Lucan · Conditions

Refugee health screening

Australian guidance: ASID Refugee Health Screening Guidelines (2nd ed)

1. Definition and epidemiology

Refugee health screening refers to the comprehensive post-arrival health assessment offered to people from refugee-like backgrounds, including those who arrived on humanitarian visas, asylum seekers, and others who may have lived in refugee-like circumstances prior to arrival in Australia. Australia accepts approximately 13,750 refugees annually through the offshore Humanitarian Programme, with this figure increasing to 18,750 by 2018-19. The population seeking assessment has shifted over time, with greater proportions now arriving from the Middle East and Asia compared with earlier cohorts that were predominantly from Sub-Saharan Africa, reflecting the changing demographics of global displacement.

2. Pathophysiology

There is no single pathophysiological mechanism underlying refugee health screening, as the condition category spans multiple infectious and non-infectious diseases. The elevated disease burden in people from refugee-like backgrounds arises from a convergence of factors: prolonged exposure to overcrowded and unsanitary living conditions in camps or transit countries, food insecurity producing micronutrient deficiencies (iron, vitamin D, vitamin B12), disruption of immunisation schedules, high background prevalence of communicable diseases in source countries, and limited access to preventive healthcare during displacement. Trauma and psychosocial adversity compound physical illness through neuroimmune and stress-axis pathways, increasing susceptibility to both infectious diseases and non-communicable diseases. Pre-migration Immigration Medical Examinations (IMEs) provide only partial coverage and do not eliminate post-arrival disease burden, meaning that clinicians must apply a systematic, organ-based and risk-stratified framework at first contact in Australia.

3. Clinical presentation and diagnostic criteria

People from refugee-like backgrounds present to Australian GPs and refugee health services without a classical single presenting complaint. The clinical encounter requires active case-finding rather than waiting for symptomatic self-referral. History should capture country of origin, transit countries, time spent in detention, visa subclass, pre-departure health checks completed, immunisation documentation (written records or Bacille Calmette-Guerin scar), and current psychosocial stressors including housing, financial stress and employment. Examination should be systematic: assess weight, height, body mass index and blood pressure; examine skin including hair, nails and BCG scar; inspect oropharynx and ears for dental caries and middle ear disease; palpate for cervical, axillary and inguinal lymphadenopathy; assess for hepatosplenomegaly; and document visual acuity. Mental and emotional wellbeing assessment is a mandatory component. The guideline specifically cautions against directly asking about torture or trauma in early consultations; a sensitive indirect approach is preferred. ASID recommends the full health assessment be offered within one month of arrival.

4. Investigations and AU-specific cutoffs

Investigations are divided into universal (offered to all) and risk-based or country-based tiers.

Universal for all: - Full blood examination (FBE): eosinophilia greater than 0.6 x 10 to the power of 9 per litre warrants investigation for intestinal parasites, strongyloides and schistosomiasis - Hepatitis B serology: HBsAg, HBsAb and HBcAb; annotate request as "query chronic hepatitis B" - Strongyloides serology - HIV serology in those aged 15 years and older (or in unaccompanied minors, or where clinically indicated in younger children) - Tuberculin Skin Test (TST) or Interferon Gamma Release Assay (IGRA) for latent tuberculosis infection (LTBI): offer to all aged 35 years and under; TST is preferred over IGRA in children under 5 years; positive TST is induration of 10mm or more in recent immigrants from high-prevalence countries, or 5mm or more in the setting of severe malnutrition, HIV or immunosuppression - Varicella serology in those aged 14 years and older with no documented history of infection - Rubella serology in women of childbearing age

Risk-based: - Ferritin (women, children, men with risk factors): treat if less than 15 micrograms per litre in adults - Vitamin D (25-hydroxy vitamin D) in those with risk factors (dark skin, limited sun exposure, covering clothing): treat if below 50 nmol per litre; also check calcium, phosphate and alkaline phosphatase in children - Serum active vitamin B12 (holotranscobalamin) in those arriving within 6 months with food insecurity or vegan diet: treat if below 35 pmol per litre - NAAT for gonorrhoea and chlamydia (self-collected low vaginal swab or first-pass urine) and syphilis serology in those with known or suspected risk factors - Helicobacter pylori stool antigen or breath test in those with family history of gastric cancer or upper gastrointestinal symptoms - Stool microscopy for ova, cysts and parasites where no documented pre-departure albendazole or persistent eosinophilia after albendazole treatment

Country-based: - Schistosoma serology: for people from endemic countries (including Burma, Congo, Eritrea, Somalia, Sudan, Iraq, India, Syria and others per Table 1.4 of the guideline) - Malaria thick and thin blood films plus rapid diagnostic test: for people who have travelled through endemic malaria areas within 3 months of arrival if asymptomatic, or within 12 months if febrile - Hepatitis C antibody: for people from regions with prevalence 3% or greater (including Egypt, Iraq, Pakistan, Congo) or with other risk factors

Medicare Items 701, 703, 705 and 707 cover the refugee health assessment for eligible visa subclasses within 12 months of arrival. Note that pathology coning applies: Medicare will only pay for the three most expensive items in a single episode, so GPs should discuss batching strategy with their pathology provider.

5. Management

The overarching principle is person-centred care delivered with a professional interpreter; family members must never serve as interpreters. The Commonwealth Telephone Interpreter Service (TIS) provides free access on 1300 131 450.

Positive results trigger the following pathways:

Hepatitis B surface antigen positive: arrange clinical assessment, abdominal ultrasound and liver function tests; vaccinate non-immune household contacts and sexual partners; test and vaccinate against hepatitis A.

HIV positive: refer to local HIV care provider.

Positive TST or IGRA: refer to specialist TB services for chest x-ray and consideration of LTBI preventive therapy; active TB must be excluded before treatment is commenced.

Schistosoma serology positive or equivocal: treat with praziquantel 20 mg per kg twice daily 4 hours apart (total 40 mg per kg, no upper limit); perform stool microscopy for ova; dipstick for haematuria and if positive send end-urine microscopy collected between 10am and 2pm.

Strongyloides serology positive or equivocal: perform stool microscopy; treat with ivermectin 200 micrograms per kg on day 1 and day 14 for those weighing 15 kg or more; refer pregnant women and children under 15 kg to a specialist.

Eosinophilia with no pre-departure albendazole: treat intestinal helminths with albendazole for 3 days (400 mg for adults and children 10 kg or more); Giardia lamblia with tinidazole 2 g single dose (adults) or metronidazole 2 g daily for 3 days; recheck eosinophils and stool microscopy at 8 weeks.

Catch-up immunisation should be offered to bring the individual to equivalent immunisation status as an Australian-born person of the same age, guided by the Australian Immunisation Handbook. Pregnancy must be excluded before administering live vaccines including measles-mumps-rubella and varicella.

Non-communicable disease screening should follow standard Australian guidelines (RACGP Red Book), but may be initiated earlier if individual risk factors are present.

6. Pharmacology and AU PBS notes

Isoniazid for LTBI preventive therapy: 10 mg per kg daily up to 300 mg, given for 6 to 9 months (pregnancy category A). Pyridoxine 6.25 to 25 mg daily by age (not per kg) is co-prescribed to prevent peripheral neuropathy in malnourished patients. Shorter rifamycin-containing regimens are also effective (pregnancy category C). PBS criteria for isoniazid apply; prescribers should confirm current PBS listing.

Praziquantel for schistosomiasis is listed on the PBS for treatment of schistosomiasis.

Ivermectin for strongyloidiasis: 200 micrograms per kg on day 1 and 14 (PBS listed for strongyloidiasis; prescribe as Stromectol).

Albendazole for intestinal helminths: 200 mg for children 6 months to less than 10 kg; 400 mg for children 10 kg and over and for adults, given for 3 days (except Ascaris which requires single-dose 400 mg); PBS listed.

Iron supplementation: treat ferritin below 15 micrograms per litre with oral iron preparations (ferrous sulfate or ferrous gluconate available on PBS without streamlined authority for iron deficiency anaemia).

Vitamin D supplementation: treat 25-hydroxy vitamin D below 50 nmol per litre with cholecalciferol (vitamin D3); high-dose loading regimens or daily dosing according to severity; PBS listed.

Chlamydia: azithromycin 1 g orally as a single dose (PBS listed; brand Zithromax or generic); or doxycycline 100 mg orally twice daily for 7 days.

Gonorrhoea: ceftriaxone 500 mg intramuscular in 2 mL of 1% lignocaine plus azithromycin 1 g orally.

7. Complications and monitoring

Untreated LTBI carries a lifetime risk of progression to active tuberculosis of 5 to 10%, rising to 17% in immigrant children under 5 years and near 100% in untreated HIV infection. Patients on isoniazid require monitoring for hepatotoxicity; baseline liver function tests are mandatory before commencing treatment, with periodic repeat if abnormal at baseline. An asymptomatic rise in liver enzymes occurs in 10 to 20% and does not always require cessation, but patients must be counselled to stop the drug and seek urgent review if they develop jaundice, dark urine, pale stools, persistent nausea or abdominal discomfort.

Chronic hepatitis B requires regular surveillance with liver function tests, hepatitis B viral load, AFP and abdominal ultrasound every 6 to 12 months depending on viral activity and fibrosis stage, given the substantially elevated risk of hepatocellular carcinoma in chronic HBV.

Post-treatment follow-up for schistosomiasis and strongyloidiasis should include a repeat FBE and stool microscopy at 8 weeks to confirm eosinophil resolution; persistent eosinophilia requires further specialist evaluation.

Mental health conditions identified at or after screening warrant ongoing longitudinal support. Formal validated instruments (Kessler Psychological Distress Scale, Strengths and Difficulties Questionnaire in children, HEADSS in adolescents) can guide referral to psychology, psychiatry or specialist refugee mental health services. Cultural and gender considerations govern the timing and framing of trauma enquiry across the follow-up period.

Developmental delay and hearing impairment in children should be identified early and referred to paediatric services, given the long-term consequences for education and integration.

Written for Australian practice and grounded in the guidance named above. Study material only — not medical advice. Always check against current guidelines.