Refugee Health

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Refugee Health

• Dr. Jill Benson
• Senior Medical Officer

Migrant Health Service21 Market St,
Adelaide82373900
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Refugee profile - General

• 13000 refugees/year to Australia, 1678 in SA
• 60 from Africa
• Sudan, Congo, Burundi, Liberia
• 33 from Middle Eastern countries
• Afghanistan, Iran, Iraq
• 7 from elsewhere
• Uzbekistan and Burma
• Up to 50 aged under 18
• Approx. equal numbers of men and women

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Refugee profile - Africans

• Higher levels of poverty
• Larger families and lower levels of education and
  English proficiency
• Families often headed by female
• Greater cultural differences
• Long periods in refugee camps - extremely unsafe,
  poor sanitation, infectious diseases, poor diet
• Come from areas where malaria, TB and other
  tropical infections endemic
• Limited or disrupted access to health care

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Flight and Camp

• Stateless, no country
• No home or privacy
• Conditions and time in refugee camp
• Limited health-care, food or sanitation
• Witnessing of hunger, rape, murder, death,
  self-abuse
• No contact with family
• Mandatory detention in safe country
• Temporary Protection Visas in past

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• those who have been exiled for gt 5 years with
  no certain prospect of leaving
• Average stay in Kakuma camp 17 years
• Many children born and raised in camps
• 8 million worldwide

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Concepts of health and survival

• Housing and food
• Caring for family
• Education
• Aspirations for a better life
• Coping with challenges of resettlement
• Dealing with loss and dislocation
• Mistrust of authority
• Fear of being sent back
• Survival is a priority, not necessarily health

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Presentation

• Patients may present with a random array of
  problems
• Expectations about the doctors role
• Cure vs treatment
• Models of health completely foreign
• Beliefs about medicine illness
• Spiritual and cultural beliefs important
• Aim for a mutual understanding of patients
  presenting problem

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Physical illnesses

• High rates of infectious diseases
• Hepatitis B rates between 10-20
• Malaria
• High rates of P Falciparum
• Mostly asymptomatic with chronic, low grade
  parasite counts
• Intestinal parasites
• Schistosomiasis (possibly up to 40)
• Giardia, hookworm and strongyloides
• Chronic diseases
• Hypertension, diabetes, dental problems

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Other Health Issues

• Nutritional deficiencies Vitamin D and Iron
• Injuries from pre-migration torture trauma
• Chronic, non-communicable diseases
  eg hypertension, diabetes
• Dental problems
• Childhood development problems
• Low immunisation rates
• Serious mental health problems eg PTSD

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Mental Health Issues

• A range of untreated psychological conditions
  which present in an extreme state
• Pre-migration
• Depression, PTSD, anxiety, grief
• Guilt, loss of a sense of hope and meaning
• Post-migration/resettlement
• Stresses of resettlement
• Cultural adjustment/family dynamics/changing
  gender roles
• Post Traumatic Stress Disorder
• Nightmares, insomnia, concentration difficulties,
  uncontrollable anger, withdrawal, flashbacks

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Cultural differences

• Appointment making and keeping
• Health literacy
• Body language and illness behaviour
• Attitudes to medication
• Expectations of treatment
• Interpreters
• Appropriate ethnic group, dialect and gender
• Free interpreters for GPs through Translating and
  Interpreting Service (TIS)
• On-site or over the phone

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Pre-departure

• HIV test for those over 15
• Urinalysis for protein, glucose and blood
• Mantoux or CXR
• Some have had treatment for malaria and parasites
  as part of voluntary Fitness to fly
• Some have Health Undertakings needing follow-up
  eg TB
• However compliance, inconsistent paperwork, delay
  in leaving etc mean that investigation and
  treatment sometimes cannot be relied upon.

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Aims of Item 714 and 716

• Information can be a combination of information
  from clinic nurse, immunisation provider and GP
• Aim is to assess the patients health and
  physical, psychological and social function and
  whether preventive health care, education and
  other assistance should be offered
• Usual screening eg maternal child health,
  diabetes, cholesterol, breast, cervical screening
• Screening for other illnesses that have minimal
  signs symptoms or are asymptomatic
• Problem list and management plan

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Initial Assessment for an Item 714

• Skilled use of appropriate interpreter
• Confirmation of visa status 200-204, 447, 451,
  786, 866, 785 (not Bridging visa)
• Time in Australia lt 12 months
• Informed consent to health assessment (must be
  documented)
• Agreement that nurse/health worker will begin
  health assessment
• Previous health checks/ Pre-departure medical
  records or treatment

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Health Assessment must include

• Taking the patients medical history
• Physically examining the patient
• Undertaking or arranging any required
  investigations
• Assessing the patient using the information
  gained from the patients medical history,
  physical examination and investigations
• Developing a management plan to address any
  issues and/or conditions, including
  making/arranging any necessary interventions or
  referrals to other health care providers.

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Visa categories

• Offshore Refugee Category including
• 200 Refugee
• 201 In Country Special Humanitarian
• 203 Emergency Rescue
• 204 Women at Risk
• Offshore Special Humanitarian Programme
• 202 Global Special Humanitarian
• Offshore Temporary Humanitarian Visas (THV)
  including
• 447 Secondary Movement Offshore Entry Temporary
• 451 Secondary Movement Relocation Temporary
• 786 Temporary Humanitarian Concern
• Onshore Protection Programme including
• 866 Permanent Protection Visa (PPV)
• 785 Temporary Protection Visa (TPV)

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Investigations

• Tuberculosis
• ? need for further screening
• Malaria Thick and thin films, antigen tests
• may be asymptomatic if partial immunity
• Schistosomiasis
• titre on blood
• microscopy of faeces /- urine
• Other parasites
• especially if anemia or eosinophilia
• Faeces cysts, ova and parasites
• Antigen or antibody titres

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Investigations (cont)

• Vitamin D deficiency
• especially if dark skin colouring and/or women
  who veil for cultural reasons
• Other nutritional deficiencies
• Hepatitis B status
• hepatitis B surface antigen will indicate prior
  exposure and further investigation needed to
  assess infectivity and morbidity
• Hepatitis C status
• especially if time in Egypt where prevalence high
• Iron studies /- haemoglobin variant analysis
• if indicated from abnormal red cells

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Investigations (cont)

• HIV
• especially if pre-departure screening has been a
  long time before and patient is from high-risk
  area
• must be appropriate pre- post-test counselling
• Post Traumatic Stress Disorder
• symptoms may not appear until a long time after
  arrival
• Other sequelae of torture and trauma
• e.g. physical injuries behavioural problems in
  children.
• Under-immunisation.

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Children

• Developmental delay
• Large family size
• Malnutrition
• Parasites
• Incomplete /- undocumented immunisation
• Hepatitis B
• Mental health issues
• Detention
• Child soldiers or sex slaves

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Team approach to care

• Dental, Hearing, Eyes
• Womens health
• Torture and trauma
• Massage therapists
• Psychologists
• Dietitians
• Podiatrists
• Social workers
• Cultural health workers

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Migrant Health Service

• Involvement aims to be short term- 6-12 months
• Services offered
• Comprehensive early health assessments
• Health information /health promotion sessions
• Cross cultural counselling MHS or STTARS
• TCA and GPMP
• Referral back to community GP
• Telephone support and education for GPs
• Advocacy
• Womens health
• Immunisation

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Case 1

• Family from sub-Saharan east Africa who fled to
  refugee camp in 2005
• Been in Australia for 2 months, seen by GP
• Parents and 8 children and 1 grandchild
• Father-53 Mother-42Children - 20, 19, 18, 16,
  14, 12, 10, 8 Grandchild - 2
• Screened at Migrant Health Service using
  screening protocol, particularly looking for
  asymptomatic diseases

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Immediate problems

• P. falciparum malaria in 8 y.o. (antigen only)
  and 10 y.o. (thick film)
• ? Symptomatic with fever but Hb OK
• Referred to W CH for treatment
• F/U 28 days later
• Chronic cough and high ESR in 2 y.o.
• Risk of TB, for CXR and referral

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Worms

• Schistosomiasis serology positive x 4
• Treat with praziquantel, no f/u needed
• Schistosomiasis eggs in stool in 19 y.o
• Treat with praziquantel and f/u stools 6-8 weeks
  later
• Hookworm eggs in stool x 4
• Treat with pyrantel or mebendazole
• All Hb above 130
• Giardia lamblia x1

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Undiagnosed problems

• Abnormal LFTs x1 anaemia x1
• ? Malnutrition
• ? Recently treated worms
• 18 cm spleen in 19 y.o.
• Normal LFTs and platelets
• ?schistosomiasis ?tropical splenomegaly
• Underweight x1 (10 y.o 35kg)
• Overweight x1 (14 y.o 61kg)

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Chronic issues

• Longterm back pain in father
• Chest tightness and wheeze in father
• GORD in mother
• Scarring of cornea in mother
• Primary eneuresis in 8 and 10 y.o
• Chronic headaches nose bleeds in 20 y.o
• Problems with vision x 3
• Sickle cell trait in grandchild (39.5)

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Other Problems

• Hep B sAg ve in 16 y.o
• eAb ve, eAg ve, ALT 14, afp 4
• Hep D Ab ve
• Will need U/S liver and f/u 12 monthly
• Rest of family
• Hep B immune x 6
• Non-immune - need Hep B vaccination x 3
• Vitamin D deficiency in 14 y.o girl
• Treat with 100,000 IU cholecalciferol

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Immunisations

• Father-53 tetx3, poliox3, MMRx2
• Mother-42 poliox1, MMRx2, HepBx3
• Children - 20, 19, 16, 10, 8
• Tet/poliox3, MMRx1
• 18, 14, 12 - Tet/poliox3, MMRx1, HepBx3
• Grandchild 2 comvax x1, meningococcal C,
  varicella, MMR

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Schistosomiasis

• Schistosomiasis (bilharzia) infects humans when
  skin comes into contact with water contaminated
  with certain snails.
• Worm pairs in venous complexes in bladder in S.
  haematobium, or in portal venous plexuses in S.
  mansoni and S. japonicum.
• 200 million people in Africa infected.
• Treatment with praziquantel 40mg/kg in two
  divided doses
• Risks of thrombocytopaenia with risk of bleeding,
  splenomegaly with risk of trauma and oesophageal
  varices

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Schistosomiasis Symptoms

• Asymptomatic in up to 80
• Most common cause of massive splenomegaly
• Most common cause of portal hypertension with
  portal vein obstruction from intrahepatic
  periportal fibrosis - pipestem fibrosis.
• Schistosomal portal hypertension occurs in only a
  minority and is usually asymptomatic with normal
  liver function tests until very late.
• The initial presentation even in the young may be
  with variceal bleeding.

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Malaria - Some figures

• Eradicated from Australia in 1981
• 40 of the worlds population at risk
• 300-500 million cases/year
• Mortality of 3 million/year has risen in recent
  years, probably due to the increasing resistance
  to medication
• 89 of these deaths in Africa
• Of the 13000 refugees each year, about 70 are
  from areas where malaria is endemic

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Malaria

• Transmitted by the anopheline mosquito but also
  transferred directly by blood transfusion,
  transplacentally or by accidental inoculation.
• Anopheles mosquitoes are still present in the far
  north of Australia so there continues to be a
  public health risk
• Plasmodium falciparum is the cause of nearly all
  malaria deaths and behaves differently in many
  other respects to P. vivax, P. malariae and P.
  ovale.

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Malaria in refugees

• A fitness to fly assessment includes a RDT
• If positive, given a 3 day course of
  artemether/lumefantrine before leaving the
  country.
• However the sensitivity of the test is only
  95-98 will miss those with early infection, a
  low parasite count or who contract the infection
  between the health assessment and leaving the
  country
• The treatment is not supervised
• Malaria in refugees is 8 in WA, 5 in SA, 10 in
  Hobart and 16 in Newcastle.

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Symptoms of malaria

• Not the traditional pattern of periodic fever
  with paroxysms of cold, hot and sweating
• Usually fever, vomiting, diarrhoea, headache
  and/or muscle pain.
• Older patients have usually developed partial
  immunity to malaria and may not be symptomatic on
  arrival. However, as their immunity wanes, they
  can potentially become ill, even up to several
  years after arrival in Australia

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Recommendations

• Current recommendations for Australia are that
  all patients with P. falciparum should be
  hospitalised
• However most regions have guidelines based on
  outpatient treatment for those who are
• Asymptomatic or minimal symptoms(not vomiting)
• Not pregnant,
• Over 10kg, and/or 12 months of age and
• Parasitaemia of less than 1.

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Haemoglobinopathies

• Sickle cell anaemia
• Carriers have 20-45 HbS
• 14 carrier rate in Sudanese
• up to 30 in other parts of Africa
• Risk in hypoxia, hypothermia, acidosis,
  hypotension and dehydration
• Alpha thalassaemia 25 in Africans
• G6PD deficiency 14 in Africans
• Iron deficiency in 20 of refugees

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Hepatitis

• Hep A, B, C and D are all very different viruses
• all cause inflammation of the liver but behave
  differently
• Most people with hepatitis B and C asymptomatic
• infection is only detected with screening
• In Australia hepatitis B and C can be treated in
  those with active infection and GPs can be
  involved in diagnosis, follow-up and shared-care
  management.
• Patients with blood-borne viruses need
  counselling, education and support

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Hepatitis B virus (HBV)

• A partially double stranded DNA virus
• Composed of a core (HepBcoreAg), surrounded by an
  outer coat (also called envelope, e) containing
  the surface antigen (HepBsAg)
• Present in blood, saliva, semen, vaginal
  secretions, and menstrual blood of infected people

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Hepatitis B - facts

• 2 billion people infected with hepatitis B virus
  (HBV) world-wide
• More than 350 million have chronic infection
• Over one million people die each year from
  cirrhosis of the liver or hepatocellular
  carcinoma (HCC) from chronic hepatitis B
• 52 of all cases of hepatocellular carcinoma is
  caused by HBV and 92 of the worlds HBV-related
  hepatocellular carcinoma occurs in developing
  countries

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Hepatitis B in Australia

• HBV 2.2 per 100,000 in 2001 cf 1.5 in 1997 with
  consequent increase in HCC
• 70 of chronic HBV born overseas
• Refugees mostly from sub-Saharan Africa and Asia
  where more than 10 have HBV
• 90 of those infected perinatally and 30-50 of
  those infected from age 1-4 will have chronic
  infection with 25 risk of cirrhosis or HCC

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Prevalence of hepatitis B
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Reasons for screening

• Counselling about ways to reduce hepatitis B
  transmission
• Vaccination of close contacts, sexual partners
  and household
• Infants born to hepatitis B sAg positive women
  need vaccine and immune globulin.
• Risk for progression to cirrhosis and
  hepatocellular carcinoma
• Eligibility for treatment
• Educate patients on medical and social
  consequences of infection including public health
  notifications

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Summary of hepatitis definitions

• HBsAg (surface antigen) persistent infection
• Anti-Hbs (surface antibody) immunity from past
  infection or vaccination
• HBeAg (envelope antigen) highly infectious
• HBV DNA circulating virus
• Anti-HBcIgM (core antibody) recent infection
• Anti-HBcIgG past infection

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Serious consequences

• 8-20 of those who are HepBsAg positive will
  progress to cirrhosis in 5 years
• Without treatment, cirrhosis can cause ascites,
  jaundice, bleeding and hepatic encephalopathy
  with only a 71 survival rate at 5 years
• Hepatocellular carcinoma arises most commonly in
  patients with cirrhosis but can also occur with
  only minimal signs of other liver damage
• A male child infected at birth has a 25-40
  lifelong risk of developing cirrhosis or
  hepatocellular carcinoma

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Treatment

• Treatment for hepatitis B will take place after
  referral to a specialised unit, and liver biopsy
  for those with abnormal ALT levels and a high
  viral load
• Success is defined as loss of HepBeAg,
  elimination of detectable HBV from the blood and
  normalisation of liver function tests
• Early diagnosis of hepatocellular carcinoma
  allows for treatment by transplantation,
  ablation, resection , hemihepatectomy,
  intra-arterial chemotherapy, embolisation or
  percutaneous intralesional ethanol injection.

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Hepatitis C in refugees

• Australia - lt1
• Egypt (transit for Sudanese) -15-20
• Central African Republic 5
• Cambodia 8
• Afghanistan- 1-2

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Course of HCV

• Cleared by 30 but HCV antibody remains positive
• Qualitative HCV PCR present if infected
• Damage to liver and other organs slowly through
  immune complex deposition
• Cirrhosis and HCC many years later
• LFTs normal in 20 with liver damage

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Treatment of HCV

• Pegylated interferon ribavirin
• Genotypes 1 3 most common in Australia
• Genotypes 2 3 6 months treatment with 80
  success (SVR)
• Genotypes 1 4 12 months treatment with 50
  success
• Decreased response if cirrhosis
• One treatment per person under PBS

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Hepatitis D

• The hepatitis D virus (HDV) is a defective virus
  whose outer coat is derived from hepatitis B
  surface antigen.
• Hence it needs the hepatitis B virus to exist and
  is transmitted by the same routes.
• Hepatitis D antigen and antibody should be
  requested where liver function tests are
  persistently elevated in a person who is HepBsAg
  positive but has a low viral load and no other
  comorbid risk factors.

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Take-home messages

• Refugees are likely to have a range of illnesses
  not usually encountered in Australia
• Many of these are asymptomatic and will only be
  detected by thorough screening
• Some of the illnesses might have previously
  tested negative or have been treated but there is
  a need to maintain a high index of suspicion
• Good preventive health care with updated
  vaccinations is also very important

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Everyone has the right to seek and enjoy in
other countries asylum from persecution Article
14, Universal Declaration of Human Rights 1948
(signed by member countries, including Australia
and NZ)
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Thank you