refugee children: health assessment and health care issues

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

Refugee children:Health assessment

and health care issues

Drs Georgie Paxton and Kirsten WalshImmigrant Health

Royal Children’s Hospital Melbourne


Outline

• Refugee health screening and variability• Common health issues

– Immunisation– Vitamin D– TB– Hepatitis B– Other medical problems

• ESL acquisition• Systems issues and resources


It’s a long way…

Kakuma

1992, 25 sq km

80,000 people


Country of origin 1996 - 2010

Source: DIAC settlement reporting facility, accessed 11 Oct 2010


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


Visa health assessment (also PDMS)Test Recipient

Chest X Ray (TB) All >11yYounger if symptoms or TB contact

HIV serology All >15y

International adoptees

History of blood Tx or clinical indications (eg parent status)

HBV serology Pregnant women

International adoptees

Unaccompanied refugee minors

Syphilis serology Applicants at risk of STI’s

Applicants >16y who have lived in refugee camps

Urinalysis All >5y

Height and weight All

Blood pressure All >11y


Post-arrival health screening

Varies Models

Specialised refugee clinic model: most statesPrimary care: Victoria, (SA)Specialist: Hobart

Coverage of health screeningComplete: NT, Tasmania, ACTHigh: WAOther: Victoria, NSW unknown (50% national intake)

Large numbers of refugees do not get post-arrival screening


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


Settlement

SETTLEMENT SUPPORT (0 - 6 months)

BSLBasic

household furniture and

goods placed in accommodation

either prior to arrival or within

a week post arrival

Emergency Presentation at Hospital

Specialist Refugee

Services at Hospitals

First weeks of Settlement (Month 1)

VFST(Foundation

House) Psychiatric screening

assessment, short term

counseling & advocacy

DIAC INITIAL CONTACT

DIAC

Maintains Humanitarian

Entrant Management

System

Sends Arrivals List

to ConsortiumPartners

AMESSettlement

Support Case

Coordinator

Red Back

Pick-up & transport

from airport & temporary

housing

Pre-Arrival First months of Settlement (Months 2-6)

Refugee Settlement Pathway for the State of Victoria: Visa 200, 201, 203 & 204

Full PDMS

Short PDMS

Settlement Consortium

Partners for Victoria

Health (TB) Undertaking Western Hospital / RCH

Red Alert

General (Yellow) Alert

Health

Education

Daily Life

Housing

UNHCR & IOM

Months 7 + onwards

Refugee Health Nurse

Private GP

GP at Community

Health CentreGP On-going

Follow-up Medication

and treatment

Centrelink

Medicare

Bank Account

Public Transport Training

Supermarket Orientation

Day 1AMES

Emergency Health

Assessment

English Language School / Centre English language learning for 6-18 year olds

Adult Migrant Education Program (AMEP) Adult English language learning (510 hours)

Free Child Care at Adult Migrant Education Program for 0-6 year olds

Family Day Care or Free Kinder Association Child Care for 0-13 year olds

Enrolment for Adults at AMEP 510 hours of English language learning

Enrolment for 6-18 year olds at ELS/C 6-12 months of English language learning & catch-up schooling

Long Term Rental Accommodation .

(6 + months, 1st month rent provided by AMES, encompasses approximately 45% of Visa 200 entrants) .

Refugee Minor Program

(Unaccompanied Minors 0-18 years)

Enrolment for 6-18 year olds in Local schools (often Catholic) .

Visa Assess-

ment 3-9 months

prior to departure

No PDMS

Accommodation with a Link (Link is a contact person who is not a relative) . (permanent, indefinite, or temporary - weeks to months, encompasses approximately 45% of Visa 200 entrants Long Term Rental Accommodation

(3+ months)AMES Temporary / Initial (Emergancy) Free Accommodation .

(temporary - weeks / months, encompasses approximately 10% of Visa 200 entrants)

Day 1HouseSafetyInfor-

mation

Tax File Number

Day 2

AMES Community

Guide

1 month of Free

MET tickets

Pathology, X-Ray,

Mantoux and other tests

Maternal & Child Health

Other Allied Health

Week 1 & 2

Enrolment for 0-6 year olds in Child or Day While paretns are learning English

Dental (Waiting List)

VFST(Foundation House) Medium to long term

counseling & advocacy

Accessing Shops, Religious Meeting Place, Social Life, Friends and Community Networks

Combined Home Visit

(DIAC, RHN & AMES with Unaccompanied

Minor wards) Multi-Page Demographic Data and Assessment Tool is used to collect information from the Humanitarian Entrant

AMES Community

Guide

AMES Community

Guide

List of Abbreviations

UNHCR United Nations High Commission for Refugees IOM International Organisation of MigrationPDMS Pre-Departure Medical ScreenDIAC Department of Immigration and CitizenshipBSL Brotherhood of St. LaurenceVFST Victorian Foundation for Survivors of Torture and TraumaRHN Refugee Health NurseAMES Adult MulitCultural Education ServiceUAC Un-Accompanied MinorTB TuberculosisGP General PractitionerCHC Community Health CentreAMEP Adult Migrant Education ProgramELS / C English Language School / Centre


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


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


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


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


Immunisation

No one will be up to date – multiple appointments needed

Funding issues: MCCV, VZV, HPV, (HBV)


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/


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, razorsPrompt cleaning of blood spillsBarrier contraceptionImmunise household contacts and partnersNotify health care staffSchools 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


Australian born


Refugee background


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


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 best5 – 7 years to grade standard

• Higher parent education associated with faster ESL acquisition• NB language transitions and past medical history


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


Resources• RCH Immigrant health – inc. education assessment

guidelines http://www.rch.org.au/immigranthealth/index.cfm?doc_id=10575

• VFST http://www.foundationhouse.org.au/home/index.htm

• DEECD refugee student resources 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

• FKA http://www.fka.com.au/

• Kindergarten fee subsidy http://www.education.vic.gov.au/ecsmanagement/careankinder/funding/subsidy.htm

• Victorian College Optometry http://www.vco.org.au/contact-us.htm

• Audiology services in Victoria http://www.rch.org.au/genmed/clinical.cfm?doc_id=2840


Resources• Multilingual GPs western region 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

• Carer’s Victoria http://www.respitenorthandwest.org.au/providers/view.chtml?filename_num=129582

• Association for children with a disability http://www.acd.org.au/

• Autism Victoria http://www.autismvictoria.org.au/home/

• ADEC (Advocacy/disability/ethnicity/community) http://www.adec.org.au/

• CMY http://www.cmy.net.au/WhatWeDo

• Special access schemes http://www.vtac.edu.au/pdf/publications/seas.pdf


Thank you and questions?

refugee children: health assessment and health care issues

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