J Am Board Fam Pract: first published as 10.3122/jabfm.10.5.337 on 1 September 1997. Downloaded from

CLINICAL REVIEW Health Problems of Refugees

Lani Kay Ackerman, MD

Background: The United States has recently seen an increase in the number of refugees and a change in the ethnicity of these refugees. It would be helpful for family physicians providing medical care to these patients to have available health data on the largest groups of new refugees. Methods: Using the key words "refugee," "Vietnam," "Laos," "former Yugoslavia" (Bosnia-Herzegovina), "former Soviet Union," "Iraq," "Afghanistan," "Somalia," "Sudan," "Ethiopia," "Haiti," and "Cuba," the MEDLINE files were searched from 1991 to the present. Cross-references from these articles were also reviewed, including pertinent information published from 1981-91.. Studies and experimental trials were discussed if they had information on conditions of refugees after arrival or on diseases currently reported from the countries of origin. Results and Conclusions: With the exception of studies of Southeast Asian refugees, there are few clinical trials on the health problems of refugees after arrival in the United States. Tuberculosis, nutritional deficiencies, intestinal parasites, chronic hepatitis B infection, lack of immunization, and depression are major problems in many groups. There is great variation in the health and psychosocial issues, as well as cultural beliefs, among the refugees. In addition to a complete history and physical examination, tests for tuberculosis, hepatitis B surface antigen, and ova and parasites, as well as a hemoglobin measurement, are advised for most groups. Ongoing clinical trials are needed to explore more fully not only the medical and psychological problems of these patients but also their health beliefs. (J Am Board Fam Pract 1997;10:337-48.)

The United States, which in 1995 admitted a large enclave of Soviet Jews, and San Francisco, 131,304 refugees, is currently accepting the Vietnamese), whereas other large metropolitan ar­ greatest number of refugees since World War II.' eas absorb refugees from various countries who During the last 20 years large groups of refugees come with a variety of medical problems and have come to the United States, predominantly cultural practices. Language and cultural barriers http://www.jabfm.org/ from Southeast Asia as an aftermath of the Viet­ make it imperative for the physician to know nam War. More recently, however, the number of which medical problems are common, what labo­ refugees from the former Soviet Union has ratory tests should be considered when caring for superseded those from Vietnam and Laos, and these patients, and what health views are unique to other countries-former Yugoslavia (Bosnia­ a given population. Because of the wide variations

Herzegovina), Somalia, Ethiopia, Sudan, Iraq, in religious practices, culture, economics, and ge­ on 1 October 2021 by guest. Protected copyright. Mghanistan, Cuba, and Haiti-now generate ographical subsets within each group, any recom­ many thousands of refugees.' For the busy family mendations or statements must be individualized. physician faced with caring for a patient from one of these countries, the task can seem formidable. Methods Some communities have a great many refugees The MEDLINE files were searched from 1991 from a single country (eg, New York City has to the present using the key words "refugee" and the country names of the largest groups of recent Submitted, revised, 14 June 1997. refugees: "Vietnam," "Laos," "former Yugoslavia" From the Department of Family and Community Medicine (Bosnia-Herzegovina), "former Soviet Union," and the International Health Clinic, John Peter Smith Hospital "Iraq," "Afghanistan," "Somalia," "Sudan," Family Practice Residency Program, Fort Worth, Texas. Address "Ethiopia," "Haiti," and "Cuba." Studies and ex­ reprint requests to Lani Kay Ackerman, MD, Department of Family and Community Medicine, John Peter Smith Hospital, perimental trials were preferentially included in 1500 South Main St, Fort Worth, TX 76104-4940. this review if they had information on refugees af-

Refugee Health Problems 337 J Am Board Fam Pract: first published as 10.3122/jabfm.10.5.337 on 1 September 1997. Downloaded from Table I. Content of Visa-Mandated Medical the United States despite the condition. Examination for Refugees. The medical examination required to obtain a visa is performed in the country where the ref­ 'lest or Examination Criteria ugee resides (home country or country of asy­ Chest radiograph 15 Y and older; Southeast Asian lum). The examination is conducted by the Inter­ refugees 2 y and older national Organization for Migration (Southeast Sputum smear for If ahnormal findings on chest acid-fast bacilli radiograph Asia and the former Soviet Union) or by panel Human immuno­ 15 y and older physicians. Table 1 displays the content of this ex­ deficiency vims amination. Conditions detected that require fol­ VDRL 15 Y and older low-up in the United States are designated class A Leprosy All (excludable, require waiver for entry) or class B Medical history of (serious condition, needs follow-up).2 physical and mental disorders The quality and comprehensiveness of the visa Class A Excludable condition; required medical examination vary. Because the examina­ to apply for waiver for entry tion is valid for 1 year before departure, a refugee (eg, infectious tuberculosis) Class B Serious condition that needs can develop infectious conditions after clearance follow-up (eg, clinically active but and before departure. Likewise, screening for not infectious tuberculosis, hypertension, diabetes) many infectious diseases (eg, malaria) is not in­ cluded.2 Using data from the Hawaii state tuber­ culosis register to evaluate the effectiveness of the ter their arrival into the country of resettlement. required overseas tuberculosis screening, re­ Because of the dearth of information available, searchers found that of the 124 refugees and im­ studies and information about endemic diseases migrants examined within 1 year of arrival, 63 in the above countries were also included. Cross­ percent were classified as having active tuberculo­ references from these articles were also reviewed, sis (B I), 14 percent had inactive tuberculosis (B2), and pertinent information published from 1981 and 23 percent were normal. These studies em­ through 1991 was included as well. Background phasized the need for prompt examination of all information on the process of refugee entrance refugees even after screening, especially those into the United States was obtained from the Of­ who are classified BI and B2.3 fice of Refugee Resettlement, Texas Department The Centers for Disease Control and Preven­ of Health, and resettlement agencies. tion (CDC) and the National Center for Pre­

vention Services, Division of Quarantine, are del­ http://www.jabfm.org/ Overseas and Domestic Health Assessment egated the responsibility of preventing the Refugees are distinguished from immigrants in introduction, transmission, and spread of com­ that they fear persecution because of religious or municable disease from foreign countries into the political beliefs or ethnicity. Their entrance into United States. Refugees can be detained and the United States is governed by the Refugee Act medically examined if they are suspected of hav­ rather than immigration quotas. They are re­ ing any of the following diseases: cholera, diph­ on 1 October 2021 by guest. Protected copyright. quired, as are immigrants, to receive an overseas theria, infectious tuberculosis, plague, smallpox, medical examination within 1 year before reset­ yellow fever, and viral hemorrhagic fevers. When tlement into the United States. These criteria are they arrive, refugees must pass through the US outlined in the Immigration and Nationality Act Public Health Service Quarantine Station at their and amended in the Immigration Act of 1990. port of entry, where persons who appear to be ill This examination is intended to exclude only can be detained. those aliens who have the following conditions: The domestic health assessment is designed to "communicable diseases of public health sig­ detect important medical conditions and protect nificance, current or past physical or mental dis­ the health of the US population. These programs orders that are or have been associated with are managed by state refugee health programs harmful behavior, and drug abuse or addiction."2 and vary from state to state.2 Table 2 lists the Refugees who have an excludable condition may components that might be included in a domestic apply for a waiver that permits their entry into health assessment.

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Vietnam and Southeast Asia Table 2. Domestic Health Assessment'" Refugees from Vietnam and Laos continue to Anemia make up a large percentage of the total refugees. Health history and physical examination In 1994, 34,110 Vietnamese and 2888 Amerasians Hepatitis B infection came into the United States as refugees. l In 1995 Immunization status there was a slight decrease to 32,250 Vietnamese, Parasitic infection 948 Amerasians, and 3682 Laotians. Many studies Pregnancy of earlier waves of Southeast Asian refugees re­ Tuberculosis infection and disease ported the usefulness of the purified protein de­ Vision, hearing, and dental abnormalities rivative (PPD) tuberculin (Mantoux) test, tests for ·Varies by state and location. ova and parasites, hepatitis B screening (hepatitis B antigen [HBsAg] for chronic carriers), and his­ tory and physical examination.4,5 Table 3 displays have positive reactions can decrease the number these and other laboratory examinations to con­ of these patients who subsequently have active sider. The most common parasites found were (in disease. Although resistance to isoniazid is in­ descending order) Necator americanus (hook­ creasingly common, it is still the drug of choice worm), Giardia lamblia, Strongyloides stercoralis, for prophylaxis. Ascaris lumbricoides, and Entamoeba histolytica.4 In a The high incidence of variant delayed reaction 1994-1995 survey conducted in Texas, pathogens to tuberculin activity among these refugees has were identified in 40 percent of recently arrived led some experts to recommend reading the skin Vietnamese refugees.6 test at the routine 48 to 72 hours and again at 6 Southeast Asia has the highest incidence of days, with booster testing at 1 to 2 weeks for tuberculosis worldwide: in 1990, 237 cases per those whose response is initially negative. Includ­ 100,000 persons (compared with 10.1 per ing those with a positive response for booster 100,000 in native-born US citizens). Ever since testing and prophylactic treatment could help to the 1970s, health assessments described tubercu- reduce even further the cases of tuberculosis in . losis as one of the most important health prob­ this population. 8 Other experts suggest the lems among these refugees. 7 Among early booster response is associated with reactivity to refugees, up to 50 percent had evidence of infec­ nontuberculous mycobacterial antigens and a his­ tion without disease, and 1.5 percent had active tory of bacillus Calmette-Guerin (BCG) vaccina­ disease. Those at highest risk were tuberculin­ tion.9 Current recommendations base treatment http://www.jabfm.org/ positive refugees who had abnormal findings on on risk factors and the size of reactivity, regardless screening chest roentgenograms.7 Providing pro­ of BCG vaccination status. Southeast Asians and phylactic treatment with isoniazid for those who all foreign-born persons are classified as high-

Table 3. Laboratory Tests Recommended for Refugees According to Country of Origin or Country of Residence During Immigration. on 1 October 2021 by guest. Protected copyright. Southeast Former Former East Middle Test Asia Soviet Union Yugoslavia Africa East Haiti Cuba

Nutritional assessment + :t :t + :t + + Stool for ova and parasites + -* + + :t Hepatitis B surface antigen + :t + + :t :t Hemoglobin or hematocrit + :t :t + :t :t :t VDRL :t + + HIV + + PPD + + + + + + + Peripheral smear for malaria :t mv -human immunodeficiency virus, PPD - purified protein derivative tub~rculin. + Strongly suggested, :t consider, - not routinely suggested. ·Unless in a concentration camp.

Refugee Health Problems 339 J Am Board Fam Pract: first published as 10.3122/jabfm.10.5.337 on 1 September 1997. Downloaded from

Table 4. Criteria for Determining Need for Preventive Therapy for Persons With Positive Tuberculin Reactions, by Category and Age-Group.

Age-Group

Catc.:gory < 35 Years 235 Yc.:ars

\Vith risk factor* -neat at all ages if reaction to 5 TU purified protein derivative (PPD) tuberculin 2 1(] n1l11 (or 2 5 n1l11 and patient is recent contact, } TTV-infected, or has radiographic c.:vidence of old hlberculosis) No risk factor, high-incidence group' 'neat if PPD > 10 mm Do not treat No risk factor, low-incidence group Treat if PPD > 15 mrn* Do not treat

From MMWR Morb Mortal \\1kly Rep.11l 'Risk ClCtors include hum'lI1 immunodeficiency virus (1 IIV) infection, recent contact with infectious person, recent skin test conversion, abnormal chest radiograph findings, intravenous drug abuse, and certain medical risk factors. tHigh-incidence groups include foreign-born persons, medically undcrserved low-income populations, and residents oflong-term-care facilities. fLower or higher cut points may be used for positive reactions, depending upon the relative prevalence of Mywbncterimn tuben-ulosis in­ fection and nonspecific cross-reactivity in the population. incidence groups and are given prophylaxis if tients often report major depression or somatic their PPD reactivity is greater than 10 mm and complaints, such as headaches, stomachaches, and they are younger than 35 years of age. If they poor sleep. Vietnamese mental health needs are have risk factors, prophylaxis is recommended for best understood in terms of an extended, patriar­ all ages. Table 4 further outlines these criteria. chal, collectivistic family unit. A careful history Infection with hepatitis B is hyperendemic in from the patient on exposure to combat, torture, Southeast Asia. Fourteen percent of refugees or reeducation camp can alert the clinician to a pa­ have hepatitis B antigenemia (HBsAg positive). 5 tient at risk. Younger children might have devel­ Detecting those who are carriers and immunizing opmental problems, whereas older children often nonimmune family members will decrease fur­ suffer from depression, psychosis, aggressive be­ ther transmission. In addition to immunizing the havior, and school problems. 14-16 newborns of mothers with infectious disease, the Attention to tobacco and alcohol abuse, healthy new recommendation of immunizing all new­ diets, cancer screening, and hepatitis B preven­ borns will decrease the child-to-child transmis­ tion is virtually unknown among recent Viet­ sion that can occur in households. I I namese immigrants in the United States. Cervical http://www.jabfm.org/ Among children immunizations are usually cancer is still a leading cause of death in young complete by standards of the World Health Vietnamese women. 17 Organization (3 diphtheria-pertussis-tetanus, 4 As in many Asian cultures, some Vietnamese, polio, and 1 measles vaccine by the fourth birth­ Laotians, and Cambodians practice traditional day) but might still be incomplete by US recom­ folk healing techniques that might not be men­ mendations (46 percent incomplete).12 Malnutri­ tioned to the physician. A view that suffering is tion and various vitamin deficiencies are common inevitable and a lack of understanding of the ben­ on 1 October 2021 by guest. Protected copyright. among refugees who consume a rice-only diet. efits of preventive services and other Western Beriberi has been described in a Vietnamese health care technologies can cause mistrust and refugee who lived in the United States for 7 delay in seeking health care. Coining (rubbing a years. Ll Iron deficiency anemia (37 percent) and coin on the skin), hair pulling, cupping (filling a hemoglobinopathies are common. Abnormal cup with burning paper and placing it over the af­ VDRL test results overall (12 percent) are re­ fected area), pinching, scratching, and other tra­ ported highest among Cambodians (19 percent).5 ditional practices can lead to inappropriate accu­ Up to 70 percent of Southeast Asian refugees sations of child abuse and expensive workups for have posttraumatic stress disorder or depression. unusual illnesses. Home remedies, herbal medi­ Underreporting symptoms, patient stoicism, and cines, and healing ceremonies are particularly cultural bias against admission of mental illness all prevalent among the Mien population (a tribe lead to a failure to diagnose posttraumatic stress from Laos).18,19 The most important factors in disorder. The symptoms are not obvious, and pa- overcoming these obstacles are understanding

340 JABFP Sept.-Oct. 1997 Vol. 10 No.5 J Am Board Fam Pract: first published as 10.3122/jabfm.10.5.337 on 1 September 1997. Downloaded from and respecting the patient's culture and a strong rubella, and combined measles, mumps, and physician-patient relationship. rubella are not provided. Although immunization rates were high in 1991, measles vaccines have Former Soviet Union been inconsistently available since late 1991. In 1991 the world's largest and third most popu­ Children's immunization records should be lous country, the Soviet Union, broke apart, and checked. Seronegativity to measles, mumps, and ethnic tensions and economic disruptions rubella is common among those who are younger erupted. As a result, the largest group of refugees than 30 years. Accordingly measles, mumps, and to the United States from 1992 to 1994 came rubella vaccines are recommended for all Soviet from the former Soviet Union. These people are refugees born after 1957.23 ethnically and linguistically diverse, representing Although the incidence of active tuberculosis five major national ethnic groups and many mi­ or infection among Russian immigrants has not nority ones. From 1983 to 1995 the United States been reported, tuberculosis is endemic in the for­ admitted 342,650 refugees, the majority of whom mer Soviet Uruon. As a result of the failing econ­ resettled in New York. 1 In 1995, the first year omy and civil wars, medication is not readily refugees were registered according to the individ­ available. Kazakhstan has the highest rates.24 For ual countries within the former Soviet Union, the first half of 1993, a regional referrallabo­ Ukraine (15,103), Russia (8610), and Uzbekistan ratory found that 20 percent of 467 isolates of (3463) were home countries of the largest groups Mycobacterium tuberculosis from both new and re­ of refugees. 1 current cases in that area were resistant to isoni­ In 1992 the CDC investigated case studies of azid. The incidence of infection with the human the health care and public health in the former immunodeficiency virus (HIV) is 42.0 per Soviet Union. They found that patterns of dis­ 100,000, and although the number of cases is low, eases and other problems approximated those in HIV infection has occurred nosocomially as a re­ Western countries, but there were serious short­ sult of inadequately sterilized needles. Hepatitis A ages of medicine, vaccines, and supplies.2o Subse­ is widespread, and poor public hygiene has led to quent to this report a cholera outbreak occurred hepatitis E outbreaks. Pockets of typhoid, brucel­ in the Ukraine (1994)21 and a diphtheria epidemic losis, anthrax, and malaria exist. Bubonic plague (1990 to 1994) continued to spread to all the in­ has been reported in Central Asia,25,26 and a se­ dependent states.22 Additionally, with the disinte­ vere influenza epidemic was reported by the 27

gration of the government, including the Min­ CDC in December 1995. http://www.jabfm.org/ istry of Health of the Soviet Union, other public Infant nutrition within the former Soviet Union health problems are escalating. countries has been compromised because mothers The geographic prevalence pattern of hepatitis have not been encouraged to breastfeed, and im­ B virus infection in the former Soviet Union is ported formulas are in short supply. Iron defi­ classified as intermediate. Hepatitis B surface ciency anemia (found in 25 to 50 percent of chil­ antigen (HBsAg) has a prevalence of 2 to 7 per­ dren) and endemic goiter are affecting growth and cent, and hepatitis B surface antibody (anti-HBs development, so that hemoglobin levels should be on 1 October 2021 by guest. Protected copyright. positivity) has a prevalence of 20 to 50 percent. measured in children.25 ,26 Heavy tobacco and al­ The reported prevalence of HBsAg positivity is cohol abuse are common, and alcoholism has be­ 4.2 percent among persons living in Moscow and come accepted as normal social behavior. Table 5 1.5 percent among refugees from the former So­ displays these and other conditions to consider viet Union who have resettled in the United when caring for Soviet refugees. States. In a study of 496 Jewish Russian refugees, Perhaps the most perplexing medical conditions however, HBsAg was detected in only 0.4 per­ are those caused by radiation exposure from the cent, suggesting routine screening might not be Chernobyl nuclear power plant disaster and sub­ needed in this population.23 sequent clean-up efforts. Approximately 80 per­ Within the former Soviet Union, distribution cent of all Soviet immigrants to the United States of measles and mumps vaccines began in the are from the areas that were most affected-Be­ 1970s, and these vaccines continue to be offered larus, the southwestern regions of Russia, and the at 12 and 14 months. Vaccines against hepatitis B, northern part of Ukraine. There has been an in-

Refugee Health Problems 341 J Am Board Fam Pract: first published as 10.3122/jabfm.10.5.337 on 1 September 1997. Downloaded from

Table 5. Medical Problems in Refugees, Based on Country of Origin or Residence.

Southeast Former Former East Middle Problems Asia Soviet Union Yugoslavia Africa East llaiti Cuba

Malnutrition X X X Depression X X X Intestinal parasites· X X X X Filariasis X X Leishmaniasis X X Hepatitis B X X X X X X Tuberculosis X X X X X X X Posttraumatic stress disorder X X X Low immunization rate X X X X X Diphtheria X Alcohol abuse X Dental caries X X X X 'Typhoid fever X X Malaria X Trachoma X X Syphilis X X X Dengue fever X X X HIV infection X X Plague X Cholera X Radiation elxposure X

HIV - human immunodeficiency vims. X - disease reported in refugees from the country or considered at risk for importation. *Includes EuterobiuJ, TrichuriJ, StrongyloideJ, and AJwriJ.

crease in thyroid cancer and leukemia in this pop­ ronment where individual incentive is valued. As ulation, so that physical examination with particu­ a result, their expectations of the health system lar attention to the thyroid gland, thyroid function are unrealistically high. Furthermore, many older tests, regular cancer screening, routine blood emigres do not learn English, and although they

chemistry tests, complete blood count, and urinal­ were professionals in their country of origin, they http://www.jabfm.org/ ysis would be appropriate. Children's growth are unable to fInd work in the United States. All should also be examined carefully. In 1993 a US these differences can lead to complications with National Chernobyl Registry Coordinating Cen­ diseases that require self-management, because ter was established at Baylor College of Medicine older Russians might not understand the need for to create long-term prospective analysis of former personal involvement in their health care.29

Soviet Union immigrants living in the United on 1 October 2021 by guest. Protected copyright. States. Caring for these patients can be challeng­ Former Yugoslavia (Bosnia-Herzegovina) ing, as they often link all of their complaints to ra­ The war in the former republic of Yugoslavia has diation exposure, and the long-term health impli­ created the largest number of European refugees cations are still unclear.28 since World War Ipo In 1994,7418 refugees Russian refugees emphasize the social aspects from the former Yugoslavia were admitted as res­ of health and illness, in contrast to the biomedical idents into the United States l ; in 1995, 9872 model used by most American health care work­ refugees were admitted from Bosnia and Herze­ ers. The former Soviet Union required the entire govina. In the United Kingdom Bosnian medical family to emigrate as a unit, so that the older Rus­ evacuees were found to be suffering from malnu­ sians often left their homeland for the sake of trition, tuberculosis, and quadriplegia, and those their children. These older refugees, who were who were not evacuated for medical reasons were accustomed to having the government provide all in good health but had experienced emotional basic necessities, have been thrust into an envi- trauma. The United Kingdom health authorities

342 }ABFP Sept.-Oct. 1997 Vol. 10 No.5 J Am Board Fam Pract: first published as 10.3122/jabfm.10.5.337 on 1 September 1997. Downloaded from recommend checking immunization status (par­ study of these new refugees found 65 percent with ticularly in children younger than 18 months), posttraumatic stress disorder and 35 percent with screening for tuberculosis, offering dental and depressive disorders. Posttraumatic stress disorder family planning services, and offering counseling severity scores correlated with the number and to rape and torture victims. They do not recom­ type of traumatic events experienced and seemed mend screening asymptomatic refugees for skin to be more severe among older patients.34 Among and gastrointestinal parasites.3D children, success in coping with stress corre­ Although the main health impact of the war has sponded with the mother's coping skills. Sleeping been war-related injuries, the effects of the war and eating disorders, separation fears, and with­ on public health are pervasive. Production of drawal or aggression were common. Children in a BCG, diphtheria, pertussis, tetanus, oral polio, collective shelter were at greater risk for mental measles, mumps, and rubella vaccines has been disorders than those with host famiIies. 35 disrupted, and the in-country immunization rate is falling. 31 It is possible that recent arrivals have East Africa enteric infections, such as typhoid and hepatitis During the past 10 years, many refugees from A, as well as scabies and head and body lice, but three countries on the African continent-Soma­ these conditions have not been reported. In 1990, lia, Sudan, and Ethiopia-have entered the before the war, Bosnia reported 2913 cases of he­ United States. In 1995,2524 Somalis (a decrease patitis B. The increased need for blood donations from 3508 in 1994) and 1693 Sudanese (an in­ and a shortage of screening reagents have re­ crease from 1289 in 1994) were admitted. Previ­ sulted in a higher rate of hepatitis B transmission. ously, Ethiopia has been the main country of ori­ Because the in-country prevalence of hepatitis B gin for African refugees; from 1983 to 1995, is intermediate, refugees should be screened for 26,360 Ethiopians entered the United States.1 HBsAg. Other recommended laboratory tests are Somalia, the site of Operation Restore Hope, included in Table 3. has been in civil turmoil for years. By far the In July 1993 nutrition surveys, the World greatest health problem is malnutrition. During Health Organization found a mean weight loss of the 1992 famine an estimated 74 percent of chil­ 10 to 12 kg per person among adults in Sarajevo dren younger than 5 years living in refugee camps but no increased protein deficiency.3D,31 Malnu­ died.36 Iron deficiency anemia, scurvy, and vita­ trition has not been reported among recent min A deficiency were and still are common. refugees, and there has been preferential feeding Communicable diseases resistant to antibiotics, http://www.jabfm.org/ of the children. 30 Dental care, limited before the particularly respiratory and diarrheal diseases, are war, now is nearly nonexistent,32 major causes of childhood mortality within In the prewar era the former Yugoslavian coun­ Somalia. Many Somali and Ethiopian refugee tries had a high incidence of tuberculosis com­ children arriving in Buffalo, NY, lacked immu­ pared with the rest of Europe. High and increas­ nizations, had intestinal parasites and dental ing numbers of cases of tuberculous meningitis in caries, and were anemic. 12 Kosovo (Serbia) indicate widespread transmission Malaria is responsible for much of the morbid­ on 1 October 2021 by guest. Protected copyright. and low BCG vaccination rates. All areas now ity and mortality among Somalis. Approximately have a shortage of antituberculous drugs and labo­ 90 percent of malaria is caused by Plasmodium fol­ ratory consumables.33 Because tuberculous infec­ ciparum; P vivax and P malariae have also been tion is common, PPD screening is recommended identified. Recurrent infections result in anemia for Bosnian refugees. Heavy tobacco abuse con­ and splenomegaly.37 Among Somali and Ethi­ tributes to respiratory problems among Bosnians. opian refugees waiting in Mombasa and Khar­ The greatest problems among Bosnian refugees toum for resettlement to the United States, 15.0 stem from the psychiatric consequences of ethnic percent and 0.8 percent, respectively, were para­ cleansing. In a country that took pride in its multi­ sitemic. Strategies to reduce the risk of imported cultural character, former neighbors and friends malaria include treatment at these centers. The are looting and murdering one another. Most threat of imported malaria is quite rea1. 38 families have at least one relative who has died in Historically Somalia has been characterized by the war or has been a prisoner of war. A recent low vaccination rates, especially among the no-

Refugee Health Problems 343 J Am Board Fam Pract: first published as 10.3122/jabfm.10.5.337 on 1 September 1997. Downloaded from matlic people. Before the fighting erupted in 1984, conditions among East African refugees living in only 19 percent of children in Mogadishu were the United States is largely unstudied. fully immunized. Even Somali children from Certain traditional practices can challenge refugee camps are often inadequately immu­ those caring for female Somali patients. Commu­ nized. 12 The very high rates of vaccine-preventable nities in many parts of Africa practice female cir­ diseases reported during times of stability are now cumcision. The Pharaonic type (infibulation), in higher. Children are not named until they are 7 which the entire clitoris, labia minora, and most of days of age, because an estimated 5 percent of all the anterior parts of the labia majora are removed, infants are affected with tetanus neonatorum (mor­ is the most common (88 percent). Circumcised tality greater than 90 percent). A high incidence of women experience, in addition to an immediate measles and vitamin A deficiency combine to result risk of sepsis, profound long-term psychologic in xerophthalmia and blindness.\'} and physical consequences, including painful uri­ The reported prevalence of infection with he­ nation, intercourse, and labor, as well as perinatal patitis B virus is 68 percent, and the rate of difficultiesYHI Traditional healers are important chronic carriers (HBsAg positive) in the general providers of health care. Skin burning for pain re­ population is 11 to 12 percent. Rates as high as 32 lief and uvulectomy or tooth removal for upper percent are reported among pregnant women. respiratory infections are common traditional Hepatitis A immunity is nearly 100 percent. He­ treatments. W \Vhether these practices are contin­ patitis C prevalence is 1.5 percent in the general ued in the United States has not been studied. population.l9 Syphilis is widespread, its preva­ Patriarchal Muslim traditions, which allow lence ranging from 3 percent among pregnant women few freedoms, make it difficult for Somali women to 28 to 69 percent among prostitutes. women to assimilate easily into Western culture. Gonorrhea is common, but the current HIV in­ In Canada community projects have aided ref­ fection rate is low. 39 ugees in this difficult transition.+2 BCG vaccination rate is low. Approximately 50 Israel has had extensive experience with Jewish percent of the population is infected with tuber­ Ethiopian refugees before the migration of culosis, which makes tuberculosis screening Ethiopians to the United States, which peaked mandatory37,39 (Table 3). Both visceral and cuta­ with 4085 persons in 1991. 1 In an investigation of neous leishmaniasis are endemic. Kala-azar (vis­ 14,465 refugees, the Israelis found typhoid fever, ceralleishmaniasis) is a chronic disease character­ tuberculosis, or malaria in 1.8 to 9.0 percent of ized by lymphadenopathy, anemia, leukopenia, immigrants. As many as 93 percent were infested http://www.jabfm.org/ fever, hepatosplenomegaly, and emaciation and with intestinal parasites. The most common para­ has an incubation period of weeks to years. In­ sites were hookworm, Schistosoma man.mlli, Giardia testinal parasitosis is common in Somalia, as lamblia, Ascaris lumbricoides, Hymenolepis nana, and would be expected in a rural seminomadic popu­ Entamoeba histolytica. Ninety-eight percent of lation (50 to 88 percent infected). Trichuris, As­ adults had serologic evidence of hepatitis B, and caris, Ancylostoma, and Giardia are the most com­ extreme malnutrition, syphilis, and chloroquine­ mon parasites and protozoa. resistant malaria were common. An active measles on 1 October 2021 by guest. Protected copyright. Schistosomiasis, a major health problem in So­ infection was the only disease that appeared to malia and surrounding regions, is found in 36 spread from Ethiopian immigrants to the indige­ percent of the population. In Somalia schistoso­ nous population. Other diseases found in low miasis is caused by Schistosoma haematobium, numbers included leprosy, louse-borne relapsing which is a major cause of bladder cancer, stones, fever, and asymptomatic shigellosis.43 and obstructive uropathy.39 A1though the vectors Tuberculosis in Ethiopian refugees continues for dengue and yellow fever are found in Somalia, to be a major concern in the United States. At only dengue fever has been reported. Other en­ least one adult-to-child tuberculosis transmission demic diseases include leptospirosis, rickettsial in a day-care setting has resulted from an active diseases, brucellosis, relapsing fever, filariasis, and case of tuberculosis in a recent Ethiopian immi­ echinococcosis.l9 1able 5 displays some medical grant.++ Strict compliance with the recommended conditions to consider when examining these pa­ screening using Mantoux testing in this popula­ tients, although the frequency of most of these tion is crucial (Table 4).

344 JABFP Sept.-Oct. 1997 Vo!' 10 No.5 J Am Board Fam Pract: first published as 10.3122/jabfm.10.5.337 on 1 September 1997. Downloaded from Cultural differences can make communication genase deficiency, are diagnosed more commonly with Ethiopian patients difficult. Ethiopian pa­ in this population than in the US population. 54-56 tients consider frank disclosure inappropriate and Adjustment problems among Iraqi refugees have insensitive. They expect bad news to be commu­ primarily been related to language barriers and nicated to a relative or friend, who will communi­ religious practices. Among the Middle Eastern cate it to the patient. In the American cultural immigrant groups studied, those who perceived context disclosure is an important aspect of health themselves to be more traditional had more phys­ care and might not be understood by Ethiopian ical symptoms and lower morale. immigrants.45 Between 1983 and 1995,22,316 Mghan refu­ The health profile of Sudan is similar to that of gees emigrated to the United States.l Although the Somalia and Ethiopia. Malnutrition is endemic. more than 6 million Afghan refugees worldwide Fifty-eight percent of Sudanese refugees sur­ represent the largest single group of refugees, little veyed in Ethiopia suffered from acute protein en­ information is available on their health status. ergy malnutrition.46 Xerophthalmia and tra­ Fourteen years of war have been devastating to the choma are also endemic.47 ,48 The prevalence of children and women in a country that has the sec­ malaria is so high in Sudan that many high-risk ond highest infant mortality rate and second high­ patients (young children and pregnant women) est mortality rate in the world for children younger are routinely treated with antimalarial medica­ than 5 years. Many Mghan women have lost hus­ tions based on fever and clinical symptoms alone bands and children to war injuries, gastroenteritis, in an attempt to decrease mortality.49 Malaria starvation, or neonatal tetanus. In one study popu­ should be considered in the differential diagnosis lation of Mghan refugee children, 67 percent were if refugees have fever. In the United States seriously undernourished, and only 30 percent splenomegaly and hyperreactive malarial syn­ were completely immunized. 57 drome are found in Sudanese refugees and can be Health concerns and needs of Mghan refugee misdiagnosed. 50 families have been studied in California. In a sur­ Because most Sudanese have intestinal para­ vey of 196 Mghan families, the most pressing sites, Sudanese refugees should be screened for problems were the psychologic disorders and stress ova and parasites5l (Table 3). Detection of infec­ resulting from trauma and loss, occupational and tions that lead to chronic disease (such as leish­ economic difficulties, and issues related to cultural maniasis and schistosomiasis) is an important pre­ conflict. Physical problems included diabetes, den­ ventive measure. 52 A survey of sexually active tal disease, and heart disease. 58 The most fre­

heterosexuals in Sudan (which included some quently reported medical conditions among newly http://www.jabfm.org/ Ethiopian refugees) found serologic markers for arrived Mghan refugees in San Francisco were (in hepatitis B and syphilis in 68 percent and 17 per­ descending order) dental caries, dermatologic dis­ cent of the participants, respectively. Antibody to orders (tinea, scabies), intestinal parasites, gas­ HIV was not detected in any participants. All Su­ trointestinal disorders, musculoskeletal com­ danese refugees should be screened for HBsAg plaints, and refractive errors. Common parasites and syphilis53 (Table 3). were Ascaris lumbricoides, Giardia lamblia, Enta­ on 1 October 2021 by guest. Protected copyright. moeba histolytica, and Hymenolepis species. 59 Iraq and Afghanistan Post-traumatic stress disorder and major de­ From 1983 to 1995, 19,848 Iraqi and Kurdish pression are common among young adult and refugees emigrated to the United States,l and in adolescent refugees, particularly those whose par­ 1995, at 3475 refugees, they constituted the ents were subjected to intense psychologic dis­ largest refugee group from the Middle East. Mal­ tress and those who experienced a great many nutrition and intestinal parasites are common traumatic events.60 Mghanistan has a strong Mus­ among Iraqi refugees, and hepatitis B and tuber­ lim religious tradition that values the extended culosis are endemic. Among Kurdish refugees 6.7 family and elders and privacy and modesty among percent of children aged 1 to 4 years and 14.4 women. As a result, refugee Mghan women en­ percent of adults were HBsAg positive. Certain counter many difficulties when making the tran­ hereditary diseases, such as familial Mediter­ sition from their traditional patriarchal society to ranean fever and glucose-6-phosphate dehydro- a more egalitarian postindustrial society.59,60

Refugee Health Problems 345 J Am Board Fam Pract: first published as 10.3122/jabfm.10.5.337 on 1 September 1997. Downloaded from

The Caribbean-Haiti and Cuba minerals needed for cyanide detoxification) and The number of refugees from Haiti entering the those who have inadequate intake of vitamin Bu , United States decreased from 5043 in 1994 to folate, or methionine.6S ,M> 2551 in 1995. 1 Haiti has long been plagued with The children are in overall good health com­ overwhelming poverty. The greatest health bur­ pared with those in many developing countries. den in Haiti is acquired immunodeficiency syn­ Regular government-sponsored mass immuniza­ drome (AIDS), currently the leading cause of tion campaigns have resulted in high immuniza­ death in sexually active adults.(J! tion rates. 67 The incidence of tuberculosis has been In a report on the health status of Haitian im­ declining in Cuba since 1979/iH Even so, the age­ migrants in 1992, the main health problems were adjusted prevalence of tuberculous infections for fever, malaria, otitis media, upper respiratory persons born in Cuba (9.7 percent) is greater than tract infection, active tuberculosis, measles, pneu­ for those of Cuban descent born in the United monia, varicella, cellulitis or abscess, and filaria­ States.m HIV infection is rare in Cuba, and HIV­ sis. 62 Of the 7315 immigrants older than 15 years infected patients are housed in sanitoriums'?o who were screened for syphilis, human immun­ Mental illness, including schizophrenia, mental odeficiency virus (l-IIV), and tuberculosis, 5 per­ retardation, atypical psychosis, and antisocial per­ cent had evidence of past or present syphilis, 7 sonality disorder, has been a serious problem in percent were HIV positive, and 5 percent had both Cuban and Haitian refugees. Because they signs of pulmonary tuberculosis, of which 3° per­ are unfamiliar with the US mental health system cent had active infection. Although 21 percent of and live in unfavorable social environments, they the MYl"oblll"teriu7lJ tuberruiosis isolates were resis­ have not been able to take advantage of mental tant to isoniazid and 5.4 percent were resistant to health services. Serious mental illnesses and crim­ two drugs simultaneously, all but 1 patient had a inal records have been reasons for detaining favorable response to a standard four-drug treat­ Cuban refugees in federal institutions. Of those ment program.6.l refugees who appealed psychiatric diagnoses None of the Haitians undergoing nutritional given in immigration proceedings, medical re­ assessment at Guantanamo Bay were suffering view boards upheld 72 percent of the exclusionary from acute malnutrition, but only 6 percent of certificates but only 42 percent of the diagnoses those surveyed were younger than 9 years old. of antisocial personality disorder/I,n Immunization rates are low. 62 Because of their low standard of living and poor hygienic condi­ Summary tions, Haitians should be screened for parasites The physical and mental problems of refugees are http://www.jabfm.org/ CIable 3). Dengue fever, an arboviral infection, challenging. Nearly all refugees have a higher in­ has been imported from Haiti and should be con­ cidence of tuberculosis, chronic infection with sidered in the differential diagnosis of febrile ill­ hepatitis 13, intestinal parasites, nutritional defi­ nesses in recent refugees.64 ciencies, and depression-although there are A new wave of refugees has been arriving from marked differences among the various countries.

Cuba. In 1994 the United States admitted 15,468 Findings from a complete history and physical ex­ on 1 October 2021 by guest. Protected copyright. Cubans, I and in 1995 it admitted a total of amination, knowledge of the physical and mental 37,037. Poor economic conditions have resulted health problems encountered in these popula­ in micronutrient deficiencies in these refugees, tions, and familiarity with their health and cul­ which in turn have been responsible for a recent tural beliefs will enable the family physician to epidemic of optic neuropathy, sensorineural deaf­ provide complete and compassionate care to new ness, peripheral sensory neuropathy, and dorso­ refugees. lateral myeloneuropathy. Multivitamin supple­ ments have curbed the epidemic, but physicians References should be alert to possible thiamine, cobalamin, 1. Fiscal year 1995 annual report to Congress. Wash­ folate, and sulfur amino acid deficits in Cuban ington, DC: Department of Health and Human Ser­ vices, Administration for Children and Families, Of­ refugees. Patients who smoke are at highest risk, fice of Refugee Resettlement, 1995. particularly those who smoke cigars (possibly be­ 2. Technical instructions for medical examination of cause they lack adequate amounts of vitamins and aliens in the United States. Atlanta, Ga: Department

346 JABFP Sept.-Oct.1997 Vo!' 10 No.5 J Am Board Fam Pract: first published as 10.3122/jabfm.10.5.337 on 1 September 1997. Downloaded from of Health and Human Services, Centers for Disease traditional and modern health services by Laothm Control, Center for Prevention Services Division of refugees. West1 Med 1992;157:310-5. Quarantine, 1991. 20. Farmer RG, Goodman RA, Baldwin RJ. Health care 3. Zuber PL, Binkin NJ, Ignacio AC, Marshall KL, and public health in the former Soviet Union, 1992. Tribble SP, Tipple MA, et al. Tuberculosis screening Ukraine-a case study. Ann Intern Med 1993; for immigrants and refugees. Diagnostic outcomes 119:324-8. in the state of Hawaii. Am J Respir Crit Care Med 21. Conradi P. Cholera attacks former Soviet Union. 1996;154:151-5. BMJ 1994;309:827-8. 4. Anderson JP, Moser RJ. Parasite screening and 22. Diphtheria acquired by U.S. citizens in the Russian treatment among Indochinese refugees. Cost-bene­ federation and Ukraine 1994. MMWR Morb Mor­ fit/utility and the General Health Policy Model. tal Wkly Rep 1995;44:237,243-4. JAMA 1985;253:2229-35. 23. Hurie MB, Gennis MA, Hernandez LV, Dindzans 5. Catanzaro A, Moser RJ. Health status of refugees VJ, Davis JP. Prevalence of hepatitis B markers and from Vietnam, Laos, and Cambodia. JAMA 1982; measles, mumps, and rubella antibodies among Jew­ 247:1303-8. ish refugees from the former Soviet Union. JAMA 6. Texas Department of Health Epidemiology and Sur­ 1995;273:954-6. veillance Division. Refugee health: screening for 24. Burns DN, Gellert GA, Crone RK. Tuberculosis in parasites. Disease Prevention News 1995;55:23. eastern Europe and the former Soviet Union: how 7. Nolan CM, Elarth AM. Tuberculosis in a cohort of concerned should we be? Lancet 1994;343: 1445 -6. southeast Asian refugees. A five-year surveillance. 25. Chen LC, Rohde JE, Jolly R. A looming crisis: Am Rev Respir Dis 1988;137:805-9. health in the Central Asian Republics. Lancet 8. RobertsonJM, Burtt DS, Edmonds KL, Molina PL, 1991;339:1465-7. Kiefe CI, Ellner JJ. Delayed tuberculin reactivity in 26. Gellert GA. International health assistance for Eura­ persons of Indochinese origin: implications for pre­ sia. N EnglJ Med 1992;326:1021-4. ventive therapy. Ann Intern Med 1996;124:779-84. 27. Texas Department of Health, Epidemiology, and 9. Cauthen GM, Snider DEJr, Onorato 1M. Boosting Surveillance Division. Influenza epidemic in Russia of tuberculin sensitivity among Southeast Asian refu­ and Ukraine. Disease Prevention News 1996;56:2. gees. AmJ Resp Crit CareMed 1994;149:1597-600. 28. Weinberg AD, Kripalani S, McCarthy PL, Schull to. Screening for tuberculosis and tuberculous infection WJ. Caring for survivors of the Chernobyl disaster. in high-risk populations. Recommendations of the What the clinician should know. JAMA 1995; Advisory Committee for Elimination ofTuberculo­ 274:408-12. sis. MMWR Morb Mortal Wkly Rep 1990;39(RR- 29. Brod M, Heurtin-Roberts S. Older Russian emigres 8):1-7. and medical care. WestJ Med 1992;157:333-6. 11. Hurie MB, Mast EE, Davis JP. Horizontal transmis­ 30. Black ME, Healing TD. Communicable diseases in sion of hepatitis B virus infection to United States­ former Yugoslavia and in refugees arriving in the boro children of Hmong refugees. Pediatrics 1992; United Kingdom. Commun Dis Rep CDR Rev 89:269-73. 1993j3:R87-90. 12. Meropol SB. Health status of pediatric refugees in 31. Status of public health-Bosnia and Herzegovina, http://www.jabfm.org/ Buffalo, NY. Arch Pediatr Adolesc Med 1995;149: August-September 1993. MMWR Morb Mortal 887-92. Wkly Rep 1993;42:973-82. 13. Vrchota K, Oberg CN, Harris KN. Beriberi in a 32. Schrader A. Dental needs in Bosnia. Br Dent J southeast Asian adolescent. Am J Dis Child 1989; 1993;175:110. 143:270-2. 33. Roure C, Felten M, Haakanson A. Control of tuber­ 14. KinzieJD, BoehnleinJK, Leung PK, Moore LJ, Ri­ culosis and other communicable diseases in former

ley C, Smith D. The prevalence of posttraumatic Yugoslavia: Report of a Joint WHO/Swedish Mis­ on 1 October 2021 by guest. Protected copyright. stress disorder and its clinical significance among sion. 1993. southeast Asian refugees. Am J Psychiatry 1990; 147: 34. Weine SM, Becker DF, McGlashan TH, Laub D, 913-7. Lazrove S, Vojvoda D, et a1. Psychiatric conse­ 15. Hauff E, Vaglum P. Chronic posttraumatic stress quences of "ethnic cleansing": clinical assessments disorder in Vietnamese refugees. A prospective com­ and trauma testimonies of newly resettled Bosnian munity study of prevalence, course, psychopathol­ refugees. Am J Psychiatry 1995; 152: 536-42. ogy, and stressors.J Nerv Ment Dis 1994;182:85-90. 35. Ajdukovic M, Ajdukovic D. Psychological well-be­ 16. Gold SJ. Mental health and illness in Vietnamese ing of refugee children. Child Abuse Negl 1993; refugees. WestJ Med 1992;157:290-4. 17:843-54. 17. Jenkins CN, McPhee SJ, BirdJA, Bonilla Nr. Can­ 36. Moore PS, Marfin AA, Quenemoen LE, Gessner cer risks and prevention practices among Viet­ BD, Ayuv YS, Miller DS, et a1. Mortality rates in dis­ namese refugees. WestJ Med 1990;153:34-9. placed and resident populations of central Somalia 18. Uba L. Cultural barriers to health care for southeast during 1992 famine. Lancet 1993;341:935-8. Asian refugees. Public Health Rep 1992;107:544-8. 37. Laughlin LW, Legters LJ. Disease threats in Soma­ 19. Gilman SC,JusticeJ, Saepharn K, Charles G. Use of lia. AmJ Trop Med Hyg 1993j48:vi-x.

Refugee Health Problems 347 J Am Board Fam Pract: first published as 10.3122/jabfm.10.5.337 on 1 September 1997. Downloaded from

.lX. Slutsker L, Tipple M, Keane V, McC1I1ce C, Camp­ Mortal Wkly Rep J<)<)1;40:H3-7 . bell Cc. Malaria in Fast African refugees resettling 50. Kulstrullk M, ELH:qUOZ D, Dllbach VC, Banziger W, to the United States: development of strategies to Lutchg W, Stalder GA. Prevalence of hepatitis B reduce the risk of imported malaria. J Infect Dis virus in Kurdish refugees. J Hepatol 1992; 15 :418-9. 1995;171:4-89-93. 57. Miller LC, Timouri Nt, Wijnker J, Schaller JG. 39. Oldfield EC 3rd, Rodier GR, Gray Gc. The en­ Afghan refugee children and mothers. Arch Pediatr demic infectious dise;lses of Somali;l. Clin Infect Dis Adolcsc Med 1994;148:704-8. 1993;IG(SuppI3):SU2-57 . SX. Lipson JG, Omidian PA, Paul SM. Afghan Health .{O. Arbesman M, Kahler L, Buck G. Assessment of the Education Projcct: a c01J1mllnity survey. Public impact of female circumcision on the gynecological, Health Nurs 1995;12:143-50. genitourinary and obstetrical health problems of 59. McCaw BR, DeLay P. DemogTaphics and disease women from Somalia: literature review and case se­ prevalence of two new refugee groups in San Fran­ ries. Women Health 1993;20(3):27-42. cisco-the Ethiopian and Afghan refugees. West J 41 'Ii>ubia N. Female circumcision as a public health is­ Med 19X5;143:271-5. sue. N EnglJ Med 1994;331:712-5. GO. Mghir R, Freed W, Raskin A, Katon W. Depression 42. Somalians in Canada: A guide for health and service and posttraumatic stress disorder among a commu­ providers (booklet). Vanier, Ontario: Somali Wom­ nity sample of adolescent and young adult Afghan en's Health Group, 1991. refugees.] Nerv Ment Dis 1995;183:24-30. 43. Berger SA, Schwartz T, Michaeli D. Infectious dis­ 61. Pape J, Johnson WD Jr. AIDS in Haiti: 19X2-92. ease among Ethiopian immigrants in Israel. Arch In­ Clin Infect Dis 1993;17(Suppl 2):S341-5. tern Med 1989; 149: 117 -9. 62. Health Status of Haitian Migrants-U.S. Naval 44. Nolan eM, Barr H, Elarth AM, BoaseJ. Tuberculo­ Base, Guandnamo Bay, Cuba-November 1991- sis in a day-care home. Pediatrics 1987;79:630-2. April 1992. MMWR MorbMortal Wkly Rep 1993; 45. Beyene Y. Medical disclosure and refugees. lelling 42:138-40. bad news to Ethiopian patients. WestJ Med 1992; 63. Malone JL, Paparello SF, Malone JD, Hill HE, 157:328-32. Conrad KA, MeyersJW, et a1. Drug susceptibility of 46. Nutritional health status of displaced persons, Su­ lV~ycobacte1'ilim tllbC1'culosis isolates from recent Hai­ dan, 1988-89. Wkly Epidemiol Rep 1990;65:162-4. tian migrants: correlation with clinical response. 47. Pizzarello LD. Age-specific xerophthalmia rates Clin Intect Dis 1994; 19:938-40. alllong displaced Ethiopians. Arch Dis Child 1986; 64. Imported Dengue-United States, 1993-94. 61:1100-3. MMWR Morb Mortal Wkly Rep 1995;44(18): 48. Update: health and nutritional profile of refugees­ 353-6. Ethiopia 1989-1990. MMWR Morb Mortal Wkly G5. Cuba Neuropathy Field Investigation Team. Epi­ Rep 1990;39:707-9, 715-8. demic optic neuropathy in Cuba-clinical character­ 49. Rien E, Candolfi HG. Malaria in refugee camps in ization ,mel risk factors. N EnglJ Med 1995;333: eastern Sudan: a sero-epidemiological approach. 1176-82. Ann 'Irop Med Parasitol 1990;84:215-22. 66. Epidemic neuropathy-Cuba, 1991-1994. MMWR 50. Ackerman L. Hyper-reactive malaria syndrome. Morb Mortal Wkly Rep 1994;43: 183, 189-92. http://www.jabfm.org/ JABFP 1996;9:356-9. 67. Lago P, Bravel,T, Anders J. Lessons from Cuba. Bull 51. Marnell 1<: Guillet A, Holland C. A survey of the in­ World Health Organ 1994;72 :221-53. testinal helminths of refugees in Juba, Sudan. Ann 68. Gonzalez E, Armas L, Alonso A. Tuberculosis in the Trop Med ParasitoI1992;86:387-93. Republic of Cuba: its possible elimination. Tuber 52. Seaman J, Pryce D, Sondorp HE, Moody A, Bryce­ I,ung Dis 1994;75: I 88-94. son AD, Davidson RN. Epidemic visceralleishmani­ 69. Prevalence of tuberculous infection among U.S. res­

as is in Sudan: a randomized trial of aminosidine plus idents of Cuban descent-Dade County, Florida, on 1 October 2021 by guest. Protected copyright. sodium stibogluconate versus sodium stibogluconate 1982-84. MMWR Morb Mortal Wkly Rep 1992; alone.J Infect Dis 1993;168:715-20. 41:74-5,81. 53. McCarthy MC, Burans JP, Constantine N'I~ el Hag 70. Cranich R,Jacobs B, MerminJ, Pont A. Cuba's na­ AA, el 'lyeb ME, el Dabi MA, et a1. Hepatitis Band tional AIDS prognlll1-the first decade. WestJ Med HIV in Sudan: a serosurvey for hepatitis B and hu­ 1995;163:139-44. man immunodeficiency virus antibodies among sex­ 71. Portes A, Kyle D, Eaton WW Mental illness and ually active heterosexuals. Am J Trop Med Hyg help-seeking behavior among Mariel Cuban and 1989;41 :726-31. Haitian refugees in south Florida. J Health Soc Be­ 54. AIDoori W, Armijo-Hussein N, Fawzi ww, Her­ hav 1992;33:283-98. rera MG. Child nutrition and armed cont1icts in 72. Boxer PA, Garvey JT. Psychiatric diagnoses of Iraq.J Trop Pediatr 1994;40:32-6. Cuban refugees in the Unites States: findings of 55. Public health consequences of acute displacement of medical review boards. AmJ Psychiatry 19X5;142: Iraqi citizens-March-May 1991. MM WR Morb 86-9.

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