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.
One who has been forced to flee his or her country because of persecution, war, or violence.
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 !
- In Ottawa: refer to Ottawa Public Health or the Bruyere Family health team Newcomer clinic
- 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.
- 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:
- 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.
- 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.
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.
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:
- Commonly neglected, often results in ED visits for refugees.
- In Ottawa, use the Refugee Health Toolkit document (http://www.swchc.on.ca/news-events/news/health-toolkit-support-refugees-now-available) for referrals intended specifically for Refugee populations.
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 firstname.lastname@example.org
- Physician or patient referral
- Bruyere Family Health team newcomer mental health services
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).
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
- 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.
- 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.
- 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.
- 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.
- Canadian Council for Refugees. Refugees and Immigrants: A Glossary. Canadian Council for Refugees. 2010. Web Jan 20 2016. http://ccrweb.ca/en/glossary.
- 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.
- Canadian Thoracic Society and Public Health Agency of Canada. Canadian Tuberculosis Standards 7th Edition. 2013. Web. Feb. 3/2016. Accessed February 3, 2016.
- 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.
- 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.
- 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.
- 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/.
- 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.
- 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
- 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.
- 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.
- 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.
- Malaria. Centers for Disease Control and Prevention. Dec. 14 2015. Web Jan. 20 2016. http://www.cdc.gov/malaria/index.html#
- 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.
- 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.
- 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.
- 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/.
- 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
- 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
- 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.
- 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,
- 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.
- 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.
- 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/
- 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
- 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.
- 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.
- 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.
- 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.
- 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