Afghan refugees and newly displaced populations: individual health assessment – GOV.UK

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Published 25 April 2022

© Crown copyright 2022
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This publication is available at https://www.gov.uk/government/publications/individual-health-assessments-for-afghan-refugees/afghan-refugees-and-newly-displaced-populations-individual-health-assessment
You should collect basic demographic information from all patients. This includes:
You should record age based on patient self-reporting. We do not recommend physical assessments of age.
You should take a patient’s height and weight to help identify malnutrition (undernutrition or overnutrition) and healthy growth in children. You should also calculate body mass index (BMI) for all patients. This will help you to consider their current and future risk of long-term conditions, such as:
You can find further considerations for physical screening in infants in the children’s health section (section 6).
You should be alert to malnutrition, both undernutrition and overnutrition. Clinical examination is essential for diagnosing malnutrition and should include:
It is also important to consider other factors and conditions that may be contributing to malnourishment, for example, diarrhoea, tuberculosis or HIV. These underlying pathologies must be addressed to improve nutrition. A patient with acute malnutrition is also likely to be lacking in vitamins and micronutrients.
Malnutrition affects the immune system, so acutely malnourished patients are vulnerable to infectious disease, especially measles. You can read more on this in:
See the children’s health section for specific considerations on malnutrition in children (section 6).
There is a moderate risk of anaemia in adults in Afghanistan (prevalence of 20 to 40% in non-pregnant women) and a high risk of anaemia in pre-school children in Afghanistan (estimated prevalence is more than 40%).
You should consider anaemia for all newly arrived migrants, in particular women and children under the age of 5. See the page on anaemia in the migrant health guide for more information.
There is a high risk of vitamin A deficiency in Afghanistan, as well as a potential risk of zinc deficiency. You should also consider vitamin D deficiency, in particular for people at higher risk due to darker skin, staying indoors, and covering up when outdoors. For further guidance see:
Afghanistan was previously a red list country for COVID-19 risk. All arrivals from Afghanistan who entered the UK before 11 October will have completed at least 10 days in a managed quarantine facility. They should also have been tested for COVID-19 on day 2 and day 8. You should continue to be alert to any symptoms of COVID-19 in patients.
Patients should be offered COVID-19 vaccination as appropriate, and some will already have been offered their first dose upon arrival.
Some patients may have been vaccinated against COVID-19 already in Afghanistan, sometimes with vaccines that are not recognised in the UK. Follow the published guidance for people who have been vaccinated overseas.
There is also advice on COVID-19 in the migrant health guide.
The leaflets for the COVID-19 vaccination programme are updated frequently. Please visit the COVID-19 vaccination programme page to see the latest versions. The collection includes:
You should give particular consideration to the infectious diseases described below when assessing new arrivals from Afghanistan. Many of these are statutory notifiable diseases, meaning you must notify your local health protection team of any suspected cases.
You can find further information about other communicable diseases and vaccinations in:
You should assess all patients for open wounds and treat these immediately to avoid infection. There is a particular risk of invasive group A Streptococcus bacterial infection. Early signs and symptoms can include:
Polio is endemic in Afghanistan and professionals should be alert to the symptoms of polio in any new arrival. Children under 5 are at the greatest risk of infection. Clinicians should appropriately investigate all acute neurological illnesses according to national guidance and report suspected cases by calling the UK Health Security Agency (UKHSA) national duty doctor line (020 8200 4400) between 9am and 5.30pm, 7 days a week. Local and regional laboratories should use the enteric virus and polio investigation referral form to refer all enterovirus positive samples to the UKHSA Enteric Virus Unit for typing.
Acute polio is a notifiable disease. You should notify your local health protection team of any suspected cases. For further resources see:
The incidence of tuberculosis (TB) in Afghanistan is high. You should screen all new entrants to the UK for TB according to National Institute for Health and Care Excellence guidelines on tuberculosis. TB is a notifiable disease. You should notify your local health protection team of any suspected cases.
If active TB is clinically suspected, treatment should begin immediately without waiting for test results. This includes referring patients for a same day review at local TB services. If TB is a possibility, you should consider doing a TB culture on samples to detect the presence of TB bacteria. Screening for TB should include:
You should offer all patients testing and treatment for latent TB as Afghanistan is a high incidence country. The guidance you should follow includes:
Public Health England (PHE) published an algorithm to support latent TB testing and treatment for migrants. You may need to refer the patient directly to TB specialist services, especially if a practice lacks blood testing capacity to diagnose TB (interferon gamma release assay).
You should assess all patients for their immunisation history and outstanding vaccines against the UK immunisation schedule. Records of immunisation status may be missing. In this case, follow guidance from the Green Book on vaccinations of individuals with uncertain or incomplete immunisation status.
You should assume children are unimmunised unless there is a reliable history of previous immunisation. You can contact your local health protection team with any specific questions.
Review the Green Book for advice on BCG vaccination.
UKHSA has specific guidance on BCG vaccination for babies, as well guidance on BCG vaccination for babies in Pashto.
You can also find information on preventing and controlling TB in the migrant health guide.
Some areas of Afghanistan are higher risk for malaria. Be alert to the signs and symptoms of malaria in any unwell patient, noting that symptoms tend to be non-specific. Early diagnosis and treatment in new arrivals is essential as acute infection can be rapidly fatal. You can find information on malaria in the migrant health guide.
Afghanistan reported the seventh highest number of measles cases globally in 2021 and there is low immunisation coverage among children.
Most adults in Afghanistan would have been exposed to measles as a child. You should routinely offer all children, as well as young adults, the measles, mumps and rubella (MMR) vaccine.
PHE published leaflets about the MMR vaccine for all ages.
Hepatitis B and C are notifiable diseases in the UK. You should notify your local health protection team of any diagnosed cases.
Afghanistan has an intermediate prevalence of hepatitis B, so you should consider offering screening to any new patients. Offer screening to pregnant women and ensure you provide post-exposure immunisation to infants born to hepatitis B infected mothers. You should offer the hepatitis B vaccine to family members and close contacts of confirmed cases. Resources providing further guidance include:
UKHSA produced a video to encourage people who come from a country where hepatitis B is prevalent to ask their doctor about a hepatitis B test.
Hepatitis B video in Urdu
The prevalence of hepatitis C in Afghanistan is higher than in the UK. You should consider screening for hepatitis C if other risk factors apply (see the migrant health guide advice on hepatitis C for more information).
There is a high risk of typhoid infection in Afghanistan. You should consider enteric fever in the differential diagnosis of any illness following arrival into the UK. The severity of this disease is variable, although most people experience fever and headache. Young children may experience a mild illness.
Typhoid is a notifiable infection. You must notify your local health protection team of any cases.
Following recovery from typhoid, patients may continue to excrete Salmonella typhi (bacteria) in their faeces. You should clinically risk assess recovered carriers to see if they present a continuing public health risk and refer them to an infectious disease physician for clinical management, if appropriate. Chronic typhoid carriers, as diagnosed clinically, will need prolonged courses of antibiotics to clear the infection.
For more information, see the public health operational guidelines for typhoid.
Up to 20% of migrants from endemic countries may have helminth infections (from a parasitic worm) upon arrival. But many infections are asymptomatic.
You should consider the possibility of helminth infection in patients with unexplained symptoms (in particular, gastrointestinal symptoms) or eosinophilia (increased white blood cell count). You should consider requesting Strongyloides serology (to identify the presence of the Strongyloides stercoralis parasite) and refer to the helminths page in the migrant health guide for further guidance on testing.
A sexual history is an important part of any health assessment, but you should do this in a way that is mindful of the patient’s cultural and religious context.
You should offer testing for sexually transmitted infections (STIs) according to risk as outlined in guidelines from the British Association for Sexual Health and HIV. If the patient needs specialist STI services, refer them to your local genitourinary medicine (GUM) clinic.
You should discuss safe sex and contraception with both men and women. You can find further advice on female contraception in section 5.2 below.
You should screen all sexually active women aged under 25 for chlamydia, irrespective of symptoms.
There is a universal antenatal screening programme for HIV, syphilis and hepatitis B.
Boys and girls aged 12 to 13 years are routinely offered HPV vaccination in schools. You should assess patients for their eligibility for the HPV vaccine and ensure it is offered through the NHS HPV vaccination programme where appropriate.
Afghanistan has a low rate of HIV so you should only offer testing if the patient falls into a high risk group (including a positive parental diagnosis). Further information is available, such as the:
The burden of non-communicable diseases (NCDs) is rising in Afghanistan. You should assess all patients for existing non-communicable diseases, including:
For patients with existing diagnoses, discuss their current medication and treatment regime and ensure their conditions continue to be managed in the UK. Where children have diagnosed long-term conditions, as well as referring the child to a paediatrician, you should encourage their families to discuss any health concerns with a health visitor or school nurse.
You should also talk to the patient about tackling modifiable factors, such as:
Also, consider the role of ethnicity as a factor in increasing risk for particular NCDs.
All patients should be integrated into existing UK screening programmes.
See the children’s health section below for additional considerations for newborn screening (section 6).
You should be alert to any safeguarding concerns, including violence against women and girls, and female genital mutilation (FGM) (see section 9 on safeguarding).
You should alert women to the need for routine screening for particular issues, such as breast and cervical cancer. They may be reluctant to attend these without professional explanation and advice to do so. You can find more information on women’s health in the migrant health guide.
You should refer pregnant and postnatal women for specialist support from maternity services or health visiting postnatal care. Information about antenatal care in Afghanistan is often limited and women may not be aware of the importance of antenatal care and how antenatal services work in England.
You should explain antenatal services to women, refer them to useful women’s health resources (such as in the resources section of the women’s health guidance in the migrant health guide, and link them in with antenatal care and postnatal care where appropriate.
A crucial part of maternity care, outlined in the Better Births report of the National Maternity Review, is focused on the ‘continuity of carer’ principle. This principle establishes consistency in the midwife or clinical team that provides hands-on care for women during all 3 stages of maternity including pregnancy, labour and postnatal care. This allows for care coordination and the development of a relationship between a woman and the healthcare professionals responsible for her maternal care. You can find more information on the continuity of carer principle in guidance on implementing better births.
You should closely examine all newborns and children under one year of age, as recommended in the healthy child programme, as there are particular concerns for poor nutrition in this population group. All new mothers and infants should be integrated into routine UK screening programmes.
Ensure that women with young children are allocated a health visitor for postnatal care and that health visiting services are made aware of the family’s details. You should also encourage all new mothers to apply for vouchers as part of the Healthy Start scheme.
You should encourage all mothers to breastfeed and provide them with information on where to get further support. It may be difficult to breastfeed in their current place of residence and all accommodation and supportive settings for this population should be encouraged to be breastfeeding friendly.
You should remind pregnant women and new mothers that they are entitled to free dental care.
You should also discuss COVID-19, pertussis (whooping cough) and flu vaccination with pregnant women. Some women may be hesitant to have a vaccine during pregnancy, but you should reassure them that this is safe. The NHS website provides guidance on the whooping cough vaccination in pregnancy.
Best Beginnings has information and resources on improving maternity services for black and minority ethnic families.
The NHS website describes the range of antenatal appointments and the offers a new mother can expect.
Maternity Action provides information on rights and benefits for pregnant women and new mothers according to their immigration status.
You should discuss contraception with women of child-bearing age. Contraception use in Afghanistan is estimated to be low, at only 20%. So, it’s important to provide women with a space where they can confidentially discuss reproductive options.
You should ensure that health visiting services are made aware of the family’s details where there are children under the age of 5.
Important resources on children’s health include:
Children and young people may consent themselves for assessment and treatment if they are deemed to be ‘Gillick competent’ You should assess capacity and consent following NHS guidelines, which explain Gillick competence, parental responsibility and when consent can be overruled.
The language you use in assessing young people is important. You should make sure that all language is clear and accessible, that they understand the questions and rationale, and that they are kept involved in the process and any follow-on management.
You should seek specialist advice from the local paediatrician for looked after children.
Unaccompanied minors are children or young people who have migrated to the UK without a parent or guardian. They are a very vulnerable group and are at increased risk of exploitation, trauma, and poor mental and physical health. You should take extra care when reviewing the safety and mental health of these young people.
It is a statutory requirement for all unaccompanied minors who are looked-after children (this is likely to be all of them) to have an appropriate health assessment within 20 working days of entering the UK care system. This should continue annually until they are 18 years old.
If you are assessing an unaccompanied minor, ask if they have already had a health assessment recently. If so, review the results of this report to tailor your next assessment. You should refer unaccompanied minors to a looked-after children specialist.
Like other children and young people, unaccompanied minors can consent to their own treatment and assessment if they are deemed ‘Gillick competent’. But it is good practice to attempt to contact a guardian for a history and for follow-up management.
In the absence of an older family member, it is important to sensitively ask the child or young person about their family health to get a representative history. You should also be alert to their risk of exploitation and associated trauma both during and after their journey to the UK.
Further guidance is available through the Royal College of Paediatrics and Child Health’s guide for paediatricians working with unaccompanied minors.
Full examination of infants is strongly recommended. All newborns should undergo routine assessment, including a:
You should offer all sexually active women under 25 chlamydia screening.
You should read this section with section 1.3 on malnutrition. You must seek specialist support from a paediatrician and dietician if you think a child is malnourished due to risks of refeeding.
Almost half of all childhood deaths under the age of 5 worldwide are linked to malnutrition and children on the move are at greater risk of poor diet and undernutrition. Afghanistan has high rates of malnutrition, with 41% of children under 5 experiencing stunting (indicating chronic malnutrition) and extremely high rates (9.5% of children under 5) of wasting (indicating severe acute malnutrition). Estimates show that 9 in 10 Afghan infants are inadequately nourished.
In infants under the age of 6 months old, malnutrition may be due to feeding practices and it is important to support the nutrition and wellbeing of the mother. This includes adequate hydration as well as breastfeeding support. Malnutrition in infants under 6 months can be difficult to identify. Beyond generalised wasting and failure to thrive, look for bilateral pitting oedema (being mindful of other diagnoses) and take anthropometric measures including weight-for-length scores.
In children, consider changes to hair, nails and skin. Children may appear miserable and wasted (consider marasmus) and may have peripheral pitting oedema (consider kwashiorkor). You should also take anthropometric measures including weight-for-length or height scores and mid-upper arm circumference measurement.
A child with acute malnutrition is likely to also be lacking in other vitamins and micronutrients.
You should plot all children for height or length, weight and head circumference on appropriate charts.
You should refer children under 5 to a health visitor and encourage the family to register with a local children’s centre. You should refer children over 5 to a school nurse. Where children have a diagnosed long-term condition, you should encourage families to discuss any health concerns with a health visitor or school nurse. Therapeutic methods such as play therapy may be beneficial to the child and family.
If you identify new or existing speech and language difficulties, you should refer children to speech and language specialists as required.
You should encourage all patients to register with a dentist. The dental health of some patients may be poor due to a lack of access to previous dental care. Young people aged under 18, pregnant women and new mothers are entitled to free dental care.
It is recommended you screen for urgent dental concerns by asking patients if they have:
If a patient needs urgent dental care, they can access this by calling NHS 111. It may be helpful to first call NHS 111 on behalf of the patient and request a call-back to the patient directly in their language of choice.
It is also possible for NHS 111 to book free dental appointments on behalf of the patient, where required.
You should assess patients for any immediate physical injury or disability and provide care where appropriate. Consider walking aids for patients with mobility issues and refer them to a physiotherapist and wheelchair service as appropriate.
Patients may have physical injuries or disabilities from their experiences during the journey to the UK, from a long history of war or from torture. You should consider these experiences as a cause of physical injury, disability, musculoskeletal issues and any chronic pain. Patients may find this difficult to disclose without careful, appropriate, trauma-informed questioning (see section 8.2 below and section 3.1 of Afghan refugees and newly displaced populations: overview and principles).
Head lice has been reported as a common concern among new migrants. You can advise patients about appropriate over-the-counter treatment at pharmacies.
It is important to assess whether children have undergone vision and hearing screening, and they should be integrated into routine UK screening programmes as appropriate. You can find more information on the vision and hearing page in the migrant health guide.
You should assess all patients for existing mental health conditions. For patients with existing diagnoses, discuss their existing medication and treatment regime and ensure they continue to have their conditions well managed in the UK.
Migrants are at increased risk of poor mental health and wellbeing and trauma as a result of their experiences before and during their migration to the UK. This may show itself in different ways.
People affected by war and conflict are at higher risk of mental disorders, including post-traumatic stress disorder (PTSD). Where appropriate, refer patients to specialist services through the Improving Access to Psychological Therapies (IAPT) service or local voluntary sector service providers.
You must take a trauma-informed approach with refugees, especially when discussing mental health and traumatic experiences. You can find information on trauma-informed practice in the migrant health guide.
Supporting patients’ mental health includes helping them to:
There are also some non-NHS services working with refugees and people seeking asylum on their mental health, including the Refugee Council.
Specialist approaches to support the mental health of refugees include:
You should consider referring patients to a range of local, non-clinical services to support their health and wellbeing (social prescribing), such as voluntary, community and faith organisations. Further guidance is available, including in:
You can also access urgent mental health support through the NHS 24/7 crisis lines.
The individual health assessment is a unique opportunity to discuss the needs of the patient in a safe, inclusive space. You should be alert to any safeguarding concerns and vulnerabilities. You should review your local safeguarding vulnerable adults and safeguarding children policies.
Some groups may be at greater risk of vulnerability, including women, children, and people with learning disabilities. You should assess capacity and consent following the usual guidelines as identified by your local authority or clinical commissioning group (CCG). It’s possible that not all safeguarding concerns will be clear at the first meeting with new patients.
Be alert to a patient’s experience of FGM. FGM is illegal in the UK but practiced in some areas of Afghanistan. FGM is typically performed on girls under the age of 15 and tends to be identified during pregnancy or childbirth. It is mandatory for all health and social care professionals to report any cases of FGM in women aged over 18 to their local authority and report any cases of FGM in girls aged under 18 to the police. For more information on FGM, see the:
Modern slavery and human trafficking are defined by the Council of Europe Convention on Action against Trafficking in Human Beings (Article 4a) and include “the transportation, transfer, harbouring, or receipt of persons by means of the threat or use of force or other forms of coercion”.
The Helen Bamber Foundation has published information and guidance on modern slavery for primary care doctors.
The same considerations for safeguarding vulnerable adults generally apply to safeguarding children and young people. You should follow the same trauma-informed approach as with adult patients.
NSPCC has published information and guidance on protecting children from domestic abuse.
It is good practice to assess children and young people in the presence of a parent. But you should also offer them a private discussion to ensure they have a confidential space in which to disclose any concerns. You should offer this private discussion at every opportunity.
Safeguarding children is broader than protecting them from harm. It also includes promoting their welfare, health and development. It is important to ensure any assessment made is detailed enough to understand the needs of children.
Integration into UK society is an important factor in improving the health and wellbeing of new migrants. This is particularly important for children, for whom social interactions and play form a critical part of their happiness and development.
You should consider signposting patients and families to other local support services, including:
This good practice framework is based on feedback from primary care staff across London specifically in the context of supporting newly displaced Afghan refugees in bridging hotels.
To support refugees to access NHS services, you should provide:
You could also consider peer-led education sessions on how to access healthcare services in combination with sessions on how to access other services.
To support refugees to register with GP you should:
Identify refugees by name, date of birth and hotel name and room number. Many refugees have similar names and their dates of birth are not always recorded by day, month, year or by UK calendar. So, including their hotel room number on all documentation as their temporary address will help identify individual refugees who need healthcare services or follow-up.
Use secure GDPR-compliant information sharing systems so that clinicians working on site have access to information about refugees who need healthcare.
Ensure that healthcare assessments and associated documentation can be transferred when refugees register with GP or access other healthcare services.
Establish shared working between local authorities or CCG and clinicians on hotel sites to identify refugees with healthcare needs. This will involve:
You should provide information for clinicians and local authorities on when and how to access local site-specific health protection teams for advice, and when to request emergency support. This should include the contact number, email and out of hours number for the team.
You should consider printing hard copies of public health and clinical guidance on infectious diseases that require public health action and how to manage them. You can laminate this information and display it in clinical rooms. You can also make it available to hotel management and hotel staff where appropriate.
You should also distribute outbreak control plans for commonly encountered diseases, for example, scabies and chickenpox.
Review the equipment available on site to support infection prevention control. For example, wipeable chairs and examination couches, disposable gloves, aprons and PPE.
Consider providing over the counter medications (Calpol, paracetamol, and ibuprofen) for clinicians, to provide directly to residents in hotel sites.
Ensure that clinicians can access securely held patient lists to help with clinical documentation, clinical handover, clinical follow-up and clinical referral.
You should establish the need for:
Children registered with GP can start their personal child health record (the red book) and should catch up on childhood immunisation programmes (especially before joining school or nursery).
Many families living in bridging hotels are quite large and so, health assessment appointments can be long, which is tiring for both patients and healthcare professionals. It may be helpful to split a family’s healthcare assessment across multiple appointments.
It may be more efficient to register and assess people at the bridging hotel, as families may not be able to travel to appointments before they receive pre-paid credit cards, which can take some time.
There are a range of resources available to support Afghan refugees and other newly displaced populations, including:
Doctors of the World provide translated guidance and information on several topics including how to register with a GP, COVID-19, wellbeing, selfcare, keeping young people healthy, migrants’ rights, and the flu vaccine. This includes:
This resource has been developed through extensive collaboration with partners. The contributions of the following individuals are noted and thanked.
Talia Boshari, Public Health Specialty Registrar, Newham Public Health team
Dr Sylvia Garry, Consultant in Public Health, London Borough of Southwark, lead on children and young people, asylum seekers and health protection, and ADPH lead for asylum seekers and refugees
Sameera Hassan, Programme Manager, London Operations Team, Office for Health Improvement and Disparities
Khushbu Hussain, Project Manager, London Operations Team, Office for Health Improvement and Disparities
Ines Campos-Matos, Head of Inclusion Health, Addiction and Inclusion Directorate, Office for Health Improvement and Disparities
Dr Leonora Weil, Consultant in Public Health, London Operations Team, Office for Health Improvement and Disparities
Julie Billett, Director of Operations, London Operations Team, Office for Health Improvement and Disparities
Amelie Julien, Project Manager, London Operations Team, Office for Health Improvement and Disparities
Dr Maha Saeed, Consultant Health Protection, UK Health Security Agency
Dr Huda Yusuf, Consultant in Public Health, Clinical Lead for Child Healthy Weight, Homelessness, and Dental Health, Office for Health Improvement and Disparities
Nicky Brown, Regional Lead Nurse for Safeguarding and children and young people, Office for Health Improvement and Disparities
Rob Marr, Consultant in Public Health, Office for Health Improvement and Disparities
Sarah Hodel, Islington Integrated Care Partnership Programme Manager
Piers Simey, Assistant Director of Public Health, London Boroughs of Camden & Islington
Ella Johnson, Senior Policy and Advocacy Officer / Outreach Lead, Doctors of the World
Charlotte Klass, Consultant in Public Health and Primary Care, NHS England & Improvement (London)
Joel Standing, Head of EPRR Special Projects NHSEI
Dr Jane Hunt, Senior Medical Advisor, Helen Bamber Foundation
Dr Bhanu Williams, Consultant Paediatrician and Director of Medical Education, London North West Health University NHS Trust
Chris Lovitt, Deputy Director of Public Health, City of London and Hackney
Dr Nicole Klynman, Consultant in Public Health, London Borough of Hackney
Emma de Zoete, Consultant in Public Health, Greater London Authority
Elizabeth Dunsford, Senior Public Health Strategist, London boroughs of Kensington and Chelsea and the City of Westminster
Sarah Crouch, Deputy Director of Public Health, London boroughs of Kensington and Chelsea and the City of Westminster
Colleagues at RESPOND: Integrated Health Service for Refugee Families
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