Background

Immigration medical examination

All permanent entrants to Australia (including skilled, family and humanitarian stream migrants) have an immigration medical examination (IME) prior to travel. The IME is used to assess whether an individual meets the health requirement of the Migration Act (1958). The purpose of the health requirement is to:

• protect the Australian community from public health and safety risks, particularly active tuberculosis (TB)
• contain public expenditure on health and community services, including social security benefits, allowances and pensions
• safeguard the access of Australian citizens and permanent residents to health care and community services in short supply.

In order to meet the health requirement, individuals must be free of health conditions that are:

• considered to be a threat to public health or a danger to the Australian community
• likely to result in significant health care and community service costs to the Australian community
• likely to require health care and community services that would limit the access of Australian citizens and permanent residents to services that are in short supply. 
  

Individuals who are found to have active TB have their visa application deferred ('Deferral' - see below) - they must complete treatment prior to visa allocation and travel, and sign a health undertaking (to ensure follow up in Australia - see below). Certain visas have provisions for health waivers - including all humanitarian visas; the health waiver for humanitarian entrants has been in place since 2012.

The IME is completed by  panel physicians for the main applicant, their spouse and any members of the family unit. In certain circumstances, non-migrating family members are also assessed against the health requirement.  See details of the health assessment, and Instructions for Panel doctors (July 2018) (technical instructions). Onshore applicants for permanent visas also undergo an IME (through BUPA Medical Visa Services).

Departure health checks

Departure health checks (DHC) for humanitarian entrants were introduced in 2005, in response to increased numbers of people from African source countries presenting with malaria soon after arrival. The departure health check is an additional (offshore) voluntary health assessment for humanitarian entrants occurring around 72 hrs prior to travel, to assess and treat acute health issues and confirm fitness to fly. Initially DHC were used in African ports of departure and for 200 (refugee) visa holders, the DHC was then rolled out to other ports of departure, and for all humanitarian entrants - see fact sheet.

The DHC includes: physical examination, malaria rapid diagnostic test and treatment if positive (endemic areas), chest x-ray (if history of TB, clinical indication or HIV positive), albendazole treatment (aged 1 yr and older), measles-mumps-rubella (MMR) vaccine (age 9 months to 54 years), +/- yellow fever vaccine (area dependent) +/- polio vaccine (area dependent), and other assessment as indicated. The DHC is also used to assess whether 'potential health alerts' are classified as 'critical health alerts' (see below).

For the Syrian/Iraqi intake, the IME and DHC were combined, also including additional developmental and mental health screening. 

Health undertakings

The IME (or the DHC) may generate a health undertaking (HU) - which is an agreement between an individual who has been granted a visa and the Australian government) for the person to follow-up with a health authority after arrival in Australia. The vast majority of HU are for follow-up of TB, and are referred to State/Territory TB services. BUPA manage HU and also deferrals. In Victoria, all TB HU are referred to the Migrant Health Service in Footscray, who then refer HU for children to the RCH TB service. Other reasons for HU include hepatitis B, hepatitis C, and HIV. People with active TB disease cannot be granted a HU, their visa application is deferred until they have completed treatment.

Deferrals

Deferrals are used for visa applicants where concerns have been raised about a medical condition (usually active TB). They apply to individuals who are still in the visa process (i.e. who have not yet had a visa granted). Deferrals for active TB are legislated under the Migration Regulations 1994 (active TB precludes the grant of a visa). This process applies to both offshore and onshore visa applicants. 

Follow-up of health undertakings and deferrals

BUPA manage HU and also deferrals; information on completed HU can be returned to BUPA on fax 03 9642 5379 or email CentralOperations@bpmvs.com.au. Phone contact for clinicians (Mon-Fri - 0800 -1700) is 03 9937 3995. 

Health alerts

Offshore IME and DHC may also generate health alerts for humanitarian entrants - the purpose of health alerts is to ensure individuals with serious medical conditions are linked with appropriate medical services on arrival in Australia. Health alerts are generated in the DHA HAP system, and then managed by the Humanitarian Settlement Program (HSP) system (also now DHA again, previously Department of Social Services from 2013 - mid-2019).

The health alert system changed in late 2017 - there are two types of health alerts in the HSP system:

• Potential medical issue - generated if the IME identifies a serious medical condition that may require immediate medical follow-up after arrival in Australia. This alert is generated at the time of the IME (which is prior to visa allocation).
• Critical medical issue - generated if the DHC identifies a serious medical condition that requires immediate medical follow-up after arrival in Australia. This can either be confirmation of the 'potential medical issues' as a critical issue, or in relation to a new issue. By this stage, individuals have been allocated a visa, location of settlement, and a HSP in Australia. People with critical health alerts may be accompanied by a health escort (either nursing or medical), and HSP providers are required to ensure medical follow-up within 24-72 hrs of arrival.

In clinical practice we have seen gaps in the health alert process, although there is often information indicating serious medical issues in the HAPlite system. Possible reasons for this situation include:

• Gaps between the DHA HAP and HSP systems
• Deterioration between the IME and travel, or
• Health conditions that have not been identified/flagged in the offshore assessment
  
• Individuals not having a DHC (meaning potential alerts are not categorised as critical health alerts) noting that DHC are voluntary. 

Feedback can be provided to the DHA on health@homeaffairs.gov.au (including feedback on health conditions not identified on the IME). Also see fact sheet on HSP process (Feb 2018).           

HAPlite

The Department of Home Affairs (DHA) uses a system called the Health Assessment Portal (HAP) to record IME and manage health undertakings (see fact sheet). The HAP is an electronic health record that can include images, radiology, and background documents, as well as the IME. HAPlite is a subset of the HAP system, that can be accessed by registered health providers - it has been available to State/Territory TB services since 2015, and for refugee health services since 2017. See HAPlite  access request form - note - our understanding is that system administrators cannot access clinical information.

Providers need to know an individual's HAP identification number to look up their HAPlite health information - HAP numbers can be obtained from HSP providers. HSP providers know individuals HAP identification number, but do not have access to the HAPlite system, they are directed to pass on the HAP identification number to health providers. As far as we can establish, HSP providers use a separate HSP number to look up the HAP number. Contact details for HSP providers are listed below. 

Prior to 2018, humanitarian entrants had a (paper) copy of their offshore health assessment. From mid-2018, only critical alerts have paper-based information, otherwise all health information is in the HAPlite system.

Tip sheets for HAPlite

• Frequently asked questions - HAP for refugee clinics and general practitioners
• Clinic administration for HAPlite
• Creating an account to access HAPlite
• Log in to HAPlite
• Search and view health case in HAPlite (Note: additional suggestion added - how to print the full report in one step).

Contacts for HSP providers (to obtain HAP numbers)

• See - Service provider locations - and previous DSS fact sheet with contact details
• Victorian contacts (AMES) - ask for the intake case coordinator, who will be able to look up the individual in the HSP system:
  • Dallas
  • Footscray
  • Noble Park
  • Other (not all of these sites handle settlement services).
    

In practice, there have been challenges accessing the HAP identification numbers - If there are issues accessing health information, feedback can be provided to the DHA on health@homeaffairs.gov.au.  

Complex medical issues - specialised case management

Humanitarian arrivals (offshore), and also people with permanent protection visa or temporary protection visas who have complex health issues can be referred for specialised and intensive case support through the HSP program - see information and referral form.

_{Immigrant health clinic resources. Author: Georgie Paxton, August 2018, updated January 2020. Contact: georgia.paxton@rch.org.au}