1. TB Control for Unaccompanied Children in ORR Custody
California TB Controllers Association Educational Conference, March 7, 2017
John Jereb, MD
Senior Consultant/Contractor, Medical Officer, DHUC-ORR, ACF
Office of Refugee Resettlement

2. Conflict of Interest Disclosure Statement
Neither I, nor my spouse/partner have or have had financial or other relationships with any commercial interest organizations.
No off-label usage of pharmaceutical products will be discussed.

3. Overview of Topics What is the Office of Refuge Resettlement (ORR)
Who are Unaccompanied Children (UC)
Where are UC placed
What is the healthcare for UC
How is TB diagnosed in UC
What are the roles of local public health
What is the epidemiology of TB among UC

4. Brief History of ORR
1980
The 1980 Refugee Act establishes the federal Office of Refugee Resettlement (ORR) to serve refugees, unaccompanied refugee minors, and Cuban/Haitian entrants
2000
ORR expands its service provision to asylees, survivors of torture, and certified adult victims of human trafficking
2003
The Homeland Security Act of 2002 transfers oversight of unaccompanied alien children to ORR
ORR expands its service provision to certified child victims of trafficking, Iraqi special immigrants visa (SIV) holders, and Afghan SIV holders

5. A person who owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion is outside the country of his nationality and is unable or, owing to such fear, is unwilling to avail himself of the protection of that country. ̶ 1951 Refugee Convention, United Nations

6. Unaccompanied Children: Statutory Definition and Rules for Referral
Intercepted in United States, younger than 18 years, no U.S. lawful immigration status, no U.S. parent or legal guardian, or, no U.S. parent or legal guardian available to provide care or legal custody.
Referred to ORR for placement by another Federal agency, usually the Department of Homeland Security.
Other Federal agencies have to transfer the custody of an unaccompanied child to ORR within 72 hours.
The majority of UC come into ORR care because they were apprehended while trying to cross the border.
Others are referred as a result of interior apprehensions after involvement with local law enforcement or internal immigration raids.

7. Why are they coming?
My grandmother wanted me to leave. She told me: “If you don’t join, the gang will shoot you. If you do join, the rival gang will shoot you—or the cops will shoot you. But if you leave, no one will shoot you.” -- Kevin, age 17 I am here because the gang threatened me. One of them “liked” me. Another gang member told my uncle that he should get me out of there because the guy who liked me was going to do me harm. In El Salvador they take young girls, rape them and throw them in plastic bags…. -- Maritza, age 15
From the UNHCR report, Children on the Run

8. Countries of Origin (FY2016) All other countries combined:
UC Referral Numbers
Countries of Origin (FY2016)
Honduras
Guatemala
El Salvador
All other countries combined:
5% of total in 2016

9. UC Age at Admission to ORR Custody

10. ORR UC Program Responsibilities
Care and custody of UC (shelter, food, clothing, and services)
Placement and transfer
Reunification with qualified sponsors
Administration of ORR-funded care provider facilities
Compliance with national and local care standards

11. States Having Shelters, January 2017
Arizona
California
Florida
Illinois
Massachusetts
Michigan
New York
Oregon
Pennsylvania
Texas
Virginia
Washington

12. Health Care for UC Routine medical examination within 48 hr
Immunizations, on catch-up schedule
Pregnancy testing (per algorithm)
HIV testing (per algorithm)
Tests and screens for TB
Mental health screening and referral
Emergency medical care
Follow-up care for chronic illnesses
Routine dental care (after extended stay)
Public health and welfare notifications per law

13. Common Health Topics Immunizations Ectoparasites (e.g., scabies)
Chickenpox
Influenza-like illness
Gastroenteritis and dehydration
Dental caries
Epilepsy (neurocysticercosis)
Sports-related injuries
Pregnancy

14. Rare Health Problems Solid-tissue tumors Leukemia Sickle cell disease
Hemophilia
Major congenital cardiac malformations
Renal failure
Chromosomal anomalies
Premature births
Zika

15. Mental Health Problems
Post-traumatic stress disorder
Depression
Suicidal ideation
Self-harming behaviors

16. DGMQ-CDC Technical Instructions for Immigrants and Refugees
Overseas screening for “excludable conditions”
TB instructions
Active case finding, aged 15 years and older
Full treatment before clearance for travel
Testing with TST, aged < 15 years

17. TB Control Strategy for UC, Part I
General health screening at time of apprehension (before ORR custody)
Active case finding
Symptoms screen and general examination
Aged 15–17 yr, chest radiography, with referral for abnormalities consistent with TB disease*
*Model: CDC Technical Instructions for Medical Examination of Aliens

18. TB Control Strategy for UC, Part II
TB prevention
Recommended by AAP, ATS, and CDC
Diagnose latent M. tuberculosis infection (LTBI)
Aged ≥5 yr, interferon-gamma release assay preferred
Aged <5 yr, tuberculin skin test preferred
Radiography after positive tests results
Information letter for sponsor
Notification to state health department at destination after release from ORR custody
No routine treatment during ORR custody

19. Roles of Local Public Health
Examination of children who might have TB
Technical support when a child is in hospital for TB examination
Treatment of TB
Education for personnel who work at shelters
Assistance with ORR information collection
Contact investigation
Follow-up for LTBI

20. TB Diagnoses (n = 15), UC in ORR Custody, FY2014–2015
Period prevalence 19/10,000

21. The 18 States Receiving >500 UC in Sponsor Placement after Release, FY2016 (N = 52,147)*
Number UC
Alabama
870
California
7,381
Florida
5,281
Georgia
1,735
Illinois
519
Kentucky
503
Louisiana
973
Maryland
3,871
Massachusetts
1,541
State
Number UC
New Jersey
2,637
New York
4,985
North Carolina
1,493
Ohio
693
Pennsylvania
604
South Carolina
562
Tennessee
1,354
Texas
6,550
Virginia
3,278
*Every state except Montana received at least one.
Source: ORR