Medical care of adult refugees, immigrants, and migrants

INTRODUCTION — In 2022, more than 280 million people lived outside their country of birth [1]. Migration patterns are dynamic, reflecting political, environmental, and social factors.

Among refugee, immigrant, and migrant (RIM) groups, morbidity and mortality rates from certain infectious diseases (eg, tuberculosis, human immunodeficiency virus [HIV], and hepatitis B) and noncommunicable diseases (eg, hemoglobinopathies/thalassemias) may be less familiar to clinicians than those found in native-born populations.

Components of the health assessment include patient health concerns, screening for diseases associated with the migration history, initiating age-appropriate immunizations, and routine health care maintenance. Guidance on a broad range of topics related to immigrant and refugee health in the United States is available from the United States Centers for Disease Control and Prevention (CDC) [2]. (See "Overview of preventive care in adults".)

Common issues related to health care for adult RIM patients will be reviewed here. Issues related to international adoption are discussed separately. (See "International adoption: Immunization considerations" and "International adoption: Infectious disease aspects".)

DEFINITIONS — A "migrant" refers to a person who moves away from their place of residence (either within a country or across an international border), temporarily or permanently. Migrants who are forcibly displaced commonly fall into the following categories (other categories also exist):

●Refugee – Someone who, "owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group, or political opinion, is outside the country of his nationality and is unable to or, owing to such fear, is unwilling to avail himself of the protection of that country" [3]. Refugees seek to establish their status as a refugee having fled their country of origin and while residing in a country of first asylum.

●Asylum seeker – An individual who has submitted a claim to a government for refugee status and is waiting for the claim to be accepted or rejected. Asylum seekers seek to establish their refugee status after fleeing to a country where they hope to be granted asylum.

●Asylee – An individual whose claim for refugee status has been granted.

●Parolee – An individual allowed into a country for urgent humanitarian reasons. Parole confers temporary status only; parolees must depart when the conditions supporting their parole cease to exist.

An "immigrant" refers to a person who moves to a new country with the purpose of permanently resettling in that country. Another common term used in the United States is "migrant worker", commonly referred to as an individual who moves from place to place frequently for a low-income position, most commonly in the agricultural industry.

Since these terms are not well defined and used in different ways in different places, we will refer to the larger group as refugees, immigrants, and migrants (RIM) groups.

SCREENING PRIOR TO ARRIVAL IN THE UNITED STATES — Most RIM populations to the United States undergo screening prior to arrival when they come through an official process. Those with refugee status who arrive through the US Refugee Resettlement System receive the most thorough screening through an organized system that includes the Department of State, the International Organization for Migration (United Nations Migration Agency), and the CDC.

The predeparture medical examination and screening for all immigrants and refugees was initially developed to identify conditions of "public health significance" such as certain infections (eg, tuberculosis [TB], sexually transmitted diseases), illicit drug use, and severe psychiatric issues. Non-refugee status immigrants are required to receive vaccinations prior to departure for the United States; refugees are exempted from this requirement.

For refugees, the screening approach has been broadened to include identification and management of conditions that may affect refugee health either during the migration process or following arrival. [4]. In addition, the CDC has expanded the predeparture immunization program for refugees and has implemented a presumptive treatment program for refugees from areas with endemic tropical infections (such as malaria and soil-transmitted parasites) [5]. All pre-departure medical evaluations and health interventions are conducted by officially designated "panel physicians" who follow instructions outlined and overseen by the CDC [6].

Other groups of migrants (such as visitors, short-term visa holders, and students) have no specific health requirements under normal circumstances, although may have requirements or recommendations from an educational institution or employer; these individuals may or may not have health and immunization records. Those arriving through non-traditional routes (eg, the Afghan evacuation), or through unofficial processes (eg, undocumented individuals, asylees) have no formal predeparture medical examination and screening but may have health and immunization records with them.

It is important for clinicians to clarify whether individuals have received any predeparture screening or treatment prior to arrival, since this will affect their initial evaluation and care following arrival. Even migrants who have been in the new country for a long period of time before being seen in the medical system may need screening, particularly those who may be at risk for certain diseases (eg, sickle cell disease or trait) or those with diseases with long latency periods (eg, viral hepatitis [B/C], TB, schistosomiasis, and strongyloidiasis) [7]. In the absence of documentation, it should not be assumed that a screening test has been done or that a vaccine or presumptive treatment has been administered.

CLINICAL APPROACH

Health assessment — Clinicians should tailor guidelines for screening, diagnostic evaluation, and management to individual circumstances, including exposure history, symptoms and signs, and risk factors:

●The CDC has published guidelines for medical examination of newly arrived refugees, as well as a checklist that includes screening recommended for refugees arriving in the United States [8].

In addition, the CDC and the Centers for Excellence in Newcomer Health have developed a clinical screening tool (CareRef) which is a web-based tool that allows clinicians to obtain specific screening recommendations for individual patients by entering the patients information such as country of birth, country of last residence, age, sex, and history of presumptive treatment.

●The Canadian Collaboration for Immigrant and Refugee Health has published guidelines for care of immigrants and refugee populations [9].

●The European Centre for Disease Prevention and Control has issued migrant screening and vaccination guidance [10].

Challenges of the first visit — Establishing rapport is critical for productive clinical encounters with refugee, immigrant, and migrant (RIM) patients. Stressful factors, especially for new RIM patients, may include lack of familiarity with the health care system, language and cultural barriers, limited health literacy, and the possibility of prior emotional or physical trauma. Patients may be reluctant to discuss health problems due to concerns about affecting their immigration status.

Health care providers in the arriving country may lack awareness of and familiarity with the predeparture health interventions, guidelines for post arrival screening, or best practices in migration health. Health care providers may also lack familiarity with illnesses seen more commonly in migrants, have difficulty with language and cultural barriers (including best practices in communicating through a professional interpreter), and find it challenging to perform the recommended significant workload of testing, immunization, and health maintenance activities in the limited amount of time for a typical visit.

Screening tests and immunizations need not be completed in the first visit. Completion of all the required elements can be facilitated by establishing a trusting relationship at the outset to facilitate a return to clinic for follow-up. Inquiring about and addressing immediate medical or social concerns prioritized by the patient will help facilitate establishment of rapport. Repeating inquiries about general and family well-being at each subsequent visit reinforces empathy and compassion. Effective listening and trust building may elicit additional concerns not revealed initially.

Health history — Use of medically trained interpreters improves patient health care outcomes, and offering these services is required by US law [11,12]. Culturally and linguistically appropriate educational materials and use of bilingual/bicultural health educators are also essential for care; resources may be found at the National Resource Center for Refugees, Immigrants and Migrants [13].

The health history should include standard elements such as current and prior medical problems, surgeries, pregnancies and their outcomes, medications (including complementary and alternative), allergies, and immunizations. Family history should also be elicited.

Mental health issues deserve special attention; many migrants have lost not only their homeland but also family members to disease, war, or forced separation. Many have experienced rape or torture or have been victimized during their migration, including by government or border officials; this information may not be offered in early interviews. Mental health screening should occur in the first or second visit and include assessment for suicide risk and other issues. (See 'Mental health screening' below.)

Social history should include inquiring about current living conditions as well as a thorough migration history, including regions of residence and travel. Migrants may spend many years enroute, which may include time in remote, rural settings, urban areas, or in refugee camps, frequently in multiple countries. Other important components of the social history include formal education level, languages spoken including preferred spoken and written language for interacting with the health system, occupational history, and current support system.

Initial health encounters should also address issues such as explaining how to navigate the local medical care delivery system, including the concept of primary care, access to after-hours care, and when and how to utilize emergency services. The concept of preventive care may be unfamiliar, and time should be devoted to making sure patients understand the importance of routine preventive care. Emphasizing the importance of establishing a medical home and primary care provider is critical.

Physical examination — Vital signs and growth parameters (height, weight, and head circumference in young children) should be measured and compared with age- and sex-based norms. Migrants may be underweight or overweight, undernourished or overnourished, and/or have specific nutritional deficiencies. They may have acute or chronic health conditions (such as hypertension and diabetes) which have gone undiagnosed or have not been revealed. Assessment of vision and hearing is important since deficiencies can affect work/school performance, job placement, and general quality of life and integration. Dental caries and other dental problems are common and should be addressed early, along with education about ongoing oral hygiene and dental care.

A complete physical examination should be performed. If there are no acute issues, a genital examination may be deferred to a follow-up appointment once trust has been established and the patient is prepared. Attention should be paid to findings that may reflect previously undiagnosed medical conditions, traditional cultural practices, or signs of abuse or torture. For example, skin lesions may reflect parasitic infection, traditional healing methods (scarification), or physical signs of previous trauma. Examples of important clinical findings include hepatosplenomegaly (a clue that may suggest hyperreactive malaria syndrome or schistosomiasis) and heart murmur (suggesting a broad array of conditions ranging from anemia to rheumatic heart disease or Chagas infection). Genital examination may reveal female genital cutting or hydrocele from filariasis. (See 'Additional pearls' below.)

Immunizations — Completion of primary immunizations and immunity to vaccine-preventable diseases should be assessed. Immunization records may be considered valid if they include the name of the vaccine and the month and year of administration and if the schedule reflects the recommended timing as outlined in the schedules published by the CDC. As an example, a measles-containing vaccine (eg, measles-mumps-rubella [MMR]) would not be considered valid if administered before one year of age.

The optimal approach to serologic testing for immunity to vaccine-preventable diseases is uncertain but varies with likelihood of previous vaccination or infection. For example, serologic testing may be appropriate for varicella and hepatitis A because of high population prevalence. Screening for chronic hepatitis B infection and immunity should be done [14]. Serologic testing for measles, mumps, and rubella may be done at the discretion of the provider; alternatively, MMR vaccine may be administered. Most favor administration of other routine vaccines without preliminary serologic testing [15]. A more thorough discussion of vaccines can be found at the US Centers for Disease Control and Prevention (CDC) Guidance for Evaluating and Updating Immunizations during the Domestic Medical Examination for Newly Arrived Refugees [16].

Issues related to immunizations are summarized in the figures (figure 1 and figure 2 and figure 3 and figure 4) and discussed separately. (See "Standard immunizations for nonpregnant adults" and "Standard immunizations for children and adolescents: Overview".)

Issues related to immunizations for children adopted internationally are discussed separately. (See "International adoption: Immunization considerations".)

Infectious disease screening

Tuberculosis — Newly arrived refugee, immigrant, and migrant (RIM) patients should have records reviewed; if originating from a country where TB is endemic, they should be evaluated for tuberculosis disease or TB infection (table 1). The CDC has published guidelines for TB screening in newly arrived refugees [17]; diagnosis of TB is also discussed further separately. (See "Diagnosis of pulmonary tuberculosis in adults" and "Tuberculosis infection (latent tuberculosis) in adults: Approach to diagnosis (screening)".)

Testing for TB infection should be performed regardless of time since immigration, since TB disease may present years after exposure [18]. Among non–United States-born individuals with TB disease in 2022, 16.5 percent (992 individuals) received a diagnosis <1 year after their initial arrival in the United States, compared with 9.8 percent (553 individuals) during 2021. A slightly lower number of individuals with newly diagnosed TB disease were living in the United States for >10 years in 2022 compared with 2021 (2821 versus 2845; 46.9 versus 50.2 percent) [19,20].

HIV — Migrants should undergo routine screening for HIV with a combination assay that detects HIV antigen and antibodies as outlined in sexually transmitted diseases (STDs) below (algorithm 1). (See "Acute and early HIV infection: Clinical manifestations and diagnosis".)

Hepatitis

Hepatitis A — Some migrants, particularly those who are older and coming from resource-limited settings, have had infection with hepatitis A as children. Younger migrants may not have had hepatitis A due to improvements in sanitation in many countries. Screening for active infection is not recommended in asymptomatic individuals. Screening for immunity may be cost effective for certain groups, such as older children and adults, those who have a history of hepatitis, or those who are candidates for routine immunization or who would otherwise require immunization (such as in the setting of travel or infection due to hepatitis B or C) [21-23]. Children should receive immunization against hepatitis A according to current recommendations. (See "Hepatitis A virus infection: Treatment and prevention", section on 'Protection prior to exposure'.)

Hepatitis B — Hepatitis B screening is recommended for all RIM patients, at least once in a lifetime. The CDC has recommended universal screening for adults aged 18 to 69 years [14]; particular attention is warranted for the following individuals, regardless of their history of hepatitis B vaccination and the duration in the United States [14,24,25]:

●Migrants from countries where the prevalence of hepatitis B infection (at the time of birth) was ≥2 percent

●Individuals born in the United States whose parents were born in countries with hepatitis B virus endemicity >8 percent and who were not vaccinated as infants

●Individuals in the United States whose mothers were infected with hepatitis B (or had unknown infection status) at the time of delivery and who did not received vaccine plus hepatitis B immune globulin at birth

Increasingly, RIM patients are receiving predeparture hepatitis B screening as well as hepatitis B vaccine as part of their routine immunizations prior to arrival; results may be available at the initial medical examination in the arriving country.

Tests used for hepatitis B screening should include three components: hepatitis B surface antigen, surface antibody, and core antibody [14]. Interpretation of hepatitis B serologies is summarized in the table (table 2) and is discussed further separately. (See "Hepatitis B virus: Screening and diagnosis in adults" and "Hepatitis B virus: Overview of management".)

Individuals living in the household of those with hepatitis B infection should also be offered screening and immunization [23]. Horizontal transmission of hepatitis B has been documented in family units. Hepatitis B–infected individuals should be evaluated for treatment, given vaccination against hepatitis A if not already immune, and, if not eligible or have failed treatment, should have routine screening for early detection of hepatocellular carcinoma; this is discussed further separately. (See "Surveillance for hepatocellular carcinoma in adults", section on 'Our approach to surveillance'.)

Hepatitis C — The United States Preventive Services Task Force recommends one-time hepatitis C screening for all adults ≥18 years and all pregnant patients during every pregnancy [26]; this is an appropriate recommendation for refugees and other migrants. The approach to screening is discussed further separately. (See "Screening and diagnosis of chronic hepatitis C virus infection".)

Screening for hepatitis C should be done, or may need to be repeated, for individuals with identified risk factors such as history of blood transfusions, injection drug use, or needle-sharing practices such as tattooing or acupuncture [26].

There is little generalizable data on the epidemiology of hepatitis C virus infection in refugee populations. Prevalence rates vary among refugee groups from very low (<1 percent) to high (7 to 8 percent); further study is needed to identify if certain RIM groups would benefit more from screening [27]. Two refugee groups of particular importance are Burmese refugees and Hmong refugees born in Thailand (with a hepatitis C virus prevalence of approximately 7 percent) [27], and Somali refugees, who have a high prevalence of hepatocellular carcinoma related to hepatitis B virus and hepatitis C virus [28]. Hepatitis C rates are also high in certain other migrant groups, including migrants from Egypt (13 percent prevalence) [29] and Pakistan (6.2 percent prevalence) [30].

Sexually transmitted infections — The CDC has published guidelines for sexual and reproductive health, including STI screening among newly arrived refugees [31].

Screening for STIs includes a thorough medical history, physical examination, and laboratory testing. The history should include reviewing any pre-departure screening, diagnosis and treatment provided (eg, pre-arrival gonorrhea screening is required for all applicants 18 to 24 years of age, and syphilis for those 18 to 45 years), by obtaining a sexual history (eg, sexual partner(s) with known or suspected STIs), prior history of STI or sexual trauma, and asking about active symptoms of current infection (genital discharge, dysuria, genital lesion, or rash). Physical examination should include lymph node palpation and genital examination. (See "Screening for sexually transmitted infections".)

Laboratory testing to be considered for all RIM groups after arrival should include:

●HIV testing in all persons >12 years and including those ≤12 years if risk factors or maternal history is unknown. Routine prearrival screening of migrants for HIV in the United States was discontinued in 2010.

●Screening for syphilis should be done in those 18 to 45 years of age who did not have pre-departure screening, anyone who has concern for increased risk, anyone who has signs or symptoms, and according to current CDC guidance [32]. (See "Syphilis: Screening and diagnostic testing".)

●Screening/testing for gonorrhea (nucleic acid amplification test) in sexually active women <25 years of age or those considered at increased risk and in accordance with CDC guidance [32].

●Screening/testing for chlamydia (NAAT) in sexually active women <25 years of age or those considered at increased risk and in accordance with CDC guidance [32].

Individuals with signs or symptoms of an STD should receive comprehensive STD testing. Additional infections to be considered include chancroid, granuloma inguinale/donovanosis, lymphogranuloma venereum, genital herpes, genital warts, and trichomoniasis.

Parasitic infections — The CDC has published guidelines for management of intestinal parasites among refugees overseas and/or after arrival [33,34]; these are summarized in the table (table 3). These guidelines are based on prevalence data in refugee populations and should only be extrapolated to populations with similar risk factors.

Many refugees arriving in the United States have received predeparture antiparasitic treatment. Other migrants have received neither screening nor treatment for intestinal parasites. At-risk asymptomatic migrants from high-endemicity settings who did not receive antiparasitic treatment (or received incomplete antiparasitic treatment) before departure may either undergo screening or receive presumptive treatment if they are seen within six months of arrival. Asymptomatic RIM patients at risk should receive either presumptive treatment or testing for Strongyloides regardless of duration in the United States if they will undergo immunosuppression. (See 'Strongyloidiasis' below.)

RIM patients at risk for parasitic infections with ongoing signs or symptoms of infection, including an unexplained elevated eosinophil count, should have diagnostic testing performed even if exposure is remote. Testing should include stool studies for ova and parasites and serology for strongyloides; additional testing should be tailored to epidemiologic exposure, and may include serologies for filaria, and/or schistosomes (along with urine sediment for schistosomes). (See "Approach to the patient with unexplained eosinophilia".)

Helminths — Screening or administration of albendazole for empiric treatment of soil-transmitted helminths may be appropriate for asymptomatic at-risk individuals following arrival from the following regions, if treatment was not administered before migration: Asia, the Middle East, Africa, Latin America, and the Caribbean (table 3) [33]. Stool screening is preferred over presumptive treatment for infants <12 months of age and may be deferred until after delivery for pregnant patients. Pregnant patients should not be treated presumptively with albendazole.

Presumptive treatment for soil-transmitted helminths before migration has been shown to reduce the prevalence of parasitic infection and cost of care in refugees resettled from selected countries [35,36].

Strongyloidiasis — Screening or administration of ivermectin for treatment of strongyloidiasis is appropriate for asymptomatic individuals following arrival from the following regions if treatment was not administered before migration: Asia, the Middle East, North Africa, sub-Saharan Africa (non-Loa loa-endemic areas) (table 4), Latin America, and the Caribbean [33,37].

Screening for strongyloidiasis consists of serologic testing; stool ova and parasite examination may be used, but its sensitivity is limited. (See "Strongyloidiasis".)

Among patients from L. loa-endemic areas (table 4), ivermectin should be administered only if L. loa microfilaria has been ruled out. Screening for L. loa microfilaria consists of a thick blood smear done between 10 am and 2 pm. (See "Loiasis (Loa loa infection)", section on 'Diagnosis'.)

Administration of presumptive treatment for strongyloidiasis is not appropriate for pregnant patients or for children <15 kg.

It is particularly important that patients from endemic areas undergo presumptive treatment for Strongyloides before anticipated immunosuppression (such as corticosteroids or other immune modulators) to minimize the likelihood of developing disseminated disease or hyperinfection. In general, this consists of ivermectin unless patients are from a L. loa-endemic area, in which case albendazole may be used (see "Strongyloidiasis").

Schistosomiasis — Screening or administration of praziquantel for empiric treatment of schistosomiasis is appropriate for asymptomatic individuals following arrival from highly endemic areas of sub-Saharan Africa, including pregnant patients and children >4 years of age, if treatment was not administered before migration (table 3) [33].

Screening for schistosomiasis should utilize serology. Stool and urine examination may be used, but sensitivity is limited. (See "Schistosomiasis: Diagnosis".)

Malaria — The CDC has published guidelines for management of malaria among refugees [38].

Presumptive treatment or laboratory testing for Plasmodium falciparum malaria is appropriate if fever or history of recent fever is present or if there is unexplained anemia, thrombocytopenia, or splenomegaly; it can be considered for asymptomatic individuals seen within three months of migrating from highly endemic areas of sub-Saharan Africa (if treatment was not administered before migration). For high-risk individuals from areas that are highly endemic for malaria (where persons may be infected but asymptomatic), presumptive treatment is preferred given the cumbersome process for screening, which consists of three blood films at 12- to 24-hour intervals. The sensitivity of rapid diagnostic testing for diagnosis of asymptomatic malaria in newly arrived refugees is limited and this test should not be used alone for screening [39]. Presumptive therapy consists of atovaquone-proguanil or artemether-lumefantrine as summarized in the table (table 5).

High-risk pregnant patients in their first trimester and children <5 kg should undergo laboratory testing and receive directed treatment if infection is detected; presumptive treatment should not be used in these groups.

The likelihood of subclinical P. falciparum malaria is rare among asymptomatic individuals from Southeast Asia, South Asia, Central Asia, parts of East Africa (eg, central Nairobi), and all areas in the Western Hemisphere; neither presumptive treatment nor laboratory screening is warranted for these individuals under normal circumstances. Similarly, neither presumptive treatment nor laboratory screening is warranted routinely for non-falciparum malaria in asymptomatic immigrants from any region at this time.

Chagas disease — Approximately 1 to 2 percent of Latin American immigrants living in the United States are infected with Trypanosoma cruzi; more than 300,000 individuals, including about 40,000 women of childbearing age, are at risk for sequelae of this infection [40,41]. Risk of mother to child transmission during pregnancy is about 1 to 5 percent, with about 100 to 300 infected infants born each year in the United States. Indications for Chagas screening are outlined separately. (See "Chagas disease: Epidemiology, screening, and prevention", section on 'Screening for chagas disease in nonendemic clinical and community settings'.)

Migrants with symptoms of Chagas present during the chronic phase of infection, with cardiac or gastrointestinal signs and symptoms. Cardiac complications include cardiomyopathy, heart failure, altered heart rate and rhythm (particularly right bundle branch block and/or left anterior fascicular block), apical aneurysm and thrombus development, and sudden cardiac arrest. Intestinal complications include an enlarged esophagus or colon (megaesophagus/megacolon) which can lead to dysphagia, abdominal pain, or constipation. Screening programs have been effective in identifying asymptomatic infected individuals in order to facilitate early diagnosis, prevent development of sequelae, and prevent vertical transmission of infection to infants [42,43].

Issues related to Chagas disease are discussed further separately. (See "Chronic Chagas cardiomyopathy: Clinical manifestations and diagnosis" and "Chagas gastrointestinal disease".)

Other infections — A number of other infections not commonly seen in the arriving country may affect RIM patients:

●Other parasitic infections:

•Filariasis (see "Lymphatic filariasis: Epidemiology, clinical manifestations, and diagnosis")

•Loiasis (see "Loiasis (Loa loa infection)")

•Onchocerciasis (see "Onchocerciasis")

•Giardiasis (see "Giardiasis: Epidemiology, clinical manifestations, and diagnosis")

•Amebiasis (see "Intestinal Entamoeba histolytica amebiasis" and "Extraintestinal Entamoeba histolytica amebiasis")

•Tapeworm infection (see "Tapeworm infections" and "Echinococcosis: Clinical manifestations and diagnosis" and "Cysticercosis: Clinical manifestations and diagnosis")

●Other chronic bacterial infections (such as melioidosis, leprosy) (see "Melioidosis: Epidemiology, clinical manifestations, and diagnosis" and "Leprosy: Epidemiology, microbiology, clinical manifestations, and diagnosis")

●Fungal infections (such as African histoplasmosis, Madura foot, paracoccidioidomycosis) (see "Diagnosis and treatment of pulmonary histoplasmosis" and "Eumycetoma" and "Clinical manifestations and diagnosis of chronic paracoccidioidomycosis")

●Viral infections (such as human T cell leukemia virus type 1) (see "Human T-lymphotropic virus type I: Disease associations, diagnosis, and treatment")

●Conditions that can masquerade as chronic infection (such as podoconiosis) (see "Clinical features and diagnosis of peripheral lymphedema", section on 'Other causes')

General screening

Blood count — A complete blood count (CBC) with differential is useful for identification of anemia, macrocytosis, microcytosis, and/or eosinophilia; these findings may indicate nutritional deficiencies, hemoglobinopathy, or parasitic infection. CBC results may be used in conjunction with other findings to help identify other health problems (such as lymphopenia in a patient with risk for HIV infection, anemia, and microcytosis in a patient with pain suggestive of sickle cell disease, or thrombocytopenia and anemia together with fever suggestive of malaria).

Eosinophilia can be a marker for parasitic infection [44]; the approach to evaluation is discussed separately. (See "Approach to the patient with unexplained eosinophilia".)

Lead screening — The CDC has published screening recommendations for lead during the domestic medical examination for newly arrived refugees. Migrants may be at risk of lead exposure due to increased levels of lead in the soil in the native country. In addition, RIM groups may settle in areas of the country with older housing leading to risk of exposure after arrival. A baseline lead level can be useful to evaluate subsequent trends.

Screening for lead is warranted following arrival and can be repeated three to six months later; this is particularly important for children between 6 months and 16 years of age and is also useful for pregnant patients [45]. The approach to screening and management of lead poisoning is discussed further separately. (See "Screening tests in children and adolescents", section on 'Lead poisoning'.)

Micronutrient screening — Deficiencies in vitamin B12 and vitamin D have been observed with high prevalence among some RIM groups [46-49].

As an example, vitamin B12 deficiency has been observed with high prevalence among Bhutanese Nepali and Iraqi refugees. There is no consensus on universal screening for vitamin B12 deficiency; given the potential for long-term neurologic sequelae, some favor providing multivitamins with B12 to newly arriving migrants.

Vitamin D deficiency is extremely prevalent in migrant populations [50] and screening is appropriate; testing or empiric supplementation is warranted for individuals with compatible signs or symptoms of deficiency, including rickets, osteopenia, poor growth, or motor delay. Some favor screening or vitamin supplementation for vitamin D in most groups of migrants.

Mental health screening — There is a high prevalence of mental health issues among refugees, particularly those arriving from areas of civil unrest; these include major depression, anxiety, and posttraumatic stress disorder [51]. For other migrant groups, the migrant journey and the stress of living undocumented in the United States is associated with increased risk for PTSD, anxiety, and depression. Mental health assessment includes a detailed social and psychiatric history; this is important but may be difficult to achieve in the initial visits.

Assessing mental health is challenging and made even more difficult by language barriers, perceptions and conceptions of mental illness in other cultures, and lack of standardized screening instruments for different populations. The process of relocation may reflect a planned move for economic and educational pursuits, or an unwanted, unanticipated move brought about by unplanned circumstances. Discussing the individual's reasons for resettlement can allow greater understanding of stresses faced in the country of origin and along the migration route.

RIM patients may have experienced loss of family members, personal health, and security. Many are victims of rape, torture, famine, or nutritional deprivation [51,52]. It is important to identify and provide support to individuals whose mental health issues interfere with their ability to engage in activities of daily living, pursue employment, or attend school.

Initial screening can be limited to questions to identify those with serious mental illness and risk for suicide. Subsequently, as rapport is established and depending on interventions available, a formal mental health assessment can be performed using a screening tool [52,53]. Screening for sexual trauma in women may inform ongoing care [54,55].

Cancer screening — Routine cancer screening should be offered to all RIM in accordance with domestic guidelines (table 6 and table 7) [56]. Significant cancer screening disparities are experienced by RIM in the United States. RIM patients should be asked if their reported age is accurate, as their stated age is often incorrect; inaccurate age may be associated with inappropriate or missed cancer screenings. Many RIM patients may be unfamiliar with the concept of cancer screening; additional effort to explain the rationale may be required. Women beyond the usual screening age for pap smears should have normal results (with co-testing for HPV) before ending cervical cancer screening.

RIM are disproportionately affected by cancers attributable to infection. Infection-related cancers are far more common in parts of the world such as sub-Saharan Africa than in North America (31 percent versus 4 percent of cancers respectively); in some countries in sub-Saharan Africa, more than 50 percent of all cancers are caused by infection; Helicobacter pylori, human papillomavirus, hepatitis B virus (HBV), and hepatitis C virus (HCV) account for 92 percent of all infection-attributable cancers worldwide [57]. Some infection-related cancers such as (hepatocellular cancer related to HBV and HCV) do have published screening guidelines.

Chronic disease screening — RIM patients should receive screening for chronic diseases including hypertension, diabetes, and hypercholesterolemia. The first few visits are also an opportunity to stress the importance of maintaining a normal body mass index, reviewing diet, and discussing the importance of exercise. Screening for tobacco and substance use is helpful as these present risks for chronic disease. Referral for dental care is also important. (See "Overview of preventive care in adults".)

Additional pearls — It is useful to consider some specific signs and symptoms that are associated with chronic infection among RIM patients. Examples include (see relevant topics):

●Eosinophilia may reflect parasitic infection such as strongyloidiasis, filariasis, or schistosomiasis.

●Hematuria, female infertility, or chronic pelvic pain may reflect schistosomiasis.

●Splenomegaly is common in certain groups (ie, Congolese) and may reflect hyperreactive malaria syndrome, schistosomiasis or other infections, or a combination of infections.

●Chronic rash or itching may reflect scabies, mycetoma, leishmaniasis, onchocerciasis, and other filarial worms [58].

●Heart failure or esophageal motility disorders may reflect Chagas disease.

●Seizures or other central nervous system symptoms may reflect neurocysticercosis.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Health care for immigrants and refugees".)

SUMMARY

●The United States Centers for Disease Control and Prevention (CDC) has published guidelines for medical examination of newly arrived refugees, as well as a checklist that includes screening recommended for refugees arriving in the United States. Recommendations for immigrant groups other than refugees are derived from these guidelines. (See 'Health assessment' above.)

●CareRef is a tool that allows clinicians to obtain more specific screening recommendations for specific refugees by entering information including country of birth, country of last residence, age, sex, and other variables such as presumptive treatment received. This may be a useful tool for other migrant groups with similar risk profiles and epidemiologic risks as refugees. (See 'Health assessment' above.)

●An assessment for completion of primary immunizations and immunity to vaccine-preventable diseases should be undertaken. Issues related to immunizations for adults and children are discussed further separately. (See "Standard immunizations for nonpregnant adults" and "International adoption: Immunization considerations".)

●RIM patients from areas with higher prevalence of tuberculosis (TB) should undergo screening. (See 'Tuberculosis' above.)

●The CDC recommends one-time hepatitis B screening for all adults aged 18 to 69 years. RIM patients from countries where the prevalence of hepatitis B infection is ≥2 percent and their children (irrespective of country of birth) are particularly vulnerable to the infection and should undergo routine screening, regardless of vaccination status or duration of residence in the United States. The CDC has published guidelines and helpful information about hepatitis screening and vaccination among newly arrived refugees. (See 'Hepatitis B' above.)

●The United States Preventive Services Task Force now recommends one-time screening for hepatitis C for all adults aged 18 and older and repeated screening in those at risk. This is an appropriate recommendation for RIM patients. (See 'Hepatitis C' above.)

●Sexually transmitted infections (STI) assessment includes a thorough medical history, physical examination, and laboratory testing. STIs to be considered include syphilis, chlamydia, gonorrhea, chancroid, granuloma inguinale/donovanosis, lymphogranuloma venereum, genital herpes, genital warts, and trichomoniasis. (See 'Sexually transmitted infections' above.)

●Guidelines for management of intestinal parasites among refugees overseas and/or after arrival are summarized in the table (table 3). Important infections include helminth infections, strongyloidiasis, and schistosomiasis. (See 'Parasitic infections' above.)

●Guidelines for management of malaria among refugees include presumptive treatment or laboratory screening for Plasmodium falciparum malaria among asymptomatic individuals following arrival from highly endemic sub-Saharan African regions, if treatment was not administered before migration (table 5). (See 'Malaria' above.)

●Cancer screening in RIM requires a nuanced approach (table 6 and table 7). In addition, many infection-related cancers and cancers related to cultural practices require provider awareness and consideration. (See 'Cancer screening' above.)

●General screening includes blood count and assessment for lead exposure, micronutrient deficiency, mental health, and screening for chronic diseases including malignancy, hypertension, and hypercholesterolemia. (See 'General screening' above.)