Refugee Health Exam

Aka: Refugee Health Exam, Immigration Health Exam, Refugee, Immigrant, Immigrant Child, Internationally Adopted Child

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II. Indications

  1. New Refugee or Immigrant into the U.S.

III. Preparation

  1. Obtain Prior Exam records from Public Health Department

IV. History

  1. Pre-flight (while still in country of origin)
    1. Baseline health status (including mental health) before leaving home country?
    2. Economic status and education level?
    3. Exposure to Violence, torture, rape, prison?
  2. Flight (e.g. in Refugee camp)
    1. Exposure to Violence, torture, rape, prison?
    2. Mental health status?
    3. Loss of loved ones (death or hiding)?
    4. Access to food, shelter, health care?
    5. Timeline (e.g. duration in Refugee camp)?
    6. Completed screening requirement and empiric treatments recommended by CDC?
  3. Destination country arrival
    1. Completed screening requirement and empiric treatments recommended by CDC?
    2. Current mental health status?
    3. Current access to health care and social services

V. Exam

  1. Complete Medical Examination
  2. Vital Signs
    1. Height
    2. Weight
    3. Blood Pressure
  3. Visual Acuity
  4. Hearing Testing
  5. Evaluate for Hansen's Disease
  6. Assess mental health needs
  7. Complete Dental Examination
  8. Signs of Trauma, Torture or Rape
    1. Post-Traumatic Stress Disorder (PTSD)
    2. Female genital mutilation (Female Circumcision)
    3. Scars
      1. Beatings
      2. Whippings
      3. Burns
      4. Electric shock

VI. Evaluation: Common presenting concerns in Refugees

  1. Psychiatric
    1. Major Depression
    2. Anxiety Disorder
    3. Post-Traumatic Stress Disorder
    4. Insomnia
    5. Social Isolation
  2. Chronic Pain (present in >65% of refugess)
    1. Headache
    2. Abdominal Pain
    3. Chronic Pelvic Pain
    4. Neck Pain or Back pain
  3. Chronic conditions
    1. Anemia
    2. Asthma or COPD
    3. Diabetes Mellitus
    4. Hypertension
    5. Hyperlipidemia
    6. Vitamin D Deficiency
    7. Vitamin B12 Deficiency
    8. Oral Health conditions
    9. Malnutrition and Growth Delay

VII. Evaluation: High risk conditions screened on immigration

  1. Granuloma Inguinale
  2. Lymphogranuloma venereum
  3. Sexually Transmitted Infections
    1. Syphilis
    2. Chmaydia
    3. Chancroid
    4. Gonorrhea
  4. Parasitic Infections
    1. Ascaris lumbricoides
    2. Necator americanus
    3. Giardia lamblia
    4. Trichuris trichiura
    5. Entamoeba histolytica
    6. Schistosoma
  5. Other Infections
    1. Tuberculosis
    2. Hansen Disease
    3. Malaria
    4. Human Immunodeficiency Virus (HIV)
    5. Hepatitis B
    6. Neonatal Tetanus
    7. Measles
    8. Mumps
    9. Rubella
    10. Diphtheria
    11. Pertussis
    12. Tetanus
  6. Chemical Dependency or Substance Abuse
  7. Serious psychiatric disorder with risk of institutionalization or harm to others
  8. Rheumatic Heart Disease

VIII. Evaluation: International adoptee protocol

  1. All Immigrants and Refugees should have an entrance exam in first month of arrival
  2. Within 24 hours
    1. Child with obvious illness
    2. Child with unstable medical condition
  3. Within 1 week
    1. Baseline growth data
    2. Brief evaluation for chronic or stable illness
    3. Reassure parents
  4. Within 2-4 weeks
    1. Review medical records accompanying child
    2. Head to toe (naked) exam
    3. Age appropriate well child exam
      1. Development
      2. Hearing and Vision evaluation
      3. Dental assessment
    4. Immunization Update
    5. Obtain Labs as below
    6. Screen and immunize contacts as needed

IX. Labs

  1. Precautions
    1. Typically completed by immigration officials prior to entry, however re-screen as indicated
  2. Complete Blood Count (CBC) with differential
    1. https://www.cdc.gov/immigrantrefugeehealth/guidelines/domestic/general/discussion/complete-blood-count.html
    2. Evaluate for Eosinophilia (Parasitic Infection)
    3. Evaluate for Anemia
  3. Consider Serum Chemistry Panel if indicated
    1. https://www.cdc.gov/immigrantrefugeehealth/guidelines/domestic/general/discussion/chemistries.html
    2. Comorbidity directed
    3. Renal disease risk (e.g. Hmong)
  4. Other labs for blood draw
    1. Serum Lead level
      1. All children 6 months to 16 years of age (and repeat in 3-6 months if <6 years old)
    2. Blood count
      1. See above
      2. Evaluate for Iron Deficiency Anemia
    3. Vitamin D
    4. Vitamin B12
      1. Especially if patient from Butan
  5. Urine testing
    1. Consider Urinalysis and Urine Culture if indicated
      1. https://www.cdc.gov/immigrantrefugeehealth/guidelines/domestic/general/discussion/urinalysis.html
      2. May identify Hematuria, renal disease
    2. Urine Pregnancy Test (urine HCG)
      1. Indicated in all females of childbearing age
  6. Sexually Transmitted Infection testing
    1. https://www.cdc.gov/immigrantrefugeehealth/guidelines/domestic/sexually-transmitted-diseases/index.html
    2. Urine or cervical swab for Gonorrhea PCR and Chlamydia PCR
      1. Consider testing if indicated for age, symptoms, history (e.g. rape), Urine Leukocyte Esterase positive
    3. Human Immunodeficiency Virus (HIV Testing with HIV Antigen and Antibody 1 and 2)
      1. Indicated in all Immigrants or Refugees who have not yet been tested
    4. Syphilis Serology (Rapid Plasma Reagin or VDRL)
      1. Indicated for all over age 15 years if not already tested
      2. Also indicated for younger than 15 years, if sexually active, rape, maternal Syphilis
      3. Differentiate from Yaws
    5. Hepatitis B Serology (esp. those from Africa Asia, Middle East)
      1. https://www.cdc.gov/immigrantrefugeehealth/guidelines/domestic/hepatitis-screening-guidelines.html
      2. xHBsAg
      3. xHBsAb
      4. Consider xHBcAb
      5. Treat carriers and evaluate and immunize contacts
      6. See Viral Hepatitis Screening
  7. Parasitic Infections
    1. Review prearrival empiric management and testing
    2. Malaria
      1. https://www.cdc.gov/immigrantrefugeehealth/guidelines/domestic/malaria-guidelines-domestic.html
      2. Test first indications (3 thick and thin smears for malaria Parasites)
        1. Pregnant or lactating women
        2. Children <5 kg (11 lb)
        3. Symptomatic or suspicious history (and not from sub-saharan africa)
      3. Empiric treatment indications (with Malarone or Coartem)
        1. Sub-saharan africa origin who were not given empiric treatment already
    3. Schistosomiasis
      1. If from sub-saharan africa, Serologic Test OR empiric treatment (Praziquantel)
    4. Strongyloides
      1. All Immigrants, Serologic Tests OR empiric treatment (Ivermectin)
      2. Exception: Do not give Ivermectin to patients from Loa loa endemic regions (risk of serious reactions)
    5. Helicobacter Pylori
      1. Consider testing if Epigastric Pain
    6. Soil Transmitted Helminths
      1. https://www.cdc.gov/immigrantrefugeehealth/guidelines/domestic/intestinal-parasites-domestic.html
      2. Obtain two stool specimens for Ova and Parasites (in addition to CBC with differential as above)
      3. Consider empiric treatment with Albendazole
  8. Tuberculin Skin Testing (PPD) or quantiferon-G
    1. Indicated for all patients age >6 months regardless of BCG vaccine

X. Management

  1. Immunizations
    1. https://www.cdc.gov/immigrantrefugeehealth/guidelines/domestic/immunizations-guidelines.html
    2. If no record, begin Primary Series for age appropriate
    3. Test VZV IgG and anti-HBsAb before giving Varicella Vaccine or Hepatitis B Vaccine
    4. Vaccinations mandated by CDC
      1. Intended for Refugees requesting adjustment status for U.S permanent residence (typically at 1 year)
  2. Mental Health Screening
    1. https://www.cdc.gov/immigrantrefugeehealth/guidelines/domestic/mental-health-screening-guidelines.html
    2. Review prearrival records
    3. History of Trauma, maltreatment or torture
    4. Mental Status Exam
    5. Major Depression screening
    6. Posttraumatic Stress Disorder screening
  3. Nutrition and growth
    1. https://www.cdc.gov/immigrantrefugeehealth/guidelines/domestic/nutrition-growth.html
    2. Plot weight, height, Body Mass Index in all children ages 6 months to 59 months of age
  4. Other preventive health
    1. Chronic disease management
      1. Diabetes Mellitus
      2. Hepatitis C
      3. Hyperlipidemia
      4. Hypertension
    2. Cancer screening
      1. Breast Cancer
      2. Cervical Cancer
      3. Colon Cancer
    3. Women's health
      1. Family Planning

XI. Resources: Refugee Health

  1. CDC Immigrant and Refugee Health
    1. https://www.cdc.gov/immigrantrefugeehealth/exams/medical-examination.html
  2. CDC Refugee Health Profiles
    1. https://www.cdc.gov/immigrantrefugeehealth/profiles/
  3. EthnoMed
    1. http://ethnomed.org/
  4. Minnesota Department of Health Refugee Health Program
    1. http://www.health.state.mn.us/refugee
  5. Centers for Victims of Torture
    1. http://www.cvt.org/
  6. Society of Refugee Healthcare Providers
    1. http://nasrhp.org/

XII. Resources: Volunteer Groups

  1. Church World Service
    1. https://cwsglobal.org/
  2. Hebrew Immigrant Aid Society (HIAS)
    1. https://www.hias.org/
  3. International Rescue Committee
    1. https://www.rescue.org/
  4. Lutheran Immigration and Refugee Service
    1. http://lirs.org/
  5. U.S. Committe for Refugees and Immigrants
    1. http://refugees.org/
  6. World Relief
    1. https://www.worldrelief.org/

XIII. References

  1. (1997) Pediatrics 100(1): 153-6 [PubMed]
  2. Charles (1998) Am Fam Physician 58(9): 2025-32 [PubMed]
  3. Gavagan (1998) Am Fam Physician 57(5): 1061-8 [PubMed]
  4. Hostetter (1996) J Postgrad Med 99(4): 70-82 [PubMed]
  5. Mitchell (1997) J Pediatr Health 11:51-60 [PubMed]
  6. Mitchell (1997) J Pediatr Health 11:117-26 [PubMed]
  7. Wolfe (1992) Med Clin North Am 76(6): 1463-80 [PubMed]
  8. Barnett (2004) Clin Infect Dis 39(6): 833-41 [PubMed]
  9. Eckstein (2011) Am Fam Physician 83(4): 429-36 [PubMed]
  10. Mishouri (2017) Am Fam Physician 96(2): 112-20 [PubMed]
  11. Stauffer (2009) Curr Opin Infect Dis 22(5): 436-43 [PubMed]

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