Association of Refugee Health Coordinators Medical Screening Committee Tools and Recommendations
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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.
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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 4
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 5 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 6 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. Screen- only 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 8
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/refugee- guidelines.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 13
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. 14
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
Name (last, first, MI) Date of Birth : Gender: Male ___/___/____ Female Alien #: US Arrival Date Country of Origin:______/___/____ Refugee Camp:______Class A status: ______Dates of Clinical Visit (s) for Screening No Yes (requires approved waiver for US entry and Screening Visit #1: ___/___/____(date) immediate follow-up upon arrival) Screening Visit #2: ___/___/____(date) Class B TB status: ______Class B Other / Specify:______ No Yes (requires follow-up soon after arrival) 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 (F0): Vision Screening: OD__/20 OS__/20 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 Description NL Description Constitutional MS Symptoms Eyes Integumentary Ears, Nose, Mouth, Neurological Throat Cardiovascular Mental Health Respiratory Endocrine GI Hematologic, Lymphatic GU/GYN Allergic, Immunologic Physical Exam Pallor__? Hepatosplenomegaly__? Lymphadenopathy__? Nutrition__? NL Description NL Description HEENT Abdomen Neck Extremities Cardiovascular Musculoskeletal Respiratory Skin and SQ Back GI/Rectal Breasts /GU Neuro 16
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) Tuberculin Skin Test (TST) NOTE: TST is preferred for testing children aged <5 years _____mm induration ___/___/____(date) old. ___/___/____(date) Not done Not done Given, not read Positive Negative Indeterminate Chest X-ray (If TST, IGRA positive, Class B or Diagnosis (must check one) Symptomatic) No TB infection or disease ___/___/____(date) Latent TB infection (LTBI), referred to TB program or patient’s Normal primary care provider for follow-up ___/___/____(date) Abnormal, referred to TB Program Active TB disease, referred to TB program for evaluation and Not done treatment. ___/___/____(date)
Hepatitis B Screening
Diagnosis (must check one) Screened? Yes___/___/____(date) No Immune (HBsAb positive) Unvaccinated and susceptible (all negative); vaccinate HBsAb Possible active (HbsAG or HBcAb positive), referred to HBsAg PMD / specialist for follow-up ___/___/____(date) HBcAb 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 No parasites found ___/___/____(date) ___/___/____(date) O&P x 2 ___/___/____(date) Serology test: (see population specific) Schistosoma Strongyloides Parasites found, check all that apply below Referral for treatment? Treatment completed ___/___/____(date) Yes ___/___/____(date) No; why not? ______ Ascaris Clonorchis Entamoeba histolytica Giardia Hookworm Paragonimus Schistosoma Strongyloides Tapeworm Trichuris Other (specify) Other (specify) Malaria Screening Fever? Pre-Departure presumptive treatment? Yes No Unknown No evidence of infection Lead Screening (<17 yrs old) Screened? Yes ___/___/____(date) Not done NOTE: Re-check all children aged 6 mo- 6 yrs within 3-6 Results: months of arrival, regardless of results of initial lead screen. 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 Vision Mental Health
Emergency/Urgent WIC 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)
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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 Assess and update immunizations for each individual. Indicate laboratory evidence of immunity for Immunizations 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 Tuberculosis (TB) 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 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 Sexually Transmitted mother’s HIV status can be confirmed as negative and the child is otherwise thought to be at low risk of Infections 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 For single-dose albendazole For high-dose pre-departure Conduct stool examinations pre-departure treatment (no pre-departure treatment with treatment (ivermectin and for ova and parasites (O&P); praziquantel) praziquantel praziquantel): two stool specimens should be obtained more than 24
hours apart; Strongyloides serology Strongyloides serology If positive for eosinophilia, Strongyloides serology (all (all refugees); (all refugees); re-check total eosinophil refugees); Schistosoma serology Treat if positive for count in 3-6 months after Schistosoma serology (sub- (sub-Saharan Africans); Strongyloides stercoralis arrival. ** Saharan Africans); Treat if positive for If positive for eosinophilia, Treat pathogenic parasites;
Strongyloides stercoralis or re-check total eosinophil Re-check total eosinophil Schistosoma spp. count in 3-6 months.** count in 3-6 months.** If positive for eosinophilia, re-check total eosinophil count in 3-6 months.**
19
Intestinal Parasites, *Eosinophilia may or may not be present with parasitic infection; an absolute eosinophil count provides continued 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.
Screen those refugees present with symptoms suspicious of malaria. For asymptomatic refugees from Malaria highly endemic areas, i.e., sub-Saharan Africa, screen or presumptively treat if no documented pre-
departure 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 URL 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
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 Routine, Expected:S, Expires: S+120, Qty-1 older"
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) Routine, Expected:S, Expires: S+120, Qty-1 [0510]
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) Routine, Expected:S, Expires: S+120, Qty-1 [3131]
RPR (SYPHYLIS SCREEN) [0240] Routine, Expected:S, Expires: S+120, Qty-1
Enhancing Partnerships in Refugee Health Final Report: Medical Screening Recommendations 22
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 Routine, Expected:S, Expires: S+120, Qty-1 younger"
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 Qty-1 USE(V06.8) 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
Enhancing Partnerships in Refugee Health Final Report: Medical Screening Recommendations 23
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
Enhancing Partnerships in Refugee Health Final Report: Medical Screening Recommendations 24
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 Qty-1 Vaccine Payment Agreement Waiver" 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
Enhancing Partnerships in Refugee Health Final Report: Medical Screening Recommendations 25
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 Qty-1 MO(V04.81) 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 Qty-1 3+YRS(V04.81) Did patient receive physician counseling? (for under 8 years of age): Yes
INFLUENZA LIVE INTRANASAL 2-49 YRS Qty-1 (V04.81) 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 Final Report: Medical Screening Recommendations 26
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) Qty-1 (V03.89) Did patient receive physician counseling? (for under 8 years of age): Yes
MENINGOCOCCL POLYSACCHRID (Menomune) Qty-1 (V03.89) 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 Qty-1 USE(V06.8) 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 Final Report: Medical Screening Recommendations 27
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 Qty-1 first dose after 12 wks age 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
Enhancing Partnerships in Refugee Health Final Report: Medical Screening Recommendations 28
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 Final Report: Medical Screening Recommendations 29
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 Routine, Expected:S, Expires: S+120, Qty-1 older"
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) Routine, Expected:S, Expires: S+120, Qty-1 [0510]
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 Final Report: Medical Screening Recommendations 32
UA MICRO IF [3307] Routine, Expected:S, Expires: S+120, Qty-1
PARASITE BLOOD SMEAR(aka MALARIA) Routine, Expected:S, Expires: S+120, Qty-1 [3131]
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 Routine, Expected:S, Expires: S+120, Qty-1 younger"
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 Qty-1 USE(V06.8) Did patient receive physician counseling? (for under 8 years of age): Yes
Enhancing Partnerships in Refugee Health Final Report: Medical Screening Recommendations 33
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
Enhancing Partnerships in Refugee Health Final Report: Medical Screening Recommendations 34
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 Qty-1 Vaccine Payment Agreement Waiver" Did patient receive physician counseling? (for under 8 years of age): Yes
Dx: Vaccine for Herpes Zoster
HIB
Enhancing Partnerships in Refugee Health Final Report: Medical Screening Recommendations 35
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 Qty-1 MO(V04.81) 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 Qty-1 3+YRS(V04.81) Did patient receive physician counseling? (for under 8 years of age): Yes
INFLUENZA LIVE INTRANASAL 2-49 YRS Qty-1 (V04.81) Did patient receive physician counseling? (for under 8 years of age): Yes
Enhancing Partnerships in Refugee Health Final Report: Medical Screening Recommendations 36
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) Qty-1 (V03.89) Did patient receive physician counseling? (for under 8 years of age): Yes
MENINGOCOCCL POLYSACCHRID (Menomune) Qty-1 (V03.89) 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 Qty-1 USE(V06.8) Did patient receive physician counseling? (for under 8 years of age): Yes
Enhancing Partnerships in Refugee Health Final Report: Medical Screening Recommendations 37
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 Qty-1 first dose after 12 wks age 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
Enhancing Partnerships in Refugee Health Final Report: Medical Screening Recommendations 38
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
Enhancing Partnerships in Refugee Health Final Report: Medical Screening Recommendations 39
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
Enhancing Partnerships in Refugee Health Final Report: Medical Screening Recommendations 40
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:
Enhancing Partnerships in Refugee Health Final Report: Medical Screening Recommendations 41
Appendix D: Pocket Guide – Minnesota
Enhancing Partnerships in Refugee Health Final Report: Medical Screening Recommendations 42
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 Date Health Officer
Enhancing Partnerships in Refugee Health Final Report: Medical Screening Recommendations 43
Table of Contents
Page 3 Background 3 The Oversees Visa Medical Examination 4 Refugees with Communicable Diseases o Class A & B Conditions 5 Communicable Diseases of Public Health Significance 6 Laws and Regulations 7 Domestic Health Assessment/Screening 7 Adjustment in Status Examination 9 Domestic Health Screening – Preparation 11 Health History and Screening 13 Vision Screening 14 Hearing Screening 15 Dental Screening 16 Tuberculosis Screening 17 Specimen Collection for QFT-IT 18 Tuberculosis Screening – TB Skin Testing 20 Immunizations 22 Hepatitis B Screening 23 Parasite Screening 24 Processing a Stool Specimen 25 Lead Screening 26 HIV Screening 27 Providing Culturally and Linguistically Appropriate Care 30 Guidelines for Using Medical Interpreters 31 Glossary
Appendices
A Refugee Contract B Domestic Examination for Newly Arrived Refugees C Domestic Refugee Health Program Frequently Asked Questions D General & Optional Testing during the Domestic Medical Examination for Newly Arriving Refugees E Screening for HIV-Infection during the Refugee Domestic Medical 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 Enhancing Partnerships in Refugee Health Final Report: Medical Screening Recommendations 44
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 treat- ment 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 well- being. 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 currently include: 1. Tuberculosis 2. Syphilis 3. Chancroid 4. Gonorrhea 5. Granuloma Inguinale 6. Lymphogranuloma Venereum 7. Hansen's Disease (Leprosy) 8. 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
Enhancing Partnerships in Refugee Health Final Report: Medical Screening Recommendations 48 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 Exami- nation, 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.
Enhancing Partnerships in Refugee Health Final Report: Medical Screening Recommendations 54 Snellen Eye Chart Vision Screening Procedure for administering a Snellen eye exam. 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 Snellen Distant Acuity Test eye. Reverse procedure, testing left eye, and then test with both eyes. Instruct client to The Snellen chart is widely used for measuring central keep both eyes open (including the eye that is visual acuity.The Snellen wall chart should be 20 feet away from the client. 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
Visual acuity test resultsThe Snellen eye test results with right eye, left eye, and both eyes. use 20 feet as the norm, represented by the numerator Referral criteria: each eye must see at in the Snellen test result. The number of the last line of least the 20/30 line. For younger children in type the client can read accurately is recorded as the denominator in the Snellen test result. 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" on the chart. Snellen chart is illustrativeEnhancing only and Partnerships not in Refugee Health 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 An estimated one-third of the world’s population is infected with Mycobacterium tuberculosis. All newly tested in Spokane County for arrived refugees should be screened for active TB were found to be infected. tuberculosis (TB) disease and latent TB infection (LTBI) 77% of active TB disease cases upon arrival in the United States. in Washington State were foreign-born. 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 public health priority. On the basis of its very high success rate 1. Don gloves 2. Cleanse site with of detecting TB cases, domestic follow-up evaluation of alcohol immigrants, refugees and asylees with Class B1, B2 and B3 TB 3. Place a tourniquet notification status should be given highest priority by all TB tightly on the client’s control programs. Legal immigrants, refugees, and asylees with arm above site where Class B1, B2 and B3 TB notification status are also a high-priority the blood will be subpopulation for screening for latent TB infection (LTBI). (See drawn SRHD TB Manual for detailed information on Class B policies 4. Collect 1ml of blood into each of the 3 QFT- and procedures) IT tubes Specimen Collection Procedure for QuantiFERON in- Tube (QFT-IT) Venipuncture collection All refugee clients 5 years of age and older will be tested for 1mL tubes draw blood slowly tuberculosis at the time of pre-screening or screening. TB so keep the tube on the screening should include a Mantoux tuberculin skin test (TST) needle for 2-3 seconds once for children under 5 years of age and QuantiFERON In-tube the tube appears to have (QFT) blood test for those 5 years of age and older; and a completed filling, to ensure medical evaluation for signs and symptoms of active TB. that the correct volume is drawn. The black mark on the Assess the client for any TB signs or symptoms using the TB side of the tubes indicates the Testing Form as a guide. Also, ask the client about any risk 1mL fill volume. Tubes must factors they may have for TB infection and disease, and have between 0.8mL – 1.2mL document those on the TB Testing Form. All refugees should of blood. If the level of blood also be documented as population risk of foreign born. Obtain in any tube is not close to the the client’s consent by having them sign the TB Testing Form indicator line, draw another and obtain the client’s consent to release their TB test tube. information, if applicable.
Syringe draws A Step-By-Step Procedure Remove the needle, ensuring QFT-G In-Tube (QFT-IT) - uses the following set of 3 heparin appropriate safety tubes provided by the Lab: procedures, transfer 1mL of Gray cap = Nil (Specimen Negative Control) blood from the syringe into Red cap = TB Antigens (ESAT-6, CFP-10 and TB7.7 each tube by removing the Purple cap = Mitogen Control (Specimen Positive caps. Control) NOTE: Contents have been dried onto the inner wall of the blood collection tubes so it is essential that the contents of the “Butterfly needle” draws tubes be thoroughly mixed with the blood. A “purge” tube (not a QFT-IT tube) should be used to 1. After drawing the blood, mix the tubes by SHAKING ensure proper suction and VIGOROUSLY (not by simple inversion) at least 10 times to that the tubing is filled with ensure that the entire inner surface of the tube has been coated blood prior to the QFT-IT tubes being used. Enhancing Partnerships in Refugee Health Final Report: Medical Screening Recommendations 59
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 vaccina- tions. 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 in- terval as defined in the Recommended Childhood or Adult Immunization
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Vaccine Information Schedules. Products and terms for vaccines and vaccine- Statements (VIS) are preventable diseases used throughout the world, along with available in many translations of foreign vaccine-related terms, can be found in translations from the the Epidemiology and Prevention of Vaccine-Preventable Immunization Action Disease – Pink Book or at Coalition web site: http://www.cdc.gov/vaccines/pubs/pinkbook/default.htm www.immunize.org/vis 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 ACIP/CDC Recommended required for all refugees and immigrants applying to change Immunization Schedules can their immigration status or applying for his/her green card. This be found at: change of status application can be made at any time after http://www.cdc.gov/vaccine he/she has resided in the U.S. a minimum of one year. The I-693 s/recs/schedules/default.ht form can be completed by any public or private provider, but m 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. Technical Instructions for Immunizations (continued) Vaccinations for Civil
Surgeons is the guide SRHD Immunization Review & Documentation uses for determining Assess refugee clients’ immunization history and needs at every vaccination requirements. visit and provide each refugee with a Washington State Lifetime http://www.cdc.gov/immigra Immunization record card. Remind the client to bring his/her ntrefugeehealth/pdf/2009- immunization record with them to all doctor’s visits. vaccination-technical- instructions.pdf 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, Guidelines for Use of State- because measles vaccination may temporarily suppress Supplied Vaccines can be tuberculin reactivity, yielding a false negative response. If the found at: TST was placed first, there is no need to wait before http://www.doh.wa.gov/cfh administration of a live vaccine as long as the TST has already /Immunize/documents/vacu been read. sage.pdf 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 Test for HBsAg, regardless of If HBsAg-positive, refer for high and intermediate HBV vaccination status in their country medical management. If negative, endemicity (HBsAg of origin, including – immigrants – assess for on-going risk for prevalence 2%) refugees – asylum seekers – hepatitis B and vaccinate if internationally adopted children indicated. US born persons not If HBsAg-positive, refer for Test for HBsAg regardless of vaccinated as infants whose medical management. If negative, maternal HBsAg status if not parents were born in assess for on-going risk for vaccinated as infants in the United regions with high HBV hepatitis B and vaccinate if States. endemicity ( 8%) 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 pre- departure presumptive treatment for parasites overseas.
For all refugee arrivals (asymptomatic and symptomatic): Hookworm Ancylostoma caninum 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)
Enhancing Partnerships in Refugee Health Final Report: Medical Screening Recommendations 68 Standard 1 Health care organizations should ensure that patients/consumers receive from all staff member's Providing Culturally and Linguistically effective, understandable, and respectful care that is provided in a manner compatible with their cultural Appropriate Care health beliefs and practices and preferred language. National standards were created by the U.S. Standard 2 Department of Health and Human Health care organizations should implement strategies Services’ (HHS) Office of Minority Health to recruit, retain, and promote at all levels of the (OMH) in response to the need to ensure organization a diverse staff and leadership that are that all people entering the health care representative of the demographic characteristics of the service area. system receive equitable and effective treatment in a culturally and linguistically Standard 3 Health care organizations should ensure that staff at appropriate manner. The standards are all levels and across all disciplines receive ongoing intended to be inclusive of all cultures and education and training in culturally and linguistically not limited to any particular population appropriate service delivery. group or sets of groups; however, they are Standard 4 especially designed to address the needs of Health care organizations must offer and provide racial, ethnic, and linguistic population language assistance services, including bilingual staff and interpreter services, at no cost to each groups that experience unequal access to patient/consumer with limited English proficiency at all health services. Ultimately, the aim of the points of contact, in a timely manner during all hours standards is to contribute to the elimination of operation. of racial and ethnic health disparities and to Standard 5 improve the health of all Americans. Health care organizations must provide to patients/consumers in their preferred language both verbal offers and written notices informing them of The 14 standards are organized by their right to receive language assistance services. themes: Culturally Competent Care Standard 6 (Standards 1-3), Language Access Services Health care organizations must assure the (Standards 4-7), and Organizational competence of language assistance provided to Supports for Cultural Competence limited English proficient patients/consumers by interpreters and bilingual staff. Family and friends (Standards 8-14). Within this framework, should not be used to provide interpretation services there are three types of standards of (except on request by the patient/consumer). varying stringency: mandates, guidelines, Standard 7 and recommendations as follows: Health care organizations must make available easily understood patient-related materials and post signage CLAS mandates are current Federal in the languages of the commonly encountered groups requirements for all recipients of Federal and/or groups represented in the service area. funds (Standards 4, 5, 6, and 7). Standard 8 CLAS guidelines are activities Health care organizations should develop, implement, and promote a written strategic plan that outlines clear recommended by OMH for adoption as goals, policies, operational plans, and management mandates by Federal, State, and national accountability/oversight mechanisms to provide accrediting agencies (Standards 1, 2, 3, 8, culturally and linguistically appropriate services. 9, 10, 11, 12, and 13). Standard 9 CLAS recommendations are suggested by Health care organizations should conduct initial and ongoing organizational self-assessments of CLAS- OMH for voluntary adoption by health care related activities and are encouraged to integrate organizations (Standard 14). cultural and linguistic competence-related measures into their internal audits, performance improvement programs, patient satisfaction assessments, and outcomes-based evaluations. Enhancing Partnerships in Refugee Health Final Report: Medical Screening Recommendations
69 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 Providing Culturally and Linguistically records, integrated into the organization's Appropriate Care (continued) management information systems, and periodically updated. Language Access Rights Standard 11 Background Health care organizations should maintain a current Many immigrants and refugees are not demographic, cultural, and epidemiological profile of aware of their legal rights with respect to the community as well as a needs assessment to accurately plan for and implement services that interpretation/translation services. Title VI respond to the cultural and linguistic characteristics of of the Civil Rights Act of 1964 and the service area. Presidential Executive Order 13166 of 2000, “Improving Access to Services for Standard 12 Persons with Limited English Proficiency,” Health care organizations should develop participatory, collaborative partnerships with stipulate that all programs that receive communities and utilize a variety of formal and Federal Financial Assistance (Medicare & informal mechanisms to facilitate community and Medicaid) must provide patient/consumer involvement in designing and interpretation/translation services to their implementing CLAS-related activities. Limited English Proficient (LEP) Standard 13 clients/patients at no cost. Health care organizations should ensure that conflict and grievance resolution processes are culturally and The refugee program strives to adhere to linguistically sensitive and capable of identifying, preventing, and resolving cross-cultural conflicts or the CLAS standards and Title VI of the Civil complaints by patients/consumers. Rights Act of 1964 when providing care to clients. Standard 14 Health care organizations are encouraged to regularly All staff working in the clinical setting will make available to the public information about their progress and successful innovations in implementing receive cultural awareness and diversity the CLAS standards and to provide public notice in trainings on an on-going basis. Trainings their communities about the availability of this venues will consist of webcasts, literature information. 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/soc- AJPM-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.nynj- phtc.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 persecu- tion 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 Optional Screen only Primary Screen Additions clinic Care Services Preparation Verify I-94 card x x x x
Engage an interpreter x x x x Review the DS 2053, noting any x x x x concerns mentioned
Complete medical history x x x x
Vital signs x x x x
Physical Exam Complete physical exam x x x x Make appropriate referrals to x x x x primary care or appropriate specialist Test for vision impairment and x x x x make appropriate referral Test for hearing impairment and x x x x make appropriate referral Evaluate need for dental referral x x x x Follow up testing and further x x evaluation of conditions causing abnormal results is consistent with established best practice Follow up on all referrals to assure x x appointments are kept
Preventive health interventions Immunizations x x x x
General testing For all age appropriate refugees CBC with differential x x x x Complete metabolic panel x x Urinalysis to screen for indicators x x x x of chronic conditions for any
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patient old enough to produce a clean catch specimen Tuberculosis screening x x x x Lead Testing x x x x Evaluate for Malaria to determine x x x x if testing is indicated Evaluate for Intestinal Parasites x x x x Hepatitis B screening x x x x Syphilis testing x x x x Chlamydia x x x x Gonococcus x x x x HIV x x x x For specific populations Lipid panel if appropriate x x Test for Vitamin D levels x x Test for Vitamin B12 x x Infant metabolic screening in x x x newborns, according to state guidelines Urine pregnancy test for women x x of child bearing age HIV in pregnancy x x x x HIV in children x x x x
Mental Health Screening Assess general mental health x x x x needs Individual additional MH x x assessment
Cancer screening x x
Other: Women x Evaluate reproductive history for x x women of child bearing years Evaluate and educate on family x x planning Refer to WIC if appropriate x x x
Other: Children Test for age appropriate x x development in children ages 0 –
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20
Other: General Assess nutrition issues by doing a x x brief screen for dairy and food groups, exercise; children and adults as indicated. Evaluate for substance use x x x x Evaluate for substance abuse x x Report all reportable diagnosis to x x x x state health department Report unusual trends or patterns x x of disease in any population to CDC Complete I-693 after one year in x x x the USA (if service is offered)
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Appendix G: Expanded Refugee Medical Screening Tool
Clinical Item Basic Optional Screen Primary Comments Screen Additions Only Clinic Care Services Preparation Verify I-94 card x x x x Xerox and keep in file Engage an interpreter x x x x Preferably a trained medical interpreter, in person or via telephone. Use family members only as last resort. Review the DS 2053, x x x x noting any concerns mentioned
Complete medical history 1. History x x x x a. Injury x x x x b. Childhood disease x x x x c. Surgeries/hospitalization x x x x d. Allergies x x 2. Review of systems x x x x a. Note impairments (cognitive & physical) x x x x b. Identify indicators of chronic health concerns x x x x 3. Review of symptoms, acute concerns x x x x a. Current pain x x x x 4. Assess current medications x x x x a. OTC, psychotropic and traditional remedies & treatments x x x x 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). x x x 5. Educate regarding x x x a. Any general and patient specific identified concerns x x x b. U.S. Health care system (how to access) x x x c. Health insurance x x x d. Primary and preventive medical care x x x x e. Emergency services, 911, primary care services x x x f. Oral health and dental care x x x x 6. How to use medications (if appropriate.) x x x x 7. Vision/ophthalmologic care.
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Vital signs x X x x 1. Weight x x x x 2. Height x x x x 3. Blood Pressure x x x x 4. Pulse x x x x 5. Temperature x x x x 6. BMI x x x x 7. Head circumference (0 - 5 years) x x x x 8. MUAC (mid upper arm circumference (6 -60 months) Physical Exam x x x x 1. Complete physical exam x x x x 2. Make appropriate referrals to primary care or appropriate specialist x x x x 3. Test for vision impairment and make appropriate referral x x 4. Test for hearing impairment and make appropriate referral x x x x 5. Evaluate need for dental referral x x 6. Follow up testing and further evaluation of conditions causing abnormal results is consistent with established best practice x x 7. Follow up on all referrals to assure appointments are kept
Preventive health interventions Immunizations x x x x 1. Evaluate overseas immunization's records to assess needed updates x x X x 2. Give age appropriate vaccines following the ACIP guidelines, complete any series that has been initiated (do not restart a series) x x x x 3. Give priority to giving vaccines needed for children to start school x x x x 4. Build toward providing all needed for Adjustment of Status x x x x 5.. If unable to provide vaccines, provide appropriate referral to obtain needed immunizations according to the ACIP guidelines x x x x 6. Record previous vaccines, lab evidence of immunity or hx of disease x x x x 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 1. CBC with differential x x 2. Complete metabolic panel
x X x 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 a. Evaluate overseas records of TB testing/treatment x x x x b. Evaluate all refugees of history of tuberculosis, tuberculosis exposure, any treatment x x x x c. Evaluate for signs or symptoms of disease (including Class A & B) x x x x d. Clinically evaluate all refugee arrivals for tuberculosis infection x x x x e. TST (chest x-ray if > 10 mm induration) IGRA (chest x-ray if positive) IGRA if age > 5 y/o x x x x f. Clinically evaluate for TB HIV+ x x x x g. Treat and report every case of active TB x x x x h. Refer all LTBI cases for follow up treatment Lead testing x x x x 1. Screen all refugee children 6 months to 16 years of age; x x 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. x x x x 3. Children with elevated BLL require referral for appropriate follow-up. Evaluate for Malaria to determine if testing is indicated x x 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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whom presumptive therapy is contraindicated should be tested. x x x x b. Sub-Saharan African refugees who received ACT presumptive therapy prior to departure do not need testing or presumptive therapy post-arrival. x x x x c. 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. x x x x 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 a. Hepatitis B surface antigen (HbsAg) x x x x b. Hepatitis B surface antibody (anti-Hbs) x x x x c. Hepatitis B core antibody (anti- Hbc) x x x x d. Vaccinate previously unvaccinated and susceptible x x x x e. Refer HbsAg+ to specialist x x x x f. Refer household contacts for further screening
Hepatitis C screening Hepatitis C screening is not recommended at this time Syphilis x x x x a. VDRL/RPR = >15 years, < 15 years if sexually active or hx of sexual abuse x x x x b. Mother who tests or tested positive, x x x x c. Exposure to country endemic for other treponemal subspecies (e.g. yaws, bejal, pinta) x x x x d. Confirmation testing for positive treponemal tests
Chlamydia x x x a. Urine nucleic amplification test
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x x x x b. Females < 25 years who are sexually active or those with risk factors (e.g. new or multiple partners), x x x x c. Luecoesterase (LE) positive on urine sample, x x x x d. Women or children with history of, or at risk, for sexual assault x x x x e. Any refugee with symptoms
Gonococcus x x a. Urine nucleic amplification test x x x x b. Luecoesterase (LE) positive on urine sample, x x x x c. Women or children with hx of, or at risk for, sexual assault x x x x 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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infected should be referred for care, treatment, and preventive services. x x x x 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. x x x x 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 x x Lipid panel if indicated. appropriate Test for Vitamin D x x Test for Vitamin D levels in which pop? levels Test for Vitamin B12 x x Test for Vitamin B12 in which pop? Infant metabolic x x x Infant metabolic screening in newborns, screening in newborns, according to state guidelines according to state guidelines Urine pregnancy test x x Urine pregnancy test for women of for women of child child bearing age bearing age HIV in pregnancy x x x 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. Test pregnant women for HIV during first trimmest, if negative, re-test during third trimester. See CDC guidelines for details HIV in children Children <12 years of age should be screened unless the mother’s HIV status can be confirmed as negative and the child is otherwise thought to be at low risk of infection )no history of high-risk exposures such as blood product transfusions, early sexual activity, or sexual abuse). In most situations, complete risk information will not be available, thus most children <12 years of age should be screened. Children < 18 months of age who test positive for HIV antibodies
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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 x x x a. Evaluate history of torture, health needs 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 Individual additional x x x x a. Mental health screening for all MH assessment adults. x x 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) x x c. Screen for caregiver stress Cancer screening x x a. Cervical (HPV test) x x b. Breast x x c. Colorectal x x d. Prostate (PSA) x x 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). Other: Women x x a. Evaluate reproductive history for women of child bearing years x x b. Evaluate and educate on family planning x x x x c. Refer to WIC if appropriate Other: Children x x a. Test for age appropriate development in children ages 0 – 20 x x i. Child and Teen Check-Up or equivalent development and emotional screening for ages zero
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to 20. x x ii. Utilize a standardized tool for assessment x x iii. Question parent for any growth & development concerns. Other: General x x a. Assess nutrition issues by doing a brief screen for dairy and food groups, exercise; children and adults as indicated. x x x x b. Evaluate for substance use x x c. Evaluate for substance abuse x x x x d.. Report all reportable diagnosis to state health department x x e.. Refer complex medical cases to appropriate medical case manager x x f. Report unusual trends or patterns of disease in any population to CDC x x x 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. Respiratory rate 7. BMI 8. Head circumference (birth through 36 months) 9. MUAC (mid upper arm circumference (6 – 60 months) if appropriate
Physical Exam http://www.cdc.gov/immigrantrefugeehealth/guidelines/domestic/guidelines-history- physical.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/foreign- products-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-guidelines- domestic.html#sect6 NOTE: Any refugee who has signs and symptoms of malaria and who originated in a malaria- endemic 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/malaria- guidelines-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-parasites- domestic.html NOTE: Post-arrival screening for IP will depend on region of departure and pre- departure 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 No documented pre-departure presumptive treatment:
For single-dose albendazole For single-dose albendazole For high-dose pre-departure ? Conduct stool examinations pre-departure treatment (no pre-departure treatment with treatment (ivermectin and for ova and parasites (O&P); praziquantel) praziquantel praziqua ntel): two stool specimens should be obtained more than 24
hours apart ; ? Strongyloides serology ? Strongyloides serology ? If positive for eosin ophilia, ? Strongyloides serology (all (all refugees); (all refugees); re-check total eosinophil refugees); ? Schistosoma serology ? Treat if positive for count in 3-6 months after ? Schistosoma serology (sub- (sub-Saharan Africans); Strongyloides stercoralis arrival. ** Saharan Afr ican s); ? Treat if positive for ? If positive for eosinophilia, ? Treat path ogenic parasites ;
Strong yloides stercoralis or re-check total eosinophil ? Re-check total eosinophil Schist osoma spp. count in 3-6 months.** count in 3-6 months.** ? If positive for eosinophilia, 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-parasites- domestic.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. Hepatitis B surface antigen (HBsAg) b. Vaccinate previously unvaccinated and susceptible c. Refer HbsAg+ to specialist d. 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-transmitted- diseases.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-hiv- infection-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-health- screening-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