Refugee health assessment
Table of contents
Overview
Offer a comprehensive post-arrival health assessment to every child, adolescent and adult from a refugee background who is new to your care, preferably within one month of arrival. Always use person-centred care principles that consider the impact of past trauma. Use language and gender appropriate interpreters. See Approach to consultation and management, Communication and interpreters.Key points
A refugee health assessment includes: migration history; a full medical history, including current concerns, developmental history in children and adolescents and psychosocial history; physical examination; investigations; and development of a management plan. For children and adolescents, history may be taken from a parent or carer where appropriate. In some states and territories, post-arrival health assessments are provided by a specialised refugee health service. In primary care, refugee health assessments can be supported by refugee health nurses or practice nurses. Refugee health nurses provide specialised support and assistance for primary care clinicians and people from refugee backgrounds. For the contact details of your local refugee health nurse or refugee health service, see State and territory referrals.Practice tip: 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. For eligible visas see ‘Health assessment for refugees and other humanitarian entrants’. Practice tip: The Refugee Health Assessment template can be used to assist GPs and nurses to undertake a health assessment.
Approach to refugee health assessment
When offering a health assessment, ensure the patient – including a parent/caregiver for children and adolescents – understands that the assessment is voluntary, and give clear explanations about the process. Be aware that screening for asymptomatic illness and disease prevention may be unfamiliar concepts for some people from refugee backgrounds. Take a gradual approach to post-arrival health assessment, aiming to build rapport. Start with the patient’s current concerns. This is to determine if active disease is present and to develop a trusting relationship. This discussion can also help you determine the patient’s level of health literacy. Next, take a detailed medical and psychosocial history, and then perform a physical examination. The complete assessment should be conducted over several appointments. Potentially sensitive issues such as sexual health and mental health screening can be addressed after rapport has been established.Practice tip: Explain that the health assessment and investigations are simply to ensure good health and will have no negative consequences for visa status. Practice tip: 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. More information.The following section is derived from Recommendations for comprehensive post-arrival health assessment for people of refugee-like backgrounds1 (ASID/RHeaNA Recommendations) for use in primary care.
History
Migration history
- Country of birth, countries of transit and any time in detention centres
- Current visa status
Medical history
Practice tip: Consider requesting a fee waiver for the transfer of previous health records from another practice.
- Current health concerns
- Past medical history, family history, medications, allergies
- Determine which screening tests and vaccinations have been completed pre-migration and since arrival in Australia. For information about access to pre-departure health information through HAPlite. Note: the Immigration Medical Examination (IME) is more limited in children. See Children, Adolescents.
- History of or contact with:
- tuberculosis (TB), malaria, parasistic infections
- hepatitis B Virus (HBV), hepatitis C Virus (HCV), human immunodeficiency virus (HIV)
- sexually transmitted infections (STIs)
- respiratory symptoms, gastrointestinal symptoms, systemic/localising symptoms
- Immunisation history including:
- written documentation pre and post arrival
- Bacille Calmette Guerin (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 hospitalisations
- 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)
Practice tip: Individuals may not want to disclose their sexual history, but should still be offered STI screening confidentially and sensitively. Some concepts may need to be explained, such as sexual intercourse, sexual contact, sexually transmitted infections and risk i.e. unprotected sex. Be aware and sensitive to a history of sexual violence/abuse at all ages and genders. A useful approach may be: ‘People can get infections from having sex. Would you like testing for these infections?’ ‘Sometimes people are forced to have sex. You do not have to tell me details, but if this has happened I think you should have testing. There is lots of help available when you are ready’ ‘Anything we talk about is confidential and I cannot tell anyone, except if you or someone else might be at risk of serious harm. Interpreters are never allowed to tell anyone about consultations.’ Would you like to know more about your risk? Do you have any other questions about your sexual health?’ For more information about discussing sexual health and STIs with people from refugee backgrounds see Sexually Transmissible Infections.
Psychosocial history
For the mental health and social and emotional wellbeing component of the assessment:- Consider the family and household composition (i.e. support network and safety in the home)
- Assess settlement stressors – ask if the patient has any particular worries getting settled. Consider factors such as supports in Australia, housing difficulties, finances and current studies, separation from significant family members, past education and occupation and time spent in immigration detention
- Observe appearance, affect and behaviour
- Ask about sleep, appetite, energy, mood, anxiety symptoms, memory, concentration and relationships/family functioning
- For children/adolescents, in addition to all of the above, ask about behaviour, schooling, nightmares and enuresis (bed wetting).
Practice tip: A useful form of questioning might be: Terrible things have often happened to people who have been forced to leave their countries. I do not need to know the details about what you have been through, but have you had any experiences that might be affecting your health or how you are feeling now?
- When mental health concerns are evident, consider further mental health assessment including suicide risk assessment
- Continue to monitor for psychosocial problems as the presentation of these can often be delayed
- Consider recall for rescreening after 6–12 months for those who visit your service less frequently
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 anaemia – consider causes such as iron, B12 and folate deficiencies and lead toxicity among other causes
- Signs of other micronutrient deficiencies – e.g. dry eyes (vitamin A), skin (zinc, vitamin C, other), gums (vitamin C), lips/tongue (B-group vitamins, including B12), hair/nails (zinc, other), goitre (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
Screening investigations for conditions of high prevalence should be offered to all new patients according to their individualised risk as recommended by ASID & RHeaNA1,2 and the RACGP3 (see Table 1^) if not previously completed. Make sure that you have informed consent for all investigations and that you offer STI screening confidentially.4 The ASID/RHeaNA recommendations for commencing risk assessment of diabetes and CVD are earlier than those given by the RACGP in the Guidelines for preventative activities in general practice,3 and so have been included in Table 1. Complete all other recommended screenings as per the RACGP Guidelines. See Table 4 for further screening and management links. Additional investigations are determined by presenting symptoms.Table 1: Recommended initial screening investigations for people from refugee backgrounds1-3
| 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 |
Practice tip: Add recommended investigations, according to the countries of origin/transit commonly seen in your practice and other risks, to your pathology favourites in your computer software list. A summary table of country-based risk can also be printed. See ASID/RHeaNA country specific recommendations for malaria, schistosomiasis and hepatitis C screening. Practice tip: Under Medicare, there is an upper limit on the number of pathology services payable in a single episode requested by a GP. This is referred to as coning. If more than three items are requested, MBS will only pay for the three most expensive items. This may impact on the ability of some GPs to undertake post-arrival refugee screening. It is recommended individual GPs discuss this issue with their local pathology provider.
Management plan and referral
- Ensure all investigation results are discussed and their significance explained.
Practice tip: Provide opportunities for the patient to ask questions or seek clarification about results and management. Some patients will have come from cultures where this is not encouraged.
- After review of the history, examination and investigations, formulate a problem list. This may include:
- Clinical findings e.g. diagnoses, undiagnosed symptoms, positive test results
- Catch-up immunisation (all patients should be offered catch-up vaccines to the equivalent Australian age)
- Psychological and/or developmental concerns
- Settlement concerns
- Preventative health – complete screening as per RACGP Guidelines (see Table 4). Note that some investigations may be unfamiliar to people from refugee backgrounds and therefore require additional time for informed consent. Chronic disease risk factor management should be considered
- Provide a management plan for each problem, including referrals if required
Practice tip: Provide education about eHealth record. As people frequently move in the early settlement period, offer a patient-held record of the completed health assessment and vaccinations. Practice tip: Commence immunisation catch-up and register all vaccines (including offshore vaccines) on the Australian Immunisation Register (AIR) as soon as possible to avoid Centrelink implications (reduced family benefit payments). Once the first set of catch-up vaccines are on AIR, payments will be optimised and remain at this rate if catch-up is continued and completed.
- For a general approach to management, prescribing tips and referral see Approach to consultation and management, Prescribing tips, Tips for making referrals
- For an approach to management of investigation results see Tables 2 and 3
- For useful links for catch-up immunisation, further screening and management of other conditions see Table 4
- For further management of psychological concerns see Management of psychological effects of torture or other traumatic events, Torture or other traumatic events
- See Settlement support, State and territory referrals
Table 2: Management of infectious conditions1,2
| 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 | Exclude active TB infection** – if suspicion of active infection refer to TB servicesEnsure appropriate infection control precautions | Exclude active TB infection** – if suspicion of active infection refer to TB servicesEnsure 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 TG (gastrointestinal)5 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 |
| 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) | Check for eosinophiliaIf documented pre-departure albendazole therapy• No eosinophilia and no symptoms – no investigation or treatment required• Eosinophilia – perform stool microscopy for OCP followed by directed treatmentIf 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 parasitesTreat 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) | Check for eosinophiliaIf documented pre-departure albendazole therapy• No eosinophilia and no symptoms – no investigation or treatment required• Eosinophilia – perform stool microscopy for OCP followed by directed treatmentIf 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 parasitesTreat 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 |
Table 3: Management of non-infectious conditions1,2
| 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 |
Table 4: Useful links for 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 |
Considerations
- Consider other Medicare item numbers when planning further appointments with patients, e.g. care plans, case conferences, and mental health items
Resources
- MBS Health assessment for refugees and other humanitarian entrants
- 2018 Refugee Health Assessment template
- ASID and RHeaNA, 2016, Recommendations for comprehensive post-arrival health assessment for people from refugee-like backgrounds
References
- Chaves NJ, Paxton G, Biggs BA, Thambiran A, Smith M, Williams J, Gardiner J, Davis JS. Recommendations for comprehensive post-arrival health assessment for people from refugee-like backgrounds: Australasian Society for Infectious Diseases and Refugee Health Network of Australia; 2016.
- Chaves NJ, Paxton GA, Biggs BA, et al. The Australasian Society for Infectious Diseases and Refugee Health Network of Australia recommendations for health assessment for people from refugee-like backgrounds: an abridged outline. The Medical Journal of Australia. 2017;206(7):310-315.
- Royal Australian College of General Practitioners. Guidelines for preventive activities in general practice. 9 ed. East Melbourne: RACGP; 2016.
- Australasian Sexual Health Alliance. Australian STI Management Guidelines for use in primary care. 2016; www.stiguidelines.org.au.
- Gastrointestinal Expert Group. Gastrointestinal. Therapeutic Guidelines. Melbourne: Therapeutic Guidelines Limited; 2016.
