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

Original Article: Primary Care for Refugees

Issue Date: February 15, 2011

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.

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.

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.

Infectious agentTestComments
  • Ascaris lumbricoides (roundworm)

    Entamoeba histolytica


    Giardia lamblia


    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
  • 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

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