Refugee health

= Refugee Health =

Refugees are often disproportionally affected by infectious disease mainly because of their geographic origin, ethnicity, conditions at a refugee camp, as well as personal, physical, and psychological conditions, either pre-existing or acquired while they fled their homeland and made way to a camp. The Federal Refugee Act of 1980 recommends that all new refugees arriving in the United States receive a comprehensive health assessment. [http://www.acf.hhs.gov/programs/orr/ The Office of Refugee Resettlement (ORR)] housed in the [http://www.hhs.gov/ Department of Health and Human Services (DHHS)] is charged with funding and oversight of this effort. Three medical interventions are either required or recommended in order to contain infectious disease and reduce the medical burdens that may be associated with refugee resettlement. First is a mandatory overseas screening for all refugees and immigrants, then a recommended domestic screening for refugees, and finally a required medical component to the Adjustment of Status (Green Card) process.

Overseas Screening

The U.S. Public Health Service requires a health screening for all immigrants and refugees prior to departure from their country of origin. Here, refugees undergo the most thorough screening. These medical exams are performed by approximately 400 physicians [called Panel Physicians] selected by the U.S. Department of State (DOS) consular officials. The Centers for Disease Control and Prevention's (CDC) [http://www.cdc.gov/ncidod/dq/ Division of Global Migration and Quarantine (DGMQ)] provide the technical instructions and guidance to the physicians conducting the overseas exams. The screening is primarily aimed at detecting infectious diseases of public health concern. The overseas exam includes a medical history inquiry, physical exam, chest x-ray for persons older than 14 years of age (Southeast Asian refugees older than 2 years of age), and specific lab tests. Testing routinely includes screening for syphilis and HIV in people over 15 years of age.

Laws

The CDC's Division of Global Migration and Quarantine is responsible for providing the U.S. Department of State and the United States Citizenship and Immigration Services (USCIS) with medical screening guidelines. The guidelines are developed in accordance with Section 212(a)(1)(A) of the Immigration and Nationality Act (INA), which outlines the reasons an alien is ineligible for a visa or admission to the United States, specifically based on health grounds. “The health-related grounds include those aliens who have a communicable disease of public health significance, who fail to present documentation of having received vaccination against vaccine-preventable diseases, who have or have had a physical or mental disorder with associated harmful behavior, and who are drug abusers or addicts.” [Section 212(a)(1)(A) of the Immigration and Nationality Act] Medical conditions recognized in refugees are categorized as Class A or Class B and are described below. If a refugee is found to have an inadmissible health-related condition, a waiver is required for the applicant to come to the United States.

Class Conditions

The health-related grounds for exclusion of refugees and immigrants set forth in the law are implemented by a regulation, "Medical Examination of Aliens" (42 CFR, Part 34). (need a reference) The regulation lists certain disorders that, if identified during the overseas medical examination, are grounds for exclusion (Class A condition) or represent such significant health problems (Class B condition) that they must be brought to the attention of consular authorities.

The purpose of the medical examination is to determine whether an alien has 1) a physical or mental disorder (including a communicable disease of public health significance or drug abuse/addiction) that renders him or her ineligible for admission or adjustment of status (Class A condition); or 2) a physical or mental disorder that, although not constituting a specific excludable condition, represents a departure from normal health or well-being that is significant enough to possibly interfere with the person's ability to care for himself or herself, or to attend school or work, or that may require extensive medical treatment or institutionalization in the future (Class B condition).

"Class A Conditions"

Class A conditions are those that preclude a refugee from entering the United States. They include communicable diseases of public health significance, mental illnesses associated with violent behavior, and drug addiction. Refugees must undergo treatment for these conditions if indicated. They could also request a waiver that would permit them to enter the U.S. Class A conditions include:
*Active or infectious tuberculosis
*Untreated syphilis
*Untreated chancroid
*Untreated gonorrhea
*Untreated granuloma inguinale
*Untreated lymphogranuloma venereum
*Human immunodeficiency virus (HIV)
*Hansen’s disease (Leprosy)
*Addiction or abuse of a specific substance without harmful behavior and/or any physical or mental disorder with harmful behavior or history of such behavior, along with the likelihood that the behavior will recur

"Class B Conditions"

Class B Conditions are conditions that are identified as amounting to a substantial departure from normal well-being. A refugee identified as having a Class B Condition will most likely receive treatment before departing for the U.S. and must seek follow-up soon after arrival in the United States. Class B conditions include:
*Inactive or noninfectious tuberculosis
*Treated syphilis
*Other sexually transmitted diseases
*Pregnancy
*Treated, tuberculoid, borderline or paucibacillary Hansen’s disease
*Sustained, full remission of abuse of specific substances (including amphetamines, cannabis, cocaine, hallucinogens, inhalants, opioids, phencyclidines, sedative hypnotics and anxiolytics) and/or any physical or mental disorder (excluding addiction or abuse of specific substances, but including other substance-related disorders) without harmful behavior or a history of such behavior considered unlikely to recur

Domestic Screening

When refugees enter the United States, they must enter through one of five authorized ports of entry that have Quarantine Stations: John F. Kennedy International Airport in New York, Newark Liberty International Airport, Miami International Airport, O'Hare International Airport in Chicago and Los Angeles International Airport. At these locations, U.S. Public Health Service personnel review refugees’ medical documents and perform limited inspections to look for obvious signs of illness. Through an electronic notification system maintained by the CDC, state health officials in the destination state are notified and sent copies of the overseas medical exam.

Upon arrival in the United States, it is recommended that refugees complete a domestic health screening that seeks to reduce health-related barriers to successful resettlement and protect the health of the U.S. population. Domestic health exams focus on infectious disease screening, but can also offer diagnosis and treatment for other health conditions identified. The parameters of the screening are based upon the [http://dhs.wisconsin.gov/international/refugee/PDF/ORRprotocal.pdf 1995 Office of Refugee Resettlement Medical Screening Protocol] , but new guidance is forthcoming.

Laws

The Refugee Act of 1980, which amended the Immigration and Nationality Act to establish a domestic refugee resettlement program, has outlined several public health activities with regards to refugee resettlement. First, all state or local health officials are to be notified of each refugees’ arrival so that they can provide timely treatment for health conditions of public health significance identified overseas. The Director of ORR has the authority to make grants to state or local health agencies to help them meet the costs of providing medical screening and initial medical treatment to refugees. In this way, states can provide domestic health assessment services with federal refugee funding support. To qualify for this funding, the state health assessments need to be in accordance with ORR requirements and approved by the ORR director. It is recommended that a refugee receive a health screening within 90 days of entering the United States. The screening protocols are left to state health officials with the approval of ORR.

Recommended Components of the Domestic Health Assessment

A Medical Screening Protocol for Newly Arriving Refugees was developed by ORR in collaboration with CDC in 1995. (need reference) Many states have added requirements in addition to the ORR protocol. DHHS is now drafting guidance for an expanded domestic protocol for screening refugees. The scope of the domestic health exam includes:
*Follow up (evaluation, treatment and/or referral) of Class A and B conditions identified during the overseas medical exam
*Identification of persons with communicable diseases of potential public health importance that were not identified during, or developed subsequent to the overseas exam
*Introduce incoming refuges and eligible clients to the U.S. health care system, and
*Identify conditions that could present a barrier to self-sufficiency

Special Considerations

"Cultural Competence"

When doctors or other health professionals work with refugee populations, it is necessary to strive for cultural competence. Refugees most often come from war-torn situations combined with prolonged time in refugee camps. Some of the educated among them may speak some English and may have knowledge of Western culture. However, some refugees from rural areas may speak only a local dialect and have very little if any knowledge of the Western world. Health care providers seeing refugees for their domestic screening are often the refugee’s first experience with Western style medical care. Physicians, nurses and other health care providers would do well to learn about the cultural background of their refugee patients and ensure that a professional bi-lingual/bi-cultural medical interpreter is present for their encounters. Interpreters should not be a relative or friend of the refugee.

“When seeing a patient, it is important to understand that it isn’t just the patient’s culture that is at play, but one’s own culture, as well as the culture of medicine. All three of these cultures interact in ways we need to be sensitive to and aware of, as they influence the outcome of the encounter. To understand patients who are culturally different from ourselves, it is first necessary to recognize our own cultural beliefs, values, and behaviors as well as how our life experiences influence the way we think about health care, and how it shapes the way we make clinical decisions.” [Immigrant Medicine, Chapter 8: Cultural Competence pp 85.]


= "Trauma" =

Prior to World War II, immigrants were often driven from their countries by forces such as unemployment, famine and poverty, often combined with various forms of prejudice and oppression. (need a reference) In other words, war and ethnopolitical conflict were not the primary causes for emigration. Beginning with World War II, however, civilians were increasingly targeted as a strategy of warfare. (need a reference) Since WW II, most newcomers (especially refugees) to the U.S. have been victimized by war and/or political repression. Like previous immigrants, these recent arrivals have known social oppression, including inadequate education, lack of job opportunities, inability to practice their faith or marry whom they wished, and inability to live where they want. However, unlike most previous immigrants, many of them have also experienced or witnessed government-sponsored torture and/or terror. That said, refugees are survivors who possess amazing resiliency, strength and resourcefulness. [Minnesota Refugee Health Provider Guide (www.health.state.mn.us/refugee)] An assessment of mental health may be included in a refugee’s domestic health screening. (this statement seems somewhat out of place)

Common Health Concerns in Refugees

Refugees may be at a higher risk for contracting certain diseases or having other health problems due to factors such as poor nutrition, poor sanitation and lack of adequate medical care. The most common health concerns are listed below.

Immunizations

Refugees tend to arrive in the United States with a variety of immunization needs. They may have had vaccinations in their country of origin, but due to the often unplanned nature of their departure are unlikely to have vaccination documentation. Some may have received immunizations as part of their overseas exam, and some may have received no immunizations. Unlike persons with immigrant status, U.S.-bound refugees are not required to have vaccinations in order to enter the United States. (need a reference) However, it is mandated that at the time of applying for adjustment of status from legal temporary resident to legal permanent resident, a refugee must be fully vaccinated in accordance with recommendations of the Advisory Committee on Immunization Practices (ACIP). Recommendations by the World Health Organization’s Expanded Program on Immunizations (EPI) are generally followed by countries worldwide with minor variations in vaccine schedules, spacing of vaccine doses, and documentation. The majority of vaccines used worldwide are from reliable local or international manufacturers, and no potency problems have been detected, with the occasional exception of tetanus toxoid and the oral polio vaccine (OPV). A list of required vaccines in the U.S. can be found on the vaccine schedule page.

Tuberculosis

“An estimated one third of the world’s population is infected with Mycobacterium tuberculosis.” [Minnesota Refugee Health Provider Guide (www.health.state.mn.us/refugee)] This high incidence necessitates that those conducting the overseas exam (Panel Physicians) screen all refugees for TB and further test anyone suspected of having active tuberculosis. Screening for tuberculosis generally involves a tuberculin skin test, followed by a chest X-ray when necessary, and laboratory testing depending on those results. Anyone between the ages of 2 and 14, living in a country with a tuberculosis incidence rate of ≥20 cases per 100,000 people (as identified by the World Health Organization), is required to have a tuberculin skin test. (need a reference) Those aged 15 and older must have a chest x-ray. (need a reference) Those individuals identified as having active tuberculosis must complete treatment before being permitted to enter the United States. Upon arriving in the United States, the CDC recommends that all refugees be screened for tuberculosis using a tuberculin skin test. A follow-up chest x-ray is required if the tuberculin skin test is positive, or if the refugee was identified as having TB (either Class A or Class B) in their overseas exam, or if they are infected with HIV.

Sexually Transmitted Infections

All refugees aged 15 years and older are screened for syphilis and HIV during the overseas exam. STIs are a significant health risk and testing is often included in the domestic health screening based on need, as identified by the doctor conducting the screening. Refugees can be at a higher risk for contracting sexually transmitted infections because of a lack of access to protection and/or treatment (the first part of this sentence is awkwardly structured), as well as the circumstances of war and flight, making them subject to higher incidences of rape and sexual abuse. Domestic screening often includes tests for syphilis, gonorrhea, chlamydia, and HIV infection as indicated by history and symptoms.

HIV

All refugees aged 15 years and older are screened for HIV as part of the overseas examination. It is not a routine part of the recommended domestic screening exam in the U.S. unless deemed necessary by the provider conducting the exam based on risk factors or symptoms of the disease.

Hepatitis B

Hepatitis B infection is endemic in Africa, Southeast Asia, East Asia, Northern Asia, and most of the Pacific Islands(need a reference). According to the CDC, the rate of chronic infection among persons emigrating to the U.S. from these areas is between 5% and 15%. Many states require or recommend that all refugees be screened for hepatitis B, and proceed with immunizations for all who are susceptible to this infection. (Should we say anything about perinatal hep B?)

Lead Poisoning

Lead poisoning is an important health issue for children all around the world. The prevalence of elevated blood lead levels (i.e., BLLs ≥ 10 µg/dL) among newly resettled refugee children is substantially higher than the 2.2% prevalence for U.S. children. (need a reference) A 2001 Massachusetts study found as many as 27% of newly arrived refugee children with elevated BLLs, making refugees one of the highest risk groups. [Geltman PL, Brown MJ, Cochran J. Lead poisoning among refugee children resettled in Massachusetts, 1995-1999. Pediatrics 2001; 108:158-162] Refugees may be exposed to lead from a number of sources which can include: leaded gasoline, herbal remedies, cosmetics, spices that contain lead, cottage industries that use lead in an unsafe manner, and limited regulation of emissions from larger industries. [Zabel, E., Smith, M.E., O’Fallon, A. Implementation of CDC Refugee Blood Lead Testing Guidelines in Minnesota. Public Health Rep. 2008 Mar-Apr;123(2):111-6.] The detrimental effects of lead on children may occur with no overt symptoms and blood lead testing is the only way to determine exposure or poisoning. The CDC recommends lead testing for newly arrived refugee children younger than 16 years of age. Guidelines for testing vary among states, ranging from testing children younger than six years of age to the CDC age limits of testing those younger than 16 years of age.

Parasitic Infections

Intestinal parasites are a major health problem for many groups, including refugees, and the presence of pathogenic parasites requires medical attention. “Over one billion persons worldwide are estimated to be carriers of Ascaris. Approximately 480 million people are infected with Entamoeba histolytica. At least 500 million carry Trichuris. At present, 200 to 300 million people are infected with one or more of the Schistosoma species and it is estimated that more than 20 million persons throughout the world are infected with Hymenolepsis nana. [Minnesota Refugee Health Provider Guide (www.health.state.mn.us/refugee)] Consequences of parasitic infection can include anemia due to blood loss and iron deficiency, malnutrition, growth retardation, invasive disease, and death. Refugees are particularly at risk given the likelihood of poor or contaminated water and poor hygienic conditions in camps. Since 1999, the CDC has recommended that U.S.-bound refugee populations from Africa and Southeast Asia undergo presumptive treatment for parasitic infections prior to departure. The U.S. Protocol includes a single dose of albendazole. [Swanson, S., Lee, B., Mamo, B., Smith, K., Stauffer, W. Changing prevalence of intestinal parasites among newly arrived Southeast Asian and African refugees after empiric predeparture albendazole treatment, Minnesota, 1993-2005. Poster presentation, ASTMH 54th annual meeting, December 2005. ] (this sentence is a little awkward) In many states, the domestic health screening exam recommends that all refugees be screened for parasitic infections whether or not they appear symptomatic. Screening often includes two stool specimens obtained more than 24 hours apart and/or a CBC with differential for evaluation of eosinophilia.

Malaria

Malaria is considered endemic in the Americas from as far north as Mexico to as far south as Argentina, in Africa from Egypt to South Africa, in Asia from Turkey to Indonesia, and in the islands of Oceania. It is estimated that 300 to 500 million people are infected each year with malaria, and over one million people die every year from the disease, predominantly in sub-Saharan Africa.(need a reference) Based on the high prevalence of asymptomatic malaria in sub-Saharan Africa, the CDC recommends that U.S.-bound refugee populations from this region undergo presumptive treatment prior to departure to the U.S. For those refugee arrivals from sub-Saharan Africa with no pre-departure treatment documentation, the CDC recommends either they receive presumptive treatment on arrival (preferred) or have laboratory screening to detect Plasmodium infection. For refugees from other areas of the world where asymptomatic malaria is not prevalent, the CDC recommends that any refugee with signs or symptoms of malaria should receive diagnostic testing for Plasmodium, and subsequent treatment for confirmed infections, but not presumptive treatment.

Anemia

Anemia is a common blood disorder worldwide. The World Health Organization (WHO) estimates the number of people affected at close to 2 billion. Acquired causes of anemia in refugees and other immigrants include iron deficiency, malaria, parasitic infection, tuberculosis, HIV, and anemia of chronic diseases. There are also several genetically based red blood cell disorders related to geographic distribution that should be considered when assessing an anemic condition, including α and β-thalassemia, hemoglobin E, sickle cell disease, hemoglobin C, G6PD deficiency and red blood cell membrane defects. [Immigrant Medicine, Chapter 46: Anemia and Red Blood Cell Disorders pp 611.]

Mental Health

Refugee mental health and integration into a new society are exquisitely interwoven. Traumatic experiences that occurred in the home country, during the resulting flight from that country, in addition to resettling in the U.S. are prevalent and increase the chances of a less successful adjustment to American society. (a convoluted sentence...are we talking specifically about resettlement in America or any country) The influence of these traumatic and stressful events may be temporary and manageable with straightforward solutions or may be disabling and enduring.

High rates of mental health concerns have been documented in various refugee populations. Most studies reveal high rates of post-traumatic stress disorder (PTSD), anxiety, depression, and somatization among newly arrived refugees. (need a reference) Variations reported in the prevalence of PTSD and depression may be ascribed to a number of factors, including prior life in their homeland, the experience of flight from that homeland, life in refugee camps, and stressors during and after resettlement in a third country. [Immigrant Medicine, Chapter 47: Mental Health and Illness in Immigrants: Epidemiology and Risk Factors, pp627-628.]

It is critical that mental health issues be addressed in the screening process. Leaving behind all that is familiar and starting a new life in a new country with a different language and culture produces an immediate crisis that can have long-term effects. This is true whether an individual is coming from Europe, sub-Saharan Africa, Central America, or elsewhere in the world. Many refugees will not share a Western perspective or vocabulary in terms of psychology, so questions will need to be explained through specific examples or re-framed in culturally congruent terms with the assistance of an interpreter or bicultural worker. [Minnesota Refugee Health Provider Guide (www.health.state.mn.us/refugee)]

Adjustment of Status Exam

Refugees are eligible to apply for adjustment of status after one year in the U.S. While most immigrants are required to have a full medical exam at the time of applying for adjustment of status, refugees are an exception. Refugees who arrived without a Class A condition (see Section 2.2.1) only require vaccinations with their adjustment of status; the full medical examination is not required. A full medical exam is only required for refugees if a Class A condition existed prior to arrival in the U.S. This full medical exam is performed by a Civil Surgeon. Civil Surgeons are designated by the District Director of the U.S. Citizenship and Immigration Services (USCIS). Immigration regulations state that each civil surgeon selected shall be a licensed physician with no less than 4 years of professional experience. If only the vaccination assessment is necessary for refugees, this may be performed by either a Civil Surgeon or local public health. [Centers for Disease Control and Prevention Division of Global Migration and Quarantine (DGMQ), www.cdc.gov/ncidod/dq/civil.htm]

ample State Programs

Because each state is responsible for coordinating refugee health screenings, protocols vary by state. A sampling of information about various state Refugee Health Programs are listed below.
*California (http://www.cdph.ca.gov/programs/Pages/RefugeeHealthSection.aspx)

*Florida (http://www.doh.state.fl.us/disease_ctrl/refugee/index.html)

*Massachusetts (http://www.mass.gov/dph/cdc/rhip/wwwrihp.htm)

*Minnesota (http://www.health.state.mn.us/refugee/)

*Texas (http://www.dshs.state.tx.us/idcu/heath/refugee_health/)

*Wisconsin (http://dhfs.wisconsin.gov/international/refugee/index.htm)

Footnotes

Bibliography


*Barnett ED. Infectious disease screening for refugees resettled in the United States. Clin. Infect Dis J 2004; 39:833-841.

*Barnett ED, Christiansen D, Figueira M. Seroprevalence of measles, rubella, and varicella in refugees. Clin Infect Dis 2002; 35:403-408.

*Geltman PL, Brown MJ, Cochran J. Lead poisoning among refugee children resettled in Massachusetts, 1995-1999. Pediatrics 2001; 108:158-162.

*Geltman PL, Cochran J, Hedgecock C. Intestinal parasites among African refugees resettled in Massachusetts and the impact of an overseas pre-departure treatment program. Am J Trop Med Hyg 2003; 69(6):657-662.

*Geltman PL, Cochran J. A private-sector preferred provider network model for public health screening of newly resettled refugees. Am J Public Health 2005; 95:196-199.

*Lifson AR, Thai D, O’Fallon A, et al. Prevalence of tuberculosis, hepatitis B virus, and intestinal parasitic infections among refugees to Minnesota. Public Health Reports 2002; 117:69-76.

*Maroushek SR, Aguilar EF, Stauffer W, et al. Malaria among refugee children at arrival in the United States. Pediatr Infect Dis J 2005; 24:450-452.

*Stauffer WM, Kamat D, Walker PF. Screening of international immigrants, refugees, and adoptees. Prim Care Clin Office Pract (2002); 29:879-905.

*Stauffer WM, Maroushek S, Kamat D. Medical screening of immigrant children. Clin Pediatr 2003; 42:763-773.

*Zabel, E., Smith, M.E., O’Fallon, A. Implementation of CDC Refugee Blood Lead Testing Guidelines in Minnesota. Public Health Rep. 2008 Mar-Apr;123(2):111-6.

Further Reading

Immigrant Medicine, Patricia F Walker and Elizabeth D Barnett, 2007, Elsevier, Inc.

Refugee and Immigrant Health. A Handbook for Health Professionals. Kemp, Charles; Rasbridge, Lance A (Editors). Cambridge University Press; 1st ed. November 2004.

External Links

"Federal Policy"

*Federal Refugee Act of 1980 (http://www.acf.hhs.gov/programs/orr/policy/refact1.htm)

*Immigration and Nationality Act (INA) (http://www.uscis.gov/propub/ProPubVAP.jsp?dockey=cb90c19a50729fb47fb0686648558dbe)

*Office of Refugee Resettlement (ORR) (http://www.acf.hhs.gov/programs/orr/)

*International Office of Migration (IOM) (http://www.iom.int/jahia/jsp/index.jsp)

*United States Citizenship and Immigration Services (USCIS) (http://www.uscis.gov/portal/site/uscis)

"Centers for Disease Control and Prevention"

*CDC Division of Global Migration and Quarantine (DGMQ) (http://www.cdc.gov/ncidod/dq)

*CDC Overseas Medical Examinations of Aliens (Refugees and Immigrants) (http://www.cdc.gov/ncidod/dq/health.htm)

*CDC Technical Instructions for Panel Physicians (http://www.cdc.gov/ncidod/dq/dsforms/)

*CDC Public Health Screening at U.S. Ports of Entry (http://www.cdc.gov/ncidod/dq/pdf/hguide.pdf)

*CDC Immigrant, Refugee and Migrant Health (http://www.cdc.gov/ncidod/dq/refugee/index.htm)

*CDC Refugee Health Domestic Screening Guidelines(http://www.cdc.gov/ncidod/dq/refugee/rh_guide/index.htm)

*CDC Domestic Refugee Health Program Frequently Asked Questions (http://www.cdc.gov/ncidod/dq/refugee/faq/faq.htm )

*CDC Tuberculosis Guidelines (http://www.cdc.gov/ncidod/dq/pdf/ti_tb_8_9_2007.pdf)

*CDC Domestic and Overseas Malaria Guidance (http://www.cdc.gov/ncidod/dq/refugee/rh_guide/index.htm)

*CDC Hepatitis B (http://www.cdc.gov/hepatitis/index.htm)

*CDC Lead Screening Guidance (http://www.cdc.gov/nceh/lead/default.htm)

*CDC Intestinal Parasite Domestic Refugee Health Guidelines (http://www.cdc.gov/ncidod/dq/refugee/rh_guide/ip/index.htm)

"Refugee Health Provider Guide"

*Minnesota Refugee Health Provider Guide(http://www.health.state.mn.us/divs/idepc/refugee/guide/howto.html)

"Refugee Mental Health"

*Refugee Mental Health(http://www3.baylor.edu/~Charles_Kemp/refugee_mental_health.htm)

"Cultural Competence"

*HRSA: Cultural Competence Resources for Health Care Providers (http://www.hrsa.gov/culturalcompetence/)

*University of Michigan: Cultural Competency - Basic Concepts & Definitions (http://www.med.umich.edu/Multicultural/ccp/basic.htm)

*Office of Minority Health on Cultural Competency (http://www.omhrc.gov/templates/browse.aspx?lvl=2&lvlID=11)


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