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Refugee children: Health assessment and health care issues. Drs Georgie Paxton and Kirsten Walsh Immigrant Health Royal Children’s Hospital Melbourne. Outline. Refugee health screening and variability Common health issues Immunisation Vitamin D TB Hepatitis B Other medical problems

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refugee children health assessment and health care issues

Refugee children:Health assessment and health care issues

Drs Georgie Paxton and Kirsten Walsh

Immigrant Health

Royal Children’s Hospital Melbourne

outline
Outline
  • Refugee health screening and variability
  • Common health issues
    • Immunisation
    • Vitamin D
    • TB
    • Hepatitis B
    • Other medical problems
  • ESL acquisition
  • Systems issues and resources
it s a long way
It’s a long way…

Kakuma

1992, 25 sq km

80,000 people

country of origin 1996 2010
Country of origin 1996 - 2010

Source: DIAC settlement reporting facility, accessed 11 Oct 2010

australian migration intake
Australian migration intake
  • Humanitarian intake (per year) 13,500
    • Refugee visas (200, 201, 203, 204) 6,500
    • Special Humanitarian Program (202) 4,600
    • Onshore (ex-Asylum seekers) 2,400
    • UHM 250-350/year (Vic)
    • Permanent residents – ‘Australians of a refugee background’
  • Migration intake
    • 171,318 migration visas
      • 67% skilled, 33% Family
    • 101,280 Temporary Skilled
    • 356,251 Student visas
post arrival health screening
Post-arrival health screening
  • Varies
  • Models
    • Specialised refugee clinic model: most states
    • Primary care: Victoria, (SA)
    • Specialist: Hobart
  • Coverage of health screening
    • Complete: NT, Tasmania, ACT
    • High: WA
    • Other: Victoria, NSW unknown (50% national intake)

Large numbers of refugees do not get post-arrival screening

settlement support
Settlement support
  • Varies with visa
    • Refugee entrants case management 6 -12 m
    • SHP entrants sponsored
    • Onus on proposer to facilitate access to health, education, other orientation
    • 1 – 5 year period – Settlement Grants Program
  • People with other visa types may have a refugee-like background
refugee children what s different
Refugee children: what’s different?
  • Health problems are often complex, multiple and ongoing
  • Greater prevalence of communicable diseases
    • Mainly an issue for the individual’s long term health
    • May impact on carer/household contacts
  • Barriers to accessing appropriate health care
prevalence of health problems
Low vitamin D levels

Positive Mantoux test

Low vitamin A levels

Anaemia/Iron deficiency

Faecal Parasites

Schistosoma infection

Hepatitis B infection

Strongyloides infection

Malaria

3 in 4 (29-87%)

1 in 2 (3-63%)

1 in 3 (19-38%)

1 in 3 (10-35%)

1 in 3 (11-39%)

1 in 3 (2-38%)

1 in 10 (2-16%)

1 in 20 (1-8%)

1 in 100 (0.5-10%)

Based on a systematic review of Australian refugee clinic data 2008

Prevalence of Health Problems
refugee health assessment post arrival
Refugee health assessment (post-arrival)
  • Acute symptoms
  • Thorough medical history
  • Education
  • Psychological symptoms
  • Resettlement issues
  • Screening for infectious diseases, anaemia, iron deficiency, Vitamin A and D deficiency
    • Bloods, faecal specimen, Mantoux test, immunisations, medications
medical presentations
Medical presentations
  • Fever within 6 months of arrival
    • Probably usual causes BUT ?Malaria
  • Abdominal pain
    • May well be gastro or constipation BUT
      • bloating/diarrhoea/worms/blood ?parasites
      • Upper abdo pain, poor appetite, nausea ?Helicobacter pylori
  • Aches and pains
    • Actually this is nearly always low Vitamin D!
  • Malaise, fever, cough > 2 weeks
    • TB until proven otherwise
immunisation
Immunisation

No one will be up to date – multiple appointments needed

Funding issues: MCCV, VZV, HPV, (HBV)

slide15
TB

Mycobacterium tuberculosis complex

  • Approx 1/3 world infected (>2 billion people)
  • 9.4 million new cases/year
  • 85% Australian cases in overseas-born
  • Latent TB: infection, not active disease,
    • asymptomatic, not-infectious
  • Active TB (primary or reactivation disease): symptomatic
  • Children <12yo rarely infectious even if symptomatic

http://www.who.int/tb/publications/global_report/2009/

hepatitis b infection
Hepatitis B infection
  • Prevalence in refugee Australian cohorts: up to 16%
  • Children are usually asymptomatic
  • Risk of long term sequelae including hepatocellular carcinoma, cirrhosis
  • Screen, immunise if negative (follow up test of immunity if house contact)
  • General advice:
      • Avoid sharing toothbrushes, razors
      • Prompt cleaning of blood spills
      • Barrier contraception
      • Immunise household contacts and partners
      • Notify health care staff
      • Schools not notified
  • Hepatitis B also common in other communities, baseline 1.1%
          • Cowie B et al. Aust NZ J Publ Health 2010;34:72-8
learning education assessment
Learning/education assessment

Birthdate

Background development

Language transitions

Lack of service points/safety net

Family history

Trauma, separation, parent mental health, migration, parent occupation/education

Other factors

Medical Ante & perinatal, malnutrition, malaria, trauma, mental health

Hearing Less likely to have been addressed

Vision Less likely to have been addressed

Social Settlement, language

Education history & progress School quality, quantity, language, ESL support

Current function

Formal assessment

second language acquisition
Second language acquisition

Key variables affecting acquisition

  • Age
  • Cognitive development in first language
  • Schooling
    • Duration: amount of L1 schooling strongest predictor of academic achievement in L2
    • Continuity
    • Type
  • Late Primary school age with continuous schooling o’seas do best
    • 5 – 7 years to grade standard
  • Higher parent education associated with faster ESL acquisition
  • NB language transitions and past medical history
barriers to service use
Barriers to service use
  • Multiple
    • Language
    • Mobility
    • Service literacy/Provider awareness
    • Interpreter availability
    • Health literacy
    • Integration of health service programs (transfer information)
    • Need for multiple providers (and appointments)
    • And health only one part of settlement
resources
Resources

RCH Immigrant health – inc. education assessment guidelines http://www.rch.org.au/immigranthealth/index.cfm?doc_id=10575

VFST http://www.foundationhouse.org.au/home/index.htm

DEECD refugee student resources http://www.education.vic.gov.au/studentlearning/programs/esl/refugees/default.htm

Carer’s allowance http://www.centrelink.gov.au/internet/internet.nsf/forms/claim_forms_carerchild.htm#forms

FKA http://www.fka.com.au/

Kindergarten fee subsidy http://www.education.vic.gov.au/ecsmanagement/careankinder/funding/subsidy.htm

Victorian College Optometry http://www.vco.org.au/contact-us.htm

Audiology services in Victoria http://www.rch.org.au/genmed/clinical.cfm?doc_id=2840

resources1
Resources

Multilingual GPs western region http://www.pivotwest.org.au/index.php?action=view&view=19731&pid=2095

MRCs

Mental health http://www.rch.org.au/immigranthealth/resources.cfm?doc_id=13068

Carer’s Victoria http://www.respitenorthandwest.org.au/providers/view.chtml?filename_num=129582

Association for children with a disability http://www.acd.org.au/

Autism Victoria http://www.autismvictoria.org.au/home/

ADEC (Advocacy/disability/ethnicity/community) http://www.adec.org.au/

CMYhttp://www.cmy.net.au/WhatWeDo

Special access schemes http://www.vtac.edu.au/pdf/publications/seas.pdf

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