Refugee Health Quarterly
A Refugee Health update from the Minnesota Department of Health
Vol. 15
Apr. 2015
Greetings from the Refugee Health Program
Spring is finally here! We have been undergoing some
spring cleaning in the form of reorganization. The MDH
Infectious Disease Epidemiology, Prevention and Control
Division now houses both the Refugee Health Program
(RHP) and the International Health Program (IHP). The
two teams work collaboratively to form the MDH Refugee
and International Health Program (RIHP). The RIHP shared
vision is “Optimal health for refugees and immigrants
achieved through innovative leadership and strong
partnerships.”
Nurse Consultant; Marge Higgins, Refugee Health Systems
Coordinator; Kailey Urban, Refugee Health Epidemiologist;
and student worker Guillaume Onyeaghala.
The RHP continues to focus on newly arrived refugees.
Its mission is to promote and enhance the health and
well-being of refugees. The RHP staff includes Blain
Mamo, Refugee Health Coordinator; Ellen Frerich, Refugee
Happy spring! We look forward to continuing to work with
our great partners towards better health for all refugees and
immigrants.
The IHP works to advance effective community health
practices with refugees, immigrants, and people with Limited
English Proficiency (LEP). The IHP staff includes Sara Chute,
International Health Coordinator; Danushka Wanduragala,
LEP Communications Planner; Ann Linde, International
Health Planner; student workers Hannah Volkman and Paw
Htoo; and interns Joy Ladu and Baninla Ladze.
March 24: World TB Day Recap
World TB Day was celebrated on March 24 to
commemorate Dr. Robert Koch’s discovery of the bacteria
that causes tuberculosis in 1882. The goals of World TB
Day are to acknowledge public health efforts to reduce
transmission and treat tuberculosis infections, and to
raise awareness that tuberculosis is still a disease of
concern, both locally and internationally.
In 2014, 25 Minnesota counties reported a total of 147 new
active tuberculosis cases. The number of new TB cases in
Minnesota has decreased 38 percent since 2007, when 238
active cases were reported. In 2013, 98 percent of the 2,082
Minnesota refugees who had health screenings got tested for
tuberculosis. 455 refugees tested positive, all but 10 of which
were for latent (noninfectious) tuberculosis.
This year’s theme for World TB Day was “Find TB. Treat
TB. Working together to eliminate TB.” MDH works to
embody this theme through collaborating with local
public health, health care providers and facilities,
laboratories, and community partners. Largely because of
these collaborations, Minnesota meets or exceeds most
of the national TB control benchmark indicators.
The CDC estimates that one in three people in the world are
infected with the TB bacteria. Although usually treatable,
tuberculosis remains an important inhibitor of health,
especially among refugees. World TB Day serves as a reminder
of the importance of screening, treatment, prevention and
education surrounding tuberculosis.
Image 1: Save the Date! World Refugee Day is June 20.
Refugee Health Program
625 Robert Street North
St. Paul, MN 55164-0975
1-877-676-5414, 651-201-5414
www.health.state.mn.us/refugee
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Provider Update: Vitamin D Deficiency
Vitamin D deficiency is a concern among refugees
arriving to Minnesota. Deficiency rates vary by ethnicity,
gender, and age, as well as individual behavioral and
health factors. While complete data are not available
on vitamin D levels among Minnesota refugee arrivals,
initial analysis shows some interesting trends. 73 percent
of Burmese refugees screened at HealthPartners/
Center for International Health (CIH) in St. Paul, MN from
September 2012 to November 2014 exhibited vitamin
D deficiency. Vitamin D deficiencies were also common
among Bhutanese and Somali refugees screened at CIH
during the same time period (79 percent and 81 percent,
respectively).
Analysis of these data also show female refugees within
these groups were more likely to be vitamin D deficient
than males (79 percent prevalence among females versus
71 percent among males). Among Burmese women
screened, the prevalence of deficiency was 94 percent.
Although other refugee groups may also experience
high rates of Vitamin D deficiency, fewer data have been
collected in Minnesota on refugees from other countries.
Additional studies support the high prevalence of
vitamin D deficiency among diverse refugees arriving to
the United States.
While the research around vitamin D deficiency continues to
grow, evidence supports its role in overall health. Symptoms
of vitamin D deficiency include bone pain, muscle weakness,
and cognitive impairment, especially in older adults. Some
research shows higher rates of vitamin D deficiency among
those who have cancer, cardiovascular disease or diabetes.
Exposure to the sun is the main source of vitamin D for
humans. Dietary sources of vitamin D include fortified foods,
milk, and infant formula, as well as fish.
Multiple factors can inhibit vitamin D absorption. Individuals
with darker skin have more melanin, which blocks the
creation of vitamin D in the skin. Living in latitudes far from
the equator limits vitamin D absorption seasonally due
to shorter hours of daylight, less skin exposure, and the
weaker angle of the sun. Cultural and individual practices of
covering skin and limiting time spent outside also impact
vitamin D exposure and absorption. Finally, people with
gastrointestinal issues may not be able to absorb dietary
vitamin D well, whether it is from food or from supplements.
If your refugee patients are at risk of deficiency or
symptomatic, consider vitamin D testing.
For individuals who are vitamin D deficient and for breastfed
infants, a daily dietary supplement is recommended.
Outreach Update: English Language Learners Health Curriculum
Free, downloadable health lessons for intermediate to
advanced adult English language (ELL) learners are now
available at http://www.health.state.mn.us/divs/idepc/
refugee/ell/index.html.
English language classrooms are a good place to reach
refugees and immigrants with health information.
The MDH Refugee and International Health Program
(RIHP) partnered with ELL instructors and a curriculum
specialist to develop the lessons. The curriculum puts
health information in the hands of ELL instructors, who
can integrate it into their classrooms rather than relying
on outside presenters. The curriculum is also a tool for
organizations serving populations with limited English
proficiency.
new information and planned to share their new knowledge
with family and friends.
Next steps for the curriculum include developing and
piloting a lesson on mental health and enhancing the online
format for the lessons. If you use the curriculum, please let us
know by emailing Ann Linde at [email protected]. We
also welcome feedback and questions on the curriculum.
We recruited health experts from around MDH and
the community to provide and review content for nine
modules: health professions, the U.S. health system,
cardiovascular health, tuberculosis, oral health, diabetes,
cancer, and hepatitis B. The curriculum specialist created
lesson plans for each module, including vocabulary,
reading, writing, conversation and other interactive
activities. Each lesson includes teacher notes, a quiz for
pre- and post-assessment, and a student survey.
ELL instructors at five sites piloted the curriculum
in spring 2014 to collect survey feedback. Teachers
indicated that the lessons were appropriate and
engaging for their students. Students reported a high
level of interest in the lessons and said that they learned
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Refugee Health Data: Secondary Refugee Notifications in 2014
Secondary refugees initially settle in a different state
but soon migrate to live in Minnesota. This migration
can occur within days, weeks, months or even years of a
refugee’s arrival to the United States. Currently, the MDH
Refugee Health Program (RHP) does not have a systematic way of capturing all secondary migration data.
To identify secondary refugees who may qualify for a domestic refugee health assessment, we began an initiative
to request that local public health (LPH) agencies notify
us of secondary refugees residing in their jurisdictions.
Since 2010, the number of LPH jurisdictions reporting
secondary refugee arrivals has increased, and has also
grown to include other organizations that serve refugees.
307 (37 percent) were screened in their primary state prior to
moving to Minnesota. An additional 40 (5 percent) completed
screening their primary state, but needed additional follow-up
for latent tuberculosis infection.
If you have any questions, please contact Kailey Nelson at
[email protected].
In 2011, we were notified of 252 secondary refugees to
Minnesota. This grew to 312 notifications in 2012, 565
in 2013, and 841 in 2014. The 2014 secondary refugee
notifications came from LPH jurisdictions across Minnesota, refugee resettlement agencies, clinics, a transitional
shelter, and the primary states of arrival.
Among 2014 secondary refugee arrival notifications, the
median time between U.S. arrival and notification of their
migration to Minnesota was 3.5 months (range: 6 days-4
years). These secondary refugees resided in 14 counties
(see Figure 1). The majority (94 percent) were Somali,
with smaller numbers from Iraq (3 percent), Burma (2
percent), and other countries (2 percent).
Figure 1. Secondary Refugee Arrival Notifications to the
Minnesota Refugee Health Program, 2014
Local Public Health Spotlight: Rachele King
In late January, Rachele King became the new State
Refugee Coordinator at the Minnesota Department of
Human Services. Her experience working with refugees
in Minnesota spans nearly 20 years, starting in case
management and outreach with Lutheran Social Services
(LSS) and includes pivotal times such as when the U.S.
began allowing HIV-positive refugees to resettle. After LSS,
she continued her leadership in refugee resettlement at
the Minnesota Council of Churches. Rachele has enjoyed
both working face-to-face with refugee families, and
the challenges in addressing macro-level issues such as
systemic barriers to services for refugees. Rachele sees
her new position as State Refugee Coordinator as an
opportunity to expand upon her work.
Rachele feels Minnesota excels in serving refugees as a
result of our welcoming, engaged community. Strong
cross-sector partnerships and participation of communitybased organizations has created a network of support
for refugees. She feels another strength of Minnesota
refugee resettlement is that we recognize the barriers
that exist and ways in which we can improve serving
refugees. Although there is effective collaboration across
the resettlement process, we need to work on sharing
uniform messaging and streamlining the continuum of
care. Enhancing partnerships and networks in all areas of the
community will help us attain the end goals we all share.
Rachele discussed emerging challenges in refugee
resettlement in Minnesota. These challenges include:
• A greater number of refugees needing significant medical
care
• Availability of affordable housing for refugees
• Secondary refugee migration into Minnesota
• Refugee migration to Greater Minnesota where there
may be less access to services or less resources for groups
serving refugees
• Finding ways to support young adult refugees who need
help accessing education, careers, and work-training
Addressing each of these challenges strains resources and
is limited by funding. However, Rachele is confident that by
working collaboratively across all sectors, these challenges can
be managed. It takes an entire community to help refugees.
As State Refugee Coordinator, Rachele would like people to feel
comfortable reaching out to her office for help or resources.
Contact Rachele King at [email protected].
Fun fact about Rachele: She loves scuba diving and the sense
of calm it brings. Once she had a small octopus stuck to her
face mask. It wasn’t quite as calming that time.
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