[Emerging Infectious Diseases]                                                         
[Volume 4 No. 3 / July - September 1998]

Special Issue

Immigrant and Refugee Health

Susan Cookson,* Ronald Waldman,* Brian Gushulak,† Douglas MacPherson,‡
Frederick Burkle, Jr.,§ Christophe Paquet,¶ Erich Kliewer,# and Patricia
Walker**
*Centers for Disease Control and Prevention, Atlanta, Georgia, USA; †The
International Organization for Migration, Geneva, Switzerland; ‡St.
Joseph's Hospital, Hamilton, Ontario, Canada; §University of Hawaii,
Honolulu, Hawaii, USA; ¶Epicentre, Paris, France; #Manitoba Cancer
Treatment and Research Foundation, Winnipeg, Manitoba, Canada; and
**Regions Hospital, St. Paul, Minnesota, USA

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Each year, more than 15 million people seek political asylum or become
refugees in various parts of the world. Most of these displaced persons are
from developing countries where infectious diseases (e.g., tuberculosis,
hepatitis, malaria, various parasitic and emerging diseases) are prevalent.
These persons migrate mainly to the United States, Australia, and Canada,
nations that receive inflows of migrants proportional to their mainstream
population.

Because of the speed and efficiency of modern transportation systems,
health interventions applicable to all persons who cross international
borders are difficult to introduce and monitor. Identifying and addressing
individual and public health risks necessitate international and quarantine
health legislation, health policy and social economic evaluation,
risk-benefit and utility analysis, and risk-predictive modeling.
Ultimately, improving the health of migrants is at the heart of reducing
the public health risk to the international community from infectious
disease spread by travel.

Medical intelligence systems that can survey, detect, and confirm the
emergence of new infectious diseases are still in their infancy. The global
ability to generate numerators (cases of existing and emerging infectious
disease) has been limited to the relatively few diseases listed in the old
World Health Organization (WHO) International Health Regulations (yellow
fever, plague, cholera, smallpox); further limitations stem from poor
detection systems and incomplete reports (with the exception of smallpox).
The dynamic problem of defining numerators and denominators (displaced
persons at risk) is compounded by the need for improved diagnostics,
heightened recognition, and effective medical interventions for the
causative agents of diseases that affect these vulnerable populations.

Migrant populations have been displaced by disasters (natural, technologic,
and human), which test the public health resources of a nation and expose
weaknesses. Public health workers increasingly appreciate the fragile
interaction between individual host, environment, and infectious and
noninfectious agents capable of producing disease. The consequences of
these relationships, including the real and potential vulnerability of
populations, are becoming increasingly important indicators of national
security.

Cholera, a disease that affects migrant populations, was examined. In
Malawi, 11 outbreaks were documented in Mozambican refugees between 1987
and 1991, with attack rates of 0.6% to 9.3%. In 1994, an estimated 60,000
cases of cholera and 10,000 deaths occurred during a 1-month massive
epidemic among Rwandan refugees (population 800,000) in Goma, Democratic
Republic of Congo. Epidemic preparedness during the 1996 return of the
epidemic proved the cornerstone of cholera control in these refugees.
Properly implemented, active case-finding and rehydration therapy in
specialized treatment centers can keep the case-fatality ratio below 1%.

In Australia, use of hospital and medical services by immigrants and
refugees was examined. Foreign-born persons had lower hospitalization rates
than native Australians, although some immigrant groups had higher rates
for some diagnoses. Hospital data may help define trends in immigrant
disease profiles; the data, however, do not indicate whether the generally
lower hospitalization rates among immigrants were due to better health
status or to barriers in accessing the medical system. In the United
States, Minnesota has been a leader in refugee resettlement since 1979; one
center for international health has established a unique multidisciplinary
primary and specialty care program for refugees and immigrants. Hmong,
Cambodian, Vietnamese, Russian, Ukrainian, African, and Latin American
refugees and immigrants have been seen; diseases such as hepatitis B,
tuberculosis, and parasitic diseases, as well as mental health problems,
have been diagnosed; and prevention strategies or therapies have been
implemented.

Successful integration of migrant populations into their new communities'
health-care systems is critical to the prevention and control of new and
reemerging infectious diseases.


Emerging Infectious Diseases
National Center for Infectious Diseases
Centers for Disease Control and Prevention
Atlanta, GA

URL: ftp://ftp.cdc.gov/pub/EID/vol4no3/ascii/cook.txt

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