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By Lauren M. Carlson, Sherrill (Charlie) Rose, and Philip R. Fischer, MD, DTM&H
Lauren Carlson and Sherrill (Charlie) Rose are students at Mayo Medical School in Rochester, MN. Dr. Fischer is Professor of Pediatrics, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN.
Ms. Carlson, Ms. Rose, and Dr. Fischer report no financial relationships relevant to this field of study.
SYNOPSIS: Physicians can improve the health of unaccompanied Central American immigrant children by ensuring appropriate vaccination, by identifying culturally and linguistically appropriate community resources, and by becoming involved in patient advocacy.
SOURCE: Robinson LK. Arrived: The crisis of unaccompanied children at our southern border. Pediatrics 2015;135:205-207.
With 60,000 children arriving in the United States through the southern border within the first eight months of 2014, physicians voiced desires to understand more about the situation of these immigrants and to find appropriate ways to help. Many of the unaccompanied children and young families are arriving from Guatemala, El Salvador, and Honduras, countries facing extreme poverty and violence. A few media and public officials have suggested that these children pose a public health threat. One response, on behalf of medical providers, is to identify the facts and to share this information with the local community, including the difference between serious and nonserious conditions, as well as opportunities for treatment. Unaccompanied children entering the country undergo health screening and vaccination through the U.S. Department of Health and Human Services (HHS), including a tuberculosis screen, urine pregnancy test for girls older than 9 years of age, and multiple critical vaccinations appropriate for a catch-up schedule identified by the Advisory Committee on Immunization Practices.
Robinson identifies three important responses by U.S.-based physicians: to vaccinate, to know your community resources, and to advocate. Identification of a catch-up immunization schedule for children is crucial, and although immigrants may not be eligible for federal assistance programs, they may be eligible for local charity care and the Centers for Disease Control and Prevention’s Vaccines for Children program. In addition to identifying local organizations serving Spanish-speaking populations through the process of clinical care and satisfaction of other essential needs, use of interpreter services and Spanish screening forms are aspects of providing culturally and linguistically appropriate resources through a clinic. Advocacy may take many forms, such as medico-legal partnerships to improve awareness of immigrant rights, as well as supporting greater access to services, both legal and medical, for immigrants and underserved populations in general. Looking ahead, providers have an opportunity to support immigrants in breaking the barrier of health care access.
There is an ongoing need for pediatricians and infectious disease physicians to consider the special needs of immigrant children in the United States. To this end, the author offers compelling direction on how to begin the process of improving the health of Central American child immigrants to the United States. Issues of immunization and infectious disease are vitally important for immigrant children. At the same time, though, infectious disease physicians can also promote overall health among vulnerable child immigrants.
It is important for physicians to be able to identify the unique health risks of a population and also to be able to separate legitimate health risks and need from health concerns that are primarily media-driven. In addition to the author’s examples of spurious connections between immigrant children and both H1N1 and Ebola, we have also seen attempts to make connections between immigrants and the recent measles and enterovirus outbreaks. The Health and Human Services Department and the CDC have denied any connection between the immigrant children and either measles or enterovirus outbreaks in the United States. In the case of measles, World Health Organization records show that from 2009-2013, the last five years for which data are available, measles vaccine rates in El Salvador, Honduras, and Guatemala have often exceeded rates in the United States.
Although Central American countries have generally strong vaccination rates, it does appear that there is greater year-to-year variation in vaccination rates in Central American countries than in the United States. During that five-year period, U.S. rates ranged from 90-92%, while rates in Central America ranged from 85-99%. These fluctuations may show that vaccination rates in Central America are more vulnerable to external influence, such as economic instability or sociopolitical factors. Also, children in migration are presumably at higher risk for missing routine preventive health care, and factors such as whether children are coming from urban or rural settings may also influence their access to care. Physicians should not assume that a child from Central America has been vaccinated but should instead rely on vaccination records when they are available and initiate catch-up vaccination schedules when necessary. Suggested schedules are available from the CDC.1
Beyond initiating catch-up vaccinations, physicians should be aware of and screen as needed for infectious diseases for which Central American immigrants may be at risk but for which no vaccine is readily available, such as Chagas disease, HIV, intestinal parasites, and sexually transmitted infections (STIs). Current HHS practices include a urine pregnancy test for girls older than the age of 9, which illustrates a need for STI screening as well, especially because of the high potential for rape before or during the journey to the border.It may be useful for physicians to research the particular endemic diseases in the country of origin as well as countries passed en route to the United States. For example, an estimated 1.98%, 3.05%, and 3.37% of immigrants from Guatemala, Honduras, and El Salvador, respectively, are infected with Trypanosoma cruzi, the causative agent of Chagas disease.2 Chagas disease is considered a neglected tropical illness. There are no guidelines for routine screening, although it may be warranted in this high-risk population, especially because infection is only curable in the acute phase and can lead to lifelong cardiac complications. Comorbid infections can worsen the prognosis for diseases like Chagas; for example, co-infection with HIV and Chagas hastens progression of illness.
Screening guidelines for Chagas infection should be considered as part of an effort to treat congenitally infected infants. All immigrant mothers should possibly be screened, as screening guidelines exist for babies born to seropositive mothers to be tested at 9 months of age. Antiparasitic treatment is indicated for all patients with acute disease, including congenital infections, and is advised for patients with chronic disease who are up to 18 years of age; even though there is no FDA-approved treatment for Chagas, nifurtimox and benznidazole have proven efficacious.3 Concerned physicians can advocate for an improvement of existing screening guidelines and treatment availability and can also educate fellow providers and the patient population about the disease.
Other important factors that impact the health of Central American children include language barriers and the resurgence of family detention centers. Many Central American immigrants speak only indigenous languages and require translation services. In addition, as immigrant families and children are detained in institutional settings, there will be added risk for contracting diseases such as TB that flourish in some detention centers.