Date: 18 th October 2010 Department of General Medicine – Immigrant Health Presenters: Kirsten Walsh and Georgie Paxton Refugee children: Health assessment and health care issues Drs Georgie Paxton and Kirsten Walsh Immigrant Health Royal Children’s Hospital Melbourne

Date: 18 th October 2010 Department of General Medicine – Immigrant Health Presenters: Kirsten Walsh and Georgie Paxton Outline Refugee health screening and variability Common health issues –Immunisation –Vitamin D –TB –Hepatitis B –Other medical problems ESL acquisition Systems issues and resources

Date: 18 th October 2010 Department of General Medicine – Immigrant Health Presenters: Kirsten Walsh and Georgie Paxton It’s a long way… Kakuma 1992, 25 sq km 80,000 people

Date: 18 th October 2010 Department of General Medicine – Immigrant Health Presenters: Kirsten Walsh and Georgie Paxton Country of origin Source: DIAC settlement reporting facility, accessed 11 Oct 2010

Date: 18 th October 2010 Department of General Medicine – Immigrant Health Presenters: Kirsten Walsh and Georgie Paxton 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 /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

Date: 18 th October 2010 Department of General Medicine – Immigrant Health Presenters: Kirsten Walsh and Georgie Paxton Visa health assessment (also PDMS) TestRecipient Chest X Ray (TB)All >11y Younger if symptoms or TB contact HIV serologyAll >15y International adoptees History of blood Tx or clinical indications (eg parent status) HBV serologyPregnant women International adoptees Unaccompanied refugee minors Syphilis serologyApplicants at risk of STI’s Applicants >16y who have lived in refugee camps UrinalysisAll >5y Height and weightAll Blood pressureAll >11y

Date: 18 th October 2010 Department of General Medicine – Immigrant Health Presenters: Kirsten Walsh and Georgie Paxton 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

Date: 18 th October 2010 Department of General Medicine – Immigrant Health Presenters: Kirsten Walsh and Georgie Paxton Settlement support Varies with visa –Refugee entrants case management 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

Date: 18 th October 2010 Department of General Medicine – Immigrant Health Presenters: Kirsten Walsh and Georgie Paxton Settlement

Date: 18 th October 2010 Department of General Medicine – Immigrant Health Presenters: Kirsten Walsh and Georgie Paxton 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

Date: 18 th October 2010 Department of General Medicine – Immigrant Health Presenters: Kirsten Walsh and Georgie Paxton 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

Date: 18 th October 2010 Department of General Medicine – Immigrant Health Presenters: Kirsten Walsh and Georgie Paxton 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

Date: 18 th October 2010 Department of General Medicine – Immigrant Health Presenters: Kirsten Walsh and Georgie Paxton 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

Date: 18 th October 2010 Department of General Medicine – Immigrant Health Presenters: Kirsten Walsh and Georgie Paxton Immunisation No one will be up to date – multiple appointments needed Funding issues: MCCV, VZV, HPV, (HBV)

Date: 18 th October 2010 Department of General Medicine – Immigrant Health Presenters: Kirsten Walsh and Georgie Paxton 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

Date: 18 th October 2010 Department of General Medicine – Immigrant Health Presenters: Kirsten Walsh and Georgie Paxton 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

Date: 18 th October 2010 Department of General Medicine – Immigrant Health Presenters: Kirsten Walsh and Georgie Paxton Australian born Child MCH ServicesSchool Mothers groupPlaygroupKinderGP SpecialistAntenatal care Neonatal screening PSN

Date: 18 th October 2010 Department of General Medicine – Immigrant Health Presenters: Kirsten Walsh and Georgie Paxton Refugee background Child MCHServices School Mothers groupPlaygroupKinderGPSpecialist Antenatal care Neonatal screening PSN

Date: 18 th October 2010 Department of General Medicine – Immigrant Health Presenters: Kirsten Walsh and Georgie Paxton 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

Date: 18 th October 2010 Department of General Medicine – Immigrant Health Presenters: Kirsten Walsh and Georgie Paxton 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

Date: 18 th October 2010 Department of General Medicine – Immigrant Health Presenters: Kirsten Walsh and Georgie Paxton 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

Date: 18 th October 2010 Department of General Medicine – Immigrant Health Presenters: Kirsten Walsh and Georgie Paxton Resources RCH Immigrant health – inc. education assessment guidelines VFST DEECD refugee student resources Carer’s allowance FKA Kindergarten fee subsidy Victorian College Optometry Audiology services in Victoria

Date: 18 th October 2010 Department of General Medicine – Immigrant Health Presenters: Kirsten Walsh and Georgie Paxton Resources Multilingual GPs western region MRCs Mental health Carer’s Victoria Association for children with a disability Autism Victoria ADEC (Advocacy/disability/ethnicity/community) CMY Special access schemes

Date: 18 th October 2010 Department of General Medicine – Immigrant Health Presenters: Kirsten Walsh and Georgie Paxton Thank you and questions?