Canada, it is often said, is a land of immigrants.
The newcomers - close to 300,000 a year - can pose particular challenges for health care practitioners: They may be lacking basic vaccines that are taken for granted in Canada, have been exposed to tropical illnesses that are rarely seen in this country, or be victims of family violence that is not acceptable in Western society.
So a group of practitioners and community activists - under the rubric the Canadian Collaboration for Immigrant and Refugee Health - have joined forces to create a new set of guidelines for care.
"There was definitely a concern that care was suboptimal," said Kevin Pottie, principal at the Centre for Global Health in the Institute for Population Health in Ottawa.
"Some of us were overscreening and overtreating because of unknowns. Others were doing nothing extra. There was no real consistency and no real guide for clinicians," he said.
Dr. Pottie said that, for example, many newcomers were undergoing elaborate testing for parasites though only two intestinal bugs require treatment. Conversely, many women were not getting referred for Pap tests, even though cervical cancer is a major killer in much of the world.
"Generally, immigrants and refugees are healthy but averages can hide some important inequities," he said.
The 102-page guidelines, published in the Canadian Medical Association Journal, urge physicians to focus on key health issues in four broad areas and offer the following recommendations:
- Vaccinate all children and adult immigrants without proper immunization records with MMR (measles, mumps and rubella), DPTP (diphtheria, pertussis, tetanus and polio) and varicella (chickenpox) vaccine.
- Screen adults and children from areas where the rate of hepatitis B virus infection is high such as Africa, Asia and Eastern Europe.
- Screen for hepatitis C virus in all immigrants and refugees from regions with prevalence of disease greater than 3 per cent (this excludes South Asia, Western Europe, North America, Central America and South America).
- Screen children, adolescents and refugees between 20 and 50 years of age from countries with a high incidence of tuberculosis.
- Screen for HIV, with informed consent, all adolescents and adults from regions where HIV prevalence is greater than 1 per cent (sub-Saharan Africa, parts of the Caribbean and Thailand).
- Test refugees for the following intestinal parasites:
- Strongyloides if they are arriving from Asia or Africa and
- Schistosoma if arriving from Africa
- Do not conduct routine screening for malaria.
- Screen immigrants and refugees under 35 for Type 2 diabetes if they are from high-risk areas (South Asia, Latin America or Africa.)
- Test women of reproductive age and children under the age of four for iron-deficiency anemia.
- Screen all immigrants for dental pain and refer to a dentist.
- Perform testing for visual impairment.
- Discuss unmet contraceptive needs and provide women with their contraceptive method of choice.
- Conduct cervical cancer screening with a Pap test.
- Vaccinate girls against HPV (human papillomavirus) infection, which can cause cervical cancer.
- Screen all adults for depression.
- Do not conduct routine screening for PTSD (post-traumatic stress disorder) but be alert to signs and symptoms, particularly in refugees.
- Be alert to signs and symptoms of child abuse or maltreatment.
- Be alert to signs and symptoms of intimate partner violence.