Journal of Immigrant and Minority Health

, Volume 15, Issue 1, pp 1–9

The Health Profile and Chronic Diseases Comorbidities of US-Bound Iraqi Refugees Screened by the International Organization for Migration in Jordan: 2007–2009

Authors

    • Division for Global Migration and Quarantine, Centers for Disease Control and PreventionNational Center for Emerging Zoonotic and Infectious Diseases
  • Marwan Naoum
    • International Organization for MigrationMigration Health Assessment Center IOM
  • Nedal Odeh
    • International Organization for MigrationMigration Health Assessment Center IOM
  • Pauline Han
    • Division for Global Migration and Quarantine, Centers for Disease Control and PreventionNational Center for Emerging Zoonotic and Infectious Diseases
  • Margaret Coleman
    • Division for Global Migration and Quarantine, Centers for Disease Control and PreventionNational Center for Emerging Zoonotic and Infectious Diseases
  • Heather Burke
    • Division for Global Migration and Quarantine, Centers for Disease Control and PreventionNational Center for Emerging Zoonotic and Infectious Diseases
Original Paper

DOI: 10.1007/s10903-012-9578-6

Cite this article as:
Yanni, E.A., Naoum, M., Odeh, N. et al. J Immigrant Minority Health (2013) 15: 1. doi:10.1007/s10903-012-9578-6

Abstract

More than 63,000 Iraqi refugees were resettled in the United States from 1994 to 2010. We analyzed data for all US-bound Iraqi refugees screened in International Organization for Migration clinics in Jordan during June 2007–September 2009 (n = 18,990), to describe their health profile before arrival in the United States. Of 14,077 US-bound Iraqi refugees ≥15 years of age, one had active TB, 251 had latent TB infection, and 14 had syphilis. No HIV infections were reported. Chronic diseases comorbidities accounted for a large burden of disease in this population: 35% (n = 4,105) of screened Iraqi refugees had at least one of three chronic medical conditions; hypertension, diabetes mellitus, or obesity. State health departments and clinicians who screen refugees need to be aware of the high prevalence of chronic diseases among Iraqi refugees resettled in the United States. These results will help public health specialists develop policies to reduce morbidity and mortality among US-bound Iraqi refugees.

Keywords

Iraqi refugeesChronic disease comorbiditiesHypertensionDiabetesObesityHereditary blood disordersConsanguinity

Introduction

The United Nations High Commissioner for Refugees (UNHCR) estimates that more than 2.8 million Iraqis are internally displaced, while an additional 2 million are refugees in neighboring countries [1, 2]. This population, one of the largest caseloads ever dealt with by UNHCR, presents a unique challenge, since most Iraqi refugees reside in urban areas of Jordan, Syria, Turkey, Lebanon, and Egypt, which has complicated the determination of population size as well as their access to health care and other services [2, 3].

The United States Refugee Admissions Program has steadily increased the number of Iraqi refugees admitted into the United States in recent years. From 1994 to 2010, more than 63,000 Iraqi refugees were resettled in the United States, representing 6% of all refugees resettled during that period [1, 4]. Most of these refugees have been resettled to Michigan, California, Texas, Illinois, and Arizona, with fewer in other states (CDC, unpublished data, 2010).

The Centers for Disease Control and Prevention (CDC) is responsible for providing technical instructions to the panel physicians and civil surgeons who conduct medical screening of immigrants and refugees. The purpose of this screening is to identify applicants with inadmissible health-related conditions that pose a threat to public health in the United States, including (1) persons with communicable diseases of public health significance, such as tuberculosis (TB), leprosy, and any other diseases designated as public health emergencies of international concern by the US Government or the World Health Organization International Health Regulations; (2) persons who have or have had a physical or mental disorder with associated harmful behavior; or (3) drug (substance) abusers or addicts [5].

Of note, refugees are exempted from the vaccination requirements at the time of their initial admission to the United States, but must fulfill these requirements when applying for adjustment of status (1 year or more after arrival) [6]. Other conditions which are not inadmissible but require follow-up by the state health department include completed treatment of active TB, extrapulmonary TB, latent TB infection, and contacts of TB patients, treated syphilis and other sexually transmitted diseases, and treated leprosy [5].

Currently, more than 500,000 Iraqi refugees reside in Jordan. The International Organization for Migration (IOM) Office in Jordan is responsible for the medical screening of all Iraqi refugees applying for resettlement to the United States through the UNHCR Office in Jordan. This screening consists of a medical history; measuring temperature, blood pressure (twice), pulse, weight and height; blood tests for syphilis, and an evaluation for TB, followed by the physical examination by an IOM panel physician [5]. Effective January 4, 2010, HIV infection testing is no longer be required as part of the US immigration medical screening process. Blood pressure is not routinely measured in children <15 years of age unless parents report hypertension or the physician thinks that the child might have hypertension related to obesity. The screened refugees’ data are entered into a secure database.

The aim of this study is to describe the health profile of US-bound Iraqi refugees screened by IOM in Jordan during 2007–2009.

Methods

We reviewed and analyzed data for all Iraqi refugees screened at the IOM clinics in Jordan from June 2007 to September 2009 (n = 18,990). This evaluation was determined to be a non-research by CDC. Infectious diseases such as TB, syphilis, HIV, and leprosy were identified. A text search was done on the exam results field entered by clinicians to classify the following noninfectious disorders: cardiovascular diseases, metabolic diseases, congenital disorders, mental health disorders, and cancer. Risk factors such as smoking and obesity were also identified from history data and exam results fields. Data were analyzed by using SPSS (v. 18) and Microsoft Excel. Simple frequencies and proportions were calculated to describe the demographic characteristics and disease burden, and the Chi-square test was used to compare the prevalence of hypertension, diabetes, and obesity by age and sex. Denominators used to estimate the prevalence of different medical conditions varied because of screening criteria (e.g., age) and missing data.

The body mass index (BMI) for adults is a number calculated from a person’s weight in kilograms divided by height in meters squared. For children and teens, the BMI was calculated, then the BMI number was plotted on the CDC BMI-for-age growth charts to obtain a percentile ranking [7]. The percentile indicates the relative position of the child’s BMI number among children of the same age and sex.

Results

Of 18,990 Iraqi refugees screened in Jordan, 49.7% were male, 25.8% were <15 years old, 54.7% were 15–45 years old, and 19.4% were >45 years of age (Fig. 1). Sixty-three percent were born in Baghdad, 7% in Jordan, and 30% in other Iraqi governorates or other countries (Fig. 2). Among 14,077 US-bound Iraqi refugees ≥15 years of age who were screened, one was diagnosed with active TB and received treatment under the supervision of IOM and National TB Program clinicians in Jordan; 251 had latent TB infection (LTBI). Fourteen were diagnosed with syphilis and were treated by IOM clinicians. No HIV infections or cases of leprosy were reported (Table 1). Chronic, noninfectious health conditions accounted for a considerable disease burden among all screened Iraqi refugees; 26.8% (n = 5,095) had at least one chronic condition.
https://static-content.springer.com/image/art%3A10.1007%2Fs10903-012-9578-6/MediaObjects/10903_2012_9578_Fig1_HTML.gif
Fig. 1

Age distribution (%) of US-bound Iraqi Refugees screened by IOM/Jordan, by Gender, 2007–2009 (n = 18,990)

https://static-content.springer.com/image/art%3A10.1007%2Fs10903-012-9578-6/MediaObjects/10903_2012_9578_Fig2_HTML.gif
Fig. 2

Number of US-bound Iraqi refugees, by province of birth in Iraq

Table 1

Selected conditions diagnosed among Iraqi refugees screened by IOM/Jordan, 2007–2009

Condition

Definition

Screened groups by age (years)

Total number of screened refugees

Positive results no. (%)

Infectious

Tuberculosis (TB), class A

Any component suggestive of TB (medical history, physical exam and chest X-ray), positive TST, positive sputum smears and culture

≥15

14,077

1 (0.007)

Latent TB

Positive TST ≥ 10 mm with normal chest X-ray, and negative smears and culture

15–30

5,709

68 (1.2)

31–45

4,480

75 (1.7)

46–60

2,137

48 (2.2)

61–75

1,157

42 (3.6)

76+

186

18 (9.6)

Syphilis

Treponema pallidum—positive rapid plasma reagin (RPR) and FTA-ABS or TP PAa

15–60

9,018

11 (0.1)

61+

500

3 (0.6)

HIV

ELISA test

Adults

16,534

0 (0)

Noninfectious

Hypertension (HTN)

Systolic blood pressure (SBP) ≥ 140 mmHg and diastolic blood pressure (DBP) ≥ 90 mmHg on two separate measurements (1–2 h interval: the first measurement by the nurse during completion of medical history and the second by the physician during the medical exam)

≥15

13,299

4,382 (33)

15–30

5,374

859 (16.0)

31–45

4,435

1,448 (32.6)

46–60

2,137

1,115 (52.2)

61–75

1,146

809 (70.6)

76+

207

151 (72.9)

3–14b

267/3,955

12 (4.5%)

HTN-stage I

SBP > 140–159 mmHg and DBP > 90–99 mmHg on two separate measurements

≥15

13,299

3,339 (25.1)

HTN-stage II

SBP ≥ 160 mmHg and DBP ≥ 100 mmHg on two separate measurements

≥15

13,299

1,055 (7.9)

Pre-hypertension

SBP ≥ 120–139 mmHg and DBP ≥ 80–89 mmHg on two separate measurements

≥15

13,299

5,565 (41.8)

Diabetes mellitus (DM)c

Type I

Type II

Elevated random blood sugar >150 mg/dL (IOM Jordan); exam results text field

All

18,990

514 (2.7)

0–2

867

0 (0)

3–14

4,036

4 (0.1)

15–30

5,737

23 (0.4)

31–45

4,643

67 (1.4)

46–60

2,247

173 (7.7)

61–75

1,235

219 (17.7)

76+

215

28 (13.0)

All

18,990

58 (0.3)

All

18,990

456 (2.4)

Overweight (adult)

BMI ≥ 25.5–29.9

≥20

11,898

4,495 (37.8)

Obesity (adult)

BMI > 30

≥20

11,898

3,982 (33.5)

Underweight (adult)

BMI (<18.5)

≥20

11,898

193 (1.6)

Overweight (children)

BMI ≥ 85 to < 95% for age

All 2–19

5,734

820 (14.3)

2–5

1,496

219 (14.6)

6–11

1,864

241 (12.9)

12–19

2,374

360 (15.2)

Obesity (children and teens)

BMI ≥ 95% for age

All 2–19

5,734

632 (11)

2–5

1,496

215 (14.4)

6–11

1,864

176 (9.4)

12–19

2,374

241 (10.2)

Underweight (children and teens)

BMI < 5% for age

All 2–19

5,734

572 (10)

2–5

1,496

176 (11.8)

6–11

1,864

204 (10.9)

12–19

2,374

192 (8.1)

Smokingc

Current history of smoking, by age group

Any type of smoking: cigarettes, water pipe

All

18,990

2,353 (12.4)

All

18,990

3,509 (19.3)

≤14

4,903

24 (0.5)

15–30

5,737

990 (17.2)

31–45

4,643

1,323 (28.5)

46–60

2,247

680 (30.2)

61–75

1,235

334 (27)

76+

215

53 (24.6)

aRapid plasma reagin (RPR with fluorescent treponemal antibody absorption (FTA-Abs), microhemagglutination or indirect hemagglutination tests for antibodies to T. pallidum (MHA-TP, TP-PA)

bOf 3,955 children and teens ages 3–14 years, 267 were screened for HTN and 12 had hypertension

cMedical conditions were self-reported by the refugee and checked by the IOM nurse and physician during clinical screening

Hypertension

Of 13,299 screened Iraqis ≥15 years of age with available blood pressure information, 4,382 (33%) had hypertension (HTN) (≥140/≥90), including 3,327 applicants (25%) classified as having stage-I HTN (≥140–159/≥90–99) and 1,055 (8%) classified as having stage-II HTN (≥160/≥100). An additional 5,565 (42%) Iraqi refugees were prehypertensive (pre-HTN) (≥120–139/≥80–89) [8] (Table 1). IOM panel physicians measured the blood pressure of children <15 years of age only if there was a concern that the child might be hypertensive. Of 3,955 children 3–14 years of age, 267 were screened for hypertension and 12 had hypertension (4.5%).

Diabetes Mellitus

Of the 18,990 Iraqi refugees screened, 514 (2.7%) were diagnosed with diabetes mellitus (DM). Of these, 11% (n = 58) had type I and 89% (n = 456) had type II DM (Table 1). Of those who were diagnosed with DM, 84% (n = 343) had HTN, 22% (n = 113) had pre-HTN, and 1.5% (n = 8) had HTN and history of angina or myocardial infarction.

HTN, DM, and obesity among Iraqis >20 years of age were significantly associated with increased age (p < 0.001, all comparisons), and HTN and obesity were associated with male gender (p < 0.001, both comparisons). In total, 35% (n = 4,105) of screened Iraqi refugees with available information had at least one of three chronic medical conditions: HTN, DM, or obesity; 17.5% (n = 2,068) had two of these conditions; and 1.4% (n = 171) had all three.

Cancer and Other Chronic Diseases

Other chronic conditions included vision problems in 4,655 (25.6%); ear, nose, and throat problems in 842 (4.6%); hearing problems in 351 (1.9%); and asthma in 324 (1.7%). Ninety-seven refugees (67 female) had previously been diagnosed with or were currently receiving treatment for cancer (Table 2).
Table 2

Other selected medical conditions diagnosed among Iraqi refugees screened by IOM/Jordan, 2007–2009

Conditionb

Definition

Screened group by age (years)

Total number of screened refugeesa

Positive number (%)

Vision problems

Myopia, hypermetropia, corrective lenses, squint, cataract

All

18,206

4,655 (25.6)

Ear, nose and throat (including dental) problems

Exam results text

All

18,207

842 (4.6)

Hearing problems

Exam results text

All

18,205

351 (1.9)

Asthma

Exam results text field

All

18,990

324 (1.7)

Myocardial infarction and angina

Exam results text field

>30

8,340

90 (1.1)

Renal disease

Exam results text field

All

18,990

73 (0.4)

Osteoporosis

Exam results text field

>31

8,340

68 (0.8)

Epilepsy

Exam results text field

All

18,990

44 (0.2)

Mental health problems

Exam results text field

All

18,990

165 (0.9)

Thyroid gland diseases (hyperthyroidism, hypothyroidism and goiter)

Exam results text field

All

18,990

106 (0.6)

All cancer

Exam results text field

All

18,990

97 (0.5)

Breast cancer

Exam results text field

Women > 15

7,161

40 (0.6)

15–30

2,695

1 (0.04)

31–45

2,312

9 (0.4)

46–60

1,305

19 (1.5)

61–75

723

11 (1.5)

76+

126

0 (0)

Ovarian cancer

Exam results text field

Women > 15

7,161

3 (0.04)

15–45

5,007

3 (0.06)

Uterine cancer

Exam results text field

Women > 15

7,161

4 (0.06)

46–60

1,305

4 (0.3)

Brain cancer

Exam results text field

31–45

4,643

4 (0.1)

Colon cancer

Exam results text field

46–60

2,247

2 (0.1)

61–75

1,235

3 (0.2)

Gastrointestinal cancer

Exam results text field

46–60

2,247

1 (0.04)

Eye cancer

Exam results text field

31–60

6,890

2 (0.03)

Kidney-uterine cancer

Exam results text field

31–75

8,125

3 (0.04)

Laryngeal cancer

Exam results text field

61+

1,450

2 (0.1)

Lymphoma

Exam results text field

3–60

16,663

9 (0.05)

Leukemia

Exam results text field

3–45

14,416

2 (0.01)

Thyroid cancer

Exam results text field

≥15

14,077

4 (0.03)

Prostate cancer

Exam results text field

Men ≥76

89

2 (2.2)

Congenital cardiovascular disorders

Exam results text field

All

18,990

16 (0.08)

G6PD

Exam results text field for all age groups

All

18,990

33 (0.2)

Sickle cell disease

Exam results text field for all age groups

All

18,990

4 (0.02)

Thalassemia

Exam results text field for all age groups

All

18,990

7 (0.04)

aTotal number of screened refugees reflects available data and excludes missing values. For diseases extracted from exam results field (text search), the total number of screened refugees is 18,990 (or relevant age categories), regardless of whether there was information in the exam results field about the disease

bMedical conditions were self-reported by the refugee and checked by the IOM nurse and physician during clinical screening

Obesity

Of 11,898 Iraqi refugees ≥20 years of age with available weight and height information, 4,495 (38%) were overweight (BMI = 25.5–29.9 kg/m2), and 3,982 (34%) were obese (BMI ≥ 30 kg/m2) (Table 1). Of those who were overweight, 35% (n = 1,581) also had HTN and 43% (n = 1,934) had pre-HTN. Of those who were obese, 50% (n = 2,006) had HTN and 37% (n = 1,485) had pre-HTN. Of 5,734 Iraqi refugees 2–19 years of age with available weight and height information, 3,710 (65%) had healthy weight (5 to <85% of BMI for age), 572 (10%) were underweight (<5% of BMI for age), 820 (14%) were overweight (≥85 to <95% of BMI for age), and 632 (11%) were obese (≥95% of BMI for age) [7].

Smoking

Of the 18,990 screened Iraqi refugees, 3,509 (19.0%) reported a history of smoking cigarettes or any form of tobacco (e.g., waterpipes); 877 (25%) were women. Current smoking was reported by 2,353 (12.4%), of whom 561 (24%) were women. Of 292 women who were pregnant at the time of screening, 14 had a history of smoking during pregnancy (5%), of whom 10 reported quitting during their current pregnancy (71.4%). Of 2,353 Iraqis who were current smokers, 866 (37%) had HTN, 81 (3%) had DM, 780 (33%) were obese, and 42 (1.8%) had asthma.

Mental and Neurodevelopmental Disorders

The data included reports of 165 (0.9%) Iraqi refugees with neurodevelopmental and mental disorders, including 45 (0.2%) with mental retardation, 44 (0.2%) with epilepsy, 39 (0.2%) with post-traumatic stress disorders, 10 with mental disorders associated with harmful behavior, including schizophrenia, severe depression, and mental retardation; 9 (0.04%) with autism, 7 with current drug or alcohol addiction; 6 with addiction in remission; and 5 (0.02%) with attention deficit hyperactivity disorder (Table 2).

Congenital and Genetic Disorders

Of the 18,990 screened refugees, 325 had congenital disorders: 16 had congenital cardiovascular defects (8.4/10,000), 33 had glucose-6-phosphate dehydrogenase deficiency (G6PD) (17.4/10,000), 4 had sickle cell diseases (SCD) (2.1/10,000), 7 thalassemia (3.7/10,000), and 116 congenital hemangioma (6.1/10,000) (Table 2).

Discussion

This group of Iraqi refugees had a low prevalence of infectious diseases of public health significance (TB and syphilis), compared with their prevalence among refugees resettling to the United States from other countries [9]. On the other hand, Iraqis have high rates of chronic noninfectious diseases comorbidities (i.e., hypertension, diabetes), closer to the rates in middle-income countries and similar to the reported increase of morbidity among urban refugees in recent conflicts [1012].

Iraqi refugees resettling to the United States may be at risk for development of cardiovascular diseases (CVD), the leading cause of death in the United States. This finding is because 35% of screened Iraqi refugees had at least 1 of the 3 medical conditions: HTN, DM, or obesity, which along with increased cholesterol, are the main CVD risk factors among Arab-Americans [13]. The prevalence of HTN in this study was similar to both the rate among Iraqi refugees living in Jordan (33%) [14] and the rate in the United States in 2008–2009 (32.6%) [15], but higher than the rates among resettled Iraqi refugees screened in San Diego County (14.8%) [16] and among Arab-Americans living in the United States (13–25%) [17, 18]. Further, a study also showed that patients with prehypertension are twice as likely to develop hypertension than those with lower blood pressure values [7]. We anticipate that many screened Iraqi refugees diagnosed with prehypertension (42%) may develop hypertension and CVD later in the United States.

The overall prevalence of diabetes among Iraqi refugees in this study (2.7%) was close to its rate in Iraq (2.2%) [19] and to that of resettled Iraqi refugees screened in San Diego County (1.9%) [16]. The prevalence of DM among adults aged 45+ years (11.3%) was also close to national age-specific rates in the United States (14%) [15] and to rates among Arab-Americans (12.7%) [17, 18, 20, 21]. However, Iraqi refugees with diabetes may face particular challenges. These immigrants may not adopt diabetes prevention measures such as low-fat diets, physical activity, and healthy lifestyle choices [14, 22]. Such a lack of acculturation might lead to a higher burden of diabetes in the future among Iraqi refugees resettled in the United States [20].

Another CVD risk factor is increased BMI. This study shows that 72% of Iraqi refugees ≥20 years of age with available information about their weight and height were overweight or obese, which was higher than the rate among Arab-Americans in the United States (51%) [18] and close to US national rates of overweight and obesity (68%) [15]. Studies have shown that obese children are more likely to become obese adults, and excess body weight is associated with excess morbidity and mortality [23, 24]. Our study showed that the prevalence of obesity among Iraqi children and teens (2–19 years old) was lower than for their peers in the United States (BMI for Age 11.0 vs. 16.9%, respectively) [25] (Table 1). In addition to measuring the refugee children’s BMI for age during the post-arrival screening, we suggest that physicians also measure the skinfold thickness and assess diet, health, and physical activity for children and teens, to provide a counseling and intervention strategy [7, 15].

Tobacco use is the number one preventable cause of morbidity and mortality in the United States [15]. Our data show that 12% of Iraqis screened in Jordan are current smokers, similar to the prevalence of smoking in Iraq (15%) [19] and lower than that among Iraqis screened after arrival to San Diego (21%) [16]. The burden of hypertension and DM among smokers in this study was close to that seen among Arab-Americans in California who were former smokers (HTN = 31%, DM = 17%) [26]. Smoking is associated with an increased risk of CVD, pulmonary diseases, and cancer [27]. Therefore, clinicians should obtain a detailed smoking history from resettled Iraqi refugees, especially those with other CVD risk factors such as HTN, DM, and obesity [13], and should encourage them to stop smoking. Further, smoking during pregnancy may cause poor pregnancy outcomes. The rates of smoking among pregnant women in our study were close to those among Arab-American pregnant women in Michigan (6%) [28]. Health care providers working with pregnant Iraqi refugee women should obtain a detailed smoking history and encourage them not to smoke and to avoid secondhand smoke, especially during pregnancy.

The economic impact of the high burden of chronic diseases comorbidity among Iraqi refugees may be significant if these diseases are not systematically controlled with tailored, culturally adapted, and gender-specific community health care interventions [22]. Iraqi refugees in Jordan have a high demand for and utilization of health services, which are likely to continue after their arrival in the United States [14]. Medical treatment for chronic diseases is expensive in the United States [2932]. For example, the average cost of treatment of a hypertensive person is $1,690 per year (adjusted to 2011 dollars) [32]. Further, the CDC Diabetes Cost-Effectiveness Group found that per-person, per-year treatment for hypertension in patients with type-2 diabetes costs between $330 and $1,000, and glycemic control costs between $500 and $2,500 (adjusted to 2011 dollars) [29]. About a third (n = ~4,000) of Iraqis screened in Jordan had hypertension, DM or both. Even these estimates are conservative, using these projections, the average annual costs for treating Iraqis with hypertension (n = 4,000) would be $6.7 million, for those with hypertension and type 2 diabetes (n = 343) would be $285,000 to $1.2 million a year, and for persons with type 2 diabetes (n = 456), annual treatment costs would be $228,000 to $1.14 million a year. Targeted community health programs and education aimed at preventing HTN and DM comorbidities among Iraqi refugees who have other CVD determinants such as prehypertension (n = ~5,500), obesity, and smoking may further reduce the incurred medical expenditures and improve their quality of life.

A relatively low number (<0.5%) of screened Iraqis had a history of cancer. However, breast cancer was the most common cause of cancer morbidity among screened Iraqi refugee women and was the leading cause of death among Arab-American women in Michigan (1985–2001) [33]. Although many Arab-American women indicated that their health insurance covered cancer screening, they either had low screening rates or delayed screening [34, 35]. Availability of health insurance coverage may not be the only barrier to timely cancer screening. Other barriers may include transportation, language, and beliefs about cancer causation and prevention [34, 35]. Health care providers should be cognizant of the health perspectives of newly resettled Iraqi refugees and should provide cancer education materials in the Arabic language to encourage timely screening.

The mental health assessment component of the overseas medical screening is not detailed. Therefore, we are unable to provide accurate data regarding the burden of mental health disorders among Iraqi refugees. In addition, the stigma associated with mental disorders in the Iraqi culture may result in psychological distress presenting as somatic complaints. More detailed mental health information on recently arrived Iraqi refugees by state health departments will help identify patients who were not identified during overseas screening and may prevent further deterioration of their mental and related physical health.

Hereditary and metabolic disorders are responsible for a substantial proportion of infant morbidity and mortality in Arab countries [36]. The occurrence of recessively inherited disorders is influenced by the frequency of carriers in the population, rates of children born to parents from the same ethnic group, and rates of consanguinity. The Iraq family health survey reported that 37% of Iraqi women are married to their cousins and 23% to other relatives [19], which may partially account for the high prevalence of certain recessively inherited disorders [36, 37]. The rates of G6PD deficiency (39.5/10,000) and thalassemia (10.5/10,000) were higher among screened Iraqi refugees born during 1992–2003 than among Arab-American children born in Michigan during the same period (2.17/10,000 and 1.36/10,000, respectively) [38]. We analyzed the data for Iraqi refugee children with G6PD and thalassemia who were born from 1992 to 2003 to compare their prevalence with the sole population-based study on birth defects among Arab-American children born in Michigan during the same period [38]. Health care providers serving Iraqi families should inquire about consanguinity and become familiar with the genetic disorders common among Arabs, such as sickle cell disease, thalassemia, and G6PD deficiency [37, 38].

The findings in this report are subject to the following limitations: First, the medical assessment was largely limited to conditions listed in the CDC technical instructions for medical examination of refugees, which mainly focus on infectious diseases [5]. As a result, the prevalence of chronic diseases might be underestimated, since some of these conditions were either self-reported by applicants on medical history or were diagnosed by physicians conducting the medical screening. Refugees may underreport their health conditions or health risks (smoking or drinking alcohol) during the medical history intake for fear it could affect approval of their application for resettlement. Second, IOM did not use ICD-10 codes as a reference for the diseases diagnosed by physicians. For example, different panel physicians might use the terms hypertension, HTN, or high blood pressure to describe the same medical condition in the text section of the medical form. Further, during our text search, misspelled medical conditions during data entry may have led to missing data, leading to possible information bias. Likewise, other noninfectious medical conditions, such as cancers, ischemic heart disease, specific mental health diagnoses, and hematologic disorders, might be underreported. Automating the data entry of applicants by IOM panel physicians and using ICD-10 coding would allow standardization and more accurate reporting of the medical conditions of refugees.

Our study shows that the prevalence of chronic disease comorbidities among Iraqi refugees may be higher than previously known [13, 15] and close to rates in the United States [14]. Studies have shown that refugees with chronic medical conditions may have limited access to secondary and tertiary level health services in receiving countries [9] and may also experience further delay in treatment until they receive a more comprehensive medical exam, typically conducted up to 3 months after arrival in the United States. This finding underscores the importance of developing a comprehensive, well-defined log of complex medical conditions diagnosed by IOM physicians that will require immediate medical attention upon arrival to the United States. The planned intervention will require better coordination and information sharing among IOM offices overseas, voluntary organizations, CDC, and State Health Departments, to ensure early referral and treatment of refugees with such medical conditions.

Conclusions

This study underscores the importance of developing culturally sensitive preventive and curative health programs to reduce the burden of chronic diseases comorbidities among Iraqis and to encourage physical activities and timely screening for cancer and other chronic diseases. More aggressive approaches for treatment of DM and HTN and prevention of CVD are needed to improve health outcomes [22]. Clinicians should provide culturally sensitive prenatal care and genetic counseling to resettled Iraqi refugees in the United States, especially for carrier testing and consanguinity counseling [38], to decrease the possibility of having children with the congenital and genetic disorders that are common in the Middle East.

Further, a culturally sensitive mental health assessment of recently arrived Iraqi refugees will also help identify patients who have conditions that were not identified during overseas screening and may prevent further deterioration of their mental and related physical health.

Acknowledgments

We are indebted to the IOM staff in Jordan for their support in data management: Ivan Vukovic, Rima Al-Azrai, Abdullah Al-Hayajneh, and to Tarissa Mitchell, Clive Brown, Rick Hull, Rachel Kaufmann, Yuling Hong, Ava Navin, and Crystal Polite for their contribution to study design, thorough review, and statistical support. This work was supported solely by the US Centers for Disease Control and Prevention.

Copyright information

© Springer Science+Business Media, LLC (Outside the USA) 2012