It is essential to know in which countries patients have lived in (and when) during their lives. This will have an impact on the screening tests that should be ordered for these patients and on the differential diagnoses of some clinical presentations (e.g. fever). Often, refugees and refugee claimants will have transitioned through different countries before arriving in Canada. It is also important to ask patients if they have stayed in a refugee camp, since this can be a risk factor for multiple conditions (e.g. gastrointestinal parasites).

Even if patients remember being vaccinated, they should not be considered immunized unless they have appropriate immunization records. While some refugees have pre-departure immunization records from the International Organization for Migration (IOM), most refugees and refugee claimants do not possess proof of vaccination. 

The CMAJ guidelines recommend adults to have had at least 1 MMR dose, a complete diphtheria/tetanus/pertussis/polio series (3 doses) and serologic proof of immunization against hepatitis B and varicella to be conidered adequately immunized. Vaccination against human papillomavirus is also recommended for female patients between the age of 9 and 26 years old. Adults who do not have records showing the above immunizations, and all pre-school age children should be referred to a local vaccination clinic for age-appropriate vaccination. In Canada, school-age children should be routinely vaccinated through school by a public health nurse (the immunization schedule may vary depending on the province).

Most of our newly arrived female refugee patients have never been screened for cervical cancer. It is thus important to ask about previous Pap tests and discuss the importance of this screening program. Screening recommendations for refugee women are that same as for the rest of the population (every 3 years between the ages 25-69). While we rarely perform a Pap test on the first visit (remember that this is an invasive procedure), we recommend discussing it as soon as possible. If a patient is not comfortable having a Pap test done by a male physician, she should be offered a referral to a female practitioner.

Do not routinely screen for a history of traumatic events. This can actually cause harm in well-functioning individuals. Remember that not all refugees who have experienced traumatic events will develop PTSD. However, since PTSD is more common in refugees than in the general Canadian population, physicians should pay close attention to potential PTSD symptoms. Again, somatic symptoms are very frequent in this population. It is important to note that post-migration mental health is largely dependent on how well refugees are able to resettle. The post-migration experience plays a significant role in PTSD (Kirmayer et al., 2011). Therefore, it is essential to ensure good socioecominic support and refer to a social worker if any social issue is identified.

In the 2011 CMAJ guidelines, Pottie et al. recommended to not routinely screen for intimate partner violence (IPV) or child abuse. The current evidence at the time did not demonstrate clear benefits and showed that screening could even cause harm. In contrast, in a recent review (Curry et al., 2018), the U.S. Preventive Services Task Force now recommends that clinicians should screen for IPV in women of reproductive age. This recommendation is however not specific to refugee patients. Our consensus at the Calgary Refugee Health Program is to at least screen all our prenatal refugee patients for IPV. We do not perform routine screening for child abuse. Even if routine screening for IPV or child abuse is not performed, physicians should always be alert to any sign or symptom that could be related to these issues.

In Calgary, the Calgary Catholic Immigration Society (CCIS) usually educates government-assisted refugees about Canadian laws regarding intimate partner violence and child maltreatment.

We usually refer all school-aged children, as well as adults with vision complaints to the optometrist. Other refugees can also be screened for visual impairment using a Snellen chart. The IFHP covers one complete eye exam by an optometrist per year.

Refer to the Vision Care section of theIFHP Benefit Grid - Supplemental Coverage table for for information.