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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:

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

Clinical recommendationEvidence ratingReferences
Physicians should focus on addressing refugees' postmigration resettlement challenges (e.g., housing, employment, social isolation) rather than directing therapies at healing past traumas.C10, 13, 14, 18
Refugees presenting with abdominal symptoms, hematuria, or failure to thrive should be assessed for parasites.C19, 21
Refugees from malaria-endemic areas presenting with fatigue, pallor, hematologic abnormalities, and possibly an enlarged spleen should be evaluated for malaria.C19
Physicians who accept federal payers should provide language translation services for refugees who need them, as required by federal law.C23
CountryNumber of refugees
Cuba119,129
Former Soviet Union87,621
Somalia60,003
Former Yugoslavia46,868
Burma46,235
Iraq40,868
Iran38,140
Liberia26,046
Sudan21,985
Vietnam20,274
State/territoryRefugees resettled, 2000 to 2009Top three countries of origin
Florida108,261Cuba, Haiti, former Yugoslavia
California75,167Iran, former Soviet Union, Iraq
Texas39,494Burma, Cuba, Somalia
New York38,785Former Soviet Union, Burma, Liberia
Minnesota31,458Somalia, Laos, Ethiopia
Washington29,412Former Soviet Union, Somalia, Burma
Arizona21,896Iraq, Somalia, Burma
Georgia20,562Somalia, former Yugoslavia, Burma
Illinois18,750Former Yugoslavia, Iraq, former Soviet Union
Michigan17,768Iraq, former Yugoslavia, Cuba
Pennsylvania17,440Former Soviet Union, Liberia, former Yugoslavia
North Carolina14,065Vietnam, Burma, former Soviet Union
Virginia13,982Somalia, Iraq, former Yugoslavia
Ohio13,817Somalia, former Soviet Union, former Yugoslavia
Massachusetts12,794Former Soviet Union, Somalia, Iraq
Missouri11,597Former Yugoslavia, Somalia, former Soviet Union
Oregon10,761Former Soviet Union, Somalia, Cuba
Kentucky10,725Cuba, former Yugoslavia, Burma
Colorado9,363Former Soviet Union, Somalia, Burma
New Jersey9,059Cuba, Liberia, former Soviet Union
Tennessee8,662Somalia, Sudan, Iraq
Maryland8,293Sierra Leone, former Soviet Union, Burma
Utah8,009Somalia, former Yugoslavia, Burma
Indiana7,132Burma, Thailand, former Yugoslavia
Wisconsin6,830Laos, former Yugoslavia, Burma
Idaho6,317Former Yugoslavia, former Soviet Union, Afghanistan
Iowa6,146Former Yugoslavia, Sudan, Burma
Connecticut5,186Former Yugoslavia, Somalia, former Soviet Union
Nevada4,689Cuba, former Yugoslavia, Iran
Nebraska4,597Sudan, Burma, former Yugoslavia
New Hampshire4,112Former Yugoslavia, Bhutan, Somalia
North Dakota2,853Former Yugoslavia, Somalia, Bhutan
South Dakota2,736Somalia, Sudan, former Yugoslavia
Louisiana2,585Cuba, former Yugoslavia, Vietnam
Vermont2,093Former Yugoslavia, Somalia, Bhutan
Rhode Island1,961Liberia, former Soviet Union, Burundi
Kansas1,754Burma, Somalia, Vietnam
New Mexico1,690Cuba, Iraq, Vietnam
Maine1,580Somalia, Sudan, former Yugoslavia
Oklahoma1,209Burma, former Soviet Union, Vietnam
Alabama1,105Iraq, Cuba, former Soviet Union
South Carolina1,043Former Soviet Union, Burma, Somalia
District of Columbia794Ethiopia, Sierra Leone, Iraq
Alaska459Former Soviet Union, Laos, Bhutan
Delaware241Liberia, Sierra Leone, Afghanistan
Puerto Rico234Cuba, Vietnam, Colombia/Haiti
Mississippi218Sudan, Somalia, Afghanistan
Hawaii154Vietnam, Burma, former Soviet Union
Arkansas105Laos, Vietnam, Cuba
Montana85Former Soviet Union, Iraq, Cuba
West Virginia54Iraq, Vietnam, Burma
Guam5Vietnam
Wyoming3Former Soviet Union
Total618,090

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.

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

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).

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

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

Infectious agentTestComments
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

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

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 (https://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 (https://www.aafp.org/afp/980301ap/gavagan.html).

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