Refugee Health Infectious Diseases, Age Determination and other health problems Dr. Jill Benson Senior Medical Officer Migrant Health Service and Director, Health in Human Diversity Unit Discipline of GP, University of Adelaide

Refugee profile >50% children >Higher levels of poverty >Families often headed by female >Greater cultural differences >Larger families with lower levels of education >Older children responsible for younger ones >Long periods (often >10 years) in refugee camps >From areas with malaria, TB and other tropical infections >Limited or disrupted access to health care >‘Unaccompanied minors’ highest risk >Forced child labour, kidnapping, child soldiers

Pre-departure >HIV > 15 years or high risk >CXR >11 years or high risk >Hep B and C in some >Some have had treatment for malaria and parasites and given MMR as part of voluntary ‘ Fitness to fly ’ >Some have ‘ Health Undertakings ’ eg TB >However compliance, inconsistent paperwork, delay in leaving etc mean that investigation and treatment sometimes cannot be relied upon.

Common Parasites and Infections >Schistosomiasis >Strongyloides >Hookworm >Pork tapeworm (taenia solium) >Giardia >Entamoeba histolytica >Malaria >Cutaneous leishmaniasis >Yaws >TB >Hepatitis B, C and D

Other Health Issues >Dental problems >Nutritional deficiencies – Vitamin D, A, B12, folate, and Iron >Injuries from pre-migration torture & trauma >Fungal infections >Rheumatic heart disease >Childhood development problems >Low immunisation rates >Serious mental health problems

Investigations >Tuberculosis >Malaria Thick and thin films, antigen >Schistosomiasis Abs, stools &/or urine >Other parasites especially if anemia or eosinophilia >Vitamin D >Other nutritional deficiencies eg Vitamin A >Hepatitis B and C status Hep B surface antigen indicates infectivity & further tests needed to assess risk (Hep B eAg and Ab) >Iron studies +/- haemoglobin variant analysis

Investigations (cont) >HIV especially if pre-departure screening has been a long time before and patient is from high-risk area Children not tested before arrival must be appropriate pre- & post-test counselling >Mental health problems symptoms may not appear until a long time after arrival (honeymoon period) Look for other signs eg eneuresis (up to 50%) >Other sequelae of torture and trauma e.g. physical injuries; behavioural problems in children. >Under-immunisation.

Schistosomiasis >Schistosomiasis (bilharzia) infects humans when skin comes into contact with water contaminated with certain snails >Asymptomatic in up to 80% >Most common cause of massive splenomegaly >Schistosomal portal hypertension occurs in only a minority with normal liver function tests until very late. >The initial presentation even in the young may be with bleeding oesophageal varices

Malaria > million cases/year >Mortality of 3 million/year, 89% of these in Africa >Children most at risk >Of the refugees each year, about 70% are from areas where malaria is endemic >A ‘fitness to fly’ assessment includes a rapid diagnostic test >If positive, given a 3 day course of treatment >Sensitivity of the test is only 95-98% so will miss those with early infection, a low parasite count or who contract the infection between the health assessment & leaving the country >Malaria in refugees is 8% in WA, 5% in SA, 10% in Hobart and 16% in Newcastle.

Symptoms of malaria >Not the traditional pattern of periodic fever with paroxysms of cold, hot and sweating >Usually fever, vomiting, diarrhoea, headache, muscle pain. >Older patients may have developed partial immunity to malaria and may not be symptomatic on arrival >Can be treated as an outpatient if: Asymptomatic or minimal symptoms Not pregnant, Over 10kg, and/or 12 months old Parasitaemia of less than 1%.

Tuberculosis >WHO estimates that more than 1/3 of the world’s population is infected with TB Africa high prevalence >300/100,000 cf Aus 5.8/100,000 >90% of those with TB in Australia are born overseas 20/100,000 in overseas-born cf 0.9/100,000 for Aus-born >Culture for AFBs in the sputum is the gold standard >Risk factors High prevalence country Crowded living conditions Poor general health HIV

Tuberculosis in refugees >Up to 50% of refugees have positive Mantoux indicates 10% lifetime risk of TB in adults 40% risk of progression to TB if < age % risk of progression to TB if age 1-15 years >Latent TB common, active TB rare >Most risk in first 2 years after arrival >Non-pulmonary TB more common, especially in children Not usually infectious if <12 years of age >Some will have had BCG >Chest Clinic does Mantoux on children through schools

Hepatitis B >HBV 2.2 per 100,000 in 2001 cf 1.5 in 1997 with consequent increase in hepatocellular carcinoma >70% of those with chronic HBV in Australia born overseas >Approximately 20% of refugees from some countries are hepatitis B sAg positive >90% of those infected perinatally will have chronic infection with 25% risk of cirrhosis or hepatoma

Vitamin D deficiency in refugees >Vitamin D deficiency in 40-80% of refugee patients >Women who wear veils for cultural reasons and dark- skinned migrants from Africa >Mostly asymptomatic >May have seizures, rickets or chronic non-specific musculoskeletal pain >Treatment with megadose of cholecalciferol such as 100,000 IU in 1ml flaxseed oil >W and CH Vit D protocol Cholecalciferol  5000 IU daily for 3 months if > 12 months  3000 IU if <12 months

Immunisation >Most have had minimal immunisation >May be forged or incomplete records >Important that vaccines are age-appropriate eg Prevenar and Pneumovax >Little or no knowledge of vaccine preventable diseases and the Australian schedule >At risk of diseases eg measles and pertussis >At risk of over immunisation if multiple providers involved >Special NARI clinics in Council areas for newly arrived refugees

Cultural practices >Most cultural practices are not harmful but important to ask as some might be eg Not giving certain foods if a child is sick eg protein ‘Cupping’, scratching or rubbing with kerosene Female and male circumcision by inexperienced people Children should not be fasting in Ramadan but some do Fear of becoming addicted to medication Massaging broken limbs

Follow-up >Review social parameters of illness Education (?prioritised over health) Housing (several kids in same bed) Transport (kids find their own way) Social supports Language and literacy Cultural communication skills Religious beliefs Financial supports

The Importance of knowing correct age >Correct vaccinations >Taught at a suitable educational level >Correct medication and dose >Developmental milestones eg urinary incontinence >Dental care >Determining potential emotional resources for dealing with stressful life events >Get married, join the army, drive, receive Centrelink payments or vote >Local authorities fulfil their obligations in providing support and services to vulnerable groups, such as unaccompanied minors aged less than 18 years

Why don’t we know the correct age? >The significance of birthdates tends to be cultural and many may know the year of birth but not the day or month >Banning of calendars (eg in Afghanistan) >Chaotic circumstances surrounding the time of birth >Child and parents may have been separated for some time >Child is the child of only one parent (eg one wife may come with the children of other wives) >Child may be adopted from another family >Visa authorities made an inappropriate estimate of the child’s age >Many other systemic or administrative errors or mishaps.

How can we assess a child’s age? >Wide range of normal even if a child has good health, adequate nutrition and a stable environment >If there is illness, undernutrition, extreme stress and disrupted socialization, any tools used to assess age are likely to be even less reliable >Use narrative accounts, physical assessment of puberty and growth, and cognitive, behavioural and emotional assessments >X-rays should be used as a last resort

Assessing age by ‘medical’ means >Left wrist X-ray standards developed in white north Americans in 1942 are not applicable in 2008 or for other geographical locations, climates, ethnicities or socioeconomic groups >Bones, teeth and sexual maturation affected by: antenatal causes general health and illnesses nutrition or malnutrition climate and altitude Vitamin D and calcium levels socio-economic status poor hygiene

Narrative account >Original records such as ‘road to health cards’ and immunisation documents >Recording an accurate narrative account requires time and patience, a good interpreter and a non-judgemental approach Where the family was at time of birth the time of year of birth (winter, summer, wet, dry) when the child first walked (approx one year) when the child was dry in the day (approx 3 years) age in relationship to other children

>The following assessment tool should be used to confirm age estimates in the absence of correct legal documentation. Accuracy of the final assessment will be within a range of approximately two years and should be expressed as an estimate for educational purposes only. This estimate is not legally binding. >If estimated age (age stated by parents and others) of child is less than 18 months different to the age on the visa, do clinical history and assessment. >If estimated age is more than 18 months different to the age on the visa add X-ray of left wrist. >Questions which may be useful in helping parents remember the child’s date of birth: Are there any other records which may show child’s age – immunisation/ health records? Where the family was at the time of birth. Time of year of birth (winter, summer, wet, dry). Walking (approx one year) – how long ago? Toilet trained i.e. dry in the day (approx 3 years) – how long ago? Age in relationship to other children in the family.

Questions / Observations:Assessed age Date of Birth on visa: Child ’ s age according to other documentation e.g. early child hood immunisation records, passport. Parents initial estimate of age: Weight : plot on 50 th percentile and find age to match Height : plot on 50 th percentile and find age to match Assessment of child ’ s date of birth according to parent ’ s story* Assessment of child ’ s current developmental stage: Puberty (if appropriate and with consent) : Girls - periods commenced (usually around age yrs) Boys - noted voice change (usually around age yrs) Health professional ’ s estimate of age on the basis of maturity and relationships with other people. X-ray left wrist: According to MHS Age Assessment protocol - which includes the above criteria, the age is assessed as:

Management difficulties >Relationship the most important tool for healing >Long-term treatment may be a very unusual thing >Multidisciplinary team approach esp with school >Try to work with family’s expectations as well as your own >Important to estimate age >Be prepared for unusual and asymptomatic illnesses

Remember, every encounter with a refugee is an opportunity to heal the past and bring hope for the future.