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Large Study of Health Issues for Newly Arrived Child Refugees
Journal of Pediatric Nursing (2015) xx, xxx–xxx
HOT TOPICS DEPARTMENT Editor: Deborah L. McBride, PhD, RN
Deborah L. McBride, PhD, RN
Large Study of Health Issues for Newly Arrived Child Refugees1,2 Deborah L. McBride PhD, RN ⁎ Samuel Merritt University, Oakland, CA Received 21 November 2015; accepted 22 November 2015
Hepatitis B, tuberculosis, parasitic worms, high blood lead levels and anemia are the top health issues of newly arrived child refugees according to a new study of refugee children. Each year, the U.S. accepts 35,000 child refugees who have fled persecution from their home country through the Department of State's Refugee Resettlement program. An additional 200,000 to 250,000 immigrant children receive lawful permanent residency in the United States each year. Before arriving in the United States, these children refugees often live in rural areas or refugee camps where medicine, food and western luxuries are seldom available. Overall, 3.7% of children living in the United States, including 7.7% of Latino children and 16.7% of Asian children, were born overseas. Although immigrant children are an important, and growing part of the U.S. population, comprehensive guidelines for the care of these children has been lacking. This has been because, in part, data on the health status of immigrant children have been missing. Despite these limitations, the Centers of Disease Control and Prevention (CDC) has used the best available data to develop screening guidelines for refugees that have been implemented by many state and local departments of public health (www.cdc.gov/immigrantrefugeehealth/ guidelines/domestic/checklist.html). These guidelines recommend a minimum set of screening tests, which usually take place within 90 days (and preferably within 30 days) of arrival, for infectious, nutritional and environmental health 1
The views expressed in this article are the authors' own and not an official position of their institutions. 2 The authors declare that there are no conflicts of interest. ⁎ Corresponding author: Deborah L McBride, PhD, RN. E-mail address: [email protected].
http://dx.doi.org/10.1016/j.pedn.2015.11.014 0882-5963/© 2015 Elsevier Inc. All rights reserved.
problems. Lacking more specific recommendations, these guidelines have been adopted by some clinicians specializing in health care of other populations of immigrant children. Now, in a large epidemiological Hepatitis B, tuberstudy of refugee children, public culosis, parasitic health researchers have described worms, high blood the health profiles of newly arrived lead levels and anerefugee children who arrived in the mia are the top U.S. in the past decade in order to develop population-specific health issues of adjustments to the CDC guidelines newly arrived child (Yun et al., 2015). The researchers refugees according analyzed medical data on 8,148 to a new study of refugee children (aged b 19 years) refugee children. who fled Bhutan, Myanmar, the Democratic Republic of the Congo, Ethiopia, Iraq and Somalia between 2006 and 2012 and arrived in four states: Colorado, Minnesota, Philadelphia, Pennsylvania, and Washington State. Within 90 days of arriving in the U.S., each child was given a routine screening which followed the domestic refugee health guidelines issued by the CDC and measured blood lead levels, anemia, hepatitis B virus (HBV) infection, tuberculosis (TB) infection or disease and markers of infection by Strongyloides (parasitic worms). As expected, the newly arrived refugee children had higher rates of those diseases than those living in the U.S. About 20% of the children in the sample had blood levels at or above 5 micrograms per deciliter, the current U.S. threshold for elevated blood lead, but fewer than 2% had levels above 10 micrograms per deciliter. Hepatitis B virus infection varied by country of origin from 0.7% in Bhutan to 5.3% in Ethiopia, leading the researchers to
2 conclude that universal HBV screening may not be necessary for children from regions where the prevalence of HBV among children is comparable to that in the United States (0.6%). TB prevalence varied by test from 11.8% when a tuberculosis blood test was used compared to 21.5% with a tuberculin skin test. The disease prevalences varied by national groups. In general, the prevalences were higher among children from the Democratic Republic of the Congo, Ethiopia and Somalia and lower for Iraqi children. Among children from Myanmar, diseases were more common among those who came to the U.S. from Thailand compared to those who came to the U.S. from Malaysia, suggesting that the living environment before departure for the U.S. plays major role in determining health risks. According to the researchers, most refugee children living in Malaysia live in urban environments, receive regular health care and experience relatively little food insecurity. In contrast most refugee children living in Thailand reside in refugee camps in a rural, border region, where they may have irregular access to preventive health services, depend upon food packages provided by nonprofit agencies, and may be exposed to environmental risks unique to rural areas (e.g., the use of lead-contaminated car batteries as household electrical sources). As a result, country of departure may be particularly important when assessing disease risk, as many children are born in host countries rather than their parents' country of origin. The odds of HBV and TB were higher among males versus female children and increased with advancing age. The odds of HBV infection, TB and Strongyloides were lower among children who had arrived in the U.S. more recently. The overall prevalence of Strongyloides infection was 3.7%, but there was a sharp drop in prevalence
Hot Topics Department among children arriving in the U.S. after 2010, suggesting that a CDC initiated program to provide routine, presumptive treatment for Strongyloids for U.S. bound refugees beginning in 2011 was responsible for this change. The researchers drew several policy implications from their study including that the CDC guidelines for medical screening of newly arrived refugee children are relevant and hold great value. In addition, they recommend that multi-state public health collaborations monitor the health of newly arrived refugee children, along with the resources available to them, and that public health officials should pool and analyze their data in a timely manner because refugee populations change significantly over time. Ongoing U.S. refugee health surveillance efforts focusing on new groups should be designed to allow the detection of differences between children from different countries of departure. The results of this study may also be of value to clinicians caring for non-refugee immigrant children from low- and middle-income countries in Asia and Africa. According to the researchers, additional work is necessary to develop screening guidelines for other populations of immigrant children, particularly children from countries with large U.S. permanent resident populations, such as Mexico, China, India, and the Philippines. The researchers hope that understanding the health profiles of children from different countries will allow clinicians to provide better counseling for parents, to prioritize specific tests and to ensure that children get a healthy start in the U.S.
Reference Yun, K., Matheson, J., Payton, C., Scott, K. C., Stone, B. L., Song, L., ... Mamo, B. (2015). Health profiles of newly arrived refugee children in the United States, 2006–2012. American Journal of Public Health, e1–e7 (Epub ahead of print).
HOT TOPICS DEPARTMENT Editor: Deborah L. McBride, PhD, RN
Deborah L. McBride, PhD, RN
Large Study of Health Issues for Newly Arrived Child Refugees1,2 Deborah L. McBride PhD, RN ⁎ Samuel Merritt University, Oakland, CA Received 21 November 2015; accepted 22 November 2015
Hepatitis B, tuberculosis, parasitic worms, high blood lead levels and anemia are the top health issues of newly arrived child refugees according to a new study of refugee children. Each year, the U.S. accepts 35,000 child refugees who have fled persecution from their home country through the Department of State's Refugee Resettlement program. An additional 200,000 to 250,000 immigrant children receive lawful permanent residency in the United States each year. Before arriving in the United States, these children refugees often live in rural areas or refugee camps where medicine, food and western luxuries are seldom available. Overall, 3.7% of children living in the United States, including 7.7% of Latino children and 16.7% of Asian children, were born overseas. Although immigrant children are an important, and growing part of the U.S. population, comprehensive guidelines for the care of these children has been lacking. This has been because, in part, data on the health status of immigrant children have been missing. Despite these limitations, the Centers of Disease Control and Prevention (CDC) has used the best available data to develop screening guidelines for refugees that have been implemented by many state and local departments of public health (www.cdc.gov/immigrantrefugeehealth/ guidelines/domestic/checklist.html). These guidelines recommend a minimum set of screening tests, which usually take place within 90 days (and preferably within 30 days) of arrival, for infectious, nutritional and environmental health 1
The views expressed in this article are the authors' own and not an official position of their institutions. 2 The authors declare that there are no conflicts of interest. ⁎ Corresponding author: Deborah L McBride, PhD, RN. E-mail address: [email protected].
http://dx.doi.org/10.1016/j.pedn.2015.11.014 0882-5963/© 2015 Elsevier Inc. All rights reserved.
problems. Lacking more specific recommendations, these guidelines have been adopted by some clinicians specializing in health care of other populations of immigrant children. Now, in a large epidemiological Hepatitis B, tuberstudy of refugee children, public culosis, parasitic health researchers have described worms, high blood the health profiles of newly arrived lead levels and anerefugee children who arrived in the mia are the top U.S. in the past decade in order to develop population-specific health issues of adjustments to the CDC guidelines newly arrived child (Yun et al., 2015). The researchers refugees according analyzed medical data on 8,148 to a new study of refugee children (aged b 19 years) refugee children. who fled Bhutan, Myanmar, the Democratic Republic of the Congo, Ethiopia, Iraq and Somalia between 2006 and 2012 and arrived in four states: Colorado, Minnesota, Philadelphia, Pennsylvania, and Washington State. Within 90 days of arriving in the U.S., each child was given a routine screening which followed the domestic refugee health guidelines issued by the CDC and measured blood lead levels, anemia, hepatitis B virus (HBV) infection, tuberculosis (TB) infection or disease and markers of infection by Strongyloides (parasitic worms). As expected, the newly arrived refugee children had higher rates of those diseases than those living in the U.S. About 20% of the children in the sample had blood levels at or above 5 micrograms per deciliter, the current U.S. threshold for elevated blood lead, but fewer than 2% had levels above 10 micrograms per deciliter. Hepatitis B virus infection varied by country of origin from 0.7% in Bhutan to 5.3% in Ethiopia, leading the researchers to
2 conclude that universal HBV screening may not be necessary for children from regions where the prevalence of HBV among children is comparable to that in the United States (0.6%). TB prevalence varied by test from 11.8% when a tuberculosis blood test was used compared to 21.5% with a tuberculin skin test. The disease prevalences varied by national groups. In general, the prevalences were higher among children from the Democratic Republic of the Congo, Ethiopia and Somalia and lower for Iraqi children. Among children from Myanmar, diseases were more common among those who came to the U.S. from Thailand compared to those who came to the U.S. from Malaysia, suggesting that the living environment before departure for the U.S. plays major role in determining health risks. According to the researchers, most refugee children living in Malaysia live in urban environments, receive regular health care and experience relatively little food insecurity. In contrast most refugee children living in Thailand reside in refugee camps in a rural, border region, where they may have irregular access to preventive health services, depend upon food packages provided by nonprofit agencies, and may be exposed to environmental risks unique to rural areas (e.g., the use of lead-contaminated car batteries as household electrical sources). As a result, country of departure may be particularly important when assessing disease risk, as many children are born in host countries rather than their parents' country of origin. The odds of HBV and TB were higher among males versus female children and increased with advancing age. The odds of HBV infection, TB and Strongyloides were lower among children who had arrived in the U.S. more recently. The overall prevalence of Strongyloides infection was 3.7%, but there was a sharp drop in prevalence
Hot Topics Department among children arriving in the U.S. after 2010, suggesting that a CDC initiated program to provide routine, presumptive treatment for Strongyloids for U.S. bound refugees beginning in 2011 was responsible for this change. The researchers drew several policy implications from their study including that the CDC guidelines for medical screening of newly arrived refugee children are relevant and hold great value. In addition, they recommend that multi-state public health collaborations monitor the health of newly arrived refugee children, along with the resources available to them, and that public health officials should pool and analyze their data in a timely manner because refugee populations change significantly over time. Ongoing U.S. refugee health surveillance efforts focusing on new groups should be designed to allow the detection of differences between children from different countries of departure. The results of this study may also be of value to clinicians caring for non-refugee immigrant children from low- and middle-income countries in Asia and Africa. According to the researchers, additional work is necessary to develop screening guidelines for other populations of immigrant children, particularly children from countries with large U.S. permanent resident populations, such as Mexico, China, India, and the Philippines. The researchers hope that understanding the health profiles of children from different countries will allow clinicians to provide better counseling for parents, to prioritize specific tests and to ensure that children get a healthy start in the U.S.
Reference Yun, K., Matheson, J., Payton, C., Scott, K. C., Stone, B. L., Song, L., ... Mamo, B. (2015). Health profiles of newly arrived refugee children in the United States, 2006–2012. American Journal of Public Health, e1–e7 (Epub ahead of print).