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Refugees and immigrants undergo tuberculosis screening prior to arrival in the United States. CDC Technical Instructions for screening changed in 2007. Our goal was to quantify TB disease in refugees after 2007 and identify risks for disease. Massachusetts refugee and tuberculosis databases were matched to identify refugees who arrived 2008-2017 and were diagnosed with tuberculosis infection or disease 2008-2018. Factors associated with disease were analyzed in SAS. Of 19,583 refugees, 4706 were diagnosed with infection at arrival and 60 with disease during the observation period. Lack of treatment for infection was strongly associated (OR = 26.5, p = 0.0001) with diagnosis of disease; in a multivariate logistic regression model, positive screening test (AOR = 12.5, p = 0.0001), class B1 status (AOR = 4.0, p = 0.0004), and 2 years since arrival (AOR = 60.0, p = 0.0001) were associated with disease. Providers should continue screening new arrivals, providing accessible services, and treating infection to further reduce tuberculosis morbidity and mortality.

Objectives (1) To examine patterns of catch-up growth and anemia correction in refugee children younger than 5 years after participation in the Special Supplemental Nutrition for Women, Infants, and Children (WIC) program, and (2) to identify factors associated with recovery from growth abnormalities. Design Records on 1731 refugee children younger than 5 years who arrived in Massachusetts between 1998-2010 were matched to WIC program records and then restricted to 779 children who had at least 2 WIC visits. Kaplan-Meier curves and Cox proportional hazards models were used to examine how sex affected time to recovery from malnutrition and anemia. Factors associated with recovery were analyzed in SAS using multivariate logistic regression. Setting Massachusetts. Participants Refugee children younger than 5 years on arrival, who visited a WIC program at least twice between 1998 and 2010. Main outcome measures (1) Proportion of children who recovered from low height-for-age (stunting), low weight-for-age, low weight-for-height (wasting), and anemia; (2) odds ratios for factors associated with recovery; and (3) Kaplan-Meier curves showing recovery over time from low height-for-age, low weight-for-age, and low weight-for-height. Results The number of WIC visits was associated with recovery from stunting, wasting, low weight-for-age, and anemia; results reached statistical significance for stunting (odds ratio [OR] = 8.64; 95% confidence interval [CI], 2.25-33.19), low weight-for-age (OR = 5.28; 95% CI, 1.35-20.73), and anemia (OR = 6.50; 95% CI, 2.69-15.69). Female sex was associated with recovery from stunting, wasting, and low weight-for-age, whereas male sex was associated with recovery from anemia; the associations were statistically significant between female sex and stunting (OR = 9.14; 95% CI, 1.93-43.29), wasting (OR = 14.78; 95% CI, 1.57-138.85), and low weight-for-age (OR = 4.29; 95% CI, 1.09-16.79). Conclusions Children who remained engaged in WIC may recover better from malnutrition than children with fewer WIC visits, although there are limitations to the available data.These findings suggest that those working with refugee families should prioritize outreach toward initiating and maintaining WIC program enrollment for eligible refugee children.

Objectives: Refugee children are known to have a high prevalence of elevated blood lead levels (EBLLs). We sought to determine trends in EBLLs among refugee children during an 18-year period and examine relationships between descriptive characteristics and EBLLs by using 10 µg/dL and 5 µg/dL levels of concern. Methods: We retrospectively evaluated refugee health screening data from Massachusetts for 1998 through 2015 for refugee children aged Results: Of 3421 eligible refugee children, 3054 (88.2%) were tested. Using 5 µg/dL and 10 µg/dL levels of concern, 1279 (41.9%) and 241 (7.9%) children, respectively, had EBLLs. Mean BLLs declined steadily from 7.58 µg/dL in 2004 to 4.03 µg/dL in 2015. African (adjusted odds ratio [aOR] = 2.49; 95% confidence interval [CI], 1.81-3.43), East Asian and Pacific (aOR = 1.98; 95% CI, 1.35-2.91), and South-Central Asian (aOR = 2.47; 95% CI, 1.53-4.01) regions of origin and anemia (aOR = 1.50; 95% CI, 1.14 -1.97) were significantly associated with BLLs ≥5 µg/dL. Conclusions: The prevalence of EBLLs among refugees compared with US-born children is high. Because EBBLs increase the risk for neurocognitive impairment in children, public health professionals, policy makers, researchers, refugee resettlement staff members, and health care providers must remain vigilant in screening for lead poisoning and educating refugees about the hazards posed to young children by lead.

Recently resettled refugee populations may be at greater risk for exposure to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a virus that causes coronavirus 2019 (COVID-19), and face unique challenges in following recommendations to protect their health. Several factors place resettled refugees at elevated risk for exposure to persons with COVID-19 or increased severity of COVID-19: being more likely to experience poverty and live in crowded housing, being employed in less protected, service-sector jobs, experiencing language and health care access barriers, and having higher rates of co-morbidities. In preparing for and managing COVID-19, resettled refugees encounter similar barriers to those of other racial or ethnic minority populations, which may then be exacerbated by unique barriers experienced from being a refugee. Key recommendations for resettlement and healthcare providers include analyzing sociodemographic data about refugee patients, documenting and resolving barriers faced by refugees, developing refugee-specific outreach plans, using culturally and linguistically appropriate resources, ensuring medical interpretation availability, and leveraging virtual platforms along with nontraditional community partners to disseminate COVID-19 messaging.

This paper explores the relationship between acculturation and oral health in a study of Somali refugees. This cross-sectional survey included structured surveys and dental examinations of a convenience sample of 439 Somali adults living in Massachusetts. Associations between an acculturation scale and: (1) lifetime history of caries and (2) access to oral health services were calculated. In bivariate analyses, many individual questions in the scale were associated with outcomes. In multivariate analysis, speaking English (OR 0.5, CI 0.28-0.84) was associated with better access to, and utilization of, dental health services while reading American books and newspapers in English was associated with increased lifetime history of dental disease (OR 2.6, CI 1.1-6.0). As specific elements of acculturation have different relationships with oral health among Somali refugees, a summary acculturation scale may have limited utility. Ongoing efforts to remove language barriers may improve oral health.

Countries that resettle refugees have developed practice guidelines for the refugee domestic health assessment. In the United States, the Centers for Disease Control (CDC) has established evidence-based guidelines for domestic health assessment of newly arrived refugees. This assessment includes disease conditions commonly seen in refugee populations. Parts of history taking, physical examination, laboratory testing, and preventive screening that have specific relevance for refugees are described in this chapter. In addition to an overview of recommendations for the domestic assessment of refugees in the United States, this chapter also reviews existing models of care and regulations governing refugee resettlement. The overseas screening medical examination is also discussed.

Little is known about the impacts of health literacy and English proficiency on the health status of Somali refugees. Data came from interviews in 2009-2011 of 411 adult Somali refugees recently resettled in Massachusetts. English proficiency, health literacy, and physical and mental health were measured using the Basic English Skills Test Plus, the Short Test of Health Literacy in Adults, and the Physical and Mental Component Summaries of the Short Form-12. Associations were analyzed using multiple linear regression. In adjusted analyses, higher English proficiency was associated with worse mental health in males. English proficiency was not associated with physical health. Health literacy was associated with neither physical nor mental health. Language proficiency may adversely affect the mental health of male Somali refugees, contrary to findings in other immigrant groups. Research on underlying mechanisms and opportunities to understand this relationship are needed.

Objectives To (1) describe prevalence of growth abnormalities and anemia in refugee children; (2) describe the proportion of age-eligible refugee children enrolled in Special Supplemental Nutrition Program for Women, Infants, and Children (WIC); and (3) identify risk factors for lack of enrollment in WIC. Design Data were collected from 1731 health screenings for refugee children younger than 5 years in Massachusetts in 1998-2010 and matched to WIC program records. Risk factors for lack of WIC enrollment were analyzed in SAS using multivariate logistic regression. Setting Massachusetts. Participants Refugee children under age 5 years. Main outcome measures (1) prevalence of growth abnormalities and anemia in refugee children, (2) proportion of age-eligible refugee children enrolled in WIC, and (3) association of risk factors with lack of WIC enrollment. Results Overall, 33% of refugee children under age 5 in Massachusetts had at least 1 growth and nutrition problem, including anemia (31%), stunting (10%), wasting (8%), and low weight for age (10%). WIC enrollment among refugee children under 5 years of age was only 62%, lower than that of all eligible children under 5 in Massachusetts (86%). Risk factors for lack of WIC enrollment among refugee children included age, world region of origin, and arrival cohort. Conclusions Although many refugee children under age 5 experience growth or nutrition problems, one-third of refugee children in Massachusetts were not enrolled in WIC for nutrition assistance, representing a failure of the system. Agencies providing services at the local level should be supported to facilitate enrollment and participation for shared clients.

Background Attention-deficit/hyperactivity disorder (ADHD) affects almost 2.4 million US children. Because American Academy of Pediatrics guidelines for ADHD recommend use of standardized diagnostic instruments, regular follow-up and the chronic care model, this pilot project sought to implement and assess an electronic registry of patients with ADHD combined with care coordination by a planned care team. Methods This quality improvement project was structured with 2 intervention and 2 control clinics to facilitate evaluation of the use of a planned care system for management of ADHD. Care teams included a pediatrician, nurse, medical assistant, and care coordinator and tracked patients using an electronic registry with data drawn from the EMR. Clinical work flows were pilot tested to facilitate use of the Vanderbilt scales and their incorporation into the EMR at intervention sites. Outcome measures included 2 recommended clinical follow-ups based on HEDIS measures as well as use of the Vanderbilt rating scales. Initiation phase measure was for follow-up after initiating medication, while the continuation phase measure was for subsequent follow-up during the first year of treatment. Measures were monitored during the project year and then also in the ensuing period of spread of the intervention to other sites. Results Although the modified HEDIS initiation phase measure for patients newly on medication remained static at approximately 50% throughout the project period, the continuation phase measure showed improvement from 35% at baseline to 45% at the end of the project assessment year, a 29% increase. Follow-up for patients stable on medications also remained unchanged during the project period, but during subsequent spreading of the intervention to nonproject sites, follow-up of these patients improved to over 90%. In adjusted analyses, patients with ADHD at intervention sites were over 2 times more likely than patients at control sites to have had a Vanderbilt score documented in their records. Conclusions The project achieved modest improvements in the diagnostic and treatment process for patients with ADHD. The use of a planned care system and electronic patient registry shows promise for improving the diagnosis and treatment process for patients with ADHD.

The Arabic miswak (Somali, adayge) is a tooth-cleaning stick from the Salvadora persica plant. In this article, we trace the social life of a “thing,” examining meanings inscribed in the stick brush, drawing on interviews with 82 Somali refugees in Massachusetts and an analysis of local and transnational science and marketing. The miswak toothbrush symbolizes relationships to nature, homeland culture, global Islam, globalizing dental medicine, and the divine as it intersects with the lives of producers, marketers, distributors, and users, creating hybrid cultural forms in new contexts.

INTRODUCTION The receipt rate of hepatitis B virus vaccine among adolescents in the United States is high, while the receipt rate of human papillomavirus vaccine is low. Rates have not been closely studied among refugees, whose home countries have high rates of disease caused by these viruses. METHODS We examined human papillomavirus and hepatitis B virus immunization rates among 2,269 refugees aged 9 to 26 years who resettled in Massachusetts from 2011 through 2013. This was a secondary analysis of data from their medical screenings. We used binary logistic regression to assess characteristics associated with immunization and bivariate analyses to compare refugee immunization rates with those of the general US population. RESULTS Forty-five percent of US adolescents aged 13 to 17 years received 1 dose of human papillomavirus vaccine, compared with 68% of similarly aged refugees. Males (adjusted odds ratio [aOR], 0.62; 95% confidence interval [CI], 0.52-0.74), refugees older than 13 years (aOR, 0.74; 95% CI, 0.60-0.93), and refugees not from Sub-Saharan Africa (aOR, 0.74; 95% CI, 0.59-0.92) were less likely to receive human papillomavirus vaccine, while arrivals in 2012 through 2013 were more likely (aOR, 1.6; 95% CI, 1.3-1.9) than those arriving in 2011. Refugees older than 13 years were less likely to receive 2 doses of hepatitis B virus vaccine (aOR, 0.49; 95% CI, 0.37-0.63) than older refugees. CONCLUSION Specialized post-arrival health assessment may improve refugees' immunization rates.

BACKGROUND: We describe development of the Early Childhood Caries (ECC) Basic Research Factors Questionnaire (BRFQ), a battery of measures assessing common potential predictors, mediators, and moderators of ECC. Individual-, family-, and community-level factors that are linked to oral health outcomes across at-risk populations are included. Developing standard measures of factors implicated in ECC has the potential to enhance our ability to understand mechanisms underlying successful prevention and to develop more effective interventions.METHODS: The Early Childhood Caries Collaborating Centers (EC4), funded by National Institute of Dental and Craniofacial Research, developed the BRFQ, which was used across four randomized trials to develop and test interventions for reducing ECC in at-risk populations. Forty-five investigators from across the centers and NIDCR were involved in the development process. Eight "measures working groups" identified relevant constructs and effective measurement approaches, which were then categorized as "essential" or "optional" common data elements (CDEs) for the EC4 projects.RESULTS: Essential CDEs include 88 items, with an additional 177 measures categorized as optional CDEs. Essential CDEs fell under the following domains: oral health knowledge, oral health behavior, utilization/insurance and cost, parent/caregiver dental self-efficacy, quality of life, caregiver and family characteristics, and child characteristics.CONCLUSIONS: The BRFQ makes available a battery of measures that support efforts to understand population risk factors for ECC and to compare oral health outcomes across populations at risk. The BRFQ development process may be useful to other clinical research networks and consortia developing CDEs in other health research fields.TRIAL REGISTRATION: All the trial that used the BRFQ were registered at Clinicaltrial.gov NCT01116726 , April 29, 2010; NCT01116739 , May 3, 2010; NCT01129440 , May 21, 2010; and NCT01205971 , September 19, 2010.

Introduction Fluoride varnish is an effective prevention intervention for caries in young children. Its routine use in clinical care is supported by meta-analyses and recommended by clinical guidelines, including the US Preventive Services Task Force (B rating). This report is the first prospective systematic assessment of adverse events related to fluoride varnish treatment in young children. Methods We determined the incidence of adverse events related to fluoride varnish treatment in 3 clinical trials on the prevention of early childhood caries, conducted under the auspices of the Early Childhood Caries Collaborating Centers, an initiative sponsored by the National Institute of Dental and Craniofacial Research. Each trial incorporated use of fluoride varnish in its protocol and systematically queried all children's parents or legal guardians about the occurrence of acute adverse events after each fluoride varnish treatment. Results A total of 2,424 community-dwelling, dentate children aged 0 to 5 years were enrolled and followed for up to 3 years. These children received a cumulative total of 10,249 fluoride varnish treatments. On average, each child received 4.2 fluoride varnish treatments. We found zero fluoride varnish-related adverse events. Conclusion Fluoride varnish was not associated with treatment-related adverse events in young children. Our findings support its safety as an effective prevention intervention for caries in young children.

Immigrants often originate from populations with disease patterns different from those at their destination.1 The “healthy immigrant effect,” a phenomenon where newcomers on average have better health status or outcomes than their native-born counterparts, is well documented. Premigration experiences, such as differential risk exposures and health behaviors have been proposed to explain this effect. A key finding in the literature on immigrant health is that over time, immigrants approach the health risk profile of their host country, and in some cases have increased risk.2,3 In the case of newly arrived refugees, this risk may be related to socioeconomic status, language, and cultural barriers. Exposure to almost all material, psychosocial, and behavioral risk factors related to poor health is influenced by socioeconomic status. This includes oral health; the burden of oral diseases and conditions is disproportionately borne by disadvantaged populations.4,5,6 In particular, immigrants and minority ethnic groups have often been designated as “whole populations at risk” for oral health deterioration primarily because of their generally adverse life circumstances.1 Yet, within entire populations or even subgroups there remains significant heterogeneity in disease susceptibility and vulnerability to inadequate health care. Given this juxtaposition of vulnerability (related to such factors as socioeconomic status, language, history of trauma) and resilience among refugees, this study was designed to advance understanding of Somali oral health and the factors influencing Somali oral health status. Somalis are one of largest refugee populations to have entered the U.S. in recent years. The civil war that began in 1991 has produced over a million refugees. Between 1992 and 2009, 84,746 Somali refugees have been resettled in the U.S.,7 including approximately 3,027 in Massachusetts (unpublished data, Massachusetts Department of Public Health). In addition to refugees formally resettled in Massachusetts during this period, many Somali families moved to Massachusetts from other states or with other kinds of visas. The oral health status of Somalis in the U.S. and the factors impacting this status are poorly understood. Past research into Somali oral health is mainly limited to gray literature that highlights the high value placed on oral health by Somalis, while presenting the new oral health risks associated with refined sugar in the country of resettlement.8,9 This article draws on data from the qualitative arm of a broader mixed-methods study that employed an extensive questionnaire and clinical exam to identify factors associated with access to dental care, English language skills, and the current oral health status of Somali and Somali Bantu refugees in Massachusetts. The quantitative arm of the study found that, contrary to expectations based on findings among other newly-arrived refugee populations, Somalis generally had good oral health and oral health practices.10 Given the good oral health status found overall among Somalis arriving in the U.S. in the last 10 years, in this paper we explore this population’s self-reported oral health explanatory models and practices. Exploring how recently arrived Somali refugees understand, negotiate, and make decisions around their personal oral health care practices may inform interventions among Somalis and other refugee populations, and provide a basis for communication between dental care providers and refugee patients.

Refugee agencies noticed a high number of suicides among Bhutanese refugees resettled in the United States between 2009 and 2012. We aimed to estimate prevalence of mental health conditions and identify factors associated with suicidal ideation among Bhutanese refugees. We conducted a stratified random cross-sectional survey and collected information on demographics, mental health conditions, suicidal ideation, and post-migration difficulties. Bivariate logistic regressions were performed to identify factors associated with suicidal ideation. Prevalence of mental health conditions were: depression (21 %), symptoms of anxiety (19 %), post-traumatic stress disorder (4.5 %), and suicidal ideation (3 %), significant risk factors for suicidal ideation included: not being a provider of the family; perceiving low social support; and having symptoms of anxiety and depression. These findings suggest that Bhutanese refugees in the United States may have a higher burden of mental illness relative to the US population and may benefit from mental health screening and treatment. Refugee communities and service providers may benefit from additional suicide awareness training to identify those at highest risk.

Objectives. We described elevated blood lead level (BLL; ≥ 10 μg/dL) prevalence among newly arrived refugee children in Massachusetts. We also investigated the incidence of BLL increases and BLLs newly elevated to 20 μg/dL or higher in the year following initial testing, along with associated factors. Methods. We merged data from the Massachusetts Department of Public Health's Refugee and Immigrant Health Program and the Childhood Lead Poisoning Prevention Program on 1148 refugee children younger than 7 years who arrived in Massachusetts from 2000 to 2007. Results. Elevated BLL prevalence was 16% among newly arrived refugee children. The rate ratio for BLL elevation to 20 μg/dL or higher after arrival was 12.3 (95% confidence interval [CI] = 6.2, 24.5) compared with children in communities the state defines as high-risk for childhood lead exposure. Residence in a census tract with older housing (median year built before 1950) was associated with a higher rate of BLL increases after resettlement (hazard ratio = 1.7; 95% CI = 1.2, 2.3). Conclusions. Refugee children are at high risk of lead exposure before and after resettlement in Massachusetts. A national surveillance system of refugee children's BLLs following resettlement would allow more in-depth analysis.

Objective. The goal of this study was to assess the effectiveness of multivitamins with iron as prophylaxis against iron deficiency and anemia in infancy.Methods. The study was a double-blinded, randomized, pragmatic, clinical trial conducted at 3 urban primary care clinics. Subjects included healthy, full-term infants who were enrolled at their 6-month well-child visit. Infants were randomly assigned to receive standard-dose multivitamins with or without iron (10 mg/day). Parents administered multivitamins by mouth daily for 3 months. Laboratory results at 9 months of age were analyzed for the presence of anemia and/or iron deficiency. Anemia was defined as hemoglobin level Results. The control (n = 138) and intervention (n = 146) groups were equivalent with respect to all important sociodemographic and nutritional variables. At 9 months of age, anemia was found in 21% of infants (n = 58). A total of 229 (81%) had iron deficiency on the basis of 1 abnormal laboratory indicator and 139 (49%) on the basis of 2 abnormal laboratory indicators. No difference existed in the occurrence of anemia and iron deficiency between the intervention and control groups. In the intervention group, 22% and 78% of 138, respectively, were anemic or had 1 abnormal laboratory outcome indicative of iron deficiency. In the control group, 19% and 84% of 144 were anemic or iron deficient. When stratified by adherence, no differences in hematologic outcomes between groups were noted. However, in multivariate logistic regression, infants whose mothers were anemic during pregnancy were 2.15 times more likely than others to have any laboratory abnormality (95% confidence interval: 1.14–4.07). Increasing adherence, regardless of group assignment, was associated with a 0.56 times reduced risk of any abnormality (95% confidence interval: 0.41–0.76).Conclusion. On the basis of intention-to-treat analysis, multivitamins with iron was not effective in preventing iron deficiency or anemia in 9-month-old infants. However, effective prevention and treatment of maternal anemia during pregnancy and giving multivitamins with or without additional iron during infancy may prove to be important approaches to the prevention of iron deficiency among high-risk children. Because of the consequences of iron deficiency and its high prevalence among low-income infants, additional investigation in these areas is warranted.

This study analyzed the prevalence of intestinal parasitoses diagnosed shortly after arrival in the United States among African refugees before and after implementation of an overseas program of empirical treatment with albendazole. Variables included results of microscopy of a single stool specimen, age, sex, ethnicity, departure origin, and receipt of albendazole. Of 1,254 refugees, 56% had intestinal parasites. Fourteen percent had helminths, and 2% had multiple helminths. In addition, 52% had protozoans with 25% having multiple protozoans. The most common pathogens were Giardia lamblia (14%) and Trichuris trichiura (9%). Overall, refugees who arrived in Massachusetts after implementation of the treatment program were less likely to have any parasites (odds ratio [OR] = 0.61, 95% confidence interval [CI] = 0.47-0.78) and helminths (OR = 0.15, 95% CI = 0.09-0.24) than refugees who arrived previously. These more recently arrived refugees were also less likely to have hookworm (OR = 0.03, 95% CI = 0.00-0.29), Trichuris (OR = 0.05, 95% CI = 0.02-0.13), Ascaris (OR = 0.07, 95% CI = 0.01-0.58), and Entamoeba histolytica (OR = 0.47, 95% CI = 0.26-0.86). Empirically treating refugees prior to departure for the United States appears to have resulted in decreases in intestinal helminths and possibly some protozoans among African refugees tested shortly after arrival in this country.

Attention has been drawn to high rates of suicide among refugees after resettlement and in particular among the Bhutanese refugees. This study sought to understand the apparent high rates of suicide among resettled Bhutanese refugees in the context of the Interpersonal-Psychological Theory of Suicidal Behavior (IPTS). Expanding on a larger investigation of suicide in a randomly selected sample of Bhutanese men and women resettled in Arizona, Georgia, New York, and Texas (Ao et al., 2012), the current study focused on 2 factors, thwarted belongingness and perceived burdensomeness, examined individual and postmigration variables associated with these factors, and explored how they differed by gender. Overall, factors such as poor health were associated with perceived burdensomeness and thwarted belongingness. For men, stressors related to employment and providing for their families were related to feeling burdensome and/or alienated from family and friends, whereas for women, stressors such as illiteracy, family conflict, and being separated from family members were more associated. IPTS holds promise in understanding suicide in the resettled Bhutanese community.

This study investigated the impact of English health literacy and spoken proficiency and acculturation on preventive dental care use among Somali refugees in Massachusetts. 439 adult Somalis in the US ≤10 years were interviewed. English functional health literacy, dental word recognition, and spoken proficiency were measured using STOFHLA, REALD, and BEST Plus. Logistic regression tested associations of language measures with preventive dental care use. Without controlling for acculturation, participants with higher health literacy were 2.0 times more likely to have had preventive care (P = 0.02). Subjects with higher word recognition were 1.8 times as likely to have had preventive care (P = 0.04). Controlling for acculturation, these were no longer significant, and spoken proficiency was not associated with increased preventive care use. English health literacy and spoken proficiency were not associated with preventive dental care. Other factors, like acculturation, were more predictive of care use than language skills.

Objectives. This study analyzed growth and identified related medical conditions among refugee children in Massachusetts. Methods. Between July 1995 and June 1998, 1825 refugee children were screened. Variables included positive tuberculin (purified protein derivative; PPD) test; dental abnormalities; pathogenic parasites; weight-for-age, height-for-age, and weight-for-height z scores; and body mass index greater than the 84th percentile. Results. Of all the children, 21% had parasites, 62% had caries, and 25% had a positive PPD reaction. Twelve percent overall and 28% younger than 2 years had anemia. Eight percent had height-for-age z scores less than –2, and 6% had weight-for-age z scores greater than +2. Of those aged 1 to 9 years, 7% had weight-for-height z scores greater than +2. Weight-for-height z scores less than –2 were concentrated among Africans and East Asians (both 8%). Height-for-age z scores less than –2 were seen among African (13%), Near Eastern (19%), and East Asian (30%) children. Weight-for-height z scores greater than +2 and body mass index greater than the 84th percentile were concentrated among children from the former Yugoslavia (8% and 15%) and the former Soviet Union (8% and 14%). Conclusions. Recently arrived refugee children have significant growth abnormalities. European refugees were overweight; those from developing countries had growth retardation.

This study assessed the effectiveness of multivitamins (MV) with iron as prophylaxis against iron deficiency (ID) and anemia in infancy. The study was a double-blind, randomized trial at 2 urban primary care clinics. Subjects included healthy, full-term infants enrolled at their 6-month well-child visit. Parents administered MV, either with iron or without iron, by mouth daily for 3 months. At 9 months of age, 28.3% of 310 had either anemia or ID without anemia. Among infants with any adherence, anemia was found in 11.1% of the iron group and 21.7% in the noniron group (RR=0.5, 95% CI=0.3-1.0). Iron deficiency without anemia was found in 18.5% of the iron group; 14.4% of the noniron group (p=0.46). When administered daily starting at age 6 months, standard-dose multivitamins with iron appear to reduce anemia prevalence at 9 months of age.

This study assessed impacts of immigrants' legal status on utilization of prenatal care and public programs by non-citizen women. Interviews and chart reviews of 171 women were conducted less than 48 hours after delivery at an urban hospital. Among non-citizens, 67% were legally documented. No differences in prenatal care adequacy by legal status were detected among non-citizens, who as a group had less health insurance, worse socioeconomics, and less program use compared to U.S. citizens. Non-citizens also were less aware of newborn's citizenship and eligibility for public programs and benefits. Non-citizens utilized fewer programs while reporting greater economic hardship than citizens; however, non-citizens selectively used programs important for pregnancy. Given changes in eligibility for federal programs and high rates of reported food insecurity and socioeconomic hardship among non-citizens, monitoring for adverse effects on utilization of prenatal care and birth outcomes is needed.

The Centers for Disease Control (CDC) has established evidence based guidelines for domestic screening of newly arrived refugees. This screening includes disease conditions commonly seen in refugee populations. Parts of history taking, physical examination, laboratory testing and preventive screening that have specific relevance for refugees are described in this chapter. In addition to an overview of recommendations for the domestic screening of refugees in the United States, the chapter also reviews existing models of care and regulations governing refugee resettlement. The overseas screening medical examination is also discussed with a brief review of current recommendations for pre-departure prophylactic treatment.

Objectives. We assessed the impact of health literacy and acculturation on oral health status of Somali refugees in Massachusetts. Methods. Between December 2009 and June 2011, we surveyed 439 adult Somalis who had lived in the United States 10 years or less. Assessments included oral examinations with decayed, missing, and filled teeth (DMFT) counts and measurement of spoken English and health literacy. We tested associations with generalized linear regression models. Results. Participants had means of 1.4 decayed, 2.8 missing, and 1.3 filled teeth. Among participants who had been in the United States 0 to 4 years, lower health literacy scores correlated with lower DMFT (rate ratio [RR] = 0.78; P = .016). Among participants who had been in the country 5 to 10 years, lower literacy scores correlated with higher DMFT (RR = 1.37; P = .012). Literacy was not significantly associated with decayed teeth. Lower literacy scores correlated marginally with lower risk of periodontal disease (odds ratio = 0.22; P = .047). Conclusions. Worsening oral health of Somali refugees over time may be linked to less access to preventive care and less utilization of beneficial oral hygiene practices.

In the original version of this article, one of the ten author names was listed incorrectly as "Trong Aoe." The name should be listed as "Trong Ao." The affiliation of two of the co-authors (Sharmila Shetty and Eboni Taylor) was incorrect. The correct affiliation is: Immigrant, Refugee and Migrant Health Branch, Division of Global Migration and Quarantine, Centers for Disease Control and Prevention. The correct full list of author names and their affiliations is presented above.

Previous studies have indicated that vitamin D deficiency is widespread among immigrants and refugees. This study sought to determine the prevalence of vitamin D deficiency among a large and diverse cohort of refugees in Massachusetts to assess its significance for routine refugee health screening of refugees. 25-hydroxyvitamin D levels for 2,610 refugees screened between 2007 and 2009 were used to estimate vitamin D status and to examine the relationship between deficiency or insufficiency and age, gender, regional origin, and season of testing. Among those tested, 78 % were either vitamin D insufficient or deficient. Insufficiency or deficiency was most prevalent in refugees from the Middle East (89 %) and lowest in those from the Caribbean (59 %). Risk was higher among women than among men from some regions, such as the Middle East, but not others. For women, the likelihood of deficiency increased with age, while for men, the likelihood of deficiency was similar for preschool children and men at the height of their working years. The high overall prevalence of vitamin D deficiency suggests that empiric supplementation or treatment may be preferred to testing until more is known about the long-term epidemiology of vitamin D deficiency and its consequences.

Introduction Better understanding of the health problems of refugees and people who are granted political asylum (asylees) in the United States may facilitate successful resettlement. We examined the prevalence of risk factors for and diagnoses of chronic disease among these groups in Massachusetts. Methods We retrospectively analyzed health screening data from 4,239 adult refugees and asylees who arrived in Massachusetts from January 1, 2001, through December 31, 2005. We determined prevalence of obesity/overweight, hypertension, coronary artery disease (CAD), diabetes, and anemia. Analyses included multivariate logistic regression to determine associations between CAD and diabetes with region of origin. Results Almost half of our sample (46.8%) was obese/overweight, and 22.6% had hypertension. CAD, diabetes, and anemia were documented in 3.7%, 3.1%, and 12.8%, respectively. People from the Europe and Central Asia region were more likely than those from other regions to have CAD (odds ratio, 5.55; 95% confidence interval, 2.95-10.47). Conclusions The prevalence of obesity/overweight and hypertension was high among refugees and asylees, but the prevalence of documented CAD and diabetes was low. We noted significant regional variations in prevalence of risk factors and chronic diseases. Future populations resettling in the United States should be linked to more resources to address their long-term health care needs and to receive culturally appropriate counseling on risk reduction.

Early childhood caries (ECC) is a serious and preventable disease which pediatric clinicians can help address by counseling to reduce risk.We implemented a multifaceted practice-based intervention in a pediatric outpatient clinic treating children vulnerable to ECC (N = 635), comparing results to those from a similar nearby clinic providing usual care (N = 452).We provided communication skills training using the approach of patient centered counseling, edited the electronic medical record to prompt counseling, and provided parents/caregivers with an educational brochure.We assessed changes in provider knowledge about ECC after the intervention, and examined providers' counseling practices and incidence of ECC over time by site, controlling for baseline ECC, patient sociodemographics and parents'/caregivers' practice of risk factors (diet, oral hygiene, tooth-monitoring), among 1045 children with complete data.Provider knowledge about ECC increased after the intervention training (percentage correct answers improved from 66% to 79%). Providers at the intervention site used more counseling strategies, which persisted after adjustment for sociodemographic characteristics. Children at the intervention site had a 77% reduction in risk for developing ECC at follow up, after controlling for age and race/ethnicity, sociodemographics and ECC risk factors; Por= 0.004.The multifaceted intervention was associated with increased provider knowledge and counseling, and significantly attenuated incidence of ECC. If validated by additional studies, similar interventions could have the potential to make a significant public health impact on reducing ECC among young children.

Objective To determine whether or not limited caregiver health literacy is associated with adherence to a daily multi-vitamin with iron regimen in infants. Methods 110 caregiver/infant dyads were enrolled in a prospective study to assess the relationship between caregiver health literacy and adherence to a daily multi-vitamin with iron regimen for infants. Households were contacted biweekly over a 3-month period. Adherence was based upon caregiver report. High adherence, our primary outcome, was defined as the administration of the multi-vitamin with iron on 5–7 days over the past week. Results As measured by the Short Test of Functional Health Literacy in Adults (S-TOFHLA), 18% of caregivers had limited health literacy skills. Caregivers with limited health literacy skills were more likely to have higher adherence than caregivers with adequate health literacy, after adjusting for a number of possible confounding variables (AOR = 2.13; 95% 1.20–3.78). Conclusion Caregivers with limited health literacy were twice as likely to report high adherence to a daily multi-vitamin with iron regimen in infants as caregivers with adequate health literacy in adjusted analysis. Practice implications Health literacy may exert a differential influence on adherence depending upon the complexity of the desired health behavior.

To determine whether low-income infants' adherence to nutritional supplementation with ferrous fumarate sprinkles was better than that with ferrous sulfate drops.The study was a randomized clinical trial of healthy 6-month-old infants. Each infant received either a daily packet of sprinkles or a dropperful of liquid. Follow-up included alternating telephone and home visits biweekly for 3 months. Adherence was defined as high if the infant's caregiver reported supplement use on 5 to 7 days during the week before assessment. Side effects and caregiver attitude about supplements were secondary outcomes. Analyses were conducted using generalized estimating equations and chi(2) and Wilcoxon rank-sum tests.A total of 150 of 225 eligible infants were enrolled. Adherence to supplementation was generally poor. High adherence ranged from 32% to 63% at any assessment in the subjects receiving drops, compared with 30% to 46% in those receiving sprinkles. The drops group was more likely to have at least four assessments with high adherence (22% vs 9.5%; P = .03). Caregivers of the drops infants were more likely to report greater than usual fussiness (P.01); however, fussiness had no consistent impact on adherence.The use of ferrous fumarate sprinkles rather than traditional ferrous sulfate drops did not improve adherence with daily iron supplementation in low-income infants.

To assess whether mental health counseling and other health services were associated with functional health outcomes of unaccompanied Sudanese refugee minors in the U.S., this study was a descriptive survey of 304 Sudanese refugee minors in foster care through the U.S. Unaccompanied Refugee Minors Program (URMP). Functional health outcomes included scores of Child Health Questionnaire (CHQ) scales and questions regarding care for symptoms or problems associated with behavioral disorders, i.e. somatization. Posttraumatic stress disorder (PTSD) was assessed using the Harvard Trauma Questionnaire (HTQ). Health services questions derived from the National Health Interview Survey. Minors reported high rates of counseling (45%); however no differences were noted in counseling use by those with PTSD compared with others. Counseling was not associated with health outcomes. The majority (76%) reported seeking medical care for symptoms or problems often associated with behavioral and emotional problems; however such care-seeking was more common among those with PTSD (OR = 2.5, 95% CI = 1.004-6.26). Through the efforts of the URMP, the Sudanese unaccompanied minors received high levels of psychosocial support despite the absence of their biological parents. Those with worse functional health were no more likely than others to have received mental health counseling while being more likely to seek care from any health professional. This was also the case for those with PTSD compared to those without it. In linear regression analyses, reported receipt of mental health counseling did not impact either positively or negatively on the score of any CHQ scale.

Objective To assess the functional and behavioral health of unaccompanied Sudanese refugee minors approximately 1 year after resettlement in the United States. Design A descriptive survey. Setting Local refugee foster care programs affiliated with the US Unaccompanied Refugee Minors Program. Participants A total of 304 Sudanese refugee minors enrolled in the US Unaccompanied Refugee Minors Program. Main Outcome Measures Health outcomes were assessed using the Harvard Trauma Questionnaire and the Child Health Questionnaire. Outcomes included the diagnosis of posttraumatic stress disorder and scores on all Child Health Questionnaire subscales and global single-item assessments. Results Twenty percent of the minors had a diagnosis of posttraumatic stress disorder and were more likely to have lower (worse) scores on all the Child Health Questionnaire subscales. Low functional and behavioral health scores were seen mainly in functioning in the home and in subjective health ratings. Social isolation and history of personal injury were associated with posttraumatic stress disorder. Conclusions Unaccompanied Sudanese minors have done well in general. The minors function well in school and in activities; however, behavioral and emotional problems manifest in their home lives and emotional states. The subset of children with traumatic symptoms had characteristics that may distinguish them from their peers and that may inform future resettlement services for unaccompanied minors in the United States.

US law and regulations stipulate a process for the health screening of refugees. The responsibility of caring for refugees resettled in the United States rests, in part, with public health or welfare departments. Massachusetts has met its screening responsibilities through the innovative creation of a network of private preferred providers. We explore the Massachusetts model of public–private collaboration within the context of federal refugee health priorities and current state fiscal restraints affecting public health programs, and demonstrate the model’s accomplishments.

Objective To review stressful experiences and stress reactions among child and adolescent refugees, as well as interventions and ethical considerations in research and clinical work, within the framework of the chronological experiences of child refugees; namely, the phases of preflight, flight, and resettlement. Highlighted are special refugee populations such as unaccompanied minors, asylum seekers, and former child soldiers. Pertinent medical findings are summarized. Method The authors reviewed articles from 1990 to 2003 addressing the topics above. Literature was gathered from databases including PsycINFO, Medline, and SocioFile . Pertinent earlier papers and those from other disciplines cited in database-identified articles were also included. Results Child and adolescent refugees suffer from significant conflict-related exposures. Reactions to stress may be mediated by coping strategies, belief systems, and social relations. Conclusions More research is needed on interventions, specifically on efficacy and cultural relevance. Interventions that have an impact on multiple ecological levels need further development and evaluation.

Background: Hepatitis A is the most common vaccine-preventable disease in international travelers. Many individuals born and raised in hepatitis A endemic areas are likely to be immune to hepatitis A. Unnecessary hepatitis A immunization could be avoided by taking into account prior exposure to hepatitis A and judicious use of serotesting prior to immunization. Methods: Patients born and raised in countries of high prevalence of hepatitis A who were seen for pretravel consultation and who had hepatitis antibody measured were eligible. Data were collected about country of birth and length of residence there before emigration, length of time till departure on current trip, current age, and hepatitis A antibody result. Results: Patients ranged from 12 to 74 years of age and were from 27 countries. Their pretravel visit occurred from 4 to more than 90 days prior to departure. Ninety-five percent (122 of 129) of patients were immune to hepatitis A, including 100% (83 of 83) of those who resided in their country of origin until at least aged 20. Most patients were seen for pretravel consultation less than 28 days prior to departure. Conclusion: Individuals born and raised until aged 20 in hepatitis A endemic countries are likely to be immune to hepatitis A. Serotesting is most helpful in assessing immunity to hepatitis A in those under 20 years of age.

Objective. Lead poisoning has been reported among immigrant and refugee populations in the United States; however, prevalences of elevated blood lead (BPb) and risk factors have not been described fully among newly arrived refugee children. This study was conducted to address this lack of data. Methods. We performed analysis of BPb levels among a cohort of refugee children, aged Results. BPb levels ≥10 μg/dL were found in 11.3% of 693 children shortly after their arrival in the United States. Children from developing countries had the highest prevalences, including 27% of Somalis and Vietnamese. Country of birth was the strongest predictor of elevated BPb. No association between elevated lead and age was found. Among 213 children with BPb tests ≥6 months after the initial test, 7% had newly elevated levels of ≥10 μg/dL. Conclusions. The prevalence of elevated BPb levels in recently arrived refugee children is more than twice that of US-born children. Children who are at particular risk are those from developing countries where environmental exposures are more ubiquitous. In addition, a significant percentage of refugees acquired elevated levels after arrival, thus suggesting the importance of follow-up testing of refugee children. Refugee status should be considered a risk factor for lead poisoning.

The authors assessed war violence exposure and behavioral symptoms in Bosnian refugee children in Massachusetts and the utility of behavioral screening of refugees during the Refugee Health Assessment (RHA), required of newly arrived refugees. The study was a survey of 31 Bosnian refugee children in 1996 at the International Clinic of Boston Medical Center, the state's largest contracted provider of the RHA. Subjects were also offered referrals to appropriate mental health services. Sixty-eight percent experienced long-term separation from a parent. Eighty-one percent were directly exposed to armed combat. Seventy-one percent experienced the death of a close friend or relative. Fifty-two percent experienced economic deprivation. Families reported behavioral symptoms for 77% of children. Only one family expressed interest in psychosocial services of any kind. Large numbers of Bosnian refugees are likely to have experienced traumatic war violence and are at risk of behavioral symptoms. The RHA affords opportunities to screen for behavioral problems but not to intervene. Primary care providers and other clinicians should be aware of likely recurrences of symptoms in high-risk children such as these.

Objectives. This study assessed the potential impact of immigration reporting requirements on pediatricians' referrals to child protective services. Methods. A random sample of 200 Massachusetts pediatricians were surveyed. Chi-square and logistic regression analyses were performed. Results. Asked whether potential deportation of the family would cause them to question or alter a decision to refer, 50% of the respondents said yes. Conclusions. Pediatricians, as mandated reporters of child abuse, will face ethical dilemmas if laws requiring reporting of immigration status are enacted. (Am J Public Health. 1998;88:967-968)

THE RWANDAN genocide of 1994 will be remembered as one of the greatest human tragedies of our time. In less than 3 months, extremists systematically slaughtered more than 500 000 people, including thousands of children. 1 The massacres reignited a bloody civil war that forced more than 4 million people to flee their homes. 2 Today, nearly 3 years later, Rwanda remains a highly traumatized society, where children are its most vulnerable members. Among those most at risk are more than 100000 children who were orphaned or separated from their parents (United Nations Children's Fund, unpublished data, press release 94/26, May 24, 1994). Between August 1994 and February 1996, we traveled on 3 occasions to Rwanda and northeastern Zaire as representatives of Medecins du Monde and Physicians for Human Rights. Our task was to assess the nature and scope of the Rwandan genocide and its effects on children. We also

During the ongoing national discussion of proposals to reform health care financing, effects on the health status of children emerged as a special concern. Public attention has shifted away from comprehensive reform of the health care system and toward reform of the welfare system (primarily the Aid to Families with Dependent Children [AFDC] program), but this debate with its focus on parental behavior has not attended to the effects of reform on children's health and well-being. Yet the changes proposed will have a profound effect on the lives of children. Children's health status is determined by a multiplicity of factors, among which social and economic factors are especially important. 1,2 Children living in poverty have poorer health than their more affluent peers, 1-16 consequently, welfare system reform carries great implications for children's health. Welfare system reforms that reduce resources for low-income families will lead to a predictable increase in adverse