Immigrants

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.
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).
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).
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).
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).
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

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

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
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)

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

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