Syrian refugees Clinical and policy update Refugee Health Fellow Program May 2017 – do not use after April 2018

Up to date 2/3/17 Syria’s pre-conflict population was 22.8 million (World Bank 2013). The main languages spoken are: Arabic, including the Levantine Arabic dialect, Kurdish, Armenian, and Turkmen. People from Aleppo and Damascus may also speak English and European languages.  At least 320,000 people have died or been killed More than 7.6 million people are internally displaced  Approximately 4.6 million people have left Syria and are registered as refugees (UNHCR) 52% (2.4 million) of the refugees are children < 18 years old,  over one-third of those children are <= 5 years old (39.2% <11yo) There are more than 8000 unaccompanied minors and more than 37,000 Syrian babies born as refugees (see UNHCR and UNICEF). The greatest numbers of Syrian refugees are located in neighbouring countries (October 2015, UNHCR) Turkey  - 2.5 million Lebanon - 1.07 million Jordan – 635,000 Iraq – 245,000 318,000 Syrians newly registered as refugees with UNHCR in 1st half 2015 Asylum applications 1st half 2015 – massive jumps due to Syrian conflict, Ukraine, Latin Americ inot US Germany received highest number 159,900 (173,100 for whole 2014, 32,500 from Syrians) Syrians main group 114,500 applications during 1st half 2015 http://data.unhcr.org/syrianrefugees/regional.php

http://www.abc.net.au/news/2015-03-13/magnitude-of-syrian-conflict-will-impact-world/6311090

http://static. businessinsider http://static.businessinsider.com/image/55f2f958bd86ef1c008b9ab9/image.jpg

http://www.unhcr.org/pages/49c3646c25d/gallery-503f73856.html

http://www.nytimes.com/2015/09/02/world/europe/keleti-train-station-budapest-migrant-crisis.html

http://www. telegraph. co http://www.telegraph.co.uk/news/worldnews/europe/germany/11861966/Germany-to-reinstate-border-controls-as-country-struggles-with-influx-of-refugees-live.html

Zaatari refugee camp – 8 km from Jordan-Syria border Photo taken 2013 – 150,000 people at the time http://edition.cnn.com/2014/03/14/sport/football/zaatari-refugee-camp/

http://ngm. nationalgeographic http://ngm.nationalgeographic.com/2015/03/syrian-refugees/stanmeyer-photography#/16-rain-over-refugee-camp-670.jpg

Syrian health systems 64% public hospitals out of service 60-70% reduction pharmaceutical production >50% doctors have left (>70% in parts) Immunisation 95% 2010 -> 41% in 2015 FASSTT organisations – mental health poor Partly updated 12/5/17 – can’t find recent data for pharmaceutical production or doctors left References: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4231133/ http://www.who.int/immunization/monitoring_surveillance/data/syr.pdf http://www.who.int/hac/crises/syr/sitreps/en/

Up to date 12/5/17

Polio Confirmed up to date 12/05/2017

Chemical weapons & Attacks on hospitals 12/5/17 http://www.who.int/mediacentre/news/statements/2017/toxic-chemicals-syria/en/

Jan –Jun 2014 – 69,000 people screened (11%) total – 45% 0-14 years – 33 culture confirmed – only 3 smear positive (3/69,000)

Up to date 12/5/17 Data from 2016 Census available from June 2017 http://blog.id.com.au/2015/population/australian-demographic-trends/the-syrian-community-in-australia/

Syrian arrivals 2011-2015

REFUGEE APPLICANT OFFSHORE ONSHORE HUMANITARIAN ENTRANT ASYLUM SEEKER ORPHAN RELATIVE ONSHORE 837 OFFSHORE 117 ONSHORE There are two main pathways refugees come to Australia Onshore and offshore linked since 1996 Convention obligations for onshore group (offshore separate) Fleeing persecution is not a crime. In fact, seeking asylum is a human right. It is not illegal to seek asylum without a visa. Around 80-90 percent of asylum seekers who come to Australia by boat are found to be refugees An Orphan Relative visa (subclass 117) is for a child whose parents are dead, permanently incapacitated or of unknown whereabouts. It allows a child in this situation to travel to and stay permanently with their sponsoring relative in Australia. The sponsoring relative usually applies on behalf of the child. The child must be outside Australia when the application is lodged and when the application is decided. These children are not eligible for casework because they’ve not come on a humanitarian visa. Comments: Next revision due: Reference: HUMANITARIAN ENTRANT ASYLUM SEEKER AIR ARRIVALS* ‘ILLEGAL’/UNAUTHORISED/IRREGULAR MARITIME ARRIVALS

ORPHAN RELATIVE ONSHORE 837 REFUGEE APPLICANT OFFSHORE ORPHAN RELATIVE ONSHORE 837 OFFSHORE 117 ONSHORE HUMANITARIAN ENTRANT ASYLUM SEEKER 1) IME (MANDATED) 2) DHC (VOLUNTARY) 3) POST-ARRIVAL (VOL) 1) IME OFFSHORE 2) POST-ARRIVAL -NO PROCESS 1) DETENTION HEALTH 2) POST-RELEASE (VOL) 3) IME AT VISA GRANT

Pre-departure health screen (offshore) Immigration Medical Exam - all (Compulsory, 3–12 m prior to travel) Hx/Exam TB screen 2-10y CXR ≥ 11y HIV ≥ 15y FWTU ≥ 5 yrs HBsAg (preg/URM/HCW) HCV (HCW) Syphilis (Humanitarian) ly) DHC - Humanitarian (Voluntary – 3 d prior to travel) Exam, parasite check Malaria RDT and Rx if positive (location) CXR and HIV if PHx TB Albendazole ≥ 1 y MMR 9m – 54y +/- YF vaccine +/- Polio vaccine Ax local conditions +/- Repeat IME Syrian cohorts Combined IME and DHC Hx/Exam TB screen 2-10 y CXR ≥ 11 y HIV ≥ 15 y HBsAg FWTU ≥ 5 y Albendazole Full 1st dose catch-up immunisations Mental health screen Development screen (<5 y) Character requirement AUSCO 12/5/17 New screening procedure implemented for Syrian arrivals, which combines the previous Immigration Medical Exam (IME) and Departure Health Check (DHC). (see next slide) Note that kids get very little screening. YF details - All people > 1 yr old who have stayed 1 night+ in YF country within 6 days of flight to australia need YF certificate Polio All people departing from Pakistan, Cameroon and Syria will need to have a full course of polio vaccinations certified before they can leave the country.   Refugee and humanitarian applicants will have one dose of OPV at the departure health check (and any new applicants referred for initial visa medical examination will also have a dose of OPV) in ten identified countries - Afghanistan, Cameroon, Equatorial Guinea, Ethiopia, Iraq, Israel, Kenya, Nigeria, Pakistan, Somalia and Syria. This will be documented by IOM on the health manifest, so it is clear to all health providers that this has occurred. (May 2014)
 The Australian Cultural Orientation (AUSCO) program is provided to refugee and humanitarian visa holders over the age of five who are preparing to settle in Australia. The program provides practical advice and the opportunity to ask questions about travel to and life in Australia. It is delivered over five days before the visa holders begin their journey to ensure that all topics are covered in sufficient detail. Outcomes +/- Visa Alert (Red. General) Health Undertaking +/- delay travel Outcomes Fitness to fly assessment Alert (Red, General) +/- Health Undertaking Australia Post arrival health screening Voluntary

Key points Major changes – asylum and offshore space Changes – offshore and onshore screening Access to health care varies depending on pathway Vic policy - equity Do not assume screening or follow-up Large numbers of new arrivals Combination of SHEVs and Syrian cohorts Refugee health = regional issue Complex physical and mental health issues Uncertainty and trauma = key drivers Child health = key