Screening of New Entrants arriving via the Syrian ... New entrant... · Syrian Vulnerable Persons...

Public Health Wales New Entrant Screening

Date: November 2015 Version: 1 Page: 1 of 18

Screening of New Entrants arriving via the

Syrian Vulnerable Persons Relocation

Scheme (VPRS):

a brief guide for service providers in Wales

Author: Dr Rhianwen Stiff, Consultant in Communicable Disease Control,

Health Protection Team, Public Health Wales

Date: 17 November 2015 Version: 1

Publication/ Distribution: (Delete as applicable)

NHS Wales Intranet

Public Health Wales Intranet

Health Boards

Local Authorities in Wales

Welsh Government

Review Date: September 2016

Purpose and Summary of Document:

The UK Government have proposed to increase opportunities for entry into

the UK of people from Syria and surrounding areas. A new programme

(Syrian Vulnerable Persons Relocation Scheme) has been established to

facilitate entry into the UK.

This document provides brief guidance for health boards, local authorities,

service providers and clinicians involved with the provision of health care to new entrants to Wales arriving via the Syrian VPRS programme. This

guidance provides an overview of the health care needs of new entrants to Wales, but concentrates on those aspects of new entrant health care

relating to screening for infectious diseases and the provision of vaccinations.



Content

Introduction ...................................................................................3

Principles underpinning new entrant healthcare provision .....................3

Audience ........................................................................................3

Definitions ......................................................................................4

The immediate needs of new entrants ................................................4

Health assessment of new entrants arriving via Syrian VPRS .................5

Specific public health concerns ..........................................................6

Vaccination status ...........................................................................8

References ...................................................................................11

Appendix A ...................................................................................12



Introduction

The UK Government have proposed to increase opportunities for entry

into the UK of refugees from Syria and surrounding areas, and a new programme (Syrian Vulnerable Persons Relocation Scheme, Syrian VPRS)

has been established to facilitate this. These individuals will therefore not enter the UK or Wales via established specific refugee or asylum seeker

routes or services.

This document provides brief guidance for health boards, local authorities,

service providers and clinicians involved with the provision of health care to new entrants to Wales arriving via the Syrian VPRS programme. This

guidance provides an overview of the health care needs of new entrants to Wales, but concentrates on those aspects of new entrant health care

relating to screening for infectious diseases and the provision of vaccinations.

As Wales will imminently be welcoming our first Syrian new entrants

arriving via the VPRS, the health care of this specific group is very topical. However, the principles outlined in this document could also be applied to

new entrants arriving in Wales via other routes including asylum seekers, refugees and reuniting families.

Principles underpinning New Entrant healthcare provision:

New entrants should have access to the same healthcare, with the

courtesy and dignity afforded to any other population group in Wales This does allow for selective screening based on risk profile, which is

also applied to other population groups in Wales

Testing based on symptoms, signs or clinical examination is diagnostic rather than for screening

Testing not prompted by clinical symptoms or signs is a form of screening and should, as far as possible, satisfy the UK criteria for a

screening programme (in particular availability of an appropriate test and opportunity for disease modification).

Audience

The intended audience for this guidance includes:

Health Boards and Local Authorities expecting the arrival of New

Entrants via the Syrian VPRS programme

Primary care clinicians registering New Entrants with their practice and/or having clinical contact with New Entrants

Specific services offering primary care provision for New Entrants only



Clinicians in other services (e.g. A&E, Child Health, Obstetrics) that

may be the first contact of New Entrant with NHS services in Wales.

Definitions

Asylum is when someone applies for protection from persecution or fear

of persecution in their own country. The UK Border Agency then decides whether the application is legitimate1.

An asylum seeker is someone who is waiting for their application to be

recognised as a refugee to be considered by the UK Government1.

A refugee is someone who has applied for asylum and has by law been granted refugee status1.

For the purpose of this document, a new entrant may be an asylum seeker or refugee, the spouse/child/family member of a person granted

refugee status (reuniting family), or an individual granted entry to Wales/UK via specific application to programmes such as the Syrian

Vulnerable Persons Relocation Scheme.

The immediate needs of New Entrants

Recommendations from expert interviews and literature reviews undertaken by the European Centre for Disease Prevention and Control1

highlighted the overall needs of New Entrants entering Europe from Syria and neighbouring areas:

Reception centres/systems for the newly arrived in order to assure health assessments immediately upon arrival

Adequate shelter to avoid crowding and ensuring good sanitation and hygienic conditions. These measures are particularly important to

prevent occurrence of louse-borne relapsing fever (LBRF), trench

fever, epidemic and endemic typhus, scabies, and other vector-, air-(meningococcal disease), and food-borne diseases.

Health education and health promotion emphasising the positive benefits of health assessment, screening, immunisation and other

measures Screening for communicable diseases according to their country of

origin and countries transited during migration Access to healthcare, free of charge, for the diagnosis and

treatment of communicable diseases including primary and emergency healthcare.

Some studies suggest that the average physical health status of asylum

seekers on arrival to the UK is not particularly poor compared to that of the general UK population2. However, many asylum seekers have much



more complex health and social care needs. Pregnant women,

unaccompanied children, those with significant mental health problems, and those who have experienced traumatic events such as rape or torture

are likely to be particularly vulnerable3.

In general the main health needs of asylum seekers include3: Communicable diseases, e.g. Tuberculosis, Hepatitis B&C, HIV, etc.

Mental health problems e.g. PTSD, anxiety and depression are more prevalent in asylum seekers than the general population

Pregnancy – late presentation for antenatal care; Hepatitis B, diabetes, hypertension

Child protection issues Human trafficking and sexual exploitation

General health needs – chronic diseases management, child health surveillance, immunisation, contraception, dental health

In addition, several barriers to accessing healthcare are faced4,8,9, e.g.:

Lack of awareness of how to access the NHS or understanding of the model of care it provides –asylum seekers may have very different

expectations and experiences of primary healthcare Lack of accessible information about health and available services

Difficulty in registering with a local GP Language and communication difficulties – language issues are a key

barrier to accessing services, including healthcare. Lack of requested documentation e.g. ID, birth certificate, vaccination

records Concerns regarding confidentiality – fear and mistrust issues; stigma

related to some health issues e.g. rape, sexually transmitted diseases, mental illness

Lack of training for NHS staff regarding the needs and entitlements of

asylum seekers Misconceived ideas and ignorance about asylum seeker needs

Health assessment of New Entrants arriving via Syrian VPRS

New entrants to Wales via the Syrian VPRS are at risk of exposure to

infectious diseases in the same way as any other resident in Wales, but may be more vulnerable due to interruptions in public health programmes

(such as immunisation programmes) in Syria. In addition, this population may be subject to specific risk for infectious diseases in relation to their

country of origin, countries visited and the conditions experienced during their journey to Wales5.

New Entrants arriving in Wales via the Syrian VPRS will have undergone

an extensive health review as part of the programme application process (see outline of VPRS process and IOM form in Appendix A). This is in



contrast to new entrants arriving via conventional refugee, asylum

seeker, migrant or reuniting family routes.

Upon arrival in Wales it is recommended that the IOM form is reviewed and that new entrants undergo initial public health screening to allow

urgent health needs to be identified and addressed.

As a guide, it is suggested that initial screening includes: Obtaining medical history [to include, where relevant, acute

symptoms, medication, chronic conditions, obstetric needs, female genital mutilation, sexual health screening, history of forced

marriage/abuse/ trauma/torture] HIV status (disclosed in medical history and/or identification of risk

factors precipitating informed consent and testing; screening tests for HIV are not currently routinely offered to new entrants arriving via non

Syrian VPRS routes)

Hepatitis B and C (disclosed in medical history and/or identification of risk factors precipitating informed consent and testing; screening tests

for HIV are not currently routinely offered to new entrants arriving via non Syrian VPRS routes)

Identification of active and latent Tuberculosis (symptom history, clinical examination signs, vaccination history, country of birth, country

& circumstances (e.g. overcrowding/refugee camp) of residence prior to arrival in Wales and appropriate diagnostic or screening tests in line

with NICE recommendations) Review of immunisation status

Mini mental assessment and PTSD assessment

Specific public health concerns

Based on expert opinion ECDC recently concluded that refugees and migrants crossing the European Union’s southern or south-eastern

borders are most at risk from respiratory tract diseases, tuberculosis, gastrointestinal diseases, relapsing fever, trench fever, epidemic and

murine typhus, meningococcal disease, poliomyelitis, measles, mumps and rubella5,6,7.

While the risk of mosquito-borne diseases has been reduced as a result of

the approaching winter, the risk to refugees of diseases whose spread are facilitated by overcrowding and lower temperatures has increased5.

During initial assessment, consideration should be given to syndromes including: upper and lower respiratory tract disease, bloody and watery

diarrhoea, fever and rash, meningitis/encephalitis or encephalopathy / delirium, lymphadenitis with fever, sepsis or unexplained shock,

haemorrhagic illness, acute jaundice, cutaneous infection, and

unexplained death10.



Tuberculosis

The social and economic vulnerability of refugee population create favourable conditions for tuberculosis as well as the high proximity in

close setting5. Therefore, tuberculosis cases among refugees are not unexpected5.

MERS CoV

New entrants, presenting with respiratory symptoms, and recently arrived

from a country where MERS CoV is circulating, should undergo risk

assessment in line with current guidance

Ebola

New entrants recently arrived from a country where Ebola virus is

circulating, should undergo risk assessment in line with PHW Ebola

guidance

Influenza

New entrants are at risk of acquiring influenza in reception camps, during their journey, and after arriving in Wales. Vaccination is an option that

should be considered for individuals in high risk groups and in line with Wales’ flu vaccination policy.

Malaria, leishmaniasis and schistosomiasis

The risk for vector-borne diseases, such as malaria ranges from very

limited to non-existing in the Middle East and North African countries, but should be considered for persons originating from sub-Saharan African

countries or Asia (India, Pakistan)5,10.

Scabies

Outbreaks of scabies in refugee accommodation centres across Europe

have been reported5. Such outbreaks are not unexpected in the context of poor living conditions and the lack of access to proper water and

sanitation conditions during migration/within some accommodation centres across Europe5.

Typhoid fever

Cases of typhoid have been reported among new entrants to Europe from

Syria5. Appropriate diagnostic testing should be undertaken in anyone presenting with consistent symptoms.

Cholera

There is an ongoing cholera outbreak in Iraq which is reported to have affected 2,200 people, with six fatalities5. WHO at this stage is not

confirming that cases of cholera have been identified in Syria5, however it is probably only a matter of time before cases are confirmed in Syria,

Kuwait and Bahrain5. Despite the short incubation period (2 hours to 5 days) which would most likely prevent symptomatic cases being able to



complete their travel to Europe, asymptomatic carriers can excrete the

vibrio for 10 days5. Therefore, transmission originating from an asymptomatic carrier among refugee populations on their way to Europe

cannot be excluded5.

Cutaneous diphtheria

In July 2015, Denmark, Germany and Sweden reported seven cases of

toxigenic cutaneous diphtheria and two cases of non-toxigenic cutaneous diphtheria among refugees from Eritrea, Libya, Syria (1 case), Ethiopia

and Libya5. Most refugees who arrive in Europe are from endemic countries and have travelled under conditions that increase the risk of

acquiring cutaneous diphtheria5. In the event that cutaneous diphtheria is suspected in an individual presenting with symptoms, the clinician should

seek urgent advice from the local Infectious Diseases Consultant of Microbiology Consultant.

Louse borne diseases

As of 12 of November 2015, 27 case on louse borne relapsing fever

(LBRF) were reported in EU member states among refugees coming from countries of the Horn of Africa5. These include descriptions of cases who

have been living in crowded accommodation in Europe for several years and had seemingly acquired LBRF by transmission from a newly arrived

infected individual. Seek advice from local Infectious Disease Consultant or Microbiology Consultant with regard to hospital admission and

antibiotic therapy.

Other

Low coverage for some vaccines, along with low immunity for some

diseases, may result in susceptible new entrants developing diseases such

as measles and chicken-pox5.

Vaccination status

Obtaining an accurate vaccination history is crucial. Vaccinators should seek written documentation from New Entrants of

each individuals vaccination status

Written documentation of receipt of vaccinations may not always be

available: in such circumstances, vaccinators should provide

immunisations in line with Public Health England’s guidance on the

Vaccination of Individuals with Uncertain or Incomplete Vaccination

Status (PHE, September 2015)

Vaccinators should not use a proxy measure to estimate which

vaccines may have been given to an individual. Although the WHO

Vaccination Schedule by Country website

(http://apps.who.int/immunization_monitoring/globalsummary/schedul

http://apps.who.int/immunization_monitoring/globalsummary/schedules



es) is an extremely valuable resource, individuals may not have been

able to access usual healthcare services for example due to conflict,

displacement from home or lack of available vaccine.

All New Entrants should be offered vaccinations in line with the UK

schedule.

The European Centre for Disease Prevention and Control specifically

recommend provision of the following vaccinations1,5:

MMR, prioritising children up to the age of 15 years.

Poliomyelitis vaccination should be considered for children and adults

coming from countries currently exporting polio virus (such as

Afghanistan and Pakistan), infected countries (such as Nigeria and

Somalia), or countries which remain vulnerable to international spread

(including Cameroon, Equadorial Guinea, Ethiopia, Iraq, Israel and

Syria).

Vaccination against meningococcal serogroups A, C, W-135 and Y (or

against serogroups A and C if quadrivalent vaccine not available)

When provision of live vaccines is required, vaccinators should make reasonable attempts to clarify the immune status of the individual,

including checking HIV status. Vaccinators should explain the potential risk of administering live vaccine to an immunosuppressed person, and if

in doubt should consider offering testing e.g. for HIV.

For details advice on the vaccines and their administration, vaccinators should follow guidance within Immunisation Against Infectious Disease:

the green book https://www.gov.uk/government/publications/immunisation-against-

infectious-disease-the-green-book-front-cover-and-contents-page

https://www.gov.uk/government/publications/immunisation-against-infectious-disease-the-green-book-front-cover-and-contents-page

https://www.gov.uk/government/publications/immunisation-against-infectious-disease-the-green-book-front-cover-and-contents-page



References

1. European Centre for Disease Prevention and Control. Expert Opinion on the public health needs of irregular migrants, refugees

or asylum seekers across the EU's southern and south-eastern borders. Stockholm: ECDC; 2015

2. British Medical Association. Asylum seekers: meeting their healthcare needs. London: British Medical Association; 2002.

3. McKay J. And Price S. Review of healthcare for asylum seekers in Wales. Public Health Wales; 2013.

4. Cardiff & Vale University Health Board. Cardiff Health Access Practice (CHAP) Practice Development Plan 2012-2014.

5. European Centre for Disease Prevention and Control.

Communicable disease risks associated with the movement of refugees in the winter season – 10 November 2015. Stockholm:

ECDC; 2015. 6. European Centre for Disease Prevention and Control (ECDC).

Expert Opinion on the public health needs of irregular migrants, refugees or asylum seekers across the EU's southern and south-

eastern borders [Internet]. Stockholm: ECDC; 2015. Available from:

http://ecdc.europa.eu/en/publications/_layouts/forms/Publication_DispForm.aspx?List=4f55ad51-4aed-4d32-b960-

af70113dbb90&ID=1377#sthash.1y0CWCyQ.dpuf. 7. European Centre for Disease Prevention and Control (ECDC). Risk

of importation and spread of malaria and other vector-borne diseases associated with the arrival of migrants to the EU.

Stockholm: ECDC; 2015. Available from:

http://ecdc.europa.eu/en/publications/_layouts/forms/Publication_DispForm.aspx?List={4F55AD51-4AED-4D32-B960-

AF70113DBB90}&ID=1393#sthash.spOKWHHk.dpuf. 8. United Nations High Commissioner for Refugees (UNHCR).

Ensuring access to health care. Operational guidance on refugee protection and solutions in urban areas. Geneva: UNHCR; 2011.

Available from: http://www.unhcr.org/4e26c9c69.pdf. 9. Morris MD, Popper ST, Rodwell TC, Brodine SK, Brouwer KC.

Healthcare barriers of refugees post-resettlement. J Community Health. 2009 Dec;34(6):529-38.

10. European Centre for Disease Prevention and Control (ECDC). Expert Opinion on the public health needs of irregular migrants,

refugees or asylum seekers across the EU's southern and south-eastern borders [Internet]. Stockholm: ECDC; 2015. Available

from:

http://ecdc.europa.eu/en/publications/_layouts/forms/Publication_DispForm.aspx?List=4f55ad51-4aed-4d32-b960-

af70113dbb90&ID=1377#sthash.1y0CWCyQ.dpuf.

http://ecdc.europa.eu/en/publications/_layouts/forms/Publication_DispForm.aspx?List=%7b4F55AD51-4AED-4D32-B960-AF70113DBB90%7d&ID=1393#sthash.spOKWHHk.dpuf





Appendix A



Migration Health Assessment WORKSHEET Form 04MH_A

1. Assessment Date: 2. Program:

3. Ref. ID No:

4. Name :

(Last) (First) (Middle)

5. Gender: F M 6. DOB: 7. Principal Applicant: No Yes

8. Case No. 9. Country: 10. Nationality:

11. Exam Place: 12. Exam Country: 13. Doctor:

14. Health Assessment completed on:

15. Medical Conditions Identified

None Syphilis Physical impairment/disability

TB, active, infectious Other sexually transmitted

diseases Significant Mental health condition

TB, active, non-infectious Human immunodeficiency virus

Addiction(abuse) of specific substances

TB, inactive Other significant condition, specify:

16. Description of significant condition / Treatment / Recommendation ICD Code(s)

17. TREATMENT Administered: No Yes (pls. provide details in Remarks above, or attach the “IOM treatment form”)

Syphilis Anti-malaria De-worming

Dates: Drugs/Dosage: Dates: Drugs/Dosage: Dates: Drugs/Dosage:

1. 2. 3.

1. 2. 3.

1. 2. 3.

18. VACCINES Administered: No Yes

Dates: Vaccine: Dates: Vaccine: Dates: Vaccine:

1. 4. 7.

2. 5. 8.

3. 6. 9.

19. Travel Recommendations 20. Pregnancy No Yes

Fit to travel: Yes Conditionally No

a)To travel Before:

Special attention on pre-flight assessment: No

Yes b) Not to travel before:

Hospitalization required: Pre-depart. Post-arrival

21. Equipment / Medication 22. Escorts No Yes

Update



Ambulance Stretcher Bowel Prep. Med. Escort-POE Family escort

WCHR 3 seats Diapers Med. Escort-FD Operational Escort

WCHS Oxygen Urinary catheter Medical Escort By: Other, specify: WCHC Interflight Th

admin. Other Doctor Nurse

23. Post-travel recommendations 23.A Follow-up needed : No Yes

Special schooling/employment needs By whom: Within:

Consequences on daily living activities (Assistance Required)

by GP one week

Special housing requirements by Specialist, specify:

one month

Excessive demands for the health service 6 months

Remarks/Details:

Date: Examining physician’s name address and telephone number (stamp may be used):

Signature:

Form 04MH_B 1. Assessment Date:

MEDICAL HISTORY&PHYSICAL EXAM 2. Program:

3. Name:

4. Case No:

5. Date of Birth:

Yes No 1. Medical History

Illness or injury requiring hospitalization Recurrent fever (last 6 months)

Surgical interventions Coughing

Heart disease or high blood pressure Loss of weight (last 6 months)

Neurologic disease, incl. stroke or seizures Sexually transmitted diseases

Mental illness/problems Skin problems (rash, etc…)

Stomach or bowel disease (incl. recent diarrhea)

Tatoos, body piercing

Liver or kidney disease History of blood transfusions

Diabetes or other endocrine disorder History of torture/violence

Urogenital problems / conditions Displaced from home, number of months:

Hematologic disease Are you taking medications, specify below

Muscle, bone and joint problems Do you have any drug allergies?

Problems with eyes or ears Smoking habits: Years: No/day:

Cancer or tumors Alcohol habits: Years: Units/week:



TB, pneumonia, or other lung disease

Illicit drug use? Specify past or present, name of the drug(s), quantity, period, when stopped (if in the past), any treatment

Household member with significant. inf. disease (or TB contact in general)

2. Reproductive history Number

Pregnancies: LM Period :

Deliveries: Are you pregnant? No Do not know Yes

Babies born alive: Gestation (what week?):

3. Physical Examination: (repeat if abnormal)

Height cm Vital sign Initial Repeated Units

Weight Kg BP mmHg

BMI Kg/m2 Pulse /min

Head circumference (< 18months) cm Resp.rate /min

Visual Acuity Uncorrected Corrected Correction (if available)

Left/ Right / / / N Abn ND N Abn ND N Abn ND

General appearance

Endocrine Extremities

Visible disabilities

Respiratory Skin (incl. scars)

Mental state

Abdominal/GIT Neurologic

EENT (incl. hearing)

Musculo-skeletal Lymph nodes

Teeth

Genito-urinary Breasts

Cardiovascular

Hernial sites Pregnant: Yes No Fundal height (cm):

Remarks/Notes:



Migration Health Assessment CXR&TB LAB WORKSHEET Form 04MH_CXR

1. Assessment Date: 2. Program:

3. Ref. ID No:

4. Name:

(Last) (First) (Middle)

5. Case NO:

6. Date of Birth:

7. Chest X-Ray Done on Normal Abnormal F/U needed Abnormal no F/U

Not Done due to: Age Pregnancy Other, Specify

8. From the Medical file:

TB signs or symptoms Contact with TB patient History of TB

9. Chest X-ray Interpretation by the Radiologist

Can suggest Active TB (need smears)

Can suggest INACTIVE TB (need smears if symptomatic)

Other X-ray findings

Infiltrate or consolidation Discrete fibrotic scar or linear opacity Musculoskeletal

Any cavitary lesion Discrete nodule(s) without calcification Cardiac or major vessels

Nodule with poorly-defined margins (such as tuberculoma)

Discrete fibrotic scar with volume loss or retraction

Pulmonary

Linear, interstitial markings (children only)

Discrete nodule(s) with volume loss or retraction

Other Pleural effusion Upper lobe retraction or volume loss

Hilar/Mediastinal adenopathy

Other (such as bronchiectasis) Other (such as miliary

findings)

Date: Radiologist’s Name: Radiologist’s Signature:

10. IOM Physician’s Comments on CXR

11. TB Smears and Cultures

Date: Smears Done Not Done Cultures Done Not DST Done Not



Done Done

Neg Scanty AFB

count 1+ (1-9 /10F)

2+ (1-10 /F)

3+ (>10/F) Neg Pos Cont Non Diagn.

12. TST Done Not Done

Date taken

Date read: Result, mm:

History of BCG

No Yes Unknown

Form 04MH_LAB 1. Assessment Date:

LAB WORKSHEET 2. Program:

3. Name

4. Case No

5. Date of Birth:

6. HIV Test Done Not Done

Type: Date: Test kit: Test Results: Test Notes:

Screening Neg Pos Indt.



Confirmatory Neg Pos Indt.

7. Syphilis Test Done Not Done

Type: Date: Test kit: Test Results: Titer: Test Notes:

Screening Neg Pos

Confirmatory Neg Pos

8. Urinalysis Done Not Done Microscopy: Date: 12-Dec-2007

Blood Neg Pos Repeat Date: 04-Dec-2007

Blood Neg Pos

Albumin Neg Pos Albumin Neg Pos

Sugar Neg Pos Sugar Neg Pos

9. CBC Done on Not Done

Name: Result: Unit Ref. range:

Name: Result: Unit Ref. range:

WBC x 103/mm3 5.0-10.0

Eosinophils, % Percent 0-4

RBC x 106/mm3 4.1-5.3

Basophils, % Percent 0-2

Hemoglobin g/dL 12.0-18.0

Neutrophils, abs x 103/mm3 1.8-7.8

Hematocrit Percent 37.0-52.0

Lymphocytes, abs x 103/mm3 0.7-4.5

Platelets x 103/mm3 140-390

Monocytes, abs x 103/mm3 0.1-1.0

Neutrophils, % Percent 45-76

Eosinophils, abs x 103/mm3 0.0-0.4

Lymphocytes, % Percent 17-44 Basophils, abs x 0.0-0.2



103/mm3 Monocytes, % Percent 3-10

10. Other tests with Numeric Results

Date: Test name: Result: Unit: Ref. Range: Test Notes:

Select the test

Select the test

Select the test

Select the test

Select the test

Select the test

Select the test

Select the test

Select the test

Select the test

11. Other tests with Neg/Positive Results

Date: Test name: Test kit: Test Results: Test Notes:

Hep B Neg Pos

Select the test Neg Pos






Lab Remarks:

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