Refugee health

Migration History

• Country of birth, countries of transit, and any time in detention centers
• Current visa status

Full Medical History

• Current health concerns
• Past medical history, family history, medications, allergies
• Screening tests and vaccinations completed pre-migration

History of or Contact with:

• Tuberculosis (TB), malaria, parasitic infections
• Hepatitis B Virus (HBV), hepatitis C Virus (HCV), human immunodeficiency virus (HIV)
• Sexually transmitted infections (STIs)
• Respiratory symptoms
• Gastrointestinal symptoms
• Systemic/localizing symptoms

Immunization History Including:

• Written documentation pre and post arrival
• Bacille Calmette-Guérin (BCG) scar
• Natural infection such as HBV and varicella
• Previous vaccine reactions

Chronic Non-Communicable Diseases and Issues Such As:

• Cardiovascular disease (CVD)
• Diabetes
• Chronic obstructive pulmonary disease (COPD)
• Thyroid
• Injuries, accidents, and hospitalizations
• Hearing, vision, and dental problems
• Other disabilities and adaptive function problems

Lifestyle/Risk Factors Including:

• Smoking
• Alcohol intake
• Substance use (including substances common in certain areas e.g. betel nut, sheesha, khat)
• Risk factors for low vitamin D
• Nutrition (food access, current nutritional status)

Current Concerns

• Specific patient groups and health concerns
  • Child/adolescent health
    • Growth
    • Development
    • Education history
    • Perinatal and postnatal history
  • Women’s health
    • Past and current pregnancies/births
    • Contraception
    • Breastfeeding
    • Cervical and breast screening
    • Female circumcision/traditional cutting
    • Intimate partner violence
  • Sexual health (men, women, and adolescents)
    • Risk factors for acquiring an STI
    • Contraception

Developmental History in Children and Adolescents

• Growth
• Development
• Education history
• Perinatal and postnatal history

Psychosocial History

• Family and household composition (i.e., support network and safety in the home)
• Settlement stressors
  • Supports in Australia
  • Housing difficulties
  • Finances and current studies
  • Separation from significant family members
  • Relationships/family functioning
  • Past education
  • Occupation
  • Time spent in immigration detention

PSYCH

• Observe appearance, affect, and behavior
• Sleep, appetite, energy, mood, anxiety symptoms, memory, concentration
• For children/adolescents: behavior, schooling, nightmares, and enuresis (bed wetting)
• Generally, not advisable to ask directly about a person’s experience of torture or other traumatic events; however, the potential impacts on psychological health should be assessed
• Suicide risk assessment

Physical Examination

• Skin conditions, including hair and nails, BCG scar
• Fever (exclude malaria)
• Ear, nose, and throat (ENT) and dental examination (look particularly for middle ear disease and dental caries)
• Blood pressure (BP)
• Body mass index (BMI), nutritional status – weight, height, waist/hip ratio (adults), head circumference (children)
• Pallor/murmur as a sign of anemia (consider causes such as iron, B12, and folate deficiencies and lead toxicity among other causes)
• Signs of other micronutrient deficiencies
  • Dry eyes (vitamin A)
  • Skin (zinc, vitamin C, other)
  • Gums (vitamin C)
  • Lips/tongue (B-group vitamins, including B12)
  • Hair/nails (zinc, other)
  • Goiter (iodine)
  • Teeth/rickets (vitamin D)
• Cervical, axillary, and inguinal lymphadenopathy (consider TB and HIV)
• Cardiorespiratory exam (consider TB, COPD, murmurs, CVD)
• Hepatosplenomegaly (consider chronic malaria, chronic liver disease including HBV, schistosomiasis, TB, HIV)
• Evidence of torture or other injuries
• Neurology (consider gait, tone, power, reflexes, and coordination)
• Visual acuity (all ages; for African people >40 years and others >50 years, refer to optometry for a glaucoma check)

Investigations

• Necessary investigations based on history and physical examination findings

Practice Tips

• The ‘Health assessment for refugees and other humanitarian entrants’ is funded up to 1 year post arrival or visa grant date through the Medicare Benefits Schedule (MBS) (Items 701, 703, 705, and 707). The assessment can be completed over a number of consults.
• Explain that the health assessment and investigations are simply to ensure good health and will have no negative consequences for visa status.
• Free translation of personal documents including medical documents and qualifications is available. The Free Translating Service provides translation into English of medical reports or vaccination certificates (in the form of an extract or summary) within the first 2 years of a patient’s eligible visa grant date.

Investigations

All
FBE
Hepatitis B Serology (HBsAg, HBsAb, HBcAb)`	Write ‘Query chronic hepatitis B?’ on the pathology request slip to meet MBS requirements
Hepatitis C Ab, and HCV RNA if HCV Ab positive
Strongyloides stercoralis serology
HIV serology*	≥15 years (Also part of IME for age >15 years) <15 years if unaccompanied/separated minor or clinical concerns
Latent TB screening with TST (Mantoux test) or IGRA (e.g. Quantiferon Gold)	Offer test with intention to treat ≤35 years; if >35 years testing depends on risk factors and local jurisdiction. Check Medicare for IGRA rebates, TST preferred in children <5 years
Age-based/risk-based
Varicella serology	≥14 years old if no known history of disease
Rubella IgG	Women of child-bearing age
Fasting glucose and or HbA1c**	Consider risk in patients ≥35 years if high-risk ethnicity (Asian, Middle Eastern, Pacific Islander, Southern European, North or Sub-Saharan African) and/or overweight and other risk factors Use Diabetes Risk Assessment Tool
Fasting lipids**	Consider risk in patients ≥35 years from CVD high-prevalence countries (South-East Asia and Southern Europe) and/or with risk factors such as obesity, hypertension or other risk factors Use CVD Risk Calculator
Ferritin	All women and children; men who have risk factors
Vitamin D, also check Ca, PO4 and ALP in children	Risk factors such as dark skin, lack of sun exposure Write risk factors on pathology request
Vitamin B12	Arrival <6 months; food insecurity; vegan; from Bhutan, Afghanistan, Iran, Horn of Africa
Syphilis serology	Risk of STIs, unaccompanied or separated minor
First-pass urine or self-obtained vaginal swabs for gonorrhoea and chlamydia PCR	Risk factors for STIs, or on request*
Helicobacter pylori stool antigen or breath test	Upper gastrointestinal symptoms or family history of gastric cancer
Stool microscopy – OCP	If no documented pre-departure albendazole, or persisting eosinophilia after albendazole treatment Also consider if abdominal pain, diarrhoea
Country-based
Schistosoma serology	Residence in and/or travel through endemic areas See ASID/RHeaNA country-specific screening recommendations
Malaria thick and thin films and malaria RDT	Travel from/through an endemic malaria area within 3 months of arrival if asymptomatic, or within 12 months if symptoms of fever See ASID/RHeaNA country-specific screening recommendations

*ASID/RHeaNA panel did not reach consensus on these recommendations.

Management plan and referral

• Preventative health
• Provide a management plan for each problem, including referrals if required
• Commence immunisation catch-up and register all 

Management of infectious conditions

Condition	Test	Result	Initial management
Eosinophilia	FBE*	Eosinophilia >0.6 x 109/L or above reference range	Investigate and treat causes of eosinophilia, including intestinal parasites, Strongyloides, schistosomiasis
Hepatitis B	HBsAg, HBsAb, HBcAb	HBsAg positive**	Arrange clinical assessment, blood tests and abdominal ultrasound Vaccinate non-immune household contacts and sexual partnersTest for and vaccinate against hepatitis A See ASID/RHeaNA Immunisation
Strongyloidiasis	Strongyloides stercoralis serology	Strongyloides serology positive or equivocal	Stool microscopy for OCP Check for eosinophilia Treat with ivermectin 200 mcg/kg (≥15 kg) on day 1 and 14 Refer pregnant women or children <15 kg to specialist Follow up serology at 6 and 12 months
Latent tuberculosis infection	Exclude active TB infection** – if suspicion of active infection refer to TB services Ensure appropriate infection control precautions
	TST or IGRA	Positive TST or IGRA	Refer to TB services for CXR and consideration of LTBI preventative therapy with isoniazid 10 mg/kg (up to 300 mg) daily for 6–9 months See ASID/RHeaNA Tuberculosis (TB and LTBI)
HIV	HIV serology	HIV serology positive**	Refer to local HIV care provider
STI	First pass urine or self-obtained vaginal swabs for gonorrhoea and chlamydia PCR Syphilis serology	Regardless of test result	Offer women a pregnancy test and contraception as appropriate See ASID/RHeaNA Women’s Health
		Chlamydia positive**	Treat with azithromycin 1 g orally as a single dose OR doxycycline 100 mg orally 12 hourly for 7 days Treat anorectal chlamydia with doxycycline 100 mg orally 12 hourly for 7 days or azithromycin 1 g orally as a single dose with a repeat dose a week later
		Gonorrhoea positive**	Take samples for gonorrhoea culture before treatment Ceftriaxone 500 mg in 2 mL of 1% lignocaine IMI PLUS azithromycin 1 g orally Repeat NAAT and culture for test of cure for gonorrhoea 2 weeks after treatment
		Syphilis positive**	Parenteral penicillin (if not previously treated) in the context of a sexual health or ID unit
Helicobacter pylori	H pylori stool Ag or breath test	Ag or stool test positive	Treat as per eTG (gastrointestinal) Follow up with repeat test at least 4 weeks after treatment If first-line therapy is unsuccessful, refer to specialist for second-line medication Refer to specialist for consideration for endoscopy irrespective of H pylori status if ‘red flags’ are present (e.g. anorexia, weight loss, dysphagia, gastrointestinal bleeding or abdominal mass) or if symptoms of dyspepsia and age >50 years

Condition	Test	Result	Initial management
Intestinal parasites	Check for eosinophilia If documented pre-departure albendazole therapy • No eosinophilia and no symptoms – no investigation or treatment required • Eosinophilia – perform stool microscopy for OCP followed by directed treatment If no documented pre-departure albendazole therapy, depending on local resources and practices, there are two acceptable options: 1. Empiric single-dose albendazole therapy (200 mg if age >6 months and weight 6 months and weight <10 kg; 400 mg if ≥10 kg) for 3 days, except for Ascaris lumbricoides, which only requires 400 mg as a single dose (200 mg in children >6 months and <10 kg). Mebendazole is an option for some parasites Treat Giardia lamblia with tinidazole 2 g as a single dose (50 mg/kg children, maximum 2 g) or metronidazole 2 g daily for 3 days (30 mg/kg/dose children, maximum 2 g)
Schistosomiasis	Schistosoma serology	Schistosomiasis serology positive or equivocal	Treat with praziquantel (40 mg/kg orally, taken in one dose or divided into two doses taken 4 hours apart; no upper dose limit) As serology does not determine parasite burden or end-organ disease, perform microscopy (urine and stool) for ova and urine dipstick for haematuria If positive dipstick, perform end-urine microscopy for ova (ideally collected between 10 a.m. and 2 p.m.) If positive for ova on urine or stool, evaluate further for end-organ disease with ultrasound and LFTs Seek advice from a paediatric specialist for treatment of children <5 years
Malaria	Malaria thick and thin films and RDT	Positive test**	Unwell patients and those with P falciparum malaria should be admitted to hospital urgently Treat in consultation with ID specialist Children, pregnant women and people with low immunity are at particular risk
Hepatitis C	Hepatitis C Ab	Anti-Hepatitis C Ab positive**	HCV RNA test – if positive, refer to a doctor accredited to treat HCV for further assessment Test for and vaccinate against hepatitis A See ASID/RHeaNA Immunisation

Management of non-infectious conditions

Condition	Diagnostic test	Result	Initial management
Anaemia	FBE	Low Hb (age and sex dependent)	Investigate and treat causes of anaemia
Iron deficiency	Ferritin	Ferritin <15 µg/L in adults Check reference ranges for children	Investigate and treat causes Treat with iron supplementation if iron <15 µg/L (or below reference range for children) and/or when clinical and haematological features indicate iron deficiency anaemia Educate about iron-rich diet and avoid excessive dairy intake in children
Low vitamin D	25-hydroxy vitamin DAlso Ca, PO4 and ALP in children	Vitamin D level <50 nmol/L	Treat to restore levels to the normal range with either daily dosing or high-dose therapy, ensuring adequate calcium intake and paired with advice about sun exposure and self-management See ASID/RHeaNA Low Vitamin D
Vitamin B12 deficiency	Serum active vitamin B12 (holotranscobalamin)	Serum active B12 if <35 pmol/L or below reference range in children	Treat if <35 pmol/L or below reference range for children with oral or IM supplementation Exclude concomitant folate deficiency Consider Helicobacter pylori infection

further screening and management

Condition	Screening and management links
Varicella immunisation status	Varicella serology If varicella non-immune, complete vaccination as per Australian Immunisation Handbook (exclude pregnancy)
Rubella immunisation status	Rubella IgG If rubella non-immune, complete vaccination as per Australian Immunisation Handbook (exclude pregnancy)
Other immunisations	No routine serology required; check for written immunisation record Catch-up vaccination as per Australian Immunisation Handbook (consider pregnancy) – so people are immunised equivalent to an Australian-born person of the same age National Immunisation Program ASID/RHeaNA Immunisation South Australian Immunisation Calculator
Cervical, breast cancer screening	Offer pap testing and mammography according to RACGP recommended guidelines RACGP breast cancer RACGP cervical cancer
Women’s health (also consider adolescent females)	Offer pregnancy screening, antenatal care or contraceptive advice as needed Pregnancy Care Guidelines Female circumcision/traditional cutting National Education Toolkit for Female Genital Mutilation/Cutting Awareness
Bowel cancer screening Osteoporosis CKD screening	Offer standard preventative screening and treatment according to age and risk Cancer Council Australia Bowel Cancer Screening RACGP Osteoporosis Kidney Health Australia for Health Professionals
Chronic disease risk factor management	Manage chronic disease risk factors, e.g. smoking, alcohol, obesity Refer to RACGP guidelines Australian Dietary Guidelines includes patient resources Physical activity guidelines
Non-communicable disease in adults	See Table 1 for diabetes and CVD screening recommendations for people from refugee backgrounds. Refer to national guidelines for chronic disease management Diabetes CVD COPD Osteoporosis CKD
Further mental health screening	Management of psychological effects of torture or other traumatic events ASID/RHeaNA Mental Health
Dental caries and oral health concerns	Refer to public dental services State and territory referrals
Visual impairment	Visual acuity testing Refer to bulk billing optometry
Glaucoma	African descent >40 years, all others >50 years Refer to low-cost optometrist for glaucoma screening
Hearing impairment	Refer to public audiology if concerns about hearing +/- ENT State and territory referrals
Disability	Refer for assessment and ongoing management if needed NDIS Local Area Coordination NDIS Early Childhood Intervention Partners
Developmental delay or learning concerns	Refer to MCH and for paediatric assessment RACGP Preventative activities in children and young people Royal Children’s Hospital Immigrant Health Clinic Developmental Assessment
Family violence	Refer to RACGP Guidelines Migrant and refugee communities 1800 RESPECT