Session 9:
"Where were you born and where have
you traveled?" Taking Care of Immigrant
Patients
Learning Objectives
1. Describe recent demographics features of immigrants in the United States.
2. List 2 important screening tests for immigrants.
3. Identify 2 diseases of long latency that may occur more frequently in
immigrants.
Session 9
"Where were you born and where have you traveled?" Taking Care of Immigrant Patients
Faculty
Elizabeth D. Barnett, MD
Professor of Pediatrics
Boston University School of Medicine,
Director, International Clinic
Boston Medical Center
Boston, Massachusetts
Dr Barnett currently serves as professor of pediatrics at Boston University School of Medicine. She attended medical
school after serving in the United States Peace Corps in Ghana for three years, and received her medical degree from
Boston University School of Medicine in 1985. Dr Barnett completed her residency in pediatrics at Boston City Hospital
(where she served as chief resident) and Children’s Hospital in Boston, Massachusetts, and a fellowship in pediatric
infectious disease at Boston City Hospital.
A fellow of the American Academy of Pediatrics, Dr Barnett is also a member of the Pediatric Infectious Diseases
Society, the Infectious Diseases Society of America, the International Society of Travel Medicine, and the American
Society of Tropical Medicine and Hygiene.
Dr Barnett has authored numerous articles and abstracts on a variety of subjects relating to pediatric infectious disease,
travel medicine, and immunization, and has been recognized with awards for both clinical excellence and teaching. She
has special interest in immigrant and refugee health, an area in which she is currently conducting research.
Faculty Financial Disclosure Statement
The presenting faculty reports the following:
Dr Barnett receives research support from Sanofi Pasteur and Intercell.
Objectives
Health Care for
Immigrant Patients
• Describe recent demographic features of
immigrants in the United States
• List 2 important screening tests for
immigrants
• Identify 2 diseases of long latency that
may occur more frequently in
immigrants
Elizabeth D. Barnett, MD
Pre-ARS: Which statement best describes the
immigrant population in the US today?
1. The number of immigrants is higher
than it has ever been.
2. The proportion of the US population
that is foreign born is higher than it has
ever been.
3. The age and sex distribution of foreign
born individuals is similar to that of the
US born population.
4. Hispanic immigrants are the fastest
growing group.
US Immigrant Arrivals 1997-2004
2010: 36.7 million (12%) of the
US population is foreign born; 33
million more (11%) have at least
one foreign born parent
Source: Maloney, S.A., Ortega, L.S., Cetron, M.S. (2007). Overseas Medical Screening for Immigrants
and Refugees. In P.F. Walker and E. D. Barnett (Ed.), Immigrant Medicine (pp.111-121). Elsevier.
1
US Refugee Admissions, 1998-2010
Immigrant Groups in the US, 2010
• 36% of all immigrants in 2010 were
Asian; a 10% increase since 2007
(and up from 1% of the population
in 1965)
• 31% of all immigrants in 2010 were
Hispanic; a 31% decrease from 2007
Age Distribution by Sex and Nativity: 2003
Post-ARS: Which statement best describes
the immigrant population in the US today?
(In Percent)
Foreign Born
Male
Native
Age
Female
Male
1. The number of immigrants is higher than it
has ever been.
2. The proportion of the US population that is
foreign born is higher than it has ever been.
3. The age and sex distribution of foreign born
individuals is similar to that of the US born
population.
4. Hispanic immigrants are the fastest growing
group.
Female
Source: Current Population Survey,
Annual Social and Economic Supplement, 2003
Health Care for Immigrants
Percentage of U.S.-Born and Foreign-Born Adults
Aged >18 Years Reporting Selected Health Risk
Factors and Conditions --- United States, 1998--2003
• Standard health care maintenance
and age-specific immunizations
PLUS
• Addressing changing health risks due
to resettlement
• Screening for conditions related to
country of birth and migration history
• Addressing diseases of long latency
Centers for Disease Control and Prevention. MMWR 2006;55:315.
2
Selected Risk Factors/Chronic Diseases Among Foreignborn Hispanic Adults, by Length of Stay:
United States, 1998-2003 (NHIS, 1998-2003)
Healthy Migrant Phenomenon
25
• “Immigrants, on a variety of measures,
are often healthier than native-born
residents in their new countries of
residence”*
• The migrant health advantage diminishes
over time
22
20
Percent
19.8
15
16.1
15.3
13.8
13.4
10
6.9 7.5
5
5.4
3.5
0
Obesity
*Fennelly K. Health and well-being of immigrants: the healthy migrant
phenomenon. Immigrant Medicine 2007:19-26.
Current Smoking
< 5 years
Maintaining the Healthy Migrant
Advantage
Diabetes
Hypertension
Cardiovascular diseases
> 5 years or more
Important Screening Tests for
Immigrants
• Recognize and affirm the strengths and
resilience of immigrant communities
• Dispel myths about health of the foreign-born
(cost, greater utilization of services)
• Pay attention to the ways in which poverty
reduces health and life chances
• Work to overcome barriers to care; help
develop sound and cost-effective policies and
measure outcomes
• Burden of disease is significant
• Risk is higher for many foreign-born
individuals
• Examples:
– Tuberculosis
– Hepatitis B
– HIV
Mohanty S et al. Health care expenditures of immigrants in the US.
Am J Public Health 2005;95:1431-8.
Trends in TB cases among US and
Foreign-born Persons, 1993-2011
Pre-ARS: Which of the following is a true
statement about tuberculosis in the US?
1. Most new cases of TB are in US born
individuals
2. Multidrug resistant TB is more common in
US born individuals
3. More than 80% of cases of TB in immigrants
occur in the first year after arrival
4. The number of states where more than 50%
of cases of TB are in foreign born individuals
is increasing
62% of cases in 2011
are in FB persons
3
Trends in TB Cases in Foreign-born
Persons
United States, 1990 – 2010*
No. of Cases
Percentage of TB Cases Among
Foreign-born Persons, United States*
2000
Percentage
2010
DC
*Updated as of July 21, 2011
DC
>50%
25%–49%
<25%
*Updated as of July 21, 2011
Primary MDR TB in
U.S.-born vs. Foreign-born Persons
United States, 1993 – 2010*
% Resistant
Percent of Foreign-born with TB by
Time of Residence in U.S. Prior to
Diagnosis, 2010
*Updated as of July 21, 2011
Note: Based on initial isolates from persons with no prior history of TB. MDR TB
defined as resistance to at least isoniazid and rifampin.
*Foreign-born TB patients for whom information on length of residence in the U.S. prior to diagnosis is
unknown or missing
Post-ARS: Which of the following is a true
statement about tuberculosis in the US?
TB in the US: 2011
1. Most new cases of TB are in US born
individuals.
2. Multidrug resistant TB is more common in
US born individuals
3. More than 80% of cases of TB in immigrants
occur in the first year after arrival
4. The number of states where more than 50%
of cases of TB are in foreign born individuals
is increasing
• 62.5% of cases (of those with known
country of birth) are in the foreign-born
• More TB cases in Asian individuals than
any other racial/ethnic group (29.9%)
• 95.4% of Asians with TB were foreignborn
• 7.9% of those with TB (of those who were
tested) were HIV infected
4
Tuberculin Skin Test Results in
Selected Immigrant Groups
Immigrant Group
Tuberculin Skin Test Results in
Selected Immigrant Groups
% TST +
Immigrant Group
% TST +
African immigrants, MN, 1997
52
Screen immigrants for
Refugees, US, 1993-95
43.2
tuberculosis regardless of time
African immigrants,
MN, 1997in the US
52
since arrival
Latino immigrants, CA, 1978-1983
53
Latino immigrants, CA, 1978-1983
53
Refugee children, MA, 1995-98
25
Refugee children, MA, 1995-98
25
Vietnamese immigrants, MA, 1994-5
70
Vietnamese immigrants, MA, 1994-5
70
Refugees/asylees, BMC, 1995-2006
51
Refugees/asylees, BMC, 1995-2006
51
Refugees, US, 1993-95
43.2
Pre-ARS: Tuberculosis Screening
Tuberculosis Testing: General Issues
A 25-year-old well-appearing man arrives wit
documentation of a negative chest radiograph in his
native Somalia. He has a BCG scar. Which is the
most appropriate next step with regard to tuberculosis
screening in this man?
1. No screening is needed (his CXR was negative).
2. A TB skin test (TST) is contraindicated (he
received BCG).
3. Either interferon gamma release assay (IGRA) or
tuberculin skin test would be appropriate for
screening.
4. IGRA testing is preferred.
• BCG is not a contraindication to TB testing
• Chest radiographs do not rule out latent TB
infection (LTBI) or extrapulmonary TB
• Neither tuberculin skin tests (TSTs) nor
blood tests distinguish LTBI from
tuberculosis disease; further evaluation is
required for anyone with a positive test
• Interferon Gamma Release Assays:
http://www.cdc.gov/tb/publications/factsheet
s/testing/IGRA.htm
Interferon Gamma Release Assays
(IGRAs)
TSTs vs. IGRAS
• Two are FDA-approved and commercially
available in the US:
– QuantiFERON-TB Gold In-Tube test (QFT-GIT)
– T-SPOT.TB test (T-Spot)
• Measure immune reactivity to M. tuberculosis
by measuring IFN-g concentration (QFT-GIT)
or number of IFN-g producing cells (T-Spot)
• Blood sample must be processed while WBCs
are still viable (8-30 hours)
TST
IGRA
• Requires 2 visits at
least 48 hours apart
• May have false
positives with BCG
• Preferred in children
<5 years of age
• Single visit; results
available in 24 hours
• Prior BCG does not
cause false positives
• Limited data for certain
groups (<5 years,
recently exposed,
immunocompromised)
Machingaidze S, et al. PIDJ 2011;30:694-700.
MMWR 2010;59(No.RR-5) http://www.cdc.gov/mmwr/pdf/rr/rr5905.pdf
5
Post-ARS: Tuberculosis Screening
Hepatitis B Infection Global Prevalence
A 25-year-old well-appearing man arrives with
documentation of a negative chest radiograph in
his native Somalia. He has a BCG scar. Which is
the most appropriate next step with regard to
tuberculosis screening in this man?
1. No screening is needed (his CXR was negative).
2. A TB skin test (TST) is contraindicated (he
received BCG).
3. Either interferon gamma release assay (IGRA) or
tuberculin skin test would be appropriate for
screening.
4. IGRA testing is preferred.
Incidence of Chronic Hepatitis B,
U.S. Acquired vs. Imported
Pre-ARS: Which of the following is
true about hepatitis B in the US?
1. Most new cases of hepatitis B are in US born
individuals
2. CDC recommends screening of immigrants
born in countries with >2% prevalence of
hepatitis B infection
3. Immigrants who have received hepatitis B
vaccine do not require screening for
hepatitis B infection
4. Liver cancer is more common in developed
countries
Cases per 100,000 pop.
25
Imported Rate
20
17.9/100,000
U.S. Rate
15
10
5
1.2/100,000
0
1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006
CDC Recommendations for Screening
of Immigrants for Hepatitis B
Common Cancers in Developed vs. Developing Countries
• All immigrants born in countries
with HBsAg prevalence >2% (or
other risks)
• All US-born individuals not
immunized at birth born to mothers
from countries with HBsAg
prevalence > 8%
Liver Cancer
MMWR 2008;57(RR-8)
6
Hepatitis B Infection, Selected
Immigrant Groups
Immigrant Group
Hepatitis B Infection, Selected
Immigrant Groups
% HBSAg +
Immigrant Group
Refugees, US, 1993-95
6.1
Refugees, US, 1993-95
African immigrants, MN, 1997
14
African immigrants, MN, 1997
Vietnamese immigrants, MA, 1994-5
14
Immigrant women, NY, 1984-85
5.9
% HBSAg +
6.1
14
Consider screening all immigrants
Vietnamese
immigrants,BMA,
1994-5 (unless
14
for hepatitis
infection
Immigrant women,
NY, 1984-85
5.9
immunized
at birth)
Refugee children, NY, 1991-93
7
Refugee children, NY, 1991-93
7
Refugees/asylees MA 1997-2009
4.3
Refugees/asylees MA 1997-2009
4.3
Refugees/asylees BMC 1995-2006
4.5
Refugees/asylees BMC 1995-2006
4.5
Pre-ARS: A 20-year-old college student has a
positive HBsAg with an elevated AST.
He had arrived from China at age 10 and was
given 3 doses of hepatitis B vaccine at that time.
Which of the following statements is correct:
Post-ARS: Which of the following is
true about hepatitis B in the US?
1. Most new cases of hepatitis B are in US born
individuals
2. CDC recommends screening of immigrants
born in countries with >2% prevalence of
hepatitis B infection
3. Immigrants who have received hepatitis B
vaccine do not require screening for
hepatitis B infection
4. Liver cancer is more common in developed
countries
1. He doesn’t need any other hepatitis vaccines as he is
already infected with hepatitis B
2. He should have an alfafetoprotein (AFP) checked
every five years
3. He should have a liver ultrasound every 6-12
months
4. He will not be at risk for hepatocellular carcinoma
unless he develops cirrhosis first
Hepatitis B Information for
Health Professionals
Hepatitis B Information for Patients
• http://www.cdc.gov/hepatitis/HBV/ProfReso
urcesB.htm
• Update hepatitis A vaccine status
• Patient education resources:
http://www.cdc.gov/hepatitis/HBV/Pati
entEduHBV.htm
– Screening and vaccination recommendations
– Interpretation of serologic results
• http://liver.stanford.edu/Media/publications/
Handbook/2012Handbook.pdf
–
–
–
–
– Testing, immunization
– Screening for liver cancer for those with chronic
infection: AFP every 6 months, ultrasound
every 6-12 months (can develop even without
cirrhosis)
7
Fact sheets
Population specific information
Vaccine information statements
Slide sets
Post-ARS: A 20-year-old college student has
a positive HBsAg with an elevated AST.
He had arrived from China at age 10 and was
given 3 doses of hepatitis B vaccine at that time.
Which of the following statements is correct:
HIV Testing and Immigrants
• HIV testing no longer required before
departure to US or for green card as of
January 4, 2010
• Rules about consent vary by state; be
familiar with what is required in your
state
• It is appropriate to address HIV testing
for all immigrants
1. He doesn’t need any other hepatitis vaccines
as he is already infected with hepatitis B
2. He should have an alfa fetoprotein (AFP)
checked every five years
3. He should have a liver ultrasound every 6-12
months
4. He will not be at risk for hepatocellular
carcinoma unless he develops cirrhosis first
Estimated Rates of New HIV
Infections, by Race/Ethnicity and
Gender, US, 2006
Barriers to HIV Testing in Immigrants
• Patients’ preconceived beliefs about testing
and treatment
• Concerns about confidentiality
• Fear of consequences of positive tests
• Lack of understanding by physicians and
patients about in pre-immigration testing
• Language and cultural barriers
No data presented
about country of
origin in this report
http://www.cdc.gov/hiv/topics/surveillance/resources/factsheets/MMWR-incidence.htm
Addressing Diseases of Long
Latency in Immigrants
HIV infection in MA and MN
• 18% of those living with HIV in MA at
the end of 2004 were foreign born (12%
of the general population is foreign born)
• 26% of those newly diagnosed, and 41%
of newly diagnosed females in MA in
2004 were foreign born
• 19% of newly reported HIV cases in MN
were in African-born (compared with 1%
African-born in MN general population)
• Strongyloides infection
– Parasitic infection that can be exacerbated
by steroid or other immunosuppressant use
– Treat presumptively or screen immigrants
who will need steroids or
immunosuppressive therapy
• Cervical cancer risk
• H pylori infection
8
Pre-ARS: Which of the following is true
about diseases of long latency in
immigrants?
Common Cancers in More and Less Developed Countries
1. Immigrant women are more likely to have
Pap smears than American born women.
2. Cervical cancer is more common in many
parts of the developing world than in the
US
3. H pylori infection is less common in
immigrants
4. Pap smears are not needed for immigrant
women
Cervical Cancer
Stomach Cancer
Cervical Cancer Rates Worldwide
Cervical Cancer Screening
(Cases per 100,000 population)
Proportion of women > 65 who had a Pap smear
in the preceding 3 years
Cambodian,
Lowell, MA
Vietnamese,
Southern CA
Asians,
National aggregate
US general
population
64.2%
65.5%
74.5%
85.8%
MMWR 2004;53:760-767
Schiffman and Castle. NEJM 2005;353:2101.
Health Disparities: H pylori
Post-ARS: Which of the following is true
about diseases of long latency in immigrants?
Prevalence of H pylori in Developed vs.
Developing Countries
1. Immigrant women are more likely to have
Pap smears than American born women.
2. Cervical cancer is more common in many
parts of the developing world than in the
US
3. H pylori infection is less common in
immigrants
4. Pap smears are not needed for immigrant
women
Logan: BMJ, Volume 323(7318).October 20, 2001.920-922
9
Summary of Key Points in the
Care of Immigrant Patients
Best Practices in Immigrant Medicine
• Assure access to care
• Provide care in the preferred language
• Develop clinical guidelines and best
practices for immigrant patients
• Diversify the work force
• Train health care providers and educate
immigrant patients
• Tailor health care messages to the patient
• Collect data about country of origin and
preferred language
• Screen for tuberculosis and hepatitis B
• Work to maintain the healthy migrant
advantage
• Be aware of the risk of diseases of long
latency over the life course of immigrants
Ohmans P. Action steps to improve the health of new Americans. In:
Immigrant Medicine, Walker and Barnett, eds. 2007.
Suggested Reading
Acknowledgements
• The Spirit Catches you and You Fall Down
By Anne Fadiman
• The Middle of Everywhere: The Worlds’
Refugees Come to Our Town by Mary Pipher
• A Long Way Gone: Memoirs of a Boy Soldier
by Ishmael Beah
• Cutting for Stone by Abraham Verghese
• The Latehomecomer by Kao Kalia Yang
• Immigrant Medicine Walker and Barnett
•
•
•
•
•
10
Patricia F. Walker
Jay Keystone
Martin Cetron
Tarissa Mitchell
Bill Stauffer