President Obama’s surge of Syrian refugees to the United States is coming with a public health risk from tuberculosis (TB) along with heightened security concerns associated with the acceleration of the vetting process from 18-24 months to just three months.
Many of the 2,545 Syrian refugees who have arrived in the U.S. in the first eight months of FY 2016, part of the Obama administration’s “surge” to resettle 10,000 this year, are coming directly from refugee camps and other parts of Jordan where a recent study, co-authored by a Centers for Disease Control (CDC) public health expert, concluded they have “high TB rates.”
“High TB rates were found among Syrian refugees through active screening and will probably persist as the Syrian crisis continues,” the study, “Impact of and response to increased tuberculosis prevalence among Syrian refugees compared with Jordanian tuberculosis prevalence: case study of a tuberculosis public health strategy,” concluded.
“Initial assessment found that tuberculosis among Syrian refugees was at a high incidence rate,” the study, in which the International Organization for Migration (IOM) screened almost 69,000 (11%) of the 608,000 Syrian refugees currently living in Jordan, noted.
Those high TB rates have not stopped the Obama administration from sending an ever increasing number of Syrian refugees from Jordan to the United States.
“According to the State Department’s Refugee Processing Center, so far this month 804 Syrians have been admitted to the U.S. as refugees, including 795 Sunni Muslims, seven identified as ‘Moslem,’ and two Catholic refugees…still well behind schedule to meet the Obama administration’s goal of 10,000 admissions this fiscal year,” Breitbart News reported on Wednesday.
A State Department spokesperson says Syrian refugees, from Jordan and elsewhere, are “subject to the same stringent security and medical requirements that apply to all applicants for U.S. refugee resettlement,” as the Washington Free Beacon reported:
A State Department spokesman told the Free Beacon that …the administration is moving to screen these individuals on a swifter timeline in order to facilitate their entry into the United States. . .
Additionally, the Department of State and Department of Homeland Security are jointly working to increase their capacity to interview refugee applicants from Jordan.
“From February through April, additional staff were posted to Jordan, where they conducted interviews of over 12,000 [U.N.]-referred refugee applicants,” the official said. “All applicants are still subject to the same stringent security and medical requirements that apply to all applicants for U.S. refugee resettlement.”
But the CDC, the federal agency responsible for managing the overseas and domestic medical screening of refugees, has not been able to demonstrate conclusively that the State Department spokesperson’s claim that all Syrian refugees arriving from Jordan and elsewhere meet the same “medical requirements that apply to all applicants for U.S. refugee resettlement.”
Though the CDC claims that all U.S. bound refugees are screened for active tuberculosis, those medical screenings failed to prevent four refugees with active TB from arriving in Indiana in 2015.
Refugees who are diagnosed in overseas medical screenings as having “active infectious tuberculosis” are classified as Class A medical risks, and are not allowed to migrate to the United States without a special waiver.
Refugees who are diagnosed as having something the CDC calls, in a classic bureaucratic oxymoron, “active tuberculosis – non-infectious,” are classified as Class B1 medical risks and are allowed to migrate to the United States.
According to the most recent 2007 standards provided by the CDC to the approximately 700 medical doctors who have been authorized by U.S. embassies or consulates overseas to be part of the U.S. Control Panels that perform overseas medical screenings of U.S. bound refugees, any refugee who (1) has a chest radiograph that suggests the presence of TB and has either (1) sputum smears that test positive or (2) sputum cultures that test positive, is categorized as a Class A medical risk.
Class A medical risks apparently are allowed to undergo medical treatment for TB and be reclassified subsequent to the successful completion of that treatment.
The language which defines how the B1 medical risk classification is established by the 2007 standards described in the Electronic Disease Notification system used by the CDC since 2009 makes it unclear if the requirement for “sputum cultures and sputum” smears is being implemented in all overseas medical screenings”:
Class B1, 1991: chest radiograph findings consistent with active tuberculosis without a positive sputum smear; CDOT [2007 standard: chest radiograph findings consistent with tuberculosis without a positive sputum smear or culture.
It makes a huge difference whether a refugee who receives a B1 medical risk classification, and is therefore allowed to migrate to the United States, has received only negative-smear results, or negative-smear results and negative-culture results.
Sputum smears can be done quickly and inexpensively. After the sputum sample is obtained, it is placed on a slide, a stain is inserted, and the reaction is observed in a microscope. Usually, smears can be completed in 24 hours or less.
Sputum cultures take longer—up to two weeks—are more expensive, and require specialized equipment usually located in laboratories rather than on-site at medical screening locations.
Smears are less finely tuned than cultures at detecting the presence of active infectious tuberculosis. In fact, patients with radiographs that indicate the presence of tuberculosis who test smear negative and have been classified as B1 medical risks have been allowed to migrate to the United States despite the possibility they may have active infectious tuberculosis and are capable of transmitting the disease.
A research article published in 2008 in the Oxford Journals of Medicine & Health on Clinical Infectious Diseases, for instance, concluded that 13 percent of all new TB cases in the Netherlands that year became active upon transmission of the tuberculosis bacterium from an active TB patient whose sputum smear tested negative.
“Although patients with sputum smear–negative TB are less infectious than patients with smear-positive TB, they also contribute to TB transmission,” the article states.
It was for this reason that the CDC replaced its 1991 tuberculosis detection standards, which only required sputum smears, for U.S. Control Panel medical doctors administering medical screenings overseas to the new 2007 standards, which required both sputum smears and sputum cultures.
Those 2007 standards were supposed to be implemented in every country that sends refugees to the United States by 2013.
It is unclear how those standards have been implemented by the U.S. Control Panels in Jordan that have administered medical screenings to the 2,545 Syrian refugees who have arrived, and continue to arrive, in the United States as part of the Obama administration’s FY 2016 surge.
The huge number of Syrian refugees currently in Jordan (608,000), the number of medical doctors in Jordan who have been authorized by the U.S. embassy to medically screens refugees, the uncertainty as to the laboratory capacity for testing sputum cultures in Jordan, and the condensed timeline to medically screen refugees, are all reasons for concern. They suggest that some of the Syrian refugees currently arriving in the United States may have been classified B1 “active tuberculosis non-infectious” based solely on a negative sputum smear, but in fact may have active infectious tuberculosis because a sputum sample that may have tested positive was not taken to a laboratory for a culture.
The CDC has not responded to several questions from Breitbart News, the answers to which could prove whether or not the Obama administration’s acceleration of the vetting process for Syrian refugees has resulted in the arrival of a number of refugees who have been inaccurately classified as having “active tuberculosis non-infectious” who, in fact, have active infectious tuberculosis.
The May 2015 study that found high TB rates among Syrian refugees in Jordan paints a bleak picture of the public health situation there:
From March 2011 through July 2014, the Syrian crisis has resulted in a regional humanitarian emergency with 2.9 million Syrian refugees, including 608,000 in Jordan. In Jordan, only 15 % of Syrian refugees are residing in camps; the majority of refugees are integrated into host communities (non-camp refugees). . .
Prior to March 2011, Syria was making public health gains in tuberculosis (TB) prevention, reducing annual TB prevalence from 85 TB cases per 100,000 persons in 1990 to 23 per 100,000 in 2011. Tuberculosis care in Syria was integrated in the healthcare system nationwide with specialty TB treatment facilities located in each governorate, including Aleppo and Homs, areas badly destroyed by the conflict. As the conflict escalated, health infrastructure has been destroyed, drug supply chains have been interrupted, and healthcare workers have fled all negatively impacting TB diagnosis and treatment efforts.
The international political and military crises that have displaced millions in the Middle East over the past several years have further worsened the region’s public health, the study finds:
Rising TB prevalence rates have been observed among internally displaced persons within the Middle East and Eurasia regions. The Iraqi TB prevalence of 94/100,000 population in 1990, dropped to 62/100,000 in 2000, but rose to 74/100,000 in 2011 following years of armed conflict…
Additionally, a systematic review of crisis-affected populations (those experiencing displacement, armed conflict, or natural disasters) largely found elevated rates of TB notification and of TB prevalence These reported higher active TB rates probably developed over time and may be seen as the Syrian crisis approaches its fourth year.
In the meantime, internally displaced Syrians are living in a crisis situation. Living in a conflict zone may result in delayed TB treatment and increased self-treatment among TB patients as reported in other conflicts.
Given the medical evidence of the high rates of TB among Syrian refugees in Jordan and the widespread public opposition to the Obama administration’s determination to accelerate the arrival of even more Syrian refugees to the United States for the balance of 2016, it is not unreasonable to place the burden of proof on the CDC and the Obama administration to demonstrate conclusively—and quickly—that these refugees will not increase the public health risk of American citizens.