An approach to refugee health assessment
Invited contribution by:
Dr Aesen Thambiran, Medical Director Humanitarian Entrant Health Service and Dr Veronica Hoad Public Health Registrar, North Metropolitan Public Health Unit
In 2010-2011, 2,248 humanitarian entrants (refugees) settled in Western Australia (WA), representing 6.7% of permanent migrants to WA that year.1 While few in number, refugees and asylum seekers may have significant health issues including communicable diseases, nutritional deficiencies, under-diagnosed medical conditions, reproductive conditions, poor oral health and the consequences of trauma, both physical and psychological.
Specifically for infectious diseases, the Commonwealth Government requires that refugees being considered for migration to Australia undergo a limited health assessment before being issued with a humanitarian entrant visa.
For those aged 15 years and over, this only involves screening for human immunodeficiency virus (HIV) and active tuberculosis. Therefore, it is essential that screening for infectious diseases and other issues is undertaken as part of a comprehensive health assessment soon after arrival in Australia
The Australian Society for Infectious Diseases (ASID) recommends that all refugees be offered a comprehensive health assessment after arriving in Australia.2 Most refugees settling in WA are referred to the Humanitarian Entrant Health Service (HEHS), administered by the North Metropolitan Health Service's Public Health and Ambulatory Care, for a voluntary health check. However, some refugees may choose to immediately join friends and family in rural areas and present to their local GP for a health check.
Conducting a comprehensive refugee health assessment may be a daunting experience for Australian GPs unfamiliar with the conditions prevalent in refugee populations. The health consultation may be challenging for both the doctor and patient due to likely differences in the parties' understanding of the medical system, cultural beliefs about illness and expectations of treatment.3 This article outlines an approach that primary care practitioners can take in assessing the health of newly arrived refugees.
Obtaining a history
Refugees are not an homogenous group and will come from a variety of cultural, social and occupational backgrounds. Asking the patient about his or her educational attainment prior to migration will help to determine their level of literacy and health literacy. This will assist you in tailoring health advice and education. Your patient may turn out to have been a health professional in their own country.
Communication is the cornerstone of a good refugee health assessment. It is imperative to use a professional interpreter when seeing a patient who does not speak English. The Commonwealth funds the Telephone Interpreter Service, which is free to GPs. Using friends and family to interpret is inadvisable from a clinical and legal perspective. Errors made by untrained interpreters may result in adverse outcomes.
Obtaining the patient's family history is important and can offer important clues about inherited conditions, such as sickle cell anaemia or exposure to tuberculosis or hepatitis B. It is also useful to ask about his or her family unit because this may reveal that family members are missing or dead due to conflict. In women, obtaining an obstetric history is very important. Women from Africa and South East Asia may have experienced post-partum haemorrhage, multiple pregnancy and neonatal losses as well as losing older children to disease, malnutrition and war. Women from East and West Africa may have also experienced female genital mutilation.
Communicable diseases are common in refugee populations. The prevalence of these varies depending on the patient's country of birth and the countries through which they have travelled to reach Australia.4 Therefore, it is important to take an accurate history of the patient's journey to determine risk of exposure to disease.
New refugee arrivals are unlikely to have active tuberculosis disease due to stringent pre-migration screening. About a third, however, will have latent tuberculosis infection. The ASID guidelines recommend that all refugees be screened for tuberculosis.2 While mantoux testing is still considered the gold standard, it may be more practical to request an Interferon-Gamma Release Assay (IGRA), such as Quantiferon Gold, on patients under the age of 35. Those who screen positive should be referred to the WA Tuberculosis Control Program. In WA, those over the age of 35 are generally not screened with an IGRA because they are unlikely to be offered preventative therapy due to the potential for adverse drug reactions.
Refugees from sub-Saharan Africa and South East Asia should be screened for schistomiasis (serology) and malaria (thick and thins films and P.falciparum antigen test). People who have lived in rural areas, refugee camps and other areas with poor sanitation should have strongyloides serology checked.
Sexually transmitted infections
Recent data from the HEHS showed that prevalence estimates for chlamydia and gonorrhoea in the WA refugee population were considerably lower than in known high-risk populations in Australia.5 In a total of 2610 refugees over 15 years of age screened during the period 2006 to 2009, the prevalence of chlamydia was found to be only 0.8%, and no gonorrhoea infections were detected. It is recommended that all sexually active adults up to 39 years be screened for gonorrhoea and chlamydia, taking into account an appropriate sexual history, but otherwise following guidelines for the general population.6
Syphilis is prevalent in some parts of Africa and Asia and serologic testing for treponemal infection should be offered to all clients, with an intention to treat all those with positive results where there is no documented history of prior treatment.2
The ASID guidelines recommend that all refugees be screened for HIV, hepatitis B and hepatitis C, which should include HIV antigen/antibody, HBcAb, HBsAg, HBsAb, and HCV antibody.2 While all refugees are screened for HIV as part of their initial visa application, some could seroconvert or be infected after their visa is granted. Hepatitis B and C are common in many parts of Africa and Asia and are leading causes of hepatocellular carcinoma in those regions. A recent study in WA highlighted the increasing burden of chronic hepatitis B in people from endemic countries being referred to Royal Perth Hospital hepatology clinic. 7
A dietary history should be taken of all patients and especially in families with children. Refugees may have experienced malnutrition and food insecurity prior to migration and may need education about healthy eating in Australia. All patients should have their iron and vitamin D levels checked. Adults should have their body mass index calculated and children should have their height and weight plotted on World Health Organization growth charts.
Assessing mental health is another important aspect of the refugee health screen. While some refugees experience post-traumatic stress disorder, other mental health conditions are also common, including anxiety and depression.3 Once in Australia, these symptoms may be exacerbated by detention, social isolation, loss of peer and family supports, language barriers and unemployment.4 At HEHS, all adults are screened using the Kessler Psychological Distress Scale (K10). This is a simple and easy mental health assessment tool commonly used in primary care. Where indicated, clients are referred to the Association for Survivors of Torture and Trauma Survivors (ASeTTs) for trauma counselling.
A thorough physical examination is important and may reveal hypertension, cardiac murmurs, perforated tympanic membranes, cataracts and thyroid enlargement. Inspection of the skin should not be overlooked because children from the tropics may have fungal skin and scalp infections. Some people from the Middle East and Central Asia may have indurated skin ulceration due to cutaneous leishmaniansis, a parasitic disease caused by Leishmania species and transmitted by sandfly bites.
The immunisation status of all refugees should be checked. Most children born in refugee camps will have had primary courses of measles-mumps-rubella (MMR) and polio vaccines provided in the camps. Their parents will usually have their immunisation cards with them. It is often older children and adults who are under-immunised. In the absence of reliable records, it is often necessary to rely on the patient's memory or knowledge about the public health programs in their countries. On occasion, an individual's catch-up immunisation needs to be commenced from scratch.
Linking in with other mainstream preventative health services
Finally, it is important to ensure that all new arrivals are linked in with other mainstream preventative health strategies like cervical cancer screening and breast cancer screening.
Further information about refugee health screening can be downloaded from the HEHS web site
- DIAC. Population Flows 2010-2011. 2012; Available from the Department of Immigration and Citizenship website.
- Murray, R.J., et al., The Australasian Society for Infectious Diseases guidelines for the diagnosis, management and prevention of infections in recently arrived refugees: an abridged outline. Med J Aust, 2009. 190(8): p. 421–5.
- Benson, J. and M. Smith, Early health assessment of refugees. Australian Family Physician, 2007. 36(1/2): p. 41–3.
- Harris, M. and N. Zwar, Refugee health. Aust Fam Physician, 2005. 34(10): p. 825–9.
- Hoad V and Thambiran A. Evaluating the chlamydia and gonorrhoea screening program in the Humanitarian Entrant Health Service, Western Australia. Med J Aust, 2012;197 (1): 47–49.
- Sexual Health Society of Victoria. National management guidelines for sexually transmissible infections. Melbourne: SHSOV, 2008. http://mshc.org.au/Portals/6/NMGFSTI.pdf.
- Subramaniam, K., et al., Hepatitis B status in migrants and refugees: increasing health burden in Western Australia. Intern Med J, 2012. 42(8): p. 880–6