Post-Arrival Medical Screening of Newly Arrived Refugees, Immigrants, and Migrants

Introduction

Ideally, a new arrival medical evaluation for people in refugee, immigrant, and migrant (RIM) communities should occur shortly after arrival to the United States. A new arrival medical evaluation is made up of medical screening for communicable and non-communicable diseases, a medical and migration history, a physical examination, immunizations, and establishing care with a primary care medical home. Screening for diseases specific to country of origin, migration route, and individual epidemiologic risk is important. No standard guidelines are available for post-arrival screening of immigrants or migrants for the United States; however, this chapter provides an approach, with evidence-based guidance largely informed by data from refugee populations. An interactive clinical assessment tool, Clinical Assessment for Refugees (CareRef), customizes screening guidance for refugees based on their age, sex, and country of origin.

Because there are RIM population-based differences in access to and coverage for medical services, healthcare professionals should carefully evaluate the individual patient's health coverage, social determinants of health, infection and disease risk based on their history, and availability of treatment or intervention for conditions identified. These factors will influence the scale and scope of the screening encounter.

For definitions of terms related to RIM populations and to better understand the pre-arrival experience of people in RIM communities, see Pre-Arrival Medical Screening and Interventions for Newly Arrived Refugees, Immigrants, and Migrants chapter.

Medical evaluation

Healthcare professionals should follow best practices in the clinical approach to RIM patients (e.g., language access, addressing social determinants of health, male/female concordance; see Health Communication with Refugee, Immigrant, and Migrant Communities chapter). Information about country of birth and migration route is important; a guide called "Ask Where" is available for primary healthcare professionals to ask questions about where people they provide care for were born. The initial medical evaluation is an important place to: learn about the individual's medical, migration, and family history; review medications and treatments received before and during migration; and review immunization records. The comprehensive physical examination confirms existing diagnoses and provides the opportunity to identify other conditions, including scarring from cultural health practices or trauma. The history and physical examination will determine if additional evaluation or testing are needed. General age- and risk-based preventive guidelines provided by the United States Preventive Services Task Force (USPSTF) for the general U.S. population apply to foreign-born individuals as well as those born in the United States unless alternative evidence-based guidance exists.

Communicable diseases

Solicitation of symptoms (e.g., cough) and examination for signs (e.g., skin lesions) of infectious disease are important parts of the initial medical examination. Many infections, such as malaria, leishmaniasis, lice, scabies, leprosy, and upper respiratory infections, can be detected through a history and physical examination.

Infections with long latency (e.g., Chagas disease, cysticercosis, hepatitis B, HIV, strongyloidiasis, schistosomiasis, tuberculosis [TB]) are important causes of morbidity and mortality in RIM populations and should be addressed regardless of the duration of time the individual has been in the United States. Most refugees arriving through the U.S. Refugee Admissions Program receive presumptive treatment for soil-transmitted helminths with albendazole, Strongyloides with ivermectin (in non-Loa loa-endemic areas), and, for those from Sub-Saharan Africa, schistosomiasis (praziquantel) and malaria (artemether-lumefantrine); some may have had screening and/or treatment for other diseases. Non-refugee populations do not receive this pre-departure treatment. Presumptive treatment or laboratory testing is encouraged for non-refugee populations and for refugees who have lived in, or migrated through, highly endemic areas who did not receive presumptive treatment before arrival. Additional diagnostic testing for parasitic diseases is appropriate for people who present with symptoms (e.g., fever, splenomegaly, eosinophilia, diarrhea) of parasitic diseases which may have been acquired in the country of origin or along the migration route. Although routine screening is not currently recommended, due to a high prevalence of Helicobacter pylori gastritis in RIM populations in the United States, there should be a low threshold for evaluation when symptomatic following criteria outlined by the American College of Gastroenterology.

Hepatitis B is the most common chronic viral hepatitis in RIM populations and is the leading risk factor for hepatocarcinoma. All individuals should have at least one documented negative screening test for infection (e.g., hepatitis B surface antigen test) regardless of vaccine status. Hepatitis C rates are variable in RIM groups; testing is recommended for all adults ≥18 and children with risk factors (e.g., blood transfusion, history of surgery, or mother with hepatitis C) and in groups with known high prevalence rates.

Testing for sexually transmitted infections in adolescents and adults is recommended in accordance with the USPSTF and refugee domestic screening guidance. Screening infants or children for sexually transmitted or congenital infections (e.g., chlamydia, gonorrhea, hepatitis B, hepatitis C, HIV, syphilis) beyond what is recommended for the U.S. general population may be appropriate if the person's social or migration history places them at risk for sexual trauma or other risk factors for infection.

Non-communicable diseases

Certain RIM populations are disproportionately affected by chronic diseases, such as hypertension, diabetes, and cardiovascular disease, compared to the general U.S. population. Many individuals will have no symptoms on initial evaluation and may have limited access to family history, making physical examination and screening tests particularly important. Abnormal basic physical examination findings and vital signs can identify elevated blood pressure or other signs of cardiopulmonary disease. General recommended laboratory screening includes a complete blood count with differential which can reveal anemia, hemoglobinopathy, eosinophilia, thrombocytopenia, or blood dyscrasia (see Post-Travel Parasitic Disease Including Evaluation of Eosinophilia chapter). Some RIM populations have a higher risk of diabetes compared to non-refugee matched controls. A random blood sugar, fasting blood sugar, or hemoglobin A1C should be considered for: (1) individuals 35–70 years old who are overweight or obese; or (2) individuals of any age who are overweight or obese with risk factors. A non-fasting lipid panel is an appropriate baseline screen for cardiovascular disease for individuals 40–75 years old with one or more cardiovascular risk factors, including hypertension, smoking, or other conditions.

Children should have routine anthropometric measurement performed at their medical evaluation. Findings of acute malnutrition or stunting should trigger additional review and consideration for diagnostic testing, including assessment for infectious diseases, thyroid disease, hemoglobinopathies, congenital heart disease, and conditions causing feeding difficulties such as cerebral palsy. Additionally, anthropometrics may identify children who are overweight or obese upon arrival. Routine newborn screening is not available in most of the world, and healthcare professionals should be alert for conditions, such as hypothyroidism, that may not have been diagnosed at birth as they would have for children in the United States. Therefore, consider sending a newborn screening panel for children <1 years old (this should be discussed with the state testing lab) and thyroid screening for children <6 years old due to global prevalence of iodine deficiency and subtlety of thyroid disease. RIM communities are disproportionately exposed to lead, both pre-arrival and after arriving to the United States. Pregnant and lactating women and children should be screened for elevated lead levels.

See Table 9.2.1 for a summary of screening tests to consider for medical evaluation of foreign-born individuals.

Table 9.2.1: Recommended laboratory testing for medical evaluation of people in refugee, immigrant, and migrant communities

Vaccinations

Immunization records provided by patients can be considered valid if the month and year of the vaccine are documented and the vaccine was given at an appropriate age according to the U.S. vaccination schedule. Age-appropriate and catch-up immunizations can be provided according to Advisory Committee on Immunization Practices' immunization schedules during initial and subsequent encounters with newly arrived individuals. A vaccine series does not need to be restarted if documentation of prior doses is available and shows the series was given according to the U.S. vaccination schedule.

Serologic testing to document immunity to vaccine-preventable diseases is an acceptable alternative to immunization in specific circumstances. Choice of testing or immunization involves factors such as availability of appropriate test, likelihood of previous infection or immunization, relative cost of test and vaccine, likelihood that the patient will return for vaccine if needed, and preference of provider and patient.

Mental health and developmental screening

Mental health screening includes gathering information about coping strategies and support systems and creating an opportunity for appropriate and timely referral to resources. It is important to perform a brief mental health screening during the initial medical evaluation to determine need for acute intervention. More thorough testing should only be done when there is care available for conditions identified. The Refugee Health Screener-15, a linguistically and culturally validated tool in certain groups, may be used for assessment of emotional distress for anyone aged 14 years or older as long as follow-up care and treatment are available for conditions identified. CDC's Refugee Health Domestic Guidance includes a section on mental and behavioral health screening that provides additional tools for mental health screening in adults. The guidance also describes mental health screening in children and explains there is no "gold standard." The guidance for children recommends focusing on symptoms and functional impairment as well as conducting a developmental assessment for children under the age of 5 years. Developmental assessments can be conducted in the primary care office using the Survey of Wellbeing of Young Children, an open-access tool available in 16 languages, or consider other tools shared in the Refugee Health Domestic Guidance. Health professionals may elect to delay mental and developmental screening until a subsequent second visit as they develop a relationship and build trust with the patient and family.

Future travel

RIM populations are likely to travel back to their country of origin and are the highest-risk population for many travel-associated infectious diseases (see Visiting Friends and Relatives: VFR Travel chapter). Patients should be counseled that if they plan to travel "home," that preexisting immunity to some diseases may have waned and they should see a healthcare professional prior to travel. When seeing RIM patients in the clinic, the healthcare professional should routinely ask about future travel plans to alert patients to the need for pre-travel medical preparation and to allow time to plan appropriate travel vaccines, medications, and advice (see The Pre-Travel Consultation chapter).

Internationally adopted children

The Red Book: Report of the Committee on Infectious Diseases, published by the American Academy of Pediatrics, and the American Academy of Pediatrics Policy Statement on Caring for the Newly Adopted Child, offers guidance to pediatricians and other healthcare professionals who will serve newly adopted children after their arrival to the United States.

Access to care

Refugees qualify for medical benefits through Refugee Medical Assistance and state Medicaid programs. Non-refugee immigrant communities will have varying access to medical coverage depending on the state where they reside. In some states, people who migrated to the United States may be ineligible for any public programs (e.g., Medicaid; Medicare; Women, Infants, and Children [WIC] Program) for a prolonged period after arrival and dependent on their legal status. Healthcare professionals should consider a patient's health coverage, social determinants, infectious and other disease risk based on history, and individual patient needs when determining the feasibility of individual elements of the new arrival medical evaluation.

Acknowledgements

The following authors contributed to the previous version of this chapter: Elizabeth D. Barnett, Jenna Beeler, Tarissa Mitchell, and Joanna Regan.