The Australasian Society for Infectious Diseases guidelines for the diagnosis, management and prevention of infections in recently arrived refugees: an abridged outline

Ronan J Murray, Joshua S Davis and David P Burgner, on behalf of the Australasian Society for Infectious Diseases Refugee Health Guidelines Writing Group
Med J Aust 2009; 190 (8): 421-425. || doi: 10.5694/j.1326-5377.2009.tb02489.x
Published online: 20 April 2009

Australia and New Zealand have obligations under the 1951 United Nations Convention relating to the Status of Refugees and the 1967 Protocol Relating to the Status of Refugees to assist in the relocation of individuals who are unable to remain in their country of origin. Currently, about 13 000 refugees migrate to Australia each year,1 with priority regions for individuals needing resettlement including southern and South-East Asia, the Middle East and sub-Saharan Africa.1

The Australian Government requires that refugees being considered for migration to Australia undergo a health assessment before being issued with a visa. This assessment includes screening for HIV infection in those aged 15 years or over, and for active tuberculosis infection (including a chest radiograph) in those older than 11 years.2 An additional “fitness-to-fly” pre-departure assessment is usually performed shortly before travelling to Australia. Testing for and treatment of malaria and empiric treatment for helminth infection have recently been added to the fitness-to-fly assessment for many sub-Saharan African refugees. However, as refugees bear a disproportionate burden from other acute and chronic infectious diseases that may be undiagnosed or untreated at the time of arrival in Australia,3-5 timely post-arrival screening for infectious diseases and other common conditions in all refugees is essential, to ensure not only the health of each refugee but also the public health of the broader Australian community.

In recent years, migrant and refugee health service providers have noted an increase in the number and variety of infectious diseases in newly arrived refugees, particularly in those from sub-Saharan Africa.3-5 These infections are often unfamiliar to local medical practitioners, as many are not endemic to Australia. This has led to a degree of uncertainty and concern among refugees, health care providers and the wider community. How should we screen for infection in refugees? Which tests should be performed? What should we do with the results? What about catch-up immunisations? The states and territories have developed their own responses to these challenges, with approaches varying from no or limited screening to comprehensive screening for both common and rarer infections.3-7

In late 2005, the Communicable Diseases Network Australia (CDNA) asked the Australasian Society for Infectious Diseases (ASID) to formulate guidelines for the screening, treatment and prevention of infections in recently arrived sub-Saharan African refugees, with the aim of providing practical assistance to general practitioners and others who provide health care services to this population (see footnote * for details of the guideline development process). Here, we summarise the major recommendations of these guidelines, which are available in full on the ASID website at <>.8 Treatment recommendations have been graded according to National Health and Medical Research Council (NHMRC) levels of evidence.9

Although the guidelines were originally written for refugees originating from sub-Saharan Africa, many of the recommendations will apply to refugees from other regions. Each section of the guidelines includes a discussion of issues specific to refugee children. The guidelines have been endorsed by the CDNA, the National Tuberculosis Advisory Committee, and the Australasian Chapter of Sexual Health Medicine of the Royal Australasian College of Physicians.

The key general recommendations of the guidelines are shown in Box 1, and a summary of recommendations for testing for and treatment of common infections in refugees is provided in Box 2. More detailed recommendations for some of the most commonly encountered infections are shown in Box 3 (tuberculosis, malaria and schistosomiasis) and Box 4 (blood-borne viral infections [HIV, hepatitis B and hepatitis C] and sexually transmitted infections). Wherever possible, treatment recommendations are based on published evidence; however, there is a clear need for further research to develop a broader evidence base to underpin the management of the complex health needs of refugees.

Newly arrived refugees have been through significant turmoil and upheaval. Therefore, post-arrival health assessments must be sensitive to their feelings of cultural disorientation, vulnerability and sometimes fear and mistrust of authorities. We have recommended a screening approach that can be performed by a single venepuncture (see Box 2), avoiding multiple blood tests and routine collection of other specimens wherever possible. We believe that the guidelines strike a balance between identifying important and treatable infections and overinvestigation.

These guidelines focus on infectious diseases. However, assessment for infectious diseases is only one component of a comprehensive overall assessment that should also address psychological health, nutritional status, sexual and reproductive health, dental health, chronic disease, cancer screening, and childhood growth and development. We refer readers to other recent Australian publications for advice regarding these important issues,6,7,26,27 which are beyond the scope of these guidelines.

It is important to note that unless the granting of an individual’s visa was contingent on a specific health undertaking, assessment and screening is offered on a voluntary basis and following informed consent. Refugee health assessments should always be undertaken with an interpreter, either in person or by telephone. The interpreter should not be related to the patient, and the need for confidentiality should be emphasised. The Australian Government provides the Translating and Interpreting Service (TIS) for people who do not speak English and for those who need to communicate with them. This service is available free of charge to practitioners who provide a Medicare service within a private practice to permanent residents or citizens who do not speak English. The service is also available within hospitals or government-funded clinics, but must be paid for in these settings. The TIS Doctors Priority Line (tel: 1300 131 450) should be used to access this service.

2 Summary of recommendations for the diagnosis, treatment and prevention of common infections in recently arrived refugees*


Recommended screening test: Mantoux test or interferon-g release assay

If positive:


Recommended screening test: malaria thick and thin blood films and Plasmodium falciparum antigen test

If positive:

Blood-borne viral infections

Recommended screening test: HIV serology

If positive:

Recommended screening test: hepatitis B (HB) serology (sAg/sAb/cAb)

If HBsAg positive:

Recommended screening test: hepatitis C serology

If positive:

Sexually transmitted infections

Recommended screening test: syphilis serology

If positive:

Recommended screening test: nucleic acid detection test for Chlamydia trachomatis and Neisseria gonorrhoeae

All adults and others who are sexually active or may have been sexually assaulted should be screened for chlamydia and gonorrhoea infection on first-void urine

Helminth infection

Recommended screening test: Strongyloides serology

If positive:

Recommended screening test: full blood count (FBC) and/or faeces microscopy

If faeces readily obtainable OR symptoms present, faeces microscopy should be followed by directed treatment

If faeces not readily obtainable AND patient is asymptomatic:


Recommended screening test: schistosomiasis serology

If positive:

Other infections that may be detected at the health assessment — indications for testing

Helicobacter pylori infection

Adults with suspected peptic ulcer disease (based on symptoms):

Children with anorexia, poor weight gain or failure to thrive should be referred to a paediatric refugee health service for assessment

Uncommon infections (eg, filariasis, tungiasis)

Discussion with or referral to an adult or paediatric infectious disease specialist is recommended


Catch-up immunisations for all ages in accordance with the Australian Standard Immunisation Schedule, unless there is written evidence of adequate immunisation; serological tests to detect existing immunity are not recommended

sAg = surface antigen. sAb = surface antibody. cAb = core antibody. eAg = e antigen. * Treatment recommendations graded according to National Health and Medical Research Council (NHMRC) levels of evidence.9

3 Detailed recommendations for tuberculosis, malaria and schistosomiasis*

Tuberculosis (TB)

With the exception of those with documented past TB disease, all newly arrived refugees, including children, should be assessed for latent TB infection (LTBI), with the following plan:



* Treatment recommendations graded according to National Health and Medical Research Council (NHMRC) levels of evidence.9

4 Detailed recommendations for blood-borne viral and sexually transmitted infections

Blood-borne viral infections (HIV, hepatitis B and hepatitis C)

Sexually transmitted infections

HCV = hepatitis C virus. HBV = hepatitis B virus. HBsAg = hepatitis B virus surface antigen. HBeAg = hepatitis B virus e antigen. eAb = anti-hepatitis B virus e antigen antibody.

  • Ronan J Murray1
  • Joshua S Davis2,3
  • David P Burgner4,5
  • on behalf of the Australasian Society for Infectious Diseases Refugee Health Guidelines Writing Group

  • 1 Royal Perth Hospital and PathWest Laboratory Medicine WA, Perth, WA.
  • 2 Royal Darwin Hospital, Darwin, NT.
  • 3 Menzies School of Health Research, Darwin, NT.
  • 4 Child and Adolescent Health Service, Western Australian Department of Health, Perth, WA.
  • 5 School of Paediatrics and Child Health, University of Western Australia, Perth, WA.

Competing interests:

None identified.

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