Updated offshore health screening
As of early 2023, there have been updates to offshore Immigration Medical exam (IME) screening for humanitarian (and other) entrants. These are outlined in the updated January 2023 DHA Panel Members Instructions and we are starting to see these in practice on the HAPlite system. Changes include:
- New Hepatitis BsAg screening in all refugee entrants 15 years and older
- New Hepatitis C screening in all refugee entrants 15 years and older
- Latent tuberculosis treatment in household contacts aged <5 years (i.e. young household contacts of active TB cases)
- Improved vaccination records - including past vaccines and more comprehensive vaccination as part of the offshore IME and departure health check.
- Excellent functional assessments - really useful for people with disability
- New layout on the HAPlite system
- New changes are being implemented for pre-emptive treatment of parasite infections in the offshore process (adjustments to albendazole age/dosing, and introduction of ivermectin and praziquantel for some ports of departure)
These updates have implications for onshore screening - noted in red *** below - please also see the detail on offshore assessments below.
Health issues
Refugee or asylum seeker children and adolescents will have typical paediatric health problems, and may also have health issues specific to their background or forced migration experience. Common paediatric problems, e.g. iron deficiency anaemia, may have a more complicated aetiology in refugee children. All refugees and asylum seekers should have a full health assessment after arrival in Australia, ideally within one month of arrival.
Assessment of newly arrived refugee or asylum seeker children and adolescents should focus on:
Children and adolescents need a thorough physical examination. Particular features to note include: growth parameters, nutritional status, anaemia, rickets, oral health assessment, ENT disease, visual acuity, presence of a BCG scar (forearm, deltoid, other, either side), respiratory examination and lymphadenopathy, hepatosplenomegaly and skin (scars, infections).
Suggested initial post-arrival screening investigations
Screening (e.g. neonatal screening, visual and hearing assessment) may have been limited or unavailable in the country of origin, and prior access to healthcare, dental care and education varies. It is important to explain the concepts of health assessment, screening and disease prevention. Families need to understand the implications of health screening and give informed consent; this means explaining all tests, the conditions being tested, the meaning of a positive test, and the next step in management. Individual counselling and an explanation of confidentiality are required in adolescents.
The following list includes suggested first-line investigations, additional investigations may be needed depending on the clinical scenario.
All children and adolescents
- Full blood examination/film
- Ferritin
- Hepatitis B serology - surface antigen (HBsAg), surface antibody (HBsAb) and core antibody (HBcAb) - *** therefore HBsAg not required if completed & negative result offshore, reasonable to vaccinate without cAb/sAb, check serology in household contacts
- Strongyloides serology*
- Tuberculosis (TB) screening - tuberculin skin test (TST) or interferon gamma release assay (IGRA). TST is preferred in children
<5y and should be used in children <2y. *** If recent (3-6m) negative IGRA 5y and older completed offshore, and no exposure history reasonable to use this result, low threshold to repeat.
- Faecal specimen - ova, cysts, parasites* (OCP, ideally fixed to improve detection of protozoa), depending on pre-arrival albendazole, and eosinophilia
- If documented pre-departure albendazole:
- No eosinophilia - no investigations
- Eosinophilia - OCP and directed treatment
- If no documented pre-departure albendazole:
- Empiric single dose albendazole (>6m,
<10kg 200 mg; 10 kg+ 400 mg). If baseline eosinophilia repeat FBE at 8 weeks, and if persisting, OCP and directed treatment OR
- OCP and directed treatment, repeat FBE and OCP at 8 weeks.
*Not Ukraine
Age-based or risk-based screening
- Vitamin D, calcium, phosphate, ALP - if risk factors for low vitamin D, see summary of
Medicare guidelines for vitamin D testing)
- Serum active vitamin B12 & folate all Afghan arrivals, arrival
<6m and any of food insecurity, vegan, Bhutan, Iran, Horn of Africa) - also homocysteine, urine methylmalonic acid if risk low B12 and disability/neurological symptoms
- Malaria screen (rapid diagnostic test (RDT) and thick/thin film) - if arrival date
<3m from endemic area, or later if symptoms. Endemic - Africa (except Egypt), Burma, Bhutan, India, Pakistan, Afghanistan - not Middle East/Ukraine/Sri Lanka - *** not required if well and completed and negative ofshore
- Hepatitis C serology (Hepatitis C virus (HCV) antibodies) - if from
endemic area or if risk factors. Endemic - Congo, Egypt, Iraq, Pakistan, consider in Syria/Ukraine - not other African/Middle Eastern or Asian countries *** therefore HCV not required if completed offshore and negative result
- Schistosoma serology - travel from/through
endemic area. Endemic - Africa, Burma, Iraq and Syria - not Middle Eastern/Asian countries, Afghanistan, Ukraine
- Varicella serology - age 14y and older if no history clinical varicella infection and no previous varicella vaccination - ***also reasonable to vaccinate without serology
- Rubella serology - females childbearing age - consider in late adolescence, ***although not needed if catch-up vaccination in place
- STI screen - N. gonorrhoea and C. trachomatis urine nucleic acid detection, syphilis serology (note: also HIV, hepatitis B) in sexually active adolescents, or if there is a history of sexual violence/abuse
- Syphilis screening - all unaccompanied or separated children; children should also be screened for syphilis if their mother has positive serology
- HIV testing - age 15y and older,
<15y if unaccompanied or separated minor, or clinical risk factors (sexually active, history of sexual violence/abuse, where parents are deceased/missing/known to be HIV positive, other STIs, history of blood transfusions, tuberculosis, hepatitis, or where there are clinical symptoms/signs)
- Helicobacter pylori screening (faecal antigen test on fresh specimen) in children with family history gastric cancer, or symptoms/signs dyspepsia/ulcer disease.
Additional investigations to consider
- Additional investigations for malaria and other infections in recently arrived children who are febrile and unwell. Consult with an infectious diseases specialist
- PTH in children with inadequate dietary calcium intake, signs/symptoms of low vitamin D, or multiple risk factors for low vitamin D
- PTH, urine calcium/phosphate/creatinine, CUE, wrist X-rays (and X-rays of leg deformity if present) in children with clinical rickets (as well as vitamin D related above)
- Nutrition screening (i.e. FBE, ferritin, vitamin D-related, B12 (as above); also folate, vitamin A, C, E, zinc, TFT, carnitine,
other tests- see details) in children with restricted food access pre-arrival, and exclusively breastfed babies where there has been poor maternal food access, or where deficiency is suspected clinically. Low vitamin A was common in refugees from African source countries arriving 2000 - 2005, B12 and folate deficiency have been reported in refugees from Afghanistan, Bhutan, Middle East and Sri Lanka.
- Thyroid function tests in any child with developmental delay (it is usually appropriate to delay other developmental bloods, including SNP microarray)
- Blood lead levels in children with pica, developmental issues or where there is a history suggesting exposure, including through traditional medicines. Blood lead screening is not routine in Australian refugee guidelines, but is
recommended for all refugee children (aged 6m-16y) in the United States
Other considerations
Screening may have been completed by other providers, and Victoria moved to a primary care model for refugee health screening from around 2006. Every attempt should be made to access screening that has been completed and avoid duplicating screening investigations. Also see
Department of Health information.
For asylum seekers, their detention 'Health Discharge Assessment' should provide details of health screening completed. Asylum seeker children received very little screening prior to mid-2014 (history, public health checklist, and TB screening if known contact history). See details on pre-arrival screening below.
Pre-arrival screening
All permanent migrants to Australia have an Immigration Medical Examination (IME) within 3-12m of departure. The IME includes:
- Full medical history and examination
- Chest x-ray (CXR) in those aged 11y and older (and in younger children if indicated)
- IGRA or TST in children 2-10y (if they: are applying for a Humanitarian or onshore protection visa, OR from a high TB prevalence country, OR declare previous household contact), with further investigation for TB if positive (from 2016)
- Urinalysis in those 5y and older (and in younger children if indicated)
- HIV testing in those 15y and older (and in younger children if indicated), all unaccompanied humanitarian minors/international adoptees/intending healthcare workers, or where HCV infection or tuberculosis is identified, and in all pregnant women (any migration pathway including temporary)
- HBsAg in all pregnant women, unaccompanied minors; international adoptees, intending healthcare worker, refugee entrants aged 15y and older (new) and those aged 15y and older applying for an onshore protection visa.
- HCV antibody tests in refugee entrants aged 15y and older (new), those aged 15y and older applying for an onshore protection visa, clinical indications, HIV or HBV infection, intending healthcare workers.
- Syphilis testing in those aged 15y and older and applying for either an onshore or offshore protection visa.
- Other tests as clinically indicated.
Humanitarian entrants are also offered voluntary pre-Departure Health Checks (DHC) within 72 hours of their intended departure for Australia. Not all humanitarian entrants undergo a DHC, as it depends on the visa subtype and port of embarkation, and uptake is incomplete. The DHC includes:
- A physical examination.
- Malaria RDT, and treatment if positive, generally with 3 days of oral artemether/lumefantrine (based on location)
- Empirical treatment for intestinal helminths with a single dose of albendazole in all those aged 12 months and older (unless pregnant)
- CXR in those with a history of TB or latent TB infection (LTBI) or clinical suspicion of active TB disease
- Measles, mumps and rubella (MMR) vaccination in those aged 9m-54y (unless pregnant)
- Yellow fever vaccine where relevant (based on location)
- Polio vaccination where relevant (based on location).
- Extended treatment for parasite infections is currently being implemented (new) based on local epidemiology
Extended screening was implemented for the Syrian and Iraqi cohorts from late 2015, combining the IME and DHC, also with review of mental health, child development, and additional immunisations (MMR, polio vaccination and diphtheria-tetanus-pertussis vaccination – in the form of hexavalent or pentavalent vaccine in children
<10y – check available paperwork).
Asylum seeker health screening
- People seeking asylum who arrived by boat generally received a health assessment on arrival in immigration detention. The detention health services provider completes this assessment. There is no published information on the format of detention health screening; however, assessment appears to have included: CXR in those 11y and older, and screening bloods in those aged 15y and older (screening for syphilis, hepatitis B, HCV and HIV; and screening with FBE, LFT, BSL testing, urinalysis and pregnancy testing where clinically indicated). Prior to mid-2014, children had very limited detention health screening. After this time they had health assessments similar to adolescents and adults, with the addition of ferritin, vitamin D levels, strongyloides serology, and malaria testing and schistosoma serology where clinically indicated. Clinical experience suggests the management of health conditions detected on the detention health assessments varied depending on access to healthcare in detention, or may have been deferred while awaiting transfer to community-based arrangements.
- Asylum seekers arriving by plane may not have had any health screening or healthcare in Australia and will not have had a pre-departure IME.
- People seeking asylum are required to have an immigration medical examination at the time they are granted a substantive visa (including at grant of temporary protection visa) - see
arranging a health examination and
health examinations for temporary visas.
Resources
Immigrant health clinic resources, Author Georgie Paxton, Updated Mar 2023, Contact: georgia.paxton@rch.org.au