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
Date: 18th October 2010Department of General Medicine – Immigrant HealthPresenters: 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
Date: 18th October 2010Department of General Medicine – Immigrant HealthPresenters: Kirsten Walsh and Georgie Paxton
It’s a long way…
Kakuma
1992, 25 sq km
80,000 people
Date: 18th October 2010Department of General Medicine – Immigrant HealthPresenters: Kirsten Walsh and Georgie Paxton
Country of origin 1996 - 2010
Source: DIAC settlement reporting facility, accessed 11 Oct 2010
Date: 18th October 2010Department of General Medicine – Immigrant HealthPresenters: 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
Date: 18th October 2010Department of General Medicine – Immigrant HealthPresenters: Kirsten Walsh and Georgie Paxton
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
Date: 18th October 2010Department of General Medicine – Immigrant HealthPresenters: Kirsten Walsh and Georgie Paxton
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
Date: 18th October 2010Department of General Medicine – Immigrant HealthPresenters: 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
Date: 18th October 2010Department of General Medicine – Immigrant HealthPresenters: Kirsten Walsh and Georgie Paxton
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
Date: 18th October 2010Department of General Medicine – Immigrant HealthPresenters: 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
Date: 18th October 2010Department of General Medicine – Immigrant HealthPresenters: 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
Date: 18th October 2010Department of General Medicine – Immigrant HealthPresenters: 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
Date: 18th October 2010Department of General Medicine – Immigrant HealthPresenters: 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
Date: 18th October 2010Department of General Medicine – Immigrant HealthPresenters: Kirsten Walsh and Georgie Paxton
Immunisation
No one will be up to date – multiple appointments needed
Funding issues: MCCV, VZV, HPV, (HBV)
Date: 18th October 2010Department of General Medicine – Immigrant HealthPresenters: 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/
Date: 18th October 2010Department of General Medicine – Immigrant HealthPresenters: 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, 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
Date: 18th October 2010Department of General Medicine – Immigrant HealthPresenters: Kirsten Walsh and Georgie Paxton
Australian born
Date: 18th October 2010Department of General Medicine – Immigrant HealthPresenters: Kirsten Walsh and Georgie Paxton
Refugee background
Date: 18th October 2010Department of General Medicine – Immigrant HealthPresenters: 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
Date: 18th October 2010Department of General Medicine – Immigrant HealthPresenters: 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 best5 – 7 years to grade standard
• Higher parent education associated with faster ESL acquisition• NB language transitions and past medical history
Date: 18th October 2010Department of General Medicine – Immigrant HealthPresenters: 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
Date: 18th October 2010Department of General Medicine – Immigrant HealthPresenters: Kirsten Walsh and Georgie Paxton
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
Date: 18th October 2010Department of General Medicine – Immigrant HealthPresenters: Kirsten Walsh and Georgie Paxton
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
Date: 18th October 2010Department of General Medicine – Immigrant HealthPresenters: Kirsten Walsh and Georgie Paxton
Thank you and questions?