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 ForeignProportion 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.