Letters to the Editor

Screening Tests for Parasites in Refugees

Am Fam Physician. 2012 Oct 1;86(7):596-598.

Original Article: Primary Care for Refugees

Issue Date: February 15, 2011

Available at: http://www.aafp.org/afp/2011/0215/p429.html

to the editor: The article on primary care for refugees by Dr. Eckstein lists recommended infectious disease screening and diagnostic tests for refugees. For nine of the 10 parasites listed in Table 5, the recommended screening test is “Three stool ova and parasites tests, collected on three different mornings.” However, the Centers for Disease Control and Prevention (CDC) Guidelines for Evaluation of Refugees for Intestinal and Tissue-Invasive Parasitic Infections During Domestic Medical Examination, which were updated in 2010, clearly recommend a different approach.1 The CDC guidelines recognize that the epidemiology of intestinal parasites varies worldwide, and that implementation of the recommended presumptive predeparture treatment varies by location. Therefore, the CDC’s recommended strategy uses three distinct algorithms based on whether the refugee received predeparture treatment, and with what medication regimen. Specifically, the algorithms rely more on a complete blood count with differential, and less on serial stool ova and parasites testing, than the older sources cited in the article.

Author disclosure: No relevant financial affiliations to disclose.

REFERENCE

1. Centers for Disease Control and Prevention. Domestic intestinal parasite guidelines. http://www.cdc.gov/immigrantrefugeehealth/guidelines/domestic/intestinal-parasites-domestic.html. Accessed February 13, 2012.

in reply: The algorithms to which Dr. Schwartz refers are intended for use during the initial domestic medical examination for all refugees. These examinations and their associated screening algorithms are used by health care professionals specifically selected to perform that initial medical examination, and do not apply to primary care physicians seeing refugees as part of their regular patient panel. Table 5 was meant to serve as a reference for primary care physicians in their regular settings (i.e., not part of the initial domestic medical examination) when refugee patients are symptomatic and an infectious cause is in the differential.

Author disclosure: No relevant financial affiliations to disclose.

editors’ note: We appreciate Dr. Schwartz’s letter and Dr. Eckstein’s response on recommended screening and diagnostic tests for infectious diseases in refugees. The online version of Table 5 has been revised to reflect that, in symptomatic patients, there is also a role for selected serologic tests (e.g., complete blood count that may indicate eosinophilia) in addition to stool testing for ova and parasites.

Table 5.

Recommended Infectious Disease Screening and Diagnostic Tests for Refugees

Infectious agent Test Comments

Parasites*†

Ascaris lumbricoides (roundworm)

Entamoeba histolytica

Filariasis

Giardia lamblia

Hookworm

Taenia species (tapeworm)

Trichuris trichiura (whipworm)

Complete blood count with differential

Three stool ova and parasites tests, collected on three different mornings

Plasmodium species

Complete blood count with differential

Three thick and thin blood smears done over six to 12 hours, preferably during a fever spike

Consider in refugees from malaria-endemic areas with fever, thrombocytopenia, splenomegaly, or anemia

Schistosoma species

Complete blood count with differential, anti- Schistosoma antibody testing

Three stool ova and parasites tests, collected on three different mornings

Consider in refugees from sub-Saharan Africa, especially if hematuria is present; infection is risk factor for bladder cancer

Strongyloides species

Complete blood count with differential, anti- Strongyloides antibody testing

Three stool ova and parasites tests, collected on three different mornings

Untreated strongyloidiasis puts patients at risk of disseminated strongyloidiasis if they become immunocompromised

Sexually transmitted infections

Gonorrhea/chlamydia

Urine or cervical gonorrhea/chlamydia

Hepatitis B

Hepatitis B core antibody, hepatitis B surface antibody, hepatitis B surface antigen

Screen all refugees coming from areas in which hepatitis B is endemic

HIV

HIV-1 and HIV-2

Syphilis

Rapid plasma reagin, VDRL

All refugees 15 years and older should be screened for syphilis

Other

Helicobacter pylori

Fecal antigen preferable over serology20

Tuberculosis

Purified protein derivative/Mantoux test, Quantiferon-G, chest radiography

All refugees should be screened for tuberculosis because it is one of the most common infectious diseases in refugees3; consider renal tuberculosis in patients with hematuria


HIV = human immunodeficiency virus; VDRL = Venereal Disease Research Laboratories.

*—Suspect parasites with eosinophilia.

†—Negative stool sample results do not always rule out parasitic infections; therefore, serologic testing for antibodies may be necessary.

Information from references 3, 19, and 20.

Table 5.   Recommended Infectious Disease Screening and Diagnostic Tests for Refugees

View Table

Table 5.

Recommended Infectious Disease Screening and Diagnostic Tests for Refugees

Infectious agent Test Comments

Parasites*†

Ascaris lumbricoides (roundworm)

Entamoeba histolytica

Filariasis

Giardia lamblia

Hookworm

Taenia species (tapeworm)

Trichuris trichiura (whipworm)

Complete blood count with differential

Three stool ova and parasites tests, collected on three different mornings

Plasmodium species

Complete blood count with differential

Three thick and thin blood smears done over six to 12 hours, preferably during a fever spike

Consider in refugees from malaria-endemic areas with fever, thrombocytopenia, splenomegaly, or anemia

Schistosoma species

Complete blood count with differential, anti- Schistosoma antibody testing

Three stool ova and parasites tests, collected on three different mornings

Consider in refugees from sub-Saharan Africa, especially if hematuria is present; infection is risk factor for bladder cancer

Strongyloides species

Complete blood count with differential, anti- Strongyloides antibody testing

Three stool ova and parasites tests, collected on three different mornings

Untreated strongyloidiasis puts patients at risk of disseminated strongyloidiasis if they become immunocompromised

Sexually transmitted infections

Gonorrhea/chlamydia

Urine or cervical gonorrhea/chlamydia

Hepatitis B

Hepatitis B core antibody, hepatitis B surface antibody, hepatitis B surface antigen

Screen all refugees coming from areas in which hepatitis B is endemic

HIV

HIV-1 and HIV-2

Syphilis

Rapid plasma reagin, VDRL

All refugees 15 years and older should be screened for syphilis

Other

Helicobacter pylori

Fecal antigen preferable over serology20

Tuberculosis

Purified protein derivative/Mantoux test, Quantiferon-G, chest radiography

All refugees should be screened for tuberculosis because it is one of the most common infectious diseases in refugees3; consider renal tuberculosis in patients with hematuria


HIV = human immunodeficiency virus; VDRL = Venereal Disease Research Laboratories.

*—Suspect parasites with eosinophilia.

†—Negative stool sample results do not always rule out parasitic infections; therefore, serologic testing for antibodies may be necessary.

Information from references 3, 19, and 20.

Send letters to Kenneth W. Lin, MD, MPH, Associate Deputy Editor for AFP Online, e-mail: afplet@aafp.org, or 11400 Tomahawk Creek Pkwy., Leawood, KS 66211-2680.

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