A recording of this presentation is available HERE.
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Many thanks to Dr. Cassandra Kasten-Arias, who gave our final Senior Resident presentation of the academic year. Don't worry, we still have a few more weeks of Grand Rounds before we take a summer break. Dr. Kasten-Arias gave an important and timely presentation on Primary Care in Recent Immigrants.
The first part of her talk featured the medical indications for specific screening tests for refugees and/or recent immigrants; the second half focused on recent executive policy changes and what clinicians need to know to reassure patients about their rights and to respond to the presence of immigration officials in clinic and hospital spaces. I recommend watching!
For those of you who prefer notes:
Those of us who work in community health are aware of the immigrant populations we currently care for in our particular communities. As seen in the images below, the largest share of immigrants in the US are from Mexico, followed by India and China. In contrast, the largest number of refugees in the US currently are from China, Afghanistan and El Salvador.
Whereas there are guidelines from the CDC for clinicians caring for refugees, most undocumented immigrants will present to our healthcare facilities having received little to no standardized health screening.
Dr. Kasten-Arias encouraged us to refer to these guidelines-- found here -- when caring for all recent immigrants.
When caring for recent immigrants, there are specific areas to pay attention to, including vaccination history, travel history, environmental exposure, infectious disease screening, mental health, and sexual health screening.
Vaccination
- Verify the validity of vaccine records (criteria for validity: name of vaccine, month and year of administration, recommended timeline)
- Which vaccines are due or need revaccination
- When records are missing, favor administration over serologic testing (risk of repeat is low)
Travel History
- country of origin
- countries along immigration journey
- any other recent travel
Environmental Exposures
- Lead screening recommended by CDC for all newly arrived refugees/immigrants
- special attention to lead (>3.5ug/dl) due to high prevalence among refugees, who may have increased risk due to nutritional deficiencies of iron/calcium/zinc
- special attention to young children, pregnant and breastfeeding patients
- common lead sources in immigrants: car batteries (used to keep warm during journey), glazed pottery, industrial emissions, lead paint, herbal supplements, gasoline, candies (esp tamarind)
Infectious Disease Screening
- HIV (age 13-64, AND children <13 if high risk and/or unknown maternal status)
- TB -- 85% of US cases is reactivation of latent TB in immigrants-- screen with TST/IGRA for all children over 2 and TST for <2
- Intestinal parasites: almost all immigrants, regardless of country of origin, are at risk for stronglyoides infection. Check O+P for anyone with unexplained eosinophilia on CBC
- Viral Hepatitis
- HBV, highest risk from specific geographic areas, including SE Asia, West Africa, some parts of Sub-Saharan Africa
- CDC recommends screening ALL adults for HBV if not previously screening, children <18 if not completely vaccinated and no previous testing, all pregnant people regardless of previous vaccination
- Offer HBV vaccine to unvaccinated
- HCV screening for all adults, consider for unaccompanied minors and children w/risk factors
An excellent resource for refugees/recent immigrants is CareRef (from Minnesota): https://careref.web.health.state.mn.us/, which compiles CDC recommendations into an easy to use form and helps clinicians guide screening assessments.
Mental health screening tool for refugees/newly arrived immigrants: https://www.cdc.gov/immigrant-refugee-health/hcp/domestic-guidance/mental-health.html
Sexual Health screening: 60% of women/girls experience sexual assault on journey to the border (Amnesty International 2010)
- CDC recommends contraception counseling, STI screening, family planning services
- pregnancy test for all refugees
- inform patients of confidential services for teens (>12 in CA)
- female genital cutting: https://www.cdc.gov/immigrant-refugee-health/hcp/domestic-guidance/sexual-and-reproductive-health.html
Screening Labs for initial visit:
Political Context and Advocacy Resources
We are all aware of the current political context with direct attacks by the federal administration on immigrant populations. In January 2025, the administration removed historical protections that protected immigration enforcement in hospitals, clinics, schools and places of worship.
In March of 2025, The Physicians for Human Rights (PHR) released a document specifically for healthcare providers titled Health Care and US Immigration Enforcement: What Providers Need to Know
- Proactively reassure patients
- Do not ask about immigration status unless required (we are NOT required in California)
- in states where you are required, you can inform patients that while we are required to ask, they are not required to respond
- Monitor and address rumors
- Share Know Your Rights information
- regardless of status, all patients have right to privacy, emergency care, and equal protection
- Ensure institutional preparedness protections against immigration enforcement
- right to remain silent (while immigration officials can enter any public space and question anyone, those being questioned have the right to remain silent and not respond to those questions)
- plain view: officers can have access to anything in plain view BUT cannot move things to get information (e.g. keep health records out of sight)
- warrants must be signed by a judge, have an individual's name on it, state the site at which it will served and accurate dates
- we are permitted to document and/or video any encounter with immigration officials
Northbay Rapid Response Network: https://www.northbayop.org/nbrrn
Additional resources:
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