medical screening of haitian orphans: parent survey, 2010

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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

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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. - PowerPoint PPT Presentation

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Page 1: Medical Screening of Haitian Orphans:  Parent Survey, 2010

Medical Screening of Haitian Orphans: Parent Survey, 2010

Heather BurkeImmigrant, Refugee, and Migrant Health Branch

Division of Global Migration and Quarantine

Page 2: Medical Screening of Haitian Orphans:  Parent Survey, 2010

The authors have no financial relationships to disclose

Page 3: Medical Screening of Haitian Orphans:  Parent Survey, 2010

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

Page 4: Medical Screening of Haitian Orphans:  Parent Survey, 2010

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

Page 5: Medical Screening of Haitian Orphans:  Parent Survey, 2010

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

Page 6: Medical Screening of Haitian Orphans:  Parent Survey, 2010

CDC Screening Recommendations

• Recommendations urgently developed– AAP Red Book adoptee recommendations– Haiti-specific health information– CDC expert input

Page 7: Medical Screening of Haitian Orphans:  Parent Survey, 2010

CDC Screening Recommendations

• Short time frame (posted Feb 1)• Process unprecedented• Dissemination of guidelines

– AAP – USCIS– JCICS– HHS partners (ORR)

Page 8: Medical Screening of Haitian Orphans:  Parent Survey, 2010

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)

Page 9: Medical Screening of Haitian Orphans:  Parent Survey, 2010

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

Page 10: Medical Screening of Haitian Orphans:  Parent Survey, 2010

Objectives

• Knowledge/implementation of CDC screening recommendations

• Health conditions identified

• Where adoptive parents of orphans accessed medical care

Page 11: Medical Screening of Haitian Orphans:  Parent Survey, 2010

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

Page 12: Medical Screening of Haitian Orphans:  Parent Survey, 2010

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

Page 13: Medical Screening of Haitian Orphans:  Parent Survey, 2010

Parent Survey• 15 questions• Demographics • Medical evaluation/diagnoses• Awareness of CDC recommendations• One survey per Haitian orphan

• Frequencies

Page 14: Medical Screening of Haitian Orphans:  Parent Survey, 2010

Results

• 383 surveys

– Median age (range) = 5 yrs (1–18)

– From 42 states

– Top 3 states for respondents: CO (10%); FL (7%); MI (6%)

Page 15: Medical Screening of Haitian Orphans:  Parent Survey, 2010

Illness upon Arrival

0

20

40

60

80

100

No illness/notreported

One symptom ≥2 symptoms

%n=108

n=202

n=73

Page 16: Medical Screening of Haitian Orphans:  Parent Survey, 2010

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%)

Page 17: Medical Screening of Haitian Orphans:  Parent Survey, 2010

Illness upon Arrival

0

20

40

60

80

100

No illness/notreported

One symptom ≥2 symptoms

%n=108

n=202

n=73

Page 18: Medical Screening of Haitian Orphans:  Parent Survey, 2010

Signs & Symptoms upon Arrival

%

Diarrhea Weight loss/low weight

Cough Rash/skin Fever Injury Other 0

20

40

60

80

100

Page 19: Medical Screening of Haitian Orphans:  Parent Survey, 2010

Signs & Symptoms upon Arrival

%

Diarrhea Weight loss/low weight

Cough Rash/skin Fever Injury Other 0

20

40

60

80

100

URIEar/eye infections

WheezingMinor surgical

Page 20: Medical Screening of Haitian Orphans:  Parent Survey, 2010

383 children

Page 21: Medical Screening of Haitian Orphans:  Parent Survey, 2010

383 children

375 (98%) childrenreceived med eval

8 (2%) childrenno med eval

Page 22: Medical Screening of Haitian Orphans:  Parent Survey, 2010

383 children

375 (98%) childrenreceived med eval

8 (2%) childrenno 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)

Page 23: Medical Screening of Haitian Orphans:  Parent Survey, 2010

383 children

375 (98%) childrenreceived med eval

8 (2%) childrenno 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%)

Page 24: Medical Screening of Haitian Orphans:  Parent Survey, 2010

Type of Medical Provider by StateN

o. o

rpha

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

Page 25: Medical Screening of Haitian Orphans:  Parent Survey, 2010

Type of Medical Provider by StateN

o. o

rpha

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

Page 26: Medical Screening of Haitian Orphans:  Parent Survey, 2010

Type of Medical Provider by StateN

o. o

rpha

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

Page 27: Medical Screening of Haitian Orphans:  Parent Survey, 2010

• 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

Page 28: Medical Screening of Haitian Orphans:  Parent Survey, 2010

Awareness of CDC Recs

38%

23%

11%

4%2%

22%

USCIS

Adoption agency

Other

CDC website

Combination

Not aware of recs

Page 29: Medical Screening of Haitian Orphans:  Parent Survey, 2010

Medical Evaluation: Screening0 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

Page 30: Medical Screening of Haitian Orphans:  Parent Survey, 2010

Screening by Clinic Type

0

20

40

60

80

100

Private (n=265) State (n=40) Adoption (n=23)

TB

Stool

HIV

Syphilis

%

Page 31: Medical Screening of Haitian Orphans:  Parent Survey, 2010

Medical Evaluation: Treatment0 20 40 60

Intestinal parasitesDiarrhea

Respiratory infectionsSkin

TBPsychological

InjuryMalariaSyphilis

Other

%

n=200

136 90

69 29

20

106

3 34

Page 32: Medical Screening of Haitian Orphans:  Parent Survey, 2010

Treated Conditions by Age Group

0

20

40

60

80

<5 yo (n=188)

≥5 yo (n=186)

%

Page 33: Medical Screening of Haitian Orphans:  Parent Survey, 2010

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

Page 34: Medical Screening of Haitian Orphans:  Parent Survey, 2010

Not Immunized (n=86): Reasons

11, 13%

12, 14%

20, 23%

36, 42%

5, 6% 2, 2% Child sick

Vaccine notindicatedVaccine not available

Parent opposed tovaccinationChild did not receivemedical evalBlank

Page 35: Medical Screening of Haitian Orphans:  Parent Survey, 2010

Providers: Screening (N=23 Providers)

23 22 22 22 21 20 18 15 116 8

0

10

20

30

No.

Pro

vide

rs

Page 36: Medical Screening of Haitian Orphans:  Parent Survey, 2010

Providers: Diagnoses (N=39 Orphans)

0

20

40

% O

rpha

ns

Page 37: Medical Screening of Haitian Orphans:  Parent Survey, 2010

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

Page 38: Medical Screening of Haitian Orphans:  Parent Survey, 2010

Limitations

• Data self-reported (recall bias)

• Not complemented by provider data

• Responses for ~1/3 of orphans

• Cannot determine if multiple children per parent

Page 39: Medical Screening of Haitian Orphans:  Parent Survey, 2010

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

Page 40: Medical Screening of Haitian Orphans:  Parent Survey, 2010

Acknowledgements

• Parents and providers who took the surveys!• AAP, JCICS, USCIS and other partners

Page 41: Medical Screening of Haitian Orphans:  Parent Survey, 2010

Thank You

Heather Burke [email protected]

http://www.cdc.gov/immigrantrefugeehealth/adoption/index.html

Page 42: Medical Screening of Haitian Orphans:  Parent Survey, 2010

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?

Page 43: Medical Screening of Haitian Orphans:  Parent Survey, 2010

Extra Slides

Page 44: Medical Screening of Haitian Orphans:  Parent Survey, 2010

Category 1 orphansChildren 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

Page 45: Medical Screening of Haitian Orphans:  Parent Survey, 2010

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

Page 46: Medical Screening of Haitian Orphans:  Parent Survey, 2010

Type of Provider Facility (n=30)

12

9

9

1

Private clinicAdoption med clinicAcademic practiceOther