Dept. of Family Medicine Grand Rounds, April 2, 2014

1. Evidence-Based Care of
Your Immigrant & Refugee
Patients
Family Medicine Grand Rounds
Schulich School of Medicine & Dentistry
April 5, 2014
Natalie Lovesey, MD, CCFP
Family Physician, Southdale Family Medical Centre
London, Ontario, Canada

2. Presentation Overview
 Definitions
 Key resource – CCIRH guidelines & online checklists
 London’s refugee populations
 Infectious diseases
 Mental Health & PTSD
 Eosinophilia & Intestinal parasites
 Throughout: Resources in London & Where to get help

3. Immigrant & Refugee Health -
Definitions
 Immigrant: one who has taken up permanent residency
in another country
 Refugee: one who has been forced to flee his or her
country because of persecution, war, or violence. A
refugee has a well-founded fear of persecution for
reasons of race, religion, nationality, political opinion or
membership in a particular social group
 This presentation will focus on refugees, but many
things are applicable to recently-arrived immigrants

4. Immigrant Health Status
 ‘Healthy Migrant’ phenomenon – immigrants often healthier than
native-born population upon arrival
 Health indices become similar to native-born population after ~5
years
 Subgroups of immigrants are at increased risk of disease-specific
mortality; for example:
 Southeast Asians from stroke ( [OR] 1.46, 95% [CI] 1.00–1.91)
 Caribbeans from diabetes mellitus (OR 1.67, 95% CI 1.03–2.32)
and infectious diseases
 Immigrant men from liver cancer (OR 4.89, 95% CI 3.29–6.49)
 Many health needs the same as native-born; but some may differ
and require increased awareness

5. Refugee Health Status
 Higher risk of past trauma, violence, and harsh living
conditions
 Health varies greatly depending on their particular
circumstances (access to health care, living conditions,
social status, etc.)
 At risk for decline in health status after arrival

6. Health Coverage for
Refugees & Immigrants

7. Coverage: New Immigrants
 3 month wait time for permanent residents in Ontario,
Quebec, BC, Nunavut and the Yukon
 Quebec has variable wait time and has exceptions for
pregnant women, infectious diseases, domestic
violence, etc.
 Vestige of pre-Medicare days when private insurance
plans typically had a 3 month wait
 Non-evidence based? ON does not specifically outline
its rationale for the wait
 Presumably thought to be cost-effective, but is it?

8. Coverage: Refugees
 Gov’t-assisted refugees: ‘expanded health care coverage’ – ie. Hasn’t
changed from previous
 Similar to coverage for those on provincial assistance
 Privately sponsored refugees and refugee claimants who are not from
designated countries of origin (DCOs),2 – ‘health care coverage’
 Includes coverage for hospital, physician, laboratory, and diagnostic services.
Medications and vaccines are generally not covered, unless they are needed to
prevent or treat a disease that poses a risk to public health or public safety—for
example, medications for HIV or tuberculosis.
 Refugee claimaints from DCOs (countries deemed by CIC to be ‘safe’ and
therefore should not produce refugees”; rejected refugee claimaints; refugees
whose claim has been suspended
 ‘public health care coverage’ – coverage for services only if they are required to
diagnose, prevent or treat a disease posing a risk to public health or to
diagnose or treat a condition of public safety concern (such as HIV or TB):
hospital services, services of a doctor or registered nurse licensed in Canada,
laboratory and diagnostic services, and medication and vaccines. This coverage is
very limited.

9. Coverage & Cuts
 “Refugee health - Providing the best possible care in
the face of crippling cuts” – Sheikh, Rashid, Berger et
al., Canadian Family Physician, June 2013
 Article is an excellent reference for different classes of
coverage
 It IS confusing, and an arduous process to find out
what/who is covered.

10. Doctors for Refugee Care
Report
 “Children and pregnant women are being turned away
from clinics despite having valid coverage.8 Patients
are being asked to pay up front of their visits despite
having coverage. E–mails obtained from the CMAJ
revealed that only 9 out of 33 walk-in clinics in Ottawa,
Ont, were accepting refugees as patients, and in those
cases in which refugees were seen, they were charged
fees of up to $60.9 Refugees are being harmed by
confusion almost as much as by the cuts themselves.”

11. Ontario Temporary Health
Program
 Launched Jan. 1, 2014 in response to IFH cuts
 Goal “ to provide access to essential and urgent health
care, as well as medications coverage to refugee
claimants living in Ontario, regardless of the status of
their claim or the country they are from.”
 Also administered by Mediavie Blue Cross
 Claims submitted first for processing to Medavie Blue Cross
through the IFHP. If the claim is rejected for services beyond
Public Health and Public Safety coverage under IFHP, it can
be sent to the OTHP for consideration of payment.

12. Tips When Providing Care
 Not clear which clinical presentations justify an
investigation to rule out an infection by a transmissible
organism, even if the eventual diagnosis is not a
notifiable disease.
 Therefore, when calling the Blue Cross, it is
important to highlight that the visit is to investigate
a possible communicable disease—for example,
evaluating a cough in order to rule out tuberculosis.

13. Refugees in London

14. Current Refugee Health Clinic
Model in London, ON
 Partnership with Cross Cultural Learner Centre and
London Intercommunity Health Centre
 Came into being from Dr. Bhayana’s refugee health
experience & Newcomer Health Project (started 2008)
 Always looking to expand roster of family doctors
accepting refugee patients
 Academic centres are ideal!

15. Populations in London, ON:
Iraqi refugees
 Many Iraqi refugees arrived as GARs in the past few
years
 Many had reasonable access to health care
 Many exposed to past violence
 Common health issues:
 Hypertension and cardiac disease
 Post-Traumatic Stress Disorder
 Depression
 MSK issues related to past trauma

16. Iraqi refugees
 56% have experienced torture (Willard, Rabin & Lawless,
2013)
 24.3% primary; 31.4% secondary
 Torture survivors more likely to report physical and mental
symptoms.
 Torture and cumulative trauma are the strongest predictors
of post-traumatic stress disorder and are associated with
chronic physical and mental health problems.
 Most individuals with a history of trauma recover (~80%),
but those with PTSD can remain symptomatic for years

17. Bhutanese Refugees
 Bhutanese refugees of ethnic Nepali descent – living in UN-
run camps in Nepal since the early 1990s
 In 2007, 108 000 Bhutanese refugees living in the camps
 Canada plans to resettle up to 6500 refugees in total (2007-
present)
 Common health issues:
 Anemia
 Vitamin B12 deficiency
 Mental health issues

18. Bhutanese Refugees
 Since 2009: at least 16 suicides among the 49,010
Bhutanese refugees resettled to the United States.
 Factors: social isolation, substance abuse, domestic
violence, depression, and resettlement issues
 Some refugees may have been tortured prior to fleeing
Bhutan. Men are more likely to report having been
tortured than women, but tortured women are more
likely to report mental health conditions than tortured
men.

19. Refugee patients in your
office: where to start

20. Refugee patients in your
office: where to start
 Interpreters can be arranged through Across
Languages
 Use a certified interpreter
 Beware Google translate!
 Beware family members as translators!
 Beware other staff as translators!
 What’s been done already?
 Canadian Immigration Exam (more in a moment)
 Usually TB screening, through the Health Unit.
 Sometimes immunizations through the Health Unit.

21. Canadian Immigration Exam
 Done in country of origin or after approval of asylum seekers
 Purpose is two fold – considers cost to health care system (‘excessive
demand’) and public health safety for Canadian society
 Includes health history, exam with vision and hearing
 Review of CXR (11 yrs and older)
 Urinalysis (5 yrs and older) - dipstick for glc, blood, protein
 HIV - added Jan. 2002
 Since 1991, HIV has not been considered to pose a public safety risk, so
immigration applicants may be denied if they are determined to place an
‘excessive demand’ on the health care system; refugees, protected
persons & family class immigrants are exempt from the ‘excessive
demand’ consideration.

22. Where to start: History
 Country of birth, migration history
 Time spent in camp? Conditions?
 Languages spoken and/or written
 Education, occupation (past/present)
 Housing situation
 Family members – any in other countries?
 EAL Level? Attending classes?

23. Where to start?
 Canadian Collaboration for Immigrant & Refugee
Health Guidelines – CMAJ 2011
 Online checklist based on country of origin

26. http://www.ccirhken.ca/

33. Infectious Diseases

34. Tuberculosis: CCIRH
 Risk of reactivation increased in refugees
 Children: Screen those < 20 yrs from countries with a high
incidence of TB (> 15 per 100 000 population) as soon as possible
after their arrival in Canada with a TST, and recommend treatment
for latent tuberculosis infection if results are positive, after ruling
out active TB.
 Adults: Screen refugees aged 20-50 yo from countries with a high
incidence of tuberculosis ASAP after their arrival in Canada with a
TST. Screen all other adult immigrants who have risk factors that
increase the risk of active with TST, and recommend treatment for
latent tuberculosis infection if results are positive, after ruling out
active TB.
 Basically, all areas except N. America, W. Europe, Australia, NZ.

35. TB screening tests
 TB skin test (TST) and Interferon-Gamma Release Assay (IGRA)
 TST: Sensitivity 70-80%, specificity 97% EXCEPT in BCG-
vaccinated individual – only 60% spec. Likelihood of false pos TST
with BCG dec’s with time; less likely if vaccinated <age 2
 IGRA: Sensitivity 70-80%; specificity 99% - lower in kids; more
indeterminate results
 Both TST & IGRA especially challenging for kids <10
 Dr. Chris Greenaway (ID, Montreal) thinks IGRA superior in BCG-
vaccinated adult, otherwise, use caution.
 IGRA available in London at Gamma Dynacare Pall Mall. Cost to
patient $100.

36. Vaccine-Preventable
Diseases
 Immigrant/Refugee children & adults more likely to have received
immunization against
 Measles
 Diphtheria
 Pertussis
 Tetanus
 Polio
 BCG (TB)
 Less likely to have received
 Mumps
 Rubella
 Varicella
 H. influenzae
 S. pneumo

37. Vaccine-Preventable
Diseases
 Seroprevalence studies:
 Measles immunity >95%
 Mumps immunity 80-92%
 Rubella 80-85%
 Td 50-60% in 20-30 yo’s, less with increasing age
 Immigrants over-represented in Rubella outbreaks, and
most cases of congenital rubella syndrome and neonatal
tetanus have been in babies of foreign-born mothers (in
US/Can.)
 Immigrants not over-represented in past mumps or measles
outbreaks

38. Vaccine-Preventable
Diseases
 CCIRH: All (adults and children) without written records
should be given a primary immunization (catch-up)
schedule
 NACI: All without records should be given a primary
immunization series
 Adults – primary series of Td (1st Tdap), and polio, and
MMR if born after 1970 & no hx of measles OR seroneg
for mumps or rubella
 There are no systemic catch-up programs in place
for adults, or for some vaccines (eg. varicella)

39. Vaccine-Preventable
Diseases
 Best approach for children WITH records is challenging
 Studies of discordance between records and immunity.
False records? Cold chain issues? Host factors?
 Most conservative: repeat series
 Alternative: screen/test and vaccinate

40. MMR Vaccine
 Effectiveness
 Measles: close to 100% protection after 2 doses
 Mumps: 64% after 1 dose; 79% after 2 doses
 Rubella: >95% protection after 1 dose
 Adverse effects
 Fever 5%
 Febrile seizure 0.3%
 Benign ITP <0.01%
 Parotitis rare
 Arthritis up to 25% of postpubertal women; higher in
never-vax than in prev-vax. (occurs within 2 weeks)

41. Varicella
 Occurs at older ages in tropical countries
 ~age 15 vs. temperate or cold countries age 5
 ~30% of adolescents & adults from tropical countries
are susceptible
 CCIRH: Vaccinate all children <13yo with varicella
vaccine
 Screen all >13 with serology and vaccinate if
susceptible

42. Hepatitis B
 Prevalence of Hep B in refugees and new immigrants is 3%, vs. 0.5% of
Canadian-born
 CCIRH: Screen those from areas where seroprevalence ≥2% with Hep B sAg,
sAb and cAb
 Everywhere except United States, Canada, western and northern Europe,
Australia, New Zealand (consider other RFs)
 Refer if sAg positive
 Vaccinate if susceptible
 1-2%/year rate of household transmission to children in 1st decade of life if
family member positive
 VACCINATE young children of parents from areas of high Hep B EVEN if parents
negative &/or child born here – extended family members may be positive.

43. Hepatitis C
 CCIRH: Screen those from areas where
seroprevalence ≥3%; refer if positive

44. Malaria
 CCIRH: Do not routinely screen, but be alert especially
for those from Sub-Saharan Africa

45. Mental Health

46. Depression: CCIRH
 Rate of depression in immigrants are slightly lower than
general population, rising over time to be similar to the
gen pop
 Rate of depression in refugees is similar to the general
population
 CCIRH: If an integrated treatment program is available,
screen adults for depression using a systematic clinical
inquiry or validated patient health questionnaire (PHQ-
9 or equivalent). Link suspected cases of depression
with an integrated treatment program and case
management or mental health care. (QOE: moderate)

47. PTSD Screening: CCIRH
 Do not conduct routine screening for exposure to
traumatic events, because pushing for disclosure of
traumatic events in well-functioning individuals may
result in more harm than good. Be alert for signs and
symptoms of post-traumatic stress disorder, especially
in the context of unexplained somatic symptoms, sleep
disorders or mental health disorders such as
depression or panic disorder, and perform clinical
assessment as needed to address functional
impairment. (QOE: low)

48. PTSD
 Primary Care PTSD Screen
 In your life, have you ever had any experience that was so
frightening, horrible, or upsetting that, in the past month, you*
 1. Have had nightmares about it or thought about it when you did
not want to?
 2. Tried hard not to think about it or went out of your way to avoid
situations that reminded you of it?
 3. Were constantly on guard, watchful, or easily startled?
 4. Felt numb or detached from others, activities, or your
surroundings?

49. PTSD
 PTSD more likely than any other mental health disease
to present with somatic symptoms
 Can result in avoidance behaviour, INCLUDING
avoiding associating physical symptoms with past
trauma.

50. PTSD Management
 Core of healing is re-building trust – Dr. Mara Rabin, Utah
 Don’t discount the importance of a regular, trusting relationship
with you.
 Don’t press for details of trauma
 Very individualized
 Practice family-centered care; trauma-informed care
 Try to value methods of recovery and resilience, rather than overly
pathologizing
 Highlight non-pharmacologic management
 Exercise prescriptions, OHIP-covered physiotherapy, social
contact

51. PTSD Management
 First line: psychotherapy
 Pharmacologic treament (guidelines differ)
 1st line – paroxetine with augmentation (bupropion, mirtazapine)
 2nd line – sertraline, venlafaxine
 Sleep/nightmares
 Prazosin 1 mg po qhs, titrate up by 1-2 mg every few days until effective
dose reached. Avg dose 3 mg. Range 1-10 mg. Monitor for orthostatic
hypotension. (Level A)
 Clonidine 0.2-0.6 mg in divided doses. (Level C) Monitor for orthostatic
hypotension.
 Benzodiazepines can INCREASE flashbacks
 Dr. Cronkright, Syracus, NY: amitriptyline first line for PTSD-assoc
back pain

52. Trauma-Informed Care
 Trauma: an event that overwhelms an individual’s
capacity to cope
 PTSD can result from the trauma, but not inevitably
 Key principles of trauma-informed care:
 Trauma awareness
 Emphasis on safety and trust
 Opportunity for choice, collaboration and connection
 Strengths-based and skill building

53. What might this mean in a
Family Medicine office?
 Awareness that many of our patients (refugee and
otherwise) are trauma victims
 Awareness that ‘simple’ tasks like filling out forms, or
taking a medical history, may be difficult for some
patients
 Sensitivity to physical examination
 Reassurance of continuity of care
 Reminding patients that they can refuse
exams/procedures

54. London Resources
 Muslim Family Resource Centre for Social Support &
Integration
 Arabic and English-speaking psychologists
 Non-religious, culturally sensitive, family-centered model
 Family Services Thames Valley
 Multilingual counsellors
 London Intercommunity Health Centre - Women of the
World – several support groups including Iraqi

58. Eosinophilia & Parasites

59. Eosinophilia
 Usually defined as >450 absolute EO/L (ie 0.45)
 Mild – up to 1500
 Severe >3000 – refer urgently (ID/Heme/Allergy-Immunology)
 “Worms, wheezes, and weird diseases”
 Most common causes in refugees:
 Ascariasis, filarial infections, hookworm, schistosomiasis,
strongyloides, trichuriasis, toxocariasis
 Hx: past living conditions? Soil/water exposure? GI symptoms?
Rashes? Hematuria? ROS.
 Workup: Repeat CBC, LFTs, stool O&P x 3, u/a, urine O&P
(sample put in stool O&P bottle), CXR

60. Eosinophilia
 Asymptomatic, stool negative: serology for strongyloides,
schistosomiasis, filariasis, toxocariasis
 Empiric anti-helminth treatment recommended for
populations at high risk of parasites (eg. Southasian) –
single-dose ivermectin/albendazole/mebendazole 100 mg
po bid x 3d or 500 mg x 1
 Wait 2/12 before repeating CBC
 Fail to find cause in about 50%
 Symptomatic: organ-specific workup; refer

61. Eosinophilia
 Negative stool O&P doesn’t rule out infection
 Non-pathogenic parasites in stool: shows you past
exposure to contaminated water
 Children more likely to have EOphilia and to have
multiple concurrent infections
 Pregnant women – EO counts go down during
pregnant, lowest at delivery – repeat postpartum

62. Parasites
 Most self-resolve within months-years after arrival in
Canada without treatment
 Two deserve special mention because they may persist
for decades sub-clinically, and can result in significant
morbidity and mortality
 Strongyloides
 Schistosomiasis

63. Strongyloidiasis
 Caused by nematode Strongyloides stercoralis
 30-100 million people worldwide
 Endemic in Africa, Asia, Southeast Asia, Central & South
America
 Human infection occurs from the nematode infiltrating intact
skin, most often bare feet on soil
 >10% Iraqi refugees positive
 69% of Bhutanese refugees positive
 Census data 2001: 77.5% of immigrants to Canada 1991-
2001 were from Strongy-endemic countries

64. Strongyloidiasis
 Most people develop an asymptomatic, chronic GI tract
infection
 Unusual features of its biology can lead to autoinfection,
disease persistence, and hyperinfection syndrome in the
setting of impaired cellular immunity
 Hyperinfection has high mortality rate, 70%
 Common trigger is systemic steroid treatment
 Case series of 10 patients with disseminated infection in
Toronto 2002 (CMAJ)
 4/10 had systemic steroid use; 3/10 had HTLV-1 infection
 Can cause secondary Gram negative sepsis as nematode
passes through GI wall

65. Strongyloides
 CCIRH Recommendation:
 Strongyloides - Screen refugees newly arriving from
Southeast Asia and Africa with serologic tests for
Strongyloides, and treat, if positive, with ivermectin (first-line
therapy) or albendazole (if there are contraindications to
ivermectin).
 How to test:
 Serology (100% sensitivity, 88% specificity)
 Public health req – S06 – “strongyloides serology”
 If indeterminate or positive: treat
 Complete Health Canada request form

66. How to Order Strongyloides
Treatment
 Health Canada Special Access Programme Form for
ivermectin (non-licensed)
 Available online – Google above
 You will be sent medication; call patient in to discuss
how to take. Need weight of patient.
 3 mg tabs - dose is 200 micrograms/kilogram/day x 2
days; repeat in 2 weeks
 ask for number of tabs needed

67. Word of Caution
 African countries considered endemic for Loa loa
(presumptive ivermectin should not be used for Strongyloides)
 Angola
Cameroon
Central Africa Republic
Chad
Republic of Congo
Democratic Republic of the Congo
Equatorial Guinea
Gabon
Nigeria
South Sudan
 Probably best to refer to ID in this case.

68. Schistosomiasis
 >200 million people infected worldwide
 Second only to malaria in terms of disease burden from
parasitic illness
 AKA “bilharzia”
 Disease caused by parasitic worms Schistosoma
mansoni, S. haematobium, and S. japonicum; less
commonly, S. mekongi and S. intercalatum.

69. Schistosomiasis Geographic
Distribution

71. Schistosomiasis Symptoms
 Early – can be asymptomatic
 Can have rash within days
 Can have fever, chills, cough, myalgias within 1-2 months
 When adult worms are present, the eggs that are produced usually travel to
the intestine, liver or bladder, causing inflammation or scarring. Children who
are repeatedly infected can develop anemia, malnutrition, and learning
difficulties. After years of infection, the parasite can also damage the liver,
intestine, lungs, and bladder. Rarely, eggs are found in the brain or spinal cord
and can cause seizures, paralysis, or spinal cord inflammation.
 Long term – bladder cancer, infertility, other
 Symptoms of schistosomiasis are caused by the body's reaction to the eggs
produced by worms, not by the worms themselves.

72. Schistosomiasis Treatment

73. Schistosomiasis – Post-
Treatment
 CCIRH: Serologic testing after treatment for
schistosomiasis is not recommended, as the antibodies
tend to persist over time.
 All treated individuals should be followed prospectively
for clinical signs or symptoms of persistent infection
and to ensure that eosinophil counts remain within or
return to normal limits within six months of receiving
effective treatment.
 Should patients have persistent symptoms and/or
eosinophilia after six months, should be pursued.

74. Other conditions

75. Type II Diabetes
 CCIRH: Screen immigrants and refugees >age 35 from
high risk groups
 South Asian
 Latin American
 African

76. Iron deficiency anemia
 CCIRH: Screen women of reproductive age with serum
hemoglobin

77. “VFR” Travel – Visiting
Friends & Relatives
 Travelers returning to their country of origin to visit family & friends, especially
those traveling from a developed to a developing country
 Often at greater risk of illness because of several factors
 May believe they are immune to diseases present in country of origin
 Less likely to consult pre-departure travel clinics; take malaria prophylaxis
 More likely to visit remote areas and be exposed to local infection risks
 May be cost barriers to recommended travel immunizations and malaria prophylaxis
 Barriers or unawareness of travel medicine clinics
 Lack of adequate screening and immunization care in country of settlement
 Travel may be last-minute, eg. attending a family member’s funeral
 May travel during pregnancy; with small infants and children
 Ask about upcoming travel plans; let patients know about the Travel Clinics;
give presumptive advice about illness eg. management of diarrhea in young
children; be on alert especially with fever in returning travelers

78. Practice Management Tips

79. Practice Management Tips
 Use certified interpreters – Across Languages
 Can be used to convey information to patients eg. asking them
to follow up
 Book longer time for visits
 Have patience – you won’t cover everything in one visit.
Have them book follow up before they leave your office.
 If newly arrived, plan regular visits every 1-3 months.
 When referring, consider hospital-based specialists – may
be easier to arrange interpreters and for patients to arrange
transportation

80. Practice Management Tips
 Ask for help – refer ID/other; email colleagues &
specialists; connect with online listserv, etc.
 Excellent conference every June – Toronto/Rochester
 North American Refugee Health Conference

81. Resources
 Caring for Kids New to Canada – Canadian Pediatric
Society – kidsnewtocanada.ca
 Sick Kids – aboutkidshealth.ca – multilingual patient
handouts
 ccihrken.ca

82. Acknowledgements
 Dr. Bhooma Bhayana
 Dr. Sherin Husein
 Canadian Collaboration for Refugee & Immigrant
Health
 Refugee patients
Questions?