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Concerns about tuberculosis halts the travel of approximately 6,000 Hmong refugees still in Thailand

Wednesday, February 02, 2005 at 5:58:01 PM

The following press releases and news article provide background on the current situation in Thailand. A Question & Answer document from the State Department and CDC is copied in below; it is not yet on either website. Thanks to Savitri Tsering, Wisconsin Refugee Health Coordinator, for sharing these items.

Press Release U.S. Department of State January 28, 2005
Enhanced Medical Screening for Hmong Refugees

Wisconsin Refugee Screening Prevents the Spread of TB

PRM Press Guidance January 28, 2005

From U.S Department of State, Bureau of Population, Refugees and Migration (PRM), Office of Multilateral Coordination and External Relations ( PRM/MCE): Robert Hilton, 202-663-1979 and Centers for Disease Control.

  1. Question: Are refugees tested for infectious diseases, such as TB, prior to coming to the U.S.?

    Answer: Yes. Under contract to the U.S. government, the International Organization for Migration performs the required medical examinations for many overseas refugee populations. The Centers for Disease Control and Prevention (CDC) is responsible for providing technical guidance to the physicians who perform the overseas medical screening examination.

  2. Question: When did the U.S. government become concerned about tuberculosis among Hmong refugees from Laos who are at the Wat Tham Krabok complex in Thailand?

    Answer: CDC routinely recommends enhanced screening for TB, such as TB cultures and other rapid testing, for migrants who have lived in or are migrating from areas of the world with high TB prevalence, including parts of Asia and Africa. The Hmong refugee group at Wat Tham Krabok met this profile and so enhanced screening procedures were established.

    In June 2004, the CDC noted a prevalence of tuberculosis among Hmong Lao, as detected by chest x-rays. This led the CDC to implement additional pre-departure tuberculosis screening procedures for this group that are standard for populations with high TB rates. Following implementation of these new procedures, CDC learned of cases of multiple drug resistant tuberculosis among this group.

  3. Question: When did you become aware of a cluster of TB in the Hmong refugees from Laos?

    Answer: In January 2005 CDC received reports of several Hmong refugees in the United States with active tuberculosis, including two cases of multiple drug resistant tuberculosis. These cases had not been identified during overseas medical examinations. Refugees receive additional TB screening upon arrival to the United States. CDC is working with state and local health officials and the Hmong refugee community in the U.S. to ensure individuals gets appropriate screening and treatment, if needed. The exact number of cases in the U.S. is still being determined.

  4. Question: Why were these cases missed in the overseas exams?

    Answer: CDC is investigating these cases. There are numerous reasons why some persons with tuberculosis might not be identified, despite enhanced screening and treatment protocols. First, although TB cultures identify the majority of persons with pulmonary TB disease, a small percentage of infected persons will have negative tests. This can be due to the nature of TB disease. In addition, some persons who have been exposed to TB will be later be infected with TB, but have not yet developed the symptoms of TB disease until after screening and migration to the U.S.

  5. Question: How long will the moratorium on Hmong refugee movements from Thailand continue? What is the impact of the suspension on overall U.S. refugee admission efforts?

    Answer: We can't say yet. CDC teams are now re-screening the remaining population in Thailand, approximately 6,000 individuals. Travel to the U.S. will not resume until CDC and the State Department believe it is safe to do so. The suspension does not affect our commitment to meeting the goals of the President's refugee determination for fiscal year 2005. We do not anticipate that the suspension will affect the overall admission figures for fiscal year 2005.

  6. Question: Is there a chance that some Hmong refugees at Wat Tham Krabok may not be able to resettle in the U.S.?

    Answer: The Department of State is committed to bringing all of the Hmong refugees approved for U.S. resettlement to the United States. Travel to the U.S. for approved refugees in this group will resume once these health issues are addressed. All refugees who pass the new medical screening will be moved to the United States as quickly as possible. Refugees who do not pass the screening initially will be provided with treatment in Thailand and will travel to the U.S. when they have completed treatment and are medically cleared.

  7. Question: Will any of the sick refugees who have been admitted be sent back to Thailand?

    Answer: No. No one will be removed from the U.S. CDC will work with state and local health officials and the Hmong community to ensure that affected individuals get the treatment they need. This heath problem does not change the underlying humanitarian reasons for which the Hmong refugees from Laos were granted refugee status and allowed to emigrate to the U.S.

  8. Question: What is the situation in Thailand? Are Thai people at risk?

    Answer: CDC has initiated an overseas epidemiological investigation in Thailand. A team of six CDC staff members, including an Epidemic Intelligence Service Officer, is traveling to Thailand now. They will join the ongoing Thailand Ministry of Public Health/CDC joint investigation into the prevalence and epidemiology of tuberculosis among the remaining Hmong refugees at Wat Tham Krabok. They will take all necessary steps to control potential disease transmission within this population and to others.

    We do not believe that the prevalence of TB within the Hmong population at Wat Tham Krabok poses a threat to the Thai people. To become infected, a person normally would have to spend a relatively long time in a closed environment where a person with untreated TB who was coughing had contaminated the air. Anyone -- in Thailand or the U.S. -- concerned about possible exposure to TB, should see a doctor.

  9. Question: How will care be provided for Hmong refugees in the U.S. who have TB?

    Answer: Upon arrival in the U.S., refugees are provided a health assessment and follow-up care in order to prevent the spread of health conditions that could affect the public health and to identify and treat any health issues that could impede resettlement. These services are supported with funds from the Office of Refugee Resettlement's Preventive Health program.

    Many refugees qualify for Medicaid which will cover their health care. For refugees not eligible for Medicaid, Refugee Medical Assistance is available for health care for the first eight months after arrival to the U.S.

  10. Question: How has the Federal Government organized itself to respond to this important issue?

    Answer: The Centers for Disease Control and Prevention is leading the federal government's response to the health issues, working with the Office of Refugee Resettlement, which is also part of the Department of Health and Human Services, and the Department of State. In Thailand, CDC and State Department officials are working with the government of Thailand, the International Organization for Migration, the United Nations High Commissioner for Refugees, and other organizations.

  11. Question: How common is TB, both in the US and worldwide?

    Answer: Worldwide, 9 million new cases of tuberculosis are reported to the WHO each year. Tuberculosis is a leading infectious cause of death and about 2 million people die from this curable disease each year. In the United States, in 2003, 14,874 new cases of tuberculosis were reported to CDC, marking 11 years of decline since the resurgence in 1992. Fifty-three percent of these cases are among foreign born. In 2003, 108 of these cases were multi-drug resistant.

  12. Question: Is tuberculosis an infectious and contagious disease that can be treated?

    Answer: Tuberculosis is an infectious disease caused by germs that are spread from person to person through the air. Tuberculosis usually affects the lungs, but it can also affect other parts of the body, such as the brain, the kidneys, or the spine. A person with tuberculosis can die if they do not get treatment. Tuberculosis disease can be cured by taking several drugs for 6 to 12 months. It is very important that people who have tuberculosis disease finish the medicine, and take the drugs exactly as prescribed. If they stop taking the drugs too soon, they can become sick again; if they do not take the drugs correctly, the germs that are still alive may become resistant to those drugs. Tuberculosis that is resistant to drugs is harder and more expensive to treat. In some situations, staff of the local health department meets regularly with patients who have tuberculosis to watch them take their medications. This is called directly observed therapy (DOT). DOT helps the patient complete treatment in the least amount of time.

  13. Question: What is drug resistant tuberculosis? Can people with drug-resistant tuberculosis be treated?

    Answer: Multidrug-resistant tuberculosis (MDR TB) (i.e., tuberculosis resistant to at least isoniazid and rifampin-the two most important drugs used to treat tuberculosis) presents difficult treatment problems. Treatment must be individualized and based on the patient's medication history and drug susceptibility studies. Unfortunately, adequate data are not available on the effectiveness of various regimens and the necessary duration of treatment for patients with organisms resistant to both isoniazid and rifampin. Moreover, many of these patients also have resistance to other first-line drugs (e.g., ethambutol and streptomycin) when drug resistance is discovered. Because of the poor outcome in such cases, it is preferable to give at least three, but often as many as four to six, new drugs to which the organism is susceptible. This regimen should be continued for a total of 18 to 24 months. MDR TB drugs should be given using a daily regimen under directly observed therapy (DOT). Intermittent administration of medications is generally not possible in treatment of MDR TB.

  14. Question: Can people be vaccinated against tuberculosis?

    Answer: BCG is a vaccine for tuberculosis disease. BCG is used in many countries, but it is not generally recommended in the United States. BCG vaccination does not completely prevent people from getting tuberculosis. It may also cause a false positive tuberculin skin test. However, persons who have been vaccinated with BCG can be given a tuberculin skin test.

  15. Question: What is the difference between tuberculosis disease and latent tuberculosis infection?

    Answer: People with latent tuberculosis infection have tuberculosis germs in their bodies, but they are not sick because the germs are not active. These people do not have symptoms of tuberculosis disease, and they cannot spread the germs to others. However, they may develop tuberculosis disease in the future. They are often prescribed treatment to prevent them from developing tuberculosis disease. People with tuberculosis disease are sick from tuberculosis germs that are active, meaning that they are multiplying and destroying tissue in their body. They usually have symptoms of tuberculosis disease. People with tuberculosis disease of the lungs or throat are capable of spreading germs to others. They are prescribed drugs that can cure tuberculosis disease.

  16. Question: Should anyone who comes in contact with refugees be tested for TB?

    Answer: To become infected, a person would have to spend a relatively long time in a closed environment, where the air was contaminated by a person with untreated TB who was coughing. A person with latent tuberculosis infection cannot spread germs to other people. If you have spent time with someone with tuberculosis disease or someone with symptoms of tuberculosis, you should be tested. People with tuberculosis disease are most likely to spread the germs to people they spend time with every day, such as family members or coworkers. Anyone concerned about possible exposure to TB, should go to your doctor or your local health department for a TB skin test.

  17. Question: A few years ago, CDC established a National Action Plan to Combat Multidrug-Resistant TB, is this program still active?

    Answer: The National Action Plan to Combat Multidrug-Resistant Tuberculosis has been revised and incorporated into a number of guidelines, including Treatment of Tuberculosis: www.cdc.gov/mmwr/preview/mmwrhtml/rr5211a1.htm

    Other guidelines and recommendations can be accessed via the CDC Division of Tuberculosis Elimination website: www.cdc.gov/nchstp/tb/

    There are a number of TB educational materials available in the Hmong language. These materials, along with other TB educational materials, can be accessed at the TB Education & Training Resources Website: www.findtbresources.org

  18. Question: Please describe the current CDC tuberculosis prevention program available through the United States?

    Answer: State and local health departments have the primary responsibility for preventing and controlling tuberculosis. However, other health care providers who provide tuberculosis services in settings such as private clinics, managed care organizations, HIV clinics, correctional facilities, and hospitals also have responsibility for preventing and controlling tuberculosis in communities.

    Prevention and control efforts should be conducted through the coordination of health care providers in a variety of settings to ensure the provision of direct services for tuberculosis patients. Prevention and control efforts should include three priority strategies:

    • Identifying and treating all persons who have tuberculosis disease. This means finding cases of tuberculosis and ensuring that patients complete appropriate therapy;
    • Finding and evaluating persons who have been in contact with tuberculosis patients to determine whether they have tuberculosis infection or disease, and treating them appropriately;
    • Testing high-risk groups for tuberculosis infection to identify candidates for treatment of latent infection and to ensure the completion of treatment.

    Although tuberculosis care and treatment are often provided by other medical care providers, the health department has the ultimate responsibility for ensuring that tuberculosis patients do not transmit M. tuberculosis to others. Health departments must ensure that medical services are available, accessible, and acceptable for tuberculosis patients, suspects, contacts, and others at high risk, without regard to the patients' ability to pay for such services.

Please see Tuberculosis on the Hmong Health Family Health page for links to bilingual patient education documents related to tuberculosis.

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