Updated offshore health screening
As of 2023, there have been updates to offshore Immigration Medical Examination (IME) screening and Departure Health Check (DHC) for humanitarian entrants. These are outlined in the updated Department of Home Affairs (DHA) Panel Members Instructions (July 2023), DHC supporting material (Sep 2023) and implemented on the HAPlite system. Changes are listed in the pre-arrival screening section below, with implications for onshore screening noted in red*.
Health issues
New arrival refugee or asylum seeker children/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 these cohorts. 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 (height, weight and head circumference), 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, cardiac examination, 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, based on the 2016 Refugee Guidelines from the Australasian Society for Infectious Diseases (ASID) and Refugee Health Network of Australia (RHeaNA) and updated for Afghan, Ukrainian and Gazan arrivals; 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) *HBsAg not required if completed & negative result offshore, reasonable to vaccinate without cAb/sAb, check serology in household contacts
- Strongyloides serology (*not Ukraine) *still indicated if offshore ivermectin
- 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
- *Parasite screening/treatment recommended for arrivals from Gaza; not required for arrivals from Ukraine.
Age-based or risk-based screening
- Vitamin D, calcium, phosphate, ALP - risk factors for low vitamin D, all Afghan and Gazan arrivals, see summary of
Medicare guidelines for vitamin D testing
- Serum active vitamin B12 & folate - arrival
<6m and any of food insecurity, vegan, Bhutan, Iran, Horn of Africa, Afghanistan, Gaza. Also check homocysteine and urine methylmalonic acid if risk low B12 and disability or neurological symptoms
- MMR and Varicella serology - consider in adolescents to determine vaccination*also reasonable to vaccinate without serology
- Schistosoma serology - travel from/through endemic area. Endemic: Africa, Burma, Iraq and Syria; not other Middle East/Afghanistan/Ukraine/other Asian countries. *still indicated if offshore praziquantel
- Malaria screen (rapid diagnostic test (RDT) and thick/thin film) - arrival date
<3m from endemic area, or later if symptoms. Endemic: Africa (except Egypt), Burma, Thailand, Cambodia, Bhutan, India, Pakistan, Afghanistan, Venezuela, not Middle East/Egypt/Sri Lanka/Ukraine, *not required if well and negative result offshore
- Hepatitis C serology (Hepatitis C virus (HCV) antibodies) - if from
endemic area or if risk factors. Endemic: Congo, Egypt, Iraq, Pakistan, Rohingya in Bangladesh, consider in Syria, Ukraine; not other African/Middle East/Afghanistan/Asian countries *not required if negative result offshore
- Hepatitis A serology - all Gazan arrivals until more information available on this cohort
- HIV testing - age 15y and older, 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)
- STI screen (HIV, syphilis, urine nucleic acid detection N. gonorrhoea and C. trachomatis, consider rectal/throat swabs) - if risk factors, and 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
- 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 tests above).
- Nutrition screening (i.e. FBE, ferritin, vitamin D-related, B12 and folate (as above); also 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. Recommend vitamin A and zinc screening (+/- other nutrition screening) in all new arrivals from Gaza.
- Thyroid function tests in any child with developmental delay (it is usually appropriate to delay other developmental bloods, including microarray which can be completed later using saliva testing)
- 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 in US refugee guidelines (for all children 6m-16y, older adolescents with clinical risk and all pregnant/breastfeeding women).
Other considerations
Screening (or partial testing) may have been completed by other providers. 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 and Aged Care information on health assessments.
For asylum seekers, the detention 'Health Discharge Assessment' should have provided 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 IME within 3-12m of departure. The IME includes: (*note: see pdf form for quick view of format)
- Full medical history and examination - all
- Chest x-ray (CXR) - age 11y and older (and in younger children if indicated)
- IGRA or TST - 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)
- Serum creatinine and estimated GFR - age 15y and older (and in younger children if indicated)
- HIV testing (EIA, + confirmation if positive) - 15y and older (and younger if indicated), all international adoptees, unaccompanied humanitarian minors, intending healthcare workers, or where intravenous drug use, HCV infection or tuberculosis are identified
- HBsAg in all pregnant women, international adoptees, unaccompanied humanitarian minors, intending healthcare workers, clinical indications, offshore humanitarian applicants 15y and older (new) and those aged 15y and older applying for an onshore protection visa, or where HCV infection is identified
- HCV antibody tests - clinical indications, all intending healthcare workers, offshore humanitarian applicants 15y and older (new) and those aged 15y and older applying for an onshore protection visa, or where HBV or HIV infection are identified
- Syphilis screening (VDRL or RPR, + confirmation if positive) - 15y and older and applying for either an onshore or offshore protection visa.
- Other tests as clinically indicated.
Humanitarian entrants are also offered a voluntary DHC. This usually occurs within 72 hours of intended departure for Australia, but may be conducted up to 4 weeks before travel. Not all humanitarian entrants undergo a DHC, although uptake is high (and likely to increase). The DHC includes:
- Clinical consultation and physical examination, including mental health screening
- Review of IME TB screening results; CXR if: history of treated/inactive TB, clinical suspicion of active TB disease, immune compromise, household contact since IME
- Pregnancy testing for women of child bearing age
- Measles, mumps and rubella (MMR) vaccination in age >9m (unless pregnant/medical contraindication/born before 1966)
- Yellow fever (YF) vaccine (or review of YF certificates) where relevant in age >12m (based on location)
- Polio vaccination - our clinical experience suggests increasing use of hexa- or pentavalent vaccines in children
- Malaria RDT, and treatment if positive, generally with 3 days of oral artemether/lumefantrine (based on location - sub-Saharan Africa, India, Bangladesh, Pakistan, Afghanistan, Burma, Thailand, Indonesia, Cambodia, Venezuela, PNG, Solomon Islands)
- Parasites - empiric treatment for:
- Soil transmitted nematodes with albendazole age 6m and older (not pregnant, age <6m, unexplained seizures or signs neurocysticercosis)
- Strongyloides infection with ivermectin where prevalence is presumed to be high (10%+): East Asia, Pacific, sub-Saharan Africa, Latin America (not pregnant, early breastfeeding, weight <15kg, Loa loa areas)
- Schistosoma infection with praziquantel in endemic areas: Venezuela, sub-Saharan Africa, including Democratic Republic of
Congo, Central African Republic, Eritrea, South Sudan and Ethiopia (not pregnant, breastfeeding, age <12m, unexplained seizures or signs neurocysticercosis).
Changes to IME and DHC (2023)
Recent changes to the IME and DHC include:
- IME
- Addition of Hepatitis B sAg screening in all refugee entrants 15 years and older
- Addition of Hepatitis C screening in all refugee entrants 15 years and older
- Improved vaccination records - including past vaccines and more comprehensive vaccination as part of the offshore IME and DHC
- Improved use of the functional assessment tool - which is practical and useful for people with disability
- DHC
- Making the DHC free for all humanitarian entrants
- Clearer consideration of pregnancy status - check of pregnancy status/gestation, consideration in all immunisation/parasite protocols, and implementation of post arrival alert for all pregnant women to ensure post arrival care
- Review of vaccination history (also uploading past immunisation records +/- additional vaccinations)
- Clearer direction on recording medications and medication supply (ideally 4 weeks)
- Expanded malaria screening areas
- Empiric treatment of parasite infections (adjustments to albendazole age/dosing, and introduction of ivermectin and praziquantel for some ports of departure as above).
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 completed 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 (syphilis, HBsAg, HCV and HIV reflecting the offshore IME; and FBE, LFT, BSL, 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 30 Sep 2024, Contact: georgia.paxton@rch.org.au