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The Centers for Disease Control and Prevention (CDC) is currently reviewing and updating the national guidelines for domestic refugee health assessments (RHAs). Clinicians with the Minnesota Center of Excellence in Refugee Health, along with other subject matter experts, are reviewing each guideline. The following guidelines have been finalized and published on CDC: Refugee Health Guidelines to date: tuberculosis (TB), intestinal parasites, immunizations, malaria, and lead. All national guideline updates will be completed by the end of 2020.
As these national guidelines are released, the MDH RIHP works to update our Minnesota guidelines for RHAs. The Minnesota guidelines are based on the national guidelines, with adaptations based on populations served in our state and resources at the state level.
Currently Minnesota clinical updates have been posted for TB and syphilis, which are briefly summarized below:
The TB update responds to these changes in the overseas screening procedure:
- Implementation of TB blood test (IGRA) instead of skin test (TST) for refugees ages 2-14
- MDH recommends repeating IGRA for any negative results. For positive IGRAs, providers should accept that result and move forward with the remainder of the TB diagnostic work-up.
- Creation of tuberculosis class of TB B0, for individuals who have been diagnosed with active tuberculosis and completed directly observed therapy (DOT) with a panel physician.
- MDH recommends assessing overseas records for adequate treatment, and assessing for recent exposure or current signs/symptoms. If this assessment does not lead to clinical concerns, no further TB screening is needed.
- Tuberculosis: Minnesota Refugee Health Provider Guide
The syphilis update responds to the changes in the CDC domestic screening guidelines. The Minnesota recommendation is for providers to re-screen for syphilis following their clinic protocol (traditional or inverse serology) and to follow best practices in terms of treatment. For patients who have a treatment history overseas, the Minnesota guidelines recommend assessing for adequate treatment and doing post-treatment serology at the correct time interval.
Pending the CDC timeline, we anticipate that the state guideline updates will be completed in 2020. Health care providers in Minnesota should follow these state-level guidelines for arrivals in Minnesota. The RIHP is also taking this opportunity to update the provider guide. The newly formatted guide will be more streamlined and web-based. In order to keep partners informed, RIHP will send email notifications when state or national guidelines are posted. Training activities highlighting any changes will be available once the guideline updates are completed.
In addition, CareRef is a valuable resource. This web-based tool allows health professionals to enter a few demographics of their patient and receive a customized list of the recommended screenings. CareRef is kept up-to-date with each guideline finalization, and it includes additional information, such as outbreak notifications.
Thank you all for your partnership, and please reach out to the RIHP team at refugeehealth@state.mn.us with any questions during this transition.
Immunizations are an important part of public health in Minnesota, including for new arrivals with refugee status. The refugee health assessment (RHA) includes assessing vaccination status and offering all immunizations appropriate for the patient based on Advisory Committee on Immunization Practices (ACIP) guidelines. From October to March, the influenza vaccine should be assessed for all arrivals age 6 months or older. Each year the “flu shot” averts significant illnesses, hospitalizations, and deaths. Visit CDC: Estimated Influenza Illnesses, Medical visits, and Hospitalizations Averted by Vaccination for more information.
While overseas immunizations have become more robust in recent years, influenza vaccine coverage continues to rely on domestic providers. The influenza vaccine is available in two different formulations each year: northern hemisphere and southern hemisphere. Select departure countries in South and Southeast Asia [MB(2] give refugees influenza vaccination with the southern hemisphere formulation. Providers should appropriately re-vaccinate new arrivals with domestic (northern hemisphere) vaccination upon arrival in Minnesota. If a child is 6 months to 9 years of age and previously received two doses of southern hemisphere influenza vaccine, they only need one dose of the northern hemisphere formulation. If they did not, they will need two doses of the current formulation.
We collaborated with the Minnesota Immunization Program to assess influenza vaccine coverage for new arrivals during the last two seasons. From October 2017 through March 2018, 430 primary refugees received an RHA in Minnesota. Of those, 259 (60%) received the influenza vaccine in the U.S. during the 2017-2018 flu season. Similarly, among the 254 primary refugees who received an RHA from October 2018 through March 2019, 139 (55%) received a flu vaccine during the 2018-2019 flu season. Many of these new arrivals received the flu vaccine during the RHA; however, some received the flu vaccine at another medical appointment.
The rates of vaccination for flu during the 2017-2018 and 2018-2019 seasons were higher among refugees than among Minnesotans overall. CDC estimated that 48% of Minnesotans 6 months and older received the flu vaccine during the 2017-2018 season, compared to 60% of refugees. An estimated 53% of eligible Minnesotans received the flu vaccine during the 2018-2019 season, compared to 55% of refugees. Among refugee arrivals who did not receive the flu vaccine in the U.S., 48% during the 2017-2018 season and 59% during the 2018-2019 season had received the southern hemisphere formulation of the vaccine overseas. Providers in Minnesota may have been unaware that these individuals needed re-vaccination in the U.S.
According to our most recent surveillance data, flu is currently widespread in Minnesota. It is important to give the flu shot to newly arrived refugees regardless of their overseas flu vaccination history, to protect them against this illness.
Number of Primary Refugees Vaccinated for Influenza
 *October through March
**Received RHA during flu season and received flu vaccine at some point during flu season. Data obtained from Minnesota Immunization Information Connection (MIIC).
***Estimates obtained from CDC: FluVaxView.
****82 (48%) of the 171 not given flu vaccine in the U.S. were given flu vaccine overseas. Due to formulation differences, refugees who received flu vaccine overseas should be re-vaccinated for flu in the U.S.
*****68 (59%) of the 115 not given flu vaccine in the U.S. were given flu vaccine overseas. Due to formulation differences, refugees who received flu vaccine overseas should be re-vaccinated for flu in the U.S.
The International Institute of Minnesota (IIMN) recently marked an incredible milestone: 100 years of welcoming new Americans to Minnesota and helping them prepare to contribute to our vibrant communities and economy.
The Institute’s refugee resettlement program works with MDH and local public health to ensure health screening and linkage to care for newly arriving refugees, as well as extended case management services for arrivals with medical needs. The Institute has also partnered with MDH to develop and implement health orientation/education materials and best practices. Their work as an agency reflects our shared mission to promote and enhance the health and well-being of refugees, and goes beyond that for the other diverse communities they serve.
The Institute began as a branch of the YWCA of St. Paul to serve immigrant women and their families after World War I. In 1938 it became an independent agency. Since 1974, the Institute has resettled nearly 25,000 refugees; currently it serves approximately 4,000 individuals each year through its various programs.
Executive Director Jane Graupman said, “Our work isn’t just about empowering New Minnesotans, it’s ultimately about empowering Minnesota as a whole. Over the past 100 years, each wave of New Minnesotans has contributed to Minnesota’s success, so when we help immigrants and refugees succeed, we’re really helping all of Minnesota succeed.”
The “Unity without Uniformity” exhibit on display at the University of Minnesota’s Andersen Library poignantly describes the focus of the International Institute’s mission and work. Here’s a sampling of titles from the various sections of the exhibit: “The Land of Lakes Welcomes the Nation of Poets,” “Rejecting the Melting Pot,” “A Pattern for a Peaceful Way of Life: The Festival of Nations in Wartime,” “Displaced by Prejudice: Japanese Americans Find Home in Minnesota,” and “All Are Welcome in Minnesota.”
As the Institute moves into its second century, it is expanding its facility just south of the Minnesota State Fairgrounds to meet the growing demand for its career pathways, language courses, and other services. To learn more about the Institute, its history, and its plans for the future, visit IIMN: History and IIMN: 100 Years & Growing.
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