Refugee children: Health assessment and health care issues

1. Refugee children:Health assessment and health care issues Drs Georgie Paxton and Kirsten Walsh Immigrant Health Royal Children’s Hospital Melbourne

2. 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. It’s a long way… Kakuma 1992, 25 sq km 80,000 people

4. Country of origin 1996 - 2010 Source: DIAC settlement reporting facility, accessed 11 Oct 2010

5. 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. Visa health assessment (also PDMS)

7. 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. 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. Settlement

10. 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. 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 Prevalence of Health Problems

12. 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. 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. Immunisation No one will be up to date – multiple appointments needed Funding issues: MCCV, VZV, HPV, (HBV)

15. 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. 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. Australian born

18. Refugee background

19. 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. 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. 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. 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

23. 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/ CMYhttp://www.cmy.net.au/WhatWeDo Special access schemes http://www.vtac.edu.au/pdf/publications/seas.pdf

24. Thank you and questions?