Refugee Crisis: Healthy Resettlement and Health Security

Martin Cetron, MD Director, Global Migration and Quarantine, CDC ESCMIDECCMID eLibrary Amsterdam

T April, 2016 M by author Overview of Refugee Crisis

ESCMID eLibrary

T M by author A refugee family from Syria with their daughter as hundreds ESCMIDof people wait to take a train to GermanyeLibrary at Keleti train station in central Budapest.

T M Maricio Lima for NYT (NYT, 2015, "Migrant Crisis Gives Germany Familiar Role in Another European Drama” by author Syrian refugee child, two and a half, stands by other children ESCMIDburning garbage at the Mafraq campseLibrary in Jordan on July 21, 2015.

http://time.com/3987244/syrian-refugees-mafraq-jordan/ T M by author ESCMID eLibrary Residents of the besieged Palestinian camp of Yarmouk, queuing to receive food supplies, in Damascus, Syria on Jan. 31, 2014. (UNRWA via AP, File) T M by author - Wars and political unrest in Syria, Iraq, and Somalia have forced people to leave their native countries.

- EthnicESCMID minorities from Burma are fleeing eLibrary persecution and poverty.

T M - Unrest in Ukraine has caused by many author to take refuge. A Syrian man kisses his daughter shortly after disembarking from a dinghy at a beach on the Greek island of Lesbos, on Nov. 16

ESCMID eLibrary Image: Santi Palacios/Associated Press T M by author 4.1 million Syrians have fled their country since the beginning of the civil war in 2011 as part of the ESCMID eLibraryArab Spring.

T M by author With so many countries under siege, this has led to the largest refugee crisis since World War II.

ESCMID eLibrary

T M by author Overview of Refugee Crisis in Europe

ESCMID eLibrary

T M by author ESCMID eLibrary by author ESCMID eLibrary Source: http://lawprofessors.typepad.com/immigration/2015/09/if-she-drowns-shes-a- refugee-if-she-floats-shes-an-economic-migrant.html T M by author Stigma Against Refugees

Paris Attacks Intensify Debate Over How Many Syrian Refugees to Allow Into the U.S.

Texas Again Trying To Ban Syrian Refugees After Family Was Settled LastESCMID Week eLibrary

“The threat to our communities by foreign T M terrorists is real.” by author Top 10 Countries of Nationality for FY15Total: US-Bound 69,933 Refugees

Burma Iraq Somalia DRC Bhutan 18,323 12,608 8,852 7,823 5,563

Iran Syria Eritrea Sudan Cuba ESCMID3,099 1,693 1,576 eLibrary1,576 1,526

T M by author FY 2006 – 2015 U.S. Refugee Arrivals, by Region

Near East/South Asia Latin America/Caribbean 80000 Europe East Asia 70000 Africa

60000

50000

40000

30000

20000

10000

0 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 ESCMID eLibrary Data source: Disease Notification Analysis (DNA) database based on Worldwide Refugee Admissions Processing System (WRAPS) from the U.S. Department of State

T M by author U.S. Refugee Admissions, FY 2016 Program*

Region Ceiling for Primary populations FY 2016 Africa 25,000 Congolese in Rwanda, Tanzania, Uganda, Burundi; Somalis in Kenya, Ethiopia, Uganda; Eritreans in Sudan and Ethiopia East Asia 13,000 Burmese in Thailand and Malaysia Europe/ Central 4,000 Religious minorities from the Asia former Soviet Union Latin America 3,000 Cubans (many) and Colombians (few), Central American minors N. East/ S. Asia 34,000 Bhutanese in Nepal, Iraqis, Iranian religious minorities, Syrians Unallocated 6,000 Available as needed for any region Reserve ESCMIDTotal 85,000 eLibrary

*Proposed Refugee Admissions for Fiscal Year 2016. Report to Congress T M by author Syrian Refugees

• US resettled 1,693 Syrians in FY15 • The Obama Administration has committed to admitting at least 10K Syrian refugees in FY16. – Majority will depart from Iraq, Jordan, Turkey, Lebanon. – Most refugees reside in urban settings. ESCMID– Additional processing site eLibrary established in Erbil, Iraq (located closer to Syrian border)

T M * FY16 global refugee by arrivals author set at 85,000 FY 2015 U.S. Refugee Arrivals by State

ESCMID eLibrary

T Data source: Disease Notification Analysis (DNA) database based on Worldwide M Refugee Admissions Processing by System (WRAPS) author from the U.S. Department of State This map shows state of initial refugee resettlement. The numbers correspond to total arrivals in the state for FY2015.

*Within a state, counts <500 not shown & circles located for ESCMID eLibraryconvenience.

T M by author New England: African-born

ESCMID eLibrary

T M by author Required Medical Screening: TB Technical Instructions

TB skin testing, Nepal

Directly observed therapy for TB, Kenya ESCMID eLibrary

T TB cultures, Nepal M by author Overseas and Domestic Medical Exams

Administering vaccines

ESCMID eLibrarySyphilis testing

T M TB screening by author Outbreak Detection and Response

ESCMIDInfluenza surveillance, eLibrary Kenya

T M by author ESCMID eLibrary

T M Response to outbreak of Hepatitis Eby among refugees author in South Sudan, 2012 – photo credit N. Marano Horn of Africa Migration Movement: Why Migration is a Health Concern

• Migration out of Somalia is global.

• In 2013, MDR TB surged in Dadaab ● Hargeisa ● and Eastleigh, Kenya. Addis Ababa • Most (>80%) were patients from Somalia seeking care.

● Mogadishu • TB anywhere is TB everywhere. • Illnesses anywhere are illnesses everywhere. ● Dadaab ● ESCMIDNairobi (Eastleigh) eLibrary

Image reproduced from Cain KP et al. The movement of multidrug-resistant tuberculosis across borders in East Africa needs a regional and global solutionT M by. PLoS Med. 2015 Febauthor 24;12(2):e1001791. Tuberculosis Cases, United States, 1995-2014

18,000 2014 TB rates: 100% Total 2.96 per 100,000

16,000 US-born 1.2 per 100,000 90% Proportion Proportion Foreign Foreign-born 15.4 per 100,000 14,000 TB : 65% Foreign-born 80% MDR TB: 88% Foreign-born 70% 12,000 60% 10,000 50%

8,000 - 40% Born No. of No.Cases 6,000 30% 4,000 20% 2,000 10%

0 0%

1995 1996 1997 1998 1999 2000 2001 2002 2003 2014 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 ESCMIDU.S.-born Foreign-born % Foreign-borneLibrary

T M by author Tuberculosis and MDR TB Rates, WHO and U.S. Screening

Worldwide, panel physicians diagnose >1,100 cases yearly ≈60% smear-negative, culture-positive

WHO – Country of US Screening3 FY 20131 screening2 Country Arrivals TB Rate MDR TB TB Rate per MDR TB per 100,000 Rate 100,000 Rate Mexico 65,742 21 2.4% 55 2.3% Dominican Republic 33,637 60 6.6% 74 3.2% Philippines 34,447 292 4.0% 1,180 1.4% China 33,042 70 5.7% 236 5.1% India 23,726 171 2.2% 166 2.6% Vietnam 22,236 144 2.7% 963 3.4%

1Department of Homeland Security, October 1, 2012 through September 30, 2013 2WHO Country Profiles, 2013 ESCMID3 eLibrary TB Indicator data, all Class A TB cases, January 1, 2013 – December 31, 2013

T M by author Impact: DGMQ Immigration Screening Reduces TB Importation and Identifies Prevention Targets

California

Rate of active TB among new immigrants* to NYC, 2001-2010

IJTLD 2011;15(6):761-6 ESCMID eLibrary

T M by author • MMWR – March 21, 2014 • Summary of TB TI implementation • Panel physicians diagnosing >1,100 cases per year – 60% smear-negative, culture-positive •ESCMIDUS health departments eLibrary save >$15 million

T M by author • Annals of Internal Medicine – March 17, 2015 – Video online accompanying article • Describes impact of TB TI implementation on US foreign-born TB • With Culture and DOT TB TI ESCMID– Increase detection by >600eLibrary cases per year

T M by author ESCMID eLibrary

T M Liuby et al. Annals of Internalauthor Medicine 2015. Cost-Benefit of Overseas Refugee LTBI Screening and Treatment

 Cost saving for high and moderate LTBI prevalence  Not cost saving for low LTBI prevalence ESCMID eLibrary Wingate, et al. BMC Public Health 2015;15:1201. DOI 10.1186/s12889-015-2530-7. by author Cost-Effectiveness of Screening Foreign Students for Tuberculosis

India China Germany Hypothetical cohort 29,981 58,015 2,795 Cases diagnosed overseas 29.2 127.8 0 (based on TB Indicators) Cases in Class B1 after 17.9 34.7 0 arrival (based on EDN) Difference in US costs* with Savings of Savings of Additional cost of overseas screening costs $458,695 $2,234,411 $5,201 ESCMID eLibrary * From the perspective of US healthcare costs Wingate, et al. PLOS One 2015 10(4): e0124116. doi:10.1371/journal.pone.0124116 by author Neglected Tropical Diseases: Parasite Treatment

ESCMID eLibrary

T M by author Global Prevalence of Disease

Soil Transmitted Helminths

Rank Disease # Infected

1. Ascaris 807,000,000

2. Trichuriasis 604,000,000

3. Hookworm 580,000,000

ESCMIDde Silva, et al. Trends Parasitol eLibrary2003;19:547-51

T M by author Presumptive Treatment for Intestinal Parasites, Dadaab Refugee Camp, Kenya

ESCMID eLibrary

T M by author Estimated Costs per Refugee (2015 USD) Overseas Mass Drug Administration (MDA) vs. Domestic Screen & Treat B. Maskery HS Joo et al., Unpublished data, 2016. Prelim results, do not cite Ratio of Domestic Domestic Screen and Screening Treat to Overseas Domestic Domestic and Overseas MDA screening treatment Treatment MDA Cost Asian refugees (albendazole and ivermectin) a $12 $121 $36 $156 13.0 African refugees (albendazole, ivermectin, praziquantel, coartem) b $36 $189 $114 $303 8.4 bStool ova and parasites x2, strongyloidiasis serology, prevalence 4.2% hookworm + ESCMIDtrichuriasis + ascariasis, 20% strongyloidiasis eLibrary aStool ova and parasites x2, strongyloidiasis and schistosomiasis serologies, malaria

T smear, prevalence 10.5% hookworm + trichuriasis + ascariasis, 20% strongyloidiasis, 8% M schistosomiasis, 8% malaria by author Estimated Program Costs & Outcomes Intestinal Parasites, Asian refugee cohort, n= 27,700 B. Maskery et al. Unpublished data, 2016. Prelim results, do not cite

Total cost (program + illness), Number with parasitic 2013 million USD infections 4.5 8,000

4.0 7,000

3.5 6,000

3.0 5,000 2.5 4,000 2.0 3,000 1.5 2,000 1.0 1,000 0.5 ESCMID eLibrary0 0.0 No program Domestic Overseas Domestic screen and Overseas MDA screen and MDA

T treat treat M by author Estimated Program Costs & Outcomes Intestinal Parasites, Asian refugee cohort, n= 27,700 B. Maskery et al. Unpublished data, 2016. Prelim results, do not cite

Total cost (program + illness), Number of discounted life years 2013 million USD with parasitic infections 4.5 160,000

4.0 140,000

3.5 120,000

3.0 100,000 2.5 80,000 2.0 60,000 1.5 40,000 1.0 20,000 0.5 ESCMID eLibrary0 0.0 No program Domestic Overseas Domestic screen and Overseas MDA screen and MDA

T treat treat M by author Prevalence of Intestinal Parasites Among Refugees Arriving in Minnesota, before/after Overseas Treatment - May 1999 Mass Drug Administration (n = 26,928) 25

Hookworm 22.5%

20 Trichuris Ascaris Strongyloides Any helminth 15

Multiple helminths Percentage 10 9.2% 8.5% 7.5%

4.6% 5 4.1% 3.1% 2.6% 0.2% 0.4% 0.3% 0.4% 0ESCMID eLibrary Pre Post Pre Post Pre Post Pre Post Pre Post Pre Post

T M Swanson, S…Cetron, by M., et al. NEJM,author 2012 Apr 19; 366(16):1498-507. Percentage of West African Refugees in Hennepin County, MN with Malaria Impact of Single Dose TMP-SMX 10 1997 1998 9 1999 8 2000 2001 7 2002 6 2003 2004

% 5

4 Pre-implementation Incremental implementation TMP-SMX mass Rx TMP=SMX mass Rx pre-departure 3

2

1

0 ESCMID eLibrary 1996 1997 1998 1999 2000 2001 2002 2003 2004

T Year M by author Refugee Vaccination Program: Overview

• Refugees not legally required to get vaccinations • Many refugees arrive in U.S. with no vaccinations – > 40 outbreaks in last 5 years – Missed opportunity to vaccinate between overseas health exam & US arrival (4-6 months) • Partnership between CDC, DOS and IOM • 5 pilot countries: Malaysia, Nepal, Thailand, Ethiopia and Kenya – scheduled for the Middle East in ESCMIDCY16 eLibrary

T M by author Disease Outbreaks in Sites that include U.S.-Bound Refugees, FY 2014-2016

KYRGYZSTAN

IRAQ (Iraqis) NEPAL (Bhutanese)

CHAD 5000 THAILAND (Burmese) ETHIOPIA (Somalis) Measles KENYA MALAYSIA (Burmese) Mumps (Somalis) Rubella 150 25 Varicella UGANDA (DRC) TANZANIA Departures Typhoid (DRC) Nationality BURUNDI (DRC) FY 2014-2016* Cholera ZAMBIA 1600 (DRC) Burmese 35,685 Watery Diarrhea Iraqi 34,420 HepESCMID. E eLibrarySomali 19,594 Bhutanese 15,120 Meningitis DRC 14,020 Influenza A *Through Jan, 2016 Not shown: Malaria in Kenyan refugee camp,by ~25,000 cases author Selected Vaccine Preventable Diseases Affecting U.S.-bound Refugees

2003-2005: Measles, rubella, varicella, Côte D’Ivoire (Liberian refugees) • Death of 1 child (measles) 2006: Polio, Dadaab, • U.S.-born child with Kenya (Somali congenital rubella refugees) • Delay of resettlement >6 m • Related outbreak during outbreak control control costs: period Dec 2012 $309,283 Vaccine 2003 2005 2006 Program 2011 Starts 2005: Measles, Eastleigh, Kenya 2011: Measles, Kuala Lumpur, (Somali refugees) Malaysia (Burmese refugees) • CDC recommended • Symptomatic in-flight; vaccination & waiting 1 transmission to 2 other incubation period before children on the plane resettlement • Several epidemiologically • Recommendations not linked cases, including a implemented due to cost case in a CBP officer concerns • Extensive overseas & ESCMID• Results: Ill refugee arrives ineLibrary domestic outbreak control U.S.; domestic outbreak and vaccination efforts response and surveillance • Related costs ~$130,000 by author Cost Comparison: Vaccination Program

• Giving 10 doses of vaccines (2 doses of each of 5 childhood vaccines) overseas costs 76% less than giving the same vaccines in the US [$93 vs $388]

• Giving 10 doses of vaccines overseas represents a 16-25% reduction in cost in getting a child fully vaccinated (35 doses of routine childhood vaccines as per ACIP) [$1406 vs $2020]

• Additional benefits of eliminating serious diseases in the refugees, preventing outbreaks and importation into the U.S. ESCMID eLibrary

T M by author Estimated Costs for Complete Vaccination Series (35 doses), Children birth- 12 years, FY 2014*

46 44.9

44 41.2 42

40 37.6

38 Millions of Dollars of Millions

36

34 All 35 doses in 5 doses 10 doses US overseas, 30 overseas, 25 ESCMIDdoses in USeLibrarydoses in US

*18,636 children birth-through 12 yrs old, includes vaccine & T M administration costs. This analysis assumes all refugee children are fully vaccinated after by arrival in the Unitedauthor States. Overseas Refugee Vaccination Program: Protecting against 11 Diseases

• Diphtheria • Haemophilus influenzae type b • Hepatitis B • Measles • Mumps • Rotavirus • Rubella • Pertussis • Polio • Streptococcus pneumoniae (pneumococcal disease) [vaccine procurement still pending] ESCMID• Tetanus eLibrary

T M by author Example: Thailand Vaccine Administration

Nurse draws up doses on- If prefilling done, is very Individual tray with doses for site limited; clearly labeled one patient

ESCMID eLibrary

Second nurse administers vaccine; patient IOM-given vaccines documented, attached to child’s is seated by authorcamp record Electronic Data Transmission

ESCMID eLibrary Overseas vaccination data in IOM’s MiMOSA -> CDC’s Electronic Disease Notification (EDN) System -> U.S. state refugee health programs/clinics by author Implementation Challenges

• Vaccine procurement – via UNICEF or local market – Country-specific requirements for importation

• Cold chain establishment and maintenance

• Logistics of 2nd dose

• Vaccine schedule changes for outbreaks

• Adverse events monitoring in non- primary care setting

• InternetESCMID access for data eLibrary entry/documentation by author Implementation Challenges: Cold Chain

ESCMID eLibrary by author Implementation Challenges: Access for 2nd Doses Scheduling of 2nd doses — careful planning required!

Photo courtesy of Luis Ortega, CDC-TUC Photo courtesy of Warren Dalal, CDC

ThoughESCMID challenges arise, there areeLibrary many benefits to administering vaccines overseas. by author Vaccination, CY 2013-2015

• > 100,000 refugees vaccinated • ~700,000 doses of vaccine

2013 2014 2015 Total # refugees 29,464 42,058 29,145 100,667 vaccinated # vaccine 222,986 255,613 219,657 698,256 doses ESCMID eLibrary

T M by author ESCMID eLibrary

T M by author Program Expansion

Tier Countries Status Comments Tier 1 Ethiopia, Kenya, Complete, in M&E Large IOM Uganda, Malaysia, phase programs Nepal, Thailand

Tier 2 Rwanda, Burundi, Initial assessment Smaller IOM Tanzania, Chad, and implementation programs, panel Zambia, Jordan, Iraq, phase in FY 2016 physicians may Slovakia, Romania, be subcontracted Former Soviet Union, by IOM Indonesia, others

Tier 3 Turkey, Egypt, In discussion non-IOM Lebanon, Austria, panel physicians ESCMIDMalta, other countries eLibrary

T M by author Refugee Health Profiles Additional information on the health profiles of US-bound refugees available at: http://www.cdc.gov/immigrantrefugeehealth/profiles/index.htm l

ESCMID eLibrary

T M by author Acknowledgements

Division of Global Migration and Quarantine, CDC Nina Marano Tarissa Mitchell Christina Phares Lisa Rotz William Stauffer Michelle Weinberg

International Organization for Migration Warren Dalal Alexander Klosovsky

Bureau of Population, Refugees, and Migration Larry Bartlett Margaret Burkhardt ESCMIDKelly GaugereLibrary

T M by author ( AP/Lefteris Pitarakis)

ESCMID eLibrary(CNS photo/Yannis Behrakis, Reuters)

T M by author THANK YOU

Photo L. Ortega, CDC http://www.theguardian.com/global- development/2013/nov/29/syrian-refugee-children-catastrophe- ESCMID eLibraryexile-un by author