Health Status of and Intervention for US-Bound Kosovar Refugees—Fort Dix, New Jersey, May-July 1999 FREE

MMWR. 1999;48:729-732

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In March 1999, as a result of armed conflict in the Kosovo province of the Federal Republic of Yugoslavia, approximately 860,000 ethnic Albanians sought refuge in neighboring Albania, the Former Yugoslav Republic of Macedonia (FYROM), the Republic of Montenegro—Federal Republic of Yugoslavia, and Bosnia-Herzegovina. As a result of massive refugee movement into FYROM, many nations, including the United States, accepted refugees for resettlement. Refugee processing centers were established in FYROM and the United States. In the United States, the Migration Health Assessment (MHA)* of refugees was undertaken at Fort Dix, New Jersey (i.e., Operation Provide Refuge), in collaboration with the Office of Emergency Preparedness (OEP), Public Health Service, under the direction of the Office of Refugee Resettlement, U.S. Department of Health and Human Services. Assessments in Skopje, FYROM, were conducted by the International Organization for Migration. This report summarizes the results of collaboration between OEP and CDC to provide preventive health programs for 4045 Kosovar refugees at Fort Dix during a 10-week period, which found that the refugees were in good health and underscores the need for a tailored intervention program targeted at the health conditions of the specific population.

The first refugees arrived at Fort Dix on May 5. On arrival, acute medical care was provided as needed, and all refugees were scheduled to undergo the required MHA. As part of the MHA, refugees aged ≥15 years underwent a general physical examination and were screened for human immunodeficiency virus infection, syphilis, and TB.

Intervention and prevention services were established at Fort Dix in addition to the acute-care services and MHA. Because of reports of inadequate vaccination programs in Kosovo during the 2 years preceding the mass exodus¹ and the emergency resettlement of the refugees in the United States, approximately 10,600 vaccines were administered to refugees from a set of recommended vaccines (unless vaccination documentation was provided). Because high birth rates were reported in Kosovo before the conflict,² women of childbearing age (18-45 years) who had abnormal menstruation or amenorrhea were screened for pregnancy to determine whether they needed prenatal care and should not receive live vaccines. Approximately 120 pregnancy tests were performed during the first month; 58 women received prenatal care, including approximately 400 prenatal visits, and seven babies were born.

On the basis of reports from camps in FYROM, refugees also were assessed for selected conditions (e.g., untreated chronic diseases in the elderly and dental conditions). A pharmacy was established and dispensed approximately 7600 medications for conditions such as hypertension and diabetes. In addition, approximately 1000 dental visits were reported.

Pharmacy- and laboratory-based surveillance systems were established within 1 day of the arrival of the first refugees to identify potential disease outbreaks. Pharmacy-based surveillance of 1% permethrin prescriptions was included because of lice infestations reported from camps in FYROM: use was 20%-40% among refugees arriving during the first week. Among the 1051 newly arriving refugees during the second week, the prevalence of lice or nits within ¼ inch of the scalp (currently infested cases only) was 10%. On the basis of treatment outcomes, no drug resistance was documented. A treatment program was initiated for head lice at Fort Dix and treatment recommendations were made for the FYROM camps.

The first step in TB screening consisted of a chest radiograph. If the radiograph suggested active TB, serial sputum samples were collected for microscopy, culture, and sensitivity through the state laboratory. If radiographs were suggestive of inactive TB and the refugee was not symptomatic, no further evaluation was performed.

Among 4045 refugees screened at Fort Dix, two had infectious (smear-positive) TB, 26 had chest radiographs suggestive of active TB (all smear-negative, eight with clinical indications for treatment), and 65 had radiographs suggestive of inactive TB. All will be reevaluated at their health departments after resettlement. Six refugees had culture-confirmed TB (all sensitive to first-line TB drugs), and 10 refugees (including two with infectious TB) were begun on treatment.

Refugees with "inadmissible" health conditions received treatment, or received waivers, and physicians were identified to provide continuity of health care. Six refugees were treated for syphilis. Seven refugees were treated for mental health disorders associated with harmful behaviors and placed with physicians in their resettlement area. No other "inadmissible" health conditions were identified. No refugees were involuntarily deported because of "inadmissible" health conditions.

Refugees were treated at a 24-hour acute-care clinic (5127 visits) and referred to specialized care when necessary (72 hospitalized during the first month). Medical charts, including medical history, conditions and medications, vaccinations, dental and prenatal records, and results of MHA, were transferred to the state and local health agencies providing health care after resettlement.

During the same period, 5303 refugees entered the United States through JFK International Airport in New York; similar numbers of refugees with chest radiographs suggestive of active (n=23) and inactive (n=60) TB were identified. No differences were reported in the age and sex distribution of refugees by port of entry. All of these refugees were referred to the state and local health agencies that provide follow-up care for TB patients.

As of August 25, Kosovar refugees continued to enter through JFK International Airport, although their numbers have diminished. On July 16, Operation Provide Refuge was declared completed and the facilities at Fort Dix closed.

K Yeskey, MD, Office of Emergency Preparedness, Public Health Service; Div of Tuberculosis Elimination, National Center for HIV, STD, and TB Prevention; Div of Epidemiology and Surveillance, National Immunization Program; Div of Parasitic Diseases and Div of Quarantine, National Center for Infectious Diseases, CDC.

The health status of refugee populations varies considerably depending on (1) the demographics of the migrating population; (2) the prevalence of health conditions and quality of health services before displacement and in the country of first refuge; (3) the length of time the population was deprived of health care; and (4) the harshness of their living conditions during displacement. Despite these variations, screening for U.S. immigration purposes has been the same for all refugee and immigrant populations. To provide more timely interventions, CDC is tailoring health assessments to specific migrating populations.³

Before this migration emergency, the only medical information transmitted to the refugee health providers in the resettlement areas was that related to the "inadmissible" health conditions. Health information collected in refugee emergency settings should include (1) baseline health status of the refugee population; (2) refugee camp health provision and surveillance; (3) immigrant/refugee health clearance; (4) identification and design for preventive interventions; and (5) postsettlement follow-up care. The CDC/OEP response at Fort Dix underscores the value of a tailored approach, including preventive health interventions specifically targeted at this population. During this emergency, using information on health conditions in Kosovo before the armed conflict and on health conditions in the camps in FYROM, health services were prepared to meet the needs of Kosovar refugees.

To establish continuity of care, medical records developed at Fort Dix were transmitted to the resettlement health providers through the refugees. In addition, health fact sheets were drafted periodically and relayed to the refugee health coordinators in the states to assist them in planning health services programs before the arrival of the refugees. This health information and data collection and dissemination should be considered basic components of the refugee admission and resettlement process.

*MHA is a health examination mandated by U.S. law for all refugees and immigrants. The assessment is designed to identify "inadmissible" health conditions, which are infectious tuberculosis, human immunodeficiency virus infection, infectious syphilis and other sexually transmitted diseases, infectious (lepromatous) Hansen disease, any physical or mental health disorder associated with harmful behavior, and drug abuse or addiction.

MMWR. 1999;48:707-710

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Methicillin-resistant Staphylococcus aureus (MRSA) is an emerging community-acquired pathogen among patients without established risk factors for MRSA infection (e.g., recent hospitalization, recent surgery, residence in a long-term-care facility [LTCF], or injecting-drug use [IDU]).¹ Since 1996, the Minnesota Department of Health (MDH) and the Indian Health Service (IHS) have investigated cases of community-acquired MRSA infection in patients without established risk factors. This report describes four fatal cases among children with community-acquired MRSA; the MRSA strains isolated from these patients appear to be different from typical nosocomial MRSA strains in antimicrobial susceptibility patterns and pulsed-field gel electrophoresis (PFGE) characteristics.

In July 1997, a 7-year-old black girl from urban Minnesota was admitted to a tertiary-care hospital with a temperature of 103 F (39.5 C) and right groin pain. An infected right hip joint was diagnosed; she underwent surgical drainage and was treated with cefazolin. On the third day of her hospital stay, antimicrobial therapy was changed to vancomycin when cultures of blood and joint fluid grew MRSA. The same day, the patient had another hip drainage procedure, but had respiratory failure and was placed on mechanical ventilation. Her course was complicated by acute respiratory distress syndrome, pneumonia, and an empyema that required chest tube drainage. She died from a pulmonary hemorrhage after 5 weeks of hospitalization.

MRSA isolated from her blood, hip joint, and sputum was susceptible to multiple antibiotic classes. An autopsy revealed bilateral bronchopneumonia with abscesses. The patient was previously healthy with no recent hospitalizations. No family members resided in LTCFs or worked in health-care settings.

In January 1998, a 16-month-old American Indian girl from rural North Dakota was taken to a local hospital in shock and with a temperature of 105.2 F (40.6 C), seizures, a diffuse petechial rash, and irritability. She was treated with ceftriaxone but developed respiratory failure and cardiac arrest and died within 2 hours of arriving at the hospital. Blood and cerebrospinal fluid cultures drawn immediately postmortem grew MRSA that was susceptible to multiple antibiotic classes. An autopsy revealed multiple small abscesses of the brain, heart, liver, and kidneys; autopsy cultures of meninges, blood, and lung tissue grew MRSA. One month earlier, the patient had been treated with amoxicillin for otitis media. Neither the patient nor family members had been hospitalized during the previous year; no family members resided in LTCFs or worked in health-care settings.

In January 1999, a 13-year-old white girl from rural Minnesota was brought to a local hospital with fever, hemoptysis, and respiratory distress. The day before admission she had a productive cough and a 2-cm papule on her lower lip. A chest radiograph revealed a left lower lobe infiltrate and a pleural effusion. She was treated with ceftriaxone and nafcillin. Within 5 hours of arriving at the hospital, she became hypotensive and was transferred to a pediatric hospital, intubated, and treated with vancomycin and cefotaxime. Despite pulmonary and hemodynamic support, the patient's respiratory status deteriorated, and she died on the seventh hospital day from progressive cerebral edema and multiorgan failure.

The patient's blood, sputum, and pleural fluid grew MRSA that was multidrug susceptible. An autopsy revealed consolidated hemorrhagic necrosis of the left lung. The patient had no chronic medical conditions and no recent hospitalizations; no family members were health-care workers or employees of an LTCF or had a history of IDU.

In February 1999, a 12-month-old white boy from rural North Dakota was admitted to a tertiary-care hospital with bronchiolitis, vomiting, and dehydration. He had a temperature of 105.2 F (40.6 C) and a petechial rash. Chest radiograph revealed an infiltrate in the right lung consistent with pneumonitis. On the second hospital day, the patient was diagnosed with a large right pleural effusion. He was transferred to the intensive-care unit, a chest tube was inserted, and treatment with vancomycin and cefuroxime was initiated. The patient developed severe respiratory distress and hypotension the following day and died.

The patient's admission blood culture was negative, but his pleural fluid and a postmortem blood culture grew multidrug-susceptible MRSA. An autopsy revealed acute necrotizing pneumonia with extensive hemorrhage and numerous gram-positive cocci in the right lung. The patient had not been hospitalized since birth and had no known medical problems; no family members were health-care workers or employees of an LTCF or known to be IDUs. His 2-year-old sister had been treated for a culture-confirmed MRSA buttock infection 3 weeks earlier. MRSA isolates from the sister and the patient had identical antibiotic susceptibility profiles.

MRSA isolates from these four cases were susceptible to all antimicrobial agents tested except beta-lactams. All vancomycin minimum inhibitory concentrations were ≤2 µg/L. Isolates from all four cases had the mecA gene by PCR assay at MDH. Isolates from cases 1 and 4 shared an indistinguishable PFGE pattern; isolates from cases 2 and 3 differed by two and three bands, respectively, suggesting clonal relatedness among these cases.² In comparison, these PFGE patterns differed by an average of >10 bands compared with PFGE patterns among nosocomial MRSA isolates from several Minnesota hospitals. Sma I was the restriction enzyme used for PFGE. No isolate produced toxic shock syndrome toxin-1.

C Hunt, M Dionne, M Delorme, D Murdock, A Erdrich, MD, Indian Health Svc; D Wolsey, MPH, A Groom, MPH, J Cheek, MD, Indian Health Svc Epidemiology Program; J Jacobson, B Cunningham, MS, L Shireley, MPH, State Epidemiologist, North Dakota Dept of Health. K Belani, MD, S Kurachek, MD, P Ackerman, Children's Hospital and Clinics—Minneapolis; S Cameron, P Schlievert, PhD, Fairview Univ Medical Center; J Pfeiffer, MPH, Hennepin County Medical Center, Minneapolis; S Johnson, D Boxrud, J Bartkus, PhD, J Besser, MS, Minnesota Dept of Health Laboratory; K Smith, DVM, K LeDell, MPH, C O'Boyle, PhD, R Lynfield, MD, K White, MPH, M Osterholm, PhD, K Moore, MD, Acute Disease Epidemiology Section; R Danila, PhD, Acting State Epidemiologist, Minnesota Dept of Health. Div of Applied Public Health Training, Epidemiology Program Office; and EIS officers, CDC.

Since the first case reports of MRSA infections in the United States in 1968,³ MRSA has become an increasing problem. The percentage of nosocomial S. aureus isolates that were methicillin resistant increased from 2% in 1974 to approximately 50% in 1997.^4- 5 Methicillin resistance is usually conferred by the chromosomal mecA gene, which encodes an altered penicillin-binding protein (PBP-2A) that causes resistance to all beta-lactam antibiotics, including cephalosporins. However, many nosocomial MRSA strains have acquired resistance to numerous other antibiotic classes through a variety of mechanisms. Approximately 50% of MRSA isolates identified at National Nosocomial Infection Surveillance (NNIS) system hospitals are susceptible only to vancomycin.⁵

Most documented MRSA infections are acquired nosocomially; previously, community-acquired cases were restricted to patients residing in LTCFs and among IDUs.⁶ However, both of these groups have extensive exposure to hospitals, and their infections are generally caused by nosocomial MRSA strains. More recently, however, community-acquired MRSA infections have been identified at a Chicago pediatric hospital, in day care centers, and among minority communities in other countries.^1,7- 9 Unlike nosocomial MRSA isolates, community-acquired isolates from patients without known MRSA risk factors are generally multidrug susceptible (except to beta-lactams) and have distinctive molecular characteristics, as did the four isolates from the fatal cases presented in this report.

These four cases demonstrate the potential severity of community-acquired MRSA infections. Beta-lactam antibiotics (including cephalosporins) are used as empiric therapy for various adult and pediatric infections, but these agents are uniformly ineffective in treating MRSA infections. All patients in this report were initially treated with a cephalosporin antibiotic; the delayed use of antibiotics to which MRSA were susceptible may have contributed to the fatal outcomes. As a result, where such infections exist, obtaining appropriate cultures of infected sites is important. Clinicians should consider MRSA as a potential pathogen in severe pediatric pneumonia or sepsis syndromes in areas where community MRSA infections have been reported. In critically ill patients with invasive infections, empiric treatment with vancomycin (in addition to a third-generation cephalosporin) pending culture results may be necessary to treat cephalosporin-resistant S. pneumoniae¹⁰ or MRSA.

The rural/urban and racial diversity among these cases suggest that MRSA colonization may be widespread, especially in this region of the United States. The extent of community-acquired MRSA infection in the United States is unknown. Few data are available to define the molecular characteristics of these strains. It is also unclear how to limit the spread of MRSA within the community and whether it is feasible to decolonize selected high-risk persons. The role that increased antibiotic use in children—particularly beta-lactams and cephalosporins—has played in selecting for MRSA strains in the community also is unknown. Local or state-based surveillance is needed to characterize and monitor community-acquired MRSA infections and to develop strategies that will improve MRSA treatment and control.

MMWR. 1999;48:732-736

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In 1998, a total of 18,361 tuberculosis (TB) cases were reported from the 50 states and the District of Columbia, a decrease of 8% from 1997 and 31% from 1992, the height of the TB resurgence in the United States.^1,2 The 1998 rate of 6.8 per 100,000 population was 35% lower than in 1992 (10.5) but remained above the national goal for 2000 of 3.5.³ This report summarizes national TB surveillance data for 1998 and compares them with similar data from previous years. The findings indicate that the overall number of TB cases continued to decrease, and that trends in the number of reported cases and TB incidence varied by geographic area and population characteristics.

All states reported at least one case in 1998, and 18 states reported <100 cases. Among the states reporting <100 cases in 1998, 17 reported <100 cases in 1992, and 14 had no change or a decrease in the number of reported cases in 1998 compared with 1992. Among all states, the proportion of counties reporting no TB cases increased from 42% in 1992 to 49% in 1998; these counties represented 11% of the total U.S. population in 1998. The 1998 TB rate in 19 states was lower than the 2000 national goal.³

California, Florida, Illinois, New York, and Texas reported the highest number of cases in 1998 and represented 54% of all reported TB cases. During 1992-1998, the five states observed a marked decrease in the number of new cases and together accounted for 68% of the overall decrease. The four cities with the highest number of TB cases were New York (1558), Los Angeles (544), Chicago (473), and Houston (424). The number of reported cases in all four cities decreased between 1992 and 1998: 59% in New York, 51% in Los Angeles, and 41% in Chicago and Houston, and together these cities accounted for 41% of the overall decline in the number of reported TB cases in the United States.

The number of reported TB cases in 1998 compared with 1992 decreased in both sexes and all age groups at varying rates. The largest decrease occurred among children aged <15 years and adults aged 25-44 years. During 1992-1998, the number of cases in U.S.-born persons decreased 44%, and the number of cases in foreign-born persons increased 4%. The proportion of TB cases among foreign-born persons steadily increased, from 27% in 1992 to 42% in 1998. The TB rate in foreign-born persons remained approximately four to six times higher than for U.S.-born persons. In 1998, among the 7591 TB cases in foreign-born persons, the birth countries with the highest number of cases were Mexico with 1757 (23%), Philippines with 968 (13%), and Vietnam with 748 (10%).

In 1993, CDC began to collect drug susceptibility results for initial Mycobacterium tuberculosis isolates on the TB case report. During 1998, results were reported for 91% (13,477 of 14,830 culture-positive cases). Overall, 1086 (8.1%) case-patients had isolates resistant to at least isoniazid, and 150 (1.1%) had isolates resistant to at least isoniazid and rifampin (i.e., multidrug-resistant TB [MDR-TB]); New York (38) and California (36) reported 49% of the MDR-TB cases. During 1993-1998, resistance to isoniazid decreased slightly (from 8.9% in 1993), and MDR-TB decreased markedly (from 2.8% in 1993). The decrease in MDR-TB reflected declines from 2.7% to 0.7% in U.S.-born persons and from 3.0% to 1.6% in foreign-born persons. As a result, the proportion of MDR-TB cases among foreign-born persons increased from 31% in 1993 to 61% in 1998. Forty-five states and the District of Columbia reported at least one MDR-TB case during 1993-1998.

In 1993, CDC began collecting information about human immunodeficiency virus (HIV) status on TB case reports; 48 states submit HIV test results on TB case reports. In 1998, 3509 (55%) of 6365 TB case reports for persons aged 25-44 years included information about HIV status, an increase from 1993 when 33% had HIV status. Among the states with information for ≥75% of the cases in this age group, the proportion of TB cases in HIV-infected persons ranged from 0% (Montana, North Dakota, Vermont, and Wyoming) to 47% (Florida).

Div of Tuberculosis Elimination, National Center for HIV, STD, and TB Prevention; and an EIS Officer, CDC.

The decline in the overall number of reported TB cases reflects the apparent strengthening of TB-control programs nationwide, particularly in states and cities with the largest number of cases. Supporting this inference are data indicating that the largest decreases in cases among U.S.-born persons during 1993-1994 occurred in areas that reported the largest increases in measures associated with effective TB control: completion of therapy, conversion of patients' sputum from positive to negative, and number of contacts per case-patient.⁴ These improvements occurred in the same cities that had the largest increases in cases during the TB resurgence.

The elimination of TB in the United States will depend increasingly on eliminating TB among persons born in countries with high TB rates.⁵ Because the percentage of reported TB cases among foreign-born persons continues to increase, CDC, in collaboration with local and state health departments, updated recommendations to prevent and control TB among foreign-born persons.⁵ Priority is placed on case-finding, completion of treatment for active TB, contact tracing, screening, and completion of preventive therapy for high-risk groups. Because rates of TB differ among countries, local TB-control staff should develop epidemiologic profiles to identify groups of foreign-born persons at high risk for TB.

Although the number and proportion of MDR-TB cases decreased markedly during 1993-1998, MDR-TB remains a serious concern. One MDR-TB case can challenge the resources and effectiveness of a TB program, and nearly every state has reported at least one MDR-TB case since 1993. Incidence of MDR-TB is increasing in eastern Europe, Asia, and Africa,⁶ and will continue to affect the clinical management and contact investigations of foreign-born TB patients who are at risk for resistant TB strains.

Incomplete reporting of HIV to the national TB surveillance system leads to underestimates of the incidence of HIV among TB cases. Incomplete reporting has made it necessary to estimate the proportion of TB cases in HIV-infected persons based on TB and acquired immunodeficiency syndrome registry matching.^7-9 Using registry match data to supplement HIV test results submitted on the TB case report, minimum estimates of the proportion of TB cases with HIV infection ranged from 15% during 1993-1994 to 10% in 1997 for persons of all ages and from 29% to 21%, respectively, for persons aged 25-44 years (CDC, unpublished data, 1999). CDC and state and local health departments are collaborating to improve HIV testing and reporting for TB patients.

Although TB rates have been decreasing since 1992, the TB elimination goal of 3.5 cases per 100,000 by 2000 and <1 case per 1,000,000 population by 2010 are unlikely to be achieved at the current rate of decrease.³ The Advisory Council for the Elimination of TB (ACET), which provides advice and recommendations for eliminating TB to the U.S. Department of Health and Human Services and CDC, recently reassessed its 1989 plan and published updated recommendations for TB elimination in the United States.¹⁰ To move from TB control to TB elimination, ACET recommends new and improved diagnostic and treatment methods, and prevention efforts that include establishing broad-based partnerships with public health programs, community-based organizations, and managed-care plans. TB elimination in the United States requires global commitment. Dedication to the goal of TB elimination is critical to sustain the progress evidenced by declining TB morbidity in the United States.

References: 10 available