Implementation of a Curriculum to Optimize Hygiene Behaviors Among Refugees and Migrants Being Resettled

Health knowledge and behaviors can impact well-being and promote community integration post-arrival for refugees and migrants being resettled. Health and hygiene curricula are efficient and accessible mechanisms to mitigate the risk of chronic and infectious diseases in populations being resettled. This report summarizes a successful interagency/interdisciplinary Uganda-based collaboration between the International Organization for Migration, U.S. Centers for Disease Control and Prevention, and the University of Minnesota. The project's objective was to co-create and align a health curriculum and education messages across the resettlement continuum. Due to timing, the curriculum expanded to include COVID-19 prevention education, thus broadening the initiative's impact. Since the initial implementation, thousands of US-bound applicants have had exposure to the curriculum modules. The curriculum is now the primary tool for health education during pre-departure procedures in Kampala, Uganda, with implementations planned in other countries. The modular format and standardized non-technical language facilitated uptake by medical and non-medical personnel. Incorporating end users in curriculum development supports the early adoption and sustainability of the project. The interagency/interdisciplinary partnership strengthens systems and supports resource sharing to optimize the health and well-being of persons resettling in the United States

Prevalence of Malaria Parasite Infections among U.S.-Bound Congolese Refugees with and without Splenomegaly.

All U.S.-bound refugees from sub-Saharan Africa receive presumptive antimalarial treatment before departing for the United States. Among U.S.-bound Congolese refugees, breakthrough malaria cases and persistent splenomegaly have been reported. In response, an enhanced malaria diagnostic program was instituted. Here, we report the prevalence of plasmodial infection among 803 U.S.-bound Congolese refugees who received enhanced diagnostics. Infections by either rapid diagnostic test (RDT) or PCR were detected in 187 (23%) refugees, with 78 (10%) by RDT only, 35 (4%) by PCR only, and 74 (9%) by both. Infections identified by PCR included 103 monoinfections (87 Plasmodium falciparum, eight Plasmodium ovale, seven Plasmodium vivax, and one Plasmodium malariae) and six mixed infections. Splenomegaly was associated with malaria detectable by RDT (odds ratio: 1.8, 95% CI: 1.0-3.0), but not by PCR. Splenomegaly was not strongly associated with parasitemia, indicating that active malaria parasitemia is not necessary for splenomegaly

Economic Analysis of the Impact of Overseas and Domestic Treatment and Screening Options for Intestinal Helminth Infection among US-Bound Refugees from Asia

<div><p>Background</p><p>Many U.S.-bound refugees travel from countries where intestinal parasites (hookworm, <i>Trichuris trichuria</i>, <i>Ascaris lumbricoides</i>, and <i>Strongyloides stercoralis</i>) are endemic. These infections are rare in the United States and may be underdiagnosed or misdiagnosed, leading to potentially serious consequences. This evaluation examined the costs and benefits of combinations of overseas presumptive treatment of parasitic diseases vs. domestic screening/treating vs. no program.</p><p>Methods</p><p>An economic decision tree model terminating in Markov processes was developed to estimate the cost and health impacts of four interventions on an annual cohort of 27,700 U.S.-bound Asian refugees: 1) “No Program,” 2) U.S. “Domestic Screening and Treatment,” 3) “Overseas Albendazole and Ivermectin” presumptive treatment, and 4) “Overseas Albendazole and Domestic Screening for <i>Strongyloides</i>”. Markov transition state models were used to estimate long-term effects of parasitic infections. Health outcome measures (four parasites) included outpatient cases, hospitalizations, deaths, life years, and quality-adjusted life years (QALYs).</p><p>Results</p><p>The “No Program” option is the least expensive ($165,923 per cohort) and least effective option (145 outpatient cases, 4.0 hospitalizations, and 0.67 deaths discounted over a 60-year period for a one-year cohort). The “Overseas Albendazole and Ivermectin” option ($418,824) is less expensive than “Domestic Screening and Treatment” ($3,832,572) or “Overseas Albendazole and Domestic Screening for <i>Strongyloides</i>” ($2,182,483). According to the model outcomes, the most effective treatment option is “Overseas Albendazole and Ivermectin,” which reduces outpatient cases, deaths and hospitalization by around 80% at an estimated net cost of $458,718 per death averted, or$2,219/$24,036 per QALY/life year gained relative to “No Program”.</p><p>Discussion</p><p>Overseas presumptive treatment for U.S.-bound refugees is a cost-effective intervention that is less expensive and at least as effective as domestic screening and treatment programs. The addition of ivermectin to albendazole reduces the prevalence of chronic strongyloidiasis and the probability of rare, but potentially fatal, disseminated strongyloidiasis.</p></div

Summary of key epidemiologic, economic, and demographic parameter estimation.

<p>Summary of key epidemiologic, economic, and demographic parameter estimation.</p

Cost-effectiveness acceptability curve, fraction of Monte Carlo Simulation iterations in which option is preferred as a function of willingness to pay per QALY gained.

<p>Cost-effectiveness acceptability curve, fraction of Monte Carlo Simulation iterations in which option is preferred as a function of willingness to pay per QALY gained.</p

Estimated costs and health outcomes for parasite control programs among Asian refugees, 27,700 annual cohort.

<p>Estimated costs and health outcomes for parasite control programs among Asian refugees, 27,700 annual cohort.</p

One-way sensitivity analyses of <i>Strongyloides</i> infection prevalence and QALY decrement on the cost per QALY gained, “Overseas Albendazole and Ivermectin” compared to “No Program” (2013 USD).

<p>One-way sensitivity analyses of <i>Strongyloides</i> infection prevalence and QALY decrement on the cost per QALY gained, “Overseas Albendazole and Ivermectin” compared to “No Program” (2013 USD).</p