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Refugee Health

Last updated 1 Jun 2026 · General Practice / Public Health

📋 Key Information Summary

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  • Australia resettles approximately 13,000–20,000 refugees annually under the Humanitarian Programme, with arrivals from Myanmar, Afghanistan, Iraq, Syria, and various African nations predominating.
  • Refugees have often endured torture, prolonged detention, sexual violence, forced displacement, and loss of family — these experiences profoundly shape clinical encounters and must be approached with trauma-informed care.
  • Perform a comprehensive initial health assessment within the first few months of arrival using the Australasian Society for Infectious Diseases (ASID) post-arrival screening guidelines.
  • Mandatory screening includes: hepatitis B (HBsAg, anti-HBs, anti-HBc), hepatitis C, HIV, tuberculosis (IGRA or TST), schistosomiasis serology, strongyloides serology, faecal microscopy (ova, cysts, parasites), eosinophil count, malaria film, and sexually transmitted infections.
  • Chronic helminth infections — particularly Strongyloides stercoralis and Schistosoma species — are highly prevalent; eosinophilia in a refugee should be treated as eosinophilia of unknown origin until proven otherwise.
  • Hepatitis B carriage rates in refugees from endemic regions (sub-Saharan Africa, Southeast Asia, China) may exceed 8–10%, requiring serological screening, liver function assessment, and specialist referral where indicated.
  • Rates of latent tuberculosis infection (LTBI) are high (20–50% in many cohorts); active TB must be excluded with chest X-ray and IGRA/TST, and LTBI treatment offered where appropriate under state TB programme guidelines.
  • STI screening should include HIV, syphilis (serology), chlamydia, gonorrhoea, and hepatitis B/C — many refugees have experienced sexual violence, and STIs may be asymptomatic.
  • Mental health conditions including PTSD, major depression, and anxiety disorders affect 20–40% of refugee populations; use trauma-informed, culturally sensitive assessment tools and professional interpreter services.
  • Use professional interpreter services (TIS National 131 450 or on-site interpreters) for all clinical encounters where English proficiency is limited — never rely on children or family members as interpreters.
  • Vaccination catch-up is required for most refugee arrivals; follow the Australian National Immunisation Program Schedule and check for documented prior vaccination where possible.
  • Iron-deficiency anaemia, vitamin D deficiency, dental disease, and unmet reproductive health needs are highly prevalent and should be actively screened for.
  • Consider Medicare eligibility — refugees on humanitarian visas have full Medicare access; those on temporary protection visas or bridging visas may have restricted access and require state-funded health services.

Introduction & Australian Epidemiology

Australia's Humanitarian Programme provides permanent resettlement to refugees and humanitarian entrants from diverse regions including South and Southeast Asia, the Middle East, sub-Saharan Africa, and Eastern Europe. General practitioners are often the first point of medical contact for newly arrived refugees and play a critical role in identifying unmet health needs, initiating preventive care, and coordinating specialist referrals.

Refugees differ from other migrant populations in that their migration is typically involuntary, often preceded by exposure to armed conflict, persecution, torture, sexual violence, prolonged periods in refugee camps, and dangerous journeys. These pre-migration and migration-phase exposures produce a distinct pattern of health conditions that may not be seen in the broader Australian population or in voluntary migrants from the same countries of origin.

Key Australian Statistics

  • In 2022–23, Australia's Humanitarian Programme granted approximately 17,875 visas, with the largest source countries being Myanmar, Afghanistan, Iraq, Syria, and the Democratic Republic of Congo.
  • Over 40% of refugees settle in Greater Sydney and Greater Melbourne, with significant secondary settlement in regional centres (e.g., Shepparton, Toowoomba, Launceston).
  • A Victorian study found that 52% of newly arrived refugees had at least one blood-borne virus or chronic infection identified at initial screening; 18% had eosinophilia consistent with helminth infection.
  • A systematic review of refugee mental health in Australia reported pooled prevalence estimates of 34% for PTSD, 31% for depression, and 24% for anxiety — rates substantially higher than the general Australian population.
  • Refugee children and adolescents arrive with significant vaccination gaps; up to 40% require catch-up vaccination on arrival, particularly for measles, hepatitis B, diphtheria-tetanus-pertussis, and HPV.
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Clinical vigilance required: Refugees may not disclose symptoms of mental illness, chronic infection, or experiences of torture/sexual violence unless specifically asked in a safe, confidential, and culturally appropriate setting with professional interpreter support. Proactive screening is essential.

Traumatic Experiences of Refugees

The majority of refugees resettled in Australia have experienced multiple and often cumulative traumatic events. Understanding the nature and clinical sequelae of these experiences is fundamental to providing effective healthcare.

Types of Traumatic Exposure

Common
Displacement & Loss
Forced displacement, loss of home and possessions, separation from family, bereavement, loss of social status and professional identity, prolonged uncertainty in refugee camps.
Present in virtually all refugee cohorts
Frequent
Exposure to Violence
Witnessing or experiencing armed conflict, bombings, beatings, imprisonment, extortion, kidnapping, destruction of community infrastructure, and threats to life.
Reported in 50–80% of refugee populations
Significant minority
Torture & Sexual Violence
Systematic torture (physical and psychological), sexual assault, rape, forced nudity, prolonged solitary confinement, mock executions. Survivors of torture estimated at 5–35% depending on cohort and country of origin.
Requires specialist referral (e.g., STARTTS, Foundation House, Survivors of Torture & Trauma Assistance & Rehabilitation Service)

Clinical Impact of Trauma

Pre-migration trauma is strongly associated with post-traumatic stress disorder (PTSD), major depressive disorder, chronic pain syndromes, somatisation, and functional impairment. However, clinicians must recognise that trauma also affects:

  • Health-seeking behaviour: Fear of authority, institutional distrust, and previous experience of medical care as a site of punishment (e.g., detention settings) may lead to delayed presentation and poor engagement with preventive care.
  • Physical health: Chronic musculoskeletal pain, headaches, gastrointestinal symptoms, and unexplained somatic complaints are common and may be trauma-related rather than representing discrete organic pathology.
  • Reproductive health: Female genital mutilation/cutting (FGM/C) is practised in many source countries (Somalia, Eritrea, Ethiopia, parts of Iraq and Indonesia); survivors require sensitive assessment, awareness of complications (obstructed labour, recurrent UTIs, dyspareunia), and referral to specialist FGM/C services.
  • Parenting and child development: Parental PTSD and depression affect attachment, child behaviour, and developmental trajectories; refugee children may present with developmental delay, behavioural disturbance, or school difficulties.
  • Substance use: Some refugees may use alcohol or other substances to self-manage psychological distress, though prevalence varies significantly by cultural group.
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Do not routinely ask for detailed accounts of torture or trauma unless there is a specific clinical indication. Direct questioning about traumatic events without appropriate clinical context may re-traumatise the patient. Use open-ended, empathic enquiries such as "Have you experienced anything that still causes you distress?" and refer to specialist torture and trauma services when indicated.

Australian Torture & Trauma Services

  • Service for the Treatment and Rehabilitation of Torture and Trauma Survivors (STARTTS) — NSW
  • Victorian Foundation for Survivors of Torture (Foundation House) — Victoria
  • PROMISe (Programme for Survivors of Torture and Trauma) — Queensland
  • Survivors of Torture and Trauma Assistance & Rehabilitation Service (STTARS) — South Australia
  • Afghanistan, Africa, Middle East Assistance & Rehabilitation Service (AAMES) — various states
  • These services offer counselling, physiotherapy, group programmes, legal support, and clinical consultation — referral is encouraged for all patients with suspected torture history.

Infectious Diseases

Infectious disease screening is a cornerstone of the post-arrival refugee health assessment. Many infections are asymptomatic and may have been acquired in countries of origin, during transit, or in refugee camp settings where overcrowding and poor sanitation are prevalent.

Recommended Post-Arrival Screening Panel

The following investigations are recommended for all newly arrived refugees, based on the Australasian Society for Infectious Diseases (ASID) guidelines and Communicable Diseases Network Australia (CDNA) recommendations:

Essential Full blood count with differential (including eosinophil count) Eosinophilia (>0.5 × 10⁹/L) in a refugee mandates investigation for helminth infection — strongyloides, schistosomiasis, hookworm, and filariasis. MBS Item 65070.
Essential Hepatitis B serology (HBsAg, anti-HBs, anti-HBc) Identifies chronic HBV carriers (8–10% in some cohorts), those with prior exposure, and susceptibility. MBS Item 69316.
Essential HIV serology (4th-generation Ag/Ab) With pre-test counselling via interpreter. Informed consent required. MBS Item 69386.
Essential Syphilis serology (RPR/VDRL + TPHA/EIA) Screen for latent or previously untreated syphilis. MBS Item 69386.
Essential Hepatitis C antibody (with reflex RNA if positive) Particularly relevant for those from high-prevalence regions or with history of injections/medical procedures in resource-limited settings. MBS Item 69376.
Essential Tuberculosis screening — IGRA (QuantiFERON-TB Gold Plus) or tuberculin skin test (TST/Mantoux) Chest X-ray if IGRA positive, symptoms present, or clinical suspicion. Refer to state TB programme for all confirmed or suspected TB. MBS Item 69347 (IGRA).
Essential Strongyloides serology All refugees from endemic regions (Southeast Asia, sub-Saharan Africa, Pacific Islands, Latin America). Hyperinfection risk if immunosuppressed. MBS Item 69400.
Essential Schistosomiasis serology For those from sub-Saharan Africa, Middle East, Southeast Asia, or South America with freshwater exposure history. MBS Item 69400.
Available Faecal microscopy — ova, cysts, and parasites (OCP) Three specimens on alternate days recommended. Identifies Giardia, hookworm, Strongyloides larvae, Entamoeba, and other intestinal parasites. MBS Item 69312.
Available Malaria film / rapid diagnostic test For those arriving from malaria-endemic regions within the past 12 months, particularly sub-Saharan Africa and Papua New Guinea. MBS Item 69332.
Available Chlamydia and gonorrhoea nucleic acid amplification test (NAAT) First-void urine or self-collected swab. Offer to all sexually active refugees. MBS Item 69312.
Available Vitamin D (25-hydroxyvitamin D) Deficiency is highly prevalent, particularly in veiled women and those from equatorial regions now in southern Australian latitudes. MBS Item 66832.
Available Iron studies, ferritin, vitamin B12, folate Iron-deficiency anaemia is common, particularly in women of reproductive age and those with hookworm infection. MBS Item 66815.
Available Renal function (eGFR), liver function tests, glucose/HbA1c Baseline metabolic assessment; identifies undiagnosed diabetes and renal/hepatic disease. MBS Item 66515.

Helminth Infections

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Eosinophilia in a refugee = helminth infection until proven otherwise. Do not attribute eosinophilia to "atopy" or "idiopathic" causes without completing a full parasitological workup including strongyloides serology, schistosomiasis serology, faecal OCP ×3, and assessment of travel/residence history.

Key helminth infections encountered in Australian refugee health practice:

Infection Common Source Regions Key Features Treatment
Strongyloides stercoralis Southeast Asia, sub-Saharan Africa, Pacific Islands, Latin America Often asymptomatic; can persist for decades via autoinfection; risk of hyperinfection syndrome with immunosuppression (corticosteroids, HTLV-1 co-infection) Ivermectin 200 mcg/kg PO daily × 2 days
Schistosoma species (haematobium, mansoni, japonicum) Sub-Saharan Africa (haematobium, mansoni), Southeast Asia/China (japonicum) Chronic infection can cause hepatosplenomegaly, portal hypertension, haematuria (S. haematobium), and increased bladder cancer risk Praziquantel 40 mg/kg PO (single dose or split dose depending on species)
Hookworm (Ancylostoma, Necator) Tropical and subtropical regions globally Iron-deficiency anaemia, eosinophilia, abdominal discomfort Albendazole 400 mg PO single dose (repeat in 2 weeks if heavy burden)
Giardia lamblia Global — particularly camp settings Chronic diarrhoea, bloating, malabsorption, failure to thrive in children Metronidazole 400 mg PO TDS × 5–7 days, or tinidazole 2 g PO single dose
Entamoeba histolytica Tropical regions, particularly South Asia, Africa Amoebic dysentery, liver abscess; distinguish from non-pathogenic E. dispar Metronidazole 800 mg PO TDS × 5 days, then diloxanide furoate 500 mg PO TDS × 10 days (luminal agent)
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CRITICAL — Strongyloides and immunosuppression: Any refugee with positive strongyloides serology must be treated with ivermectin BEFORE commencing immunosuppressive therapy (including corticosteroids, biologics, or chemotherapy). Strongyloides hyperinfection syndrome has a mortality rate exceeding 70%. Document strongyloides status in the medical record and alert all treating specialists.

Sexually Transmitted Infections (STIs)

STI screening is an essential component of the refugee health assessment. Many refugees come from settings with limited access to sexual health education, contraception, and STI treatment. Additionally, sexual violence — both pre-migration and during transit — is a significant and often undisclosed exposure.

  • HIV: Prevalence varies by source region. Higher in sub-Saharan African cohorts (particularly those from countries with >5% population prevalence). All refugees should be offered HIV testing with informed consent and pre-/post-test counselling via interpreter.
  • Hepatitis B: Chronic carriage rates of 8–10% in Southeast Asian and sub-Saharan African refugees. Requires full serological workup (HBsAg, anti-HBs, anti-HBc) and liver function tests. Refer to hepatology/gastroenterology if HBsAg positive.
  • Syphilis: Screen all refugees with treponemal and non-treponemal serology. Treponemal-only positive results (TPHA+) with negative RPR may represent previously treated infection or late latent syphilis — seek specialist advice.
  • Chlamydia and gonorrhoea: NAAT on first-void urine (or self-collected swabs). Asymptomatic carriage is common. Treat empirically if testing is not immediately available or follow-up uncertain.
  • Female genital mutilation/cutting (FGM/C): Not an STI per se, but has significant sexual and reproductive health implications. FGM/C may complicate cervical screening, obstetric care, and cause chronic genitourinary symptoms. Refer to specialist FGM/C services (e.g., Royal Women's Hospital Melbourne, Westmead Hospital Sydney).

Key Medications for Infectious Disease Management

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Ivermectin
Stromectol® · Antiparasitic
Adult dose 200 mcg/kg PO daily × 2 days (strongyloides)
Paediatric dose 200 mcg/kg PO daily × 2 days (>15 kg body weight)
Route Oral, on empty stomach with water
Renal adjustment None required
PBS status ✔ PBS Authority Required
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Praziquantel
Biltricide® · Antiparasitic
Adult dose Schistosoma: 40 mg/kg PO (single dose or split into two doses 4–6 hours apart)
Paediatric dose 40 mg/kg PO (as above; ≥4 years)
Route Oral, taken with food
Renal adjustment None required; avoid in hepatic impairment (severe)
PBS status ⚠ Not PBS listed — Special Access Scheme (SAS) or import
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Albendazole
Eskazole® · Antihelminthic
Adult dose Hookworm/roundworm: 400 mg PO single dose; hydatid: 400 mg PO BD × 28 days
Paediatric dose ≥2 years: 400 mg PO single dose (hookworm/roundworm)
Route Oral, with fatty meal (increases absorption)
Renal adjustment None required
PBS status ⚠ Authority Required — hydatid disease
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Metronidazole
Flagyl® · Antiprotozoal / Antibiotic
Adult dose Giardia: 400 mg PO TDS × 5–7 days; Amoebiasis: 800 mg PO TDS × 5 days
Paediatric dose Giardia: 10 mg/kg PO TDS × 5–7 days; Amoebiasis: 12 mg/kg PO TDS × 5 days
Route Oral (IV for severe infection)
Renal adjustment Reduce dose by 50% if eGFR <10 mL/min
PBS status ✔ PBS General Benefit
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Tinidazole
Fasigyn® · Antiprotozoal
Adult dose Giardia: 2 g PO single dose
Paediatric dose >3 years: 50 mg/kg PO single dose (max 2 g)
Route Oral, with food
Renal adjustment None required
PBS status ✔ PBS General Benefit
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Diloxanide furoate
Furamide® · Luminal amoebicide
Adult dose 500 mg PO TDS × 10 days (following metronidazole for invasive amoebiasis)
Paediatric dose 20 mg/kg/day PO in 3 divided doses × 10 days
Route Oral
PBS status ⚠ Not PBS listed — Special Access Scheme or compounding pharmacy

Tuberculosis Screening & Management

Tuberculosis remains a significant health concern in refugee populations. Australian state and territory TB programmes coordinate screening and management:

  • All refugees should be screened for latent TB infection (LTBI) using IGRA (QuantiFERON-TB Gold Plus preferred) or tuberculin skin test (TST).
  • A chest X-ray is required for all with positive IGRA/TST, respiratory symptoms, or clinical suspicion of active TB.
  • Active TB must be managed in consultation with the state/territory TB programme — it is a notifiable condition in all Australian jurisdictions.
  • LTBI treatment (typically isoniazid 300 mg daily × 6 months, or isoniazid 900 mg + rifapentine weekly × 12 weeks [3HP regimen]) should be offered where indicated, particularly for those who may require future immunosuppression.
  • BCG vaccination status should be assessed; BCG is not routinely recommended for those with positive IGRA but may be considered for IGRA-negative children <5 years with ongoing TB exposure risk.

Vaccination Catch-Up

Most refugee arrivals require vaccination catch-up as per the Australian National Immunisation Program (NIP). Key considerations:

  • Check for any documented vaccination history, but treat incomplete or absent records as non-immune — serological testing may be useful for hepatitis B, measles, rubella, and varicella to avoid unnecessary doses.
  • Prior BCG vaccination (indicated by scar) does not contraindicate any NIP vaccines.
  • Hepatitis B vaccination should be offered to all non-immune refugees (NIP-funded if <20 years; funded under catch-up for refugees regardless of age in most states).
  • HPV vaccine (Gardasil 9) can be given from age 9 — catch-up funded under NIP to age 25.
  • Influenza and COVID-19 vaccines should be offered annually and as per current ATAGI recommendations.
  • MMR — two doses required if seronegative. Avoid in pregnancy.

Mental Health in Refugees

Mental health conditions are among the most prevalent and impactful health issues facing refugees in Australia. The intersection of pre-migration trauma, hazardous transit, prolonged uncertainty in refugee camps, and post-migration stressors (social isolation, unemployment, discrimination, visa insecurity, language barriers) creates a uniquely high burden of psychological distress.

Prevalence of Mental Health Conditions

Condition Estimated Prevalence in Refugees Australian General Population
Post-traumatic stress disorder (PTSD) 30–40% ~4–5%
Major depressive disorder 30–40% ~6–8%
Anxiety disorders 20–30% ~6–10%
Prolonged grief disorder 15–25% ~7–10% (bereaved)
Somatoform/somatic symptom disorder 15–30% ~5–7%
Psychotic disorders Increased risk (2–5× in some cohorts) ~0.5–1%

Post-Migration Stressors

Research consistently demonstrates that post-migration stressors are equally or more important than pre-migration trauma in determining long-term mental health outcomes. Key post-migration stressors include:

  • Visa uncertainty: Temporary protection visas, bridging visas, and prolonged processing times create chronic uncertainty that undermines recovery from trauma and engagement with rehabilitation.
  • Family separation: Ongoing separation from spouses, children, and elderly parents causes profound distress; family reunion processes may take years.
  • Unemployment and financial hardship: Professional credentials may not be recognised; refugees experience unemployment rates 2–4× higher than the Australian-born population.
  • Social isolation: Loss of community networks, cultural dislocation, language barriers, and (in some cases) discrimination contribute to loneliness and social withdrawal.
  • Racism and discrimination: Experiences of racism in housing, employment, education, and public settings negatively impact mental health and wellbeing.

Assessment Approach

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Mental health assessment in refugees should be conducted in a trauma-informed, culturally sensitive manner with a professional interpreter. The GP consultation is often the only safe space for disclosure.

Recommended screening and assessment tools:

  • Kessler-10 (K-10): A validated, brief psychological distress scale. Available in multiple languages. Scores ≥25 suggest severe psychological distress. Useful as a starting point but not diagnostic.
  • Refugee Health Screener-15 (RHS-15): Specifically designed and validated for refugee populations. Includes somatic, emotional, and PTSD symptom items. Available in multiple languages through the Victorian Foundation for Survivors of Torture.
  • PCL-5 (PTSD Checklist): 20-item self-report measure of PTSD symptoms. Score ≥31 suggests probable PTSD. Available in multiple languages.
  • PHQ-9: Validated depression screening tool. Score ≥10 suggests moderate depression. Available in multiple languages.
  • Cross-cultural assessment: Be aware that psychological distress may present predominantly through somatic symptoms (headaches, chest pain, abdominal pain, musculoskeletal pain) in many cultural groups. Do not dismiss somatic presentations as "just psychological" — investigate appropriately while also considering the trauma-related contribution.

Management of Mental Health Conditions

1
Establish Safety & Therapeutic Alliance
Prioritise safety, predictability, and trust. Explain confidentiality clearly. Ensure interpreter is present. Allow the patient to set the pace. Address immediate practical needs (housing, income, visa) before expecting engagement with psychological therapy.
2
Psychoeducation
Normalise the patient's distress as a response to abnormal circumstances. Explain the link between trauma, physical symptoms, and mental health in culturally appropriate language. Involve family where acceptable to the patient.
3
GP Mental Health Treatment Plan
Prepare a GP Mental Health Treatment Plan (MBS Item 2710/2712) to enable access to up to 10 Medicare-subsidised sessions per calendar year with a psychologist or allied mental health professional. Prioritise practitioners with cross-cultural and trauma expertise.
4
Referral to Specialist Services
Refer to STARTTS, Foundation House, or equivalent state torture/trauma service for trauma-focused therapy (e.g., Narrative Exposure Therapy, trauma-focused CBT). These services offer culturally appropriate counselling, group therapy, and specialist consultation.
5
Pharmacotherapy
SSRIs (sertraline, fluoxetine) are first-line for PTSD and comorbid depression. Start low, titrate slowly. Be aware of potential medication interactions with traditional/herbal medicines. Benzodiazepines should be avoided — high risk of dependence and potential for re-traumatisation through disinhibition. Prazosin may be considered for trauma-related nightmares (off-label).

Key Medications for Refugee Mental Health

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Sertraline
Zoloft® · SSRI — first-line for PTSD and depression
Adult dose Start 25–50 mg PO daily, titrate to 100–200 mg PO daily
Duration Minimum 12 months for PTSD; longer for recurrent depression
Renal adjustment None required
Hepatic adjustment Reduce dose in hepatic impairment
PBS status ✔ PBS General Benefit
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Fluoxetine
Prozac® · SSRI
Adult dose Start 20 mg PO daily (morning), max 60 mg daily
Paediatric dose ≥8 years: start 10 mg PO daily, max 20 mg daily (depression)
Renal adjustment None required
PBS status ✔ PBS General Benefit
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Prazosin
Minipress® · Alpha-1 blocker — off-label for PTSD nightmares
Adult dose Start 1 mg PO nocte, titrate by 1 mg every 1–2 weeks to 5–15 mg nocte
Key caution First-dose hypotension — take at bedtime; monitor lying/standing BP
PBS status ✔ PBS General Benefit (authority for PTSD — off-label use)
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Children and adolescents: Refugee children are at particular risk of developmental delay, behavioural disturbance, separation anxiety, and school difficulties. Engage paediatric and child mental health services early. The Child and Adolescent Mental Health Service (CAMHS) and specialist refugee paediatric services (e.g., Royal Children's Hospital Melbourne Refugee Health Clinic) can provide multidisciplinary assessment.

Communication Tips & Barriers to Access

Effective communication is fundamental to delivering quality healthcare to refugees. Language barriers, differing health beliefs, unfamiliarity with the Australian healthcare system, and cultural differences in doctor-patient relationships all create significant challenges. Addressing these barriers requires systematic approaches at the practice, clinician, and system level.

Language Services

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Never use family members (including children) as interpreters. Family interpreting leads to information distortion, loss of confidentiality (particularly regarding sensitive topics such as sexual health, mental health, and torture history), role reversal that is harmful to children, and potential for domestic violence if sensitive information is disclosed. Always use a professional interpreter.
  • Translating and Interpreting Service (TIS National): Phone 131 450. Available 24/7 in over 150 languages. Funded by the Australian Government — no cost to the practice for Medicare-eligible patients. Can be accessed on-demand or booked in advance.
  • On-site interpreters: Preferred for complex consultations (initial health assessments, mental health assessments, breaking bad news, consent discussions). Book through TIS National or state interpreter services (e.g., Victorian Interpreting and Translating Service — VITS; NSW Service for the Treatment and Rehabilitation of Torture and Trauma Survivors — STARTTS interpreter pool).
  • AUSLAN interpreters: Required for deaf refugees — book through Deaf Australia or relevant state service.
  • Video remote interpreting: Increasingly available and useful for rare languages. TIS National offers video interpreting for selected languages.
  • Written translations: Use professional translation services for patient information sheets and consent documents — do not rely on Google Translate or similar for clinical materials.

Effective Communication Strategies

1
Prepare Before the Consultation
Book the interpreter in advance for complex consultations. Allow double or triple the standard appointment time for initial refugee health assessments. Have relevant forms, screening questionnaires in the patient's language, and referral information ready.
2
Establish Rapport
Welcome the patient warmly. Introduce yourself and the interpreter. Explain the role of each person in the room. Ask the patient how they wish to be addressed. Be aware of gender preferences for clinicians and interpreters, particularly for reproductive health and sexual violence discussions.
3
Use Plain Language
Speak in short, clear sentences. Avoid medical jargon, idioms, and colloquialisms. Pause frequently to allow interpretation. Check understanding using teach-back methods ("Can you tell me in your own words what we've discussed?"). Use visual aids and diagrams where helpful.
4
Navigate Cultural Differences
Be aware that concepts of disease causation, mental health, gender roles, and the doctor-patient relationship vary across cultures. Some patients may prefer a more directive consultation style. Avoid assumptions about health literacy or beliefs. Explore the patient's explanatory model: "What do you think is causing your symptoms?"
5
Provide Written & Visual Aids
Use pictorial medication instructions (e.g., "take 1 tablet in the morning with food" with pictograms). Provide written information in the patient's language where available. Teach inhaler technique with demonstrator devices. Ensure referral letters and discharge summaries are sent to the patient's GP with clear follow-up plans.

Barriers to Healthcare Access

Medicare eligibility
Refugees on permanent humanitarian visas have full Medicare access. Those on Temporary Protection Visas (TPV), Safe Haven Enterprise Visas (SHEV), or bridging visas may have limited or no Medicare eligibility and must rely on state-funded health services, asylum seeker health services, or community health centres. Check visa status at each visit as it may change.
Transport and geography
Refugees often settle in outer suburban areas with limited public transport. Regional resettlement further compounds access issues. Many refugees cannot drive and rely on public transport, community transport services, or family/friends. Telehealth (phone or video) can supplement face-to-face care for follow-up consultations.
Health literacy
Many refugees have limited formal education or literacy in their own language. Written health information, appointment systems, and navigating the Australian healthcare system (booking appointments, obtaining referrals, understanding PBS co-payments) are significant challenges. Practice staff should proactively explain how the system works.
Financial hardship
PBS co-payments, allied health fees, dental care costs, and gap payments may be prohibitive. Use PBS bulk-billing where possible. Refer to community health centres for free/low-cost dental, allied health, and mental health services. Ensure patients are aware of their rights under the Australian Charter of Healthcare Rights.
Fear and mistrust
Refugees from authoritarian regimes may fear government institutions, including healthcare systems. Those on temporary visas may fear that seeking healthcare will affect their visa application. Confidentiality must be explicitly addressed. Some patients may be reluctant to disclose symptoms of mental illness due to stigma. Trust takes time to build — consistent, reliable, non-judgemental care is essential.
Childcare and competing priorities
Refugee families may have multiple young children, no childcare options, and significant competing priorities (housing, employment, legal appointments, school enrolment). Offer flexible scheduling, combined family appointments where appropriate, and co-locate services where possible.

Useful Australian Refugee Health Resources

  • Refugee Health Network Australia (RHNA): Coordinates refugee health policy and practice nationally. Provides clinical guidelines, resources, and links to state-based services.
  • Migrant Health Nurse / Refugee Health Nurse: Many Primary Health Networks (PHNs) and Local Health Districts fund specialist refugee health nurses who can coordinate care, conduct initial assessments, and link patients with GPs and specialist services.
  • Refugee Health Clinics: Major refugee health clinics exist in most capital cities (e.g., Monash Refugee Health Clinic, Royal Children's Hospital Refugee Clinic, Westmead Refugee Health Service, Mater Refugee Health Service Brisbane).
  • MYAN (Multicultural Youth Advocacy Network): Supports young refugees and asylum seekers with health, education, and settlement.
  • Settlement Services International (SSI): Provides settlement support including health navigation.

Special Populations

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Children & Adolescents

Developmental screening
All refugee children <5 years should receive developmental screening (e.g., ASQ-3, PEDS). Premigration malnutrition, deprivation in camp settings, and parental mental illness all contribute to developmental delay. Refer to early childhood intervention services where indicated.
Vaccination catch-up
Prioritise catch-up vaccination for all refugee children per NIP schedule. Serological testing for hepatitis B, measles, rubella, and varicella can guide catch-up. BCG scar does not contraindicate any vaccine.
Nutritional assessment
Measure height, weight, and BMI. Screen for iron-deficiency anaemia, vitamin D deficiency, and micronutrient deficiencies. Growth faltering is common and may require paediatric dietitian involvement.
School readiness and learning
Language delay, interrupted schooling, and trauma-related concentration difficulties affect educational outcomes. Early intervention and liaison with school support services is essential.
Hearing and vision
Undiagnosed hearing loss (from chronic otitis media, camp settings) and visual impairment are common. Screen and refer for audiology and ophthalmology assessment.
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Pregnant Women

Antenatal screening
All routine antenatal screening plus: hepatitis B serology, HIV, syphilis, strongyloides serology (if from endemic region), malaria film (if recent arrival from endemic region), FGM/C assessment, vitamin D, iron studies, and rubella immunity. MBS Items 16500+ apply to antenatal shared care.
FGM/C considerations
Assess type and extent of FGM/C at first antenatal visit. Refer to specialist FGM/C service. De-infibulation may be required prior to delivery. Plan delivery at a centre experienced in managing FGM/C complications.
Mental health in pregnancy
Perinatal mental health screening (Edinburgh Postnatal Depression Scale) should be conducted, ideally with interpreter support. Untreated PTSD and depression in pregnancy adversely affect both maternal and neonatal outcomes. Refer to perinatal mental health services where indicated.
Thalassaemia and haemoglobinopathies
Offer thalassaemia screening for all refugees from Mediterranean, Middle Eastern, South Asian, and Southeast Asian backgrounds. Refer to haematology if carrier status identified (implications for partner screening and prenatal diagnosis).
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Elderly Refugees

Isolation and dependency
Elderly refugees are at high risk of social isolation, particularly if they are non-English speaking and dependent on adult children for transport and interpretation. They may have limited understanding of the Australian healthcare system and rely entirely on family members for health decisions.
Chronic disease burden
Undiagnosed hypertension, diabetes, cardiovascular disease, and chronic kidney disease are common. Screen proactively. Ensure chronic disease management plans (MBS Item 721) are in place.
Cognitive decline
Dementia may be difficult to assess across language and cultural barriers. Use culturally appropriate cognitive screening tools where available. Refer to geriatrician and Dementia Australia for support services in the patient's language.
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Patients with Renal Impairment

Drug dose adjustments
Many antiparasitic agents, antibiotics, and psychiatric medications require renal dose adjustment. Calculate eGFR using CKD-EPI equation. Be aware that some refugees may have undiagnosed CKD from uncontrolled hypertension or diabetes in countries of origin.
Strongyloides hyperinfection risk
Renal transplant recipients who are strongyloides seropositive must be treated pre-transplant. Hyperinfection in immunosuppressed patients is a medical emergency.
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Patients with Hepatic Impairment

Hepatitis B management
Refugees with chronic hepatitis B require liver function tests, HBV DNA quantification, and assessment for fibrosis (FibroScan or serum markers). Refer to hepatology/gastroenterology for antiviral treatment decisions. All household contacts should be screened and vaccinated if non-immune.
Hepatitis C treatment
Direct-acting antivirals (DAAs) are PBS-listed for all patients with confirmed HCV infection. Refer to GP prescriber or hepatologist. Treatment is curative in >95% of cases. MBS Item 12206 applies.
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Immunocompromised Patients

Pre-immunosuppression screening
Before commencing any immunosuppressive therapy (corticosteroids, biologics, chemotherapy), screen all refugee patients for: strongyloides serology, hepatitis B (HBsAg, anti-HBc), HIV, tuberculosis (IGRA), and schistosomiasis serology. Treat latent infections before immunosuppression.
Live vaccines
BCG, MMR, varicella, and yellow fever vaccines are contraindicated in immunocompromised patients. Ensure vaccination catch-up is completed before starting immunosuppression where possible.
HTLV-1 screening
Consider HTLV-1 screening in refugees from endemic regions (Japan, sub-Saharan Africa, Central/South America, Caribbean, Pacific Islands) — co-infection with strongyloides dramatically increases hyperinfection risk.

Aboriginal and Torres Strait Islander Health Considerations

Aboriginal and Torres Strait Islander Health
Shared determinants of health inequity
Aboriginal and Torres Strait Islander peoples and refugees share many social determinants of poor health: socioeconomic disadvantage, intergenerational trauma, racism, housing instability, limited access to culturally safe healthcare, and marginalisation from mainstream services. GPs working with refugee populations should recognise that many of the same principles of culturally safe, trauma-informed care apply to Aboriginal and Torres Strait Islander patients.
Intersectionality
A small but significant number of refugees may identify as or be married into Aboriginal and Torres Strait Islander communities. These individuals may face compounded disadvantage from both refugee and Indigenous health inequities. Culturally safe care requires understanding of both cultural contexts and avoidance of assuming homogeneity in health beliefs or practices.
Lessons from Indigenous health for refugee healthcare
Aboriginal Community Controlled Health Organisations (ACCHOs) provide a model of culturally safe, holistic primary care that centres community governance and self-determination. Principles from ACCHO models — including yarning-based consultations, family-inclusive care, connection to country, and social and emotional wellbeing frameworks — can inform culturally safe practice with refugee patients.
Remote and regional communities
Some refugees settle in regional and remote areas where Aboriginal and Torres Strait Islander health services may be the primary or sole healthcare provider. In these settings, collaborative models of care that integrate refugee health screening into existing Indigenous health service structures may be the most effective approach.
Infectious disease overlap
Both Aboriginal and Torres Strait Islander peoples and refugees experience disproportionately high rates of rheumatic heart disease, chronic suppurative lung disease, hepatitis B, skin infections, and sexually transmitted infections. Coordinated public health responses and screening programmes should consider both populations in high-prevalence settings.
Mental health and trauma
Intergenerational trauma from colonisation, the Stolen Generations, and ongoing systemic racism significantly impacts Aboriginal and Torres Strait Islander mental health. Both populations benefit from trauma-informed care that acknowledges historical and ongoing harms. Social and emotional wellbeing models — which encompass connection to land, culture, spirituality, ancestry, community, and family — should be integrated into mental health care for both groups.

📚 References

  1. 1. Australasian Society for Infectious Diseases (ASID). Recommendations for Post-Arrival Health Assessment of Newly Arrived Refugees and Other Migrants to Australia. Sydney: ASID; 2016.
  2. 2. Department of Home Affairs, Australian Government. Australia's Humanitarian Programme 2023–24. Canberra: Commonwealth of Australia; 2024.
  3. 3. Australian Institute of Health and Welfare (AIHW). Refugee and Migrant Health. AIHW; 2023. Available at: www.aihw.gov.au.
  4. 4. Fazel M, Wheeler J, Danesh J. Prevalence of serious mental disorder in 7000 refugees resettled in western countries: a systematic review. Lancet. 2005;365(9467):1309–1314.
  5. 5. Steel Z, Chey T, Silove D, Marnane C, Bryant RA, van Ommeren M. Association of torture and other potentially traumatic events with mental health outcomes among populations exposed to mass conflict and displacement: a systematic review and meta-analysis. JAMA. 2009;302(5):537–549.
  6. 6. Silove D, Ventevogel P, Rees S. The contemporary refugee crisis: an overview of mental health challenges. World Psychiatry. 2017;16(2):130–139.
  7. 7. Paxton GA, Smith MM, Kay ML, et al. The Australasian Society for Infectious Diseases Guidelines for Health Assessment for Refugees. Sydney: ASID; 2016.
  8. 8. Communicable Diseases Network Australia (CDNA). Australian National Notifiable Diseases Surveillance System — Guidelines for Refugee Health Screening. Canberra: CDNA; 2023.
  9. 9. Benson J, Phillips C, Kay M, et al. Low vitamin B12 levels among newly arrived refugees from Bhutan, Iran and Afghanistan: a multicentre Australian study. PLoS One. 2013;8(2):e57145.
  10. 10. RACGP. Management of Type 2 Diabetes: A Handbook for General Practice. Melbourne: RACGP; 2020. (Note: diabetes management principles applied to refugee context.)
  11. 11. Victorian Foundation for Survivors of Torture (Foundation House). Guidelines for Working with Interpreters in Mental Health Settings. Melbourne: Foundation House; 2019.
  12. 12. National Health and Medical Research Council (NHMRC). Australian Immunisation Handbook. Australian Government Department of Health; 2022. Available at: immunisationhandbook.health.gov.au.
  13. 13. Correa-Velez I, Gifford SM, Barnett AG. Longing to belong: social inclusion and wellbeing among youth with refugee backgrounds in the first three years in Melbourne, Australia. Soc Sci Med. 2010;71(8):1399–1408.
  14. 14. Murray K, Davidson G, Schweitzer R. Review of refugee mental health interventions following resettlement: best practices and recommendations. American Psychologist. 2010;65(8):577–589.
  15. 15. Horyniak D, Melo JS, Farrell RM, Ojeda VD, Strathdee SA. Epidemiology of substance use among forced migrants: a global systematic review. PLoS One. 2016;11(7):e0159134.
for PBS scripts. Utilise ACCHS pharmacies and Remote Area Aboriginal Health Worker programs for medication supply in remote areas. Avoid initiating benzodiazepines; support holistic pain management including community-based exercise programs.
Preventive health
Promote bone health: encourage vitamin D supplementation (1000 IU daily in deficient individuals), smoking cessation support, reduction of alcohol intake, and weight-bearing exercise. MBS Item 715 health checks provide a structured opportunity to assess bone health, screen for osteoporosis risk factors, and discuss musculoskeletal health in a culturally safe context.

Quick Reference: Differential Diagnosis at a Glance

Costovertebral dysfunction
Paracetamol ± NSAID; manual therapy
2–6 weeks
Provocable on palpation; no red flags
Thoracic compression fracture
Paracetamol; ± calcitonin; DXA + osteoporosis Rx
6–12 weeks healing
Elderly; osteoporosis; acute onset
ACS (posterior MI)
Aspirin 300 mg, GTN, heparin; urgent PCI
Time-critical
ECG, troponin; CV risk factors
Aortic dissection
IV labetalol; urgent CT aortogram; surgery (Type A)
Time-critical
Tearing pain; BP differential >20 mmHg
Vertebral osteomyelitis
IV antibiotics (vancomycin + ceftriaxone initially); ID consult
6 weeks IV antibiotics
Fever, elevated CRP, IV drug use
Biliary colic / cholecystitis
Paracetamol ± morphine; lap cholecystectomy
Surgical within 72 h (cholecystitis)
RUQ/infrascapular; post-prandial; RUQ US

📚 References

  1. 1. Briggs AM, Smith AJ, Straker LM, Bragge P. Thoracic spine pain in the general population: prevalence, incidence and associated factors in children, adolescents and adults. A systematic review. BMC Musculoskelet Disord. 2009;10:77.
  2. 2. National Health and Medical Research Council (NHMRC). Evidence-based management of acute musculoskeletal pain. Canberra: NHMRC; 2003 (updated 2020).
  3. 3. Australian Institute of Health and Welfare (AIHW). Aboriginal and Torres Strait Islander Health Performance Framework: Summary report 2023. Canberra: AIHW; 2023.
  4. 4. Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about low back pain? JAMA. 1992;268(6):760–765.
  5. 5. Stochkendahl MJ, Kjaer P, Hartvigsen J, et al. National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. Europ Spine J. 2018;27(1):60–75.
  6. 6. Erwin WM, Jackson PC, Homonko DA. Innervation of the human costovertebral joint: implications for clinical back pain syndromes. J Manipulative Physiol Ther. 2000;23(6):395–403.
  7. 7. Royal Australian College of General Practitioners (RACGP). Guidelines for preventive activities in general practice. 9th edn. Melbourne: RACGP; 2018 (updated 2023).
  8. 8. Hirsch JA, Singh V, Falco FJE, et al. Thoracic facet joint interventions. Pain Physician. 2016;19(4):E581–E593.
  9. 9. Erwin WM, Jackson PC. The costovertebral joint: anatomy, biomechanics, and clinical significance in thoracic back pain syndromes. J Can Chiropr Assoc. 2003;47(2):112–120.
  10. 10. Strayer RJ, Gunnerson JM, Brown LH, et al. Aortic dissection: clinical features, diagnosis, and management. Aust Crit Care. 2019;32(2):144–153.
  11. 11. Ombregt L. A system of orthopaedic medicine. 3rd edn. Edinburgh: Churchill Livingstone Elsevier; 2013. Chapter 18: Thoracic spine.
  12. 12. Lin CC, Chen KH, Li DM, et al. Characteristics and outcomes of patients presenting with thoracic back pain to the emergency department. Emerg Med Australas. 2020;32(5):805–811.
for PBS-listed medicines at participating pharmacies.
Cultural safety
Engagement with Aboriginal Community Controlled Health Organisations (ACCHOs) is essential. Cultural safety training for non-Indigenous clinicians, use of Aboriginal Health Workers and Liaison Officers, and incorporation of traditional healing practices alongside Western medicine improve treatment adherence and outcomes. Avoidance of eye contact, respect for gender-sensitive examination practices, and understanding of sorry business protocols are critical elements of culturally safe care.
Medication adherence
Complex DMARD regimens with frequent monitoring requirements present adherence challenges. Long-acting depot injections (e.g., methotrexate SC) may improve adherence compared to oral regimens. Community pharmacy partnerships through the Indigenous Pharmacy Programmes improve medication management.
Specific conditions
Rheumatic heart disease (RHD) requires secondary prophylaxis with benzathine penicillin G (BPG) 1.2 MU IM every 3–4 weeks for a minimum of 10 years or until age 21 (whichever is longer). RHD registers (e.g., NT RHD Register) facilitate recall and follow-up. The Australian RHD Endgame Strategy targets elimination by 2031.
Referral pathways
Referral through ACCHOs and Aboriginal Hospital Liaison Officers (AHLOs) improves engagement. The Specialist Outreach Assistance Programme provides funded specialist visits to remote communities. NT, WA, and QLD have specific rheumatology outreach programmes targeting Indigenous communities.

📚 References

  1. 1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
  2. 2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
  3. 3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
  4. 4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
  5. 5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
  6. 6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
  7. 7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
  8. 8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
  9. 9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
  10. 10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
  11. 11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
  12. 12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
  13. 13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).
for PBS-listed medicines at participating pharmacies.
Cultural safety
Engagement with Aboriginal Community Controlled Health Organisations (ACCHOs) is essential. Cultural safety training for non-Indigenous clinicians, use of Aboriginal Health Workers and Liaison Officers, and incorporation of traditional healing practices alongside Western medicine improve treatment adherence and outcomes. Avoidance of eye contact, respect for gender-sensitive examination practices, and understanding of sorry business protocols are critical elements of culturally safe care.
Medication adherence
Complex DMARD regimens with frequent monitoring requirements present adherence challenges. Long-acting depot injections (e.g., methotrexate SC) may improve adherence compared to oral regimens. Community pharmacy partnerships through the Indigenous Pharmacy Programmes improve medication management.
Specific conditions
Rheumatic heart disease (RHD) requires secondary prophylaxis with benzathine penicillin G (BPG) 1.2 MU IM every 3–4 weeks for a minimum of 10 years or until age 21 (whichever is longer). RHD registers (e.g., NT RHD Register) facilitate recall and follow-up. The Australian RHD Endgame Strategy targets elimination by 2031.
Referral pathways
Referral through ACCHOs and Aboriginal Hospital Liaison Officers (AHLOs) improves engagement. The Specialist Outreach Assistance Programme provides funded specialist visits to remote communities. NT, WA, and QLD have specific rheumatology outreach programmes targeting Indigenous communities.

📚 References

  1. 1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
  2. 2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
  3. 3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
  4. 4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
  5. 5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
  6. 6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
  7. 7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
  8. 8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
  9. 9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
  10. 10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
  11. 11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
  12. 12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
  13. 13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).