TB Control for Unaccompanied Children in ORR Custody
IUATLD-NTCA Annual TB ConferenceDenver, Colorado, 27 February 2016
John Jereb, MDMedical Officer, UC Medical TeamOffice of Refugee Resettlement
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Overview of Topics
• What is the Office of Refuge Resettlement (ORR)• Who are Unaccompanied Children (UC)• Where are UC placed• What is the health care for UC• How is TB diagnosed in UC• What is the epidemiology of TB among UC
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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
2007-2009
• ORR expands its service provision to certified child victims of trafficking, Iraqi special immigrants visa (SIV) holders, and Afghan SIV holders
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
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.
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
Referral Numbers
0
10,000
20,000
30,000
40,000
50,000
60,000
70,000
2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Honduras
Guatemala
El Salvador
All other countries combined: <5% of total in 2014
Countries of Origin (FY2014)
UC Age at Admission to ORR Custody
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
FY2011 FY2012 FY2013 FY2014 FY2015
17 yr15–16 yr13–14 yr0–12 yr
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 care standards
12 States Receiving >500 UCin Sponsor Placement after Release,
FY2015 (N = 27,520)*State Number UC
Alabama 813
California 3,576
Florida 2,885
Georgia 1,028
Maryland 1,784
Massachusetts 723
New Jersey 1,440
New York 2,615
North Carolina 833
Tennessee 757
Texas 3,209
Virginia 1,676Source: ORR*Every state received at least one.
ORR‐Funded Health Care for UC• Routine medical examination within 48 hr
• Immunizations, on catch‐up schedule• Pregnancy testing (per algorithm)• Tests and screens for TB
• Mental health screening and referral• Acute/emergency care• Follow‐up care• Routine dental care (after extended stay)• Public health and welfare notifications per law
Common Health Topics• Immunizations• Ectoparasites (e.g., scabies)• Chickenpox• Influenza‐like illness• Gastroenteritis and dehydration• Dental caries• Epilepsy (neurocysticercosis)• Sports‐related injuries• Pregnancy
Rare Health Problems
• Solid‐tissue tumors• Leukemia• Sickle cell disease• Hemophilia• Congenital cardiac malformations• Renal failure• Chromosomal anomalies• Premature births
Mental Health Problems
• Post‐traumatic stress disorder• Depression• Suicidal ideation• Self‐harming behaviors• Sociopathy, gang membership, etc.
Health Information Systems
Children in ORR care center
Sources of healthcare
Health department
ACF‐ORR(You are here…)
Underwriter contractor
$$
Health information
Billing information & requests for approval
Children needing care
Requ
ests fo
r app
roval
$$
$$ Policies a
nd procedu
res
Health inform
ation
TB Control Strategy for UC, Part I• General health screening at time of apprehension (before ORR custody)
• Active case finding– Symptoms screen and general examination– Aged 15–17 yr, chest radiography, with referral for abnormalities consistent with TB disease*
*Model: CDC Technical Instructions for Medical Examination of Aliens
TB Control Strategy for UC, Part II
• TB prevention– Diagnose latent M. tuberculosis infection (LTBI)
• Aged ≥5 yr, interferon‐gamma release assay preferred• Aged <5 yr, tuberculin skin test preferred
– Radiography after positive tests results– Information letter for sponsor– Notification to state health department at destination after release from ORR custody
– No routine treatment during ORR custody
Health Information Systems
Children in ORR care center
Sources of healthcare
Health department
ACF‐ORR(You are here…)
Underwriter contractor
$$
Health information
Billing information & requests for approval
Children needing care
Requ
ests fo
r app
roval
$$$$ Policies
Health inform
ation
TB Diagnoses (n = 15),UC in ORR Custody, FY2014–2015
Period prevalence 19/10,000
TB Examinations, Records Audit, Children Aged <2 Years (n=277),
Oct2014–Sep2015Chest X‐Ray
Test Normal Abnormal No CXR results
TST or IGRA
Positive 3 0 0
Negative 0 0 79
Discrepant TST & IGRA results 0 0 0
No TST or IGRA results 3 0 192
85 (30.7%) had at least one TB result (TST, IGRA, or CXR) recorded
TB Examinations, Records Audit, Children Aged 2–4 Years (n=405),
Oct2014–Sep2015Chest X‐Ray
Test Normal Abnormal No CXR results
TST or IGRA
Positive 5 0 3
Negative 0 0 351
Discrepant TST & IGRA results 0 0 0
No TST or IGRA results 2 0 44
361 (89.1%) had at least one TB result (TST, IGRA, or CXR) recordedPrevalence positive 2.2%
TB Examinations, Records Audit, Children Aged 5–14 Years (n=9,717),
Oct2014–Sep2015Chest X‐Ray
Test Normal Abnormal No CXR results
TST or IGRA
Positive 382 19 93
Negative 109 0 8,025
Discrepant TST & IGRA results 7 0 7
No TST or IGRA results 283 3 789
8,928 (91.9%) had at least one TB result (TST, IGRA, or CXR) recordedPrevalence positive 5.7%
TB Examinations, Records Audit, Children Aged 15–17 Years (n=22,731),
Oct2014–Sep2015Chest X‐Ray
Test Normal Abnormal No CXR results
TST or IGRA
Positive 753 32 190
Negative 189 22 8,406
Discrepant TST & IGRA results 2 1 1
No TST or IGRA results 10,530 3 789
20,256 (89.1%) had at least one TB result (TST, IGRA, or CXR) recorded
Conclusions:• Thousands of UC in ORR custody are being screened or tested for TB.
• The coverage for TB screening and testing is at least 90% of what was intended, as measured by recording results.
• Prevalence of TB disease and LTBI are about what we expect for the countries of origin.
• The burden of work is large, and coordination with TB control authorities is essential.
