"Pretty much all the honest truth telling there is in the w - PowerPoint PPT Presentation

"Pretty much all the honest truth telling there is in the w orld is done by children." — Oliver Wendell Holmes, author and poet

Health Care for Internationally Adopted Children and Immigrants Miriam Toporowicz MD MPH Professor Department of Pediatrics Georgetown University MGUH

Scope • 2014: over 42 million immigrants in USA • 13% of the total population. • 19.7 million naturalized citizens • 9.9 million lawfully present immigrants • 12.5 million undocumented immigrants. • >250,000 children in last 15 years have come to join their adoptive families

Child migration and displacement • In 2015, there were 244 million people worldwide living outside their country of birth; 31 million of them were children . Among the world’s migrants are more than 21 million refugees – some 10 million of whom are children – who have been forcibly displaced from their own countries. An additional 41 million people in 2015 were internally displaced due to conflict and violence, and estimated 17 million of those were children.

U.S. Population by Immigration Status, 2014 316 Million Total U.S. Population U.S. Born Citizens 87% All Immigrants 13% (42.2 million) 6%, 3%, 4% Immigrants as a Share of the Total Naturalized citizens (19.7 million) Lawfully Present Immigrants (9.9 million) Undocumented Immigrants (12.5 million) SOURCE: Kaiser Family Foundation analysis of March 2015 Current Population Survey, Annual Social and Economic Supplement

Share of US Population, 2014 4 3 6 US born Naturalized Lawful undocumented 87

Terminology • Adoption • Migrant • Immigrant • Naturalized • Lawfully present • Undocumented • Refugee

Medical examination for immigrants and refugees • Under the authority of the Immigration and Nationality Act (INA) and the Public Health Service Act, the Secretary of Health and Human Services promulgates regulations outlining the requirements for the medical examination of aliens seeking admission into the United States. The Division of Global Migration and Quarantine provides the Department of State (DOS) and the U.S. Citizenship and Immigration Services (USCIS) with medical screening guidelines for all examining physicians, which outline in detail the scope of the medical examination . The purpose of the medical examination is to identify, for the DOS and USCIS, applicants with inadmissible health- related conditions.

IN USA • The immigration medical exam must be conducted by a physician designated by USCIS (also known as a "civil surgeon").

ABROAD • The immigration medical exam must be conducted by a physician designated by the U.S. Department of State (also known as a "panel physician").

Civil Surgeons These are the Technical Instructions for Medical Examination of • Aliens used by the Civil Surgeons in the medical examinations conducted in the United States. • Introduction and Background • Medical History and Physical Examination • Tuberculosis Syphilis • • Gonorrhea • Hansen’s Disease • Physical or Mental Disorders with Associated Harmful Behaviors and Substance-related Disorders • Other Physical or Mental Abnormality, Disease or Disability Vaccinations • • On October 6, 2008, HHS/CDC post

• Medical examinations in the United States are typically required for adjustment of status cases (Form I-485), and may also be required for requests for “V” nonimmigrant status (Form I-539).

Domestic medical screening for refugees Currently 12 guidelines are available. • • General Guidelines • Guidelines for the History and Physical • Hepatitis Screening Guidelines • HIV Infection Screening Guidelines Immunizations Guidelines • • Intestinal Parasite Guidelines • Lead Screening Guidelines • Mental Health Screening Guidelines • Malaria Guidelines Nutrition and Growth Guidelines • • Sexually Transmitted Diseases Guidelines • Tuberculosis Guidelines

Panel Physicians These are the Technical Instructions for Medical Examination of • Aliens used by the Panel Physicians in the medical examinations conducted outside of the United States. • Introduction and Background • Medical History and Physical Examination • Tuberculosis Screening and Treatment Syphilis • • Gonorrhea • Hansen’s Disease • Physical or Mental Disorders with Associated Harmful Behaviors and Substance-related Disorders • Other Physical or Mental Abnormality, Disease, or Disability Communicable Diseases of Public Health Concern • • Vaccinations

Done overseas • The visa medical exam includes: • a physical exam • a series of vaccines* • a screening for tuberculosis/TB (skin test/chest x-ray examination) • a blood test for syphilis (not routinely done for children under 15 unless there is reason to suspect infection) • *Some adopted children can receive a waiver to have their vaccinations delayed until after they arrive in the United States. Children who receive a waiver must receive the required vaccines once they arrive in the United States.

CDC

Laws governing adoption process U.S. Federal Law Laws of child’s country of birth Laws of State or Territory of residence

International adoption in USA • 2004 23000 • 2015 5648 • 88 countries • 42% China

International Adoptions • Year <5 years of age <1 year of age 2003 87% 56 % 2015 54% 0.6%

Geography • Countries • States

Adoptions from all countries by year

Top 5 Adopting Countries and States

2015

Delaware adoptions

Preadoption Travel for parents Medical exam at origin point Communication during travel Review of documents Counseling

Post Placement Evaluation Office contact Initial Visit Evaluation components Nutrition/ feeding Behavior Immunizations Laboratory Referrals Follow up

MEDICAL EVALUATION

Preadoption Parent(s)/ Family travel and preparation Post placement and adoption evaluation

Pre adoption • Counseling. No child assigned • Planning stage. Child assigned • Documentation review

Parent- Family Travel advice Immunizations Contact with Agency Contact with Pediatrician

Post Placement/Adoption Evaluation • System Contact • Office contact • Initial Visit • Comprehensive evaluation • Evaluation components • Immunizations • Referrals

Comprehensive Evaluation • Review records • Physical exam • Measurements • Nutrition • Behavior • Screening • Immunizations

Comprehensive Evaluation • Review records • Physical exam • Measurements • Nutrition • Behavior • Screening • Immunizations

Records • Language • Translation • Official records • ??

Screening • CBC • Hepatitis • HIV • Syphilis • Thyroid • Lead • Urinalysis • Stool

• Newborn Metabolic screen • Vit D • PPD • Others – G6PD – Hemoglobin electrophoresis – Tailor to patient and epidemiology of country

…and /or Referrals • Audiology • Ophthalmology • Dental • Developmental evaluation • Others

WORK UP check list 1 2 3 4 5 6 7 8

Immunizations • Review records • Determine acceptable from record • Formulate plan • Immunize • Catch up

Follow up • Review laboratories and results • Growth and Development • Feeding • Behavior • Long term issues • Routine care • Work up Sheet

GOALGOAL • Incorporate to regular care • Follow up as needed • Relationship • Healthy and Happy

SOURCES • U.S Department of State • Bureau of Consular Affairs • UNICEF • UNICEF Global Database • CDC • AAP • Department of Homeland Security ( US Citizenship and Immigration Services) • Medical Literature