Refugee Health in Côte des Neiges, 2018 Saint Mary’s Hospital Family Medicine Centre Grand Rounds August 29, 2018 Dr. Hannah Shenker MD CCFP Dr. Ann Katrin Richter MD CCFP CLSC Côte des Neiges
Refugee Health in
Côte des Neiges, 2018
Saint Mary’s Hospital
Family Medicine Centre Grand Rounds
August 29, 2018
Dr. Hannah Shenker MD CCFP
Dr. Ann Katrin Richter MD CCFP
CLSC Côte des Neiges
We have no conflict of interest to declare; We have
no affiliation, honoraria or monetary support from
an industry source.
Case Study 1 Amena
22 year old G3P2 presenting for prenatal care.
Born in Syria, had been living in a refugee camp in
Jordan x 5 years where she met her husband and
gave birth to 2 daughters.
Unilingual arabic
All 4 family members are government sponsored
refugees who arrived in Canada 3 months earlier
Living in an apartment in Villeray with support from
the Centre Sociale d’Aide aux Immigrants (CSAI)
Referred to PRAIDA for a voluntary refugee health
assessment
A Refugee health assessment (BSR) was performed at the CLSC Cote des Neiges by a nurse from PRAIDA
12 weeks pregnant
Iron deficiency
Vitamin D deficiency
OCD and PTSD
Contact dermatitis both hands due to repetitive hand washing
Hyperemesis gravidarum - mild
CBC and Hb electrophoresis normal
HIV, VDRL, HBV, HCV, Strongyloides all negative
Rubella immune, Varicella immune
CXR Normal
Referred to La Maison Bleue for interdisciplicary prenatal care and to RIVO for psychological services
Definitions Asylum seeker;
A person who requests protection from Canada upon
arrival in the country or during a temporary stay.
Under the United Nations’ Convention relating to the Status of Refugees, Canada grants asylum to certain
people on its territory who fear persecution or whose
lives would be in danger if they were to return to their
country of origin.
Canada’s Immigration and Refugee Board evaluates
each application and renders its decision on whether
or not to grant refugee status.
Definitions Refugee
A person who receives protection from Canada
Refugees selected abroad;
admitted to Canada after having spent many years in a refugee camp or because they were persecuted in their own country.
Upon arrival, they either receive assistance from the State, local NGO, or by a group or organization that has agreed to sponsor them.
Refugees recognized in Canada;
Recognized by the Immigration and Refugee Board after submitting an asylum application upon their arrival in Canada.
Definitions A Person without legal status
a tourist or temporary resident who has not renewed
his/her tourist visa or study permit, or whose work
permit has expired, and who has not left Canada
a person whose asylum application has been refused,
who has exhausted all possible recourse and who has
not obeyed a removal order
a person who has illegally crossed the border and has
not reported to the authorities
What are the steps involved in the
asylum application process?
Routine identity, health and security screening performed by the Canada Border Services Agency.
People are directed to temporary shelters.
The Québec government provides essential services to asylum seekers until the Immigration and Refugee Board (IRB) has rendered its decision on whether or not to grant refugee status.
If the IRB recognizes their refugee status, Québec issues a Certificat de sélection du Québec.
If a claim is rejected, individuals may be able to appeal the decision to the Refugee Appeal Division of the IRB
Statistics www.immigration-quebec.gouv.qc.ca
The top 5 birth countries of asylum seekers in
Québec in 2017
Haiti, Nigeria, USA, India, Saudi Arabia
On August 3, 2018 (Montreal):
56 new asylum seekers were provided with
accommodation
842 asylum seekers were being temporarily housed in
the Greater Montreal area
Statistics - cont
Asylum Claims Canada Québec
2016 23, 925 5,525
2017 49, 775 24,980
As of April 17, 2018, 14, 860 asylum seekers were living in Québec while waiting for their claim to be processed by the federal government.
Services offered to Asylum seekers while awaiting evaluation of their claim;
Temporary accommodation
Support to find permanent accommodation
Last resort financial assistance
Healthcare (Federal Interim Health Program)
Language classes
Access to school for minors
https://www.immigration-quebec.gouv.qc.ca/publications/en/divers/Guide-asylum-seekers.pdf
Health Screening of refugees and
asylum seekers performed by the
Canada Border Services Agency
Designed to assess a limited number of public health risks, not to provide preventative screening
Done within 12 months prior to arrival in Canada, or within 60 days of saylum claim in Canada
Physical exam by a designate physician
CXR (>11y)
VDRL (>15y)
UA (> 5y)
HIV (>15y or HIV +ve mother or recipient blood products)
Results are not necessarily linked with any f/u
Patient may not be aware of need for f/u
Results difficult to access as they are property of the government
Refugee Health Assessment Voluntary
Covered by the Interim federal health program
Offered in 14 cities across Québec
PRAIDA is designated service for the Island of Montreal
Well being assessment by a social worker
Health assessment by a nurse
History and physical exam
CBC, Hb electrophoresis, Vit D level
Screening for HIV, VDRL, Shisto, varicella IgG, HBV, HCV, TB
Referral for further assessment or treatment as necessary
Registration on GAMF
CMAJ, September 6, 2011, 183 (12)
Key points from the Canadian clinical
practice guideline for immigrant and
refugee health, 2011
Clinical preventive care should be informed by the person’s region or country of origin and migration history.
Forced migration, low income and limited proficiency in English or French increase the risk of a decline in health and should be considered in the assessment and delivery of preventive care.
Routinely offer:
Vaccination
measles, mumps, rubella, diphtheria, tetanus, pertussis, polio, VZV, hepatitis B, HPV
Screening for
hepatitis B and C, TB, HIV, intestinal parasites (strongyloides, schisto)
iron deficiency, dental pain, loss of vision, cervical cancer
Detecting and addressing the following conditions should be individualized to improve detection, adherence and treatment outcomes.
malaria, depression, PTSD, child maltreatment, intimate partner violence, diabetes mellitus, contraceptive needs, pregnancy
Pregnancy in the Refugee
Population Social Isolation, Depression, PTSD
associated with SGA infants and increased maternal morbidity
Sexual Abuse
Associated with unwanted pregnancies, psychological distress, STIs, PID, reproductive tract trauma, social rejection, infant abandonment or mistreatment
Infectious Diseases – Hep B, HIV, Syphilis, Zika
Hemoglobinopathies
Poor Nutritional Status
Workplace hazards
Female genital mutilation
Higher incidence of HTN Disorders of Pregnancy
Incorrect or incomplete obstetrical histories
Previous cesarien section with unclear indication, no OR report.
La Maison Bleue Centre de Perinatalité sociale
3 sites in Montreal (CDN, Park Ex, St Michel)
Interdisciplinary care of pregnant women and their
children living in contexts of social vulnerability
http://maisonbleue.info/
Case Study 2 Mme Diawara
46yo refugee claimant from Guinea referred to your
clinic from PRAIDA
Known for diabetes treated with glyburide
C/o insomnia and blurred vision
Has been in Canada for 3 weeks with her 2 young
grandchildren
Victim of persecution due to her role educating
and empowering women
Victim of physical and sexual assault
Daughter (mother of her grandchildren) was
imprisoned and has since disappeared
PHYSICAL HEALTH
Has not taken any medication in last 2 weeks
C/o polyuria and polydipsia
Random glycemia is 13.2
MENTAL HEALTH
C/O depressed mood and re-experiencing trauma
Poor overall functioning; difficulty caring for
grandchildren
Children are withdrawn and having nightmares
Making An Asylum Claim In
Canada Asylum claim made in Canada at port of entry or inland with
Immigration, Refugee and Citizenship Canada (IRCC) office
IRCC determines if an individual is eligible to make a claim
if eligible, claim is referred to the Refugee Protection Division of the Immigration and Refugee board of Canada for a hearing
if eligible, claimant has access to social assistance, education, emergency housing, and legal aid while a decision is pending
if decision of refugee claim is positive; person receives the protected person status and can apply for permanent residency
If an asylum claim is rejected by the Refugee Protection Division;
possible to appeal to the Refugee Appeal Division
if no right to appeal; may request the federal court to review the decision
if all appeals are exhausted, removal order becomes enforceable and person either leaves voluntarily or is deported
if eligible, prior to deportation a pre-removal risk assessment
persons who would not normally be eligible to become permanent residents of Canada may be able to apply on Humanitarian and Compassionate grounds
www.canada.ca/en/immigration-refugee-citizenship/services/refugees.html
PRAIDA Programme Regionale d’Acceuil et d’Integration des
Demandeurs d’Asile
located at 3725 St Denis, MOntreal
Mandated by the MSSS
Responds to the needs of individuals requesting refugee status in Quebec
Part of the Integrated Health and Social Services University Network for West-Central Montreal (CIUSSS West-Central Montreal).
PRAIDA’s mandate starts when a person who requests refugee status receives an official document from the Quebec Immigration Service identifying him or her as an asylum seeker.
www.ciusss-centreouestmtl.gouv.qc.ca
Services Provided By
PRAIDA Information regarding the immigration process
Assistance with emergency housing
Referral to organizations who can assist in search for more permanent housing
Aid with applications for social assistance
Assistance in obtaining a work permit
Contact information for immigration lawyers
Information about registering children for school
Nursing triage and resources for medical evaluations
Does an asylum seeker have
access to health and social
services?
YES
Any asylum seeker is eligible for health care and
social services free of charge.
Medical coverage by the Interim Federal Health
program via the Blue Cross – medavie insurance
company.
Interim Federal Health
Program (PFSI) Basic medical coverage
similar to health-care coverage from provincial or territorial health insurance plans
In-patient and out-patient hospital services by physicians and allied healthcare professionals
Pre and Post-natal care
Laboratory, diagnostic and ambulance services
Prescription drug coverage
similar to the coverage provinces and territories give to social assistance recipients
Prescription medications and other products listed on provincial/territorial public drug plan formularies
Supplemental coverage (similar to the coverage given to social assistance recipients by provincial and territorial governments)
limited vision and urgent dental care
home care and long-term care
services from allied health-care practitioners including clinical psychologists, psychotherapists, counselling therapists, occupational therapists, speech language therapists, physiotherapists
assistive devices, medical supplies and equipment, including:
orthopedic and prosthetic equipment
mobility aids
hearing aids
diabetic supplies
incontinence supplies
oxygen equipment
https://www.canada.ca/en/immigration-refugees-citizenship/services/refugees/help-within-canada/health-care/professionals.html
*health care providers who see asylum seekers may register with medavie blue cross for billing purposes.
Clinique pour Demandeurs
D’asile et Refugiés (CDAR)
clinic dedicated exclusively to the care of refugees
and asylum seekers
located in the CLSC CDN
team consists of
5 part time family doctors (equivalent to 1.2 full time
physician)
2 full time nurses
1 part time nurse practitioner
Services provided to refugees at CDAR
evaluation of medical needs screening BSR and
short term care
referral to specialists and to local support services
Registration on the GAMF
Services provided to asylum seekers at CDAR
medium term care for the most vulnerable asylum
seekers
Unstable chronic medical conditions
severe mental health conditions
Attestation letters describing scars and FGM
Referrals come to us through the PRAIDA triage RN
and lawyers in the community
PTSD in the Refugee
Population Most Canadian immigrants and refugees from countries
involved in war or significant social unrest have been exposed to traumatic events before migration
most (estimated at 80%) who experience traumatic events heal spontaneously after reaching safety
pushing for disclosure of traumatic events in well-functioning individuals may result in more harm than good
empathy, reassurance and advocacy are key elements of the recovery process
keep a high index of suspicion for mental health disorders; many patients present with somatic complaints
BACK TO MME DIAWARA
WHAT CAN WE DO FOR
HER?
Approach to the new Immigrant
and Refugee Claimant PMHx
Migration History
History of Trauma
Psychological evaluation/support network
Vaccination Hx
Lifestyle habits
Countries endemic for TB, Hep B
Exposure to health risks Living conditions – access to water, sanitation
Vectors of Dx – mosquitos, stagnant water
Basic Needs
refer to PRAIDA for
housing
immigration information
social assistance
school registration for her grandchildren
Medical Needs send to hospital or CLSC for immigration screening
labs and appropriate labs for her medical condition
send to local pharmacy for medication renewal
send to CLSC for diabetes teaching and follow up;
program cardiometabolique
refer to CLSC for vaccination and to enfance famille
Physical Exam vision and hearing screen
dental health
nutritional status, growth parameters
evidence of female genital mutilation
Laboratory work up and
Screening Tests CBC, ferritin, Hb electrophoresis
Creat, BUN
ALT
strongyloides, schistosomiasis (sub-saharan Africa)
VDRL, HIV, Hep B and C
G/C, Chlamydia if at risk
PPD
Usual screening as per gender, age group and risk factors:
PAP, Hba1c, ac glucose, lipids, mammogram, BMD
Mental Health Needs supportive counselling and self help care
referral to psychotherapy (RIVO resilience; reseau
d’intervention aupres des personnes ayant subi de
la violence organisee)
referral to CLSC GASMA for ongoing care or
psychiatry evaluation
medication for sleep and PTSD
Recommendations for
Mental Health Screening
depression; PHQ-9 screening if an integrated
treatment program is available
PTSD; no routine screening for exposure to
trauma; vigilance
child maltreatment; vigilance
intimate partner violence; vigilance
Questions?