1. Medical Screening of Haitian Orphans: Parent Survey, 2010 Heather Burke Immigrant, Refugee, and Migrant Health Branch Division of Global Migration and Quarantine

2. The authors have no financial relationships to disclose

3. Haiti Earthquake, January 2010 https://www.cia.gov/librar y/publications/the- world- factbook/geos/ha.html >200,000 deaths 1.2 million displaced Nation with serious health concerns Thousands orphaned Estimates from www.usaid.gov and www.unicef.orgwww.usaid.govwww.unicef.org https://www.cia.gov/library/publications/the-world-factbook/geos/ha.html

4. Adoption Medical Screening U.S. immigrants required to undergo medical screening – Inadmissible infectious conditions (e.g., TB, syphilis) – Mental health issues (involving harmful behavior) – Immunizations—waived for some intl adoptees Performed by panel physicians overseas

5. Haiti Humanitarian Parole Policy Policy announced by DHS, Jan 18 2010 Certain Haitian orphans allowed to enter U.S. – Category 1: in process of adoption before 12 Jan – Category 2: eligible and matched before 12 Jan 1,150 arrivals All allowed to bypass overseas screening

6. CDC Screening Recommendations Recommendations urgently developed – AAP Red Book adoptee recommendations – Haiti-specific health information – CDC expert input

7. CDC Screening Recommendations Short time frame (posted Feb 1) Process unprecedented Dissemination of guidelines – AAP – USCIS – JCICS – HHS partners (ORR)

8. Specific CDC Recommendations History (trauma, known TB or HIV) Physical exam (trauma, congenital, nutrition) Screening for infectious diseases – HIV – Intestinal parasites – Malaria (if symptomatic) – Syphilis (congenital) – Tuberculosis – Vaccine-preventable diseases (hepatitis B)

9. Highlights: TB and Syphilis Tuberculosis – Haiti incidence ~ x 100 U.S. – Orphans with negative initial—repeat in 6 mos Congenital syphilis – AAP recommends screening of all internationally adopted – Disease of concern in Haiti

10. Objectives Knowledge/implementation of CDC screening recommendations Health conditions identified Where adoptive parents of orphans accessed medical care

11. Methods Parent survey, Apr 23 – Aug 4, 2010 – Web-based (SurveyMonkey®) – JCICS – USCIS listserv Provider survey, Apr 30 – Aug 1, 2010 – Web-based (SurveyMonkey®) – Link distributed via AAP listserv – Link sent to parents

12. Methods Parent survey, Apr 23 – Aug 4, 2010 – Web-based (SurveyMonkey®) – JCICS – USCIS listserv Provider survey, Apr 30 – Aug 1, 2010 – Web-based (SurveyMonkey®) – Link distributed via AAP listserv – Link sent to parents

13. Parent Survey 15 questions Demographics Medical evaluation/diagnoses Awareness of CDC recommendations One survey per Haitian orphan Frequencies

14. Results 383 surveys – Median age (range) = 5 yrs (1–18) – From 42 states – Top 3 states for respondents: CO (10%); FL (7%); MI (6%)

15. Illness upon Arrival % n=108 n=202 n=73

16. Illness upon Arrival % n=108 n=202 n=73 N=275 (72%)

17. Illness upon Arrival % n=108 n=202 n=73

18. Signs & Symptoms upon Arrival %

19. % URI Ear/eye infections Wheezing Minor surgical

20. 383 children

21. 375 (98%) children received med eval 8 (2%) children no med eval

22. 383 children 375 (98%) children received med eval 8 (2%) children no med eval Child not covered by parents’ insurance (n=4) Didn’t know eval needed (n=3) Didn’t know where to take child for eval (n=1)

23. 383 children 375 (98%) children received med eval 8 (2%) children no med eval Private doc 265 (72%) Fed/state clinic 42 (11%) Adoption clinic / specialist 25 (7%) Others (10%)— Hospital/ER (4%) Refugee/immigrant health provider (2%) Other specialist (1%)

24. Type of Medical Provider by State No. orphans

25. Type of Medical Provider by State No. orphans

26. Type of Medical Provider by State No. orphans

27. Median (range) days to eval = 6 (0-84) – Child ill on arrival: 5 (0-60) – Child not ill on arrival: 10 (0-84) – p value <0.001 Time to Medical Evaluation

28. Awareness of CDC Recs

29. Medical Evaluation: Screening % n=296 281 263 159 132 128 50

30. Screening by Clinic Type %

31. Medical Evaluation: Treatment % n=200 136 90 69 29 20 10 6 3 34

32. Treated Conditions by Age Group %

33. Medical Evaluation: Immunizations Immunized in HaitiImmunized in the U.S.

34. Not Immunized (n=86): Reasons

35. Providers: Screening (N=23 Providers) No. Providers

36. Providers: Diagnoses (N=39 Orphans) % Orphans

37. Summary 98% children received medical evals in U.S. – Time from arrival to exam variable – Most seen by private medical provider Most (parents of 78%) aware of CDC recs Most (88%) received ≥1 recommended test – Minority reported syphilis test Diarrhea and parasites most common; injury uncommon

38. Limitations Data self-reported (recall bias) Not complemented by provider data Responses for ~1/3 of orphans Cannot determine if multiple children per parent

39. Discussion Target multiple adoption partners for dissemination of recommendations (adoption agencies, USCIS, medical providers) Strategy for reaching medical providers in time-sensitive situations – Sharing of recommendations – Feedback

40. Acknowledgements Parents and providers who took the surveys! AAP, JCICS, USCIS and other partners

41. Thank You Heather Burke hburke@cdc.gov http://www.cdc.gov/immigrantrefugeehealth/adoption/index.html

42. Questions How can guidelines be disseminated effectively? How can information be obtained from providers? What issues were facing providers relating to guidelines/arrival of Haitian orphans?

43. Extra Slides

44. Category 1 orphans Children who have been legally confirmed as orphans eligible for intercountry adoption by the Government of Haiti, were in the process of being adopted by Americans prior to Jan. 12, 2010 and meet the below criteria. Required Criteria Evidence of availability for adoption, which MUST include at least one of the following: Full and final Haitian adoption decree Government of Haiti Custody grant to prospective adoptive parents for emigration and adoption Secondary evidence in lieu of the above. Evidence of suitability for adoption, which MUST include at least one of the following: Notice of Approval of Form I-600A, Application for Advance Processing of an Orphan Petition Current FBI Fingerprints and background security check clearances Physical custody in Haiti plus a security background check

45. Category 2 orphans Children who have been identified by an adoption service provider or facilitator as eligible for intercountry adoption, were matched to prospective American adoptive parents prior to Jan. 12, 2010 and meet the below criteria. Required Criteria Significant evidence of a relationship between the prospective adoptive parents and the child AND of the parents’ intention to complete the adoption, which could include the following: – Proof of travel by the prospective adoptive parents to Haiti to visit the child – Photos of the child and prospective adoptive parents together – An Adoption Service Provider “Acceptance of Referral” letter signed by the prospective adoptive parents – Documentary evidence that the prospective adoptive parents initiated the adoption process prior to Jan. 12, 2010 with intent to adopt the child (filed Form I-600A, Application for Advance Processing of an Orphan Petition, and/or Form I-600, Petition to Classify an Orphan as an Immediate Relative, completed a home study, located an ASP to work with in Haiti, etc.) Evidence of the child’s availability for adoption, which could the following: – IBESR (Haitian Adoption Authority) approval – Documentation of legal relinquishment or award of custody to the Haitian orphanage – Secondary evidence in lieu of the above Evidence of suitability for adoption, which MUST include at least one of the following: – Notice of Approval of Form I-600A, Application for Advance Processing of an Orphan Petition; OR – Current FBI Fingerprints and background security check clearances

46. Type of Provider Facility (n=30)