1. As part of the periodic health assessment of newly arrived immigrants:
    1. Assess vaccination status (as it may not be up to date).
    2. Provide the necessary vaccinations to update their status.
  2. As part of the ongoing care of immigrants, modify your approach (when possible) as required by their cultural context (e.g., history given only by husband, may refuse examination by a male physician, language barriers).
  3. When dealing with a language barrier, make an effort to obtain the history with the help of a medical interpreter and recognize the limitations of all interpreters (e.g., 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):
    1. Screen for depression (i.e., because they are at higher risk and frequently isolated).
    2. Inquire about a past history of abuse or torture.
    3. Assess patients for availability of resources for support (e.g., family, community organizations).
  5. In immigrants presenting with a new or ongoing medical condition, consider in the differential diagnosis infectious diseases acquired before immigration (e.g., malaria, parasitic disease, tuberculosis).
  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).

Immigrant Screening

Mandatory Immigration Medical Examination (before arriving to Canada)

  • Complete physical examination (including vision/hearing screen)
  • >5yo - Urinalysis for protein, glucose (think diabetes), blood (think shistosomiasis)
    • If abnormal, urine microscopy
  • >11yo - CXR r/o TB
  • >15yo or risk factor (eg. known infected mother, unprotected sex)
    • HIV testing, Syphilis

Recommended Screening (by Canadian Collaboration for Immigrant and Refugee Health 2011)

  • Hep B (Africa, Asia, Eastern Europe and parts of South America)
    • Vaccinate susceptible, refer chronic infection for treatment (and consider screen HCC as indicated)
  • Hep C (specifically subSaharan Africa [10%]; eastern Europe, especially Uzbekistan and Tajikistan [27%]; Egypt [25%–50%]; Vietnam [10%]; and Pakistan [5-35%]) and exposure to contaminated blood, usually as nosocomial transmission through unscreened blood products, surgery or receipt of intramuscular injections)
    • If positive, vaccinate Hep A/B, limit alcohol and refer for treatment
  • TB PPD skin test (Sub-Saharan Africa, Asia, and Central and South America, and some in Eastern Europe)
    • CXR to rule out active disease
  • HIV (sub-Saharan Africa, Caribbean, Thailand)
    • Post-test counselling and refer to HIV treatment program
  • Intestinal parasites if from endemic area, compatible sign/symptoms of infection (asthma) or evidence of peripheral eosinophilia
      • Strongyloides serology (consider in immigrants from Southeast Asia and Africa)
        • If positive, treat with ivermectin (or albendazole)
      • Shistosomiasis serology (Africa)
        • If positive, treat with praziquantel
  • DM2 >35yo South Asian, Latin American and African
  • Iron-deficiency anemia with hemoglobin for women of reproductive age, and children 1-4yo
  • Dental disease (ask all if any pain, and look for evidence of disease)
    • Refer to dentist (and treat pain with NSAID)

The First Visit in Canada

  • Medical Interpreter (consider CanTalk - telephone interpreter)
  • Document findings (scars)
  • Medication review, including alternative/herbal remedies
  • Infection
    • Consider malaria, TB, hepatitis, HIV, parasitic disease in differential
  • Chronic disease
    • Age-appropriate screening
    • Screening for immigrants as above (Hep B/C, TB, HIV, parasites, DM2, Iron-deficiency anemia, Dental)
    • Consider other screening
      • Sickle cell, Thalassemia
      • Vision
  • Mental Health
    • Depression, PTSD
    • Trauma (child neglect, genital mutilation, intimate partner violence, torture, abuse, war)
    • Culture/tradition/religion/gender roles
  • Women's health
    • Contraception
    • Cervical cancer screening
    • HPV vaccine
  • Vaccination
    • Primary immunization schedule according to age (Tdap, MMRV, etc...)
    • Consider Hepatitis A/B
    • If positive for sickle cell or thalassemia
      • Consider pneumococcal, H influenzae, meningococcal