1. 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

2. 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

3. 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

4. Date: 18 th October 2010 Department of General Medicine – Immigrant Health Presenters: Kirsten Walsh and Georgie Paxton Country of origin 1996 - 2010 Source: DIAC settlement reporting facility, accessed 11 Oct 2010

5. 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 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

6. 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

7. 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

8. 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 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

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

10. 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

11. 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

12. 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

13. 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

14. 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)

15. 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 http://www.who.int/tb/publications/global_report/2009/

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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 http://www.rch.org.au/immigranthealth/index.cfm?doc_id=10575 http://www.rch.org.au/immigranthealth/index.cfm?doc_id=10575 VFST http://www.foundationhouse.org.au/home/index.htm http://www.foundationhouse.org.au/home/index.htm DEECD refugee student resources http://www.education.vic.gov.au/studentlearning/programs/esl/refugees/default.htm 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 http://www.centrelink.gov.au/internet/internet.nsf/forms/claim_forms_carerchild.htm#forms FKA http://www.fka.com.au/ http://www.fka.com.au/ Kindergarten fee subsidy http://www.education.vic.gov.au/ecsmanagement/careankinder/funding/subsidy.htm http://www.education.vic.gov.au/ecsmanagement/careankinder/funding/subsidy.htm Victorian College Optometry http://www.vco.org.au/contact-us.htm http://www.vco.org.au/contact-us.htm Audiology services in Victoria http://www.rch.org.au/genmed/clinical.cfm?doc_id=2840 http://www.rch.org.au/genmed/clinical.cfm?doc_id=2840

23. Date: 18 th October 2010 Department of General Medicine – Immigrant Health Presenters: Kirsten Walsh and Georgie Paxton Resources Multilingual GPs western region http://www.pivotwest.org.au/index.php?action=view&view=19731&pid=2095 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 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 http://www.respitenorthandwest.org.au/providers/view.chtml?filename_num=129582 Association for children with a disability http://www.acd.org.au/ http://www.acd.org.au/ Autism Victoria http://www.autismvictoria.org.au/home/ http://www.autismvictoria.org.au/home/ ADEC (Advocacy/disability/ethnicity/community) http://www.adec.org.au/ http://www.adec.org.au/ CMY http://www.cmy.net.au/WhatWeDo http://www.cmy.net.au/WhatWeDo Special access schemes http://www.vtac.edu.au/pdf/publications/seas.pdf http://www.vtac.edu.au/pdf/publications/seas.pdf

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