21,896

Iraq, Somalia, Burma

Georgia

20,562

Somalia, former Yugoslavia, Burma

Illinois

18,750

Former Yugoslavia, Iraq, former Soviet Union

Michigan

17,768

Iraq, former Yugoslavia, Cuba

Pennsylvania

17,440

Former Soviet Union, Liberia, former Yugoslavia

North Carolina

14,065

Vietnam, Burma, former Soviet Union

Virginia

13,982

Somalia, Iraq, former Yugoslavia

Ohio

13,817

Somalia, former Soviet Union, former Yugoslavia

Massachusetts

12,794

Former Soviet Union, Somalia, Iraq

Missouri

11,597

Former Yugoslavia, Somalia, former Soviet Union

Oregon

10,761

Former Soviet Union, Somalia, Cuba

Kentucky

10,725

Cuba, former Yugoslavia, Burma

Colorado

9,363

Former Soviet Union, Somalia, Burma

New Jersey

9,059

Cuba, Liberia, former Soviet Union

Tennessee

8,662

Somalia, Sudan, Iraq

Maryland

8,293

Sierra Leone, former Soviet Union, Burma

Utah

8,009

Somalia, former Yugoslavia, Burma

Indiana

7,132

Burma, Thailand, former Yugoslavia

Wisconsin

6,830

Laos, former Yugoslavia, Burma

Idaho

6,317

Former Yugoslavia, former Soviet Union, Afghanistan

Iowa

6,146

Former Yugoslavia, Sudan, Burma

Connecticut

5,186

Former Yugoslavia, Somalia, former Soviet Union

Nevada

4,689

Cuba, former Yugoslavia, Iran

Nebraska

4,597

Sudan, Burma, former Yugoslavia

New Hampshire

4,112

Former Yugoslavia, Bhutan, Somalia

North Dakota

2,853

Former Yugoslavia, Somalia, Bhutan

South Dakota

2,736

Somalia, Sudan, former Yugoslavia

Louisiana

2,585

Cuba, former Yugoslavia, Vietnam

Vermont

2,093

Former Yugoslavia, Somalia, Bhutan

Rhode Island

1,961

Liberia, former Soviet Union, Burundi

Kansas

1,754

Burma, Somalia, Vietnam

New Mexico

1,690

Cuba, Iraq, Vietnam

Maine

1,580

Somalia, Sudan, former Yugoslavia

Oklahoma

1,209

Burma, former Soviet Union, Vietnam

Alabama

1,105

Iraq, Cuba, former Soviet Union

South Carolina

1,043

Former Soviet Union, Burma, Somalia

District of Columbia

794

Ethiopia, Sierra Leone, Iraq

Alaska

459

Former Soviet Union, Laos, Bhutan

Delaware

241

Liberia, Sierra Leone, Afghanistan

Puerto Rico

234

Cuba, Vietnam, Colombia/Haiti

Mississippi

218

Sudan, Somalia, Afghanistan

Hawaii

154

Vietnam, Burma, former Soviet Union

Arkansas

105

Laos, Vietnam, Cuba

Montana

85

Former Soviet Union, Iraq, Cuba

West Virginia

54

Iraq, Vietnam, Burma

Guam

5

Vietnam

Wyoming

3

Former Soviet Union

Total

618,090


Information from reference 2.

Table 2.   Top Three Refugee Countries of Origin by U.S. State or Territory

View Table

Table 2.

Top Three Refugee Countries of Origin by U.S. State or Territory

State/territory Refugees resettled, 2000 to 2009 Top three countries of origin

Florida

108,261

Cuba, Haiti, former Yugoslavia

California

75,167

Iran, former Soviet Union, Iraq

Texas

39,494

Burma, Cuba, Somalia

New York

38,785

Former Soviet Union, Burma, Liberia

Minnesota

31,458

Somalia, Laos, Ethiopia

Washington

29,412

Former Soviet Union, Somalia, Burma

Arizona

21,896

Iraq, Somalia, Burma

Georgia

20,562

Somalia, former Yugoslavia, Burma

Illinois

18,750

Former Yugoslavia, Iraq, former Soviet Union

Michigan

17,768

Iraq, former Yugoslavia, Cuba

Pennsylvania

17,440

Former Soviet Union, Liberia, former Yugoslavia

North Carolina

14,065

Vietnam, Burma, former Soviet Union

Virginia

13,982

Somalia, Iraq, former Yugoslavia

Ohio

13,817

Somalia, former Soviet Union, former Yugoslavia

Massachusetts

12,794

Former Soviet Union, Somalia, Iraq

Missouri

11,597

Former Yugoslavia, Somalia, former Soviet Union

Oregon

10,761

Former Soviet Union, Somalia, Cuba

Kentucky

10,725

Cuba, former Yugoslavia, Burma

Colorado

9,363

Former Soviet Union, Somalia, Burma

New Jersey

9,059

Cuba, Liberia, former Soviet Union

Tennessee

8,662

Somalia, Sudan, Iraq

Maryland

8,293

Sierra Leone, former Soviet Union, Burma

Utah

8,009

Somalia, former Yugoslavia, Burma

Indiana

7,132

Burma, Thailand, former Yugoslavia

Wisconsin

6,830

Laos, former Yugoslavia, Burma

Idaho

6,317

Former Yugoslavia, former Soviet Union, Afghanistan

Iowa

6,146

Former Yugoslavia, Sudan, Burma

Connecticut

5,186

Former Yugoslavia, Somalia, former Soviet Union

Nevada

4,689

Cuba, former Yugoslavia, Iran

Nebraska

4,597

Sudan, Burma, former Yugoslavia

New Hampshire

4,112

Former Yugoslavia, Bhutan, Somalia

North Dakota

2,853

Former Yugoslavia, Somalia, Bhutan

South Dakota

2,736

Somalia, Sudan, former Yugoslavia

Louisiana

2,585

Cuba, former Yugoslavia, Vietnam

Vermont

2,093

Former Yugoslavia, Somalia, Bhutan

Rhode Island

1,961

Liberia, former Soviet Union, Burundi

Kansas

1,754

Burma, Somalia, Vietnam

New Mexico

1,690

Cuba, Iraq, Vietnam

Maine

1,580

Somalia, Sudan, former Yugoslavia

Oklahoma

1,209

Burma, former Soviet Union, Vietnam

Alabama

1,105

Iraq, Cuba, former Soviet Union

South Carolina

1,043

Former Soviet Union, Burma, Somalia

District of Columbia

794

Ethiopia, Sierra Leone, Iraq

Alaska

459

Former Soviet Union, Laos, Bhutan

Delaware

241

Liberia, Sierra Leone, Afghanistan

Puerto Rico

234

Cuba, Vietnam, Colombia/Haiti

Mississippi

218

Sudan, Somalia, Afghanistan

Hawaii

154

Vietnam, Burma, former Soviet Union

Arkansas

105

Laos, Vietnam, Cuba

Montana

85

Former Soviet Union, Iraq, Cuba

West Virginia

54

Iraq, Vietnam, Burma

Guam

5

Vietnam

Wyoming

3

Former Soviet Union

Total

618,090


Information from reference 2.

A refugee's personal history is often marked by trauma, torture, loss of family and friends, and the trials of resettlement in a new country and orientation to a new culture. Although refugees come from many different countries and cultures, their shared pattern of experiences allows for some generalizations to be made about their health care needs and challenges. The purpose of this article is to provide primary care physicians with a guide to some of the common issues that arise when caring for refugees.

Initial Medical Screening Examination

Before being accepted for resettlement into the United States, all refugees must pass the overseas medical screening examination performed by panel physicians under the technical oversight of the Centers for Disease Control and Prevention (CDC), with the goal of detecting class A and B conditions3  (Table 34). The CDC further recommends, but does not mandate, an initial domestic screening examination, the purpose of which is to further identify medical conditions that pose a public health risk or that might interfere with successful resettlement. 5 Several documents on the CDC Web site provide guidance as to the components of an initial history, physical examination, and laboratory assessment (http://www.cdc.gov/immigrantrefugeehealth/guidelines/domestic/domestic-guidelines.html).6 Each state develops its own protocol for completing the initial medical examination, which often is performed by a combination of local health department and private physicians.

Table 3.

Components of the Refugee Initial Overseas Medical Examination, Including Class A and Class B Conditions

Examination components

Full medical history (i.e., current medical conditions and medications, previous hospitalizations, social history, and complete review of systems)

Physical examination including, at a minimum: examination of the eyes, ears, nose, throat, extremities, heart, lungs, abdomen, lymph nodes, skin, and external genitalia

Mental status examination including, at a minimum: assessment of intelligence, thought, cognition (comprehension), judgment, affect (and mood), and behavior

Laboratory syphilis screen

Tuberculosis screen

Appropriate immunizations

Class A conditions: a physical or mental disorder (including a communicable disease of public health significance or drug abuse/addiction) that renders a person ineligible for admission or adjustment of status

Active or infectious tuberculosis

Untreated syphilis

Untreated chancroid

Untreated gonorrhea

Untreated granuloma inguinale

Untreated lymphogranuloma venereum

Hansen disease

Addiction to or abuse of a specific substance* without harmful behavior and/or any physical or mental disorder with harmful behavior or history of such behavior, along with likelihood that behavior will recur

Class B conditions: significant health problems affecting ability to care for oneself or attend school or work, or that require extensive treatment or possible institutionalization

Inactive or noninfectious tuberculosis

Treated syphilis

Other sexually transmitted infections

Pregnancy

Treated, tuberculoid, borderline, or paucibacillary Hansen disease

Sustained, full remission of abuse of specific substances* and/or any physical or mental disorder (excluding addiction to or abuse of specific substances, but including other substance-related disorders) without harmful behavior or with a history of such behavior considered unlikely to recur


*—Amphetamines, cannabis, cocaine, hallucinogens, inhalants, opioids, phencyclidines, sedative-hypnotics, and anxiolytics.

Information from reference 4.

Table 3.   Components of the Refugee Initial Overseas Medical Examination, Including Class A and Class B Conditions

View Table

Table 3.

Components of the Refugee Initial Overseas Medical Examination, Including Class A and Class B Conditions

Examination components

Full medical history (i.e., current medical conditions and medications, previous hospitalizations, social history, and complete review of systems)

Physical examination including, at a minimum: examination of the eyes, ears, nose, throat, extremities, heart, lungs, abdomen, lymph nodes, skin, and external genitalia

Mental status examination including, at a minimum: assessment of intelligence, thought, cognition (comprehension), judgment, affect (and mood), and behavior

Laboratory syphilis screen

Tuberculosis screen

Appropriate immunizations

Class A conditions: a physical or mental disorder (including a communicable disease of public health significance or drug abuse/addiction) that renders a person ineligible for admission or adjustment of status

Active or infectious tuberculosis

Untreated syphilis

Untreated chancroid

Untreated gonorrhea

Untreated granuloma inguinale

Untreated lymphogranuloma venereum

Hansen disease

Addiction to or abuse of a specific substance* without harmful behavior and/or any physical or mental disorder with harmful behavior or history of such behavior, along with likelihood that behavior will recur

Class B conditions: significant health problems affecting ability to care for oneself or attend school or work, or that require extensive treatment or possible institutionalization

Inactive or noninfectious tuberculosis

Treated syphilis

Other sexually transmitted infections

Pregnancy

Treated, tuberculoid, borderline, or paucibacillary Hansen disease

Sustained, full remission of abuse of specific substances* and/or any physical or mental disorder (excluding addiction to or abuse of specific substances, but including other substance-related disorders) without harmful behavior or with a history of such behavior considered unlikely to recur


*—Amphetamines, cannabis, cocaine, hallucinogens, inhalants, opioids, phencyclidines, sedative-hypnotics, and anxiolytics.

Information from reference 4.

Common Presenting Problems

Refugees present to primary care physicians with a variety of health problems. The most common are musculoskeletal and pain issues, mental and social health problems, infectious diseases, and longstanding undiagnosed chronic conditions (Table 4).

Table 4.

Common Presenting Health Problems and Conditions Among Refugee Patients

Mental health

Adjustment disorder

Depression/anxiety

Posttraumatic stress disorder

Social isolation

Pain

Abdominal pain

Back pain

Female pelvic pain

Headache

Neck pain

Undiagnosed chronic conditions

Anemia

Asthma

Chronic obstructive pulmonary disease

Diabetes mellitus

Dyslipidemia

Hypertension

Vitamin D deficiency


note: See Table 5 for common infectious disease–related problems.

Table 4.   Common Presenting Health Problems and Conditions Among Refugee Patients

View Table

Table 4.

Common Presenting Health Problems and Conditions Among Refugee Patients

Mental health

Adjustment disorder

Depression/anxiety

Posttraumatic stress disorder

Social isolation

Pain

Abdominal pain

Back pain

Female pelvic pain

Headache

Neck pain

Undiagnosed chronic conditions

Anemia

Asthma

Chronic obstructive pulmonary disease

Diabetes mellitus

Dyslipidemia

Hypertension

Vitamin D deficiency


note: See Table 5 for common infectious disease–related problems.

MUSCULOSKELETAL AND PAIN ISSUES

Many refugees seek medical attention for musculoskeletal pain, most commonly of the neck and lower back.79 Contributing factors (e.g., past physical trauma), current employment in jobs involving physical labor (e.g., housekeeping, factory work), and difficult living conditions (e.g., sleeping on floors or couches) must be considered in the assessment and treatment plan.

Chronic headaches are another common pain issue, as is ill-defined, whole body pain. Pain in the abdomen and pelvis is more common in women.79 Organic causes for abdominal, pelvic, and whole body pain are often difficult to identify despite extensive workups, which should include assessment for Helicobacter pylori, intestinal parasites, and vitamin D deficiency, and imaging as indicated.1012

MENTAL AND SOCIAL HEALTH

It is not surprising that refugees, given their often traumatic pasts, have higher rates of depression, anxiety, and posttraumatic stress disorders than the general population. 8,1315 Postmigration resettlement stressors, such as social isolation, financial problems, generational acculturation differences, culture shock, employment difficulty, disability issues, and housing issues, also adversely affect refugees' mental and physical health.10,13,14,1618

The relative contribution of pre- versus postmigration stress to the development and maintenance of mental health disorders is unknown. Many experts emphasize the importance of addressing refugees' postmigration resettlement challenges (e.g., housing, employment, social isolation) rather than directing therapies at healing past traumas.13,1618 When possible, these patients should be referred to local community agencies that can assist them with their social needs.

INFECTIOUS DISEASES

Although many physicians think of infectious diseases when dealing with refugees, other diagnoses such as musculoskeletal pain and mental health issues are actually more prevalent.7 Because refugees are such a tightly controlled population, with preand postmigration screening for and prophylactic treatment of infectious diseases, they account for less international spread of infectious diseases than international travelers and other migrant populations.3

That said, infectious diseases, particularly tuberculosis, should remain high on the list of possible diagnoses when evaluating symptomatic refugees.3  Table 5 lists some of the recommended infectious disease screening and diagnostic tests.3,19,20

Patients presenting with abdominal symptoms, hematuria, or failure to thrive should be assessed for parasites19,21  (Table 53,19,20). At times, the only sign of a parasitic infection may be an asymptomatic eosinophilia. Although collection and analysis of multiple stool samples are a common way to assess for the presence of parasites, negative results do not rule out parasitic infection, and serologic testing for antibodies may be necessary. If such infection is suspected, consultation with an infectious disease expert can be helpful.19,21

Table 5.

Recommended Infectious Disease Screening and Diagnostic Tests for Refugees [corrected]

Infectious agent Test Comments

Parasites*†

Ascaris lumbricoides (roundworm)

Complete blood count with differential

Three stool ova and parasites tests, collected on three different mornings

Entamoeba histolytica

Filariasis

Giardia lamblia

Hookworm

Taenia species (tapeworm)

Trichuris trichiura (whipworm)

Plasmodium species

Complete blood count with differential

Three thick and thin blood smears done over six to 12 hours, preferably during a fever spike

Consider in refugees from malaria-endemic areas with fever, thrombocytopenia, splenomegaly, or anemia

Schistosoma species

Complete blood count with differential, anti- Schistosoma antibody testing

Three stool ova and parasites tests, collected on three different mornings

Consider in refugees from sub-Saharan Africa, especially if hematuria is present; infection is risk factor for bladder cancer

Strongyloides species

Complete blood count with differential, anti- Strongyloides antibody testing

Three stool ova and parasites tests, collected on three different mornings

Untreated strongyloidiasis puts patients at risk of disseminated strongyloidiasis if they become immunocompromised

Sexually transmitted infections

Gonorrhea/chlamydia

Urine or cervical gonorrhea/chlamydia

Hepatitis B

Hepatitis B core antibody, hepatitis B surface antibody, hepatitis B surface antigen

Screen all refugees coming from areas in which hepatitis B is endemic

HIV

HIV-1 and HIV-2

Syphilis

Rapid plasma reagin, VDRL

All refugees 15 years and older should be screened for syphilis

Other

Helicobacter pylori

Fecal antigen preferable over serology20

Tuberculosis

Purified protein derivative/Mantoux test, Quantiferon-G, chest radiography

All refugees should be screened for tuberculosis because it is one of the most common infectious diseases in refugees3; consider renal tuberculosis in patients with hematuria


HIV = human immunodeficiency virus; VDRL = Venereal Disease Research Laboratories.

*—Suspect parasites with eosinophilia.

†—Negative stool sample results do not always rule out parasitic infections; therefore, serologic testing for antibodies may be necessary.

Information from references 3, 19, and 20.

Table 5.   Recommended Infectious Disease Screening and Diagnostic Tests for Refugees [corrected]

View Table

Table 5.

Recommended Infectious Disease Screening and Diagnostic Tests for Refugees [corrected]

Infectious agent Test Comments

Parasites*†

Ascaris lumbricoides (roundworm)

Complete blood count with differential

Three stool ova and parasites tests, collected on three different mornings

Entamoeba histolytica

Filariasis

Giardia lamblia

Hookworm

Taenia species (tapeworm)

Trichuris trichiura (whipworm)

Plasmodium species

Complete blood count with differential

Three thick and thin blood smears done over six to 12 hours, preferably during a fever spike

Consider in refugees from malaria-endemic areas with fever, thrombocytopenia, splenomegaly, or anemia

Schistosoma species

Complete blood count with differential, anti- Schistosoma antibody testing

Three stool ova and parasites tests, collected on three different mornings

Consider in refugees from sub-Saharan Africa, especially if hematuria is present; infection is risk factor for bladder cancer

Strongyloides species

Complete blood count with differential, anti- Strongyloides antibody testing

Three stool ova and parasites tests, collected on three different mornings

Untreated strongyloidiasis puts patients at risk of disseminated strongyloidiasis if they become immunocompromised

Sexually transmitted infections

Gonorrhea/chlamydia

Urine or cervical gonorrhea/chlamydia

Hepatitis B

Hepatitis B core antibody, hepatitis B surface antibody, hepatitis B surface antigen

Screen all refugees coming from areas in which hepatitis B is endemic

HIV

HIV-1 and HIV-2

Syphilis

Rapid plasma reagin, VDRL

All refugees 15 years and older should be screened for syphilis

Other

Helicobacter pylori

Fecal antigen preferable over serology20

Tuberculosis

Purified protein derivative/Mantoux test, Quantiferon-G, chest radiography

All refugees should be screened for tuberculosis because it is one of the most common infectious diseases in refugees3; consider renal tuberculosis in patients with hematuria


HIV = human immunodeficiency virus; VDRL = Venereal Disease Research Laboratories.

*—Suspect parasites with eosinophilia.

†—Negative stool sample results do not always rule out parasitic infections; therefore, serologic testing for antibodies may be necessary.

Information from references 3, 19, and 20.

Malaria remains endemic in sub-Saharan Africa, south Asia, Asia, and some areas of the Middle East. Refugees from endemic areas presenting with fatigue, pallor, hematologic abnormalities, and possibly an enlarged spleen should be evaluated for malaria.19

UNDIAGNOSED COMMON CHRONIC CONDITIONS

In addition to the special health considerations described above, refugees have the same common chronic conditions as non-refugee patients, such as diabetes mellitus, hypertension, hyperlipidemia, and asthma.9 Depending on the health care available to refugees in their country of origin or their host country (where refugees sometimes spend up to 20 years in refugee camps before coming to the United States), these conditions may or may not have been diagnosed and managed before these patients arrived in the United States.

Health Maintenance and Immunizations

Health care maintenance screening guidelines, such as cervical cancer screening, mammography, and colonoscopy, should be used with refugee patients, just as with nonrefugee patients. In addition, refugees often present for an appointment only to request necessary immunizations. The U.S. Immigration and Naturalization Service has determined that vaccinations are not mandatory for refugees on entry to the United States. However, they become mandatory one year after arrival, when these persons are applying for adjustment of status to legal permanent resident. Table 6 lists the CDC-mandated immunizations for all immigrants and refugees requesting adjustment of status for U.S. permanent residence.22

Table 6.

CDC-Mandated Immunizations for Refugees Requesting Adjustment of Status


CDC = Centers for Disease Control and Prevention; DT = pediatric formulation diphtheria and tetanus toxoids; DTaP = diphtheria and tetanus toxoids and acellular pertussis vaccine; DTP = diphtheria and tetanus toxoids and pertussis vaccine; Hib = Haemophilus influenzae type b conjugate vaccine; IPV = inactivated poliovirus vaccine (killed); MCV = meningococcal conjugate vaccine; MMR = combined measles, mumps, and rubella vaccine; PCV = pneumococcal conjugate vaccine; PPV = pneumococcal polysaccharide vaccine; Td = adult formulation tetanus and diphtheria toxoids; Tdap = adolescent and adult formulation tetanus and diphtheria toxoids and acellular pertussis vaccine (Boostrix for persons 10 to 18 years of age; Adacel for persons 11 to 64 years of age).

Adapted from Centers for Disease Control and Prevention. Vaccination requirements for adjustment of status for U.S. permanent residence: technical instructions for civil surgeons. December 14, 2009. http://www.cdc.gov/immigrantrefugeehealth/pdf/2009-vaccination-technical-instructions.pdf. Accessed April 14, 2010.

Table 6.   CDC-Mandated Immunizations for Refugees Requesting Adjustment of Status

View Table

Table 6.

CDC-Mandated Immunizations for Refugees Requesting Adjustment of Status


CDC = Centers for Disease Control and Prevention; DT = pediatric formulation diphtheria and tetanus toxoids; DTaP = diphtheria and tetanus toxoids and acellular pertussis vaccine; DTP = diphtheria and tetanus toxoids and pertussis vaccine; Hib = Haemophilus influenzae type b conjugate vaccine; IPV = inactivated poliovirus vaccine (killed); MCV = meningococcal conjugate vaccine; MMR = combined measles, mumps, and rubella vaccine; PCV = pneumococcal conjugate vaccine; PPV = pneumococcal polysaccharide vaccine; Td = adult formulation tetanus and diphtheria toxoids; Tdap = adolescent and adult formulation tetanus and diphtheria toxoids and acellular pertussis vaccine (Boostrix for persons 10 to 18 years of age; Adacel for persons 11 to 64 years of age).

Adapted from Centers for Disease Control and Prevention. Vaccination requirements for adjustment of status for U.S. permanent residence: technical instructions for civil surgeons. December 14, 2009. http://www.cdc.gov/immigrantrefugeehealth/pdf/2009-vaccination-technical-instructions.pdf. Accessed April 14, 2010.

Special Challenges

LANGUAGE BARRIERS

Use of qualified translators is essential to caring for refugee patients. Refugees are not required to bring their own translator to an appointment, and federal law mandates that physicians who accept patients with federal payers must provide language translation to all of their patients who require it.23 In most cases, insurance plans will pay for the translation services, but it is the responsibility of the physician's office to make arrangements for the provision of those services.

CROSS-CULTURAL MEDICINE

Western notions of body, health, and illness are often different from those of other cultures, as are perceived roles of patients, physicians, and medications. For example, some Somalis expect physicians to know what is wrong with them without needing to ask any questions, and may also expect medications and a cure.24 A previous article in American Family Physician summarized some of the common beliefs of certain large refugee groups (http://www.aafp.org/afp/2005/1201/p2267.html). Familiarizing oneself with some general principles of a refugee's culture can be useful, but care must be taken not to stereotype persons within any group. An alternative and possibly more feasible approach may be to adopt and practice “cultural humility,” exploring similarities and differences between oneself and each patient encountered, rather than learning the details of each culture.25

HEALTH SYSTEM LITERACY

Refugees' health literacy levels are typically very low. For example, many refugees do not understand the concept of medication refills. Often, they will finish a bottle of medication that is intended to be refilled and used long-term, thinking the treatment is complete, or think they need to return to the physician's office for more medication. Many also do not understand the distinction between primary care and other subspecialties. As a result, they may not schedule or keep an appointment with a subspecialist referral, but rather return to their primary care physician, whom they view as “their doctor.”

Lack of transportation or ability to schedule the appointment with the subspecialist further contributes to poor compliance with subspecialist referrals.26 The notion of set appointment times may also be unfamiliar to refugees, because many experienced previous systems in which they just showed up and waited their turn to see the physician.

Finally, many refugees do not understand the U.S. health insurance process. In states in which Medicaid requires reapplication on a biannual or annual basis, many refugees have a lapse in insurance coverage because they missed the reapplication deadline. A previous article on medical care for refugees and immigrants in American Family Physician provides some further insight into additional challenges refugees may face (http://www.aafp.org/afp/980301ap/gavagan.html).

The Author

BARBARA ECKSTEIN, MD, MPH, is associate program director of the Family and Community Medicine Residency, medical director of the Family Medicine Center, and assistant professor in the Department of Family and Community Medicine at the University of Arizona, Tucson.

Address correspondence to Barbara Eckstein, MD, MPH, University of Arizona, P.O. Box 245052, Tucson, AZ 85724 (e-mail: eckstein@email.arizona.edu). Reprints are not available from the author.

Author disclosure: Nothing to disclose.

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