Health profile of adult special immigrant visa holders arriving from Iraq and Afghanistan to the United States, 2009-2017: A cross-sectional analysis.

BACKGROUND: Between 2,000 and 19,000 Special Immigrant Visa (SIV) holders (SIVH) from Iraq and Afghanistan resettle in the United States annually. Despite the increase in SIV admissions to the US over recent years, little is known about the health conditions in SIV populations. We assessed the burden of select communicable and noncommunicable diseases (NCDs) in SIV adults to guide recommendations to clinicians in the US. METHODS AND FINDINGS: We analyzed overseas medical exam data in Centers for Disease Control and Prevention's (CDC) Electronic Disease Notification system (EDN) for 19,167 SIV Iraqi and Afghan adults who resettled to the US from April 2009 through December 2017 in this cross-sectional analysis. We describe demographic characteristics, tuberculosis screening results, self-reported NCDs, and risk factors for NCDs (such as obesity and tobacco use). In our data set, most SIVH were male (Iraqi: 59.7%; Afghan: 54.7%) and aged 18-44 (Iraqi: 86.3%; Afghan: 95.6%). About 2.3% of Afghan SIVH and 1.1% of Iraqi SIVH had a tuberculosis condition. About 0.3% of all SIVH reported having chronic hepatitis. Among all SIVH, 56.5% were overweight or had obesity, 2.4% reported hypertension, 1.1% reported diabetes, and 19.4% reported current or previous tobacco use. Iraqi SIVH were 3.7 times more likely to have obesity (95% CI: 3.4-4.0), 2.5 times more likely to report diabetes (95% CI: 1.7-3.5), and 2.5 times more likely to be current or former smokers (95% CI: 2.3-2.7) than Afghan SIVH. Limitations include the inability to obtain all SIVH records, self-reported medical history of NCDs, and the underdiagnosis of NCDs such as hypertension and diabetes because formal laboratory testing for NCDs is not used during overseas medical exams. CONCLUSION: In this analysis, we found that 56.5% of all SIVH were overweight or had obesity, 2.4% reported hypertension, 1.1% reported diabetes, and 19.4% reported current or previous tobacco use. In general, Iraqi SIVH were more likely to have obesity, diabetes, and be current or former smokers than Afghan SIVH. State public health agencies and clinicians doing domestic screening examinations of SIVH should consider screening for obesity-as per the CDC's Guidelines for the US Domestic Medical Examination for Newly Arriving Refugees-and smoking and, if appropriate, referral to weight management and smoking cessation services. US clinicians can consider screening for other NCDs at the domestic screening examination. Future studies can explore the health profile of SIV populations, including the prevalence of mental health conditions, after integration into the US.

Health profile of pediatric Special Immigrant Visa holders arriving from Iraq and Afghanistan to the United States, 2009-2017: A cross-sectional analysis.

BACKGROUND: The United States has admitted over 80,000 Special Immigrant Visa holders (SIVH), which include children. Despite the increase in the proportion of SIVH admissions to the US over recent years, little is known about health conditions in SIV children. We report the frequency of selected diseases identified overseas and assess differences in selected conditions between SIV children from Iraq and Afghanistan. METHODS AND FINDINGS: We analyzed 15,729 overseas medical exam data in Centers for Disease Control and Prevention's Electronic Disease Notification system (EDN) for children less than 18 years of age from Iraq (29.1%) and Afghanistan (70.9%) who were admitted to the US from April 2009 through December 2017 in a cross-sectional analysis. Variables included age, sex, native language, measured height and weight, and results of the overseas medical examination. From our analysis, less than 1% of SIV children (Iraqi: 0.1%; Afghan: 0.12%) were reported to have abnormal tuberculosis test findings, less than 1% (Iraqi: 0.3%; Afghan: 0.7%) had hearing abnormalities, and about 4% (Iraqi: 6.0% Afghan: 2.9%) had vision abnormalities, with a greater prevalence of vision abnormalities noted in Iraqis (OR: 1.9, 95% CI 1.6-2.2, p <0.001). Seizure disorders were noted in 46 (0.3%) children, with Iraqis more likely to have a seizure disorder (OR: 7.6, 95% CI 3.8-15.0, p < 0.001). On average, children from Afghanistan had a lower mean height-for-age z-score (Iraqi: -0.28; Afghan: -0.68). Only the data quality assessment for height for age for children ≥5 years fell within WHO recommendations. Limitations included the inability to obtain all SIVH records and self-reported medical history of noncommunicable diseases. CONCLUSION: In this investigation, we found that less than 1% of SIV children were reported to have abnormal tuberculosis test findings and 4% of SIV children had reported vision abnormalities. Domestic providers caring for SIVH should follow the US Centers for Disease Control and Prevention (CDC) Guidelines for the US Domestic Medical Examination for Newly Arriving Refugees, including an evaluation for malnutrition. Measurement techniques and anthropometric equipment used in panel site clinics should be assessed, and additional training in measurement techniques should be considered. Future analyses could further explore the health of SIV children after resettlement in the US.

Telomere length is inversely correlated with urinary stress hormone levels in healthy controls but not in un-medicated depressed individuals-preliminary findings.

OBJECTIVE: Leukocyte telomere length (LTL) is a biomarker of cellular aging affected by chronic stress. The relationship of LTL to the stress hormones, cortisol and catecholamines, is unclear, as are possible differences between healthy controls (HC) and individuals with Major Depressive Disorder (MDD). This small pilot study is the first to examine the relationship between cortisol, catecholamines and LTL specifically in un-medicated MDD in comparison with HC. METHODS: Participants included 16 un-medicated MDD subjects and 15 HC for assay of LTL, 12-hour overnight urinary free cortisol and catecholamine levels. RESULTS: LTL, cortisol and catecholamine levels did not significantly differ between groups. In HC, a hierarchical regression analysis indicated that higher levels of cortisol were correlated with shorter LTL (p=0.003) above and beyond age and sex. Higher catecholamine levels were nearly-significant with shorter LTL (p=0.055). Neither hormone was correlated with shorter LTL in MDD (p's>0.28). To assess a possible cumulative effect of stress hormone activation, a summary score was calculated for each subject based on the number of stress hormone levels above the median for that group (HC or MDD). A significant inverse graded relationship was observed between LTL and the number of activated systems in HC (p=0.001), but not in MDD (p=0.96). CONCLUSION: This pilot study provides preliminary evidence that stress hormone levels, especially cortisol, are inversely related to LTL in HC, but not in un-medicated MDD. Clarification of these relationships in larger samples could aid in understanding differential mechanisms underlying stress-related cellular aging in healthy and depressed populations.

Cost analysis of measles in refugees arriving at Los Angeles International Airport from Malaysia.

Background On August 24, 2011, 31 US-bound refugees from Kuala Lumpur, Malaysia (KL) arrived in Los Angeles. One of them was diagnosed with measles post-arrival. He exposed others during a flight, and persons in the community while disembarking and seeking medical care. As a result, 9 cases of measles were identified. Methods We estimated costs of response to this outbreak and conducted a comparative cost analysis examining what might have happened had all US-bound refugees been vaccinated before leaving Malaysia. Results State-by-state costs differed and variously included vaccination, hospitalization, medical visits, and contact tracing with costs ranging from $621 to $35,115. The total of domestic and IOM Malaysia reported costs for US-bound refugees were $137,505 [range: $134,531 - $142,777 from a sensitivity analysis]. Had all US-bound refugees been vaccinated while in Malaysia, it would have cost approximately $19,646 and could have prevented 8 measles cases. Conclusion A vaccination program for US-bound refugees, supporting a complete vaccination for US-bound refugees, could improve refugees' health, reduce importations of vaccine-preventable diseases in the United States, and avert measles response activities and costs.

Higher serum DHEA concentrations before and after SSRI treatment are associated with remission of major depression.

BACKGROUND: Dehydroepiandrosterone (DHEA) and its sulfated ester DHEA-sulfate (DHEA-S), (together DHEA[S]), are the most abundant adrenal steroids in humans and are found in blood and the brain, where they function as neurosteroids with direct receptor affinities. Preclinical studies suggest that DHEA(S) has antidepressant/neuroprotective properties, and exogenously administered DHEA has shown antidepressant efficacy in humans. Nonetheless, the role of endogenous DHEA(S) levels in major depressive disorder (MDD) and antidepressant outcomes remains unclear. METHODS: Morning fasting serum DHEA(S) concentrations were determined in 36 healthy, unmedicated MDD adults with Hamilton Depression (HDRS) ratings ≥17, and 75 healthy controls. MDD participants then completed eight weeks of open-label SSRI treatment before DHEA(S) levels were re-sampled; those with post-treatment HDRS ratings ≤7 were classified as "Remitters." Pre- and post-treatment DHEA(S) levels of Remitters and Non-remitters were compared, controlling for age, sex, and BMI. RESULTS: Pre-treatment HDRS ratings did not differ between Remitters and Non-remitters (p=0.179). Baseline DHEA levels of Remitters were significantly higher than both Non-remitters (p=0.008) and controls (p=0.004); baseline DHEA-S levels of Remitters were also higher than Non-remitters (p=0.040) but did not significantly differ from controls (p=0.096). Non-remitters did not significantly differ from controls. Post-treatment DHEA(S) levels remained higher in Remitters compared to Non-remitters (DHEA: p=0.013; DHEA-S: p=0.040). CONCLUSIONS: These data suggest that higher circulating DHEA(S) levels (while unmedicated and after eight weeks of SSRI treatment) predict SSRI-associated remission in MDD. This raises the possibility that endogenous DHEA(S) abundance is a physiological adjunct to SSRI efficacy, as suggested by prior preclinical and clinical studies.

Cortisol/DHEA ratio and hippocampal volume: A pilot study in major depression and healthy controls.

Structural imaging studies investigating the relationship between hippocampal volume (HCV) and peripheral measures of glucocorticoids (GCs) have produced conflicting results in both normal populations and in individuals with MDD, raising the possibility of other modulating factors. In preclinical studies, dehydroepiandrosterone (DHEA) and its sulfate ester (DHEAS; together abbreviated, DHEA(S)) have been shown to antagonize the actions of GCs on the central nervous system. Therefore, considering the relationship of HCV to both of these hormones simultaneously may be important, although it has rarely been done in human populations. Using high-resolution magnetic resonance imaging (MRI), the present pilot study examined the relationship between morning serum cortisol, DHEA(S), and HCV in nineteen normal controls and eighteen unmedicated subjects with Major Depressive Disorder (MDD). Serum cortisol and DHEA(S) were not significantly correlated with HCV across all subjects (cortisol: r=-0.165, p=0.33; DHEA: r=0.164, p=0.35; DHEAS: r=0.211, p=0.22, respectively). However, the ratios of cortisol/DHEA(S) were significantly negatively correlated with HCV in combined group (Cortisol/DHEA: r=-0.461, p=0.005; Cortisol/DHEAS: r=-0.363, p=0.03). Significant or near-significant correlations were found between some hormonal measurements and HCV in the MDDs alone (DHEA: r=0.482, p=0.059; DHEAS: r=0.507, p=0.045; cort/DHEA: r=-0.589, p=0.02; cort/DHEAS: r=-0.424p=0.10), but not in the controls alone (DHEA: r=0.070, p=0.79; DHEAS: r=0.077, p=0.77; cort/DHEA: r=-0.427, p=0.09; cort/DHEAS: r=-0.331, p=0.19). However, Group (MDDs vs controls) did not have a significant effect on the relationship between cortisol, DHEA(S), and their ratios with HCV (p>0.475 in all analyses). Although the exact relationship between serum and central steroid concentrations as well as their effects on the human hippocampus remains not known, these preliminary results suggest that the ratio of cortisol to DHEA(S), compared to serum cortisol alone, may convey additional information about "net steroid activity" with relation to HCV.

Emotional and Behavioral Problems among Impoverished Kenyan Youth: Factor Structure and Sex-Differences.

Data on youth emotional and behavioral problems from societies in Sub-Saharan Africa are lacking. This may be due to the fact that few youth mental health assessments have been tested for construct validity of syndrome structure across multicultural societies that include developing countries, and almost none have been tested in Sub-Saharan Africa. The Youth Self-Report (YSR), for example, has shown great consistency of its syndrome structure across many cultures, yet data from only one developing country in Sub-Saharan Africa have been included. In this study, we test the factor structure of YSR syndromes among Kenyan youth ages 11-18 years from an informal settlement in Nairobi, Kenya and examine sex-differences in levels of emotional and behavioral problems. We find the eight syndrome structure of the YSR to fit these data well (Root Mean Square Error of Approximation=.049). While Kenyan girls have significantly higher internalizing (Anxious/Depressed, Withdrawn/Depressed, Somatic) problem scores than boys, these differences are of similar magnitude to published multicultural findings. The results support the generalizability of the YSR syndrome structure to Kenyan youth and are in line with multicultural findings supporting the YSR as an assessment of emotional and behavioral problems in diverse societies.

Dysregulated diurnal cortisol pattern is associated with glucocorticoid resistance in women with major depressive disorder.

Dysfunction of the hypothalamic-pituitary-adrenal (HPA) axis is believed to play a role in the pathophysiology of depression. To investigate mechanisms that may underlie this effect, we examined several indices of HPA axis function - specifically, diurnal cortisol slope, cortisol awakening response, and suppression of cortisol release following dexamethasone administration - in 26 pre-menopausal depressed women and 23 never depressed women who were matched for age and body mass index. Salivary cortisol samples were collected at waking, 30 min after waking, and at bedtime over three consecutive days. On the third day, immediately after the bedtime sample, participants ingested a 0.5mg dexamethasone tablet; they then collected cortisol samples at waking and 30 min after waking the following morning. As predicted, depressed women exhibited flatter diurnal cortisol rhythms and more impaired suppression of cortisol following dexamethasone administration than non-depressed women over the three sampling days. In addition, flatter diurnal cortisol slopes were associated with reduced cortisol response to dexamethasone treatment, both for all women and for depressed women when considered separately. Finally, greater self-reported depression severity was associated with flatter diurnal cortisol slopes and with less dexamethasone-related cortisol suppression for depressed women. Depression in women thus appears to be characterized by altered HPA axis functioning, as indexed by flatter diurnal cortisol slopes and an associated impaired sensitivity of cortisol to dexamethasone. Given that altered HPA axis functioning has been implicated in several somatic conditions, the present findings may be relevant for understanding the pathophysiology of both depression and depression-related physical disease.

Multiple traumas, postelection violence, and posttraumatic stress among impoverished Kenyan youth.

Research on posttraumatic stress disorder (PTSD) among youth has focused on specific subgroups from developed countries. Most of the world's youth and war-like violence, however, is concentrated in developing countries, yet there is limited mental health data within affected countries. This study focused on a random community-based sample of 552 impoverished youth ages 6-18 within an informal settlement in Nairobi, Kenya, which experienced war-like violence for a month following the contested presidential election of 2007. Six months after the violence ended, 99 (18%) had PTSD according to the UCLA PTSD Reaction Index (Steinberg, Brymer, Decker, & Pynoos, 2004), and an additional 18 (3%) were found to have partial PTSD due to high overall scores. Kenyan psychologists conducted diagnostic interviews and found the positive predictive value of the assessment tool to be 72% in this sample; the confirmed prevalence was 12%. Similar to other studies worldwide, Criterion C (avoidance) was the limiting factor for diagnosing PTSD according to the DSM-IV-TR, and parent-child agreement was at best fair. The number of traumatic experiences was strongly associated with PTSD outcomes. Differences due to age or sex were not found. The findings indicate the need for universal mental health services for trauma-exposed youth and their families in the impoverished informal settlements of Nairobi, Kenya.

Serum BDNF levels before treatment predict SSRI response in depression.

OBJECTIVES: The "neurotrophin hypothesis" of depression posits a role of brain-derived neurotrophic factor (BDNF) in depression, although it is unknown whether BDNF is more involved in the etiology of depression or in the mechanism of action of antidepressants. It is also unknown whether pre-treatment serum BDNF levels predict antidepressant response. METHODS: Thirty un-medicated depressed subjects were treated with escitalopram (N=16) or sertraline (N=14) for 8 weeks. Twenty-five of the depressed subjects completed 8 weeks of antidepressant treatment and had analyzable data. Twenty-eight healthy controls were also studied. Serum for BDNF assay was obtained at baseline in all subjects and after 8 weeks of treatment in the depressed subjects. Depression ratings were obtained at baseline and after 8 weeks of treatment in the depressed subjects. RESULTS: Pre-treatment BDNF levels were lower in the depressed subjects than the controls (p=0.001) but were not significantly correlated with pre-treatment depression severity. Depression ratings improved with SSRI treatment (p<0.001), and BDNF levels increased with treatment (p=0.005). Changes in BDNF levels were not significantly correlated with changes in depression ratings. However, pre-treatment BDNF levels were directly correlated with antidepressant responses (p<0.01), and "Responders" to treatment (≥ 50% improvement in depression ratings) had higher pre-treatment BDNF levels than did "Non-responders" (p<0.05). CONCLUSIONS: These results confirm low serum BDNF levels in un-medicated depressed subjects and confirm antidepressant-induced increases in BDNF levels, but they suggest that antidepressants do not work simply by correcting BDNF insufficiency. Rather, these findings are consistent with a permissive or facilitatory role of BDNF in the mechanism of action of antidepressants.

Leukocyte telomere length in major depression: correlations with chronicity, inflammation and oxidative stress--preliminary findings.

BACKGROUND: Depression is associated with an unusually high rate of aging-related illnesses and early mortality. One aspect of "accelerated aging" in depression may be shortened leukocyte telomeres. When telomeres critically shorten, as often occurs with repeated mitoses or in response to oxidation and inflammation, cells may die. Indeed, leukocyte telomere shortening predicts early mortality and medical illnesses in non-depressed populations. We sought to determine if leukocyte telomeres are shortened in Major Depressive Disorder (MDD), whether this is a function of lifetime depression exposure and whether this is related to putative mediators, oxidation and inflammation. METHODOLOGY: Leukocyte telomere length was compared between 18 unmedicated MDD subjects and 17 controls and was correlated with lifetime depression chronicity and peripheral markers of oxidation (F2-isoprostane/Vitamin C ratio) and inflammation (IL-6). Analyses were controlled for age and sex. PRINCIPAL FINDINGS: The depressed group, as a whole, did not differ from the controls in telomere length. However, telomere length was significantly inversely correlated with lifetime depression exposure, even after controlling for age (p<0.05). Average telomere length in the depressed subjects who were above the median of lifetime depression exposure (≥9.2 years' cumulative duration) was 281 base pairs shorter than that in controls (p<0.05), corresponding to approximately seven years of "accelerated cell aging." Telomere length was inversely correlated with oxidative stress in the depressed subjects (p<0.01) and in the controls (p<0.05) and with inflammation in the depressed subjects (p<0.05). CONCLUSIONS: These preliminary data indicate that accelerated aging at the level of leukocyte telomeres is proportional to lifetime exposure to MDD. This might be related to cumulative exposure to oxidative stress and inflammation in MDD. This suggest that telomere shortening does not antedate depression and is not an intrinsic feature. Rather, telomere shortening may progress in proportion to lifetime depression exposure.

Low serum IL-10 concentrations and loss of regulatory association between IL-6 and IL-10 in adults with major depression.

Elevated circulating pro-inflammatory cytokines are associated with symptoms of depression, and disorders involving chronic inflammation are often co-morbid with major depression. Since healthy immune regulation is accomplished through counter-balancing effects of pro- and anti-inflammatory cytokines, we hypothesized that depressed subjects (compared to controls) would express lower concentrations of the anti-inflammatory/immunoregulatory cytokine interleukin (IL)-10, and a higher IL-6/IL-10 ratio. We also examined the possibility that depressed subjects may exhibit a deficiency in the regulatory loop involving IL-6 induced secretion of IL-10. Therefore, we hypothesized that circulating IL-6 and IL-10 would be positively correlated in controls, while the correlation would be weaker in depressed subjects. Resting state serum cytokine concentrations were quantified in 12 unmedicated depressed subjects, and 11 age, gender, and ethnicity-matched controls. Depressed subjects showed significantly lower IL-10 (p=0.03, Cohen's d=-0.96), non-significantly higher IL-6, and significantly higher IL-6/IL-10 ratios (p=0.05, Cohen's d=0.50). Across all participants, higher scores on the self-rated Inventory of Depressive Symptoms were associated with lower IL-10 (r(21)=-0.57, p=0.005) and non-significantly higher IL-6/IL-10 ratios (r(21)=0.38, p=0.07), but not related to IL-6 concentrations. As hypothesized, IL-6 and IL-10 concentrations were strongly and positively correlated in controls (r(9)=0.81, p=0.003), but were completely dissociated in depressed subjects (r(10)=0.01, p=0.98). These results suggest that lower IL-10 levels, a higher IL-6/IL-10 ratio, and the apparent absence of a counter-balancing, immunoregulatory increase in IL-10 in response to elevated IL-6 concentrations contribute to the pro-inflammatory physiological milieu that is known to be associated with major depression. Therefore, reduced induction/availability of IL-10, that would normally inhibit pro-inflammatory cytokine actions and resolve inflammation, may contribute to the depressogenic as well as the inflammatory disease-promoting effects of chronic, low-level elevations in pro-inflammatory cytokines.

Salivary cortisol levels in children of low-income women with high depressive symptomatology.

Children (N = 324 boys, 315 girls) between the ages of 2.5 and 6 (mean age = 3.63) were identified in a house to house survey in low-income areas (income <20th percentile nationally) of urban Mexico. The Center for Epidemiologic Studies-Depression Scale was administered to mothers of all children. Salivary cortisol samples were taken in children as a measure of hypothalamic-pituitary-adrenocortical (HPA) system activity at time of arrival (baseline, Time 0), 25 min after arrival (Time 1), and 50 min after arrival (Time 2). Between Time 0 and Time 1, children were administered several cognitive tests. Results of hierarchical linear modeling analyses revealed that higher levels of maternal depressive symptoms were associated with lower baseline cortisol levels in their children (p < .05), while controlling for age, gender, and time since awakening. Higher levels of maternal depressive symptoms were associated with less of an increase in salivary cortisol to the arrival of the experimenters and subsequent cognitive testing (p < .05). All results were moderated by gender, with enhanced cortisol response in girls and no response in boys. These results suggest that among very low-income families, high maternal depressive symptoms are associated with hypoactivity of the HPA system in children, particularly boys.

Depression and cortisol responses to psychological stress: a meta-analysis.

The purpose of this meta-analysis is to examine the association between depression and cortisol responses to psychological stressors. A total of seven studies comparing plasma or cortisol responses to psychological stressors in clinically depressed (MDD) and non-depressed (ND) individuals (N = 196: 98 MDD, 98 ND; 83 men, 113 women; mean age = 40 years) were included. Sample size-adjusted effect sizes (Cohen's d statistic) were calculated and averaged across baseline (before stressor onset), stress (stressor onset up to 25 min after stressor offset), and recovery (more than 25 min after stressor offset) periods. Overall, MDD and ND individuals exhibited similar baseline and stress cortisol levels, but MDD patients had much higher cortisol levels during the recovery period than their ND counterparts. There was also a significant time of day effect in which afternoon studies were more likely to reveal higher baseline cortisol levels, blunted stress reactivity, and impaired recovery in MDD patients. This blunted reactivity-impaired recovery pattern observed among the afternoon studies was most pronounced in studies with older and more severely depressed patients.

Depressive symptoms are associated with blunted cortisol stress responses in very low-income women.

OBJECTIVE: The purpose of this study was to examine the association between depressive symptoms and salivary cortisol responses to stress in a high-risk population of very poor Mexican women. METHODS: Adult women (N = 1109) between the ages of 18 and 44 years (mean age, 29) were identified in a house-to-house survey in low-income areas (income <20th percentile nationally) of urban Mexico. An interview containing the Spanish version of the Center for Epidemiologic Studies--Depression Scale (CES-D) was administered to all women. The naturalistic stressor was defined as the unexpected arrival of a team of researchers at the participants' homes followed by an in-depth interview and physical assessment, with saliva samples taken at time of arrival (baseline), 25 minutes, and 50 minutes after arrival. RESULTS: The mean CES-D score was 19.42 (range, 0-53). Results of hierarchical linear modeling analyses revealed no effect of depressive symptoms on baseline salivary cortisol levels. However, a significant depressive symptom by time interaction revealed that women with elevations in depressive symptoms (CES-D scores = 35) failed to exhibit a cortisol response to the stressor. In contrast, in women with lower CES-D scores, cortisol levels significantly increased in response to the stressor. CONCLUSION: Consistent with research on individuals with major depressive disorder, results of this study demonstrate that women with very high levels of depressive symptoms exhibit blunted cortisol responses to a naturalistic psychological stressor. Results also contribute to previous research by generalizing findings to a high risk, underserved population of women.