INTRODUCTION — Over 250 million people live outside their country of birth. The patient's country of origin and travel history must be taken into account during medical assessment of immigrant and refugee populations. Among migrants, rates of certain infectious diseases (such as tuberculosis, human immunodeficiency virus [HIV], and hepatitis B) and noncommunicable diseases (eg, hemoglobinopathies/thalassemias) may differ from native-born individuals.
Components of the health assessment for immigrants and refugees include addressing patient health concerns, screening for infections and diseases associated with the country of origin and migration history, initiating age-appropriate immunizations, and routine health care maintenance. Guidance on a broad range of topics related to immigrant and refugee health in the United States is available from the United States Centers for Disease Control and Prevention [1]. (See "Overview of preventive care in adults".)
Issues related to health care for adult immigrants and refugees will be reviewed here; issues related to international adoption are discussed separately. (See "International adoption: Immunization considerations" and "International adoption: Infectious disease aspects".)
DEFINITIONS — A “migrant” refers to a person who moves away from their place of residence (either within a country or across an international border), either temporarily or permanently. Migrants who are forcibly displaced commonly fall into the following categories:
●Refugee – Someone who, "owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group, or political opinion, is outside the country of his nationality and is unable to or, owing to such fear, is unwilling to avail himself of the protection of that country" [2]. Refugees seek to establish their status as a refugee having fled their country of origin and while residing in a country of first asylum.
●Asylum seeker – An individual who has submitted a claim to a government for refugee status and is waiting for the claim to be accepted or rejected. Asylum seekers seek to establish their refugee status after fleeing to a country where they hope to be granted asylum.
●Asylee – An individual whose claim for refugee status has been granted.
●Parolee – An individual allowed into a country for urgent humanitarian reasons. Parole confers temporary status only; parolees must depart when the conditions supporting their parole cease to exist.
An “immigrant” refers to a person who moves to a new country with the purpose of permanently resettling in that country.
SCREENING PRIOR TO ARRIVAL — Refugees and immigrants to the United States undergo screening prior to arrival. Refugees receive the most thorough screening through an organized system that includes the Department of State, the International Organization for Migration, and the United States Centers for Disease Control and Prevention (CDC).
The predeparture medical examination and screening was initially developed to identify conditions of “public health significance” such as certain infections (eg, tuberculosis [TB], sexually transmitted diseases), illicit drug use, and severe psychiatric issues. Increasingly, the approach to this examination has broadened to include identification and management of conditions that may affect refugee health (either during the migration process or following arrival) [3]. In addition, the CDC expanded the predeparture immunization program and implemented a presumptive treatment program for refugees from areas with endemic tropical infections (such as malaria and soil-transmitted parasites) [4]. These examinations are conducted by “panel physicians” who follow instructions outlined and overseen by the CDC [5].
Other groups of migrants (such as visitors, short-term visa holders, and students) have no specific requirements; these individuals may or may not have health and immunization records. Undocumented migrants, including asylees, have no formal predeparture medical examination and screening but may have health and immunization records with them.
It is important for clinicians to clarify whether individuals have received any predeparture screening or treatment before arrival in the new country, since this will affect their care after arrival. Even migrants who have been in the new country for a long period of time before being seen in the medical system may need screening, particularly for diseases with long latency (such as hepatitis B, TB, schistosomiasis, and strongyloidiasis) [6]. In the absence of documentation, it should not be assumed that a screening test has been done or that a vaccine or presumptive treatment has been administered.
CLINICAL APPROACH
Health assessment — Clinicians should tailor guidelines for screening, diagnostic evaluation, and management to individual circumstances, including exposure history, symptoms and signs, and risk factors:
●The United States Centers for Disease Control and Prevention (CDC) has published guidelines for medical examination of newly arrived refugees, as well as a checklist that includes screening recommended for refugees arriving in the United States [7].
In addition, the CDC and the Centers for Excellence in Refugee Health have developed CareRef, a web-based tool which allows clinicians to obtain specific screening recommendations by entering information including country of birth, country of last residence, age, sex, and other variables such as presumptive treatment received.
●The Canadian Collaboration for Immigrant and Refugee Health has published guidelines for care of immigrants and refugee populations [8].
Establishing rapport and the first visit — Establishing rapport is critical for productive clinical encounters with recent migrants. Stressful factors for these patients include lack of familiarity with the health care system, language and cultural barriers, limited health literacy, and the possibility of prior emotional or physical trauma. Patients may be reluctant to discuss concerns due to fear that revealing health problems may affect their immigration status.
Health care providers in the arriving country may lack awareness and familiarity with the predeparture health interventions, the guidelines for postarrival screening, or best practices in migration health. In addition, providers may lack familiarity with illnesses seen more commonly in migrants, have difficulty with language and cultural barriers (including communication through an interpreter), and find it challenging to perform a significant workload of testing, immunization, and health maintenance activities in a limited amount of time.
Screening tests and immunizations need not be completed in the first visit. Completion of all the required elements will be facilitated by establishing a trusting relationship at the outset. Explaining what to expect and inquiring about immediate medical or social concerns will help facilitate establishment of rapport. Addressing immediate concerns at the first visit and repeating inquiries about general and family well-being at each subsequent visit reinforces empathy and compassion. Effective listening may elicit additional concerns not revealed initially.
Health history — Bilingual educational materials and use of bilingual/bicultural health educators should be used for patients who do not speak English. The health history should include standard elements such as current and prior medical problems, surgeries, pregnancies and their outcomes, medications (including complementary and alternative), allergies, and immunizations. Family history should also be elicited.
Mental health issues deserve special attention; many migrants have lost not only their homeland but also family members to disease, war, or forced separation. Many have experienced rape or torture or have been victimized during their migration, including by government or border officials; this information may not be offered in early interviews. Mental health screening should occur in the first or second visit and include assessment for suicide risk and other issues. (See 'Mental health screening' below.)
Social history should include inquiring about current living conditions as well as a thorough migration history, including regions of residence and travel. Migrants may spend many years en route, which may include time in remote, rural settings, urban areas, or in refugee camps, frequently in multiple countries. Other important components of the social history include formal education level, languages spoken including preferred spoken and written language for interacting with the health system, occupational history, and current support system.
Initial health encounters should also be used to address issues such as explaining how to navigate the local medical care delivery system, including the concept of primary care, access to after-hours care, and when and how to utilize emergency services. The concept of preventive care may be foreign and time should be devoted to making sure patients understand the importance of routine preventive care.
Physical examination — Vital signs and growth parameters (height, weight, and head circumference in young children) should be measured and compared with age- and sex-based norms. Migrants may be underweight or overweight, nutritional deficiencies may be more prevalent, and chronic conditions such as hypertension and diabetes may have gone undiagnosed. Assessment of vision and hearing is important, as deficiencies can affect work/school performance, job placement, and general quality of life. Dental caries and other dental problems are common and should be addressed early, along with education provided about ongoing oral hygiene and dental care.
A complete physical examination should be performed, although if there are no acute issues, genital exams may be deferred to a follow-up appointment. Special attention should be paid to findings that may reflect previously undiagnosed medical conditions, traditional cultural practices, or signs of prior abuse or torture. For example, skin lesions may reflect parasitic infection, traditional healing methods (scarification) or female genital mutilation, or retained shrapnel related to trauma. Hepatosplenomegaly may be present in patients with hyperreactive malaria syndrome or schistosomiasis. Heart murmurs may be present in patients with conditions ranging from anemia to undiagnosed congenital heart disease (eg, tetralogy of Fallot) and valvular disease, and signs of heart failure may be appreciated in patients with rheumatic heart disease or Chagas disease. Genital examination may reveal findings more common in refugees, including female genital cutting or hydrocele from filariasis. (See 'Additional pearls' below.)
Immunizations — Assessment for completion of primary immunizations and immunity to vaccine-preventable diseases, when appropriate, should be undertaken. Immunization records may be considered valid if they include the name of the vaccine and the month and year of administration and if the schedule reflects the recommended timing as outlined in the schedules published by the CDC. As an example, a measles-containing vaccine (eg, measles-mumps-rubella [MMR]) would not be considered valid if administered before one year of age.
The optimal approach to serologic testing for immunity to vaccine-preventable diseases is uncertain but varies with likelihood of previous vaccination or infection. For example, serologic testing may be appropriate for varicella and hepatitis A because of high population prevalence. Testing for immunity to hepatitis B should be done in conjunction with testing for hepatitis B infection [9,10]. Serologic testing for measles, mumps, and rubella may be done at the discretion of the provider; alternatively, MMR vaccine may be administered. Most favor administration of other routine vaccines without preliminary serologic testing [11].
Issues related to immunizations are summarized in the figures (figure 1 and figure 2 and figure 3 and figure 4) and discussed separately. (See "Standard immunizations for nonpregnant adults" and "Standard immunizations for children and adolescents: Overview".)
Issues related to immunizations for children adopted internationally are discussed separately. (See "International adoption: Immunization considerations".)
Infectious disease screening
Tuberculosis — Immigrants from regions where tuberculosis (TB) is endemic should undergo screening for active and latent TB infection (LTBI) (table 1). The CDC has published guidelines for TB screening in newly arrived refugees [12]; diagnosis of TB is also discussed further separately. (See "Diagnosis of pulmonary tuberculosis in adults" and "Tuberculosis infection (latent tuberculosis) in adults: Approach to diagnosis (screening)".)
Testing for LTBI should be performed regardless of time since immigration, since TB disease may present years after exposure [13]. In one study, 59 percent of foreign-born individuals diagnosed with active TB had resided in the United States for more than five years, 15 percent had been in the United States for less than one year, and 18 percent between one and four years [14].
Testing for LTBI is usually done by interferon-gamma release assay (IGRA), although tuberculin skin test (TST) is still acceptable. IGRA or TST testing should be done at the time of live vaccine administration or deferred until at least four weeks after the last dose of the live vaccine. For diagnosis of LTBI in patients with a history of Bacille Calmette-Guérin vaccination, IGRA is preferred over TST. (See "Tuberculosis infection (latent tuberculosis) in adults: Approach to diagnosis (screening)" and "Latent tuberculosis infection in children".)
Interpretation of the TST depends on the patient's risk factors for TB. A TST of ≥5 mm is considered positive for individuals with HIV infection, other immunocompromising conditions, history of exposure to TB disease, and those with signs of TB on chest radiograph; a TST of ≥10 mm is considered positive in all other categories of migrants.
Patients with a positive TST or IGRA should undergo chest radiography and assessment for signs of active TB. In the absence of active disease, treatment for LTBI should be administered. (See "Treatment of tuberculosis infection in nonpregnant adults without HIV infection" and "Diagnosis of pulmonary tuberculosis in adults".)
HIV — Migrants should undergo routine screening for HIV with a combination assay that detects HIV antigen and antibodies as outlined in sexually transmitted diseases (STDs) below (algorithm 1). (See "Acute and early HIV infection: Clinical manifestations and diagnosis".)
Hepatitis — The CDC has published guidelines for hepatitis screening among newly arrived refugees [15].
Hepatitis A — Some migrants, particularly those who are older and coming from resource-limited settings, have had infection with hepatitis A as children. Younger migrants may not have had hepatitis A as children due to improvements in sanitation in many countries. Screening for active infection is not recommended in asymptomatic individuals. Screening for immunity may be cost effective for certain groups, such as older children and adults, those who have a history of hepatitis, or those who are candidates for routine immunization or who would otherwise require immunization (such as in the setting of travel or infection due to hepatitis B or C) [16-18]. Children should receive immunization against hepatitis A according to current recommendations. (See "Hepatitis A virus infection: Treatment and prevention", section on 'Protection prior to exposure'.)
Hepatitis B — Hepatitis B screening is warranted for the following individuals, regardless of their history of hepatitis B vaccination and the duration in the United States [19,20]:
●Migrants from countries where the prevalence of hepatitis B infection (at the time of birth) was ≥2 percent
●Individuals born in the United States whose parents were born in countries with hepatitis B virus endemicity >8 percent and who were not vaccinated as infants
●Individuals in the United States whose mothers were infected with hepatitis B (or had unknown infection status) at the time of delivery and who did not received vaccine plus hepatitis B immune globulin at birth
Increasingly, refugees are receiving predeparture hepatitis B screening prior to arrival; results may be available at the initial medical examination in the arriving country.
Tests used for hepatitis B screening include hepatitis B surface antigen, surface antibody, and core antibody. Interpretation of hepatitis B serologies is summarized in the table (table 2) and is discussed further separately. (See "Hepatitis B virus: Screening and diagnosis" and "Hepatitis B virus: Overview of management".)
Individuals living in the household of those with hepatitis B infection should also be offered screening and immunization [18]. Horizontal transmission of hepatitis B has been documented in family units. Hepatitis B–infected individuals should be evaluated for treatment, given vaccination against hepatitis A if not already immune, and, if not eligible or have failed treatment, should have routine screening for early detection of hepatocellular carcinoma; this is discussed further separately. (See "Surveillance for hepatocellular carcinoma in adults", section on 'Our approach to surveillance'.)
Hepatitis C — The United States Preventive Services Task Force recommends one-time hepatitis C screening for all adults ≥18 years and all pregnant patients during every pregnancy [21]; this is an appropriate recommendation for refugees and other migrants. The approach to screening is discussed further separately. (See "Screening and diagnosis of chronic hepatitis C virus infection".)
Screening for hepatitis C should also be done, or may need to be repeated, for individuals with identified risk factors such as history of blood transfusions, injection drug use, or needle-sharing practices such as tattooing or acupuncture [21].
There is little generalizable data on the epidemiology of hepatitis C virus infection in refugee populations. Prevalence rates vary among refugee groups from very low (<1 percent) to high (7 to 8 percent); further study is needed [22]. Two refugee groups of particular interest are Burmese refugees and Hmong refugees born in Thailand, with a hepatitis C virus prevalence of approximately 7 percent [22], and Somali refugees, who have a high prevalence of hepatocellular carcinoma related to hepatitis B virus and hepatitis C virus [23]. Hepatitis C rates are also high in certain other migrant groups, including migrants from Egypt (13 percent prevalence) [24] and Pakistan (6.2 percent prevalence) [25].
Sexually transmitted diseases — The CDC has published guidelines for STD screening among newly arrived refugees [26].
Screening for STDs includes a thorough medical history, physical examination, and laboratory testing. The history should include inquiry regarding sexual partner(s) with known or suspected STDs, active symptoms of current infection (genital discharge, dysuria, genital lesion, or rash), and prior history of STD or sexual trauma. Physical examination should include lymph node palpation and genital examination. (See "Screening for sexually transmitted infections".)
Laboratory testing to be considered should include:
●HIV testing in all persons >12 years and including those ≤12 years if risk factors or maternal history is unknown. Routine prearrival screening of migrants for HIV in the United States was discontinued in 2010.
●Screening for syphilis (rapid plasma reagin [RPR] or Venereal Disease Research Laboratory [VDRL] or equivalent test) in patients ≥15 years of age and at younger ages based on risk factors, signs, or symptoms. Confirmatory testing (fluorescent treponemal antibody [FTA], treponema pallidum particle agglutination assay [TPPA], or enzyme-linked immunosorbent assay [ELISA]) should be performed for all patients with positive RPR or VDRL.
●Screening/testing for chlamydia (nucleic acid amplification test) in women ≤25 years of age, women with new sexual partner or multiple sexual partners, or patients with symptoms or leukocyte esterase on urine dipstick
●Screening/testing for gonorrhea (nucleic acid amplification test) in patients with symptoms or leukocyte esterase on urine dipstick
Screening is also appropriate for individuals with a history of rape or sexual assault. Individuals with signs or symptoms of an STD should receive comprehensive STD testing. Additional infections to be considered include chancroid, granuloma inguinale/donovanosis, lymphogranuloma venereum, genital herpes, genital warts, and trichomoniasis.
Parasitic infections — The CDC has published guidelines for management of intestinal parasites among refugees overseas and/or after arrival [27,28]; these are summarized in the table (table 3). These guidelines are based on prevalence data in refugee populations and should only be extrapolated to populations with similar risk factors.
Most refugees arriving in the United States have received predeparture antiparasitic treatment. Other migrants usually have received neither screening nor treatment for intestinal parasites. At-risk asymptomatic migrants from high-endemicity settings who did not receive antiparasitic treatment (or received incomplete antiparasitic treatment) before departure may either undergo screening or receive presumptive treatment if they are seen within six months of arrival. Asymptomatic migrants should receive either presumptive treatment or testing for Strongyloides regardless of their duration in the United States if they will undergo immunosuppression. (See 'Strongyloidiasis' below.)
Migrants with ongoing signs or symptoms of infection, including an unexplained elevated eosinophil count, should have diagnostic testing performed even if exposure is remote. Testing should include stool studies for ova and parasites and serology for strongyloides; additional testing should be tailored to epidemiologic exposure, and may include serologies for filaria, trichinella, and/or schistosomes (along with urine sediment for schistosomes). (See "Approach to the patient with unexplained eosinophilia".)
Helminths — Screening or administration of albendazole for empiric treatment of soil-transmitted helminths may be appropriate for asymptomatic at-risk individuals following arrival from the following regions, if treatment was not administered before migration: Asia, the Middle East, Africa, Latin America, and the Caribbean (table 3) [27]. Stool screening is preferred over presumptive treatment for infants <12 months of age and may be deferred until after delivery for pregnant patients. Pregnant patients should not be treated presumptively with albendazole.
Presumptive treatment for soil-transmitted helminths before migration has been shown to reduce the prevalence of parasitic infection and cost of care in refugees resettled from selected countries [29,30].
Strongyloidiasis — Screening or administration of ivermectin for treatment of strongyloidiasis is appropriate for asymptomatic individuals following arrival from the following regions if treatment was not administered before migration: Asia, the Middle East, North Africa, sub-Saharan Africa (non-Loa loa-endemic areas) (table 4), Latin America, and the Caribbean [27,31].
Screening for strongyloidiasis consists of serologic testing; stool ova and parasite examination may be used, but its sensitivity is limited. (See "Strongyloidiasis".)
Among patients from L. loa-endemic areas (table 4), ivermectin should be administered only if L. loa microfilaria has been ruled out. Screening for L. loa microfilaria consists of a thick blood smear done between 10 am and 2 pm. (See "Loiasis (Loa loa infection)", section on 'Diagnosis'.)
Administration of presumptive treatment for strongyloidiasis is not appropriate for pregnant patients or for children <15 kg.
It is particularly important that patients from endemic areas undergo presumptive treatment for Strongyloides before anticipated immunosuppression (such as corticosteroids or other immune modulators) to minimize the likelihood of developing disseminated disease or hyperinfection. In general, this consists of ivermectin unless patients are from a L. loa-endemic area, in which case albendazole may be used. (See "Strongyloidiasis".)
Schistosomiasis — Screening or administration of praziquantel for empiric treatment of schistosomiasis is appropriate for asymptomatic individuals following arrival from highly endemic areas of sub-Saharan Africa, including pregnant patients and children >4 years of age, if treatment was not administered before migration (table 3) [27].
Screening for schistosomiasis consists of serology. Stool and urine examination may be used, but sensitivity is limited. (See "Schistosomiasis: Diagnosis".)
Malaria — The CDC has published guidelines for management of malaria among refugees [32].
Presumptive treatment or laboratory testing for Plasmodium falciparum malaria is appropriate if fever or history of recent fever is present or if there is unexplained anemia, thrombocytopenia, or splenomegaly; it can be considered for asymptomatic individuals seen within three months of migrating from highly endemic areas of sub-Saharan Africa (if treatment was not administered before migration). For high-risk individuals from areas that are highly endemic for malaria (where persons may be infected but asymptomatic), presumptive treatment is preferred given the cumbersome process for screening, which consists of three blood films at 12- to 24-hour intervals. The sensitivity of rapid diagnostic testing for diagnosis of asymptomatic malaria in newly arrived refugees is limited and this test should not be used alone for screening [33]. Presumptive therapy consists of atovaquone-proguanil or artemether-lumefantrine as summarized in the table (table 5).
High-risk pregnant patients in their first trimester and children <5 kg should undergo laboratory testing and receive directed treatment if infection is detected; presumptive treatment should not be used in these groups.
The likelihood of subclinical P. falciparum malaria is rare among asymptomatic individuals from Southeast Asia, South Asia, Central Asia, parts of East Africa (eg, central Nairobi), and all areas in the Western Hemisphere; neither presumptive treatment nor laboratory screening is warranted for these individuals under normal circumstances. Similarly, neither presumptive treatment nor laboratory screening is warranted routinely for non-falciparum malaria in asymptomatic immigrants from any region at this time.
Chagas disease — Approximately 1 to 2 percent of Latin American immigrants living in the United States are infected with Trypanosoma cruzi; more than 300,000 individuals and about 40,000 women of childbearing age are at risk for sequelae of this infection [34,35]. Indications for Chagas screening are outlined separately. (See "Chagas disease: Epidemiology, screening, and prevention", section on 'Screening for chagas disease in nonendemic clinical and community settings'.)
Migrants with symptoms of Chagas present during the chronic phase of infection, with cardiac or gastrointestinal signs and symptoms. Cardiac complications include cardiomyopathy, heart failure, altered heart rate and rhythm (particularly right bundle branch block and/or left anterior fascicular block), apical aneurysm and thrombus development, and sudden cardiac arrest. Intestinal complications include an enlarged esophagus or colon (megaesophagus/megacolon) which can lead to dysphagia, abdominal pain, or constipation. Screening programs have been effective in identifying asymptomatic infected individuals in order to facilitate early diagnosis, prevent development of sequelae, and prevent vertical transmission of infection to infants [36,37].
Issues related to Chagas disease are discussed further separately. (See "Chronic Chagas cardiomyopathy: Clinical manifestations and diagnosis" and "Chagas gastrointestinal disease".)
Other infections — A number of other infections not commonly seen in the arriving country may affect migrants:
●Other parasitic infections:
•Filariasis (see "Lymphatic filariasis: Epidemiology, clinical manifestations, and diagnosis")
•Loiasis (see "Loiasis (Loa loa infection)")
•Onchocerciasis (see "Onchocerciasis")
•Giardiasis (see "Giardiasis: Epidemiology, clinical manifestations, and diagnosis")
•Amebiasis (see "Intestinal Entamoeba histolytica amebiasis" and "Extraintestinal Entamoeba histolytica amebiasis")
•Tapeworm infection (see "Tapeworm infections" and "Echinococcosis: Clinical manifestations and diagnosis" and "Cysticercosis: Clinical manifestations and diagnosis")
●Other chronic bacterial infections (such as melioidosis, leprosy) (see "Melioidosis: Epidemiology, clinical manifestations, and diagnosis" and "Leprosy: Epidemiology, microbiology, clinical manifestations, and diagnosis")
●Fungal infections (such as African histoplasmosis, Madura foot, paracoccidioidomycosis) (see "Diagnosis and treatment of pulmonary histoplasmosis" and "Eumycetoma" and "Clinical manifestations and diagnosis of chronic paracoccidioidomycosis")
●Viral infections (such as human T cell leukemia virus type 1) (see "Human T-lymphotropic virus type I: Disease associations, diagnosis, and treatment")
●Conditions that can masquerade as chronic infection (such as podoconiosis) (see "Clinical features and diagnosis of peripheral lymphedema", section on 'Other causes')
General screening
Blood count — A complete blood count (CBC) with differential is useful for identification of anemia, macrocytosis, microcytosis, and/or eosinophilia; these findings may indicate nutritional deficiencies, hemoglobinopathy, or parasitic infection. CBC results may be used in conjunction with other findings to help identify other health problems (such as lymphopenia in a patient with risk for HIV infection, anemia, and microcytosis in a patient with extremity pain suggestive of sickle cell disease, or thrombocytopenia and anemia together with fever suggestive of malaria).
Eosinophilia can be a marker for parasitic infection [38]; the approach to evaluation is discussed separately. (See "Approach to the patient with unexplained eosinophilia".)
Lead screening — The CDC has published screening recommendations for lead during the domestic medical examination for newly arrived refugees. Migrants may be at risk of lead exposure due to increased levels of lead in the soil in the native country. In addition, migrants may settle in areas of the country with older housing stock leading to risk of exposure after arrival. A baseline lead level can be useful to evaluate subsequent trends.
Screening for lead is warranted following arrival and can be repeated three to six months later; this is particularly important for children between 6 months and 16 years of age and is also useful for pregnant patients [39]. The approach to screening and management of lead poisoning is discussed further separately. (See "Screening tests in children and adolescents", section on 'Lead poisoning'.)
Micronutrient screening — Deficiencies in vitamin B12 and vitamin D have been observed with high prevalence among some immigrant groups [40-43].
As an example, vitamin B12 deficiency has been observed with high prevalence among Bhutanese Nepali and Iraqi refugees. There is no consensus on universal screening for vitamin B12 deficiency; given the potential for long-term neurologic sequelae, some favor providing multivitamins with B12 to newly arriving migrants.
Vitamin D deficiency is extremely prevalent in migrant populations [44] and screening is appropriate; testing or empiric supplementation is warranted for individuals with compatible signs or symptoms of deficiency, including rickets, osteopenia, poor growth, or motor delay. Some favor screening or vitamin supplementation for vitamin D in most groups of migrants.
Mental health screening — There is a high prevalence of mental health issues best documented in refugees, particularly those arriving from areas of civil unrest; these include major depression, anxiety, and posttraumatic stress disorder [45]. The process of migration is stressful and may predispose most migrant groups to mental health conditions. Mental health assessment includes a detailed social and psychiatric history; this may be difficult to achieve in the initial visit but is important.
Assessing mental health is challenging and made even more difficult by language barriers, perceptions and conceptions of mental illness in other cultures, and lack of standardized screening instruments for different populations. The process of relocation may reflect a planned move for economic and educational pursuits or an unwanted, unanticipated move for refugees and asylum seekers. Discussing the individual’s reasons for resettlement can allow greater understanding of stresses faced in the country of origin and along the migration route.
Refugees may have experienced loss of family members, personal health, and security. Many are victims of rape, torture, famine, or nutritional deprivation [45,46]. It is important to identify and provide support to individuals whose mental health issues interfere with their ability to engage in activities of daily living, pursue employment, or attend school.
Initial screening can be limited to questions to identify those with serious mental illness and risk for suicide. Subsequently, as rapport is established and depending on interventions available, a formal mental health assessment can be performed using a screening tool [46,47]. Screening for sexual trauma in women may inform ongoing care [48,49].
Cancer screening — Types of cancer vary by geographic location and other exposures. For example, in many resource-limited countries, cervical and lung cancer are the leading causes of cancer deaths among women and men, respectively [50]. Cancers related to infectious diseases occur more commonly in migrant populations including cervical (human papillomavirus [HPV] infection), gastric (Helicobacter pylori), and hepatocellular cancer (hepatitis B).
Exposures to specific agents such as betel nut predispose certain populations to head and neck cancers, and nasopharyngeal cancer is more common in patients of southern Chinese origin. Adults should undergo routine screening and preventive medicine as described separately. (See "Screening for cervical cancer in resource-rich settings" and "Overview of preventive care in adults", section on 'Cancer screening'.)
Migrants should be asked if their reported age is accurate, as their stated age is often incorrect, sometimes by many years. Inaccurate age will lead to inappropriate or missed health screenings for recommendations based on age. In addition, women beyond the usual screening age for pap smears need normal results (with cotesting for HPV) before ending screening.
Many migrants have never had routine health screening and the concept may be foreign; additional effort to explain the rationale for screening and preventive care may be required.
Chronic disease screening — Migrants should receive screening for chronic diseases including hypertension, diabetes, and hypercholesterolemia. The first few visits are also an opportunity to stress the importance of maintaining a normal body mass index, reviewing diet, and discussing the importance of exercise. Screening for tobacco and substance use is helpful as these present risks for chronic disease. Referral for dental care is also important. (See "Overview of preventive care in adults".)
Additional pearls — It is useful to consider global health issues that can cause chronic infection among migrants. Examples include (see relevant topics):
●Eosinophilia may reflect parasitic infection such as strongyloidiasis, filariasis, or schistosomiasis.
●Hematuria, female infertility, or chronic pelvic pain may reflect schistosomiasis.
●Splenomegaly is common in certain groups (ie, Congolese) and may reflect hyperreactive malaria syndrome, schistosomiasis or other infections, or a combination of infections.
●Chronic rash or itching may reflect scabies, mycetoma, leishmaniasis, onchocerciasis, and other filarial worms [51].
●Heart failure or esophageal motility disorders may reflect Chagas disease.
●Seizures or other central nervous system symptoms may reflect neurocysticercosis.
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Health care for immigrants and refugees".)
SUMMARY
●The United States Centers for Disease Control and Prevention (CDC) has published guidelines for medical examination of newly arrived refugees, as well as a checklist that includes screening recommended for refugees arriving in the United States. Recommendations for immigrant groups other than refugees are derived from these guidelines. (See 'Health assessment' above.)
●CareRef is a tool that allows clinicians to obtain more specific screening recommendations for specific refugees by entering information including country of birth, country of last residence, age, sex, and other variables such as presumptive treatment received. This may be a useful tool for other migrant groups with similar risk profiles and epidemiologic risks as refugees. (See 'Health assessment' above.)
●An assessment for completion of primary immunizations and immunity to vaccine-preventable diseases should be undertaken. Issues related to immunizations for adults and children are discussed further separately. (See "Standard immunizations for nonpregnant adults" and "International adoption: Immunization considerations".)
●Immigrants from areas with higher prevalence of tuberculosis (TB) should undergo screening for active and latent TB infection (LTBI). (See 'Tuberculosis' above.)
●Immigrants from countries where the prevalence of hepatitis B infection is ≥2 percent and their children (irrespective of country of birth) should undergo routine screening for infection, regardless of vaccination status or duration they have resided in the United States. The CDC has published guidelines and helpful information about hepatitis screening and vaccination among newly arrived refugees. (See 'Hepatitis B' above.)
●The United States Preventive Services Task Force now recommends one-time screening for hepatitis C for all adults aged 18 and older and repeated screening in those at risk. This is an appropriate recommendation for migrants. (See 'Hepatitis C' above.)
●Sexually transmitted disease (STD) assessment includes a thorough medical history, physical examination, and laboratory testing. STDs to be considered include syphilis, chlamydia, gonorrhea, chancroid, granuloma inguinale/donovanosis, lymphogranuloma venereum, genital herpes, genital warts, and trichomoniasis. (See 'Sexually transmitted diseases' above.)
●Guidelines for management of intestinal parasites among refugees overseas and/or after arrival are summarized in the table (table 3). Important infections include helminth infections, strongyloidiasis, and schistosomiasis. (See 'Parasitic infections' above.)
●Guidelines for management of malaria among refugees include presumptive treatment or laboratory screening for Plasmodium falciparum malaria among asymptomatic individuals following arrival from highly endemic sub-Saharan African regions, if treatment was not administered before migration (table 5). (See 'Malaria' above.)
●General screening includes blood count and assessment for lead exposure, micronutrient deficiency, mental health, and screening for chronic diseases including malignancy, hypertension, and hypercholesterolemia. (See 'General screening' above.)
