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Am Fam Physician. 2018;98(3):141-142

Original Article: Primary Care for Refugees: Challenges and Opportunities

Issue Date: July 15, 2017

To the Editor: We would like to thank Drs. Mishori, Aleinikoff, and Davis for reviewing the challenges and opportunities for refugees seen in primary care settings. We agree that refugees often face barriers to care as a result of cultural, language, and socioeconomic factors. We would respectfully like to provide clarification on a few points mentioned in the article.

The article states that the pre-resettlement examination is performed overseas, following technical guidelines from the Centers for Disease Control and Prevention with oversight from the U.S. State Department and the International Organization for Migration. It also states that documentation from this examination is available to state and local health departments through the National Notifiable Diseases Surveillance System ( In fact, documentation from the overseas medical examination is provided to state and local health officials through the Electronic Disease Notification system ( This is a web-based system that notifies state or local health officials when all refugees (regardless of examination findings) and immigrants who are at risk of tuberculosis arrive in their jurisdictions.1 Furthermore, panel physicians with the International Organization for Migration conduct examinations in many countries and manage resettlement logistics, but they do not provide oversight for the medical examination.

Table 3 states that hepatitis B screening should be performed for refugees from countries with greater than 2% prevalence. However, guidelines specify a prevalence rate of 2% or greater. It should be noted that most eligible refugees receive predeparture treatment for soil-transmitted helminths, schistosomiasis, Strongyloides, and malaria before arrival in the United States.2

Lastly, in Table 3, the action column for immunizations recommends that physicians order varicella zoster virus (VZV) immunoglobulin G (IgG) and hepatitis B surface antibody tests before vaccinating. We believe the authors meant that it is reasonable to check VZV IgG before administering the VZV vaccine. A positive VZV IgG result indicates previous infection, so the vaccination is not needed. We would agree with this approach. However, we were confused by the suggestion to check hepatitis B surface antibody test results before vaccinating. Most refugees are checked for hepatitis B infection before departure by screening for hepatitis B surface antigen. When that test result is negative, the vaccine series is initiated overseas. If testing has not been performed previously, it should be done after arrival, regardless of the vaccine history (as indicated by the authors). The hepatitis B surface antibody test can be used to indicate immunity by vaccination, but only in a completely immunized person. On its own, in a partially vaccinated or unvaccinated person, it is not particularly helpful. A positive hepatitis B surface antibody test result with a negative anti–hepatitis B core antibody result must be interpreted with caution in a recently or partially immunized person.3

Editor's Note: This letter was sent to the authors of “Primary Care for Refugees: Challenges and Opportunities,” who declined to reply.

Email letter submissions to Letters should be fewer than 400 words and limited to six references, one table or figure, and three authors. Letters submitted for publication in AFP must not be submitted to any other publication. Letters may be edited to meet style and space requirements.

This series is coordinated by Kenny Lin, MD, MPH, deputy editor.

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