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Immigrant and Refugee Health

Infectious and Communicable Diseases

Central American Refugee Health Profile

Arboviruses: Dengue, Chikungunya, and Zika Viruses

Dengue, chikungunya, and Zika viruses cause mosquito-borne infections of increasing concern in El Salvador, Guatemala, and Honduras. Dengue fever is endemic throughout much of Central and South America. However, chikungunya first arrived in this region in 2014 after appearing in the Caribbean in 2013. Currently, local chikungunya transmission is occurring in more than 45 countries and territories in the Americas, including El Salvador, Guatemala, and Honduras28, 29. Active Zika virus transmission has been reported throughout Central America, including El Salvador, Guatemala, and Honduras30.

Acute dengue, chikungunya, and Zika infections have similar presentations and may be clinically indistinguishable. Common symptoms include fever, headache, severe myalgia, arthralgia, joint swelling, and rash. Chikungunya is unique in that it may cause persistent joint inflammation for months, and sometimes years, even after acute symptoms have resolved. Chikungunya should be considered in those with chronic rheumatologic symptoms from areas of local transmission. Dengue is unique because reinfection with another dengue virus can cause a condition called severe dengue. Severe dengue can be fatal if not properly treated in a timely manner. With good medical management, mortality due to severe dengue can be less than 1%. Severe dengue is more likely when an individual returns to a disease-endemic area and unlikely in a newly arriving refugee. Zika may be associated with conjunctivitis and other symptoms that are generally less severe than dengue and chikungunya. Zika virus infection is frequently asymptomatic . Despite the relatively benign nature of acute infection, Zika has recently been associated with an increased risk of Guillain-Barré syndrome, and birth defects (e.g., microcephaly) when acquired during pregnancy31, 32. CDC has posted interim screening guidelines for infants with microcephaly and possible Zika infection. Clinical presentation of these infections during the domestic screening visit is unlikely since the incubation period is generally short, with symptoms often resolving within 10 days of exposure.

Hepatitis B Virus Infection

The prevalence of chronic hepatitis B virus infection in Central American children arriving in the United States is unknown. However, recent data suggest that the general prevalence in El Salvador, Honduras, and Guatemala is low (<2%). In addition, all three countries include a birth dose of hepatitis B vaccine in their national immunization schedules. Therefore, it is reasonable to conduct targeted screening for chronic hepatitis B virus infection in at-risk individuals including:

  • Known or suspected IV drug users
  • Men who have sex with men
  • People with tattoos
  • Pregnant women
  • Children of mothers with known hepatitis B virus infection
  • Household contacts of infected individuals
  • HIV- or hepatitis C-infected individuals
  • Children who received whole blood products or blood components before immigration
  • Children with a history of known or possible sexual exploitation

Children should complete the 3-dose hepatitis B vaccine series if no official documentation of prior completion is available.

For further information, see the domestic hepatitis B screening guidelines for refugees.

Sexually Transmitted Infections (HIV, Syphilis, Gonorrhea, etc.)

HIV screening is not required for refugees before resettlement to the United States. However, HIV screening should be offered to all refugees, in accordance with existing domestic refugee screening guidelines for HIV developed by CDC. Although HIV prevalence is relatively low in Central America, minors arriving from El Salvador, Guatemala, and Honduras should be screened, as maternal HIV status is likely unknown and vertical transmission is possible. No data are available regarding the prevalence of syphilis, gonorrhea, and chlamydia. Syphilis and gonorrhea screening is done per current CDC technical instructions on all refugees 15 years or older. Any patient, regardless of age, should be tested for syphilis, gonorrhea, or chlamydia if symptomatic or if there is a history of or concern about possible sexual activity or exploitation.

Tuberculosis

El Salvador reported 2,206 new and relapsed cases of tuberculosis in 2014, and a prevalence of 49 cases per 100,000 population33. Within El Salvador, six new cases of multidrug-resistant (MDR) tuberculosis were confirmed in 201433. Guatemala and Honduras both reported higher numbers of cases and prevalence rates than El Salvador. Guatemala and Honduras reported 3,163 and 2,820 new and relapsed cases, respectively34, 35. Tuberculosis prevalence was 106 per 100,000 population in Guatemala, and 49 per 100,000 population in Honduras in 201434, 35. Additionally, 79 new cases of MDR TB were reported in Guatemala and 38 new cases of MDR TB were reported in Honduras for 201434, 35.

Refugee children are screened for TB infection. Any child with known latent tuberculosis infection (LTBI) at the time of arrival should be offered LTBI treatment. In addition, those without documentation of LTBI screening should be tested, with treatment offered to those who test positive.

For additional information regarding tuberculosis, see the World Health Organization Tuberculosis Profile.

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