medical screening of haitian orphans: parent survey, 2010 heather burke immigrant, refugee, and...
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Medical Screening of Haitian Orphans: Parent Survey, 2010
Heather Burke
Immigrant, Refugee, and Migrant Health Branch
Division of Global Migration and Quarantine
The authors have no financial relationships to disclose
Haiti Earthquake, January 2010
https://www.cia.gov/library/publications/the-world-factbook/geos/ha.html
• >200,000 deaths• 1.2 million displaced• Nation with serious
health concerns• Thousands orphaned
Estimates from www.usaid.gov and www.unicef.org https://www.cia.gov/library/publications/the-world-factbook/geos/ha.html
Adoption Medical Screening
• U.S. immigrants required to undergo medical screening
– Inadmissible infectious conditions (e.g., TB, syphilis)– Mental health issues (involving harmful behavior)– Immunizations—waived for some intl adoptees
• Performed by panel physicians overseas
Haiti Humanitarian Parole Policy
• Policy announced by DHS, Jan 18 2010
• Certain Haitian orphans allowed to enter U.S. – Category 1: in process of adoption before 12 Jan– Category 2: eligible and matched before 12 Jan
• 1,150 arrivals• All allowed to bypass overseas screening
CDC Screening Recommendations
• Recommendations urgently developed– AAP Red Book adoptee recommendations– Haiti-specific health information– CDC expert input
CDC Screening Recommendations
• Short time frame (posted Feb 1)• Process unprecedented• Dissemination of guidelines
– AAP – USCIS– JCICS– HHS partners (ORR)
Specific CDC Recommendations
• History (trauma, known TB or HIV)• Physical exam (trauma, congenital, nutrition)• Screening for infectious diseases
– HIV– Intestinal parasites– Malaria (if symptomatic)– Syphilis (congenital)– Tuberculosis– Vaccine-preventable diseases (hepatitis B)
Highlights: TB and Syphilis
• Tuberculosis– Haiti incidence ~ x 100 U.S.– Orphans with negative initial—repeat in 6 mos
• Congenital syphilis– AAP recommends screening of all internationally
adopted– Disease of concern in Haiti
Objectives
• Knowledge/implementation of CDC screening recommendations
• Health conditions identified
• Where adoptive parents of orphans accessed medical care
Methods
• Parent survey, Apr 23 – Aug 4, 2010– Web-based (SurveyMonkey®)– JCICS– USCIS listserv
• Provider survey, Apr 30 – Aug 1, 2010– Web-based (SurveyMonkey®)– Link distributed via AAP listserv– Link sent to parents
Methods
• Parent survey, Apr 23 – Aug 4, 2010– Web-based (SurveyMonkey®)– JCICS– USCIS listserv
• Provider survey, Apr 30 – Aug 1, 2010– Web-based (SurveyMonkey®)– Link distributed via AAP listserv– Link sent to parents
Parent Survey
• 15 questions• Demographics • Medical evaluation/diagnoses• Awareness of CDC recommendations• One survey per Haitian orphan
• Frequencies
Results
• 383 surveys
– Median age (range) = 5 yrs (1–18)
– From 42 states
– Top 3 states for respondents: CO (10%); FL (7%); MI (6%)
Illness upon Arrival
0
20
40
60
80
100
No illness/notreported
One symptom ≥2 symptoms
%n=108
n=202
n=73
Illness upon Arrival
0
20
40
60
80
100
No illness/notreported
One symptom ≥2 symptoms
%n=108
n=202
n=73
N=275 (72%)
Illness upon Arrival
0
20
40
60
80
100
No illness/notreported
One symptom ≥2 symptoms
%n=108
n=202
n=73
Signs & Symptoms upon Arrival
%
Diarrhea Weight loss/low weight
Cough Rash/skin Fever Injury Other 0
20
40
60
80
100
Signs & Symptoms upon Arrival
%
Diarrhea Weight loss/low weight
Cough Rash/skin Fever Injury Other 0
20
40
60
80
100
URI
Ear/eye infections
Wheezing
Minor surgical
383 children
383 children
375 (98%) children
received med eval
8 (2%) children
no med eval
383 children
375 (98%) children
received med eval
8 (2%) children
no med eval
Child not covered by parents’ insurance (n=4)
Didn’t know eval needed (n=3)
Didn’t know where to take child for eval (n=1)
383 children
375 (98%) children
received med eval
8 (2%) children
no med eval
Private doc 265 (72%) Fed/state clinic 42 (11%)
Adoption clinic / specialist 25 (7%)
Others (10%)—
Hospital/ER (4%)
Refugee/immigrant health provider (2%)
Other specialist (1%)
Type of Medical Provider by State
No
. orp
ha
ns
0
10
20
30
40
50
CO FL MI NY KS WI CA OH WA PA TX
Private Local/state/fed Adoption Other None
Type of Medical Provider by State
No
. orp
ha
ns
0
10
20
30
40
50
CO FL MI NY KS WI CA OH WA PA TX
Private Local/state/fed Adoption Other None
Type of Medical Provider by State
No
. orp
ha
ns
0
10
20
30
40
50
CO FL MI NY KS WI CA OH WA PA TX
Private Local/state/fed Adoption Other None
• Median (range) days to eval = 6 (0-84)
– Child ill on arrival: 5 (0-60)
– Child not ill on arrival: 10 (0-84)
– p value <0.001
Time to Medical Evaluation
Awareness of CDC Recs
38%
23%
11%
4%
2%
22%
USCIS
Adoption agency
Other
CDC website
Combination
Not aware of recs
Medical Evaluation: Screening
0 20 40 60 80 100
Any TB test
Stool specimen
HIV test
Vaccine titers
Congenital Syphilis test
Malaria test
Other test/s
%
n=296
281
263
159
132
128
50
Screening by Clinic Type
0
20
40
60
80
100
Private (n=265) State (n=40) Adoption (n=23)
TB
Stool
HIV
Syphilis
%
Medical Evaluation: Treatment
0 20 40 60
Intestinal parasitesDiarrhea
Respiratory infectionsSkin
TB
PsychologicalInjury
MalariaSyphilis
Other
%
n=200
136
90
69
29
20
10
6
3
34
Treated Conditions by Age Group
0
20
40
60
80
<5 yo (n=188)
≥5 yo (n=186)
%
Medical Evaluation: Immunizations
68, 18%
179, 46%136, 36%
Immunized in Haiti Immunized in the U.S.
25, 7%
272, 71%
86, 22%
yes no Unknown/blank
Not Immunized (n=86): Reasons
11, 13%
12, 14%
20, 23%
36, 42%
5, 6% 2, 2% Child sick
Vaccine notindicated
Vaccine not available
Parent opposed tovaccination
Child did not receivemedical eval
Blank
Providers: Screening (N=23 Providers)
23 22 22 22 21 20 18 1511
6 8
0
10
20
30
No
. P
rovi
der
s
Providers: Diagnoses (N=39 Orphans)
0
20
40
% O
rph
an
s
Summary
• 98% children received medical evals in U.S.– Time from arrival to exam variable– Most seen by private medical provider
• Most (parents of 78%) aware of CDC recs
• Most (88%) received ≥1 recommended test– Minority reported syphilis test
• Diarrhea and parasites most common; injury uncommon
Limitations
• Data self-reported (recall bias)
• Not complemented by provider data
• Responses for ~1/3 of orphans
• Cannot determine if multiple children per parent
Discussion
• Target multiple adoption partners for dissemination of recommendations (adoption agencies, USCIS, medical providers)
• Strategy for reaching medical providers in time-sensitive situations– Sharing of recommendations– Feedback
Acknowledgements
• Parents and providers who took the surveys!• AAP, JCICS, USCIS and other partners
Thank You
Heather Burke
http://www.cdc.gov/immigrantrefugeehealth/adoption/index.html
Questions
• How can guidelines be disseminated effectively?
• How can information be obtained from providers?
• What issues were facing providers relating to guidelines/arrival of Haitian orphans?
Extra Slides
Category 1 orphans
Children who have been legally confirmed as orphans eligible for intercountry adoption by the Government of Haiti, were in the process of being adopted by Americans prior to Jan. 12, 2010 and meet the below criteria.Required CriteriaEvidence of availability for adoption, which MUST include at least one of the following:
Full and final Haitian adoption decree Government of Haiti Custody grant to prospective adoptive parents for emigration and adoption Secondary evidence in lieu of the above.Evidence of suitability for adoption, which MUST include at least one of the following: Notice of Approval of Form I-600A, Application for Advance Processing of an Orphan Petition Current FBI Fingerprints and background security check clearances Physical custody in Haiti plus a security background check
Category 2 orphans Children who have been identified by an adoption service provider or facilitator as eligible for
intercountry adoption, were matched to prospective American adoptive parents prior to Jan. 12, 2010 and meet the below criteria.
• Required Criteria• Significant evidence of a relationship between the prospective adoptive parents and the child AND
of the parents’ intention to complete the adoption, which could include the following: – Proof of travel by the prospective adoptive parents to Haiti to visit the child – Photos of the child and prospective adoptive parents together – An Adoption Service Provider “Acceptance of Referral” letter signed by the prospective
adoptive parents – Documentary evidence that the prospective adoptive parents initiated the adoption process
prior to Jan. 12, 2010 with intent to adopt the child (filed Form I-600A, Application for Advance Processing of an Orphan Petition, and/or Form I-600, Petition to Classify an Orphan as an Immediate Relative, completed a home study, located an ASP to work with in Haiti, etc.)
• Evidence of the child’s availability for adoption, which could the following: – IBESR (Haitian Adoption Authority) approval – Documentation of legal relinquishment or award of custody to the Haitian orphanage – Secondary evidence in lieu of the above
• Evidence of suitability for adoption, which MUST include at least one of the following: – Notice of Approval of Form I-600A, Application for Advance Processing of an Orphan
Petition; OR – Current FBI Fingerprints and background security check clearances
Type of Provider Facility (n=30)
12
9
9
1
Private clinic
Adoption med clinic
Academic practice
Other