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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)


Refugee children health assessment and health care issues
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