Refugee screening

Humanitarian entrants and other migrants who have experienced refugee-like situations are at an increased risk of tuberculosis compared with other migrants[1]. The reasons for this include exposure to TB in crowded refugee camps or in prisons, and under-nutrition. In addition, TB control in their countries of origin may have been disrupted by civil strife or war[2].

The origin of refugees settling in NSW is dynamic. From the late 1970's to the early 1990's the majority originated from South East Asia, in particular Vietnam, with relatively high risks of developing TB[3, 4]. The humanitarian intake during the1990s was increasingly from the Balkan region and from the Middle East, in particular Iraq and Iran[5]. These countries have lower incidence rates of tuberculosis compared with most South East Asian countries. The most recent trend is increasing humanitarian migration from a number of African nations, with 70 per cent of the total refugee intake now from that region. Countries of origin include Sudan, Somalia, Ethiopia, Sierra Leone, Liberia and Burundi[5].

Refugees (i.e. humanitarian migrants) are required to undergo the same pre-migration health screen as other migrants. Humanitarian entrants aged 11 years and over undergo chest x-ray overseas to identify TB[6]. Persons found to have active TB undergo treatment prior to migrating. Those with either a past history of tuberculosis or with an abnormal CXR are placed on a Health Undertaking.

From the late 1970's, health screening of refugees arriving to NSW included repetition of the chest x-ray and tuberculin testing. The x-ray was repeated due to concerns regarding time delays between the medical examination and migration, and anecdotal reports of x-ray substitution. An evaluation of repeat CXR screening was undertaken by the Refugee Screening Program in 1993-94. Of 1200 small films performed, only one active case of tuberculosis was detected (M.Smith,pers.comm.)[7]. Furthermore, database follow up of over 20,000 refugees screened in the 1980's and early 1990's[4] led to the conclusion that active case finding amongst refugees post-arrival was not an effective public health intervention. It was also perceived that the delay between chest x-ray and arrival date had reduced, and that screening by overseas posts had improved (K.King, pers.comm.). Routine CXR screening of refugees after arrival to NSW ceased in 1995.

Asylum seekers in detention centres are screened for TB within two weeks of arrival[8]. Those who gain refugee status and are subsequently released are required to meet certain health requirements for the granting of that visa.

Similarly, persons arriving on a valid visa before applying for asylum in Australia now must undergo a health assessment as part of that application process[6].

Indications for Tuberculin Skin Testing

Tuberculin Skin Testing (TS) should be offered to newly arrived refugees where:

  • the person has symptoms of TB to assist in diagnosing or excluding TB disease, or
  • the person has a history of contact with TB, or
  • the person has medical risk factors that increase the likelihood of latent infection progressing to disease, or
  • prior to BCG vaccination in those over 6 months of age, or
  • as an assessment for possible preventive therapy, especially in those under 35 years of age.

The above indications for TST should be read in conjunction with NSW Health Department Policy Directive 2005_ 209 Tuberculin Skin Testing. It should be noted that BCG programs exist in many countries from which refugees originate, including in many refugee camp settings.

Note the importance of individual advice regarding relevant symptoms and general community education with regard to TB.

Health care worker education, particularly amongst General Practitioners who work with relevant communities, is essential to raise the index of suspicion of TB in humanitarian entrants and others with refugee-like backgrounds.

References

  1. Walker PF & Jaranson J (1999). Refugee and immigrant health care. Medical Clinics of North America 84(4): 1103-1120
  2. Toole MJ, Waldman RJ, Zwi AB (2001). Complex Humanitarian Emergencies. In: Merson MH, Black RE, Mills AJ (eds). International Public Health - diseases, programs, systems and policies. Gaithersburg: Aspen Publishers: 439-513
  3. MacIntyre CR & Plant AJ (1999). "Longitudinal incidence of tuberculosis in South East Asian refugees after re-settlement." International Journal of Tuberculosis & Lung Disease 3(4): 287-93.
  4. Marks, G. B., J. Bai, et al. (2000). "Incidence of tuberculosis among a cohort of tuberculin-positive refugees in Australia: re-appraising the estimates of risk." American Journal of Respiratory & Critical Care Medicine 162(5): 1851-4
  5. DIMIA (2005). HH Refugee and Humanitarian Issues - Australia's Response. Commonwealth of Australia: p 34.
  6. DIBP (2015). The Health Requirement [online]. Further information can be found at DIBP Health Requirement​.
  7. Smith M, Stewart G, Simpson S (1994). The NSW Refugee Screening Program. NSW Public Health Bulletin; 5(12): 134-6
  8. Marks, G. B., J. Bai, et al. (2000). "Incidence of tuberculosis among a cohort of tuberculin-positive refugees in Australia: re-appraising the estimates of risk." American Journal of Respiratory & Critical Care Medicine 162(5): 1851-4
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Page Updated: Tuesday 22 September 2015
Contact page owner: Communicable Diseases