[Show abstract][Hide abstract] ABSTRACT: For more than two decades, as the number of tuberculosis (TB) cases overall in the United States has declined, the proportion of cases among foreign-born persons has increased. In 2013, the percentage of TB cases among those born outside the country was 64.6%. To address this trend, CDC has developed strategies to identify and treat TB in U.S.-bound immigrants and refugees overseas. Each year, approximately 450,000 persons are admitted to the United States on an immigrant visa, and 50,000-70,000 are admitted as refugees. Applicants for either an immigrant visa or refugee status are required to undergo a medical examination overseas before being allowed to travel to the United States. CDC is the federal agency with regulatory oversight of the overseas medical examination, and panel physicians appointed by the U.S. Department of State perform the examinations in accordance with Technical Instructions (TI) provided by CDC's Division of Global Migration and Quarantine (DGMQ). Beginning in 1991, the algorithm for TB TI relied on chest radiographs for applicants aged ≥15 years, followed by sputum smears for those with findings suggestive of TB; no additional diagnostics were used. In 2007, CDC issued enhanced standards for TB diagnosis and treatment, including the addition of sputum cultures (which are more sensitive than smears) as a diagnostic tool and treatment delivered as directly observed therapy (DOT). This report summarizes worldwide implementation of the new screening requirements since 2007. In 2012, the year for which the most recent data are available, 60% of the TB cases diagnosed were in persons with smear-negative, but culture-positive, test results. The results demonstrate that rigorous diagnostic and treatment programs can be implemented in areas with high TB incidence overseas.
MMWR. Morbidity and mortality weekly report 03/2014; 63(11):234-6.
[Show abstract][Hide abstract] ABSTRACT: More than 50,000 refugees are resettled to the United States annually, many from areas highly endemic for parasites. Some of these infections present little clinical consequence after migration, but others are responsible for morbidity and mortality. The Centers for Disease Control and Prevention has issued predeparture presumptive treatment and postarrival medical guidelines for the management of parasites. Although these guidelines are evidence based, there remain significant challenges to presumptive treatment programs in refugees. Gaps in the evidence continue; resettling populations are continually changing, thus altering the epidemiology; and there are logistical and cost barriers to fully implementing recommendations. This article will review the evolution and status of current guidelines, as well as identify gaps and challenges to full implementation. It is imperative for clinicians serving this population to be familiar with interventions received by refugees, since previous treatment will impact screening, diagnostic evaluation, and treatment decisions.
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND: Approximately 70,000 refugees are resettled to the United States each year. Providing vaccination to arriving refugees is important to both reduce the health-related barriers to successful resettlement, and protect the health of communities where refugees resettle. It is crucial to understand the process and resources expended at the state/local and federal government levels to provide vaccinations to refugees resettling to the United States. OBJECTIVES: We estimated costs associated with delivering vaccines to refugees at the Board of Health Refugee Services, DeKalb county, Georgia (DeKalb clinic). METHODS: Vaccination costs were estimated from two perspectives: the federal government and the DeKalb clinic. Data were collected at the DeKalb clinic regarding resources used for vaccination: staff numbers and roles; type and number of vaccine doses administered; and number of patients. Clinic costs included labor and facility-related overhead. The federal government incurred costs for vaccine purchases and reimbursements for vaccine administration. RESULTS: The DeKalb clinic average cost to administer the first dose of vaccine was $12.70, which is lower than Georgia Medicaid reimbursement ($14.81), but higher than the State of Georgia Refugee Health Program reimbursement ($8.00). Federal government incurred per-dose costs for vaccine products and administrative reimbursement were $42.45 (adults) and $46.74 (children). CONCLUSIONS: The total costs to the DeKalb clinic for administering vaccines to refugees are covered, but with little surplus. Because the DeKalb clinic 'breaks even,' it is likely they will continue to vaccinate refugees as recommended by the Centers for Disease Control and Prevention and the Advisory Committee on Immunization Practices.
[Show abstract][Hide abstract] ABSTRACT: More than 340 million cases of bacterial and protozoal sexually transmitted infections (STIs) occur annually. Approximately 70,000 refugees arrive in the United States on a yearly basis. Refugees are a particularly disenfranchised and vulnerable population. The prevalence of Chlamydia and gonorrhea in refugee populations has not been described, and the utility of routine screening is unknown. We performed a descriptive evaluation of 25,779 refugees who completed a screening medical examination in Minnesota during 2003-2010. A total of 18,516 (72%) refugees were tested for at least one STI: 183 (1.1%) of 17,235 were seropositive for syphilis, 15 (0.6%) of 2,512 were positive for Chlamydia, 5 (0.2%) of 2,403 were positive for gonorrhea, 136 (2.0%) of 6,765 were positive for human immunodeficiency virus, and 6 (0.1%) of 5,873 were positive for multiple STIs. Overall prevalence of Chlamydia (0.6%) and gonorrhea (0.2%) infection was low, which indicated that routine screening may not be indicated. However, further research on this subject is encouraged.
The American journal of tropical medicine and hygiene 02/2012; 86(2):292-5. · 2.53 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Refugees are at risk for poor outcomes from acute respiratory infections (ARI) because of overcrowding, suboptimal living conditions, and malnutrition. We implemented surveillance for respiratory viruses in Dadaab and Kakuma refugee camps in Kenya to characterize their role in the epidemiology of ARI among refugees.
From 1 September 2007 through 31 August 2010, we obtained nasopharyngeal (NP) and oropharyngeal (OP) specimens from patients with influenza-like illness (ILI) or severe acute respiratory infections (SARI) and tested them by RT-PCR for adenovirus (AdV), respiratory syncytial virus (RSV), human metapneumovirus (hMPV), parainfluenza viruses (PIV), and influenza A and B viruses. Definitions for ILI and SARI were adapted from those of the World Health Organization. Proportions of cases associated with viral aetiology were calculated by camp and by clinical case definition. In addition, for children < 5 years only, crude estimates of rates due to SARI per 1000 were obtained.
We tested specimens from 1815 ILI and 4449 SARI patients (median age = 1 year). Proportion positive for virus were AdV, 21.7%; RSV, 12.5%; hMPV, 5.7%; PIV, 9.4%; influenza A, 9.7%; and influenza B, 2.6%; 49.8% were positive for at least one virus. The annual rate of SARI hospitalisation for 2007-2010 was 57 per 1000 children per year. Virus-positive hospitalisation rates were 14 for AdV; 9 for RSV; 6 for PIV; 4 for hMPV; 5 for influenza A; and 1 for influenza B. The rate of SARI hospitalisation was highest in children < 1 year old (156 per 1000 child-years). The ratio of rates for children < 1 year and 1 to < 5 years old was 3.7:1 for AdV, 5.5:1 for RSV, 4.4:1 for PIV, 5.1:1 for hMPV, 3.2:1 for influenza A, and 2.2:1 for influenza B. While SARI hospitalisation rates peaked from November to February in Dadaab, no distinct seasonality was observed in Kakuma.
Respiratory viral infections, particularly RSV and AdV, were associated with high rates of illness and make up a substantial portion of respiratory infection in these two refugee settings.
[Show abstract][Hide abstract] ABSTRACT: Among approximately 163.5 million foreign-born persons admitted to the United States annually, only 500,000 immigrants and refugees are required to undergo overseas tuberculosis (TB) screening. It is unclear what extent of the unscreened nonimmigrant visitors contributes to the burden of foreign-born TB in the United States.
We defined foreign-born persons within 1 year after arrival in the United States as "newly arrived", and utilized data from U.S. Department of Homeland Security, U.S. Centers for Disease Control and Prevention, and World Health Organization to estimate the incidence of TB among newly arrived foreign-born persons in the United States. During 2001 through 2008, 11,500 TB incident cases, including 291 multidrug-resistant TB incident cases, were estimated to occur among 20,989,738 person-years for the 1,479,542,654 newly arrived foreign-born persons in the United States. Of the 11,500 estimated TB incident cases, 41.6% (4,783) occurred among immigrants and refugees, 36.6% (4,211) among students/exchange visitors and temporary workers, 13.8% (1,589) among tourists and business travelers, and 7.3% (834) among Canadian and Mexican nonimmigrant visitors without an I-94 form (e.g., arrival-departure record). The top 3 newly arrived foreign-born populations with the largest estimated TB incident cases per 100,000 admissions were immigrants and refugees from high-incidence countries (e.g., 2008 WHO-estimated TB incidence rate of ≥100 cases/100,000 population/year; 235.8 cases/100,000 admissions, 95% confidence interval [CI], 228.3 to 243.3), students/exchange visitors and temporary workers from high-incidence countries (60.9 cases/100,000 admissions, 95% CI, 58.5 to 63.3), and immigrants and refugees from medium-incidence countries (e.g., 2008 WHO-estimated TB incidence rate of 15-99 cases/100,000 population/year; 55.2 cases/100,000 admissions, 95% CI, 51.6 to 58.8).
Newly arrived nonimmigrant visitors contribute substantially to the burden of foreign-born TB in the United States. To achieve the goals of TB elimination, direct investment in global TB control and strategies to target nonimmigrant visitors should be considered.
PLoS ONE 01/2012; 7(2):e32158. · 3.53 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Refugees are highly vulnerable populations with limited access to health care services. The United States accepts 50,000-75,000 refugees for resettlement annually. Despite residing in camps and other locations where vaccine-preventable disease outbreaks, such as measles, occur frequently, refugees are not required to have any vaccinations before they arrive in the United States.
We estimated the medical and public-health response costs of a case of measles imported into Kentucky by a refugee.
The Kentucky Refugee Health Coordinator recorded the time and labor of local, state, and some federal personnel involved in caring for the refugee and implementing the public health response activities. Secondary sources were used to estimate the labor and medical care costs of the event.
The total costs to conduct the response to the disease event were approximately $25,000. All costs were incurred by government, either public health department or federal, because refugee health costs are paid by the federal government and the event response costs are covered by the public health department.
A potentially preventable case of measles that was imported into the United States cost approximately $25,000 for the public health response.
To maintain the elimination of measles transmission in the United States, U.S.-bound refugees should be vaccinated overseas. A refugee vaccination program administered during the overseas health assessment has the potential to reduce the risk of importation of measles and other vaccine-preventable disease and would eliminate costs associated with public health response to imported cases and outbreaks.
[Show abstract][Hide abstract] ABSTRACT: During May 4, 2007-February 29, 2008, the United States resettled 6,159 refugees from Tanzania. Refugees received pre-departure antimalarial treatment with sulfadoxine-pyrimethamine (SP), partially supervised (three/six doses) artemether-lumefantrine (AL), or fully supervised AL. Thirty-nine malaria cases were detected. Disease incidence was 15.5/1,000 in the SP group and 3.2/1,000 in the partially supervised AL group (relative change = -79%, 95% confidence interval = -56% to -90%). Incidence was 1.3/1,000 refugees in the fully supervised AL group (relative change = -92% compared with SP group; 95% confidence interval = -66% to -98%). Among 39 cases, 28 (72%) were in refugees < 15 years of age. Time between arrival and symptom onset (median = 14 days, range = 3-46 days) did not differ by group. Thirty-two (82%) persons were hospitalized, 4 (10%) had severe manifestations, and 9 (27%) had parasitemias > 5% (range = < 0.1-18%). Pre-departure presumptive treatment with an effective drug is associated with decreased disease among refugees.
The American journal of tropical medicine and hygiene 10/2011; 85(4):612-5. · 2.53 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Malaria is a major health concern for displaced persons occupying refugee camps in sub-Saharan Africa, yet there is little information on the incidence of infection and nature of transmission in these settings. Kakuma Refugee Camp, located in a dry area of north-western Kenya, has hosted ca. 60,000 to 90,000 refugees since 1992, primarily from Sudan and Somalia. The purpose of this study was to investigate malaria prevalence and attack rate and sources of Anopheles vectors in Kakuma refugee camp, in 2005-2006, after a malaria epidemic was observed by staff at camp clinics.
Malaria prevalence and attack rate was estimated from cases of fever presenting to camp clinics and the hospital in August 2005, using rapid diagnostic tests and microscopy of blood smears. Larval habitats of vectors were sampled and mapped. Houses were sampled for adult vectors using the pyrethrum knockdown spray method, and mapped. Vectors were identified to species level and their infection with Plasmodium falciparum determined.
Prevalence of febrile illness with P. falciparum was highest among the 5 to 17 year olds (62.4%) while malaria attack rate was highest among the two to 4 year olds (5.2/1,000/day). Infected individuals were spatially concentrated in three of the 11 residential zones of the camp. The indoor densities of Anopheles arabiensis, the sole malaria vector, were similar during the wet and dry seasons, but were distributed in an aggregated fashion and predominantly in the same zones where malaria attack rates were high. Larval habitats and larval populations were also concentrated in these zones. Larval habitats were man-made pits of water associated with tap-stands installed as the water delivery system to residents with year round availability in the camp. Three percent of A. arabiensis adult females were infected with P. falciparum sporozoites in the rainy season.
Malaria in Kakuma refugee camp was due mainly to infection with P. falciparum and showed a hyperendemic age-prevalence profile, in an area with otherwise low risk of malaria given prevailing climate. Transmission was sustained by A. arabiensis, whose populations were facilitated by installation of man-made water distribution and catchment systems.
[Show abstract][Hide abstract] ABSTRACT: The world's population is becoming increasing mobile. Each mobile population (e.g. immigrants, refugees, travelers) has certain characteristics that determine public health risk and infectious disease burden. Refugees present unique challenges to public health officials and infectious disease specialists.
Refugee migration to the United States represents the most controlled population movement between countries from a health perspective. Medical screening and programs that provide presumptive treatment for highly prevalent infectious diseases both prior to and after migration alter the infectious disease epidemiology in these populations.
Infectious disease specialists must recognize that different characteristics of distinct mobile populations will alter infectious disease burden. This article specifically highlights how recent public health approaches have altered the epidemiology and clinical presentation of malaria, intestinal parasites and tuberculosis in refugee populations.
Current Opinion in Infectious Diseases 08/2009; 22(5):436-42. · 5.03 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: In 2007, a total of 57.8% of the 13,293 new cases of tuberculosis in the United States were diagnosed in foreign-born persons, and the tuberculosis rate among foreign-born persons was 9.8 times as high as that among U.S.-born persons (20.6 vs. 2.1 cases per 100,000 population). Annual arrivals of approximately 400,000 immigrants and 50,000 to 70,000 refugees from overseas are likely to contribute substantially to the tuberculosis burden among foreign-born persons in the United States.
The Centers for Disease Control and Prevention (CDC) collects information on overseas screening for tuberculosis among U.S.-bound immigrants and refugees, along with follow-up evaluation after their arrival in the United States. We analyzed screening and follow-up data from the CDC to study the epidemiology of tuberculosis in these populations.
From 1999 through 2005, a total of 26,075 smear-negative cases of tuberculosis (i.e., cases in which a chest radiograph was suggestive of active tuberculosis but sputum smears were negative for acid-fast bacilli on 3 consecutive days) and 22,716 cases of inactive tuberculosis (i.e., cases in which a chest radiograph was suggestive of tuberculosis that was no longer clinically active) were diagnosed by overseas medical screening of 2,714,223 U.S.-bound immigrants, representing prevalences of 961 cases per 100,000 persons (95% confidence interval [CI], 949 to 973) and 837 cases per 100,000 persons (95% CI, 826 to 848), respectively. Among 378,506 U.S.-bound refugees, smear-negative tuberculosis was diagnosed in 3923 and inactive tuberculosis in 10,743, representing prevalences of 1036 cases per 100,000 persons (95% CI, 1004 to 1068) and 2838 cases per 100,000 persons (95% CI, 2785 to 2891), respectively. Active pulmonary tuberculosis was diagnosed in the United States in 7.0% of immigrants and refugees with an overseas diagnosis of smear-negative tuberculosis and in 1.6% of those with an overseas diagnosis of inactive tuberculosis.
Overseas screening for tuberculosis with follow-up evaluation after arrival in the United States is a high-yield intervention for identifying tuberculosis in U.S.-bound immigrants and refugees and could reduce the number of tuberculosis cases among foreign-born persons in the United States.
New England Journal of Medicine 07/2009; 360(23):2406-15. · 54.42 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: An outbreak of watery diarrhea struck within the Kakuma refugee camp in Kenya in April 2005; 418 people were treated, and 4 persons died. Vibrio cholerae O1 was isolated from 33 patients. In June 2005, we conducted a retrospective matched case-control study to define risk factors associated with cholera among camp residents and identify interventions that could prevent further cases and future outbreaks. We identified cases of cholera through medical records at the main health facility in the camp and matched controls (without watery diarrhea since November 2004) to the cases by age category (< 2, 2-4, 5-14, and > 14 years) and location of residence within the camp. Cases were defined as any person of any age with profuse, effortless watery diarrhea (three or more stools in 24 hours). A multivariate model showed that storing drinking water at home in sealed or covered containers was protective against cholera (matched odds ratio [MOR] = 0.49 [0.25, 0.96]), whereas "sharing a latrine with at least three households" (MOR = 2.17 [1.01, 4.68]) and arriving at the Kakuma camp on or after November 2004 (MOR = 4.66 [1.35, 16.05]) were risk factors. Improving sanitation and promoting methods to ensure safe drinking water are likely to be effective measures in moderating future cholera outbreaks in this setting. Higher risks for cholera illness among refugees recently "in-migrated" suggest that there may be value in targeting new arrivals in the camp for risk reduction messages and interventions, such as covered water storage containers, to prevent cholera.
The American journal of tropical medicine and hygiene 04/2009; 80(4):640-5. · 2.53 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background: Up to 70,000 refugees are resettled to the U.S. annually, often from malaria-endemic areas. Strategies are needed to prevent imported malaria. Methods: We investigated 37 cases of imported malaria disease (symptomatic and microscopically confirmed falciparum parasitemia) among 4578 refugees from Tanzanian camps who resettled to the U.S. during May 4-December 4, 2007. Malaria disease in the camps was high throughout this period per UNHCR surveillance data. Refugees departing May 4-July7 received overseas presumptive treatment with sulfadoxine-pyrimethamine (SP group) while those departing July 8-December 4 received artemether-lumefantrine (AL group). Results: In the SP group, 28 cases were detected among 1805 refugees, an incidence of 15.5/1000 refugees. In the AL group, 9 cases (8 of whom were aged ≤14 years) were identified among 2773 refugees. These values translate to an incidence of 3.2/1000 refugees, a 79% decline (95% CI: 56%, 90%). In a Poisson regression model that controlled for age, disease incidence was 4.8 times higher among refugees in the SP group than in the AL group (95% CI: 2.3, 10.2). Median time between arrival and symptom onset was 13.5 days (range: 3-46 days) and did not differ by treatment group. Thirty-one (84%) of 37 cases were hospitalized (median and range: 3 and 1-12 days) including 4 with severe manifestations (impaired consciousness, respiratory distress, anemia, hypoglycemia, or acidosis). Among 32 cases with known parasite density, 9 (28%) had parasitemias ≥5%. No cases were fatal. Conclusions: Mass presumptive treatment with an effective drug decreases the burden of imported disease among refugees, but does not eliminate all risk. U.S. clinicians should be aware of the risk of malaria in this population regardless of treatment history.
Infectious Diseases Society of America 2008 Annual Meeting; 10/2008
[Show abstract][Hide abstract] ABSTRACT: Plasmodium infection, often sub-clinical, is common in migrating sub-Saharan refugee populations. Refugees who subsequently develop clinical malaria suffer illness and exact a cost on state and local health care facilities. Untreated infection is also of public health concern because of the potential for local transmission. In response to increasing numbers of refugees originating in sub-Saharan Africa guidelines for the management of malaria in refugees migrating to the United States have been broadened and updated. The guidelines are based on available evidence-based literature and recent public health experience. These guidelines were critically reviewed, assessed, and approved by multiple National and State entities as well as outside experts. These consensus guidelines recommend that sub-Saharan African refugees relocating to the United States receive presumptive treatment of P. falciparum malaria before departure or during the domestic refugee medical screening after arrival. Presumptive therapy is not currently recommended for either non-falciparum malaria or for refugees relocating from areas outside sub-Saharan Africa.
The American journal of tropical medicine and hygiene 09/2008; 79(2):141-6. · 2.53 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Schistosomiasis and strongyloidiasis cause substantial morbidity and mortality among hundreds of millions of infected persons worldwide. In the United States, these infections are most commonly found among international travelers, immigrants, and refugees from areas of endemicity. Refugees resettled to the United States since 2000 include >3800 "Lost Boys and Girls" of Sudan and 8000 Somali Bantu. Many Lost Boys and Girls of Sudan reported chronic abdominal pain only since arrival, and some received diagnoses of schistosomiasis or strongyloidiasis. We assessed seroprevalence of these infections among these refugees and hypothesized an association between infection and abdominal pain.
We offered a survey assessing chronic abdominal pain and serologic testing for schistosomiasis and strongyloidiasis to all 800 attendees of a Lost Boys and Girls of Sudan reunion in the United States. Serologic testing was performed on preimmigration specimens obtained from 100 United States-bound Somali Bantu refugees.
Of the 462 Sudanese refugees (58%) tested, 44% and 46% were seropositive for schistosomiasis (primarily due to Schistosoma mansoni) and strongyloidiasis, respectively; 24% of those who tested positive for schistosomiasis had S. mansoni antigenemia. Forty-six percent reported chronic abdominal pain, which was not associated with either infection. Among 100 Somali Bantu, 73% and 23% tested seropositive for schistosomiasis (primarily due to Schistosoma haematobium) and strongyloidiasis, respectively.
The high seroprevalence of schistosomiasis and strongyloidiasis among Sudanese Lost Boys and Girls and Somali Bantu refugees supports presumptive treatment for these refugees. Current refugee resettlement policies inadequately address these diseases; our data support consideration of predeparture presumptive therapy for all refugees from areas of endemicity.
[Show abstract][Hide abstract] ABSTRACT: Background: Schistosomiasis and strongyloidiasis cause substantial morbidity and mortality among the millions of infected persons worldwide. In the U.S., these diseases are found most frequently among the 28,000 refugees and hundreds of thousands of other immigrants resettled annually.
Prevalence in such groups is unknown because of infrequent testing and use of insensitive stool and urine examinations. Using sensitive serologic tests, we assessed infection rates among some of the 3,800 resettled Lost Boys of Sudan (LBOS) during an evaluation of abdominal pain at a national reunion and subsequently among a group of Somali Bantu refugees.
Methods: All consenting LBOS answered questions about symptoms and were tested by enzyme immunoassays for antibodies to Schistosoma and Strongyloides, and a Schistosoma mansoni antigen assay. Randomly selected Somali Bantus underwent similar testing.
Results: Of 462 LBOS, 203 (43.9%) and 214 (46.3%) were seropositive for schistosomiasis and strongyloidiasis, respectively. Forty-eight (10.4%) had S. mansoni antigenemia, indicating active infection of at least moderate intensity. By immunoblot, S. mansoni was more common then Schistosoma haematobium or mixed infections in a randomly selected subset of 21 persons. Although 214 (46.3%) reported abdominal pain, no association was seen between this or other symptoms and schistosomiasis or strongyloidiasis.
Among 100 Somali Bantus, 73 (73.0%) and 23 (23.0%) were seropositive for schistosomiasis and strongyloidiasis, respectively. The predominant schistosome species by immunoblot was S. haematobium.
Conclusions: The high seroprevalence of schistosomiasis and strongyloidiasis and evidence of active infection support presumptive treatment of all LBOS and Somali Bantus refugees. Such serologic testing could also be used to estimate infection rates and need for presumptive treatment among other refugee populations. Current immigration policies inadequately address testing and treatment for these diseases; our data support reevaluation of such policies for all immigrants from Schistosoma or Strongyloides endemic areas.
Infectious Diseases Society of America 2005 Annual Meeting; 10/2005
[Show abstract][Hide abstract] ABSTRACT: An estimated 1.9 million children travel overseas annually. Infectious disease risks associated with international travel are diverse and depend on the destination, planned activities, and baseline medical history. Children have special needs and vulnerabilities that should be addressed when preparing for travel abroad. Children should have a pretravel health assessment that includes recommendations for both routine and special travel-related vaccination; malaria chemoprophylaxis, if indicated; and prevention counseling regarding insect and animal exposures, food and water safety, and avoiding injuries. Special consideration should be given to children with chronic diseases. Families should be given anticipatory guidance for management of potential illnesses and information about the location of medical resources overseas.
Seminars in Pediatric Infections Diseases 08/2004; 15(3):137-49.