Immigrant Health Service

Initial assessment

  • 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 non-existent 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))
    • Strongyloides serology
    • Tuberculosis screening - tuberculin skin test (TST) or interferon gamma release assay (IGRA). TST is preferred in children < 5 years
    • Faecal specimen - 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 (> 6 months, <1 0kg 200 mg; 10 kg or greater 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.

    Age-based or risk-based screening

    • Vitamin D, calcium, phosphate, ALP - if risk factors for low vitamin D, see Medicare guidelines for vitamin D testing)
    • Serum active vitamin B12 - arrival < 6 months, food insecurity, vegan, Bhutan, Afghanistan, Iran, Horn of Africa)
    • Malaria screen (rapid diagnostic test (RDT) and thick/thin film) - if arrival date < 3 months from endemic area, or later if symptoms. Endemic - Africa (except Egypt), Burma, Bhutan, India, Pakistan, Sri Lanka- not Middle East
    • Hepatitis C serology (Hepatitis C virus (HCV) antibodies) - if from endemic area or if risk factors. Endemic - Congo, Egypt, Iraq, Pakistan, consider in Syrians - not other African/Middle Eastern or Asian countries
    • Schistosoma serology - travel from/through endemic area. Endemic - Africa, Burma, Iraq and Syria - not other Middle Eastern or Asian countries
    • Varicella serology - age 14 years and older if no history clinical varicella infection and no previous varicella vaccination
    • 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 should be completed in all unaccompanied or separated children, and children should also be screened for syphilis if their mother has positive serology
    • HIV testing - age 15 years and older, < 15 years 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, 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 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 6 months-16 years) 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). Details on pre-arrival screening below.

    Pre-arrival screening

    All permanent migrants to Australia have an Immigration Medical Examination (IME) within 3-12 months of departure. The IME includes:

    • Full medical history and examination
    • Chest x-ray (CXR) in those aged 11 years and older (and in younger children if indicated)
    • Interferon gamma release assay(IGRA) or tuberculin skin test (TST) in children 2-10 years (if they: are applying for a Humanitarian or onshore protection visa, OR from a high tuberculosis (TB) prevalence country, OR declare previous household contact), with further investigation for TB if positive (starting in 2016)
    • Urinalysis in those 5 years and older (and in younger children if indicated)
    • Human immunodeficiency virus (HIV) testing in those 15 years and older (and in younger children if indicated), all unaccompanied humanitarian minors, or where hepatitis C virus (HCV) infection is identified
    • Hepatitis B surface antigen (HBsAg) in pregnant women, unaccompanied minors; those aged 15 years and older and intending to study or work as a doctor, dentist, nurse or paramedic; and those aged 15 years and older applying for an onshore protection visa.
    • Hepatitis C antibody tests in those aged 15 years and older and intending to study or work as a doctor, dentist, nurse or paramedic; or applying for an onshore protection visa.
    • Syphilis testing in those aged 15 years 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 9 months-54 years (unless pregnant)
    • Yellow fever vaccine where relevant (based on location)
    • Polio vaccination where relevant (based on location).

    Extended screening has been implemented for the Syrian and Iraqi cohorts, with additional review of mental health and additional immunisations (MMR, polio vaccination and diphtheria-tetanus-pertussis vaccination – in the form of hexavalent or pentavalent vaccine in children <10 years – check available paperwork).

    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 11 years and older, and screening bloods in those aged 15 years 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 changes to health examinations (November 2015); arranging a health examination and health examinations for temporary visas.

    Resources

    Immigrant health clinic resources, Author Georgie Paxton, Updated May 2018, Contact: georgia.paxton@rch.org.au