Teen Newsletter: February 2021 – Refugee Health

Under the Immigration and Nationality Act (INA), a refugee is an alien who, generally, has experienced past persecution or has a well-founded fear of persecution on account of race, religion, nationality, membership in a particular social group, or political opinion. Individuals who meet this definition may be considered for either refugee status under Section 207 of the INA if they are outside the United States (U.S.), or asylum status  under Section 208 of the INA, if they are already in the U.S.

Watch this video from the Secretary of Homeland Security to see exactly what a potential refugee goes through to resettle in the U.S.

The refugee process can be lengthy:

1. Refugees Flee their Homeland: Because of a well-founded fear of persecution, a refugee will flee his/her home country.
2. Refugees Seek Protection: A refugee seeks protection from the United Nations High Commissioner for Refugees (UNHCR). Protection can come from one of three possible solutions:
   1. Return to the home country when homeland is deemed safe.
   2. Settle into the country to which they fled.
   3. Resettle permanently into a third country.
3. Access to the U.S. Refugee Program: A refugee can access the U.S. Refugee Program through an application process that includes referrals.
4. Permanent Resettlement into a Third Country: If permanent resettlement is deemed a possibility, the refugee is interviewed in his/her current place of residence by U.S. Citizenship and Immigration Services (USCIS) to see if he/she will be granted permission to enter the U.S. Refugee Program.
5. Approval: If a refugee is approved by USCIS, the case is allocated to one of nine domestic resettlement agencies.
6. Resettlement: The refugee’s case is sent to a local office in the U.S., where help is found for the refugee. Assurance is based on an analysis of available resources in each community to meet the needs of specific refugees.

This newsletter will focus on the health issues surrounding the refugee resettlement process, which is part of steps 3 and 4 in the list above.

Public health problems are diverse and can include infectious diseases, chronic diseases, emergencies, injuries, environmental health problems, as well as other health threats. Regardless of the topic, we take the same systematic, science-based approach to a public health problem by following four general steps.

1. Surveillance (What is the problem?)

In public health, we identify the problem by using surveillance systems to monitor health events and behaviors occurring among a population.

For this newsletter’s topic we will use an example of a public health intervention for a specific refugee population described in an article written by CDC Refugee Health professionals published in The American Journal of Tropical Medicine and Hygiene (AJTMH).  Read the entire article.

Data are often collected from refugees upon their arrival to the U.S. In 2007, blood sample analysis showed that 44% of refugee arrivals from Sudan, a country in northeastern Africa, were infected with Strongyloides.

Shown above, Strongyloidiasis is a parasitic disease caused by nematodes, or roundworms, in the genus Strongyloides. The parasites enter the body through exposed skin, such as bare feet. Most people who are infected with Strongyloides do not know they are infected and have no symptoms. Others, particularly those who are on some immunosuppressive therapies, may develop a severe form and, if untreated, become critically ill and possibly die.

2. Risk Factor Identification (What is the cause?)

After we’ve identified the problem, the next question is, “What is the cause of the problem?” For example, are there factors that might make certain populations more susceptible to disease, such as something in the environment or certain behaviors that people are practicing?

CDC works with partners to administer presumptive medicine to refugees. Presumptive medicine is medicine given to prevent infections regardless of if the person has been tested for the disease or not. Strongyloidiasis is most common in tropical or subtropical climates. For refugees coming from an area of the world where certain infections are common, it is more cost effective and efficient to treat everyone for that infection than it is to test and treat individuals. Strongyloides can be treated with a drug called ivermectin, and that drug is part of the recommendation for sub-Saharan African refugees. However, it is not recommended for refugees from central and west Africa. In these two parts of Africa another parasite, Loa loa, is endemic, or present. Persons who have been exposed or are infected with Loa loa can develop encephalopathy, or brain damage, when they take ivermectin, the medicine to treat Strongyloides. This can lead to a gap in treatment creating a higher risk for untreated Strongyloides infections in central and west African refugees.

3. Intervention Evaluation (What works?)

Once we’ve identified the risk factors related to the problem, we ask, “What intervention works to address the problem?” We look at what has worked in the past in addressing this same problem and if a proposed intervention makes sense with our affected population.

In our example, one possible method of intervening might be to increase medical provider knowledge in areas in the U.S. where refugees are resettled. Since treating refugees before they come to the U.S. with ivermectin carries a risk of brain damage, it is important for doctors in the U.S. to recognize these tropical infections in refugee patients. Since these are not common infections in the U.S., many doctors may not be familiar with these infections, which can lead to misdiagnosis.

4. Implementation (How did we do it?)

In the last step, we ask, “How can we implement the intervention? Given the resources we have and what we know about the affected population, will this work?”

Treatment of tropical infections is part of the recommendations CDC provides through the Refugee Health Guidelines mentioned in the CDC’s Work section of this newsletter.

Many domestic U.S. medical providers may not be familiar with the recommendations, suggesting that additional medical provider training is necessary. One of CDC’s core functions is training. The CDC Learning Connection helps public health and health care professionals stay informed about quality trainings from CDC, other federal agencies, and federally-funded partners.

Through training and web resources, CDC is able to provide topic specific materials to medical providers, who in turn can treat refugees.

Each refugee resettlement community operates differently, but many resettlement agency providers are connected with their county health departments, federally qualified health centers (FQHCs), and culturally competent private medical providers in their areas. Refugee health clinics typically have waiting rooms where several refugee patients may be waiting with their families at the same time for appointments. One example of a COVID-19 resource that a provider might have in their waiting room is – “Contact Tracing: Do your part to keep your family, friends, and community safe.”

Languages: English | Español | Chinese | Vietnamese | Korean | Marshallese

Change to: Look for the social media challenge below to engage with the refugee COVID-19 resources!

As you can see, using The Public Health Approach helps public health professionals identify a problem, find out what is causing it, and determine what solutions/interventions work.

This month we are featuring historic photographs related to refugee health and CDC. Refugee entry to the United States started after the U.S. government passed the 1952 Immigration and Nationality Act. This act has been amended many times. In 1967, CDC became involved in quarantining of persons traveling to the U.S.

Now let’s turn to the Vietnamese War, which ended in April 1975. The conclusion of the war precipitated the Vietnamese boat people (refugees who fled Vietnam by boat and ship at the end of the war) and the larger Indochina refugee crisis. Between 1975-1998, 1.2 million refugees from Vietnam/Southeast Asia resettled in the U.S.

These images are from the CDC Museum Collection and they document that, in 1975, CDC began to assist the U.S. government with visa and entry screening, immunization, and follow up regarding the health of Vietnamese refugees in the U.S. These images show Vietnamese refugees at Camp Pendleton, a Marine base in California.

Left: Red Cross volunteers aid in dispensing medication to Vietnamese refugees being processed in Camp Pendleton, California.

Right: Young girl screams as a Navy Corpsman gives her a shot. She is one of the many refugees being vaccinated during processing in Camp Pendleton, California.

Maj G.L. Gill, 1975
Official Marine Corps Photographs