Refugees (and newly arrived migrants from similar settings)
Overview
- Consider engaging an accredited interpreter for all discussions with refugees, migrants and others born outside Australia.
- The prevalence of chlamydia and gonorrhoea infections is very low in newly arrived refugees settling in Australia and other developed countries.
- Chronic hepatitis B infection is common in source countries for migration and found in 6-16% of refugee cohorts in Australia.
- Syphilis infection has a higher incidence in many parts of Africa and Asia and has been detected in refugees settling in Australia (prevalence rate between 5-8%).
- Undiagnosed HIV infection is very rare in newly settled refugees due to pre-migration screening processes. This includes blood-borne virus screening in Immigration Detention Centres.
Testing advice
| Infection | Consideration |
|---|---|
| Syphilis |
If clinical suspicion of syphilis, refer to the syphilis guideline. |
| Hepatitis B |
Vaccinate if not immune. |
| Gonorrhoea | Offer if at risk due to history of sexual assault or unprotected sex. Consider Self-collection of samples for NAAT testingVaginal swab: instruct the patient to insert the swab into the vagina like a tampon and then remove and place into the transport tube. Rectal swab: instruct the patient to insert the swab into the anal canal 2-4cms and then remove and place into the transport tube. FPU (First pass urine): Collect approximately 20 ml (1/3 of the standard urine jar) of the first part of the urine stream in a specimen jar at the time you are consulting the patient. The patient does not need to have held their urine for more than 20 minutes prior to specimen collection. A midstream urine (MSU) or early morning specimen (i.e. first void urine) are not required for NAAT. Click here for information on how to describe self-collection technique to a patient. |
| Chlamydia | Offer if at risk due to history of sexual assault or unprotected sex. Consider Self-collection of samples for NAAT testingVaginal swab: instruct the patient to insert the swab into the vagina like a tampon and then remove and place into the transport tube. Rectal swab: instruct the patient to insert the swab into the anal canal 2-4cms and then remove and place into the transport tube. FPU (First pass urine): Collect approximately 20 ml (1/3 of the standard urine jar) of the first part of the urine stream in a specimen jar at the time you are consulting the patient. The patient does not need to have held their urine for more than 20 minutes prior to specimen collection. A midstream urine (MSU) or early morning specimen (i.e. first void urine) are not required for NAAT. Click here for information on how to describe self-collection technique to a patient. |
| HIV |
Repeat test if patient exposed within previous 12 weeks (window period). |
|
NAAT - Nucleic Acid Amplification Test |
|
Specimen collection
Urethral swabs for microscopy should be collected when the patient has not urinated for at least 1 hour and only if the patient has frank urethral discharge. Squeeze the urethra to express the discharge and collect on urethral swab. It is not necessary to insert the swab into the urethra. Vaginal swab: instruct the patient to insert the swab into the vagina like a tampon and then remove and place into the transport tube. Rectal swab: instruct the patient to insert the swab into the anal canal 2-4cms and then remove and place into the transport tube. FPU (First pass urine): Collect approximately 20 ml (1/3 of the standard urine jar) of the first part of the urine stream in a specimen jar at the time you are consulting the patient. The patient does not need to have held their urine for more than 20 minutes prior to specimen collection. A midstream urine (MSU) or early morning specimen (i.e. first void urine) are not required for NAAT. Click here for information on how to describe self-collection technique to a patient.Clinician collected for NAAT/culture/microscopy
Rectal swabs should be collected by inserting a sterile swab 2-4cms into the anal canal and moving the swab gently side to side for 10-20 seconds.
Pharyngeal swabs should be collected from the tonsils and oropharynx.
High vaginal swab of vaginal discharge smeared onto a glass slide, air dried and sent for microscopy. Swab inserted into transport medium for culture.Self-collection of samples for NAAT testing
Clinical indicators for testing
- All refugees should be offered individualised post-arrival health screening which takes into account past screening and risk assessment
- Screening for chronic hepatitis B and syphilis should be offered to all
- NAAT screening for chlamydia and gonorrhoea should be offered to newly arrived individuals considered at risk due to history of sexual assault or unprotected sex
- Repeat HIV testing should be offered for adolescents and adults settling from regions of prevalence >1% (i.e. sub-Saharan Africa, Thailand) in whom the pre-migration test was months previously, or if other risks are identified on history, as per the HIV National Testing Policy
- Young persons aged 15-29 years in Australia for longer periods should be offered testing consistent with guidelines for young people, e.g. annual chlamydia testing.
- It is not recommended to routinely test for herpes and genital warts with serology. Consider testing for herpes and genital warts only if there are clinical signs and symptoms.
Special considerations
- Gender based violence is common in conflict zones and refugee camps. Full STI testing should be offered to any person disclosing a history of sexual assault or gender based violence regardless of age. Consider pregnancy and/or need for emergency contraception.
- Anecdotal reports suggest male to male sex is occurring in Immigration Detention Centres in Australia.
- Most women from refugee backgrounds have never had a cervical smear and should be offered opportunistic testing. Be mindful of access to gynaecological care if on-going management required.
Follow up
Even if all test results are negative, use the opportunity to:
- Educate about condom use and risk minimisation
- Vaccinate against hepatitis B if non-immune on testing
- Discuss and activate reminders for regular screening tests according to risk - especially if their behaviors indicate the need for more frequent screening and risk assessment
- Discuss and activate reminders for regular testing according to risk, especially if their behaviours indicate the need for more frequent testing
- Discuss contraception if warranted.
Auditable outcomes
- 80-90% of people of refugee background are offered individualised post-arrival health screening, taking into account past screening and risk assessment
- 80-90% of people of refugee background are offered screening for chronic hepatitis B and syphilis.
References
- Hoad VC, Thambiran A. Evaluating the chlamydia and gonorrhoea screening program in the Humanitarian Entrant Health Service, Western Australia. Med J Aust 2012;197(1):47-9.
- Stauffer WM, Painter J, Mamo B, Kaiser R, Weinberg M, Berman S. Sexually transmitted infections in newly arrived refugees: is routine screening for Neisseria gonorrheae and Chlamydia trachomatis infection indicated? The American journal of tropical medicine and hygiene 2012;86(2):292-5.
- Paxton GA, Sangster KJ, Maxwell EL, McBride CR, Drewe RH. Post-arrival health screening in Karen refugees in Australia. PloS one 2012;7(5):e38194.
- Tiong AC, Patel MS, Gardiner J, Ryan R, Linton KS, Walker KA, et al. Health issues in newly arrived African refugees attending general practice clinics in Melbourne. Med J Aust 2006;185(11-12):602-6.
- Martin JA, Mak DB. Changing faces: A review of infectious disease screening of refugees by the Migrant Health Unit, Western Australia in 2003 and 2004. Med J Aust 2006;185(11-12):607-10.
- Pottie K, Greenaway C, Feightner J, Welch V, Swinkels H, Rashid M, et al. Evidence-based clinical guidelines for immigrants and refugees. Canadian Medical Association Journal 2011;183(12):E824-E925.