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.
Hepatitis C screening should follow CDC guidelines for the general population, focusing on high-risk groups such as injection drug users, victims of sexual violence, people with multiple sexual partners, recipients of blood transfusions, people with any other type of hepatitis, and one-time screening for individuals born between 1945 and 1965.39,40
Monitor for malaria
Many refugees come to the United States from areas where malaria is endemic.41 In 2007, the CDC instituted empiric treatment before arrival in the United States for all refugees from sub-Saharan Africa because the rapid test for malaria approved by the US Food and Drug Administration has low sensitivity and specificity,2 malarial vectors are present throughout much of the United States, and malaria (specifically Plasmodium falciparum) causes significant morbidity and mortality. If written confirmation of predeparture treatment is not available, refugees from sub-Saharan Africa should receive presumptive treatment, outlined in TABLE 3,42 as part of the initial DRME.
TABLE 3
Presumptive postarrival malaria treatment for refugees from sub-Saharan Africa42
| Directly observed treatment received in country of origin? | Recommended treatment* | |
|---|---|---|
| Children | Adults | |
| Yes | None | None |
| No | Atovaquone-proguanil (62.5/25 mg): 5-8 kg: 2 tablets per day for 3 days 9-10 kg: 3 tablets per day for 3 days Atovaquone-proguanil (250/100 mg): 11-20 kg: 1 tablet per day for 3 days 21-30 kg: 2 tablets per day for 3 days 31-40 kg: 3 tablets per day for 3 days >40 kg: 4 tablets per day for 3 days | Atovaquone-proguanil (250/100 mg): 4 tablets per day for 3 days |
| *Do not presumptively treat pregnant or lactating women or children weighing <5 kg. An infectious disease consult is recommended for these patients. | ||
Based on our experience and expert opinion, we recommend routinely monitoring all refugees from endemic areas for symptoms of malarial disease during the initial 3 months after resettlement. Relapsing fevers, unexplained malaise or fatigue, pallor, thrombocytopenia, or splenomegaly should trigger additional testing with thick- and thin-blood smears for trophozoites (3 separate samples drawn at 12- to 24-hour intervals).
Be alert for malnutrition
Acute and chronic malnutrition, as well as micronutrient deficiencies, have been noted in refugees coming from refugee camps. A survey of Bhutanese refugees in a camp in Nepal found that 25.1% of children were underweight and 4.8% of them were severely underweight. Moreover, 43.3% of children had anemia.43 Recognizing that refugees may be at high risk for iron deficiency, we recommend evaluating children and adolescents for this deficit according to AAP guidelines.44
We also recommend screening body mass index (BMI) to identify refugees at risk. Height, weight, and BMI must be followed over time to ensure appropriate acclimation to the US diet.
Also consider vitamin D deficiency and rickets in refugee populations, particularly people with darker skin and women who wear veils.45,46 Based on our experiences and CDC guidelines, we recommend a multivitamin with iron for children 6 to 59 months of age.12
Check lead levels in children
Refugee children are at risk of elevated blood lead levels (>10 ’g/dL) resulting from pre-departure environmental exposure and iron deficiency anemia, which can enhance absorption of lead. Refugees also are more likely to resettle in poor neighborhoods with substandard housing, increasing their risk of domestic lead exposure.
Studies of refugee children at initial screening have shown prevalences of elevated blood lead levels of 6.3% in a Cuban refugee population in Miami and higher rates (11%-22%) in mixed refugee populations in Massachusetts.6,47 A study in New Hampshire found that approximately 30% of refugee children with normal lead levels on initial screen had elevated levels when checked several months later.48
Consistent with CDC guidelines,49 our experience, and the findings of the State of Minnesota,50 we recommend checking blood lead levels in all children 6 months to 16 years of age upon arrival in the United States and repeat lead testing 3 to 6 months after placement in a permanent residence.
Bring vaccinations up to date
US law requires anyone seeking an immigrant visa to show proof of vaccination against vaccine-preventable diseases, as recommended by the US Advisory Committee on Immunization Practices.51 Vaccination requirements that apply to other immigrant groups do not apply to refugees at the time of their initial admission to the United States, but refugees must be vaccinated when they seek a green card or permanent US residence.
All refugees are eligible for adjustment of status after they have lived in the United States for a year and need proof of vaccination to apply.51 Moreover, schools may bar refugee children from attending if their vaccinations are not up-to-date, which, in turn, may hinder their parents’ ability to find employment. CDC guidelines for vaccinating immigrants and refugees applying for permanent residence are available at https://www.cdc.gov/immigrantrefugeehealth/pdf/2009-vaccination-technical-instructions.pdf (see the table on page 12).52 Because of the large number of vaccinations required for children and even many adults, health care providers should be familiar with the CDC’s recommended immunization and catch-up schedules.35
