Clinical Guidelines

These clinical practice guidelines have been consolidated from the latest recommendations from the CDC and AAP as of February 2020. Sources are listed individually under each section, but we recommend checking the CDC website and https://www.aap.org/en-us/Documents/3_AAP_MedicalScreening.pdf for any further questions.

Contributors:

  • Maria Martes Gomez, DO, LAC USC Pediatrics
  • John Bosco, MD, UCLA Combined Internal Medicine-Pediatrics
  • Camille Hamilton, MD, UCLA Pediatrics

Clinical Guidelines

  • Vaccination records from foreign countries can be accepted if doses are appropriately timed and credible-appearing documentation is present
  • If not, vaccination or re-vaccination is standard of care (checking serologic titers is an alternative), as the risks from non-vaccination are greater than re-vaccination.
  • All refugees originating from countries where hepatitis is intermediately or highly endemic (hepatitis B virus surface antigen prevalence >2%), as well as those who are at risk for hepatitis B infection (www.cdc.gov/hepatitis/HBV/HBVFaq.htm) should be tested for hepatitis B virus infection and existing immunity.

Source:

https://www.cdc.gov/immigrantrefugeehealth/guidelines/domestic/immunizations-guidelines.html

Intestinal parasites: StrongyloidesSchistosoma species and Soil-transmitted Helminth Infections (Ascaris, Trichuriasis, Hookworms: Necator americanusAncylostoma duodenale)

 

All intestinal parasites may be presumptively treated with pathogen specific anti-parasitic therapy unless contraindicated per the CDC tables below, OR managed with a ‘test and treat’ approach involving two or more separate stool ova and parasite tests done by concentration technique; samples must be collected 12 to 24 hours apart because shedding may be intermittent*.

*Test and treat approach for suspected Strongyloides infection must include IgG serology.

 

Note: Eosinophilia is a common presenting sign of intestinal parasite infection

 

Strongyloides:

  • The majority of refugees receive pre-departure treatment overseas with ivermectin before departure, unless contraindicated
  • A relative contraindication is a confirmed or suspected concomitant infection with Loa loa, because persons with pre-existing Loa loa infection and a high microfilarial load are at risk of complications when treated with ivermectin.
  • Test and treat approach for suspected Strongyloides infection must include IgG serology. However, the sensitivity of serology for Strongyloides infection may vary significantly by the test being used.
  • For management of Strongyloides in those at risk for Loa Loa infection, see https://www.cdc.gov/immigrantrefugeehealth/guidelines/domestic/intestinal-parasites-domestic.html

 

Loa Loa:

  • Refugees are not presumptively treated for Loa loa before departure with Ivermectin
  • Refugees from areas with Loa loa are not treated with ivermectin for strongyloidiasis (West and Central Africa) https://www.who.int/apoc/raploa/en/

 

Schistosoma:

  • Most refugees from endemic areas receive overseas pre-departure treatment with praziquantel, unless contraindicated

 

Soil-transmitted helminth infections (Ascaris, Trichuriasis, Hookworm (Necator americanusAncylostoma duodenale)):

  • Most refugees receive overseas presumptive treatment with albendazole, unless contraindicated

Source:

https://www.cdc.gov/immigrantrefugeehealth/guidelines/domestic/intestinal-parasites-domestic.html

Hepatitis B Surface Ag (infection, not immunity)

  • Recommend checking Hepatitis B Surface Antigen if coming from a part of the world where prevalence of Hepatitis B is >2%

Sources:

https://wwwnc.cdc.gov/travel/yellowbook/2020/travel-related-infectious-diseases/hepatitis-b#5182

https://www.cdc.gov/immigrantrefugeehealth/guidelines/domestic/hepatitis-screening-guidelines.html

  • Beginning January 4th, 2010, refugees are no longer tested for HIV-infection prior to arrival in the U.S.
  • Screening should be performed on all refugees unless they decline
  • Rapid HIV 1/2 4th generation (Antigen/Antibody) is recommended as the initial screening test per CDC guidelines

Source:

https://www.cdc.gov/immigrantrefugeehealth/guidelines/domestic/screening-hiv-infection-domestic.html

Screening syphilis testing should be performed routinely for refugees in the following categories:

  • All refugees >15 years of age, if no overseas results are available
  • Children < 15 years of age who are at risk for congenital transmission (mother tests positive), sexually active, or who have been sexually abused according to the Congenital Syphilis section of the CDC Sexually Transmitted Diseases Treatment Guidelines, 2015.

Source:

https://www.cdc.gov/std/tg2015/default.htm

Nucleic acid amplification tests for both Gonorrhea and Chlamydia for the following:

  • Female refugees <25 years old who are sexually active or female refugees >25 years who have risk factors (e.g., new sex partner or multiple sex partners, sex partner with concurrent partners) who do not have documented predeparture testing
  • Female refugees with abnormal vaginal or rectal discharge, intermenstrual vaginal bleeding, or lower abdominal or pelvic pain
  • Male refugees with urethral discharge, dysuria, or rectal pain or discharge.

Source:

https://www.cdc.gov/std/tg2015/default.htm

Nutritional assessment is not a required component of the overseas pre-departure examination.

 

Common vitamin deficiencies include:

  • Iron deficiency (most common)
  • Vitamin D deficiency (relatively common)

Other less common deficiencies: Vitamin A, Thiamine (B1), B3/Niacin and tryptophan, B12, Vitamin C, Iodine and Zinc

 

  • All children 6 months-59 months of age should be prescribed an age- appropriate daily multivitamin.
  • Primary care should be established for ongoing monitoring of growth and development, as well as age-appropriate nutritional screening and counseling
  • Initial laboratory testing should include CBC with differential and red blood cell indices, in addition to serum levels of vitamins/minerals suspected to be deficient.

Source:

https://www.cdc.gov/immigrantrefugeehealth/guidelines/domestic/nutrition-growth.html

All newly arrived immigrant children should have formal dental examination, especially those with clear evidence of active disease.

For listed Mental Health resources in your area, visit the Mental Health Section of the toolkit.

  • Newly arrived immigrant children might have been exposed to trauma, including war, prolonged travel, torture and family separation, increasing their risk for mental illness.
  • Clinicians performing the evaluations should educate themselves about the history and cultural beliefs of the refugee populations they serve. The Cultural Orientation Resource Center Website may be useful to clinicians trying to familiarize themselves with new cultures. (www.cal.org/co/overseas/prog_high_archive.htmlExternal).
  • Clinicians should be aware that refugees from cultures with stigmas against acknowledging psychiatric symptoms may present with stress-related somatic symptoms.
  • Refugees may not volunteer or admit symptoms at initial screening, but symptoms may emerge several months or years after resettlement. Therefore, follow-up primary care referral for on-going health care is imperative.
  • Primary care clinicians should become familiar with refugee care, including diagnosis and treatment of commonly encountered mental health conditions.

AAP National Immigrant Child Mental Health Resources

Online Resources and Screening Tools:

 

Other Mental Health/Trauma screening tools:

 

  1. Anxiety/PTSD/Depression
  • Child PTSD Symptom Scale (CPSS)
  • Trauma Symptom Checklist for Children and Trauma Symptom Checklist for Young Children (TSCC and TSCYC)
  • Adverse Childhood Experience (ACE) Questionnaire
  • Univ. of California at Los Angeles Posttraumatic Stress Disorder Reaction Index (UCLAPTSDRI)
  • Patient health questionnaire (PHQ-9)
  1. Relational, emotional and behavioral development in pre-school children:
  • Strengths and Difficulties Questionnaire (SDQ) in many languages
  • Ages & Stages Questionnaires®: Social Emotional (ASQ:SE)
  • The Survey of Well-being of Young Children (SWYC)
  • Pediatric Symptom Checklist in many languages

 

Source:

https://39jifo1k95sa2427bumhl63k-wpengine.netdna-ssl.com/wp-content/uploads/2019/05/Health-toolkit-Clinical-Guidelines.pdf

Screening

  • Place PPD if younger than 5yo per CDC (less than 2 y/o per Redbook)
  • Interferon-Gamma Release Assay (IGRA) if ≥ 5yo per CDC (older than 2 y/o per Redbook)
  • If either test is positive, get CXR to rule out pulmonary TB, then begin treatment for latent TB if no other signs/symptoms for active TB (cough, fever, night-sweats, weight loss, lymphadenopathy)
  • Key points in Testing:
    • Disregard BCG vaccine status when interpreting PPD results (but no cross reactivity potential with IGRA testing)
    • May consider repeating in 6 months if patient with chronic illness or malnourished, since this could potentially cause anergy (not a concern with IGRA testing since the control test results will tell you if patient is anergic)
    • PPD can be placed same day as live-virus vaccines, but should wait > 4 weeks if placing after live-virus vaccine already given

Treatment

Latent TB Infection Treatment Regimens
Drugs Duration Interval Comments
Isoniazid and Rifapentine 3 months Once weekly* Not recommended for persons who are:

●  Less than 2 years old,

●  Living with HIV/AIDS and taking antiretroviral medications with clinically significant or unknown drug interactions with rifapentine,

●  Presumed infected with INH- or RIF-resistant M. tuberculosis, and

●  Women who are pregnant or expect to become pregnant within the 12 week regimen.

Rifampin 4 months Daily Not recommended for persons who are:

●  Living with HIV/AIDS and taking antiretroviral medications with clinically significant or unknown drug interactions with rifampin (rifabutin may be used as a substitute),

●  Presumed infected with RIF-resistant M. tuberculosis, and

●  Women who are pregnant or expect to become pregnant within the 4 month regimen.

Isoniazid 6 months Daily Not recommended for persons who are presumed infected with INH-resistant M. tuberculosis.
Twice weekly** Not recommended for persons who are presumed infected with INH-resistant M. tuberculosis.
Isoniazid 9 months Daily Not recommended for persons who are presumed infected with INH-resistant M. tuberculosis.

Preferred treatment for:

●  Persons living with HIV AIDS and taking antiretroviral medications with clinically significant or unknown drug interactions with once-weekly rifapentine or daily rifampin,

●  Pregnant women (with pyridoxine/vitamin B6 supplements)

Twice weekly** Not recommended for persons who are presumed infected with INH-resistant M. tuberculosis.

Preferred treatment for pregnant women (with pyridoxine/vitamin B6 supplements)

*Use Directly Observed Therapy (DOT) or Self-Administered Therapy (parentally-administered SAT to children)

**Use Directly Observed Therapy (DOT)

Note: Due to the reports of severe liver injury and deaths, CDC recommends that the combination of rifampin (RIF) and pyrazinamide (PZA) should not be offered for the treatment of latent TB infection.

 

Additional resources

 

Table 3.84

Validated Questions for Determining Risk of LTBI in Children in the United States

Has a family member or contact had tuberculosis disease?
Has a family member had a positive tuberculin skin test result?
Was your child born in a high-risk country (countries other than the United States, Canada, Australia, New Zealand, or Western and North European countries)?
Has your child traveled to a high-risk country? How much contact did your child have with the resident population?

 

LTBI indicates latent M tuberculosis infection.

 

Sources:

https://www.cdc.gov/tb/education/FAQforProviders.htm

https://www.cdc.gov/tb/topic/treatment/ltbi.htm

https://redbook.solutions.aap.org/chapter.aspx?sectionid=189640207&bookid=2205#192304142

Who should be tested?

Newly arrived refugees of all ages and ethnicities

 

Pay attention to the following:

  • White blood cell count for infection
  • Hemoglobin/Hematocrit for anemia
  • RBC indices for potential hemoglobinopathies (ie. Thalassemia or Sickle Cell Trait)
  • Eosinophilia (absolute eosinophil count >400 warrants further investigation - possible parasitic infection)

Sources:

https://www.cdc.gov/immigrantrefugeehealth/guidelines/domestic/general/discussion/complete-blood-count.html#eos

https://www.cdc.gov/immigrantrefugeehealth/guidelines/overseas/intestinal-parasites-overseas.html

  • There is no evidence that newborn screening is beneficial in refugee infants or children
  • Newborn screening should be done before birth hospital discharge if born in the United States
  • Clinicians should perform targeted confirmatory testing (plasma amino acids, urine organic acids, acylcarnitine profile) if a metabolic disorder is suspected- consult with a Geneticist

Sources:

https://www.cdc.gov/newbornscreening/index.html

https://www.cdph.ca.gov/Programs/CFH/DGDS/Pages/nbs/default.aspx

Immigrant and Refugee Populations at Risk

  • Refugee children from all regions of the world, especially those from resource-poor countries, are at risk of having lead poisoning upon their arrival in the United States.
  • Malnourished children may be at increased risk for lead poisoning, likely through increased intestinal lead absorption mediated by micronutrient deficiencies. The best studied micronutrient deficiency related to lead levels is iron deficiency. Iron deficient children are at increased risk of developing lead poisoning. Deficiencies in calcium and zinc may also increase a child’s risk.

Recommendations for Post-Arrival Lead Screening

  1. Check blood lead level (BLL) of all refugee children 6 months–16 years of age upon their arrival in the United States (generally within 90 days, preferably within 30 days of arrival).
  2. Within 3–6 months post-resettlement, a follow-up blood lead test should be conducted on all refugee children aged 6 months–6 years of age, regardless of the initial screening BLL result.
  3. Within 90 days of their arrival in the United States, children aged 6 months–6 years of age should also undergo nutritional assessment and testing for hemoglobin or hematocrit level with one or more of the following: mean corpuscular volume (MCV) with the red cell distribution width (RDW), ferritin, transferrin saturation, or reticulocyte hemoglobin content. A routine complete blood count with differential is recommended for all refugees following their arrival in the United States, and these red cell parameters are included in this testing.
  4. Provide daily pediatric multivitamins with iron to all refugee children aged 6 months–6 years of age.

Examples of culture-specific exposures associated with elevated BLL children

Table 1.

Exposure Area of origin Reported uses Description
Pay-loo-ah Southeast Asia Treatment of fever and rash Orange-red colored powder. Administered by itself or mixed in tea
Daw tway gaw mo dah Burmese traditional remedy General infant remedy (multi-symptom) Brown pellets
Greta Mexico Treatment of digestive problems Yellow-orange colored powder. Administered with oil, milk, sugar, or tea. Sometimes it is added to baby bottles and tortilla dough
Azarcon Mexico Treatment of digestive problems Bright orange powder. Administered similarly to greta
Litargirio Dominican Republic Deodorant/antiperspirant; treatment of burns and fungal infections of the feet Yellow or peach-colored powder
Surma India Improve eyesight Black powder administered to inner lower eyelid
Unidentified ayuvedic Tibet Treatment for slow development Small gray-brown colored balls administered several times a day
Tiro (also known as tozali and kwalli) Nigeria Eye cosmetic; improve vision; ward off “evil-eye” Fine powder
Lozeena Iraq Added to foods for flavor, particularly rice and meat dishes Bright orange spice
Tamarind Mexico As a key ingredient in lollipops, fruit rolls, candied jams ‘Bolirindo’ lollipops by Dulmex are soft and are dark brown in color. Candied jams are typically packaged in ceramic jars
Lead-glazed ceramics Often made in Latin America Provides a glaze for vessels and helps ceramics hold water. Often found on bean pots and water jugs. Shiny coating on vessels
Make-up and beauty products Multiple cultures Enhance beauty Many types

 

Questions on history that may reveal a child’s exposure to lead

Medical history

  • Does the child have symptoms of lead toxicity?
  • Is there a history of pica?
  • Are there known previous exposures or documented elevated blood lead levels (BLL’s)?
  • Is there a family history of siblings with elevated BLL’s?
  • Is there anything concerning upon thorough review of the child’s developmental history?

Environmental exposures

Paint, soil, and metal

  • What is the age and condition of the residence?
  • Does the child chew or eat peeling paint on woodwork, furniture, or toys?
  • How long has the child lived in this residence?
  • When was the house built?
  • Were recent renovations or repairs done in the home or immediate area?
  • Inquire about other areas where the child spends significant amounts of time (day care, schools, etc.).
  • Do the child’s outdoor play areas contain bare soil?
  • Does the home contain mini-blinds made overseas and purchased before 1997?

Relevant behavioral characteristics of the child

  • To what degree does the child exhibit hand-to-mouth activity, or pica?
  • Are the child’s hands washed before meals and snacks?

Exposures to and behaviors of household members

  • What are the caregiver’s occupations?
  • What are the occupational and hobby history of adults with whom the child spends time (e.g., fishing, ceramic work, stained glass work, hunting)?
  • Are there potential cultural exposures as discussed in Table 1 (e.g., imported foods, cosmetics, folk remedies)?
  • Are painted materials or unusual materials burned in the household fireplace?
  • Is food prepared or stored in imported pottery or metal vessels?

 

Source:

https://www.cdc.gov/immigrantrefugeehealth/guidelines/lead-guidelines.html#table1

  • The only patients requiring screening or presumptive treatment are those from sub-Saharan Africa who have not received pre-departure. This is due to the low likelihood of an asymptomatic or subclinical P. falciparum malaria infection in patients arriving from locations outside sub-Saharan Africa and the efficacy of pre-departure treatment for those arriving from sub-Saharan Africa. Any patient with symptoms suggestive of malaria should be tested, regardless of origin or treatment.
  • Pre-departure treatment should be documented, and directly-observed therapy completed no sooner than 5 days before departure. The current recommended ACT regimen is artemether-lumefantrine given availability and minimal side effect profile
  • If a patient is from sub-Saharan Africa but has been in a non-endemic region for more than 3 months, falciparum malaria is unlikely. These patients only require testing if symptomatic
  • For patients from sub-Saharan Africa without pre-departure therapy, they should receive presumptive treatment or screening based on the tables below. Presumptive treatment is contraindicated for pregnant women in the first trimester of pregnancy, infants less than 5kg, or those with known allergies to the recommended anti-malarial medication.

Presumptive Therapies

Table 1:

Medication Pediatric dosing (children 5kg to <35kg) Adult dosing (>35kg)
Atovaquone-proguanil

(adult tablet = 250mg atovaquone/100mg proguanil, pediatric tablet =62.5mg atovaquone/25mg proguanil

5-8kg: two pediatric tablets one a day for 3 days

 

9-10kg: three pediatric tablets once a day for 3 days

 

11-20kg: one adult tablet once a day for 3 days

 

21-30kg: two adult tablets once a day for 3 days

 

31-35kg: three adult tablets once a day for 3 days

Four adult tablets once a day for 3 days
Artemether-lumefantrine (20mg artemether/120mg lumefantrine)

Should be taken with foods rich in fat, such as milk

A six-dose regimen (given at 0, 8, 24, 36, 48, and 60 hours) is recommended with 1-3 tablets per dose depending on body weight

 

5 to <15kg: one tablet per dose

 

15 to <25kg: two tablets per dose

 

25 to <35kg: three tablets per dose

A standard 3-day treatment schedule with a total of 6 doses (total course = 24 tablets). Initial dose consists of four tablets, after 8 hours 4 more tablets, then four tablets twice daily (morning and evening) for following 2 days

 

Table 2: Relative sensitivity of malaria testing modalities

Very sensitive Moderately sensitive Least sensitive
Malaria polymerase chain reaction (PCR) Blood smears (three samples obtained 12-24hrs apart) Malaria rapid diagnostic test (RDT)

 

Source: https://www.cdc.gov/immigrantrefugeehealth/guidelines/domestic/malaria-guidelines-domestic.html

  • The CDC currently recommends testing ONLY pregnant women with symptoms OR ultrasound findings suggestive of Zika who have traveled from a known endemic region
  • Symptomatic non-pregnant patients should be considered for Dengue testing, NOT Zika testing at this time

 

Source:

https://www.cdc.gov/zika/hc-providers/testing-guidance.html