The refugee medical exam: What you need to do
Refugees arrive in this country with complex medical needs. Here’s how best to care for these patients during the initial medical examination, and beyond.
Although sustained domestic transmission is unlikely, these parasites may cause growth delay, anemia, hyperinfestation syndrome and disseminated infection (A lumbricoides and S stercoralis), and increased cancer risk (Schistosoma hematobium).7 In the late 1990s, the CDC initiated empiric treatment before departure for the United States for A lumbricoides (albendazole), S stercoralis (ivermectin), Schistosoma species (praziquantel), and other parasites in certain refugee populations, which has decreased but not eliminated the threat.7
All refugees should be receiving appropriate predeparture treatment for parasitic infections. For newly arrived refugees who have received no predeparture therapy or incomplete therapy, the CDC recommends screening for parasites or providing presumptive treatment (TABLE 2).
TABLE 2
Empiric treatment of parasites
| Refugee region of origin | Organism | Adult therapy |
|---|---|---|
| Middle East, South Asia, Southeast Asia | Strongyloides stercoralis Other roundworms | Ivermectin 200 μg/kg/d orally for 2 days Albendazole 400 mg orally, 1 dose |
| Africa | Schistosoma species S stercoralis Other roundworms | Praziquantel 20 mg/kg orally, 2 doses Ivermectin 200 μg/kg/d orally for 2 days Albendazole 400 mg orally, 1 dose |
| Source: CDC. Immigrant and Refugee Health: Domestic Intestinal Parasite Guidelines. Available at: https://www.cdc.gov/immigrantrefugeehealth/guidelines/domestic/intestinal-parasites-domestic.html. Accessed November 19, 2012. | ||
The optimal screening regimen for parasites in refugee populations is controversial. Although most screening programs rely on one or more microscopic examinations of stool for ova and parasites, this test is expensive, requires special handling, depends on the reviewer’s expertise, and remains relatively insensitive. A comprehensive review of stool ova and parasites in high-risk populations concluded that the use of 2 independently collected stool samples improved sensitivity at acceptable cost.30
New, more sensitive and specific assays have been developed for many parasites, including Cryptosporidium parvum, Entamoeba histolytica, G lamblia, S stercoralis, and Schistosoma species, but we do not recommend these specialized tests unless the provider strongly suspects a specific parasite based on history and physical exam or persistent eosinophilia.
All refugees should have a complete blood count with differential to help identify occult parasitemia. Although a finding of eosinophilia may result from successful empiric therapy for an already-treated parasite, it must be followed up with more specific testing for S stercoralis, even in otherwise asymptomatic patients. African refugees with eosinophilia also should be tested for Schistosoma, and Somali Bantu should be treated empirically for both S stercoralis and Schistosoma.31 In line with CDC guidelines, ongoing failure to identify the cause of eosinophilia in a refugee should prompt referral to an infectious disease specialist and further work-up.
Three to 6 months after antibiotic treatment of any parasite, immunocompromised patients and those with suspected treatment failure should undergo a test of cure comprised of 2 stool ova and parasite studies and a follow-up CBC with differential.32
Screen for HIV
Since January 4, 2010, after HIV was removed from the Class A diagnosis list, refugees are no longer tested for HIV before arrival in the United States.11 Nevertheless, we recommend screening all refugees on arrival, regardless of age, for HIV types 1 and 2, unless they opt out, for the following reasons:
- approximately 14% of incoming refugees arrive from countries with an HIV prevalence of more than 5%33
- the increasing use of rape as a tool of torture and repression puts refugees at particular risk for HIV
- current CDC guidelines recommend HIV screening at the time of first encounter in all health care settings for everyone from 13 to 64 years of age and any patient who requests it.34
We also strongly recommend repeat screening 3 to 6 months after resettlement for refugees with recent potential exposure or who engage in high-risk activity.
Watch for ubiquitous hepatitis infection
In accordance with CDC vaccination guidelines and American Association of Pediatrics (AAP) Bright Futures recommendations, we endorse hepatitis A serology testing with reflex vaccination unless immunity is documented for refugees 1 to 18 years of age.35,36
A third of the world’s population shows serologic evidence of past infection with hepatitis B virus (HBV); high rates occur in Southeast Asia and sub-Saharan Africa, where most infections are transmitted perinatally.37,38 A study of Minnesota refugees found 7% to be positive for hepatitis B surface antigen (HBsAg), with a higher prevalence among refugees from sub-Saharan Africa.8
Most screening protocols for refugees test for HBsAg and antibody to hepatitis B surface antigen (HBsAb); it is reasonable to add a screen for antibody to hepatitis B core antigen (HBcAb). We recommend screening for HBV infection using HBsAg, HBsAb, and HBcAb to minimize underdiagnosis in this high-risk population. Refugees without immunity to HBV should be offered vaccination.18 Encourage immunization, especially for patients with hepatitis or cirrhosis from any cause.
