Refugee Health Quarterly
A Refugee Health update from the Minnesota Department of Health
Vol. 17
Oct. 2015
Greetings from the Refugee Health Program
This summer, the refugee crisis and heartbreaking
stories from Syria and other parts of the Middle East
have been front and center in our mind. This reminds us
how important it is to welcome all refugees through the
resettlement process after they’ve endured unimaginable
living conditions. Only 0.005 percent of the world’s 14.4
million registered refugees get resettled during a given
year; most of these refugees are children and women. We
do not know how many Syrian refugees will be coming
to Minnesota in the coming years. No matter, as our
data highlights, we’ll continue to see a diverse group of
refugees in the coming year and our efforts to improve
health for all refugees that come to Minnesota will
continue.
We have many exciting updates to share! In September,
the Refugee Health Program, along with its principal
partners at the University of Minnesota, HealthPartners,
and the Philadelphia Refugee Health Collaborative,
received the CDC’s Center of Excellence award. The work
will focus on multi-state surveillance of chronic and
infectious diseases among refugees, help develop clinical
guidelines relevant for the refugee populations settling
in the U.S, and disseminate best practices. Partners will
be meeting in Atlanta in mid-November to discuss the
implementation of proposed activities.
In collaboration with the
No one puts their
University of Minnesota, the
children in a boat
Refugee and International
unless the water is
Health Program also received
safer than land.
a grant from the CDC to
conduct a five-year study
-Excerpt from “home”
on malaria disease among
by Warsan Shire
people visiting friends and
relatives (VFR) in West and
Central Africa. The team will be working with partners across
the nation, including Albert Einstein College of Medicine
in New York, the Uniformed Services University of the
Health Sciences in Maryland, and locally, HealthPartners
and Hennepin County Medical Center. The main goal of the
project is to identify barriers in VFR communities that lead to
increased risk of malaria acquisition during travel; to generate
and test replicable targeted interventions focused on the
community, community healthcare system, and healthcare
provider; and to ultimately reduce the number of malaria
cases in the U.S. This year, the project will focus on engaging
key communities to construct and disseminate culturally
sensitive surveys about knowledge, attitudes, and practices
in order to inform future interventions.
Lastly, our team has started planning for the annual LPH/
VOLAG forum, to be held in Thursday, January 28, 2016. Save
the date!
Diverse Media Project
The Diverse Media Project is a collaborative project
between refugee health, immunization, and
communications staff at MDH. Advertisements on an
array of immunization topics are placed in diverse
community newspapers, websites, and radio shows.
These advertisements are also translated into other
languages. The October 2015 advertisements featured
messages about the importance of flu vaccine for high
risk individuals (shown at right). This project will continue
into 2016.
Top: October ad translated into Somali.
Bottom: October ad translated into Amharic.
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: Managing Diabetes in Refugees
Since 2010, 87 newly arriving refugees in Minnesota have had
a diabetes mellitus diagnosis pre-arrival. While they come from
a variety of countries, approximately half (48%) have been
Somali (Table 1). Diabetes has no single presentation among
newly arriving refugees; some may have mild cases of type 2
diabetes with no medication and random blood glucose (RBG)
within normal limits, while others may have serious and poorly
controlled disease. The overseas medical screening process
does not generally include diabetes screening. Providers may
diagnose new cases of type 2 diabetes through the screening
and referral process here in Minnesota.
Health care providers should consider these factors to
effectively manage diabetes among recently arrived refugees:
• Assessment for severity
• For patients with known diabetes, providers often
choose to include an HbA1c in the screening lab work.
Some providers are able to add on HbA1c as a standing
order if a refugee presents with an elevated RBG value.
• Many clinics have found it helpful to have an established
protocol for assessing diabetes and other chronic
conditions, including workflow for initial patient
education and an expedited referral process when
appropriate.
• Patient education
• As with all patients, clear, relevant, and respectful
education is the most effective.
• Even patients who were first diagnosed years ago may
not have a basic understanding of how diabetes impacts
their bodies.
• Watch for any potential barriers to education and work
with your patient to overcome them (e.g. literacy/health
Year of US
Arrival
2010
2011
2012
2013
2014
Jan – Sep 2015
Total
literacy, language barriers, learning disabilities, trauma/
traumatic brain Injury).
• For education materials, please see Ethnomed Diabetes
Patient Education Materials (http://ethnomed.org/patienteducation/diabetes/Latino%20DM%20Slideshow_081015.
pdf ). Keep in mind that not all patients are literate even in
their primary languages.
• Dietary considerations
• During resettlement, diets can sometimes change
dramatically, impacting diabetes management and overall
health.
• Discuss healthy eating with all patients, including concrete
advice (e.g. “look for sugar on food labels” may be confusing;
give examples or specific recommendations based on the
patient’s food preferences).
• For patients who might observe religious fasts including
Ramadan, discuss the importance of healthy living during
fasting times; patients with chronic conditions including
diabetes should not fast.
• Blood glucose testing issues
• It is important to explain the need for blood sugar testing.
Even long-term insulin-dependent diabetics may not test
their blood sugars and sometimes calculate insulin dosage
based on how their body feels.
• All patients should be reminded NOT to share single-patient
blood glucometers, due to the risk of transferring blood
borne pathogens.
• Patients may need help in obtaining testing supplies and
glucometer.
• Practices in diabetes management overseas may not be in sync
with US best practices.
Table 1. Age and country of origin for primary refugee arrivals to Minnesota with
a diabetes diagnosis included in overseas paperwork
No. of
Average Age at
No. with
Primary
Country of Origin (%)
US arrival,
Diabetes * (%)
Refugee
years (Range)
Arrivals
2,321
6 (<1%)
42 (34-49)
Somalia (50%); Iraq (33%); Ethiopia (17%)
1,891
6 (<1%)
49 (27-81)
Somalia (50%); Burma (33%); Laos/Hmong (17%)
2,259
18 (1%)
55 (43-71)
Somalia (39%); Burma (22%); Bhutan (11%); Iraq
(11%); Iran (6%); Moldova (6%); Sudan (6%)
2,141
18 (1%)
50 (14-77)
Somalia (28%); Iraq (22%); Bhutan (17%); Burma
(17%); Ethiopia (11%); Sudan (6%)
2,475
23 (1%)
48 (13-86)
Somalia (57%); Burma (22%); Iraq (17%); Bhutan (4%)
45 (24-75)
Somalia (75%); Burma (13%); Iraq (13%); Ukraine
1,571
16 (1%)
(4%)
12,658
87 (1%)
49 (13-81)
Somalia (48%); Burma (18%); Iraq (16%); Bhutan
(7%); Ethiopia (3%); Sudan (2%); Iran (1%);
Laos/Hmong (1%); Moldova (1%); Ukraine (1%)
*Listed as “Class B Other” on overseas medical paperwork
Data extracted from the CDC Electronic Disease Notification system may be incomplete.
Table 2. Random Blood Glucose values for refugees with pre-arrival diagnosis of diabetes in the
Complex Medical Case Program at Refugee Health Assessment (RHA), January 2012- September 2015
Median Random
Median Random
Median Random
Blood Glucose
No. of with
No. on Medication
Blood Glucose
Glucose Value,
Country of Origin
No. RHA* (%)
Value,
Diabetes
upon US Arrival (%)
Value, mg/dL
Not on Medication,
on Medication,
(Range)
mg/dL (Range)
mg/dL (Range)
21 (75%)
158 (82-353)
180 (82-353)
97 (97-98)
Somalia
28
25 (89%)
Burma
12
11 (92%)
12 (100%)
187 (63-468)
187 (63-468)
71 (n/a)
Iraq
9
9 (100%)
9 (100%)
125 (89-524)
125 (89-524)
n/a
Bhutan
7
5 (71%)
6 (86%)
205 (87-359)
242 (134-359)
148 (87-208)
Other**
8
8 (100%)
8 (100%)
239 (107-492)
239 (107-492)
n/a
Total
64
58 (91%)
56 (88%)
186 (63-524)
188 (63-524)
98 (71-208)
*RHA generally initiated within 90 days of US Arrival; 2015 results are pending (eSHARE data)
**Includes Ethiopia, Iran, Moldova, Sudan, and Ukraine
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Refugee Health Data Update
Minnesota resettled 2,475 primary refugee arrivals in
2014. Among these, 2,428 were eligible for a post-arrival
Refugee Health Assessment (RHA), typically started
within 90 days of U.S. arrival, and 2,420 (>99 percent)
received a RHA. The RHA includes a health history and
physical examination; immunization assessment and
update; screening for infectious diseases; lead screening
for children under 17 years; and assessment and referral
for health problems including dental, vision and mental
health. Demographics, screening rates, and health
summaries for 2014 primary and secondary refugee
arrivals is available at our Refugee Health Statistics (www.
health.state.mn.us/refugee/stats) page.
From January to June 2015, 990 primary refugees arrived
to Minnesota. The majority of arrivals were Somali (48
percent) and Burmese (31 percent) (Figure 1). Fortynine percent resettled in Ramsey County, 21 percent in
Hennepin County, 11 percent in Stearns County, and
the remaining 19 percent established their home in 16
other counties across the state (Figure 2). During this
time period, the RIH program also received notification of
581 secondary refugee arrivals, an increase of 56 percent
compared to the same time period in 2014. The majority
of secondary arrivals were Somali (91 percent).
If you have any questions, please contact Kailey Urban at
[email protected].
Figure 1. Country of Origin of Primary Refugee
Arrivals to Minnesota, January – June 2015
Kittson
2014 Primary Refugee Arrival To
Minnesota (N=2,475)
Lake
of the
Woods
Roseau
Koochiching
Marshall
St. Louis
Beltrami
Pennington
Polk
Cook
Clear
Water
Red Lake
Lake
Itasca
Mahnomen
Norman
Hubbard
Cass
Becker
Clay
Aitkin
Wadena
Crow Wing
Number of Refugees Arrival By
Initial County Of Resettlement
Carlton
Otter Tail
Wilkin
Pine
Todd
Mille
Lacs
Grant
Douglas
Stevens
Pope
Kanabec
0
Morrison
Benton
Traverse
Stearns
1- 10
Isanti
Big Stone
Sherburne
Swift
11 - 30
Chisago
Kandiyohi
Anoka
Meeker
71
Wright
Chippewa
Hennepin
Hennepin
Lac Qui Parle
McLeod
Renville
31 - 100
WashingRam-ton
sey
101 - 250
Carver
Scott
Yellow Medicine
251 – 500
Dakota
Sibley
Lincoln
Lyon
Redwood
Le
Sueur
Nicollet
Rice
501 – 1,500
Goodhue
Wabasha
Brown
Pipestone
Murray
Rock
Nobles
Watonwan
Blue Earth
Waseca
Steele
Dodge
Olmsted
Winona
Cottonwood
Jackson
Martin
Faribault
Freeborn
Mower
Fillmore
Houston
Figure 2. County of Resettlement of Primary Refugee
Arrivals to Minnesota, January – June 2015.
Outreach Update: Syrian Refugees
As the worldwide population of refugees has reached a
high of nearly 60 million, the greatest numbers of refugees
and internally displaced people have come from Syria,
according to the United Nations. By the end of 2014, 7.6
million Syrian residents were displaced within the country,
and nearly 4 million had fled as refugees due to the civil
war that began in 2011.
The U.S. is a leading resettlement country, welcoming
more than half of the world’s refugees. Each year, the
President consults with Congress to determine how many
refugees to accept. In recent years, the U.S. has admitted
70,000-80,000 refugees annually. For fiscal year 2016,
which began October 1, President Obama has authorized
resettling 85,000 refugees, including 10,000 Syrian
refugees.
It is not known at this time how many Syrian refugees will
be resettled in Minnesota. Minnesota typically resettles
about 2,000-2,500 refugees each year, but where in the U.S.
a refugee resettles depends on factors such as the capacity
of communities to support incoming refugees (including
language capacity) and whether the refugee has any family
connections in the receiving location.
Minnesotans wishing to assist refugees arriving
in Minnesota may inquire or volunteer with
local resettlement agencies:
• Arrive Ministries
• Catholic Charities (St. Paul and Minneapolis)
• Catholic Charities (Winona)
• International Institute of MN
• Lutheran Social Services
• MN Council of Churches
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