Refugee New Arrival Medical Screening Checklist

• Pregnancy T
  • Prior to vaccines and/or medications considered incompatible with pregnancy, or as clinically indicated
  • Prenatal vitamins and referral for services for positive test

• Record previous vaccines, lab evidence of immunity, or history of disease;
  • Doses are valid if given according to accepted ACIP or State schedules.
  • If patient has no documentation, assume he or she is not vaccinated.
  • Give age-appropriate vaccines as indicated. Complete any series that has been initiated. (Do not restart a vaccine series.)
  • Laboratory evidence of immunity may be checked per the judgment of the provider (see discussion in immunization section)

• Evaluate overseas records
• Evaluate for signs or symptoms of disease and physical examination (low threshold for evaluation)
• Skin test or IGRA
• Appropriate evaluation of positive screening test (see text)

• Screen all refugee children 6 months to 16 years of age.
• Additional lead test on all children aged 6 mo - 6 yrs within 3-6 months of placement in a permanent residence, regardless of the results of the initial lead screen.

Note: All sub-Saharan African refugees who are eligible should be assumed to have received pre-departure presumptive antimalarial therapy with artesunate-combination therapy (ACT)

• Sub-Saharan African refugees who received no presumptive antimalarial therapy or therapy other than ACT prior to departure should either be tested or receive post-arrival presumptive therapy. Pregnant women and refugees for whom presumptive therapy is contraindicated should be tested.
• Sub-Saharan African refugees who received ACT presumptive therapy prior to departure do not need testing or presumptive therapy post-arrival.
• Refugees arriving from P. falciparum malaria-endemic areas outside sub-Saharan Africa or non-falciparum malaria areas should not receive routine testing or presumptive therapy.
• Note: Any refugee who has signs and symptoms of malaria and who originated in a malaria-endemic country should be tested for malaria.
• Find malaria endemicity information with the online CDC Malaria Map Application.

Note: Post-arrival screening for IP will depend on region of departure and pre-departure presumptive therapy received.

Screening for IP in asymptomatic refugees—

• Who had no documented pre-departure treatment.
  • Presumptive therapy or serologies for strongyloides (all refugees), serologies for schistosomaisis (sub-Saharan African refugees), stool ova & parasite examination (x 2) and eosinophil count* (Figure 1)
• Who received single-dose pre-departure albendazole +/- praziquantel.
  • Presumptive therapy or serologies for strongyloides (all refugees), serologies for schistosomiasis (sub-Saharan African refugees who did not receive praziquantel) and/or eosinophil count* (Figure 2)
• Who received high-dose pre-departure albendazole (7 days) OR ivermectin +/- praziquantel.
  • Note Eosinophil absolute count* (Figure 3)

  * Eosinophil count is routinely recommended as part of the hematology testing and is not sensitive or specific for invasive parasites, however, a persistently elevated count demands further investigation.

History for signs or symptoms and physical examination

• Syphilis
  • VDRL/RPR
    • ≥ 5 years
    • < 15 years if
      • sexually active or history of sexual abuse,
      • mother who tests or tested positive,
      • exposure in an country endemic for other treponemal subspecies (e.g., yaws, bejal, pinta)--link to Table 3 of guidelines
    • Confirmation testing for positive treponemal tests (see text)
• Chlamydia
  • Urine nucleic amplification test
    • Women and girls < 25 years who are sexually active or those with risk factors (e.g., new or multiple partners),
    • Luecoesterase (LE) positive on urine sample,
    • women or children with history of or at risk for sexual assault,
    • any refugee with symptoms
• Gonococcus
  • Urine nucleic amplification test
    • Luecoesterase (LE) positive on urine sample, women or children with history of or at risk for sexual assault, or any refugee with symptoms

(As of January 4, 2010, refugees are no longer tested for HIV infection prior to arrival in the U.S.)

• All refugees 13-64 years of age should be screened for HIV, unless they decline (opt out). CDC also encourages screening of all refugees on arrival, including those < 12 and > 64 years of age. Refugees should be clearly informed orally or in writing when/if they will be tested for HIV.
• Screening should be repeated 3-6 months following resettlement for refugees who had recent exposure or are at high risk.
• A refugee’s decision to decline an HIV test should be documented in the medical record.
• Specific testing for HIV-2 should be conducted for refugees who screen positive for HIV and are native to or have transited through the following countries: Angola, Benin, Burkina Faso, Cape Verde, Côte d’Ivoire, Gambia, Ghana, Guinea, Guinea-Bissau, Liberia, Mali, Mauritania, Mozambique, Niger, São Tomé, Senegal, Sierra Leone, and Togo.
• All HIV-infected refugees should receive culturally sensitive and appropriate counseling in their primary spoken language. The competence of interpreters and bilingual staff to provide language assistance to patients with limited English proficiency must be ensured.
• All refugees confirmed to be HIV-infected should be referred for care, treatment, and preventive services.
• Special considerations for children
  • Children ≤12 years of age should be screened unless the mother’s HIV status can be confirmed as negative and the child is otherwise thought to be at low risk of infection (no history of high-risk exposures such as blood product transfusions, early sexual activity, or sexual abuse). In most situations, complete risk information will not be available; thus, most children ≤12 years of age should be screened.
  • Children <18 months of age who test positive for HIV antibodies should be tested with DNA or RNA assays. Results of positive antibody tests in this age group can be unreliable because they may detect persistent maternal antibody.
  • All children born to or breast-fed by an HIV-infected mother should receive chemoprophylactic trimethoprim/sulfamethoxazole beginning at 6 weeks of age and continuing until they are confirmed to be uninfected.
• Special considerations for pregnant women
  • Identifying and treating HIV-infected pregnant women can prevent HIV infection in their infants. All pregnant refugee women should be screened for HIV as part of their routine postarrival and prenatal medical screening and care.