Skip to main content

Refugee Health: A Framework for Emergency Physicians


In our current political and social climate, refugee health is undoubtedly going to become an increasingly prevalent Emergency Department (ED) issue.  In the past few years, Canada has been accepting an average of 25 000 refugees from all over the world each year; now we have taken the same number of refugees from Syria alone in a span of just a few months.  So the need right now is huge! Yet, as ER physicians, we get almost no formal training on the subject, and most available resources are targeted at primary care providers, and don’t apply to our practice setting.


Here we will attempt to filter the existing information into a practical framework that is actually applicable to your ER practice.  This is intended for refugees in the ED in general, but includes some specific recommendations for the Syrian refugee population.  

Forbes Online

The Basics:

Refugee:
One who has been forced to flee his or her country because of persecution, war, or violence. 

Communication: 
ALWAYS take the time to get an interpreter. It's frustrating and time consuming, but it is standard of care, and EVERY major Canadian hospital should have the ability to get urgent interpretation services 24/7, either face-to-face or over the phone.

The Immigration Medical Exam (IME):
Before deciding how to investigate a patient, you need to know what has already been done. Every refugee or immigrant arriving to Canada will have the IME, usually before arriving on Canadian soil. The components include:
  • Medical history and focused exam
  • CXR to rule out pulmonary TB for those >11 years old
  • Syphilis serology for those 15 years old
  • HIV serology for those 15 years old
  • Urinalysis for those  5 years old
NB: A positive test result does not necessarily preclude acceptance to Canada, but might require proof of treatment or re-examination prior to acceptance. 



Fever in the new Refugee: 

1. Vaccine-Preventable Illnesses

  • Most refugees won't have vaccination records, in which case you should assume they are unvaccinated. 
  • This just means to keep the DDx broad, but ultimately to rely on your clinical suspicion. 
  • Use the CDC website to guide you as to what is endemic in the region your patient is from.
  • ESSENTIAL STEP: If your patient is unvaccinated, refer them upon discharge to your local newcomer/refugee clinics or local public health agencies to get the vaccines updated ! 

2. Malaria

  • If febrile, and from a malaria endemic region (check the CDC website!), they should be tested for malaria with a rapid antigen test and thick/thin smears. 
  • Consider this particularly in refugees from Sub-Saharan Africa. 
  • Syria is non-endemic for malaria, and most Syrian refugees are coming to Canada via Lebanon or Jordan, which are also non-endemic, so these patients do not need malaria screening, even if they have fever. 

3. TB

  • Screened as part of the IME if >11 years old; if positive they are only allowed to enter Canada after providing proof of treatment, negative sputum and negative CXR. 
  • Consider investigating if they are from a high-risk area (check the CDC website!) or if other risk factors for TB infection are noted (immunocompromised, HIV positive, contact with positive case). 
  • Syria = low risk for TB. 

4. HIV, Hepatitis B, Hepatitis C

  • HIV is screened as part of the IME, so most refugees will know their status; low incidence (<0.1%) in Syria. 
  • Hep B and Hep C are NOT part of the IME screening, so refugees may be unaware of their status.

5. GI Parasites

  • Most are benign and self-limiting; don't worry about memorizing them. 
  • Only two you need to remember because they are potentially fatal and treatable:
    • Strongyloides
      • Usually present with chronic mild GI infection, but can develop Strongyloides Hyperinfection Syndrome.
      • Causes overwhelming gram negative sepsis, shock, ARDS
      • 70% mortality untreated
      • Treat with lvermectin and supportive care, ID consultation for guidance. 
    • Schistosomiasis
      • Initially asymptomatic, then develop flu-like symptoms, and in late stages develop end organ failure (affects liver, lungs, bladder and CNS). 
      • Consider in patients with unexplained hepatitis, hematuria and seizures. 
      • Treatment regime is complex, involve ID and public health.

5. Middle East Respiratory Syndrome (MERS)

  • Many refugees are arriving in Canada during peak viral season, and are presenting with fever, but because they have travelled through Jordan (which has had some reported MERS), they screen positive for possible MERS at ER triage. 
  • This can result in unnecessary admission to hospital until MERS has been ruled out; unnecessarily utilizing hospital resources. 
  • KEY POINT: Syria has NO reported MERS, Syrian refugees are very low risk for MERS.

Bottom Line:

    Always consider the weird and wonderful causes of fever, and use the CDC website to help narrow the DDx for your specific patient, but remember that most fever in refugees will be due to common Canadian viruses. 

    Syrian refugees, LA Times

    Chronic Disease in Refugees

    • KEY POINT: The vast majority of illnesses we will see in refugees in the ER will be chronic illnesses that have gone unmanaged for many years (diabetes, hypertension, anemia). 
    • Establishing long-term follow up is key:
      • In Ottawa, refer to the Bruyere Family Health team Newcomer Clinic.
      • In other cities, look for your local Refugee/newcomer clinic, or ask your local Refugee Health Task Force for referral suggestions. 
    • Vision/Dental care:

    Bottom Line:

    Although infectious disease tends to get the most buzz in this population, the vast majority of disease we will see in Refugee patients in the ER is common chronic illnesses that we are quite comfortable managing! 

    Mental Health and Refugees

    • Mental health concerns are a common problem in refugee populations
    • CMAJ 2015 guidelines recommend AGAINST screening all refugee patients for mental illness, as this may induce more harm than good.
    • However, if a patient comes forward with mental health issues, culturally appropriate referral services are critical! 
    • In Ottawa, use:
      • Bruyere Family Health team newcomer mental health services 
        • Two psychiatrists, a psychiatric RN and social worker, all with experience working with refugee populations
      • Ottawa Community Immigrant Services Organization
        • 613-725-5671, ext. 322 or clinical@ociso.org 
        • Physician or patient referral 

    Bottom Line:

    Be aware that mental health is a prevalent issue in this population, and know your local referral resources. 

    Refugee Health Care Funding

    • Refugees receive temporary health care coverage to bridge them until they are eligible for local Provincial coverage through the Interim Federal Health Program (IFHP). 
    • Up until now, due to recent cuts to funding, this has been a bit confusing, but don't worry! As of April 1st, 2016, full IFHP coverage will be restored to all Refugees. 
    • Under IFHP, Refugees will have coverage for:
      • Basic medical care (ER visits, GP visits, nursing care).
      • Supplemental medical care (basic vision, dental and mental health care).
      • Basic prescription drugs (in Ontario, think similar to Ontario Drug Benefit Coverage). 

    Bottom Line:

    Most emergency room services will be covered for Refugees under IFHP; keep prescriptions to a minimum, and choose drugs that are typically covered under local drug benefit plans! 







    Dr. Thara Kumar is a 3rd year Emergency Medicine resident at the University of Ottawa, with a special interest in global health and public health initiatives. 




    Edited by Dr. Shahbaz Syed, PGY-4, Emergency Medicine resident at the University of Ottawa











    References:

    1. Alberer M, Wendeborn M, Löscher T, Seilmaier M. Spectrum of diseases occurring in refugees and asylum seekers: data from three different medical institutions in the Munich area from 2014 and 2015]. Dtsch Med Wochenschr. 2016;141(1):e8-e15. doi:10.1055/s-0041-106907.
    2. Canada’s refugees by the numbers: the data - Canada. CBC News. http://www.cbc.ca/news/canada/canada-s-refugees-by-the-numbers-the-data-1.3240640. Accessed January 20, 2016.
    3. Canadian Council for Refugees. Brief history of Canada’s responses to refugees.  2009. Web January 20, 2016. http://ccrweb.ca/sites/ccrweb.ca/files/static-files/canadarefugeeshistory6.htm.
    4. Canadian Council for Refugees. Health care for claimants at one-tenth of cost for Canadians. Canadian Council for Refugees. http://ccrweb.ca/en/health-care-claimants-one-tenth-cost-canadians. Web Jan 16, 2016. http://ccrweb.ca/en/health-care-claimants-one-tenth-cost-canadians.
    5. Canadian Council for Refugees. Refugees and Immigrants: A Glossary. Canadian Council for Refugees. 2010. Web Jan 20 2016. http://ccrweb.ca/en/glossary.
    6. Canadian Immigration and Citizenship. #WelcomeRefugees. Government of Canada. November 2015. Web Jan 16 2016. http://www.cic.gc.ca/english/refugees/welcome/overview/security.asp.
    7. Canadian Thoracic Society and Public Health Agency of Canada.  Canadian Tuberculosis Standards 7th Edition.  2013. Web. Feb. 3/2016. Accessed February 3, 2016.
    8. DesMeules M, Gold J, Kazanjian A, et al. New approaches to immigrant health assessment. Can J public Heal = Rev Can santé publique. 95(3):I22-I26.  http://www.ncbi.nlm.nih.gov/pubmed/15191128. Accessed February 13, 2016.
    9. Evans A, Caudarella A, Ratnapalan S, Chan K. The cost and impact of the interim federal health program cuts on child refugees in Canada. PLoS One. 2014;9(5):e96902. doi:10.1371/journal.pone.0096902.
    10. Facts and figures 2014 – Immigration overview: Permanent residents. August 2015. http://www.cic.gc.ca/english/resources/statistics/facts2014/index.asp. Accessed January 20, 2016.
    11. Gulli, C. “Why is Canada denying some refugees health coverage? “ Maclean’s. Sept. 11 2015,  n.p., Maclean’s magazine online, access Jan. 16/16.  http://www.macleans.ca/news/world/courting-trouble-why-are-we-denying-some-refugees-health-coverage/.
    12. Interim Federal Health Program: Summary of Benefits. Government of Canada, April 2012. Web January 16, 2016.http://www.cic.gc.ca/english/refugees/outside/summary-ifhp.asp.
    13. Janus, Andrea. Courts: Gov’e cuts to refugee health care ‘cruel and unusual.”  CTV News. July 4 2014. Web Jan 16 2016. http://www.ctvnews.ca/canada/court-gov-t-cuts-to-refugee-health-care-cruel-and-unusual-treatment-1.1898922
    14. Kiss V, Pim C, Hemmelgarn BR, Quan H. Building knowledge about health services utilization by refugees. J Immigr Minor Health. 2013;15(1):57-67. doi:10.1007/s10903-011-9528-8.
    15. Konkin, J., Milne, V. Health care for Syrian refugees: is Canada ready? Healthy Debate. Dec. 3 2015. Web Jan. 18, 2016. http://healthydebate.ca/2015/12/topic/syrian-refugees-primary-health-care.
    16. Lovesey, Natalie. Evidence-Based Care of Your Immigrant & Refugee Patients. Family Medicine Grand Rounds Schulich School of Medicine & Dentistry. April 5, 2014. Web Jan 16 2016. http://www.slideshare.net/natalielovesey/evidencebased-care-of-your-immigrant-refugee-patients.
    17. Malaria. Centers for Disease Control and Prevention.  Dec. 14 2015. Web Jan. 20 2016. http://www.cdc.gov/malaria/index.html#
    18. McBride DL. Large Study of Health Issues for Newly Arrived Child Refugees. J Pediatr Nurs. December 2015. doi:10.1016/j.pedn.2015.11.014.
    19. McNeely CA, Morland L. The Health of the Newest Americans: How US Public Health Systems Can Support Syrian Refugees. Am J Public Health. 2016;106(1):13-15. doi:10.2105/AJPH.2015.302975.
    20. Miedema B, Hamilton R, Easley J. Climbing the walls: Structural barriers to accessing primary care for refugee newcomers in Canada. Can Fam Physician. 2008;54(3):335-336. http://www.cfp.ca.proxy.bib.uottawa.ca/content/54/3/335.long. Accessed January 18, 2016.
    21. Muise, M. Here’s How Refugees are Screened Before Arriving in Canada. Global News. Nov. 19 2015. Web Jan. 16 2016. http://globalnews.ca/news/2349421/heres-how-refugees-are-screened-before-arriving-in-canada/.
    22. Ontario Ministry of Health and Long-Term Care. Health System Action Plan: Syrian Refugees. Ontario Ministry of Health and Long-Term Care 2015. Web. Jan 19 2016. http://www.health.gov.on.ca/en/pro/programs/emb/syrianrefugees/default.aspx
    23. Optimism for Restoration of Refugee Health Care. CMAJ January 5, 2016 vol. 188 no. 1. First published November 16, 2015. Web Jan 16 2016. www.cmaj.ca/content/188/1/E1.extract
    24. Pottie K, Greenaway C, Feightner J, et al. Evidence-based clinical guidelines for immigrants and refugees. CMAJ. 2011;183(12):E824-E925. doi:10.1503/cmaj.090313.
    25. Pottie K, Gruner D, Ferreyra M, Ratnayake A, Ezzat O, Ponka D, Rashid M, Kellam H, Sun R., & K. Miller (2012). Refugees and Global Health: A Global Health E-Learning Program, Canadian Collaboration for Immigrant and Refugee Health (CCIRH) and the University of Ottawa, Canada. Web Jan 20 2016. http://ccirhken.ca/e-learning/?page_id=6,
    26. Pottie, K et al. Canadian Medical Association Journal: Caring for a newly arrived Syrian refugee family. http://www.cmaj.ca/site/misc/caring-for-a-newly-arrived-syrian-refugee-family-cmaj.151422.xhtml. Accessed January 18, 2016.
    27. Refugee Health Care: Resources to Assist Family Physicians. The College of Family Physicians Canada. http://www.cfpc.ca/Refugee_Health_Care/. Accessed January 20, 2016.
    28. Robson, J. “Making sense of Canada’s refugee and immigration numbers? “ Maclean’s. Sept. 8 2015,  n.p., Maclean’s magazine online, access Jan. 20 2016.  http://www.macleans.ca/politics/ottawa/making-sense-of-canadas-refugee-and-immigration-numbers/
    29. Rodgers, Lucy et al.  Syria: the story of the conflict. BBC News. Feb 3 2016. Web. Feb 6 2016. http://www.bbc.com/news/world-middle-east-26116868
    30. Rousseau C, Laurin-Lamothe A, Rummens JA, Meloni F, Steinmetz N, Alvarez F. Uninsured immigrant and refugee children presenting to Canadian paediatric emergency departments: Disparities in help-seeking and service delivery. Paediatr Child Health. 2013;18(9):465-469. /pmc/articles/PMC3885101/?report=abstract. Accessed January 17, 2016.
    31. Sheikh H, Rashid M, Berger P, Hulme J. Refugee health: Providing the best possible care in the face of crippling cuts. Can Fam Physician. 2013;59(6):605-606. http://www.cfp.ca/content/59/6/605.short. Accessed January 18, 2016.
    32. Singh et al. Health, Life Expectancy, and Mortality Patterns Among Immigrant Populations in the United States on JSTOR. http://www.jstor.org.proxy.bib.uottawa.ca/stable/41994330?seq=1#page_scan_tab_contents. Accessed February 13, 2016.
    33. United Nations High Commission on Refugees. Culture, Context, and the Mental Health and Psychosocial Wellbeing of Syrians. 2015. http://www.unhcr.org/55f6b90f9.pdf. Accessed January 19, 2016.
    34. United Nations High Commission on Refugees. 2015 UNHCR Country Operations Profile- Syrian Arab Republic. UNHCR 2015. Web Feb 6 2016. http://www.unhcr.org/pages/49e486a76.html


    Comments

    Popular posts from this blog

    Tips for Success in your Emergency Medicine Rotation

    Our wonderful medical students are preparing to start their first clinical rotations. With this in mind here are some of the top tips for success in your EM rotation
    1)Be On Time – show up to your shifts on time, better yet 5 minutes early.That first impression is immensely important.
    2)Introduce yourself to the team - “Hi my name is John Doe, I am the medical student on shift today” introduce yourself to the attending, residents, nurses, etc.You will be called on a lot more to help when there is something interesting going on if they know your name.
    3)Be goal-oriented – have a goal for each shift, whether it’s a procedure or a type of presentation to see.
    4)Don’t just stand there, do something – whenever there is a trauma or code, come to the bedside.Get gowned up for traumas and pay attention.Help with things that are within your scope of practice: chest compressions, moving patient, cardioversion
    5)Don’t just stand there, do nothing – there are times in medicine when the best thing to d…

    2014 Canadian Guidelines for AF Management: Part 1: Introduction and CCS “CHADS-65” Algorithm

    by Ian Stiell MD @EMO_Daddy














    In this and subsequent postings we will discuss the latest recommendations for ED management of atrial fibrillation (AF) as presented in the newly published 2014 Focused Update of the Canadian Cardiovascular Society Guidelines for the Management of Atrial Fibrillation. The Guidelines PDF can be downloaded from the CCS website at 2014 Canadian Cardiovascular Society Guidelines for the Management of Atrial Fibrillation
    The 2014 Focused Update uses the GRADE system of evidence evaluation as was the case in the comprehensive 2010 AF Guidelines and the 2012 Update. The CCS AF Guidelines Panel is comprised of Canadian cardiologists plus physicians from internal medicine, family medicine, neurology, and emergency medicine. This 2014 Update provides evidence review and recommendations for 8 aspects of AF care, including ED Management (written by myself and Dr. Laurent Macle of the Montreal Heart Institute). The 2014 Update focuses on advances in oral anticoagulant (O…

    You CAN reverse that! Reversal of NOAC's and more..

    We have seen a large surge of the utilization of New Oral Anticoagulants (NOAC's) in the past few years, as such, it has been a novel challenge when these patients present to the Emergency Department (ED) with life threatening bleeding. Dr. Michael Ho looks to discuss treatment options, and future options in these patients. 
    NOACs vs WarfarinDabigatran, Rivaroxaban and Apixaban have seen a dramatic increase in use since their approval in Canada. Dabigatran is a direct thrombin (Factor II) inhibitor, while the latter two are direct Xa inhibitors. These drugs are collectively referred to as novel oral anticoagulants (NOACs). They have also been called direct, or target-specific oral anticoagulants (DOACs or TSOACs) [1]. 
    The NOACs have many practical advantages over warfarin: Rapid onset of actionShorter half-lifeLess food and drug interferencePredictable pharmacokineticsEase of use and no requirement for monitoringThe downsides to NOACs are the higher cost to the patient, the inabilit…