Association of Refugee Health Coordinators Medical Screening Committee
Tools and Recommendations
2
Executive Summary
A domestic medical screening examination for newly arrived refugees is at the center of
each state’s refugee health program. These examinations primarily focus on the
identification of infectious diseases that are endemic in the home country of the refugee
and the country of refuge. Identification of infectious diseases promotes the health of the
refugee and protects the public health of the resettlement community. The exam also
includes vaccinations in accordance with the recommendations of the CDC Advisory
Committee on Immunization Practices (ACIP). In many states, the screening includes a
complete physical examination as well as an evaluation for mental health concerns.
While federal guidance on the examination exists, each state is allowed to create its own
screening protocol, which may or may not include all recommended components. Further,
refugee health examinations are performed in a variety of settings: some in public health
clinics, some in primary care settings, some by clinicians who exclusively offer care to newly
arrived refugees, some by providers who know very little about the refugee resettlement
program, and many by providers somewhere in between. Without a clearly articulated federal
expectation for examination quality or rate of completion, the quality and quantity of
examinations completed varies greatly from state to state.
The Association of Refugee Health Coordinators (ARHC) Enhancing Partnerships in
Refugee Health project, supported by a cooperative agreement between the Centers for
Disease Control and Prevention’s Division of Global Migration and Quarantine
(CDC/DGMQ) and the Association of State and Territorial Health Officials (ASTHO),
brought attention to these concerns and requested recommendations in the following
areas to enhance uniformity and standardization in domestic refugee screening:



Standardization in program development
Resources for clinician
Expectations for protocol implementations (i.e., all health screenings involve a
professional interpreter; health screening data should returned to the state’s
refugee health program).
The objectives set forth for the ASTHO Medical Screening Committee as part of the
Enhancing Partnerships in Refugee Health project include:
Objective One: Develop operational guidance documents for refugee health screening for state
programs.
a) Create step-by-step guidance applicable to all programs large and small nationally.
b) Consider prioritizing options for states with greater or lesser capacity/personnel based
on discussions with ARHC colleagues across the country.
c) Identify existing tools and guidance and adapt for use as resources, as appropriate.
3
Objective Two: Develop operational guidance for each of the published CDC/DGMQ
Domestic Guidelines for clinicians who screen refugees.
a) Ensure guidance is clear and presented in language and format familiar to most
practicing clinicians.
b) Suggest practical ways to make this guidance easily available to clinicians.
c) Identify existing tools and guidance and adapt for use as resources, as
appropriate.
Objective Three: Characterize refugee health screening operational guidance by state
and/or local capacity.
a) Recommend core components of refugee health screening.
b) Prioritize enhancements to the core screening protocol.
c) Differentiate screening recommendations for a screening-only clinic.
d) Differentiate screening recommendations for a primary care clinic.
Objective Four: Identify and adapt, as appropriate, existing tools and guidance for
refugee screening in public health clinics, primary care clinics, and clinics set up to only
screen refugees.
The committee’s recommendations are intended to provide more consistent services to
refugees arriving in the United States, as well as user-friendly guidance to clinicians. The
recommendations are also intended to address some of the current limitations in refugee
health surveillance, thereby allowing state and federal partners to better collect, analyze, and
disseminate data related to the health of newly-arriving refugee populations.
Recommendations include:





Encourage all states to use a Universal Refugee Health Screening Examination
tool.
Develop a master Provider Guide based on state models.
Ask CDC and ARHC to post the master Provider Guide, once developed, to their
Immigrant and Refugee Health website.
Coordinate between CDC and ARHC to develop mobile apps to enhance
standardization of refugee screening.
Develop a “reverse Yellow Book” (CDC’s reference for clinicians who advise
international travelers about health risks) as a reference document for domestic
clinicians working with foreign-born populations.
New tools developed by the committee include:





Medical Screening Operational Guidance for State Programs.
A universal refugee health screening form.
Recommendations for protocols to be utilized in screening-only clinics and in
primary care clinics.
Recommended parameters for both a basic and expanded refugee health
screening protocol.
Detailed guidance on recommended parameters for each type of screening,
including a rationale for inclusion
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The recommendations and tools created by the ASTHO Medical Screening Committee will
be transferred to the ARHC Medical Screening Committee for prioritization and
implementation. Thank you to those who participated in the creation of these tools,
guidelines, and recommendations.
Recommendations and Operational Guidance
Overview
The mission of the Association of Refugee Health Coordinators (ARHC) is to strengthen state
and local refugee health leadership, expertise, and advocacy in order to achieve wellness in
domestic refugee populations. ARHC members are state refugee health coordinators and staff
from state or local governmental agencies or nonprofits who provide health services to
refugees. While infrastructure and capacities vary by state, these programs work to provide
refugees with domestic health assessments, immunizations, and linkages to ongoing medical
services.
In the fall of 2010, CDC/DGMQ provided short-term support to ARHC through a cooperative
agreement with the Association of State and Territorial Health Officials (ASTHO) for the
Enhancing Partnerships in Refugee Health project.
Because refugee screening is recommended, but not required, states vary in how
screenings are completed. States can opt out of refugee screening altogether; however, if
a state participates in the refugee program, it is expected to operate all components of
the program, including preventive health, refugee cash and medical assistance, social
services, and an unaccompanied minors program if appropriate. A state is also expected
to coordinate the provision of assistance and services in accordance with 45 C.F.R.
§400.5(b). If a state wishes to be responsible for only part of the refugee program, it must
obtain prior approval from the Director of the Office of Refugee Resettlement (ORR).
While there is national guidance for the domestic medical screening itself, the states are
not required to coordinate these screenings, work in partnership with all players, seek
funding, or hold their programs to a high standard of care. States vary in the
comprehensiveness of their screenings, their capacity to follow up on problems identified
in screening, and in the percentage of refugee arrivals that actually complete a screening.
Refugees may experience a comprehensive and culturally competent screening
examination or a brief and cursory examination without benefit of an interpreter,
depending on their resettlement community. In addition to these concerns, turnover in
state refugee program leadership often results in gaps in services. When a new leader
begins work, he or she may have to develop a program despite broken relationships with
resettlement agencies, clinics, and local public health agencies.
Methods
The ARHC executive secretary recruited volunteers from ARHC membership to form the
initial project group. They were joined by subject matter experts to participate in one of
three committees (Health Education, Medical Screening, and Surveillance) to develop the
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medical screening guidance, tools, and recommendations. Each medical screening
subcommittee focused on one of the objectives described in this document.
The executive secretary and the project leadership team developed a work plan and
shared it with each subcommittee. All work was developed in accordance with current
evidence-based published reports, if available. The ARHC Leadership Team and Executive
Board reviewed the draft recommendations. The recommendations received further
critical review and editing after they were presented to the ARHC membership and
federal and national partners at the Enhancing Partnerships in Refugee Health
Conference in May 2011.
The Enhancing Partnerships in Refugee Health Leadership Team identified three concerns
as the highest priority for further guidance and recommendations:
Objective 1: Address the lack of operational guidance for state refugee health
programs. Several years ago, ARHC created a document called The Quick Start Guide that
details federal regulations, acronyms, federal and national contacts, and resources for
state refugee health programs. This guide has proved invaluable to ARHC members,
especially to newly hired refugee health coordinators.
Operational Guidance was developed during the first six months of the project for states
that are either developing a new medical screening protocol or reviewing and updating
the structure of their programs. The subcommittee was composed of federal partners
and refugee health coordinators who identified six priority areas needed for a strong
refugee health program. The group then developed detailed guidance for the
development of each priority area.
Objective 2: Develop recommendations and guidance as a complement to the
CDC/DGMQ and ORR guidance for refugee medical examinations. Over the past several
years the CDC/DGMQ, in collaboration with ORR, developed and posted specific guidance
for performing a domestic refugee health examination. The guidelines were designed to
assist state public health departments and medical professionals/clinicians in determining
the most effective evidence-based tests to perform during routine post-arrival medical
examination of refugees.
These guidelines are intended as recommendations rather than mandates; they also very
detailed and quite lengthy. The subcommittee took these excellent guidelines and
developed complementary recommendations and guidance that would be more
operational and accessible to refugee health programs and clinicians.
Objectives 3 and 4. Address the variability in refugee medical screening protocols state
to state. This subcommittee was asked to develop a recommended basic protocol for
refugee medical examinations as well as a list of expanded parameters that could be
added on a state by state basis, as appropriate. A very expansive list of possible
parameters was developed based on CDC guidance and various state protocols currently
in practice. The subcommittee, consisting of many clinicians, CDC medical advisors, and
refugee health coordinators from the state and city/county levels, reviewed this list and
sorted each parameter into the “Basic” or “Expanded” category. The subcommittee used
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the same original inclusive parameters to determine what should be done in a “screen
only” clinic (where refugees receive their screening examination but will not return for
primary care of any kind) or a primary care clinic that would not only screen refugees but
also function as their new medical home.
Guidance and Tools

Medical Screening Operational Guidance for State Programs (Appendix A). This
document is intended as a companion to the ARHC Quick Start Guide developed in 2008
and updated in 2010. The document offers detailed guidance for states that are
developing, reorganizing, or updating their refugee health programs. It recommends
the following six priority areas be addressed at the state level:
o Secure positioning and funding for state refugee health coordinator and
staff.
o Develop a state protocol for refugee health examinations and screenings.
o Identify clinics to perform health examinations and screenings.
o Secure resources to ensure that state refugee health programs are notified
of refugee arrivals.
o Develop a state refugee health program database.
o Establish working relationships with key stakeholders.

Universal Screening Form (Appendix B). This form was developed to help
operationalize the CDC guidelines for refugee medical screening.

Basic Refugee Medical Screening Tool (Appendix F). This tool defines basic level
screening as well as components appropriate for a “screen-only” clinic setting. Screenonly clinics do not screen refugees for chronic conditions like diabetes, hypertension, or
cancer, as they will not be following up on these conditions. The tool closely follows the
checklist found on the CDC website and is a companion piece to the Core Components
Appendix (Appendix H).

Expanded Refugee Medical Screening Tool (Appendix G). This tool was developed
with state refugee health programs in mind, offering assistance to states that are
creating or updating their refugee screening protocols. These expanded clinical
components can be added in whole or in part to the basic examination depending
upon the skills and resources of the states and clinics performing the examination.
This creates a model of expanded screening for states with the capacity to offer a
more comprehensive refugee health screening examination.
This tool is appropriate for use in primary care clinics, which offer ongoing care to
new refugee arrivals. It is designed as a companion piece to the Refugee Medical
Screening Appendix (Appendix H).

Refugee Medical Screening Appendix (Appendix H). This document is based on
CDC guidance, but goes into greater detail and gives appropriate references for
each recommended core component, identifying clinical details with hyperlinks to
the source of each recommendation.
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Recommendations
Recommendation 1: ARHC, ORR, and CDC/DGMQ should promote use of a Universal
Refugee Health Screening Examination Form with an adaptable format to be
accompanied by an appendix and compendium of recommended resources (see
Appendix B). The universal form acts as a checklist that includes all ARHC recommended
clinical parameters. States can use the same screening form template while still
determining which specific elements to include in their state screening. Parameters not
chosen by a state will remain blank or hidden. This universal screening tool could be
offered in paper or electronic format with space to note the results of each test
performed and possibly (in electronic format) a hyperlink to more information. A
utilization strategy for this form will need to be developed by the partners listed above.
ORR should strongly endorse the implementation of CDC/DGMQ Domestic Guidelines in
all states receiving new refugee arrivals to ensure a baseline standard of healthcare.
Recommendation 2: ARHC should oversee efforts to produce a master Provider Guide based
on the efforts of Massachusetts (www.mass.gov/dph/refugee), Minnesota
(www.health.state.mn.us/refugee/guide/index.html), and Washington (see Appendix E). These
Provider Guides were developed for clinicians performing the refugee health screening
examination. The Provider Guides offer extensive guidance on each parameter of a typical
refugee health screening as well as background on the development of a given state’s protocol,
a glossary of commonly used acronyms, and resources and hyperlinks on many health topics—
for example, to help determine the pathology of a particular intestinal parasite, or the
preferred treatment for that parasite. Many of the guides also include a chapter on refugee
mental health to help providers get a context for what refugees have endured and the possible
psychological impact of a refugee experience. The committee urged ARHC to develop one
Master Provider Guide that could then be adapted for each state program.
Recommendation 3: ARHC should oversee the development of a mobile app based on
the Refugee Health Assessment Pocket Guide (Minnesota, Washington—see Appendix D)
with hyperlinks to CDC resources. Another example of a pocket guide is available from
the Group on Immunization Education/Society of Teachers of Family Medicine:
http://www.immunizationed.org/ShotsOnline.aspx.
Recommendation 4: ARHC should work in collaboration with CDC toward the
development of “smart sets” in widely used medical records programs.
 Explore EPIC’s Community Library Exchange and similar existing programs.
 Ensure that Appendix H and all others offering recommendations related to
refugee health screening are compatible in content and expectations.
Recommendation 5: ARHC and CDC should promote the use of protocols developed for
“screen-only” and primary care clinics. Tools for addressing these concerns are found in
Appendix F-G.
Recommendation 6: CDC should develop a reverse “Yellow Book” as both a reference to
the Universal Refugee Health Screening Examination Form and as a mobile app. The
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Yellow Book is published every two years by CDC as a reference for those who advise
international travelers about health risks. The proposed reverse Yellow Book would serve
as a guide to domestic clinicians working with foreign-born populations, especially newly
arrived refugees and immigrants.
The tools and recommendations from this committee encourage increased
standardization of refugee medical screening examinations across the country. ARHC
strongly encourages each state to include the recommended basic components in their
state screening protocol. Tools to support this effort include the Universal Refugee Health
Screening Form and the potential for developing a master Provider Guide as well as
electronic tools that can be utilized at the clinic level.
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Committee Membership
Jenny Aguirre (IL)
Marc Altshuler, MD (Thomas Jefferson Medical College)
Marta Brenden (ORR)
Jackie Brown (CO)
Eric Cleghorn (NY)
Susan Dicker (MN), Chair
Patricia Erwin (CA)
Anne Fox (NJ)
Luta Garbat-Welch (KY)
Paul Geltman MD (MA)
Annette Holland (WA)
Barb Hummel (CO)
Cathy Joyce (FL)
Judy Kendall (SD)
Jossie Lange (TN)
Jessica Montour (TX), Chair
Ann O’Fallon (MN), Chair
Bill Stauffer, MD (CDC)
Kevin Scott, MD (Thomas Jefferson Medical College)
Kate Shoemaker (ORR)
Michelle Weinberg, MD (CDC)
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Appendix A: Medical Screening Operational Guidance for State Programs
1. Secure Positioning and Funding for State Refugee Health Coordinator and Staff
a. State Health Department
The State Health Department may or may not provide funding for a Refugee Health
Program. Health department funding may be dependent upon the general budget
as well as the structure of refugee resettlement within each state. Private
organizations are included as a part of the administrative/funding structures for
refugee resettlement oversight within states with a Wilson-Fish alternative
program. In this case, the state health department may not have direct oversight
over the Refugee Health Program.
Positioning the Refugee Health Program in the state health department allows for
collaboration with other public health programs, and in some cases recognition of
authority by health care providers. State Refugee Health Coordinators positioned
within private organizations, however, may have more flexibility in initiatives,
planning, and travel.
b. Refugee Medical Assistance (RMA)
Refugee Medical Assistance funds can be utilized for staff positions for Refugee
Health Programs. For traditional states RMA funds can be accessed through
interagency agreements with the State Coordinator’s office. Wilson-Fish Refugee
Medical Assistance for Wilson-Fish alternative programs can also be accessed
through the Wilson-Fish Cooperative Agreement with the Office of Refugee
Resettlement (ORR), through the State Refugee Coordinator’s office.
c. ORR Preventive Health Grant
The ORR Preventive Health Grant is a grant provided by ORR for additional support
of the Refugee Health Screening process and related project initiatives and can be
utilized to support funding for staff positions.
d. National and Local Foundation Support
National and local foundations that fund health related projects may provide
funding for refugee health programs. Examples include: Robert Wood Johnson
Foundation, health insurance foundations, and local Medicaid HMOs.
2. Develop a State Protocol for Refugee Health Assessments and Screenings
a. Utilize Existing Federal Guidance

The Office of Refugee Resettlement created the Medical Screening Protocol for
Newly Arriving Refugees in 1995. The document and other health related
information can be found at:
http://www.acf.hhs.gov/programs/orr/benefits/health.htm
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
The Centers for Disease Control and Prevention (CDC) provides overseas and
domestic guidelines for the screening of refugee populations. The guidelines can
be found at:
http://www.cdc.gov/immigrantrefugeehealth/guidelines/refugeeguidelines.html
b. Review with Clinicians
It may be helpful and/or necessary to review your screening protocol with health
department physicians or providers who will be working in refugee health screening
clinics. It is important to have buy in and feedback from clinicians in order to
establish a successful screening protocol.
c. Standardize the Protocol Statewide
In order to maintain successful oversight of refugee health screening practices
across multiple clinics within a state, it is ideal to have a standardized protocol that
is used statewide. This will also prevent inconsistencies in care throughout your
program.
3. Identify Clinics to Perform Health Assessments and Screenings
a. Types of Clinics
 Community Health Centers
 Local Health Departments (City, County, Regional)
 Private Not for Profit Clinics
 Free Standing Private Clinics
 Federally Qualified Health Care Centers (FQHCs)
 State Department of Health Clinics
 Mobile Health Units
 University affiliated Clinics
 Hospital affiliated Clinics
b. Implementation of a State Protocol
Each state should ideally expect that each entity providing screening complete all
components of the state protocol. Depending on resources, however, some clinics
may only be able to complete a public health screening rather than a full health
assessment.
c. Training Clinicians
States should ideally have a standardized statewide protocol for the screenings
done within their state and all providers regardless of role should receive training in
the protocol.
d. Contract with Screening Clinics
If possible states should contract with entities providing the screening to ensure
follow through on the protocol, ensure quality of care, and avoid states being
unable to obtain screening from clinics. In some states, it may also be necessary or
possible to utilize state employees to staff refugee health screening clinics.
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4. Arrival Notification Resources for State Refugee Health Programs
a. Electronic Disease Notification System (EDN)
EDN is a secure, web-based electronic system to notify CDC’s public health partners
of immigrant, refugee, Special Immigrant Visa holders (SIVs), and select asylee and
parolee arrivals. It includes information obtained during overseas exams, including
tuberculosis status, vaccination records, and other information on diseases of public
health importance. EDN contains arrival jurisdictions at the state level, but can also
be separated further into counties.
The information contained in this electronic system includes personally-identifiable
medical information and other confidential information that requires protection
from unauthorized access. As a condition for access to the EDN system, individuals
must obtain a digital certificate and agree to comply with the user rules established
by CDC. To access EDN, users must complete and obtain required authorization
signatures, on the most current version of the EDN “Rules of Behavior” and
“Agreement to Participate and Consent” forms. Forms are available via email at:
[email protected].
b. U.S. Department of Health and Human Services (DHHS)
DHHS is the sole federal agency authorized to certify adult foreign victims of human
trafficking. The agency is also responsible for granting eligibility of minor foreign
victims of trafficking access to federal benefits and services to the same extent as
refugees, including placement in the Unaccompanied Refugee Minors program. ORR
issues all certifications and eligibility letters. State Refugee Health Programs must
contact ORR and provide the name(s) and contact information for the person
responsible for receiving these notifications.
c. Worldwide Refugee Admissions Processing System (WRAPS)
WRAPS is a standardized computer refugee resettlement case management system.
This system links the Bureau of Population, Refugees and Migration (PRM) partners
with a data communications network capable of facilitating the entire refugee
resettlement process. WRAPS is maintained by the U.S. Department of State to
track refugee and SIV applicants as they move through the required processing
steps. Information accessible to states include: alien number, file number,
relationship, name, date of birth, gender, nationality, voluntary resettlement
agency, city of resettlement, and arrival date. The reports available to states
include: Monthly Arrivals Report, Monthly Assurances Report, and Quarterly
Forecasting Report. State Refugee Health Programs can request access though their
State Coordinator to an e-mail account to which reports are delivered. At this time
access to WRAPS by ARHC members is limited.
d. Local Refugee Resettlement Agencies
Local refugee resettlement agencies in each state receive assurances and
notifications of new arrivals requesting resettlement services. Notifications of
certain eligible populations are available through these agencies that are not
provided through other means. These include persons granted asylum status in the
U.S. and secondary refugee populations that are still eligible to receive the domestic
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health screening. State Refugee Health Programs should partner with all local
refugee resettlement agency affiliates to develop a referral process for new arrivals.
5. Develop a State Refugee Health Program Database
a. Justification
A database maintained by the state Refugee Health Program to keep track of
notifications, screening status, health outcomes, etc. is vital to the program’s
success. This database should be reflective of the specific needs of each state as
well as their clinic sites. In creating databases and information sharing processes, it
is also necessary to review HIPAA and other confidentiality policies at the state and
local levels.
b. Database Examples

Microsoft Access
Microsoft Access is a relational database management system available as part
of Microsoft Office. The system includes the ability to create data tables,
queries, forms, reports, etc. Many state refugee health programs use Access as
their main database or use it as a back-up for another primary database.

The Electronic System for Health Assessment of Refugees (eSHARE)
eSHARE is a web-based system used by refugee health programs in many states
(MN, TX, IN, IL, etc.) to collect domestic screening results and conduct disease
surveillance in the populations served by the program. Users of eSHARE are able
to generate health and demographic summary reports as well as individual
patient summary reports. eSHARE is a dynamic reporting system providing both
state and local users access to timely and complete screening data. eSHARE
source code is available free of charge through a limited license agreement with
the Minnesota Department of Health.
For more information:
http://www.health.state.mn.us/divs/idepc/refugee/hcp/eshare.html

Internally Developed System
Many Refugee Health Programs have worked with their agency’s Information
Technology departments to develop databases to fit the needs of their
programs. One example is Apache Maven.
6. Establish Working Relationships with Key Stakeholders
a. Clinic Staff Providing Health Assessments
In order to establish an effective Refugee Health Program within a state, it is ideal
to have an open line of direct communication with staff providing health screening
and assessment services. By having a mutually beneficial relationship with staff,
there will be increased awareness of expectations held by clinics and the state
Refugee Health Program. Ultimately, this should result in a higher quality of care for
patients.
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b. Resettlement Agencies and Other Groups Serving Refugees
Establishing collaborative relationships with the agencies providing refugee
resettlement within your state is essential. Ongoing working relationships will help
establish effective coordination and cooperation between resettlement and refugee
health stakeholders. It is also important to communicate and partner with
Community Based Organizations (CBOs) and Mutual Assistance Associations (MAAs)
providing services to refugee populations.
c. State Coordinator of Refugee Resettlement
Many state Refugee Health Programs are funded by RMA through an interagency
agreement with their State Coordinator’s office. Thus, it is crucial that they
understand the scope and needs of the program. The State Coordinator may also
have established working relationships with resettlement agencies on a national
and local level as well as with other national stakeholders. By having a successful
collaborative partnership with your State Coordinator, you will gain a better
understanding of the refugee resettlement process as a whole, and he or she will
gain a better understanding of the medical needs of the population and such needs
impact resettlement.
d. Association of Refugee Health Coordinators (ARHC)
Becoming involved with ARHC is the best way to collaborate with other state
Refugee Health Programs. The association includes State Refugee Health
Coordinators and related staff, as well as local providers. The group has a number of
innovative sub-committees, an interactive internal website, and monthly
conference calls including federal partners.
e. Federal Partners
There are numerous federal partners in the refugee resettlement and health arena
which can assist in establishing and maintaining an effective Refugee Health
Program.

The Office of Refugee Resettlement (ORR) within the U.S. Department of Health
and Human Services operates a number of different programs, provides funding
for cash and medical assistance, and provides discretionary grants including the
Preventative Health Grant.

The Bureau of Population, Refugees, and Migration (PRM) at the U.S.
Department of State works overseas as well as domestically to ensure the
successful reception and placement of refugees. Voluntary resettlement
agencies within the U.S. function under a cooperative agreement with PRM.
The Centers for Disease Control and Prevention (CDC) are also a key stakeholder in the success
of a state Refugee Health Program. The CDC’s Division of Global Migration and Quarantine
provides overseas and domestic refugee health screening guidelines.
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Appendix B: Refugee Health Clinical Assessment
Gender:  Male
 Female
Name (last, first, MI)
Date of Birth :
___/___/____
Alien #:
US Arrival Date
Country of Origin:__________________
___/___/____
Refugee Camp:____________________
Dates of Clinical Visit (s) for Screening
Screening Visit #1: ___/___/____(date)
Screening Visit #2: ___/___/____(date)
Class B Other / Specify:____________________________
 No  Yes (requires follow-up soon after arrival)
Class A status: ____________________
 No  Yes (requires approved waiver for US entry and
immediate follow-up upon arrival)
Class B TB status: ____________________
 No  Yes (requires follow-up soon after arrival)
Interpreter Needed:  Yes, language _______________  Professional interpreter__________________(name)
 No NOTE: Family and friends not recommended as interpreters
Consent for Treatment:
I consent to examination, diagnostic testing (which may include TB, hepatitis B, HIV, CBC), and treatment services provided by
___________________.
Signature:________________________________ Date___/___/____
Vital Signs
Height (in.):
Weight (lbs.):
Head Circum (in.):
BMI:
Pulse:
Blood Pressure:
Respirations:
Temperature (F ):
Vision Screening: OD__/20 OS__/20
0
Hearing Screen:  Normal  Abnormal
Past Medical History
Current Medications: None  Yes (list / attach) ________________________________________________________
Medication Allergies:  None  Yes (list / attach) ________________________________________________________
Herbal/Traditional treatments:  None  Yes (list / attach) ________________________________________________________
Vision problems:  Yes  No
Hearing problems:  Yes  No
Pregnant:  Yes EDD: _____________ No LMP: ___________
Dental problems:  Yes  No
G:_______ P:__________AB:__________
Cardiovascular:  Yes  No
Respiratory:  Yes  No
Skin:  Yes  No
Gastrointestinal:  Yes  No
Genitourinary:  Yes  No
Neurological/Seizures:  Yes  No
Mental Health Concern:  Yes  No
Musculoskeletal:  Yes  No
Endocrine:  Yes  No
Other:_________________________________________________
Tobacco / betel nut use:  Yes  No
Alcohol/ drug use:  Yes  No
Review of Systems
NL
Constitutional
Symptoms
Eyes
Ears, Nose, Mouth,
Throat
Cardiovascular
Description
NL
Description
MS
Integumentary
Neurological
Mental Health
Respiratory
Endocrine
GI
Hematologic, Lymphatic
GU/GYN
Allergic, Immunologic
Physical Exam Pallor__? Hepatosplenomegaly__? Lymphadenopathy__? Nutrition__?
NL
Description
NL
HEENT
Abdomen
Neck
Extremities
Cardiovascular
Musculoskeletal
Respiratory
Skin and SQ
Back
GI/Rectal
Breasts /GU
Neuro
Description
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Pregnancy Test (Urine pregnancy test for all women of childbearing age)
Screened?  Yes, ______(date)  Not done Results:  Negative  Positive
Immunizations
mm/dd/yr
mm/dd/yr
mm/dd/yr
mm/dd/yr
mm/dd/yr
mm/dd/yr
Measles
Mumps
Rubella
Varicella (VZV)
Diphtheria, Tetanus, and Pertussis (DTaP, DTP,
DT)
Diphtheria-Tetanus (Td, Tdap)
Polio (IPV, OPV)
Hepatitis B (HBV)
Hepatitis A
Meningococcal conjugate (MCV)
Haemophilus influenzae type b (Hib)
Influenza
Pneumococcal
Human Papilloma Virus (HPV)
Zoster (shingles)
Tuberculosis Screening Exposure to TB__? Cough__? Night Sweats__? Received BCG Vaccine___?
Interferon-Gamma Release Assays (IGRAs)
NOTE: TST is preferred for testing children aged <5 years
old.
___/___/____(date)
 Not done
 Positive
 Negative
 Indeterminate
Chest X-ray (If TST, IGRA positive, Class B or
Symptomatic)
___/___/____(date)
 Normal
 Abnormal, referred to TB Program
 Not done
Tuberculin Skin Test (TST)
_____mm induration ___/___/____(date)
 Not done
 Given, not read
Diagnosis (must check one)
 No TB infection or disease
 Latent TB infection (LTBI), referred to TB program or patient’s
primary care provider for follow-up ___/___/____(date)
 Active TB disease, referred to TB program for evaluation and
treatment. ___/___/____(date)
Hepatitis B Screening
Screened?  Yes___/___/____(date)  No
HBsAb
HBsAg
HBcAb
Diagnosis (must check one)
 Immune (HBsAb positive)
 Unvaccinated and susceptible (all negative); vaccinate
 Possible active (HbsAG or HBcAb positive), referred to
PMD / specialist for follow-up ___/___/____(date)
 Pending
Syphilis Screening (VDRL/RPR )
Screened?  Yes, ___/___/____(date)  Not done
Results:
 Negative  Positive; treated ___/___/____(date) or referred ___/___/____(date)  Titer ____________
Chlamydia /Gonorrhea Screening (urine specimen)
Gonorrhea
or referred ___/___/____(date)
Chlamydia
or referred ___/___/____(date)
HIV Screening CDC recommends for all persons 13-64 years of age; 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
17
infection (no history of high-risk exposures such as blood product transfusions, early sexual activity, or sexual
abuse).
Screened?  Yes, ___/___/____(date)  Offered, but refused
 Not done
Results:
 Negative  N/A  Positive, and referred to HIV/AIDS program ___/___/____(date)
CBC with Differential
Screened?  Yes, _____________(date)  Not done
Results: Eosinophil _______ MCV_____ RDW_____
Eosinophilia present?  Yes, referred for further evaluation ___/___/____(date)  No  N/A
Intestinal Parasite Screening
Pre-Departure presumptive treatment?  Yes  No Unknown
 O&P x1
 Results Rec’d
 Domestic presumptive treatment
___/___/____(date)
___/___/____(date)
 O&P x 2
___/___/____(date)
 Serology test: (see population specific)  Schistosoma  Strongyloides
 No parasites found
 Parasites found, check all that apply below
 Treatment completed ___/___/____(date)
Referral for treatment?
 Yes ___/___/____(date)
 No; why not? ____________________
 Clonorchis
 Entamoeba histolytica
 Hookworm
 Paragonimus
 Strongyloides
 Tapeworm
 Other (specify)
 Other (specify)
 Ascaris
 Giardia
 Schistosoma
 Trichuris
Malaria Screening Fever?
Pre-Departure presumptive treatment?  Yes  No Unknown
 No evidence of infection
Lead Screening (<17 yrs old)
 NOTE: Re-check all children aged 6 mo- 6 yrs within 3-6
months of arrival, regardless of results of initial lead screen.
Screened?  Yes ___/___/____(date)  Not done
Results:
 Negative
 Positive ________ (elevated BLL ≥10 μg/dL )
Mental Health Screening  Negative  Positive, referred to:______________________
Tortured__?
Ever been to prison__?
Weight Loss__? Appetite__?
Sleep__? Nightmares__?
Energy__? Down, depressed, hopeless or decreased interest in doing things over last two weeks__?
Do you have thoughts of harming yourself or hurting others__?
Referrals: (check all that apply)
 Primary care
 Dental
 Emergency/Urgent
 WIC
 Vision
 Mental Health
 Children with Special  Other___________________________
Health Care Needs
 Vitamins recommended:  Multivitamin  Vitamin D  Prenatal  Population specific:
 Bhutanese, B12
 Other___________________
Additional Labs and Screening
 Population specific: Test for Vitamin B12 in Bhutanese with clinical manifestations suggestive of deficiency
 Infant metabolic screening in newborns, according to state guidelines
 In clinic settings allowing for follow up in primary care consider: complete metabolic panel; lipid panel if appropriate,
cancer screening
Provider Name/Title
______/______/______ (date)
18
Health Screening Tests Recommended for All Refugees
Components of Refugee Health Assessment: Complete history, review of systems, physical examination including
assessment for infectious disease and chronic disease, and laboratory testing. Infectious diseases continue to be
significant and can be readily addressed when identified. There is increased recognition that chronic health disorders are
common and may pose greater long-term threat to the individual’s health.
Disease or Condition Screening Recommendations
Immunizations
Tuberculosis (TB)
Hepatitis B
Sexually Transmitted
Infections
Assess and update immunizations for each individual. Indicate laboratory evidence of immunity for
measles, mumps, rubella, varicella, polio, hepatitis B or hepatitis A, if available; immunizations are not
needed if immune. For all other immunizations, update series or begin primary series if immunization
dates are not found. If you need assistance translating immunization records or determining needed
immunizations, call CDC hotline 800-CDC-INFO (1-800-232-4636).
Always update the personal immunization record card.
Perform a tuberculin skin test (TST) or blood interferon gamma assay (IGRA) for TB for all
individuals regardless of BCG history, unless documented previous positive test. TST is preferred for
testing children aged <5 years old. Pregnancy is not a medical contraindication for TST testing or for
treatment of active or latent TB. TST administered prior to 6 months of age may yield false negative
results.
 A chest x-ray should be performed for all individuals with a positive TST or IGRA test
 A chest x-ray should also be performed regardless of TST results for:
o those with a TB Class A or B1 designation from overseas exam or
o those who have symptoms compatible with TB disease.
Administer a hepatitis B screening panel including hepatitis B surface antigen (HBsAg), hepatitis B
surface antibody (anti-HBs), and hepatitis B core antibody (anti-HBc) to all adults and children.
Vaccinate previously unvaccinated and susceptible children, 0-18 years of age. Vaccinate susceptible
adults at increased risk for HBV infection (due to close interaction within their communities) or from
endemic countries. Refer all persons with chronic HBV infection for additional ongoing medical
evaluation. Consider vaccination in individuals with any chronic liver disease (e.g. hepatitis C).
Routine screening for HIV, ages 13- 64 years; 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) using Anti-HIV 1+2 assay. Screen for syphilis by administering VDRL or RPR. Confirm
positive VDRL or RPR by FTA-ABS/MHATP or other confirmatory test. Repeat VDRL/FTA in 2 weeks if
lesions typical of primary syphilis are noted and person is sero-negative on initial screening. Use your
clinical judgment to screen for chlamydia and gonorrhea using urine specimen if possible. Screen other
STDs if indicated by self-report or endemicity in homeland.
For all refugee arrivals (asymptomatic and symptomatic):
 Confirm specific pre-departure presumptive treatment
 Evaluate for eosinophilia* by obtaining a CBC with differential
(eosinophilia >400cells/µl)
Intestinal Parasites
PLUS
Documented pre-departure presumptive treatment
No documented pre-departure
presumptive treatment:
For single-dose albendazole
pre-departure treatment (no
praziquantel)
For single-dose albendazole
pre-departure treatment with
praziquantel
For high-dose pre-departure
treatment (ivermectin and
praziquantel):

Strongyloides serology
(all refugees);
Schistosoma serology
(sub-Saharan Africans);
 Treat if positive for
Strongyloides stercoralis or
Schistosoma spp.
 If positive for eosinophilia,
re-check total eosinophil
count in 3-6 months.**

Strongyloides serology
(all refugees);
 Treat if positive for
Strongyloides stercoralis
 If positive for eosinophilia,
re-check total eosinophil
count in 3-6 months.**

If positive for eosinophilia,
re-check total eosinophil
count in 3-6 months after
arrival. **






Conduct stool examinations
for ova and parasites (O&P);
two stool specimens should
be obtained more than 24
hours apart;
Strongyloides serology (all
refugees);
Schistosoma serology (subSaharan Africans);
Treat pathogenic parasites;
Re-check total eosinophil
count in 3-6 months.**
19
Intestinal Parasites,
continued
*Eosinophilia may or may not be present with parasitic infection; an absolute eosinophil count provides
supplemental diagnostic information.
** Persistent eosinophilia or symptoms requires further diagnostic evaluation.
If parasites are identified, one stool specimen should be submitted 2-3 weeks after completion of
therapy to determine response to treatment. For background information and treatment guidelines see
CDC’s Evaluation of Refugees for Intestinal and Tissue-Invasive Parasitic Infections during Domestic
Medical Examination, as well as The Medical Letter on Drugs and Therapeutics: Drugs for Parasitic
Infections.
Malaria
Screen those refugees present with symptoms suspicious of malaria. For asymptomatic refugees from
highly endemic areas, i.e., sub-Saharan Africa, screen or presumptively treat if no documented predeparture therapy (note contraindications for pregnant or lactating women and children < 5 kg)
Lead
Venous blood lead level (BLL) screening is recommended for all refugee children under 17 years.
Check for lead sources in children with elevated BLL ≥10 μg/dL; check BLLs in all family members.
Follow up management. Prescribe daily pediatric multivitamins with iron for refugee children 6 to 59
months of age.
Mental Health
Assess for signs of post traumatic stress, acute psychiatric disorders; assess mental health as reflected
in general health and well being (e.g., sleeplessness, headaches, nightmares, irritability).
Appendix C: “Smart Sets” Sample
SmartSet: NEW ARRIVAL SCREENING (ID:910)
General Information
Display name:
New Arrival Screening
Type:
General
Merge priority:
0
Version comment:
Updated per xxxx
Third party content:
Synonyms:
SmartSet notes:
Description:
Web information:
Title
1.
Questionnaire:
Configuration
Documentation
New Arrival Screening
NEW ARRIVAL SCREENING (Right Click to begin
documentation)
Blank text, so you may insert your own phrases
Lab
URL
21
Lab
TB GOLD, QUANTIFERON
Routine, Expected:S, Expires: S+120, Qty-1
CHLAMYDIA & GC
Routine, Expected:S, Expires: S+120
What is the source of the sample?: CERVIX
What is the source of the sample?: URINE
HEMOGRAM/PLTS/DIFF [3656]
Routine, Expected:S, Expires: S+120, Qty-1
BASIC METABOLIC PANEL [3690]
Routine, Expected:S, Expires: S+120, Qty-1
ALT (SGPT) "For patients 12 years of age and
older"
Routine, Expected:S, Expires: S+120, Qty-1
AST "For patients 12 years of age and older"
Routine, Expected:S, Expires: S+120, Qty-1
HEP A VAC SCREEN
Routine, Expected:S, Expires: S+120, Qty-1
HBSAG (B SURFACE ANTIGEN) [0186]
Routine, Expected:S, Expires: S+120, Qty-1
HEPATITIS B SURFACE, AB(aka HBSAB)
[0510]
Routine, Expected:S, Expires: S+120, Qty-1
HEPATITIS B CORE,AB [0185]
Routine, Expected:S, Expires: S+120, Qty-1
HEPATITIS C AB [0982]
Routine, Expected:S, Expires: S+120, Qty-1
UA MICRO IF [3307]
Routine, Expected:S, Expires: S+120, Qty-1
PARASITE BLOOD SMEAR(aka MALARIA)
[3131]
Routine, Expected:S, Expires: S+120, Qty-1
RPR (SYPHYLIS SCREEN) [0240]
Routine, Expected:S, Expires: S+120, Qty-1
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HIV 1/2 ANTIBODY [0404]
Routine, Expected:S, Expires: S+120, Qty-1
PREGNANCY TEST (URINE) [0195]
Urine,random, Routine, Expected:S, Expires: S+120,
Qty-1
LEAD "For patients 6 years of age and
younger"
Routine, Expected:S, Expires: S+120, Qty-1
V ZOSTER IMMUNE STATUS
Routine, Expected:S, Expires: S+120, Qty-1
OVA AND PARASITE EXAM X 2
Panel
OVA & PARASITE EXAM #1
Stool, Routine, Qty-1
OVA & PARASITE EXAM #2
Stool, Routine, Qty-1
Immunization Orders
DIPHTHERIA - TETANUS - PERTUSSIS
DTAP (V06.1A)
Qty-1
Did patient receive physician counseling? (for
under 8 years of age): Yes
DTAP-HEP B-IPV INACTIVATED-IM
USE(V06.8)
Qty-1
Did patient receive physician counseling? (for
under 8 years of age): Yes
DTAP/HIB (FOR PTS >= 15 MOS)(V06.8)
Qty-1
Did patient receive physician counseling? (for
under 8 years of age): Yes
DTAP/IPV/HIB (<5 YEARS OLD) (V06.8)
Qty-1
Did patient receive physician counseling? (for
under 8 years of age): Yes
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TD (ADULT ONLY) (V06.5C)
Qty-1
Did patient receive physician counseling? (for
under 8 years of age): Yes
TD PRESERVATIVE FREE(V06.5C)
Qty-1
Did patient receive physician counseling? (for
under 8 years of age): Yes
TDAP 10-64 YRS (BOOSTRIX) (V06.1A)
Qty-1
Did patient receive physician counseling? (for
under 8 years of age): Yes
TDAP 11-64 YRS (ADACEL) (V06.1A)
Qty-1
Did patient receive physician counseling? (for
under 8 years of age): Yes
Dx: Vaccine for Dis Combinations NEC
Dx: Vaccine for DTP
Dx: Vaccine for Tetanus-Diphtheria (TD)
GARDASIL
HUMAN PAPILLOMAVIRUS VACCINE (V04.89)
Qty-1
Did patient receive physician counseling? (for
under 8 years of age): Yes
Dx: Vaccine for HPV
HEPATITIS A & B
HEPATITIS A (1-19 YRS) (V05.3)
Qty-1
Did patient receive physician counseling? (for
under 8 years of age): Yes
HEPATITIS A ADULT (V05.3)
Qty-1
Did patient receive physician counseling? (for
under 8 years of age): Yes
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HEPA & HEPB ADULT (V05.3)
Qty-1
Did patient receive physician counseling? (for
under 8 years of age): Yes
HEPATITIS B 0-19YRS (V05.3)
Qty-1
Did patient receive physician counseling? (for
under 8 years of age): Yes
HEPATITIS B ADULT(V05.3)
Qty-1
Did patient receive physician counseling? (for
under 8 years of age): Yes
HIB/HBV (V06.8)
Qty-1
Did patient receive physician counseling? (for
under 8 years of age): Yes
Dx: Vaccine for Viral Hepatitis
Dx: Vaccine for Dis Combinations NEC
HERPES ZOSTER (SHINGLES)
ZOSTER -All patients will need to sign a "Zoster
Vaccine Payment Agreement Waiver"
Qty-1
Did patient receive physician counseling? (for
under 8 years of age): Yes
Dx: Vaccine for Herpes Zoster
HIB
HIB PRP-T CONJUGATE (ACTHIB)(V03.81)
Qty-1
Did patient receive physician counseling? (for
under 8 years of age): Yes
HIB-PRP-OMP(PEDVAXHIB)(V03.81)
Qty-1
Did patient receive physician counseling? (for
under 8 years of age): Yes
HIB/HBV (V06.8)
Qty-1
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Did patient receive physician counseling? (for
under 8 years of age): Yes
DTAP/HIB (FOR PTS >= 15 MOS)(V06.8)
Qty-1
Did patient receive physician counseling? (for
under 8 years of age): Yes
Dx: Vaccine for Hem Influenza B
Dx: Vaccine for Dis Combinations NEC
INFLUENZA
INFLUENZA 6-35 MO (V04.81)
Qty-1
Did patient receive physician counseling? (for
under 8 years of age): Yes
INFLUENZA VAC 100% PRE FREE, 6-35
MO(V04.81)
Qty-1
Did patient receive physician counseling? (for
under 8 years of age): Yes
INFLUENZA 3+YRS (V04.81)
Qty-1
Did patient receive physician counseling? (for
under 8 years of age): Yes
INFLUENZA PRESERVATIVE FREE
3+YRS(V04.81)
Qty-1
Did patient receive physician counseling? (for
under 8 years of age): Yes
INFLUENZA LIVE INTRANASAL 2-49 YRS
(V04.81)
Qty-1
Did patient receive physician counseling? (for
under 8 years of age): Yes
Dx: Vaccine for Influenza
MMR
MMR (V06.4)
Qty-1
Did patient receive physician counseling? (for
under 8 years of age): Yes
Enhancing Partnerships in Refugee Health
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MMR/VARICELLA (V06.8)
Qty-1
Did patient receive physician counseling? (for
under 8 years of age): Yes
Dx: Vaccine for Measle-Mumps-Rubella
Dx: Vaccine for Dis Combinations NEC
MENINGOCOCCAL
MENINGOCOCCAL CONJUGATE (Menactra)
(V03.89)
Qty-1
Did patient receive physician counseling? (for
under 8 years of age): Yes
MENINGOCOCCL POLYSACCHRID (Menomune)
(V03.89)
Qty-1
Did patient receive physician counseling? (for
under 8 years of age): Yes
Dx: Vaccine for Meningococcal
POLIO
IPV POLIO (V04.0)
Qty-1
Did patient receive physician counseling? (for
under 8 years of age): Yes
DTAP-HEP B-IPV INACTIVATED-IM
USE(V06.8)
Qty-1
Did patient receive physician counseling? (for
under 8 years of age): Yes
DTAP/IPV (4-6 YEARS) (V06.8)
Qty-1
Did patient receive physician counseling? (for
under 8 years of age): Yes
DTAP/IPV/HIB (<5 YEARS OLD) (V06.8)
Qty-1
Did patient receive physician counseling? (for
under 8 years of age): Yes
Enhancing Partnerships in Refugee Health
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Dx: Vaccine for Polio
Dx: Vaccine for Dis Combinations NEC
PNEUMOCOCCAL
PNEUMOCOCCAL, PED (Prevnar) (V03.82)
Qty-1
Did patient receive physician counseling? (for
under 8 years of age): Yes
PNEUMOCOCCAL (Pneumovax) (V03.82)
Qty-1
Did patient receive physician counseling? (for
under 8 years of age): Yes
Vaccine for Strep Pneumoniae
ROTAVIRUS
ROTAVIRUS, ORAL (V04.89) - Not approved for
first dose after 12 wks age
Qty-1
Did patient receive physician counseling? (for
under 8 years of age): Yes
Dx: Vaccine for Viral Disease
VARICELLA
VARICELLA (VARIVAX)(V05.4)
Qty-1
Did patient receive physician counseling? (for
under 8 years of age): Yes
MMR/VARICELLA (V06.8)
Qty-1
Did patient receive physician counseling? (for
under 8 years of age): Yes
Dx: Vaccine for Varicella
Dx: Vaccine for Dis Combinations NEC
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Other Orders
Other Orders
CHEST PA/LAT 2VIEWS [IMG1209]
Qty-1, Expected:S, Expires: S+365, Ancillary
Performed, Routine
MANTOUX TEST (V74.1) [86580]
Qty-1, Normal, Routine
Diagnosis
Diagnosis
Radiological Examination, not Elsewhere
Classified
Preventive Care Exam
Positive Mantoux
Pregnancy Test, Preg Unconfirmed
Screening for Pulmonary Tuberculosis
Screening Examination for Venereal Disease
Screening for Lead Poisoning
Screening Examination for Parasitic Infection
Enhancing Partnerships in Refugee Health
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Patient Instructions
Patient Instructions
New Arrival Screening Information
LOS
LOS
PREVENTIVE EXAM NEW PT - INFANT
PREVENTIVE EXAM NEW PT AGE 1-4
PREVENTIVE EXAM NEW PT AGE 5-11
PREVENTIVE EXAM NEW PT AGE 12-17
PREVENTIVE EXAM NEW PT AGE 18-39
PREVENTIVE EXAM NEW PT AGE 40-64
PREVENTIVE EXAM NEW PT AGE 65 AND OVER
Criteria
Suggestions:
Filter:
RESTRICTION LOCATOR-OUTPATIENT[179]
Restrict SmartSet:
Inpatient Settings
Enhancing Partnerships in Refugee Health
Final Report: Medical Screening Recommendations
30
Discontinue action:
Do not show other orders when one is discontinued
Deselect sections for
Pended/Held orders:
Pended/Held orders
display:
Release date:
Use System Definitions Setting
Disallow user override:
SmartSet: NEW ARRIVAL SCREENING (ID:910)
General Information
Display name:
New Arrival Screening
Type:
General
Merge priority:
0
Version comment:
Updated per xxxx
Third party content:
Synonyms:
SmartSet notes:
Description:
Web information:
Title
URL
1.
Questionnaire:
Configuration
Documentation
New Arrival Screening
Enhancing Partnerships in Refugee Health
Final Report: Medical Screening Recommendations
31
NEW ARRIVAL SCREENING (Right Click to begin
documentation)
Blank text, so you may insert your own phrases
Lab
Lab
TB GOLD, QUANTIFERON
Routine, Expected:S, Expires: S+120, Qty-1
CHLAMYDIA & GC
Routine, Expected:S, Expires: S+120
What is the source of the sample?: CERVIX
What is the source of the sample?: URINE
HEMOGRAM/PLTS/DIFF [3656]
Routine, Expected:S, Expires: S+120, Qty-1
BASIC METABOLIC PANEL [3690]
Routine, Expected:S, Expires: S+120, Qty-1
ALT (SGPT) "For patients 12 years of age and
older"
Routine, Expected:S, Expires: S+120, Qty-1
AST "For patients 12 years of age and older"
Routine, Expected:S, Expires: S+120, Qty-1
HEP A VAC SCREEN
Routine, Expected:S, Expires: S+120, Qty-1
HBSAG (B SURFACE ANTIGEN) [0186]
Routine, Expected:S, Expires: S+120, Qty-1
HEPATITIS B SURFACE, AB(aka HBSAB)
[0510]
Routine, Expected:S, Expires: S+120, Qty-1
HEPATITIS B CORE,AB [0185]
Routine, Expected:S, Expires: S+120, Qty-1
HEPATITIS C AB [0982]
Routine, Expected:S, Expires: S+120, Qty-1
Enhancing Partnerships in Refugee Health
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UA MICRO IF [3307]
Routine, Expected:S, Expires: S+120, Qty-1
PARASITE BLOOD SMEAR(aka MALARIA)
[3131]
Routine, Expected:S, Expires: S+120, Qty-1
RPR (SYPHYLIS SCREEN) [0240]
Routine, Expected:S, Expires: S+120, Qty-1
HIV 1/2 ANTIBODY [0404]
Routine, Expected:S, Expires: S+120, Qty-1
PREGNANCY TEST (URINE) [0195]
Urine,random, Routine, Expected:S, Expires: S+120,
Qty-1
LEAD "For patients 6 years of age and
younger"
Routine, Expected:S, Expires: S+120, Qty-1
V ZOSTER IMMUNE STATUS
Routine, Expected:S, Expires: S+120, Qty-1
OVA AND PARASITE EXAM X 2
Panel
OVA & PARASITE EXAM #1
Stool, Routine, Qty-1
OVA & PARASITE EXAM #2
Stool, Routine, Qty-1
Immunization Orders
DIPHTHERIA - TETANUS - PERTUSSIS
DTAP (V06.1A)
Qty-1
Did patient receive physician counseling? (for
under 8 years of age): Yes
DTAP-HEP B-IPV INACTIVATED-IM
USE(V06.8)
Qty-1
Did patient receive physician counseling? (for
under 8 years of age): Yes
Enhancing Partnerships in Refugee Health
Final Report: Medical Screening Recommendations
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DTAP/HIB (FOR PTS >= 15 MOS)(V06.8)
Qty-1
Did patient receive physician counseling? (for
under 8 years of age): Yes
DTAP/IPV/HIB (<5 YEARS OLD) (V06.8)
Qty-1
Did patient receive physician counseling? (for
under 8 years of age): Yes
TD (ADULT ONLY) (V06.5C)
Qty-1
Did patient receive physician counseling? (for
under 8 years of age): Yes
TD PRESERVATIVE FREE(V06.5C)
Qty-1
Did patient receive physician counseling? (for
under 8 years of age): Yes
TDAP 10-64 YRS (BOOSTRIX) (V06.1A)
Qty-1
Did patient receive physician counseling? (for
under 8 years of age): Yes
TDAP 11-64 YRS (ADACEL) (V06.1A)
Qty-1
Did patient receive physician counseling? (for
under 8 years of age): Yes
Dx: Vaccine for Dis Combinations NEC
Dx: Vaccine for DTP
Dx: Vaccine for Tetanus-Diphtheria (TD)
GARDASIL
HUMAN PAPILLOMAVIRUS VACCINE (V04.89)
Qty-1
Did patient receive physician counseling? (for
under 8 years of age): Yes
Dx: Vaccine for HPV
HEPATITIS A & B
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HEPATITIS A (1-19 YRS) (V05.3)
Qty-1
Did patient receive physician counseling? (for
under 8 years of age): Yes
HEPATITIS A ADULT (V05.3)
Qty-1
Did patient receive physician counseling? (for
under 8 years of age): Yes
HEPA & HEPB ADULT (V05.3)
Qty-1
Did patient receive physician counseling? (for
under 8 years of age): Yes
HEPATITIS B 0-19YRS (V05.3)
Qty-1
Did patient receive physician counseling? (for
under 8 years of age): Yes
HEPATITIS B ADULT(V05.3)
Qty-1
Did patient receive physician counseling? (for
under 8 years of age): Yes
HIB/HBV (V06.8)
Qty-1
Did patient receive physician counseling? (for
under 8 years of age): Yes
Dx: Vaccine for Viral Hepatitis
Dx: Vaccine for Dis Combinations NEC
HERPES ZOSTER (SHINGLES)
ZOSTER -All patients will need to sign a "Zoster
Vaccine Payment Agreement Waiver"
Qty-1
Did patient receive physician counseling? (for
under 8 years of age): Yes
Dx: Vaccine for Herpes Zoster
HIB
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HIB PRP-T CONJUGATE (ACTHIB)(V03.81)
Qty-1
Did patient receive physician counseling? (for
under 8 years of age): Yes
HIB-PRP-OMP(PEDVAXHIB)(V03.81)
Qty-1
Did patient receive physician counseling? (for
under 8 years of age): Yes
HIB/HBV (V06.8)
Qty-1
Did patient receive physician counseling? (for
under 8 years of age): Yes
DTAP/HIB (FOR PTS >= 15 MOS)(V06.8)
Qty-1
Did patient receive physician counseling? (for
under 8 years of age): Yes
Dx: Vaccine for Hem Influenza B
Dx: Vaccine for Dis Combinations NEC
INFLUENZA
INFLUENZA 6-35 MO (V04.81)
Qty-1
Did patient receive physician counseling? (for
under 8 years of age): Yes
INFLUENZA VAC 100% PRE FREE, 6-35
MO(V04.81)
Qty-1
Did patient receive physician counseling? (for
under 8 years of age): Yes
INFLUENZA 3+YRS (V04.81)
Qty-1
Did patient receive physician counseling? (for
under 8 years of age): Yes
INFLUENZA PRESERVATIVE FREE
3+YRS(V04.81)
Qty-1
Did patient receive physician counseling? (for
under 8 years of age): Yes
INFLUENZA LIVE INTRANASAL 2-49 YRS
(V04.81)
Qty-1
Did patient receive physician counseling? (for
under 8 years of age): Yes
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Dx: Vaccine for Influenza
MMR
MMR (V06.4)
Qty-1
Did patient receive physician counseling? (for
under 8 years of age): Yes
MMR/VARICELLA (V06.8)
Qty-1
Did patient receive physician counseling? (for
under 8 years of age): Yes
Dx: Vaccine for Measle-Mumps-Rubella
Dx: Vaccine for Dis Combinations NEC
MENINGOCOCCAL
MENINGOCOCCAL CONJUGATE (Menactra)
(V03.89)
Qty-1
Did patient receive physician counseling? (for
under 8 years of age): Yes
MENINGOCOCCL POLYSACCHRID (Menomune)
(V03.89)
Qty-1
Did patient receive physician counseling? (for
under 8 years of age): Yes
Dx: Vaccine for Meningococcal
POLIO
IPV POLIO (V04.0)
Qty-1
Did patient receive physician counseling? (for
under 8 years of age): Yes
DTAP-HEP B-IPV INACTIVATED-IM
USE(V06.8)
Qty-1
Did patient receive physician counseling? (for
under 8 years of age): Yes
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DTAP/IPV (4-6 YEARS) (V06.8)
Qty-1
Did patient receive physician counseling? (for
under 8 years of age): Yes
DTAP/IPV/HIB (<5 YEARS OLD) (V06.8)
Qty-1
Did patient receive physician counseling? (for
under 8 years of age): Yes
Dx: Vaccine for Polio
Dx: Vaccine for Dis Combinations NEC
PNEUMOCOCCAL
PNEUMOCOCCAL, PED (Prevnar) (V03.82)
Qty-1
Did patient receive physician counseling? (for
under 8 years of age): Yes
PNEUMOCOCCAL (Pneumovax) (V03.82)
Qty-1
Did patient receive physician counseling? (for
under 8 years of age): Yes
Vaccine for Strep Pneumoniae
ROTAVIRUS
ROTAVIRUS, ORAL (V04.89) - Not approved for
first dose after 12 wks age
Qty-1
Did patient receive physician counseling? (for
under 8 years of age): Yes
Dx: Vaccine for Viral Disease
VARICELLA
VARICELLA (VARIVAX)(V05.4)
Qty-1
Did patient receive physician counseling? (for
under 8 years of age): Yes
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MMR/VARICELLA (V06.8)
Qty-1
Did patient receive physician counseling? (for
under 8 years of age): Yes
Dx: Vaccine for Varicella
Dx: Vaccine for Dis Combinations NEC
Other Orders
Other Orders
CHEST PA/LAT 2VIEWS [IMG1209]
Qty-1, Expected:S, Expires: S+365, Ancillary
Performed, Routine
MANTOUX TEST (V74.1) [86580]
Qty-1, Normal, Routine
Diagnosis
Diagnosis
Radiological Examination, not Elsewhere
Classified
Preventive Care Exam
Positive Mantoux
Pregnancy Test, Preg Unconfirmed
Screening for Pulmonary Tuberculosis
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Screening Examination for Venereal Disease
Screening for Lead Poisoning
Screening Examination for Parasitic Infection
Patient Instructions
Patient Instructions
New Arrival Screening Information
LOS
LOS
PREVENTIVE EXAM NEW PT - INFANT
PREVENTIVE EXAM NEW PT AGE 1-4
PREVENTIVE EXAM NEW PT AGE 5-11
PREVENTIVE EXAM NEW PT AGE 12-17
PREVENTIVE EXAM NEW PT AGE 18-39
PREVENTIVE EXAM NEW PT AGE 40-64
PREVENTIVE EXAM NEW PT AGE 65 AND OVER
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Criteria
Suggestions:
Filter:
RESTRICTION LOCATOR-OUTPATIENT[179]
Restrict SmartSet:
Inpatient Settings
Discontinue action:
Do not show other orders when one is discontinued
Deselect sections for
Pended/Held orders:
Pended/Held orders
display:
Release date:
Use System Definitions Setting
Disallow user override:
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Final Report: Medical Screening Recommendations
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Appendix D: Pocket Guide – Minnesota
Enhancing Partnerships in Refugee Health
Final Report: Medical Screening Recommendations
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Appendix E: Spokane Regional Health District Refugee
Program Manual
Spokane Regional Health
District
Refugee
Program
Manual
Spokane Regional Health District adheres to the Refugee
Screening guidelines set forth by DSHS- Community Services
Division contract, and Centers for Disease Control and Prevention
Technical Instructions for Immigrant and Refugee Health.
__________________________
Joel McCullough, MD, MPH
Health Officer
_____________________
Date
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Table of Contents
Page
3
3
4
5
6
7
7
9
11
13
14
15
16
17
18
20
22
23
24
25
26
27
30
31
Background
The Oversees Visa Medical Examination
Refugees with Communicable Diseases
o Class A & B Conditions
Communicable Diseases of Public Health Significance
Laws and Regulations
Domestic Health Assessment/Screening
Adjustment in Status Examination
Domestic Health Screening – Preparation
Health History and Screening
Vision Screening
Hearing Screening
Dental Screening
Tuberculosis Screening
Specimen Collection for QFT-IT
Tuberculosis Screening – TB Skin Testing
Immunizations
Hepatitis B Screening
Parasite Screening
Processing a Stool Specimen
Lead Screening
HIV Screening
Providing Culturally and Linguistically Appropriate Care
Guidelines for Using Medical Interpreters
Glossary
Appendices
A
B
C
D
Refugee Contract
Domestic Examination for Newly Arrived Refugees
Domestic Refugee Health Program Frequently Asked Questions
General & Optional Testing during the Domestic Medical Examination for
Newly Arriving Refugees
Screening for HIV-Infection during the Refugee Domestic Medical
E
Examination
F
Guidelines for Evaluation of Refugees for Intestinal and Tissue-Invasive
Parasitic Infection during Domestic Medical Examination
G
Vaccination Requirements for Adjustment of Status for US Permanent
Residence: Technical Instructions for Civil Surgeons
H
Recommendations for Routine Testing & Follow-up for Chronic Hepatitis B
Virus (HBV) Infection
I
Interpretation of Hepatitis B Serologic Test Results
J
Cultural Competency Training
K
Laws Referring to Language Access
Created 7/12/10 CJ
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Background
The Refugee Health Program (RHP) was created in response to the
Federal Refugee Act of l980, which created a uniform system of services
for refugees across the United States. The Act entitled all newly arriving
refugees to a comprehensive health assessment, to be initiated as soon
as possible following arrival. One agency in each state is designated to
monitor the provision of these health assessment services. In
Washington, that agency is the Department of Social and Health Services
(DSHS) – Community Services Division. Voluntary agencies (Volags) such
as World Relief are also notified of refugee arrivals, but through a
separate, but parallel system.
Medical Examinations for Refugees
Refugees may undergo two to three major medical examinations
as part of their process of immigration. Nursing staff should
become familiar with the medical documents from these
examinations, as refugees may bring them along for their medical
appointments.
The Overseas Visa Medical Examination
An overseas health screening is conducted prior to departure for
the United States to ensure that refugees seeking to enter the U.S.
do not have health conditions which would create social or
economic burdens to our country. This exam is performed in
refugee camps or areas of significant refugee settlement. This
mandatory examination is designed to exclude individuals who
have communicable diseases of public health significance, physical
or mental disorders that involve harmful behaviors, or problems
with current drug abuse or addiction. International Organization
for Migration (IOM) physicians (or a local panel of physicians
approved by the CDC) perform the examination using locally
available facilities and document their findings on the DS-2053
form.
The quality of the Overseas Visa Medical Examination varies and
depends on such factors as the site of the examination, the panel
of physicians, and the length of time for which the examination
process has been in place at a given location. The Overseas Visa
Medical Examination is valid for up to one year prior to departure.
The Overseas Visa Medical Examination includes:
 Medical history and physical examination.
 A TB exam that consists of a physical examination, medical
history, and various TB screening tests which
The Overseas Visa Medical Examination (continued)
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



may include a tuberculin skin testing (TST), interferon gamma release assay (IGRA),
chest x-ray, and other diagnostic testing as needed to determine if the arrival has latent
TB infection (LTBI) or active TB. Arrivals with TB-related findings are assigned a “TB
Class”.
Serologic testing for syphilis for age > 15 years. Refugees with positive results are
required to undergo treatment prior to departure for the US; physical exam for evidence
of other STDs. As of January 4, 2010, refugees will no longer be tested for HIV infection
prior to arrival in the US.
Physical exam for signs of Hansen’s disease. Refugees with lab-confirmed Hansen’s
disease are placed on treatment for six months before they are eligible for travel to
the US.
Treatment for parasitic infections which varies from country to country.
A determination regarding whether or not a refugee has a mental disorder;
physicians rely on a medical history provided by the patient and his/her relatives and
any documentation such as medical and hospitalization records.
Refugees found to have Communicable Diseases during Oversees Exam
Departure of refugees with communicable diseases that prevent their entry into the United
States (e.g., syphilis, gonorrhea, or Hansen’s disease) may be delayed until appropriate treatment is initiated and they are no longer infectious. Following treatment, refugees will be
allowed to immigrate to the U.S. Waivers may be requested for conditions that are grounds for
exclusion. Medical conditions are categorized as Class A or B.
Class A Conditions
Class A conditions prevent a refugee from entering the United States. They include
communicable diseases of public health significance, mental illnesses associated with
violent behavior, and drug addiction. Class A conditions require approved waivers for U.S.
entry and immediate follow-up upon arrival.
 Chancroid, gonorrhea, granuloma inguinate, lymphogranuloma venereum, and
syphilis.
 Tuberculosis, active and infectious
 Drug addiction
 Hansen’s disease (leprosy)
 Mental illness with violent behavior
Class B Conditions
Significant health problems: physical or mental abnormalities, diseases, or disabilities serious
in degree or permanent in nature amounting to a substantial departure from normal wellbeing. Class B conditions require follow-up soon after arrival in the United States.
 Tuberculosis: active, not infectious; extrapulmonary; old or healed TB; contact to an
infectious case-patient; positive TST
 Hansen’s disease, not infectious
 Other significant physical disease, defect, or disability
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Communicable Diseases of Public Health Significance –
January 2010
These
1.
2.
3.
4.
5.
6.
7.
8.
currently include:
Tuberculosis
Syphilis
Chancroid
Gonorrhea
Granuloma Inguinale
Lymphogranuloma Venereum
Hansen's Disease (Leprosy)
Any quarantinable, communicable disease specified by current or future Presidential
Executive Orders - current diseases:
 pandemic flu
 SARS
 viral hemorrhagic fevers
 cholera
 diphtheria
 infectious tuberculosis
 plague
 smallpox
 yellow fever
9. Any communicable disease that is a public health emergency of international concern
reported to the World Health Organization (under revised International Health
Regulations of 2005), such as
 Smallpox
 poliomyelitis due to wild-type poliovirus
 cholera
 viral hemorrhagic fevers (Ebola)
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Laws and Regulations Relating to Refugees
Legal Authorities for Medical Examination of Aliens
The Department of Health and Human Services has regulatory authority to create regulations
that establish requirements for the medical examination of aliens (immigrants, refugees,
asylees, and parolees) before they may be admitted into the United States. Under this
authority, the Division of Global Migration and Quarantine administers the regulations which
include the health-related conditions that make aliens ineligible for entry into the United
States. The legal foundation for this authority is found in Title 8 and 42 of the U.S. Code and
relevant supporting regulations.
United States Federal Laws and Regulations for Medical Examination of Aliens
United States Code
The United States Code is a consolidation and codification by subject matter of the general and
permanent laws of the United States. Section 252 of the following portion of the code applies:
Title 42 - The Public Health and Welfare, Chapter 6A - Public Health Service, Subchapter II General Powers and Duties, Part C – Hospitals, Medical Examination, and Medical Care. Also,
Section 1182 and 1122 of the following portion of the code apply: Title 8- Aliens and
Nationality, Chapter 12 – Immigration and Nationality, Subchapter II – Immigration, Part II –
Admission Qualifications for Aliens; Travel Control of Citizens and Aliens and Part IV –
Inspection, Apprehension, Examination, Exclusion, and Removal. Links from the Office of the
Law Revision Counsel U.S. House of Representatives.
 42 USC 252. Medical Examination of Aliens
 8 USC 1182. Aliens with Diseases of Public Health Significance
 8 USC 1222. Detention of aliens for physical and mental examination
Code of Federal Regulations
The Code of Federal Regulations (CFR) is the codification of the general and permanent rules
published in the Federal Register by the executive departments and agencies of the Federal
Government. It is divided into 50 titles that represent broad areas subject to Federal regulation.
Part 34 of the following portion of the CFR apply: Title 42 - Public Health, Chapter 1 - Public
Health Service, Department of Health and Human Services. Links from the Office of the Federal
Register, National Archives and Records Administration on the United States Government
Printing Office web site. 42 CFR, Part 34: Medical Examination of Aliens
Additional United States Federal Law Resources
8 USC 1522. Authorization for programs for domestic resettlement of and assistance to
refugees The United States Code is a consolidation and codification by subject matter of the
general and permanent laws of the United States. Section 412 of the following portion of the
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code applies: Title 8- Aliens and Nationality, Chapter 12 – Immigration and Nationality,
Subchapter IV – Refugee Assistance. Links from the Office of the Law Revision Counsel , U.S.
House of Representatives.
Domestic Refugee Health Assessment/Screening
The domestic refugee health assessment is designed to reduce health-related barriers to successful
resettlement, while protecting the health of Washington residents and the U.S. population. The exam is
recommended, but not mandatory. This examination focuses on the individual’s health and
assures appropriate linkages to healthcare services. Most refugees are eligible for Refugee
Medical Assistance (medical coupons) for their first eight months in this country. SRHD’s role is
to ensure follow-up (evaluation, treatment and/or referral) of Class A and B conditions identified during
the overseas exam and reported on the OF 157; and identify persons with communicable diseases of
public health significance. Ideally the screening process should take place within 90 days of arrival.
The domestic refugee health screening includes the following:
 Health history and basic health exam (heart, lungs, height, weight, blood pressure)
 Vision and hearing testing
 Stool testing for parasites, and referral for
treatment if necessary
 TB testing, and referrals for chest x-ray and
treatment if necessary
 HIV, Hepatitis B, CBC, and Syphilis testing, as
recommended or indicated
 Immunizations
 Referrals to primary/specialty care, WIC and
other SRHD programs
Adjustment of Status Examination
Refugees and asylees are eligible to apply for adjustment of status to permanent residence and
obtain a green card one year following: (1) admission as a refugee, or (2) the grant of asylum.
Special medical and vaccination requirements are set for both refugees and asylees applying for
adjustment of status to permanent residence.
Refugees
 Refugees (including children) are required to have the Overseas Visa Medical Examination, but they are not required to comply with the vaccination requirements at that
time.
 Refugees are required to comply with the vaccination requirements when they apply
for adjustment of status (at least one year following their admission to the United
States).
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 Most refugees will only need to submit the USCIS form I-693 with their adjustment of
status application. This form must be completed and signed by a designated civil
surgeon in the United States; however, an USCIS blanket waiver allows local health
departments to sign off on the I-693 as a Civil Surgeon for the immunization section of
the I-693. Refer to the Vaccination Requirements for Adjustment of Status for
Permanent Residence: Technical Instructions for Civil
Adjustment of Status Examination (continued)
Surgeons dated December 14, 2009 for most current USCIS policy. or
http://www.cdc.gov/immigrantrefugeehealth/pdf/2009-vaccination-technical-instructions.pdf
 Although the Overseas Visa Medical Examination reports are generally valid for up to
one year, USCIS regulations do not require a refugee applying for adjustment of status
to submit a new medical report unless there were medical grounds of inadmissibility
(Class A condition) that existed at the time of initial admission as a refugee.
 The completed and signed I-693 should be placed in a sealed envelope and given to the
refugee to be handed in with his or her application to the USCIS.
Asylees
 Applicants for asylum are not required to have the Overseas Visa Medical Examination.
This is because they are already in the United States and are not applying for admission.
If an individual is granted political asylum, all medical requirements, including the
vaccinations, must be met when applying for adjustment of status (at least one year
later).
 Asylees applying for adjustment of status (including children) after September 30,
1996, must submit a complete medical report. The medical report must include the
vaccination (I-693) supplement.
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Domestic Refugee Health Screening
Preparation
1) Prepare refugee chart for visit
 Retrieve pre-made refugee chart from refugee filing cabinet; ensure the appropriate
paperwork is included; the chart should contain the following:
1. A copy of the alien card
2. Household Information sheet (face sheet)
3. Progress notes
4. Screening forms (Refugee Health Clinical Assessment and SRHD
Individual Health Summary)
5. TB Testing form
2) Gather and prepare the necessary forms for screening:
 Add to the chart the Immunization Consent and Screening Form for each family
member and copy KIPHS numbers from Spokane Regional Health District – TB Testing
Form to Immunization Consent and Screening
Form.
 Attach Request for QuantiFERON-TB Gold
Test form to the back of the Spokane Regional
Health District – TB Testing Form.
o Fill in patient’s name, date of birth,
sex, age
o For “Chart number or other ID”, document “Refugee”
o Under “2. Specimen Information”,  the first box: Option 1: No incubation.
o Tubes must arrive in the Lab within 16 hours of collection.”
 TB Testing Form:
o Name, birth date, address, sex, age, phone number should already be filled out.
o Check mark  “Foreign Born” in Population risk section
o In Consent Section, check mark () the appropriate consent boxes:
 If the person is 18 years or older,  the 1st and 3rd boxes (must
verify that client has received a copy)
 If the person is under 18 years,  the 2nd and 3rd boxes and
write the child’s name on the appropriate line next to the 2nd
box
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Preparation (continued)

PAML Clinical Requisition Form: Used to request Hepatitis B Antibody and Antigen
Testing for all refugees 5 years of age and older
o Include the “PAML Clinical Requisition Form” for a Hepatitis B blood draw
 Fill in patient’s name, date of birth, sex,  “Hepatitis B
Surface AG” and “Hepatitis B Surface AB”
 Stamp in red ink, “Do Hep B Core if HbsAg is Reactive” on the
form. The red stamp and pad can be found in the laboratory
(room 114) in the drawer closest to the window.
Pre-screening vs. Screening
Pre-screening
 Only eligible for families of 4 or more living in the same household.
o Requires 2 visits to complete the health screening process.
 1st visit: vaccinations started, TSTs administered if indicated,
QFTs drawn.
 2nd visit: usually scheduled one month after pre-screening
visit; health screening questions, hearing test, eye exam,
dental inspection, blood pressure/pulse assessment.
Screening
 Used when 3 or less in a family are scheduled for screening.
o Requires 1 visit to complete the screening process.
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Health History & Screening
Background
Over 600,000 refugees have resettled in the United States over the past decade, with a steady
increase in numbers since 2006. Refugees arrive from around the world and settle throughout
the United States. Depending on their country of origin, refugees are at increased risk for many
diseases, both infectious and noninfectious, not commonly seen in the native US-born
population. Conditions such as tuberculosis and other communicable diseases are particularly
important to recognize early, given their potential public health consequences.
The initial history and physical (H&P) examination is an important first step in the assessment of
newly arrived refugees. A thorough H&P can both assist in identifying disease and help refugees
develop a sense of trust in our medical system and in the care being provided (e.g., in many
cultures a clinical encounter is viewed as useless if a physical examination is not performed
during the visit). Given the complexity of the domestic medical screening visit, it is important
that clinicians set aside an adequate amount of time, create a trusting environment, and
provide competent interpretation services to facilitate compassionate and culturally
appropriate history and performance of the physical examination.
A Step-By-Step Procedure
1. Obtain a weight and height when bringing clients back to your exam room at the scale
located in the hallway; record the information on the SRHD Individual Health Summary.
2. Verify that the Interpreter Services Invoice form has been signed by the Clinic Manager
which authorizes the interpreter expense. Pacific Interpreters is the agency used for
most interpretations.
a. Dial: 9, then 800-311-1232 (you do not need to use the scan line for a toll-free
phone number). Choose option 1
b. You will be asked for the access code which is: 829014. They will also ask for
your first and last name. Tell them the language needed and head of household’s
first and last name.
c. When the interpreter is located be ready to write in pencil the interpreter’s
number in the space next to “interpreter’s signature.”
d. Press “speaker” on your phone and hang up the phone. Turn the phone volume
to max.
e. When the interpreter comes on, document in pencil the start time of the call,
and document the end time of the call, when appropriate.
f. Sign in pen next to “Signature verifying services performed” and date where
indicated.
g. Place this Interpreter Request form in Clinic Manager’s box outside his/her office
door when finished.
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A Step-By-Step Procedure (continued)
3. Make sure that the refugee brought their medical card with them; a copy may have
already been made at the front desk and should be attached to the client’s encounter
form.
4. Verify the client’s telephone number and address. If needed, document corrected
information in the chart.
5. Explain to the client, through an interpreter, what will happen during the visit; describe
the specifics of the hearing test and eye exam, if necessary (i.e. for the vision test, make
sure the client knows that his/her role is to tell the nurse which direction the capital
letter “E” is facing (up, down, right, left))
6. Apply lidocaine cream to any young children who will be having a QFT blood draw –
explain through the interpreter that this will make the blood draw less painful.
7. Use the SRHD Individual Health Summary as a guide to ask the health screening
questions.
 Transfer concerns or health issues needing a referral or follow-up from
the SRHD Individual Health Summary to the Refugee Health Clinical
Assessment form.
8. After the Refugee Health Clinical Assessment form is completed make a copy and place
in an SRHD stamped envelope; seal (with tape or a paperclip), and write “Give to
Doctor” on the front, along with the client’s name. Explain to the client that they must
bring this envelope to the doctor’s appointment that will be made for them.
9. After the health screening is complete, list in order of importance each individual’s
health needs on the referral form and give to the Refugee Outreach Worker so that
she/he can make medical appointments and referrals.
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Snellen Eye Chart
Vision Screening
Procedure for administering a Snellen eye
exam.
Snellen Distant Acuity Test
The Snellen chart is widely used for measuring central
visual acuity.The Snellen wall chart should be 20 feet
away from the client.
Visual acuity test resultsThe Snellen eye test results
use 20 feet as the norm, represented by the numerator
in the Snellen test result. The number of the last line of
type the client can read accurately is recorded as the
denominator in the Snellen test result.
 The Snellen “E” chart is primarily used
for refugees who do not know the English
alphabet.
 Tell the client, “This is an E. Show me
with your fingers which way the E is pointing.”
 The Snellen chart must be in good
lighting, and glare must be eliminated from
the chart surface. The chart is hung on the
door at the end of the clinic hallway. There is
a mark on the hallway wall which is 20 feet
from the chart. Have the client stand behind
this line.
 Have the client cover his/her left eye
with an eye patch, or card to test the right
eye. Reverse procedure, testing left eye, and
then test with both eyes. Instruct client to
keep both eyes open (including the eye that is
covered) and to read the letter you point to
(pointing should be from below the letter).
 Start with at least the 20/40 line and
move down to the 20/20 line. If the client is
unable to read the 20/40 line, move upward.
Failure to read more than half of the letters
on a line requires moving to the line above
until visual acuity level is established.
 Instruct clients who wears glasses to
keep their glasses on, unless they state their
sight is better without glasses or glasses are
used only for reading.
 Document the results on the Refugee
Health Clinical Assessment form. Record the
line number for the last line correctly read
with right eye, left eye, and both eyes.
 Referral criteria: each eye must see at
least the 20/30 line. For younger children in
preschool and kindergarten, they must see at
least 20/40.
The "Snellen Eye Chart – E chart" should be used for
those who do not know the English letters. It requires
the individual to indicate the orientation of the letter "E"
Enhancing
Partnerships
in Refugee Health
on the chart. Snellen chart is illustrative
only and
not
suitable for vision testing.
Final Report: Medical Screening Recommendations
55
Hearing Screening: Procedure for hearing test using Welch Allyn AudioScope 3
1. Before starting, check that the lens is centered within the instrument.
2. Select an area that is relatively quiet and free from distracting conversation, fan noises,
etc.
3. Select a small, medium, or large AudioSpec ear speculum. Use the largest speculum that
can be inserted comfortably into the ear canal, yet still allow visualization of the
tympanic membrane. A snug fit assures an acoustic seal of the speculum in the ear
canal. Secure the AudioSpec to AudioScope 3 by twisting it clockwise onto the
instrument.
4. Turn AudioScope 3 ON by sliding the selection switch to the desired screening level (20
dB HL, 25 dB HL, or 40 dB HL). The white indicator band should completely fill the square
next to the desired sound level. The green READY indicator will become illuminated
indicating that the instrument is ready for service.
5. 20 dB HL: a typical screening level for the school-aged child
6. 25 dB HL: the standard screening level used
with adults and children in situations where ambient
noise prohibits use of 20 dB HL
7. 40 dB HL: screening level often used to
assess hearing impairment in those people aged 65
and above; typically, failure at any frequency except
4000 Hz should be referred; an inability to hear
4000 Hz accompanied by inability to hear at least
one other frequency also requires a referral.
8. Instruct the client that he/she will hear a loud tone (or beep) and then some fainter
tones (or beeps). The client should be asked to respond every time a tone is heard.
Responses can be verbal: (“yes” or “beep”), gross motor (raising a hand, dropping a
block in a bucket, waving a paper towel), or fine motor (raising a finger). Very young
children may respond better via a verbal response, whereas seniors seem to perform
better via a gross motor response.
9. Children as young as four years of age may be tested with this instrument. It is
particularly important to reduce all sources of distracting auditory and visual stimuli. It is
recommended that children be seated in such a position that they face a blank wall.
Very young or uncooperative children should be referred to an audiologist since special
procedures are required with these patients
10. Retract the client’s pinna with the thumb and index finger. Gently pull it slightly up and
back. With children, the pinna should be pulled back more than up. This facilitates
insertion of the tip.
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11. Grasp AudioScope 3 and gently insert speculum tip into the ear canal. NOTE: The handle
may also be held in a horizontal position. Use little finger to stabilize instrument with
respect to patient’s head.
12. Grasp AudioScope 3 and gently insert speculum tip into the ear canal. NOTE: The handle
may also be held in a horizontal position. Use little finger to stabilize instrument with
respect to patient’s head.
13. Position the tip so that the tympanic membrane or a portion of it can be visualized. This
visualization ensures free passage of sound. If the tympanic membrane is significantly
occluded by wax, the ear should be cleaned prior to performing the hearing screen.
Excessive wax may reduce the hearing sensitivity of a patient.
14. Maintain AudioScope 3 in the same position and depress the START button. The green
light will then go out, and tone indicators which show the tone being presented will light
sequentially.
15. Observe each tone indicator and the patient’s response. If, for any reason (i.e., patient
movement, excessive ambient noise, etc.), the test is disrupted, it may be restarted at
any time by depressing the START button again. It is important to keep AudioScope 3
stationary during the test to prevent generation of noise.
16. Repeat steps on the opposite ear. Rescreen if necessary.
17. Turn the instrument OFF by sliding selection switch down.
18. Record results on Refugee Health Clinical Assessment form in the Hearing problems
section as follows: “20 dB 500, 1000, 2000, 4000” – (modify charting as needed to
describe dB used for test and patient’s response)
References
Welch Allyn (1988). AudioScope 3 Operating Instructions, Skaneateles Falls, NY, 6-10.
Chauvin, V. G. (1993)
Hearing Screening: Guidelines for School Nurses (2nd ed.). Scarborough, ME: National
Association of School Nurses, Inc.
Professional Standards Committee of the National Association of School Nurses, Inc. (1992).
Vision Screening Guidelines for School Nurses (2nd ed.). Scarborough, ME: National Association
of School Nurses, Inc. 7-9.
Dental Screening
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

All refugees should receive an oral exam to assess for dental problems. Abnormal
findings may include missing/broken teeth, caries, significant spacing problems, poorly
fitting dentures, gingivitis, signs of oral cancer, multiple fillings, etc…
Document any concerns and the need for a dental referral on the Refugee Health
Clinical Assessment form.
Tuberculosis Screening
Purpose of TB Testing in the Refugee Population
To detect latent tuberculosis (TB) infection (LTBI) and active TB disease and to ensure effective
treatment, prevention, and control of TB among newly arrived refugees in Washington.
Background
Foreign-born persons and racial/ethnic minorities bear a disproportionate burden of TB disease
in the United States. In 2008, the rate of TB among foreign-born persons in the United States
was ten times higher than among U.S.-born persons. The ethnic diversity among foreign-born TB
cases poses significant challenges for providing culturally
appropriate TB prevention, treatment, and control services.
In 2009, 26% of refugees
tested in Spokane County for
TB were found to be infected.
77% of active TB disease cases
in Washington State were
foreign-born.


An estimated one-third of the world’s population is
infected with Mycobacterium tuberculosis. All newly
arrived refugees should be screened for active
tuberculosis (TB) disease and latent TB infection (LTBI)
upon arrival in the United States.
TB facts
 All refugees are screened overseas for TB prior
to departing to the United States.
Many refugees have been vaccinated against TB with the Bacillus Calmette-Guerin (BCG)
vaccine. QFT and TST testing are not contraindicated in BCG-vaccinated persons and TST
reactions in such persons should be interpreted using the same criteria used for
unvaccinated individuals. QFT is more specific to Mycobacterium tuberculosis and do not
detect prior BCG vaccination.
Drug-resistant TB and extrapulmonary TB disease are both more common among
persons born outside the U.S.
Class B TB Follow-up
B1/B2/B3 notifications are sent by the Centers for Disease Control and Prevention (CDC) to the
Washington State Tuberculosis (TB) Services as follow-up to overseas screening mandated by
US immigration law. The CDC and the Advisory Council for the Elimination of Tuberculosis
(ACET) recommend screening high-risk populations for TB, including recent arrivals from areas
of the world with a high prevalence of TB. Therefore, screening of foreign-born persons is a
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Obtaining a Blood Specimen
1. Don gloves
2. Cleanse site with
alcohol
3. Place a tourniquet
tightly on the client’s
arm above site where
the blood will be
drawn
4. Collect 1ml of blood
into each of the 3 QFTIT tubes
Venipuncture collection
1mL tubes draw blood slowly
so keep the tube on the
needle for 2-3 seconds once
the tube appears to have
completed filling, to ensure
that the correct volume is
drawn. The black mark on the
side of the tubes indicates the
1mL fill volume. Tubes must
have between 0.8mL – 1.2mL
of blood. If the level of blood
in any tube is not close to the
indicator line, draw another
tube.
Syringe draws
Remove the needle, ensuring
appropriate safety
procedures, transfer 1mL of
blood from the syringe into
each tube by removing the
caps.
“Butterfly needle” draws
A “purge” tube (not a QFT-IT
tube) should be used to
ensure proper suction and
that the tubing is filled with
blood prior to the QFT-IT
tubes being used.
public health priority. On the basis of its very high success rate
of detecting TB cases, domestic follow-up evaluation of
immigrants, refugees and asylees with Class B1, B2 and B3 TB
notification status should be given highest priority by all TB
control programs. Legal immigrants, refugees, and asylees with
Class B1, B2 and B3 TB notification status are also a high-priority
subpopulation for screening for latent TB infection (LTBI). (See
SRHD TB Manual for detailed information on Class B policies
and procedures)
Specimen Collection Procedure for QuantiFERON inTube (QFT-IT)
All refugee clients 5 years of age and older will be tested for
tuberculosis at the time of pre-screening or screening. TB
screening should include a Mantoux tuberculin skin test (TST)
for children under 5 years of age and QuantiFERON In-tube
(QFT) blood test for those 5 years of age and older; and a
medical evaluation for signs and symptoms of active TB.
Assess the client for any TB signs or symptoms using the TB
Testing Form as a guide. Also, ask the client about any risk
factors they may have for TB infection and disease, and
document those on the TB Testing Form. All refugees should
also be documented as population risk of foreign born. Obtain
the client’s consent by having them sign the TB Testing Form
and obtain the client’s consent to release their TB test
information, if applicable.
A Step-By-Step Procedure
QFT-G In-Tube (QFT-IT) - uses the following set of 3 heparin
tubes provided by the Lab:
 Gray cap = Nil (Specimen Negative Control)
 Red cap = TB Antigens (ESAT-6, CFP-10 and TB7.7
 Purple cap = Mitogen Control (Specimen Positive
Control)
NOTE: Contents have been dried onto the inner wall of the
blood collection tubes so it is essential that the contents of the
tubes be thoroughly mixed with the blood.
1. After drawing the blood, mix the tubes by SHAKING
VIGOROUSLY (not by simple inversion) at least 10 times to
ensure that the entire inner surface of the tube has been coated
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with blood. Thorough mixing is required to ensure complete integration of the tube’s
contents into the blood. If this step is omitted, the result may be compromised.
2. Label all tubes with the patient’s LAST NAME, FIRST; DATE AND TIME drawn.
3. Samples must be submitted with an SRHD Laboratory, Request for QuantiFERON-TB
Gold (QFT-G) requisition. The form must be completed fully and legibly. The date, time
drawn and incubation sections must be filled in. The lab must receive the sample no
later than 3:30pm.
Tuberculosis Screening-TB Skin Testing (TST)
All refugees 4 years of age and younger will be tested for TB using a TB Skin Test.
(Note: No TSTs on Thurs or Fridays)
Administration of the Tuberculin Skin Test
The Mantoux tuberculin skin test used to be the standard method of identifying persons
infected with M. tuberculosis. However, the
QuantiFERON Gold TB test is now used by Spokane
Regional Health District as the standard method of
TB testing for persons 5 years of age or older. For
children 4 years old and younger the Mantoux
tuberculin skin test (TST) is still the standard method
of testing for this age group.
The TB skin test solution is a purified protein
derivative (PPD) containing 5 tuberculin units (TU).
The solution may also be referred to as PPD solution. Proper storage and handling of the
solution is important to maintain the effectiveness of the solution.
 Storage: Refrigerate between 35-46F; light sensitive; do not freeze
 Dose: 0.1ml
 Route: intradermally; with the bevel up; injection should produce a pale
elevation in the skin (wheal) 6-10mm in diameter
 Site: inner surface of the left forearm, 2-3 finger breadths below the elbow;
consistently placing the test on the same arm will facilitate the reading, if there
is no reaction or slight reaction.
 Syringe: tuberculin safety syringe; 1ml, 26G-27G 3/8”
Step-by-Step Procedure for Administering a TB Skin Test
1. Ask the parent/guardian about any TB signs or symptoms the child has been having.
Also, ask if the client has any risk factors for TB infection and disease. Use the TB Testing
Form as a guide.
2. Obtain signed consent from the parent/guardian prior to administration of the
tuberculin skin test. The consent on the TB Testing Form must be signed.
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3. Explain the procedure to the parent/guardian; how the test will be administered; the
importance of returning for the read in 48-72hours.
4. Remove the PPD solution from the refrigerator. Check the expiration date. DO NOT use
if expired. If you are opening a new vial, document the date opened and write your
initials on the vial and vial box. Unused PPD solution must be discarded 30 days after
opening.
5. Wash hands with soap and water or use an alcohol based hand cleanser.
6. Wipe the top of the vial with an alcohol pad, and allow drying. Withdraw 0.1ml of PPD
solution into a 1 ml tuberculin safety syringe.
7. Select a site on the inner surface of the left forearm, 2-3 finger widths below the bend
of the arm.
8. Cleanse the site with alcohol.
9. Insert the needle at a 15-degree angle (intradermal) to the skin, with the bevel up.
Step-by-Step Procedure for Administering a TB Skin Test (continued)
10. Inject solution. A wheal (raised area) of 6-10 mm in diameter should be produced. If a
wheal does not form, the injection was not given properly. Repeat the test at a site 2
inches from the previous site.
11. After use, engage the safety feature and place the syringe in a puncture-resistant
container for disposal.
12. Instruct the client not to massage, scratch, or apply pressure to the injection site. A
drop of blood may form at the site. If this occurs, instruct the client to lightly dab the
site with a cotton ball. DO NOT apply a bandaid.
13. Document the date & time the TB skin test was given and lot number on the TB Testing
Form. Indicate what organization or employer the TB skin test results should be sent to,
if applicable.
14. Schedule a return appointment for reading the test 48-72 hours later. If the client is
unable to return for the reading, DO NOT apply the skin test. Exceptions to this policy
may be approved by the Public Health Clinic Manager or TB Program Coordinator.
15. Anaphylactic reactions are rare after a PPD. However, emergency supplies are available.
Emergency supplies are kept in the locked medication closet.
Reading the TB Skin Test
The reaction to the Mantoux skin test should be read by a properly trained healthcare worker.
The reaction should be read 48-72 hours after the injection.
The reading should take place under good light. The presence or absence of induration (an area
of hardened tissue) is the basis of the reading of the test. Induration is determined by visual
inspection, and by transverse palpation of the site by light stroking with fingertips to feel the
presence or absence of induration. Erythema (redness) is disregarded and is NOT read or
recorded as positive.
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If induration is present, the edges must be carefully noted and measured using a flexible ruler
marked in millimeters (mm). The diameter of the indurated area should be measured across
the forearm (perpendicular to the long axis).
All reactions should be measured in millimeters. If no induration is found, “00mm” should be
documented and initialed by the nurse on the TB Testing Form.
Immunizations
The Refugee Screening program ensures that every child and adult refugee are appropriately
immunized against vaccine-preventable diseases by determining which immunizations have
been administered and initiating age-appropriate vaccinations.
Outbreaks of vaccine-preventable diseases occur overseas as well as in the United States. High
infant mortality from vaccine-preventable diseases in developing countries has led to major
childhood immunization efforts. Recommendations by the World Health Organization’s
Expanded Program on Immunizations (EPI) are
generally followed by countries worldwide with
minor variations in vaccine schedules, spacing of
vaccine doses, and documentation. Refugees may
have had vaccinations in their country of origin, but
due to the nature of their departure are unlikely to
have vaccination documentation. The majority of
vaccines used worldwide are from reliable local or
international manufacturers, and no potency
problems have been detected, with the occasional exception of tetanus toxoid and the oral
polio vaccine (OPV). Only doses of vaccine with written documentation of the date of receipt
should be accepted as valid. Self-reported doses of vaccine without written documentation should not
be accepted, and patients should be considered susceptible.
Vaccination Screening
 Immigrants, refugees, and other non-U.S.-born people need the age-appropriate
vaccinations. Follow the ACIP/CDC Recommended Childhood or Adult Immunization
Schedules to determine needed vaccinations. These schedules are found in the
tabbed sections of this manual or at:
http://www.cdc.gov/vaccines/recs/schedu
les/default.htm
 Review existing immunization records.
Documented immunizations administered
overseas are considered valid as long as
they were given at the correct age and interval as defined in the Recommended
Childhood or Adult Immunization
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Vaccine Information
Statements (VIS) are
available in many
translations from the
Immunization Action
Coalition web site:
www.immunize.org/vis
ACIP/CDC Recommended
Immunization Schedules can
be found at:
http://www.cdc.gov/vaccine
s/recs/schedules/default.ht
m
Technical Instructions for
Vaccinations for Civil
Surgeons is the guide SRHD
uses for determining
vaccination requirements.
http://www.cdc.gov/immigra
ntrefugeehealth/pdf/2009vaccination-technicalinstructions.pdf
Guidelines for Use of StateSupplied Vaccines can be
found at:
http://www.doh.wa.gov/cfh
/Immunize/documents/vacu
sage.pdf
Schedules. Products and terms for vaccines and vaccinepreventable diseases used throughout the world, along with
translations of foreign vaccine-related terms, can be found in
the Epidemiology and Prevention of Vaccine-Preventable
Disease – Pink Book or at
http://www.cdc.gov/vaccines/pubs/pinkbook/default.htm
 If a refugee has started a vaccine series (e.g., hepatitis B)
but has not completed it, pick up where the shots left off and
complete the series. No vaccine series needs to be started over
because of a delay between doses,
 Proof of age-appropriate immunizations, documented
on the USCIS form I-693 and signed by a civil surgeon, is
required for all refugees and immigrants applying to change
their immigration status or applying for his/her green card. This
change of status application can be made at any time after
he/she has resided in the U.S. a minimum of one year. The I-693
form can be completed by any public or private provider, but
the refugee or immigrant must have it signed by a designated
U.S. civil surgeon.
 A USCIS blanket waiver allows local health departments
that have a licensed physician on staff to sign off on the USCIS
form I-693 as a civil surgeon for refugees only.
Immunizations (continued)
Immunization Review & Documentation
Assess refugee clients’ immunization history and needs at every
visit and provide each refugee with a Washington State Lifetime
Immunization record card. Remind the client to bring his/her
immunization record with them to all doctor’s visits.
Tuberculosis Testing and Vaccinations
A Mantoux tuberculin skin test (TST) can be administered
simultaneously with a live or inactivated vaccine. If the client
received a live vaccine (e.g., MMR or varicella) the previous day
or earlier, the TST must be delayed for at least four weeks,
because measles vaccination may temporarily suppress
tuberculin reactivity, yielding a false negative response. If the
TST was placed first, there is no need to wait before
administration of a live vaccine as long as the TST has already
been read.
Hepatitis B Screening
Purpose
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To detect Hepatitis B Virus (HBV) infection and to identify and vaccinate refugees in accordance
with CDC recommendations. All infected persons will be referred for appropriate follow-up
medical care. Spokane Regional Health District will screen all new refugees 5 years of age and
older for hepatitis B infection.
Background
HBV infection is highly endemic in all of Africa, Southeast Asia, East Asia, and Northern Asia, and in most
of the Pacific Islands. A complete list of HBV endemicity by country is available at
http://www.cdc.gov/hepatitis/HBV/PDFs/HBV_figure3map_08-27-08.pdf
According to the CDC, the prevalence of chronic HBV infection among persons immigrating to the United
States from these areas is estimated to be between 5 and 15 percent, and reflects the patterns of HBV
infection in the countries and regions of origin. Intermediate and high endemicity are defined by CDC as
2 to 7 percent and >8 percent of population infected, respectively. In the United States, approximately 1
to 1.25 million persons are chronically infected with HBV. An estimated 5,000 persons with chronic HBV
infection die in the U.S. each year as a result of chronic liver disease (cirrhosis and liver cancer)
The most current Hepatitis B testing guidelines can be found in the tabbed section of this
manual or at http://www.cdc.gov/hepatitis/HBV/PDFs/ChronicHepBTestingFlwUp.pdf
CDC Recommendations for Routine Testing for Chronic Hepatitis B Virus (HBV) Infection
Population
Testing
Vaccination/Follow-up
Persons born in regions of
high and intermediate HBV
endemicity (HBsAg
prevalence 2%)
US born persons not
vaccinated as infants whose
parents were born in
regions with high HBV
endemicity ( 8%)
Test for HBsAg, regardless of
vaccination status in their country
of origin, including – immigrants –
refugees – asylum seekers –
internationally adopted children
Test for HBsAg regardless of
maternal HBsAg status if not
vaccinated as infants in the United
States.
If HBsAg-positive, refer for
medical management. If negative,
assess for on-going risk for
hepatitis B and vaccinate if
indicated.
If HBsAg-positive, refer for
medical management. If negative,
assess for on-going risk for
hepatitis B and vaccinate if
indicated.
Interpreting the Results
A quick guide to interpreting hepatitis B screening results can be found in the tabbed section of
this manual or at: http://www.cdc.gov/hepatitis/HBV/PDFs/SerologicChartv8.pdf
Hepatitis B Log
Document all HPV screening tests on the log sheet kept in the “Point of Care” testing and log
notebook in the clinical lab, room 114. Tests results will be provided to the client’s primary care
physician for follow-up.
Parasite Screening
Purpose
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To detect parasitic infections in refugees and to provide referral for treatment.
Background
According to the CDC over one billion persons worldwide are estimated to be carriers of
Ascaris. Approximately 480 million people, or 12 percent of the world population, are infected
with Entamoeba histolytica. At least 500 million carry Trichuris. At present, 200 to 300 million
people are infected with one or more of Schistosoma species and it is estimated that more than
20 million persons throughout the world are infected with Hymenolepis nana. In the United
States, an estimated 65 million people are infected with intestinal parasites. Consequences of
parasitic infection can include anemia due to blood loss and iron deficiency, malnutrition,
growth retardation, invasive disease, and death.
All refugees will be screened for parasitic
infections. Some refugees may have received predeparture presumptive treatment for parasites
overseas.
For all refugee arrivals (asymptomatic and
Hookworm Ancylostoma caninum
symptomatic):
 Confirm and document pre-departure
presumptive treatment on Refugee Health
Clinical Assessment form.
 Evaluate for eosinophilia by obtaining a CBC
with differential (eosinophilia >400 cells/μL)
 Provide stool specimen collection bottles to the refugee(s) at the time of pre-screening
or screening.
 Through an interpreter, provide verbal instructions on how to collect the sample and to
return the bottles to SRHD when complete. Include translated instructions with the
collection bottles.
 If a refugee is diagnosed with parasites, refer him/her to their primary care physician for
treatment. Include a copy of the lab results in the information provided to the PCP or
fax. Document type of parasite identified in the Parasite Screening section of the
Refugee Health Clinical Assessment form.
Eosinophilia
Eosinophils are one type of granulocytic white blood cell (other granulocytes are neutrophils
and basophils) that helps in the body’s defense against certain types of infectious agents. The
immune response mediated by eosinophils is particularly effective against invasive infections
with certain types of parasites called helminths (roundworms).
Parasites associated with tissue invasion can cause marked eosinophilia. Examples of helminthic
infections in which eosinophilia may be seen include trichinosis, visceral larva migrans, filariasis,
strongyloidiaisis, hookworm infection, and schistosomiasis.
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Processing Stool Specimens
When a stool specimen is received by client services, it is placed in the clinic laboratory and a
pink laminated sign reading “SPECIMENS IN LAB AND/OR FRIDGE TO BE PROCESSED” is
attached to the encounter staging area. An available nurse will proceed to the laboratory and
complete the following steps:
1. Wash hands.
2. Don adequately-fitting gloves.
3. Empty outer plastic/paper bags of stool specimens which should be contained within a
plastic sealed biohazard bags – do not open the biohazard bags.
4. Look into the biohazard bags to determine the client’s name, date of birth, and gender;
record on a scratch piece of paper and on the Clinical Requisition Report.
5. On the piece of paper record client name, birth date, nurse’s name and stool specimen.
Give to client services so that an encounter form can be generated.
6. Upon receipt of encounter, the nurse will circle the following:
o O&P Trichrome Stain
o O&P Conc Smear
o O&P Concentration
o Circle nurse’s name and indicate time spent on the procedure
7. Prepare the CLINICAL REQUISITION/REPORT
o Document “STOOL” under the “SPECIMEN” category
o Specify “PARASITOLOGY” below
o Complete the following information:
a. Patient Name: LAST, FIRST
b. Patient birth date: DD/MM/YY
c. Patient age
d. Patient sex: M/F
e. Requested by: (nurse’s initials)
f. Clinic: Refugee
g. Date Collected: Current Date
o Complete above steps for each specimen.
8. Return specimens to original plastic/paper bag.
9. Place Clinical Requisition Report and specimens in dumb waiter and send up to main
laboratory.
10. Wash hands.
11. Return pink laminated sign reading “SPECIMENS IN LAB AND/OR FRIDGE TO BE
PROCESSED” to client services.
12. Turn in completed encounter form(s) for processing and billing.
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Lead Screening
Purpose
Blood lead testing of refugees will help identify children who require medical intervention or
additional effort to avoid continued lead exposure.
Background
Refugee children arriving in recent years have much higher rates of elevated BLL on average,
when they enter the United States, due to exposures prior to relocation. In addition, refugee
children are at above-average risk for lead poisoning from exposures within the United States,
because they typically settle into high-risk areas and substandard housing.
The Washington State Department of Health (DOH) does not consider Medicaid-eligible
children in Washington State to be at higher risk of lead poisoning than other children,
however, it is important to note that the Federal government requires all children covered by
Medicaid to have a blood lead test at 12 and 24 months of age. Head Starts and Early Head
Starts in Washington also require enrolled children to have a blood lead test.
Spokane Regional Health District (SRHD) will inform providers of current lead screening federal
requirements and guidelines for refugee children. Lead testing of refugee children will be the
responsibility of community providers.
CDC Refugee Lead Screening guidelines can be found at:
http://www.cdc.gov/immigrantrefugeehealth/pdf/lead.pdf
HIV Screening
Purpose
To detect refugees with HIV infection so that they can be refer for medical care and case
management.
Background
On November 2, 2009, the Department of Health and Human Services published a final rule
regarding HIV infection. In this final rule, HIV infection was removed from the list of
inadmissible conditions for immigration purposes and from the scope of the immigrant medical
examination. The rule is effective on January 4, 2010. Beginning January 4, 2010, HIV testing
will no longer be required as part of the U.S. immigration medical screening process and
persons with HIV infection will no longer require waiver processing by the Department of
Homeland Security to be admitted into the United States.
As of 7/1/10, SRHD will begin providing routine HIV screening for all refugees 13-64 per CDC
guidelines since testing is no longer provided as part of the oversees medical examination.
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HIV Screening
Screening should be performed on all refugees unless they decline (opt out). Refugees should
be clearly informed orally or in writing that HIV testing will be performed. Oral or written
information should include an explanation of HIV infection and the meanings of positive and
negative test results, and the patient should be offered an opportunity to ask questions.
Consent for HIV screening will be obtained. If the client refuses HIV testing, document refusal
on the Refugee Health Clinical Assessment form.
SRHD will:
 Obtain informed consent from clients
 Provide pre/post test counseling (*CDC contract requirement and WAC requirement)
 Ensure that HIV testing staff attend CTR training (*CDC contract requirement)
 Fill out PEMS forms (*CDC contract requirement)
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Standard 1
Health care organizations should ensure that
patients/consumers receive from all staff member's
effective, understandable, and respectful care that is
provided in a manner compatible with their cultural
health beliefs and practices and preferred language.
Standard 2
Health care organizations should implement strategies
to recruit, retain, and promote at all levels of the
organization a diverse staff and leadership that are
representative of the demographic characteristics of
the service area.
Standard 3
Health care organizations should ensure that staff at
all levels and across all disciplines receive ongoing
education and training in culturally and linguistically
appropriate service delivery.
Standard 4
Health care organizations must offer and provide
language assistance services, including bilingual staff
and interpreter services, at no cost to each
patient/consumer with limited English proficiency at all
points of contact, in a timely manner during all hours
of operation.
Standard 5
Health care organizations must provide to
patients/consumers in their preferred language both
verbal offers and written notices informing them of
their right to receive language assistance services.
Standard 6
Health care organizations must assure the
competence of language assistance provided to
limited English proficient patients/consumers by
interpreters and bilingual staff. Family and friends
should not be used to provide interpretation services
(except on request by the patient/consumer).
Standard 7
Health care organizations must make available easily
understood patient-related materials and post signage
in the languages of the commonly encountered groups
and/or groups represented in the service area.
Standard 8
Health care organizations should develop, implement,
and promote a written strategic plan that outlines clear
goals, policies, operational plans, and management
accountability/oversight mechanisms to provide
culturally and linguistically appropriate services.
Providing Culturally and Linguistically
Appropriate Care
National standards were created by the U.S.
Department of Health and Human
Services’ (HHS) Office of Minority Health
(OMH) in response to the need to ensure
that all people entering the health care
system receive equitable and effective
treatment in a culturally and linguistically
appropriate manner. The standards are
intended to be inclusive of all cultures and
not limited to any particular population
group or sets of groups; however, they are
especially designed to address the needs of
racial, ethnic, and linguistic population
groups that experience unequal access to
health services. Ultimately, the aim of the
standards is to contribute to the elimination
of racial and ethnic health disparities and to
improve the health of all Americans.
The 14 standards are organized by
themes: Culturally Competent Care
(Standards 1-3), Language Access Services
(Standards 4-7), and Organizational
Supports for Cultural Competence
(Standards 8-14). Within this framework,
there are three types of standards of
varying stringency: mandates, guidelines,
and recommendations as follows:
CLAS mandates are current Federal
requirements for all recipients of Federal
funds (Standards 4, 5, 6, and 7).
CLAS guidelines are activities
recommended by OMH for adoption as
mandates by Federal, State, and national
accrediting agencies (Standards 1, 2, 3, 8,
9, 10, 11, 12, and 13).
Standard 9
CLAS recommendations are suggested by
Health care organizations should conduct initial and
OMH for voluntary adoption by health care
ongoing organizational self-assessments of CLASorganizations (Standard 14).
related activities and are encouraged to integrate
cultural and linguistic competence-related measures
into their internal audits, performance improvement
programs, patient satisfaction assessments, and
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outcomes-based evaluations.
Final Report: Medical Screening Recommendations
Standard 10
Health care organizations should ensure that data on
the individual patient's/consumer's race, ethnicity, and
spoken and written language are collected in health
records, integrated into the organization's
management information systems, and periodically
updated.
Standard 11
Health care organizations should maintain a current
demographic, cultural, and epidemiological profile of
the community as well as a needs assessment to
accurately plan for and implement services that
respond to the cultural and linguistic characteristics of
the service area.
Standard 12
Health care organizations should develop
participatory, collaborative partnerships with
communities and utilize a variety of formal and
informal mechanisms to facilitate community and
patient/consumer involvement in designing and
implementing CLAS-related activities.
Standard 13
Health care organizations should ensure that conflict
and grievance resolution processes are culturally and
linguistically sensitive and capable of identifying,
preventing, and resolving cross-cultural conflicts or
complaints by patients/consumers.
Standard 14
Health care organizations are encouraged to regularly
make available to the public information about their
progress and successful innovations in implementing
the CLAS standards and to provide public notice in
their communities about the availability of this
information.
69
Providing Culturally and Linguistically
Appropriate Care (continued)
Language Access Rights
Background
Many immigrants and refugees are not
aware of their legal rights with respect to
interpretation/translation services. Title VI
of the Civil Rights Act of 1964 and
Presidential Executive Order 13166 of
2000, “Improving Access to Services for
Persons with Limited English Proficiency,”
stipulate that all programs that receive
Federal Financial Assistance (Medicare &
Medicaid) must provide
interpretation/translation services to their
Limited English Proficient (LEP)
clients/patients at no cost.
The refugee program strives to adhere to
the CLAS standards and Title VI of the Civil
Rights Act of 1964 when providing care to
clients.
All staff working in the clinical setting will
receive cultural awareness and diversity
trainings on an on-going basis. Trainings
venues will consist of webcasts, literature
reviews and classroom, as available. SRHD
will use interpreters and translated
materials to communicate with refugees.
The Refugee Program currently meets the following standards:
Standard 1
Standard 3
Standard 4
Standard 5 (“I speak” cards in development which will notify non-English speaking clients of
their rights to receive interpreter services)
Standard 6
Standard 7
Standard 10
The agency as a whole is working on meeting the remaining standards.
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Cultural Competency and Training Resources:
Office of Minority Health http://minorityhealth.hhs.gov/templates/browse.aspx?lvl=1&lvlID=3
The Community Guide – Cultural Competency http://www.thecommunityguide.org/social/socAJPM-evrev-healthcare-systems.pdf
HRSA – Cultural Competency and Health Literacy Resources for the Health Care Provider
http://www.hrsa.gov/culturalcompetence/
National Network of Public Health Training Centers – Cultural Competency and Diversity 101:
http://www.asph.org/userfiles/PHTC_FINALCCDiversitybundle.pdf
School of Public Health – University At Albany: “Communicating Across Cultures”
http://www.albany.edu/sph/coned/t2b2communicating.htm
Other relevant trainings offered by University At Albany: http://www.nynjphtc.org/pages/catalog/
Refugee Health Information Network: http://www.rhin.org/
Diversity Rx: http://www.diversityrx.org/index.htm
Culture Connect: http://www.cultureconnectinc.org/ispeak.html
Laws Relating to Providing Interpreters to those with Limited English Proficiency (LEP)
Medicaid - Medicaid regulations require Medicaid providers and participating agencies,
including long-term care facilities, to render culturally and linguistically appropriate services.
The Health Care Financing Administration, the Federal agency that oversees Medicaid, requires
that states communicate both orally and in writing "in a language understood by the
beneficiary" and provide interpretation services at Medicaid hearings.
Medicare – Medicare addresses linguistic access in its reimbursement and outreach education
policies. Medicare "providers are encouraged to make bilingual services available to patients
wherever the services are necessary to adequately serve a multilingual population." Medicare
reimburses hospitals for the cost of the provision of bilingual services to patients.
Title VI of the Civil Rights Act of 1964 - "No person in the United States shall, on ground of race,
color or national origin, be excluded from participation in, be denied the benefits of, or be
subjected to discrimination under any program or activity receiving Federal financial
assistance."
Washington Laws Related to Addressing Language Needs in Healthcare
http://www.healthlaw.org/images/stories/issues/Washington.pdf
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Guidelines for Using Medical Interpreters
1. Use Qualified Interpreters to Interpret: SRHD uses the services of Pacific Interpreters
for the non-Russian refugees. For Russian speaking clients, the health district employs a
medically certified, bilingual worker in the Refugee Program.
Pacific Interpreters offers:
o Convenient, easy to use, transparent interpreter service
o Medically qualified, highly trained interpreters
o Over 180 languages and dialects; language availability of 99.925%
o Available 24/7/365; connect to an interpreter in 25 seconds or less
o Experienced—providing service since 1992; one of the largest providers of
medical interpreting in the U.S.
o Confidentiality; HIPAA Compliant
2. Do not depend on children or other relatives/friends to interpret.
3. Plan enough time for the healthcare visit – it will take more time with an interpreted
conversation. Every statement or a question will be spoken twice.
4. Address yourself to the client, not the interpreter. Speak directly to the client, not the
interpreter. Make eye contact with the client, if culturally appropriate.
5. Don’t say anything that you don’t want the client to hear. Expect everything you say to
be translated, as well as everything the client says. Remember what can be said in a few
words in one language may require a lengthy paraphrase in another.
6. Use words, not gestures to convey you meaning. This is especially important when
using a phone interpreter.
7. Speak in a normal voice, clearly, and not too fast. Speak your normal voice, not louder
or slower (unless the interpreter asks you to slow down). Sometimes it is easier for an
interpreter to interpret speech at a normal speed, with normal rhythms.
8. Avoid jargon and technical terms.
9. Keep sentences or information short. Pause to allow for the interpretation. Speak for a
short time (one long sentence or two-three short sentences), then stop in a natural
place to let the interpret pass along your message. Short simple sentences are best. Do
not pause for interpretation in the middle of a sentence.
10. Only ask one question at a time.
11. Expect the interpreter to interrupt when necessary for clarification. Be prepared to
have the interpreter when necessary to ask you to slow down, to repeat something, to
explain a word or concept or to add explanation to the client can understand.
12. Be prepared to repeat yourself in different words if your message is not understood. If
mistranslation is suspected (the response does not fit the question), go back and repeat
what you said in different words.
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Glossary
Refugee
A foreign-born resident who is not a United States citizen and who cannot return to his or her
country of origin or last residence because of persecution or the well-founded fear of persecution because of race, religion, nationality, membership in a particular social group, or political
opinion, as determined by the State Department or the U.S. Citizen and Immigration Service
(USCIS). A refugee receives this status prior to entering the United States.
Asylee
An immigrant who flees his or her country in fear of persecution or with a well-founded fear of
persecution because of race, religion, nationality, political opinion, or membership in a social
group and who is already present in the United States at the time he/she obtained asylum. One
seeks asylum from the USCIS.
Parolee
A foreign-born person, or alien, who, appearing to be inadmissible to the inspecting USCIS
officer, is allowed to enter the United States under
emergency (humanitarian) conditions or when that
individual’s entry is determined to be in the public interest.
Immigrant
A person who is not a U.S. citizen or national who enters
the United States as an actual or prospective permanent
resident, with the intent to remain for an indefinite period
of time.
Non-immigrant
A person who can be classified under one or more of the following: undocumented individual,
tourist, visitor on business, or foreign/international student.
Division of Global Migration and Quarantine, (DGMQ/CDC)
The CDC Division of Global Migration and Quarantine is committed to reducing morbidity and
mortality due to infectious diseases among immigrants, refugees, international travelers, and
other mobile populations that cross international borders. In addition, the Division of Global
Migration and Quarantine is committed to promoting border health and preventing the
introduction of infectious agents into the United States.
I-693
USCIS form called the Report of Medical Examination and Vaccination Record. This is the form
used to document the medical aspects of the Adjustment of Status application.
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Glossary (continued)
I-94
USCIS document that records each alien’s arrival and departure from the United States. It
identifies the period of time for which the alien is admitted and the alien’s immigrant status.
Office of Refugee Resettlement (ORR)
Advises the U.S. Assistant Secretary for Children and Families and the Secretary of Health and
Human Services on policies and programs regarding refugee resettlement, immigration, and
repatriation matters. ORR plans, develops, and directs implementation of a comprehensive
program for domestic refugee and entrant resettlement assistance. ORR also provides direction
and technical guidance to the nationwide administration of resettlement and repatriation
programs.
Volunteer Resettlement Agency (Volag)
A national or local non-profit voluntary agency. Volags are assigned responsibility for initial
refugee resettlement processing under a contract with the Department of State. The national
Volag assigns continuing responsibility for the refugee to a
local affiliated Volag or sponsor. During the initial
resettlement process, the Volag or sponsor is responsible
for assisting the refugee in seeking healthcare,
employment, and/or schooling and housing
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Appendix F: Basic Refugee Medical Screening Tool
Clinical Item
Basic
Screen
Optional
Additions
Screen only
clinic
Primary
Care
Services
Verify I-94 card
x
x
x
x
Engage an interpreter
x
x
x
x
Review the DS 2053, noting any
concerns mentioned
x
x
x
x
Complete medical history
x
x
x
x
Vital signs
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
Preparation
Physical Exam
Complete physical exam
Make appropriate referrals to
primary care or appropriate
specialist
Test for vision impairment and
make appropriate referral
Test for hearing impairment and
make appropriate referral
Evaluate need for dental referral
Follow up testing and further
evaluation of conditions causing
abnormal results is consistent with
established best practice
Follow up on all referrals to assure
appointments are kept
Preventive health interventions
Immunizations
General testing
For all age appropriate refugees
CBC with differential
Complete metabolic panel
Urinalysis to screen for indicators
of chronic conditions for any
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
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patient old enough to produce a
clean catch specimen
Tuberculosis screening
Lead Testing
Evaluate for Malaria to determine
if testing is indicated
Evaluate for Intestinal Parasites
Hepatitis B screening
Syphilis testing
Chlamydia
Gonococcus
HIV
For specific populations
Lipid panel if appropriate
Test for Vitamin D levels
Test for Vitamin B12
Infant metabolic screening in
newborns, according to state
guidelines
Urine pregnancy test for women
of child bearing age
HIV in pregnancy
HIV in children
Mental Health Screening
Assess general mental health
needs
Individual additional MH
assessment
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
Cancer screening
x
x
Other: Women
Evaluate reproductive history for
women of child bearing years
x
x
x
Evaluate and educate on family
planning
Refer to WIC if appropriate
x
x
Other: Children
Test for age appropriate
development in children ages 0 –
x
x
x
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x
76
20
Other: General
Assess nutrition issues by doing a
brief screen for dairy and food
groups, exercise; children and
adults as indicated.
Evaluate for substance use
x
x
Evaluate for substance abuse
Report all reportable diagnosis to
state health department
Report unusual trends or patterns
of disease in any population to
CDC
Complete I-693 after one year in
the USA (if service is offered)
x
x
x
x
x
x
x
x
x
x
x
x
x
x
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77
Appendix G: Expanded Refugee Medical Screening Tool
Clinical Item
Preparation
Verify I-94 card
Engage an interpreter
Review the DS 2053,
noting any concerns
mentioned
Basic
Screen
Optional
Additions
Screen
Only Clinic
Primary
Care
Services
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
Comments
Xerox and keep in file
Preferably a trained medical
interpreter, in person or via
telephone. Use family members
only as last resort.
Complete medical history
x
x
x
1. History
a. Injury
b. Childhood disease
c. Surgeries/hospitalization
d. Allergies
2. Review of systems
a. Note impairments (cognitive &
physical)
b. Identify indicators of chronic
health concerns
3. Review of symptoms, acute
concerns
a. Current pain
4. Assess current medications
a. OTC, psychotropic and
traditional remedies & treatments
b. Assess for use of remedies or
treatments contraindicated with
use of a prescription medication or
for products that may contain toxic
elements (i.e., lead, arsenic).
5. Educate regarding
a. Any general and patient specific
identified concerns
b. U.S. Health care system (how to
access)
c. Health insurance
d. Primary and preventive medical
care
e. Emergency services, 911, primary
care services
f. Oral health and dental care
6. How to use medications (if
appropriate.)
7. Vision/ophthalmologic care.
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Vital signs
x
x
x
x
x
x
x
x
X
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
1. Weight
2. Height
3. Blood Pressure
4. Pulse
5. Temperature
6. BMI
7. Head circumference (0 - 5 years)
8. MUAC (mid upper arm
circumference (6 -60 months)
x
x
x
x
x
x
x
x
x
x
x
x
1. Complete physical exam
2. Make appropriate referrals to
primary care or appropriate
specialist
3. Test for vision impairment and
make appropriate referral
4. Test for hearing impairment and
make appropriate referral
5. Evaluate need for dental referral
6. Follow up testing and further
evaluation of conditions causing
abnormal results is consistent with
established best practice
7. Follow up on all referrals to
assure appointments are kept
Physical Exam
x
x
x
x
x
x
x
x
x
x
Preventive health interventions
Immunizations
x
x
x
x
x
x
X
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
1. Evaluate overseas immunization's
records to assess needed updates
2. Give age appropriate vaccines
following the ACIP guidelines,
complete any series that has been
initiated (do not restart a series)
3. Give priority to giving vaccines
needed for children to start school
4. Build toward providing all
needed for Adjustment of Status
5.. If unable to provide vaccines,
provide appropriate referral to
obtain needed immunizations
according to the ACIP guidelines
6. Record previous vaccines, lab
evidence of immunity or hx of
disease
7. Provide refugee with a record of
immunity &/or vaccination, enter
into state immunization registry if
available.
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General testing
For all age appropriate refugees
x
x
x
x
x
X
x
x
1. CBC with differential
x
2. Complete metabolic panel
x
3. UA to screen for indicators of chronic
conditions for any patient old enough to
produce a clean catch specimen
Tuberculosis screening
1. Tuberculosis testing
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
a. Evaluate overseas records of TB
testing/treatment
b. Evaluate all refugees of history of
tuberculosis, tuberculosis exposure,
any treatment
c. Evaluate for signs or symptoms of
disease (including Class A & B)
d. Clinically evaluate all refugee
arrivals for tuberculosis infection
e. TST (chest x-ray if > 10 mm
induration) IGRA (chest x-ray if
positive) IGRA if age > 5 y/o
f. Clinically evaluate for TB HIV+
g. Treat and report every case of
active TB
h. Refer all LTBI cases for follow up
treatment
Lead testing
x
x
x
x
x
x
x
x
1. Screen all refugee children 6
months to 16 years of age;
2. 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.
3. Children with elevated BLL
require referral for appropriate
follow-up.
Evaluate for Malaria to determine if testing is
indicated
x
x
a. 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
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Final Report: Medical Screening Recommendations
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x
x
x
x
x
x
x
x
x
x
x
x
whom presumptive therapy is
contraindicated should be tested.
b. Sub-Saharan African refugees
who received ACT presumptive
therapy prior to departure do not
need testing or presumptive
therapy post-arrival.
c. Refugees arriving from P.
falciparum malaria-endemic areas
outside sub-Saharan Africa or nonfalciparum malaria areas should not
receive routine testing or
presumptive therapy.
d. Find malaria endimicity
information with the online CDC
Malaria Map Application.
Intestinal Parasites
NOTE: Post-arrival screening for IP will depend on region of departure and pre-departure presumptive therapy
received. Please reference the Medical Screening Appendix for details on assessment and treatment.
Hepatitis A screening
Hep A screening is not recommended at
this time;
Hepatitis B screening
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
Hepatitis C screening
a. Hepatitis B surface antigen
(HbsAg)
b. Hepatitis B surface antibody
(anti-Hbs)
c. Hepatitis B core antibody (antiHbc)
d. Vaccinate previously
unvaccinated and susceptible
e. Refer HbsAg+ to specialist
f. Refer household contacts for
further screening
Hepatitis C screening is not
recommended at this time
Syphilis
Chlamydia
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
a. VDRL/RPR = >15 years, < 15 years
if sexually active or hx of sexual
abuse
b. Mother who tests or tested
positive,
c. Exposure to country endemic for
other treponemal subspecies (e.g.
yaws, bejal, pinta)
d. Confirmation testing for positive
treponemal tests
a. Urine nucleic amplification test
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x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
Gonococcus
b. Females < 25 years who are
sexually active or those with risk
factors (e.g. new or multiple
partners),
c. Luecoesterase (LE) positive on
urine sample,
d. Women or children with history
of, or at risk, for sexual assault
e. Any refugee with symptoms
a. Urine nucleic amplification test
b. Luecoesterase (LE) positive on
urine sample,
c. Women or children with hx of, or
at risk for, sexual assault
d. Any refugee with symptoms
HIV
NOTE: 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.
x
x
x
x
Refugees should be clearly
informed orally or in writing
when/if they will be tested for HIV.
x
x
x
x
Screening should be repeated 3-6
months following resettlement for
refugees who had recent exposure
or are at high risk.
x
x
x
x
A refugee’s decision to decline an
HIV test should be documented in
the medical record.
x
x
x
x
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.
x
x
x
x
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.
x
x
x
x
All refugees confirmed to be HIV-
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x
x
x
x
x
x
x
x
infected should be referred for care,
treatment, and preventive services.
In geographic areas in which the
prevalence of HIV is high, patients
who have primary syphilis should
be retested for HIV after 3 months if
the first HIV test result was
negative.
HIV-infected persons who are
treated for syphilis, should be
evaluated clinically and
serologically for treatment failure
(syphilis) at 3, 6, 9, 12, and 24
months after therapy. See CDC
treatment guidelines for detail.
General testing for specific populations
Lipid panel if
appropriate
Test for Vitamin D
levels
Test for Vitamin B12
Infant metabolic
screening in newborns,
according to state
guidelines
Urine pregnancy test
for women of child
bearing age
HIV in pregnancy
HIV in children
x
x
x
x
Lipid panel if indicated.
x
x
Test for Vitamin D levels in which pop?
x
x
x
x
Test for Vitamin B12 in which pop?
Infant metabolic screening in newborns,
according to state guidelines
x
x
Urine pregnancy test for women of
child bearing age
x
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 post arrival
and pre-natal medical screening and
care.
x
x
Test pregnant women for HIV
during first trimmest, if negative,
re-test during third trimester. See
CDC guidelines for details
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
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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/sulfamethoxasole
beginning at 6 weeks of age and
continuing until they are confirmed
to be uninfected.
Mental Health Screening
Assess general mental
health needs
Individual additional
MH assessment
x
x
x
x
x
x
x
a. Evaluate history of torture,
trauma, incarceration, sexual
assault, maltreatment and acute
psychiatric disorders. Capture
family history of mental illness
include any psychotropic meds,
include over the counter and
traditional medicine/drug use
a. Mental health screening for all
adults.
b. Educate and screen for abuse
within the family (must disclose
that child abuse is a "required to
report" offense...there may also be
some state specific requirements)
c. Screen for caregiver stress
x
x
x
x
x
x
x
x
x
x
x
x
x
x
a. Cervical (HPV test)
b. Breast
c. Colorectal
d. Prostate (PSA)
e. Maintain high index of suspicion
for disease when presenting with
hepatitis and H. pylori, or for
thyroid cancer with history of
radiation exposure (Russian).
x
x
x
x
a. Evaluate reproductive history for
women of child bearing years
b. Evaluate and educate on family
planning
c. Refer to WIC if appropriate
Cancer screening
Other: Women
x
x
x
x
Other: Children
x
x
x
x
a. Test for age appropriate
development in children ages 0 – 20
i. Child and Teen Check-Up or
equivalent development and
emotional screening for ages zero
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x
x
x
x
x
x
to 20.
ii. Utilize a standardized tool for
assessment
iii. Question parent for any growth
& development concerns.
Other: General
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
a. Assess nutrition issues by doing a
brief screen for dairy and food
groups, exercise; children and
adults as indicated.
b. Evaluate for substance use
c. Evaluate for substance abuse
d.. Report all reportable diagnosis
to state health department
e.. Refer complex medical cases to
appropriate medical case manager
f. Report unusual trends or patterns
of disease in any population to CDC
Complete/refer for I-693
(Adjustment of Status) after one
year in the USA
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Appendix H: Refugee Medical Screening Appendix
Preparation:
1. Xerox the I-94 and keep in file
2. Preferably retain a trained medical interpreter, in person or via telephone. Use family
members only as last resort.
3. Review the DS 2053, noting any concerns mentioned
Complete medical history:
1. History http://www.cdc.gov/immigrantrefugeehealth/
guidelines/domestic/guidelineshistoryphysical.html#history
a. Injury
b. Childhood disease
c. Surgeries/hospitalization
d. Allergies
e. Menstrual history
f. Family history of major diseases (e.g. diabetes, sickle-cell anemia, hypertension.)
2. Review of systems
a. Note impairments (cognitive. physical)
b. Identify indicators of chronic health concerns
3. Review of symptoms, acute concerns
a. Current pain, fever, weight loss, night sweats, pulmonary complaints, diarrhea or
abdominal complaints, pruritis, and skin lesions/rashes.
4. Assess current medications
a. OTC, psychotropic and traditional remedies/treatments
b. Assess for use of remedies or treatments contraindicated with use of a
prescription medication or for products that may contain toxic elements (i.e.,
lead, arsenic).
5. Educate regarding
a. Any general and patient specific identified concerns
b. U.S. Health care system (how to access)
c. Health insurance
d. Primary and preventive medical care
e. Emergency services, 911
f. Oral health and dental care
g. How to use medications (if appropriate).
h. Vision/ophthalmologic care.
Vital Signs:
1. Weight
2. Height
3. Blood Pressure
4. Pulse
5. Temperature
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6.
7.
8.
9.
Respiratory rate
BMI
Head circumference (birth through 36 months)
MUAC (mid upper arm circumference (6 – 60 months) if appropriate
Physical Exam
http://www.cdc.gov/immigrantrefugeehealth/guidelines/domestic/guidelines-historyphysical.html#physical
1. Complete physical exam
2. Make appropriate referrals to primary care or appropriate specialist
3. Test for vision impairment and make appropriate referral
4. Test for hearing impairment and make appropriate referral
5. Evaluate need for dental referral
6. Follow up testing and further evaluation of conditions causing abnormal results is
consistent with established best practice
7. Follow up on all referrals to assure appointments are kept
Preventive Health Interventions
Immunizations
1. Evaluate overseas immunization's records to assess needed updates.
a. Language translations for vaccine names are available at:
http://www.immunize.org/izpractices/p5121.pdf and,
b. http://www.cdc.gov/vaccines/pubs/pinkbook/downloads/appendices/B/foreignproducts-tables.pdf
c. The following documents may be useful when the generic or trade name is not
familiar to the provider: http://www.immunize.org/izpractices/p5120.pdf
2. Give age appropriate vaccines following ACIP guidelines, complete any series that has
been initiated (do not restart a series).
3. Give priority to giving vaccines needed for children to start school
a. http://www.cdc.gov/vaccines/recs/schedules/child-schedule.htm#printable.
4. Build toward providing all needed for Adjustment of Status
5. If unable to provide vaccines, provide appropriate referral to obtain needed
immunizations according to the ACIP guidelines
6. Record previous vaccines, lab evidence of immunity or hx of disease
7. Provide refugee with a record of immunity &/or vaccination, enter into state
immunization registry if available.
General Testing
Provide refugee with a record of all confirmed completed treatment. Also forward appropriate
documents to state for required reporting.
For all age appropriate refugees
a. CBC with differential
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b. Complete metabolic panel
c. UA to screen for indicators of chronic conditions for any patient old enough to
produce a clean catch specimen
1. Tuberculosis
http://www.cdc.gov/immigrantrefugeehealth/guidelines/domestic/tuberculosisguidelines.html
#domestic
a. Evaluate overseas records of TB testing/treatment including BCG vaccination.
b. Evaluate all refugees of history of tuberculosis, tuberculosis exposure, any
treatment.
c. Evaluate for signs or symptoms of disease
i. TST (chest x-ray if > 10 mm induration) IGRA (chest x-ray if positive) IGRA
if age >5 y/o
ii. cough > 3 weeks, dyspnea, weight loss, fever, night sweats or hemoptysis
iii. children, a history of recurrent pneumonias, failure to thrive, or recurrent
or persistent fevers
d. Clinically evaluate all refugee arrivals for tuberculosis infection (symptoms)
i. TST (chest x-ray if > 10 mm induration) IGRA (chest x-ray if positive) IGRA
if age > 5 y/o
e. Clinically evaluate for those with previous hx of infection of Class A or B TB
i. TST (chest x-ray if > 10 mm induration) IGRA (chest x-ray if positive) IGRA
if age > 5 y/o
f. Clinically evaluate for TB if refugee is HIV+
i. TST (chest x-ray if > 5 mm induration) IGRA (chest x-ray if positive) IGRA if
age > 5 y/o
g. Treat and report every case of active TB
h. Negative TST and/or IGRA does not eliminate TB disease from the differential
diagnosis of a symptomatic patient.
i. Refer all LTBI cases for follow up treatment
2. Lead Testing
http://www.cdc.gov/immigrantrefugeehealth/guidelines/leadguidelines.html#evaluation
1. Screen all refugee children 6 months to 16 years of age;
2. 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.
3. Children with elevated BLL require referral for appropriate follow-up.
3. Evaluate for Malaria to determine if testing is indicated
http://www.cdc.gov/immigrantrefugeehealth/guidelines/domestic/malaria-guidelinesdomestic.html#sect6
NOTE: Any refugee who has signs and symptoms of malaria and who originated in a malariaendemic country should be tested for malaria.
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1. 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.
2. Sub-Saharan African refugees who received ACT presumptive therapy prior to
departure do not need testing or presumptive therapy post-arrival.
3. Certain populations are excluded from all presumptive regimens; these groups
include pregnant women, lactating women, and persons with other contraindications
such as allergy or hypersensitivity to medications and children <5 kilograms
http://www.cdc.gov/immigrantrefugeehealth/guidelines/domestic/malariaguidelines-domestic.html#sect9
a. 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.
b. Find malaria endemicity information with the online CDC Malaria Map
Application.
http://www.cdc.gov/malaria/map/
4. Intestinal Parasites
http://www.cdc.gov/immigrantrefugeehealth/guidelines/domestic/intestinal-parasitesdomestic.html
NOTE: Post-arrival screening for IP will depend on region of departure and predeparture presumptive therapy received.
For all refugee arrivals (asymptomatic and sympt omatic):
? Confirm specific pre-departure presumptive treatment
? Evaluate for eosinophilia * by obtaining a CBC with differential
(eosinophilia >400cells/µl)
PLUS
Documented pre-departure pr esumptive treatment
For single -dose albendazole
pre-departure treatment (no
praziquantel)
?
?
?
?
Strongyloides serology
(all refu gees);
Schistosoma serology
(sub-Saharan Africans);
Treat if positive for
Strong yloides stercoralis or
Schist osoma spp .
If positive for eosinophilia,
re-check total eosinophil
count in 3 -6 months.**
For single -dose albendazole
pre-departure treatment with
praziquantel
?
?
?
Strongyloides serology
(all refugees) ;
Treat if positive for
Strongyloides stercoralis
If positive for eosinophilia,
re-check total eosinophil
count in 3 -6 months.**
No documented pre-departure
presumptive trea tment:
For high-dose pre-departure
treatment (ivermectin and
praziqua ntel):
?
If positive for eosin ophilia,
re-check total eosinophil
count in 3-6 months after
arrival. **
?
?
?
?
?
Conduct stool examin ations
for ova and parasites (O&P);
two stool specimens should
be obtained more than 24
hours apart ;
Strongyloides serology (all
refugees);
Schistosoma serology (subSaharan Afr ican s);
Treat path ogenic parasites ;
Re-check total eosinophil
count in 3 -6 months.**
* Eosinophilia may or may not be present with parasitic infection; an absolute eosinophil count provides supplemental diagnostic information.
** Persistent eosinophilia or symptoms requires further diagnostic evaluation.
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If parasites are identified, one stool specimen should be submitted 2-3 weeks after completion
of therapy to determine response to treatment. For background information and treatment
guidelines see CDC’s Evaluation of Refugees for Intestinal and Tissue-Invasive Parasitic
Infections during Domestic Medical Examination, as well as The Medical Letter on Drugs and
Therapeutics: Drugs for Parasitic Infections. www.themedicalletter.org
To determine pathogenic and non=pathogenic parasites, see Table 2
http://www.cdc.gov/immigrantrefugeehealth/guidelines/domestic/intestinal-parasitesdomestic.html#sect2
5. Hepatitis A
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5912a1.htm?s_cid=rr5912a1_e
a. No testing recommended at this time.
6. Hepatitis B
http://www.cdc.gov/hepatitis/HBV/TestingChronic.htm
a.
b.
c.
d.
Hepatitis B surface antigen (HBsAg)
Vaccinate previously unvaccinated and susceptible
Refer HbsAg+ to specialist
Refer household contacts for further screening
Optional additional testing:
e. Hepatitis B surface antibody (anti-Hbs)
f. Hepatitis B core antibody (anti-Hbc)
7. Hepatitis C
http://www.cdc.gov/std/treatment/2010/hepC.htm#a2
a. No testing recommended at this time
Screening for HIV and all other STI’s should be repeated 3-6 months following screening for
refugees who had recent exposure or who are at high risk.
http://www.cdc.gov/immigrantrefugeehealth/guidelines/domestic/sexually-transmitteddiseases.html
8. Syphilis
a. VDRL/RPR for
i. ≥15 years regardless of status and < 15 years if sexually active or hx of
sexual abuse or have mother who tests or tested positive.
ii. Exposure to country endemic for other treponemal subspecies (e.g. yaws,
bejal, pinta)
b. Confirmation testing for positive treponemal tests
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9. Chlamydia
Urine nucleic amplification test for:
a. Females ≤ 25 years who are sexually active or those with risk factors (e.g. new or
multiple partners),
b. Luecoesterase (LE) positive on urine sample,
c. Women or children with history of, or at risk, for sexual assault,
d. Any refugee with symptoms
10. Gonococcus
Urine nucleic amplification test for:
a. Luecoesterase (LE) positive on urine sample,
b. Women or children with hx of, or at risk for, sexual assault
c. Any refugee with symptoms
11. HIV
http://www.cdc.gov/immigrantrefugeehealth/guidelines/domestic/screening-hivinfection-domestic.html
NOTE: As of January 4, 2010, refugees are no longer tested for HIV infection prior to
arrival in the U.S.)
a. General guidance
i. 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.
ii. Refugees should be clearly informed orally or in writing when/if they will
be tested for HIV.
iii. Screening should be repeated 3-6 months following resettlement for
refugees who had recent exposure or are at high risk:
iv. A refugee’s decision to decline an HIV test should be documented in the
medical record.
v. 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.
vi. 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.
vii. All refugees confirmed to be HIV-infected should be referred for care,
treatment, and preventive services.
viii. In geographic areas in which the prevalence of HIV is high, patients who
have primary syphilis should be retested for HIV after 3 months if the first
HIV test result was negative.
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ix. HIV-infected persons who are treated for syphilis, should be evaluated
clinically and serologically for treatment failure (syphilis) at 3, 6, 9, 12,
and 24 months after therapy. See CDC treatment guidelines for detail.
12. General testing for specific populations
a. Lipid panel if appropriate
b. Vitamin D levels
c. Vitamin B-12 levels
i. Reference the MMWR on this subject
d. Infant metabolic screening in newborns, according to state guidelines
e. HIV testing in pregnancy
i. 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 post-arrival and prenatal medical
screening and care.
ii. See CDC treatment guidelines for detail. Test pregnant women for HIV
during first trimester; if negative, re-test during third trimester.
f. HIV testing in children
i. Children < 13 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 <13 years of age should be screened.
ii. 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.
g. 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.
h. Urine pregnancy test for all women of childbearing years.
14. Mental Health Assessment
http://www.cdc.gov/immigrantrefugeehealth/guidelines/domestic/mental-healthscreening-guidelines.html
i. Evaluate history of torture, trauma, incarceration, sexual assault, maltreatment
and acute psychiatric disorders. Capture family history of mental illness include
any psychotropic meds, include over the counter and traditional medicine/drug
use
j. Depression screening for all adolescents and adults.
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k.
Educate and screen for abuse within the family (must disclose that child abuse is
a "required to report" offense...there may also be some state specific
requirements)
l. Screen for caregiver stress
13. Cancer Screening
http://www.cdc.gov/cancer/dcpc/prevention/screening.htm
NOTE: Cancer screening special note regarding pelvic exam. Pap smears for any woman
over 21 years of age (or sexual active) who has never been screened. ONLY proceed
once a trusting relationship with each woman has been established over time
a. Cervical (HPV test)
b. Breast
c. Colorectal
d. Prostate (PSA)
e. Maintain high index of suspicion for disease when presenting with hepatitis and
H. pylori, or for thyroid cancer with history of radiation exposure (Russian).
14. Other: Women
a. Evaluate reproductive history for women of child bearing years
b. Evaluate and educate on family planning
c. Refer to WIC if appropriate
15. Other: Children
a. Test for age appropriate development in children ages 0 – 20
i. Child and Teen Check-Up or equivalent development and emotional
screening for ages zero to 20.
ii. Utilize a standardized tool for assessment
iii. Question parent for any growth & development concerns.
16. Other: General
a. Assess nutrition issues by doing a brief screen for dairy and food groups,
exercise; children and adults as indicated.
b. Evaluate for substance abuse
c. Report all reportable diagnosis to state health department
d. Refer complex medical cases to appropriate medical case manager
e. Report unusual trends or patterns of disease in any population to CDC
f. Complete I-693 (Adjustment of Status) after one year in the US
Enhancing Partnerships in Refugee Health
Final Report: Medical Screening Recommendations