TB Control for Unaccompanied Children in ORR Custody California TB Controllers Association Educational Conference, March 7, 2017 John Jereb, MD Senior Consultant/Contractor, Medical Officer, DHUC-ORR, ACF Office of Refugee Resettlement

Conflict of Interest Disclosure Statement Neither I, nor my spouse/partner have or have had financial or other relationships with any commercial interest organizations. No off-label usage of pharmaceutical products will be discussed.

Overview of Topics What is the Office of Refuge Resettlement (ORR) Who are Unaccompanied Children (UC) Where are UC placed What is the healthcare for UC How is TB diagnosed in UC What are the roles of local public health What is the epidemiology of TB among UC

Brief History of ORR 1980 The 1980 Refugee Act establishes the federal Office of Refugee Resettlement (ORR) to serve refugees, unaccompanied refugee minors, and Cuban/Haitian entrants 2000 ORR expands its service provision to asylees, survivors of torture, and certified adult victims of human trafficking 2003 The Homeland Security Act of 2002 transfers oversight of unaccompanied alien children to ORR 2007-2009 ORR expands its service provision to certified child victims of trafficking, Iraqi special immigrants visa (SIV) holders, and Afghan SIV holders

A person who owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion is outside the country of his nationality and is unable or, owing to such fear, is unwilling to avail himself of the protection of that country. ̶ 1951 Refugee Convention, United Nations

Unaccompanied Children: Statutory Definition and Rules for Referral Intercepted in United States, younger than 18 years, no U.S. lawful immigration status, no U.S. parent or legal guardian, or, no U.S. parent or legal guardian available to provide care or legal custody. Referred to ORR for placement by another Federal agency, usually the Department of Homeland Security. Other Federal agencies have to transfer the custody of an unaccompanied child to ORR within 72 hours. The majority of UC come into ORR care because they were apprehended while trying to cross the border. Others are referred as a result of interior apprehensions after involvement with local law enforcement or internal immigration raids.

Why are they coming? My grandmother wanted me to leave. She told me: “If you don’t join, the gang will shoot you. If you do join, the rival gang will shoot you—or the cops will shoot you. But if you leave, no one will shoot you.” -- Kevin, age 17 I am here because the gang threatened me. One of them “liked” me. Another gang member told my uncle that he should get me out of there because the guy who liked me was going to do me harm. In El Salvador they take young girls, rape them and throw them in plastic bags…. -- Maritza, age 15 From the UNHCR report, Children on the Run

Countries of Origin (FY2016) All other countries combined: UC Referral Numbers Countries of Origin (FY2016) Honduras Guatemala El Salvador All other countries combined: 5% of total in 2016

UC Age at Admission to ORR Custody

ORR UC Program Responsibilities Care and custody of UC (shelter, food, clothing, and services) Placement and transfer Reunification with qualified sponsors Administration of ORR-funded care provider facilities Compliance with national and local care standards

States Having Shelters, January 2017 Arizona California Florida Illinois Massachusetts Michigan New York Oregon Pennsylvania Texas Virginia Washington

Health Care for UC Routine medical examination within 48 hr Immunizations, on catch-up schedule Pregnancy testing (per algorithm) HIV testing (per algorithm) Tests and screens for TB Mental health screening and referral Emergency medical care Follow-up care for chronic illnesses Routine dental care (after extended stay) Public health and welfare notifications per law

Common Health Topics Immunizations Ectoparasites (e.g., scabies) Chickenpox Influenza-like illness Gastroenteritis and dehydration Dental caries Epilepsy (neurocysticercosis) Sports-related injuries Pregnancy

Rare Health Problems Solid-tissue tumors Leukemia Sickle cell disease Hemophilia Major congenital cardiac malformations Renal failure Chromosomal anomalies Premature births Zika

Mental Health Problems Post-traumatic stress disorder Depression Suicidal ideation Self-harming behaviors

DGMQ-CDC Technical Instructions for Immigrants and Refugees Overseas screening for “excludable conditions” TB instructions Active case finding, aged 15 years and older Full treatment before clearance for travel Testing with TST, aged < 15 years

TB Control Strategy for UC, Part I General health screening at time of apprehension (before ORR custody) Active case finding Symptoms screen and general examination Aged 15–17 yr, chest radiography, with referral for abnormalities consistent with TB disease* *Model: CDC Technical Instructions for Medical Examination of Aliens

TB Control Strategy for UC, Part II TB prevention Recommended by AAP, ATS, and CDC Diagnose latent M. tuberculosis infection (LTBI) Aged ≥5 yr, interferon-gamma release assay preferred Aged <5 yr, tuberculin skin test preferred Radiography after positive tests results Information letter for sponsor Notification to state health department at destination after release from ORR custody No routine treatment during ORR custody

Roles of Local Public Health Examination of children who might have TB Technical support when a child is in hospital for TB examination Treatment of TB Education for personnel who work at shelters Assistance with ORR information collection Contact investigation Follow-up for LTBI

TB Diagnoses (n = 15), UC in ORR Custody, FY2014–2015 Period prevalence 19/10,000

The 18 States Receiving >500 UC in Sponsor Placement after Release, FY2016 (N = 52,147)* Number UC Alabama 870 California 7,381 Florida 5,281 Georgia 1,735 Illinois 519 Kentucky 503 Louisiana 973 Maryland 3,871 Massachusetts 1,541 State Number UC New Jersey 2,637 New York 4,985 North Carolina 1,493 Ohio 693 Pennsylvania 604 South Carolina 562 Tennessee 1,354 Texas 6,550 Virginia 3,278 *Every state except Montana received at least one. Source: ORR