Transplantation and immigration: Comparing infectious complications and outcomes between foreign-born and US-born kidney transplant recipients in Minnesota.

BACKGROUND: Foreign-born kidney transplant recipients (FBKTRs) are at increased risk for reactivation of latent infections that may impact outcomes. We aimed to compare the etiology of infections and outcomes between FBKTR and United States KTRs (USKTR). METHODS: We performed a retrospective study of patients who underwent kidney transplantation between January 1, 2014 and December 31, 2018 at two transplant centers in Minnesota. Frequency and etiology of infections as well as outcomes (graft function, rejection, and patient survival) at 1-year post-transplant between FBKTR and USKTR were compared. RESULTS: Of the 573 transplant recipients, 124 (21.6%) were foreign-born and 449 (78.4%) US-born. At least one infection occurred in 411 (71.7%) patients (38.2% bacterial, 55% viral, 9.4% fungal). Viral infections were more frequent in FBKTR, particularly BK viremia (38.7% vs. 21.2%, p < .001). No statistical differences were found for bacterial or fungal infections; no parasitic infections were identified in either group. No geographically-restricted infections were noted aside from a single case of Madura foot in a FBKTR. Rejection episodes were more common in USKTR (p = .037), but stable/improving graft function (p = .976) and mortality (p = .451) at 1-year posttransplantation were similar in both groups. After adjusting for covariates, previous transplantation was associated with a higher number of infections (IRR 1.35, 95% confidence intervals 1.05-1.73, p = .020). CONCLUSION: Although viral infections were more frequent in FBKTR, overall frequency and etiology of most infections and outcomes were similar between FBKTR and USKTR suggesting that comprehensive transplant care is providing timely prevention, diagnosis, and treatment of latent infections in FBKTR.

Where was my patient born? The Intersection of tropical medicine and migrant health.

PURPOSE OF REVIEW: There is unprecedented movement of people across international borders and parasitic infections, previously restricted to endemic regions, are now encountered in nonendemic areas of the world. RECENT FINDINGS: Migrants may import parasitic infections acquired in their countries of origin. Increasingly, clinicians in nonendemic regions are faced with patients with neglected diseases such as Chagas disease, malaria and strongyloidiasis. There are gaps in knowledge among physicians in nonendemic regions, which lead to missed opportunities for preventive strategies and early treatment. Both primary care and infectious disease physicians should have a broad knowledge of common parasitic infections to improve health outcomes and decrease healthcare disparities through early identification and treatment of disease encountered in migrants. SUMMARY: Migrant health is still a young field in medicine; clinicians should be aware of diseases seen in migrants, and access both educational and clinical resources, including experts in tropical medicine, in order to reduce health disparities among migrants. Collaboration between primary care and infectious disease/tropical medicine experts should be strengthened.

Spectrum of illness in international migrants seen at GeoSentinel clinics in 1997-2009, part 1: US-bound migrants evaluated by comprehensive protocol-based health assessment.

BACKGROUND: Many nations are struggling to develop structured systems and guidelines to optimize the health of new arrivals, but there is currently no international consensus about the best approach. METHODS: Data on 7792 migrants who crossed international borders for the purpose of resettlement and underwent a protocol-based health assessment were collected from the GeoSentinel Surveillance network. Demographic and health characteristics of a subgroup of these migrants seen at 2 US-based GeoSentinel clinics for protocol-based health assessments are described. RESULTS: There was significant variation over time in screened migrant populations and in their demographic characteristics. Significant diagnoses identified in all migrant groups included latent tuberculosis, found in 43% of migrants, eosinophilia in 15%, and hepatitis B infection in 6%. Variation by region occurred for select diagnoses such as parasitic infections. Notably absent were infectious tuberculosis, soil-transmitted helminths, and malaria. Although some conditions would be unfamiliar to clinicians in receiving countries, universal health problems such as dental caries, anemia, ophthalmologic conditions, and hypertension were found in 32%, 11%, 10%, and 5%, respectively, of screened migrants. CONCLUSIONS: Data from postarrival health assessments can inform clinicians about screening tests to perform in new immigrants and help communities prepare for health problems expected in specific migrant populations. These data support recommendations developed in some countries to screen all newly arriving migrants for some specific diseases (such as tuberculosis) and can be used to help in the process of developing additional screening recommendations that might be applied broadly or focused on specific at-risk populations.

Spectrum of illness in international migrants seen at GeoSentinel clinics in 1997-2009, part 2: migrants resettled internationally and evaluated for specific health concerns.

BACKGROUND: Increasing international migration may challenge healthcare providers unfamiliar with acute and long latency infections and diseases common in this population. This study defines health conditions encountered in a large heterogenous group of migrants. METHODS: Migrants seen at GeoSentinel clinics for any reason, other than those seen at clinics only providing comprehensive protocol-based health screening soon after arrival, were included. Proportionate morbidity for syndromes and diagnoses by country or region of origin were determined and compared. RESULTS: A total of 7629 migrants from 153 countries were seen at 41 GeoSentinel clinics in 19 countries. Most (59%) were adults aged 19-39 years; 11% were children. Most (58%) were seen >1 year after arrival; 27% were seen after >5 years. The most common diagnoses were latent tuberculosis (22%), viral hepatitis (17%), active tuberculosis (10%), human immunodeficiency virus (HIV)/AIDS (7%), malaria (7%), schistosomiasis (6%), and strongyloidiasis (5%); 5% were reported healthy. Twenty percent were hospitalized (24% for active tuberculosis and 21% for febrile illness [83% due to malaria]), and 13 died. Tuberculosis diagnoses and HIV/AIDS were reported from all regions, strongyloidiasis from most regions, and chronic hepatitis B virus (HBV) particularly in Asian immigrants. Regional diagnoses included schistosomiasis (Africa) and Chagas disease (Americas). CONCLUSIONS: Eliciting a migration history is important at every encounter; migrant patients may have acute illness or chronic conditions related to exposure in their country of origin. Early detection and treatment, particularly for diagnoses related to tuberculosis, HBV, Strongyloides, and schistosomiasis, may improve outcomes. Policy makers should consider expansion of refugee screening programs to include all migrants.

Infections with long latency in international refugees, immigrants, and migrants seen at GeoSentinel sites, 2016-2018.

BACKGROUND: The continued increase in global migration compels clinicians to be aware of specific health problems faced by refugees, immigrants, and migrants (RIM). This analysis aimed to characterize RIM evaluated at GeoSentinel sites, their migration history, and infectious diseases detected through screening and diagnostic workups. METHODS: A case report form was used to collect data on demographics, migration route, infectious diseases screened, test results, and primary infectious disease diagnosis for RIM patients seen at GeoSentinel sites. Descriptive statistics were performed. RESULTS: Between October 2016 and November 2018, 5,319 RIM patients were evaluated at GeoSentinel sites in 19 countries. Africa was the region of birth for 2,436 patients (46 %), followed by the Americas (1,644, 31 %), and Asia (1,098, 21 %). Tuberculosis (TB) was the most common infection screened and reported as positive (853/2,273, 38 % positive by any method). TB, strongyloidiasis, and hepatitis B surface antigen positivity were observed across all migration administrative categories and regions of birth. Chagas disease was reported only among RIM patients from the Americas (393/394, 100 %) and schistosomiasis predominantly in those from Africa (480/510, 94 %). TB infection (694/5,319, 13 %) and Chagas disease (524/5,319, 10 %) were the leading primary infectious disease diagnoses. CONCLUSIONS: Several infections of long latency (e.g. TB, hepatitis B, and strongyloidiasis) with potential for long-term sequelae were seen among RIM patients across all migration administrative categories and regions of origin. Obtaining detailed epidemiologic information from RIM patients is critical to optimize detection of diseases of individual and public health importance, particularly those with long latency periods.

Cancer Screening in Refugees and Immigrants: A Global Perspective.

Clinicians in the United States are trained to screen for cancer based on patient age, gender, family history, and environmental risk factors such as smoking. These cancers generally include, breast, cervical, colon, lung, and prostate cancers. We know that refugees and other immigrants to the United States experience dramatic disparities in cancer screening. Additionally, many immigrants experience elevated risks from infection-attributable cancers due to their country or region of origin. U.S.- based clinicians may not routinely consider these unique risk factors. Although this article focuses on refugees, it is also intended to guide clinicians caring for other foreign-born immigrant groups living in the United States (hereafter referred to as "immigrants"). The document contains two sections: 1) special considerations for U.S. Preventive Services Task Force guidelines cancer screening recommendations in immigrants and 2) cancer risks and screening recommendation unique to certain immigrant groups. Disparities in cancer screening and prevalence are often greater for specific immigrant groups than for broader racial or ethnic groups (e.g., Black, Asian, Hispanic) into which they may fit. Disaggregation of data by language or country of origin is useful to identify such disparities and to design intervention opportunities within specific communities that are culturally distinct and/or who have different environmental exposures. Unique cancer risks and disparities in screening support a nuanced approach to cancer screening for immigrant and refugee populations, which is the focus of this narrative review.

Improving Care for Patients with Chronic Hepatitis B via Establishment of a Disease Registry.

In the United States, there is poor clinician adherence to the American Association for the Study of Liver Disease and other guidelines for chronic hepatitis B virus (CHB) management. This prospective cohort study evaluated whether a CHB registry improves CHB management. We included patients with CHB aged ≥ 18 years and who had a clinical encounter during September 1, 2016-August 31, 2019. We divided patients into three groups based on care received before September 1, 2019: 1) CIH: primary care clinician at HealthPartners Center for International Health, 2) GI: not CIH and seen by gastroenterology within previous 18 months, and 3) primary care (PC): not CIH and not seen by gastroenterology within previous 18 months. We created and implemented a CHB registry at CIH that allowed staff to identify and perform outreach to patients overdue for CHB management. Patients with laboratory testing (i.e., alanine transaminase and hepatitis B virus DNA) and hepatocellular carcinoma screening in the previous 12 months were considered up to date (UTD). We compared UTD rates between groups at baseline (September 1, 2019) and pilot CHB registry end (February 28, 2020). We evaluated 4,872 patients, 52% of whom were female: 213 CIH, 656 GI, and 4,003 PC. At baseline, GI patients were most UTD (69%) followed by CIH (51%) and PC (11%). At pilot end the percent of UTD patients at CIH increased by 11%, GI decreased by 10%, and PC was unchanged. CHB registry use standardized care and increased the percent of CHB patients with recent laboratory testing and HCC screening.

The cost of global connectivity: Faster and more efficient spread of antimicrobial resistance by international travelers - A controversial commentary.

Although the relationship between human mobility and global dissemination of antimicrobial resistance (AMR) is well established, there are important aspects regarding dynamics and character of this spread that have not been well described such as the decreasing time from emergence to global dissemination. In addition, AMR spread through migrants is increasingly being discussed and examined. We believe caution should be exercised to not overly focus on this population since we believe migrants play a minor role and there is a history of stigmatizing and blaming migrants for emerging infections and disease outbreaks. International travelers are proportionately much more likely to perpetuate AMR spread due to the vastly greater volume combined with the increasing efficiency and speed at which they travel. Research, infection prevention measures, and policy development are likely to have the greatest impact if focused on the international traveler rather than on migrant populations.

The Value and Interpretation of Race and Ethnicity Data in the Era of Global Migration: A Change Is in Order.

Human migration and travel are leading to increasingly diverse populations throughout the world. Data collection practices need to adapt to these changes to expand our understanding of health disparities and to optimize the efforts to address health equity, particularly during public health emergencies such as the current COVID-19 pandemic. Race and ethnicity classifications in the United States have failed to evolve since the 1970s despite an increasingly diverse population. Current commonly collected categories are inadequate to accurately describe the economic, educational, and sociopolitical circumstances of different groups. Further, these categories lend little practical information to inform health policy. More predictive and actionable variables should be routinely collected to improve appropriateness and timeliness of health interventions. The immediate adoption of the collection of primary/preferred language and country of birth/origin by public health organizations, health systems, and clinical providers would be a concrete and valuable first step.

Disparities in tobacco cessation medication orders and fills among special populations.

BACKGROUND: There is considerable interest in measuring and eliminating health care disparities among various special populations, but there is limited understanding of their extent, causes, or potential remedies. To improve this for tobacco cessation, we measured differences in the frequency of receiving and filling cessation medication prescriptions by race, ethnicity, age, language preference, health insurance, and pregnancy. METHODS: The relevant variables for all patients of a Minnesota medical group aged 18 years and older with clinician visits were extracted from the electronic medical records of 1 large medical group from March 2006 to February 2007. This was combined with claims data from 1 insurance plan that covered most of these individuals. Order and fill rates for cessation medications were then adjusted for each of the other variables. RESULTS: There were 32,733 current users of tobacco, 18,047 of whom had both health insurance and pharmacy claims data available. After adjustment, 15.4% overall had received an order for cessation medications during this year, but only 78% had filled it. Groups receiving fewer orders than their comparison groups were aged 18-34 years or older than 65 years, men, pregnant women, Asians and Hispanics, and those with non-English-language preference, on Medicaid, or with fewer visits. The same groups were less likely to fill that prescription, except patients with non-English preference or Medicaid. DISCUSSION: There are disparities in both the receipt of cessation medication orders and the likelihood of filling them for some special populations. The causes are likely to be complex, but this information provides a starting point for learning to improve this problem.

A surveillance source of tobacco use differences among immigrant populations.

INTRODUCTION: Tobacco use disproportionately affects some ethnic minority populations. Important gains in understanding the relationship between acculturation and tobacco use have been hindered by the lack of available data, large samples of specific immigrant groups. This study is among the first to use electronic medical record (EMR) data to examine differences in tobacco use associated with acculturation among various population groups. METHODS: Relevant variables for all medical group patients aged 18 years and older with clinician visits were extracted from the EMR of one large medical group from March 2006 to February 2007. Preferred language and country of origin data from the EMR were used to create distinct cultural groupings. Adjusted prevalences were computed. RESULTS: One hundred thousand [corrected] three hundred [corrected] twenty nine patients reported [corrected] languages as English, Hmong, Vietnamese, Oromo, Amharic, Somali, and Spanish and were categorized as U.S. born or non-U.S. born. After adjusting for age, utilization, and insurance status, more acculturated Mexican and Hmong women were more likely to be tobacco users compared with less acculturated women. Among non-English speaking, current tobacco use was more prevalent among men compared with women. DISCUSSION: Interpreted language and country of origin data collected in a clinical setting were useful for describing tobacco use differences between and within cultural groups. Using preferred language and country of origin as a proxy for acculturation status may help understand some of the within and between cultural differences in tobacco use. These novel data sources have potential usefulness for tobacco surveillance of relatively small cultural groups.

A Best Practice Alert for Identifying Hepatitis B-Infected Patients.

We developed and evaluated the Global Health Wizard Hepatitis B Best Practice Alert (BPA) to increase primary care provider adherence to evidence-based guidelines for hepatitis B virus (HBV) infection screening in non-U.S.-born patients. We conducted a pilot study using nine clinics to test BPA effectiveness. Eligible patients were aged ≥ 12 years, from a country of origin with ≥ 2% HBV prevalence, had no electronic health record documentation of HBV screening, and were seen for primary care during July 2012-March 2013. The BPA triggered for > 4,500 patients and identified six previously unrecognized HBV-infected patients. The pilot project demonstrated BPA effectiveness and continued to be used at pilot clinics until 2018 and was expanded to additional clinics in 2019; 29 additional HBV-infected patients were identified. Although successful, BPA usage steadily decreased over time. Poor BPA usage limits the power to achieve the goal of improved population-based HBV screening.

Travel arrangements in chronic hemodialysis patients: A qualitative study.

INTRODUCTION: For patients on renal replacement therapy (RRT), "travel" and "independence" are rated as 2 of the top 5 factors that inform their choice of treatment modality. While home dialysis modalities offer patients a high degree of independence, the most common RRT in the United States is in-center hemodialysis (IHD). The limits imposed by IHD treatment can present a variety of challenges for patients who wish to travel. This study explored how IHD patients managed their travel and the role of dialysis social workers in executing travel arrangements for patients. METHODS: We performed a qualitative descriptive investigation using semi-structured interviews with adults receiving IHD (n = 16) and renal social workers (n = 8) from Iowa, Minnesota, North Dakota, South Dakota, and Wisconsin. Data were analyzed using a constant comparative method. FINDINGS: Three themes emerged from the interviews: travel process, travel-related barriers, and travel-related facilitators. The travel process entailed transient dialysis unit challenges and the need for multiple preparations and precautions. Barriers included comorbidities and not having a relationship with transient dialysis unit staff. Facilitators focused on the importance of travel and staff professionalism at transient dialysis units. Overall, there was lack of uniform protocols to guide the travel process at the patient and the dialysis unit levels. DISCUSSION: This study identified multiple perspectives regarding travel arrangements in chronic IHD patients. There is limited research on travel issues for IHD patients and this investigation is among the first to articulate barriers and facilitators associated with travel from the perspective of patients and social workers. Supporting travel for IHD patients can increase their sense of autonomy and provide opportunities to improve their quality of life.

Barriers to malaria prevention among immigrant travelers in the United States who visit friends and relatives in sub-Saharan Africa: A cross-sectional, multi-setting survey of knowledge, attitudes, and practices.

BACKGROUND: Despite achievements in the reduction of malaria globally, imported malaria cases to the United States by returning international travelers continue to increase. Immigrants to the United States from sub-Saharan Africa (SSA) who then travel back to their homelands to visit friends and relatives (VFRs) experience a disproportionate burden of malaria illness. Various studies have explored barriers to malaria prevention among VFRs and non-VFRs-travelers to the same destinations with other purpose for travel-but few employed robust epidemiologic study designs or performed comparative analyses of these two groups. To better quantify the key barriers that VFRs face to implement effective malaria prevention measures, we conducted a comprehensive community-based, cross-sectional, survey to identify differences in malaria prevention knowledge, attitudes, and practices (KAP) among VFRs and others traveling to Africa and describe the differences between VFRs and other types of international travelers. METHODS AND FINDINGS: Three distinct populations of travelers with past or planned travel to malaria-endemic countries of SSA were surveyed: VFRs diagnosed with malaria as reported through a state health department; members of the general VFR population (community); and VFR and non-VFR travelers presenting to a travel health clinic, both before their pretravel consultation and again, after return from travel. A Community Advisory Board of African immigrants and prior qualitative research informed survey development and dissemination. Across the three groups, 489 travelers completed surveys: 351 VFRs and 138 non-VFRs. VFRs who reported taking antimalarials on their last trip rated their concern about malaria higher than those who did not. Having taken five or more trips to SSA was reported more commonly among VFRs diagnosed with malaria than community VFRs (44.0% versus 20.4%; p = 0.008). Among travel health clinic patients surveyed before and after travel, VFR travelers were less successful than non-VFRs in adhering to their planned use of antimalarials (82.2% versus 98.7%; p = 0.001) and employing mosquito bite avoidance techniques (e.g., using bed nets: 56.8% versus 81.8%; p = 0.009). VFRs who visited the travel health clinic were more likely than VFR respondents from the community to report taking an antimalarial (83.0% versus 61.9%; p = 0.009), or to report bite avoidance behaviors (e.g., staying indoors when mosquitoes were out: 80.9% versus 59.5%; p = 0.009). CONCLUSIONS: We observed heterogeneity in malaria prevention behaviors among VFRs and between VFR and non-VFR traveler populations. Although VFRs attending the travel health clinic appear to demonstrate better adherence to malaria prevention measures than VFR counterparts surveyed in the community, specialized pretravel care is not sufficient to ensure chemoprophylaxis use and bite avoidance behaviors among VFRs. Even when seeking specialized pretravel care, VFRs experience greater barriers to the use of malaria prevention than non-VFRs. Addressing access to health care and upstream barrier reduction strategies that make intended prevention more achievable, affordable, easier, and resonant among VFRs may improve malaria prevention intervention effectiveness.

Case Report: Epididymo-Orchitis due to Mycobacterium tuberculosis.

Genitourinary tuberculosis (TB) is a rare but well-described form of extrapulmonary TB. We present a case of a 35-year-old man from Ethiopia with scrotal swelling and fever who was found to have epididymo-orchitis due to Mycobacterium tuberculosis. The patient presented to the hospital multiple times before undergoing operative debridement with fine needle aspiration and tissue biopsy to confirm the diagnosis. He improved with antituberculous therapy. Patients with TB risk factors presenting with epididymitis that is refractory to empiric antibiotic therapy warrant consideration of TB epididymitis. Our case demonstrates the high index of suspicion required to establish a diagnosis of genitourinary TB.

Role of immigrants and migrants in emerging infectious diseases.

Population migration plays a critical role in the spread of disease by initiating outbreaks of acute diseases, changing the prevalence of infectious diseases at a given location, and changing the face of chronic disease resulting from previous infection. This article focuses on the recent demographic changes in North America that have facilitated the introduction and spread of new microbial threats, the role migrant populations play in changing the demographics of specific infectious diseases, and the potential responses of clinicians and public health officials in addressing the challenges posed by these infections. The emphasis of the article is on immigrant and migrant populations entering North America; the role of travelers in emerging infectious diseases is addressed in another article in this issue.