Health Status of and Intervention for U.S.-Bound Kosovar Refugees -- Fort Dix, New Jersey, May-July 1999
In March 1999, as a result of armed conflict in the Kosovo province of the Federal Republic of Yugoslavia, approximately 860,000 ethnic Albanians sought refuge in neighboring Albania, the Former Yugoslav Republic of Macedonia (FYROM), the Republic of Montenegro--Federal Republic of Yugoslavia, and Bosnia-Herzegovina. As a result of massive refugee movement into FYROM, many nations, including the United States, accepted refugees for resettlement. Refugee processing centers were established in FYROM and the United States. In the United States, the Migration Health Assessment (MHA)* of refugees was undertaken at Fort Dix, New Jersey (i.e., Operation Provide Refuge), in collaboration with the Office of Emergency Preparedness (OEP), Public Health Service, under the direction of the Office of Refugee Resettlement, U.S. Department of Health and Human Services. Assessments in Skopje, FYROM, were conducted by the International Organization for Migration. This report summarizes the results of collaboration between OEP and CDC to provide preventive health programs for 4045 Kosovar refugees at Fort Dix during a 10-week period, which found that the refugees were in good health and underscores the need for a tailored intervention program targeted at the health conditions of the specific population.
The first refugees arrived at Fort Dix on May 5. On arrival, acute medical care was provided as needed, and all refugees were scheduled to undergo the required MHA. As part of the MHA, refugees aged greater than or equal to 15 years underwent a general physical examination and were screened for human immunodeficiency virus infection, syphilis, and TB.
Intervention and prevention services were established at Fort Dix in addition to the acute-care services and MHA. Because of reports of inadequate vaccination programs in Kosovo during the 2 years preceding the mass exodus (1) and the emergency resettlement of the refugees in the United States, approximately 10,600 vaccines were administered to refugees from a set of recommended vaccines (unless vaccination documentation was provided) (Table 1). Because high birth rates were reported in Kosovo before the conflict (2), women of childbearing age (18-45 years) who had abnormal menstruation or amenorrhea were screened for pregnancy to determine whether they needed prenatal care and should not receive live vaccines. Approximately 120 pregnancy tests were performed during the first month; 58 women received prenatal care, including approximately 400 prenatal visits, and seven babies were born.
On the basis of reports from camps in FYROM, refugees also were assessed for selected conditions (e.g., untreated chronic diseases in the elderly and dental conditions). A pharmacy was established and dispensed approximately 7600 medications for conditions such as hypertension and diabetes. In addition, approximately 1000 dental visits were reported.
Pharmacy- and laboratory-based surveillance systems were established within 1 day of the arrival of the first refugees to identify potential disease outbreaks. Pharmacy-based surveillance of 1% permethrin prescriptions was included because of lice infestations reported from camps in FYROM: use was 20%-40% among refugees arriving during the first week. Among the 1051 newly arriving refugees during the second week, the prevalence of lice or nits within 1/4 inch of the scalp (currently infested cases only) was 10%. On the basis of treatment outcomes, no drug resistance was documented. A treatment program was initiated for head lice at Fort Dix and treatment recommendations were made for the FYROM camps.
The first step in TB screening consisted of a chest radiograph. If the radiograph suggested active TB, serial sputum samples were collected for microscopy, culture, and sensitivity through the state laboratory. If radiographs were suggestive of inactive TB and the refugee was not symptomatic, no further evaluation was performed.
Among 4045 refugees screened at Fort Dix, two had infectious (smear-positive) TB, 26 had chest radiographs suggestive of active TB (all smear-negative, eight with clinical indications for treatment), and 65 had radiographs suggestive of inactive TB. All will be reevaluated at their health departments after resettlement. Six refugees had culture-confirmed TB (all sensitive to first-line TB drugs), and 10 refugees (including two with infectious TB) were begun on treatment.
Refugees with "inadmissible" health conditions received treatment, or received waivers, and physicians were identified to provide continuity of health care. Six refugees were treated for syphilis. Seven refugees were treated for mental health disorders associated with harmful behaviors and placed with physicians in their resettlement area. No other "inadmissible" health conditions were identified. No refugees were involuntarily deported because of "inadmissible" health conditions.
Refugees were treated at a 24-hour acute-care clinic (5127 visits) and referred to specialized care when necessary (72 hospitalized during the first month). Medical charts, including medical history, conditions and medications, vaccinations, dental and prenatal records, and results of MHA, were transferred to the state and local health agencies providing health care after resettlement.
During the same period, 5303 refugees entered the United States through JFK International Airport in New York; similar numbers of refugees with chest radiographs suggestive of active (n=23) and inactive (n=60) TB were identified. No differences were reported in the age and sex distribution of refugees by port of entry. All of these refugees were referred to the state and local health agencies that provide follow-up care for TB patients.
As of August 25, Kosovar refugees continued to enter through JFK International Airport, although their numbers have diminished. On July 16, Operation Provide Refuge was declared completed and the facilities at Fort Dix closed.
Reported by: K Yeskey, MD, Office of Emergency Preparedness, Public Health Service; Div of Tuberculosis Elimination, National Center for HIV, STD, and TB Prevention; Div of Epidemiology and Surveillance, National Immunization Program; Div of Parasitic Diseases and Div of Quarantine, National Center for Infectious Diseases, CDC.
The health status of refugee populations varies considerably depending on 1) the demographics of the migrating population; 2) the prevalence of health conditions and quality of health services before displacement and in the country of first refuge; 3) the length of time the population was deprived of health care; and 4) the harshness of their living conditions during displacement. Despite these variations, screening for U.S. immigration purposes has been the same for all refugee and immigrant populations. To provide more timely interventions, CDC is tailoring health assessments to specific migrating populations (3).
Before this migration emergency, the only medical information transmitted to the refugee health providers in the resettlement areas was that related to the "inadmissible" health conditions. Health information collected in refugee emergency settings should include 1) baseline health status of the refugee population; 2) refugee camp health provision and surveillance; 3) immigrant/refugee health clearance; 4) identification and design for preventive interventions; and 5) postsettlement follow-up care. The CDC/OEP response at Fort Dix underscores the value of a tailored approach, including preventive health interventions specifically targeted at this population. During this emergency, using information on health conditions in Kosovo before the armed conflict and on health conditions in the camps in FYROM, health services were prepared to meet the needs of Kosovar refugees.
To establish continuity of care, medical records developed at Fort Dix were transmitted to the resettlement health providers through the refugees. In addition, health fact sheets were drafted periodically and relayed to the refugee health coordinators in the states to assist them in planning health services programs before the arrival of the refugees. This health information and data collection and dissemination should be considered basic components of the refugee admission and resettlement process.
* MHA is a health examination mandated by U.S. law for all refugees and immigrants. The assessment is designed to identify "inadmissible" health conditions, which are infectious tuberculosis, human immunodeficiency virus infection, infectious syphilis and other sexually transmitted diseases, infectious (lepromatous) Hansen disease, any physical or mental health disorder associated with harmful behavior, and drug abuse or addiction.
TABLE 1. Recommended vaccinations for Kosovar refugees resettling in the United States -- 1999 =============================================================================================== Group Vaccine --------------------------------------------------------------------------------------------- Age 2 months-6 years Diphtheria and tetanus toxoids and acellular pertussis Age >=7 years (including pregnant women) Tetanus and diphtheria toxoids Age 2 months-17 years Oral poliovirus Age 6 months*-17 years Measles-mumps-rubella (MMR) Nonpregnant women aged 18-45 years MMR Age 2 months-1 year Haemophilus influenza type b Newborn through age 17 years (including Hepatitis B pregnant women) Age >=65 years (and age >=2 years with chronic Pneumococcal disease) --------------------------------------------------------------------------------------------- * MMR vaccination should be initiated at age 6 months in high-risk circumstances (e.g., over- crowding). If a child is vaccinated at age <12 months, repeat vaccination is recommended at age 12-15 months. The routine dose at age 4-6 years (i.e., preschool age) should still be administered. ===============================================================================================
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