Course:PostgradFamilyPractice/ExamPrep/99 Priority Topics/Immigrants

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Immigrants - Key Features

1. As part of the periodic health assessment of newly arrived immigrants:
a) Assess vaccination status (may not be up to date)
b) Provide the necessary vaccinations to update their status

All immigrants are required to undergo a medical examination before immigrating. These medical examinations can be carried out in any country, but must be carried out by specific doctors working “under the authority” of Health Canada. The exam includes physical exam and vision screen, CXR (for TB), syphilis screen, urinalysis and HIV testing (age 15 and older). These reports are not likely to be followed-up on except TB, syphilis and HIV. Reviewing and updating immunizations is not included in this mandatory medical examination. These designated doctors are not allowed to give patients the results of their tests (they are considered property of the Canadian government). The applicant will only receive a letter if there is a problem with their medical examination.

There is no official list of diseases that will make an applicant medically inadmissible. Each applicant is considered individually particularly with respect to any disease or condition that 1) is a danger to the health or safety of Canadians or 2) would cause excessive demand on the health care system (i.e. dialysis) or social services.

Vaccination schedules for children not vaccinated in early infancy, children > 7 years of age and adults can be found in the Canadian Immunization Guide at www.phac-aspc.gc.ca/publicat/cig-gci/index.html. Many immigrants are susceptible to vaccine-preventable diseases upon arrival. For example, 30-50% of new immigrants are susceptible to tetanus and 32-54% are susceptible to measles, mumps or rubella. Recommendations and evidence for each vaccination for new immigrants and refugees can be found in the Summary for evidence based recommendations for immigrant and refugee health.

2. As part of the ongoing care of immigrants, modify your approach (when possible) as required by their cultural context (i.e. history given only by husband, may refuse examination by male physician, language barriers)

Other issues to consider when caring for immigrants and refugees:
• Previously limited screening for breast and cervical cancer (may not know what a pap test is and require explanation of the procedure and purpose).

o All sexually active women should be screened by Papanicolaou test

• Mental and emotional issues:

o Loss of personal or cultural identity
o Separation from family – ask about family members remaining in home country
o Change in family roles and norms
o Isolation – especially in women who may not be able to access ESL as readily due to child care responsibilities
o Uncertainty about community resources
o Unemployment or underemployment

• Diet changes – ask about diet since arriving in Canada, have they found grocery stores, counsel about the prevalence of fatty/sugary foods available here and the need to maintain a healthy diet.
• Sex inequality and domestic violence – be alert for signs and symptoms of intimate partner violence.
• Genital mutilation
• Contraception – screen immigrant women of reproductive age for unmet contraceptive needs. Provide culturally sensitive patient-centered contraceptive counselling to decrease unintended pregnancy and promote patient satisfaction

3. When dealing with a language barrier, make an effort to obtain the history with the help of a medial interpreter and recognize the limitations of all interpreters (i.e. different agendas, lack of medical knowledge, something to hide).

4. As part of the ongoing care of all immigrants (particularly those who appear not to be coping):
a) Screen for depression (at higher risk and frequently isolated)
b) Inquire about a past history of abuse or torture
c) Assess patients for availability of resources for support (family, community organizations)

Depression – may need to ask specifically about sleep, concentration, worry and ‘nerves’ to begin to assess depression. Also, multiple somatic complaints (stomach pain, body aches, headaches, etc.) - once organic causes are ruled out - may be the presenting feature of an underlying depression. Some cultures don’t easily have words or ways to describe their mental health.

PTSD – very common in refugees, must inquire sensitively.
• Be alert for signs and symptoms of PTSD – especially in the context of unexplained somatic symptoms, sleep disorders, history of trauma.
• No evidence that routine screening for PTSD in well-functioning individuals results in more harm than good, but should screen in those with any symptoms/complaints.
• But be alert and screen in patients not seeming to adjust well or with multiple clinic visits for various somatic concerns.
• Hyperarousal symptoms:

o Sleep – is it hard to fall asleep, insomnia, awakening and nightmares, sleeping with lights on, caffeine intake
o Startle response – how do loud noises or sirens affect you
o Memory and concentration, irritability and outbursts of anger – how is this affecting you, relationships, work, ability to learn English.

• Intrusive recollection (and panic disorder)

o Morbid rumination – how many hours a day do you read news from your home country? Do you think all the time? What about?
o Nightmares and flashbacks
o Panic Disorder
o Somatization – frequent pains, headaches

• Avoidance and numbing

o Avoidance of triggers of bad memories, avoidance of people/isolation.
o Avoidance of feelings/restricted affect


5. In immigrants presenting with a new or ongoing medical condition, consider in the differential diagnosis infectious disease acquired before immigration (e.g. malaria, parasitic disease, TB)

Hepatitis B – 20-80% of immigrants who come from countries where chronic hepatitis B virus infection is prevalent are not immune and have not been immunized. Immigrants from countries with high prevalence of chronic hepatitis B (>2% HBsAg positive) should be screened and treated to prevent hepatitis and HCC (i.e. from Africa, Asia, Eastern Europe and parts of South America). Those susceptible (negative HBsAg, anti-HBc and anti-HBs) should be vaccinated.

Tuberculosis – Screen children, adolescents <20y and refugees between 20-50y from countries with high TB incidence as soon as possible after arrival with tuberculin skin test. If tests are positive rule out active TB and treat latent TB.

HIV – screen for HIV with informed consent all adolescents and adults from countries where HIV prevalence is greater than 1% (sub-Saharan Africa, parts of Caribbean and Thailand).

Hep C – screen for antibody to HCV in all immigrants and refugees from regions with prevalence of disease >3% (excludes South Asia, Western Europe, North America, Central America and Sound America).

Intestinal parasites:

• Strongyloidiasis – screen refugees from Southeast Asia and Africa using serologic tests (rather than stool tests). If positive treat with Ivermectin (first line) or albendazole (if contraindications to Ivermectin)
• Schistosomiasis – Screen refugees from Africa with serologic tests for Schistosoma and if positive treat with Praziquantel.


Malaria – do not routinely screen for malaria. Be alert for symptomatic malaria in migrants who have lived or travelled in malaria-endemic regions in previous 3 months.

6. As part of the ongoing care of all immigrants, inquire about the use of alternative healers, practices, and/or medications (e.g. natural or herbal medicines, spiritual healers, medications from different countries, moxibustion).

Study Guide

Immigrants

Resources

CMAJ Evidence Based Guidelines for Immigrants and Refugees (2011) www.cmaj.ca/content/183/12/E824.full.pdf
Summary of evidence based recommendations for Immigrant and Refugee Health: www.cmaj.ca/content/suppl/2010/06/07/cmaj.090313.DC1/imm-summary-2-at.pdf
November 2011 McMaster Module on New Immigrants and Refugees
Short article from CMAJ 1998: www.cmaj.ca/cgi/reprint/159/4/388.pdf