1. Kevin Pottie MD MClSc CCFP FCFP Associate Professor, Departments of Family Medicine and Epidemiology and Community Medicine, University of Ottawa on behalf of the Canadian Collaboration for Immigrant and Refugee Health www.ccirhken.ca Evidence-Based eChecklist for Immigrants & Refugees

2. Faculty/Presenter Disclosure Faculty: Kevin Pottie Program: 51 st Annual Scientific Assembly Relationships with Organizations: –Grants/Research Support: CIHR Peer Reviewed Funding, Canadian Task Force on Preventive Health Care –Consulting Fees: Canadian Thoracic Society Guideline Methods Support, WHO Guideline Methodologist (GRADE) –Other: Chair of the Canadian Collaboration for Immigrant and Refugee Health

3. Disclosure of Commercial Support This program has received financial support from the Canadian Collaboration for Immigrant and Refugee Health. This program has received in-kind support in the form of translation from the Department of Family Medicine, University of Ottawa Potential for conflict(s) of interest: –No commercial support or potential conflict of interest

4. Mitigating Potential Bias Declaration: I declare that I am an evidence based (GRADE approach) guideline methodologist and developer for several organizations

5. Objectives Brief evidence based guideline overview Current methods to access CCIRH guidelines Walk-through of the e-checklist

6. 6 \ Photo Credit: International Organization for Migration and WHO

7. >1 Billion Migrants Worldwide 215 M international migrants (UNDESA) 740 M internal migrants (UNDP) (includes 15 M refugees (UNHCR) - 50% of migrant women

8. Guideline Objective To develop evidence-based preventive guidelines for immigrants and refugees (focus on first 5 years after arrival) 8

9. Evidence Based Clinical Guidelines for Immigrants & Refugees Infectious Diseases MMR/DPTP-HIB Varicella (Chicken Pox) Hepatitis B* Tuberculosis* HIV/ AIDS* Hepatitis C Intestinal Parasites* Malaria Mental Health and Maltreatment Depression * Post Traumatic Stress Disorder* Child Maltreatment* Intimate Partner Violence * Other Chronic Disease Diabetes* Dental disease* Contraception Cervical Cervix/HPV Iron Deficiency Anemia* Vision Disorders Pregnancy Care Pottie K, Greenaway C, Feightner J, et al. Evidence Based Clinical Guidelines for Immigrants and Refugees. CMAJ 2011

10. HOW EASILY INTERVENTIONS LOSE TRACTION Efficacy X Access X Targeting Accuracy X Provider Compliance X Consumer Adherence = Effectiveness 20% X 80% X 75% = 7% X 80% From Efficacy to Effective Coverage Health System Factors Averages mask inequities Credit: Don deSavigny

12. 102 page…summary! Evidence Based Clinical Guidelines for Immigrants & Refugees

13. Point of Access – www.ccirhken.ca

15. What about a practical point-of-care tool that also provides a quick reference? Point of Access – www.ccirhken.ca

16. Checklist Rourke-inspired adaptation of CMAJ CCIRH guidelines 2 versions; identical content Paper –Checklist with references Online –Links to podcasts and resources

17. Checklist

18. Web Checklist Walkthrough http://www.ccirhken.ca/

19. Case studies Scenario “Jemi Family arrives from Kenya” Mr. Jemi is 35 years old man French/Lingala from the Democratic Republic of Congo who arrived in Canada 6 weeks ago as a convention refugee. Ms Jemi is a 32 year old wife who speaks Lingala and Swahili but not French. (convention refugee) Three children: 15 year old boy, 8 year old girl, 3 year old girl. (convention refugees) 19

20. VACCINATION Do MMR and TDP-P serology on Mrs Jemi on arrival? yes no maybe Do Hepatitis B serology on Mrs Jemi on arrival? yes no maybe Do varicella serology on Mrs Jemi on arrival? yesnomaybe 20

21. VACCINATION Vaccinate against MMR (1 dose ) and TDP-P (3 doses, at least 1 dose of acellular pertussis- aP). Vaccinate girls and women against HPV (9-26 year old to prevent cervical cancer). Vaccinate against Hepatitis B, if susceptible. Vaccinate against Varicella, if susceptible. 21

22. INFECTIOUS DISEASESINFECTIOUS DISEASES Screen the Jemi family for malaria? yesnomaybe Screen Mr. Jemi for HIV? yesnomaybe Screen the Jemi family for intestinal parasites with stool for ova and parasites? yesnomaybe 22

23. INFECTIOUS DISEASESINFECTIOUS DISEASES Screen high risk immigrants/refugees for latent TB (Mantoux) and treat with Isoniazid (9 months). Screen for HIV, if from HIV endemic region. Screen for Chronic Hepatitis B, if from endemic region Screen for Hepatitis C, if from endemic region Serology for refugees: strongyloides if from SSA and Asia, schistosomiasis (SSA) (stool if symptomatic) Be alert for malaria if fever, do not routinely screen Pottie K, Greenaway C, Feightner J, et al. Evidence Based Clinical Guidelines for Immigrants and Refugees. CMAJ 2011 23

24. Scenario “Jemi Family arrives from Kenya” Both Mr. and Ms. Jemi are in high spirits during the visit, but should they be screened for mental health issues such as PTSD? What about screening for intimate partners violence and potential child abuse? 24

25. MENTAL HEALTH AND MALTREATMENTMENTAL HEALTH AND MALTREATMENT Screen Mr. and Ms. Jemi for depression? yesnomaybe Screen Ms. Jemi for PTSD? yesnomaybe Screen the Jemi children for child maltreatment? yesnomaybe 25

26. MENTAL HEALTH AND MALTREATMENTMENTAL HEALTH AND MALTREATMENT If linked to an integrated treatment program, screen adults for depression Be alert for signs of Post Traumatic Stress Disorder, do not routinely screen Be alert for intimate partner violence, if 1 night in shelter refer for empowerment program Be alert for child maltreatment, do not routinely screen, rather offer high risk mothers nurse visitation program to prevent childhood injuries Pottie K, Greenaway C, Feightner J, et al. Evidence Based Clinical Guidelines for Immigrants and Refugees. CMAJ 2011 26

27. COMMON MENTAL HEALTH PROBLEMSCOMMON MENTAL HEALTH PROBLEMS Newly arrived immigrants had the lowest rates of depression ([OR] 0.33, 95% CI) and alcohol dependence (OR 0.05, 95% CI). Highest rates- Europe; lowest- Africa and Asia. Refugees who have had severe exposure to violence often have higher rates of trauma-related disorders, including post-traumatic stress disorder and chronic pain or other somatic syndromes. Elevated risk of acute psychosis among first-generation migrants: 2.7 (95%CI 2.3–3.2); highest-developing country origin Assessment of risk for mental health problems includes consideration of pre-migration exposures, stresses and uncertainty during migration, and post-migration resettlement experiences. Kirmayer et al. Common mental health problems in immigrants and refugees: general approach in primary care. CMAJ 2010 27

28. PTSD The majority of those who experience traumatic events will heal spontaneously after reaching safety. However, around 44% of those who do develop PTSD are likely to have depression simultaneously. Be alert for PTSD symptoms. Empathy, reassurance and advocacy are key clinical to the recovery process. Pushing for disclosure of traumatic events for well-functioning individuals could be harmful. Rousseau, Pottie et al. Post Traumatic Stress Disorder: Evidence review for newly arriving immigrants and refugees. CMAJ 2011 28

29. CHILD MALTREATMENTCHILD MALTREATMENT CCIRH recommends against routine screening due to poor performance of screening instruments and potential harms because of the very high false positive rates. Sensitivity ranged between 25% and 100%; specificity ranged between 16.5% and 94.3%; and positive predictive value (when available) ranged between 1.7% and 28.2%. Hassan et al. Child Maltreatment, Evidence Review for newly arriving immigrants and refugees. CMAJ 2011 29

30. CHRONIC NON-COMMUNICABLE DISEASESCHRONIC NON-COMMUNICABLE DISEASES Screen immigrants > 35 years of age from ethnic groups at high risk for type 2 diabetes (South Asian, Latin American and African) with fasting blood glucose Screen for iron def anemia in children (1-4) and women (15-50) hemoglobin and follow-up ferritin Screen children and adults for visual impairment (not tropical eye diseases) Screen for obvious dental pathology, treat dental pain with NSAIDS, and refer to dental specialist Pottie, Greenaway et al. Evidence Based Clinical Guidelines for Immigrants and Refugees. CMAJ 2011 30

31. TYPE 2 DIABETESTYPE 2 DIABETES Certain ethnicities face a two-to-four fold higher prevalence of type 2 diabetes with earlier onset compared to Caucasians. Persons with hypertension and hypercholesterolemia are at high risk for complications from diabetes and have the most to gain from treatment of obesity, high cholesterol, hypertension and hyperglycaemia. Culturally-appropriate diabetes education and lifestyle interventions are effective at preventing or improving disease management, at least in the short-term. Cultural tailoring involves patient-centred tailoring, shifting the reference point for interventions from the needs and perspective of the providers to those of the client population. (Patient Centred) Dominic, Pottie et al. Type 2 Diabetes mellitus: Evidence review for newly arriving immigrants and refugees. CMAJ 2011 31

32. VISION HEALTHVISION HEALTH Even modest visual impairment (visual acuity < 6/12) is associated with significant morbidity. Regionally prominent “tropical” eye diseases, such as onchocerciasis (river blindness), active trachoma and xerophthalmia, have not been reported in immigrants or refugees to Canada. Special considerations exist for doing vision screening of children < 8 years of age. Referral for assessment is also warranted for other risk factors for blinding eye disease, including diabetes, age > 65 years, blacks >40 years, glaucoma in a first-degree relative and myopia exceeding –6 diopters. Buhrmann, et al. Vision Health: Evidence review for newly arriving immigrants and refugees. CMAJ 2011 32

33. WOMEN’S HEALTHWOMEN’S HEALTH Screen adolescent females and women for unmet contraceptive need, soon after arrival Screen for iron deficiency anemia in women of childbearing age. Screen for cervical cancer (pap test) and offer HPV vaccination for 9-26 year old females. Remain alert for intimate partner violence, do not routinely screen Research needed for interventions for social isolation in pregnancy Pottie, Greenaway et al. Evidence Based Clinical Guidelines for Immigrants and Refugees. CMAJ 2011 33

34. CONTRACEPTION Screening should begin soon after women’s arrival in Canada. Women from developing countries are often unaware of emergency contraception. Acceptability of contraception and method preferences varies across world regions. (e.g. intrauterine device use is predominant in Asia and Latin America). In some communities, condoms have connotations of infidelity, promiscuity or sexually transmitted infection, or are used only with non-marital partners. Giving women their method of choice, providing the contraceptive method on-site and having a good personal rapport improve contraception-related outcomes. Dunn S, Janakiram et al. Contraception, Evidence Review and Clinical Guide for Care of Newly Arrived Immigrants and Refugees. CMAJ 2011 34

35. CERVICAL CANCERCERVICAL CANCER Subgroups of immigrant and refugee women have low cervical cytology screening. Women who have never had cervical screening or have not had cervical screening in the previous five years account for 60%–90% of invasive cervical cancers. Providing information to patients, building rapport and offering access to female practitioners can improve acceptance of Pap testing. Pottie et al. Cervical cancer - Evidence review for newly arriving immigrants and refugees. CMAJ 2011 35

37. Project Team

38. Thank you! Questions? Canadian Collaboration for Immigrant and Refugee Health Knowledge Exchange Network http://www.ccirhken.ca/ Physician friendly e-checklist, Cochrane immigrant podcasts, refugee health e-learning and calendar for events and training opportunties)