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

2. 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  million
Lebanon 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

5. http://static. businessinsider

10. http://www. telegraph. co

11. Zaatari refugee camp – 8 km from Jordan-Syria border
Photo taken 2013 – 150,000 people at the time

14. http://ngm. nationalgeographic

19. Syrian health systems 64% public hospitals out of service
60-70% reduction pharmaceutical production
>50% doctors have left (>70% in parts)
Immunisation
95% > 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:

20. Up to date 12/5/17

21. Polio
Confirmed up to date 12/05/2017

22. Chemical weapons & Attacks on hospitals
12/5/17

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

24. Up to date 12/5/17
Data from 2016 Census available from June 2017

25. Syrian arrivals

26. 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 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

27. 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

28. 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

29. 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