The refugee medical exam: What you need to do

Vaccinations given in other countries are acceptable if appropriately recorded in Institute of Medicine documentation, or if original vaccination records are available and the vaccinations conform to appropriate intervals and age guidelines. Refugees must bring their records with them to medical appointments. Laboratory evidence of immunity is acceptable for measles, mumps, rubella (MMR), hepatitis A, hepatitis B, polio, and varicella, but there is debate about whether such testing should be performed before immunization.^18,53 Health care providers need to assess each patient based on age and risk factors to decide whether immunity testing is appropriate.

In our practice, we routinely test all adults for immunity to varicella, hepatitis A, hepatitis B, and MMR. For children, we rely on documented immunization records, not antibody titers, for evidence of previous vaccination.

Pay attention to mental health issues
Many refugees have been exposed to trauma, often including war and torture, increasing their risk for mental illness. A large 2005 review found that serious mental disorders, including post-traumatic stress disorder (PTSD), major depressive disorder, and generalized anxiety disorder are significantly more prevalent among refugees than the general population.⁵ Many screening tests for PTSD have been proposed⁵⁴ but have not been validated in all immigrant or refugee populations.⁵⁵

Mental health care for refugees is complicated by language and cultural barriers, adjustment disorders, access to psychiatric services, and uncertainty about effective treatments in refugee populations. Despite the higher prevalence of mental illness among refugees, many in the mental health field have raised concerns about the applicability of Western concepts of mental health, including PTSD, in this group.⁵⁶

Refugees who are victims of torture should be referred to experienced mental health practitioners. After ruling out acute psychosis and destructive behaviors, we recommend postponing an exhaustive mental health screening until several months after arrival. In our medical home model, we evaluate patients on an ongoing basis, giving us an opportunity to identify emerging or worsening mental health conditions.

Evaluate dental health
The incidence of dental caries and periodontal disease among refugees varies widely among different groups of refugees. Data on pediatric refugees in the United States have shown dental caries to be common, with prevalences between 16.7% and 42%, with marked differences based on region of origin.^3,57,58 In our practice, we also have noted heavy use of betel nut in the Southeast Asian community, leading to significant dental disease.

All refugees should have their dentition evaluated at the initial DRME. We recommend subsequent formal dental examination for all patients, giving priority to those with clear evidence of active disease.

Identify and address chronic disease
Refugees carry a substantial burden of chronic disease, although marked regional variation has been noted.⁴ A study of Massachusetts refugees from 2001 through 2005 demonstrated that 46.8% were overweight or obese, 22.6% had hypertension, and 3.1% had diabetes. Smoking is also highly prevalent in refugee populations.⁵⁹

Our findings confirm high rates of chronic disease, particularly among Iraqi and geriatric refugees. These patients require close follow-up after the DRME to minimize sequelae from chronic conditions. Multi-disciplinary teams in the patient-centered medical home may provide an opportunity to promptly address chronic health conditions that can have severe short-term consequences if not adequately managed (eg, insulin dosage adjustment based on diet in patients with diabetes).

We recommend a comprehensive medical history and evaluation for chronic disease, including diabetes and hypertension, at the DRME and on an ongoing basis. Although many refugees have never had any health screening and substantial cultural barriers may exist, especially with regard to women’s health and age-based cancer screening, refugees generally should receive the same preventive care as the rest of the US population until further research has been done in this area.

We recommend introducing age-based cancer screening and other preventive care for refugees within 2 months of their initial visit. This model of care has already been endorsed by the Minnesota Department of Health’s Refugee Health Program, one of the leading health care providers for refugees in the United States.⁶⁰

Toward better care models

The medical care of refugees is complex, but the prepared primary care provider can manage it effectively. TABLE 4 summarizes our recommendations for the DRME based on our experiences and the available literature. Standardized screening guidelines and comprehensive programs, perhaps incorporating the concept of the patient-centered medical home, will likely improve both the initial and continuing care of this population.