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Paediatric refugee health

Georgie Paxton

Immigrant health

November 2010

A quick cook’s tour

• Demography

• Screening pre/post arrival

• TB

• Vitamin D• Vitamin D

• Parasites 

• Immunisation

• Things to think of: trauma, FGM, Adolescents

Background

Definition of refugee: someone who:

“owing to a well founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group, or political opinion, is outside the country of his nationality, and is unable or, owing to such fear, is unwilling to avail himself of the protection of that country, or who, not having a nationality and being outside the country of his former habitual residence asa nationality and being outside the country of his former habitual residence as a result of such events, is unable or, owing to such fear, is unwilling to return to it.”.

UNHCR 1951 ‘Convention Relating to the Status of Refugees’ and 1967 ‘Protocol relating to the status of refugees’

Background (UNHCR definitions)

• Asylum seekers• Individuals whose applications for asylum or refugee status are pending a final 

decision

• Internally displaced persons• People/groups individuals forced to leave their homes/places habitual 

residence as a result of/in order to avoid armed conflict generalisedresidence as a result of/in order to avoid…armed conflict..generalised violence…violations of human rights or natural/human made disasters and who have not crossed an international border

• Stateless persons• Individuals not considered as nationals by any State under relevant national 

laws

• Other groups/persons of concern• Individuals falling outside these definitions to whom UNHCR has extended 

protection/assistance based on Humanitarian/other grounds

UNHCR end 2009 statistics

• 43.3 M forcibly displaced

• 15.2 M refugees (10.4 M UNHCR, 5.5 M protracted)

• 27.1 M IDP

• 983,000 asylum seekers (18,700 UHM)

• 6.6 M stateless identified (60 countries)• Estimated actual 12M

• >26 M UNHCR mandate http://www.unhcr.org/4c11f0be9.html

UNHCR end 2009 statistics

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Distribution and numbers ‐ refugees

• 4 out of 5 refugees in developing countries • > 1/2 in urban areas

• < 1/3 in camps (6/10 in Africa)

• Only 17% outside region of origin

• 2.9 M Afghani refugees

• 1.8 M Iraqi refugees

• Pakistan host to 1.7 M, Syria 1.05 M

Resettlement/return

• 2009 voluntary repatriation• 251,500 refugees (2008 = 604,000)

• 2.1 M IDP (2008 = 1.3 M)

• 1% resettled

Permanent resettlement

2008  09• Total  88,800  112,400

• USA  60,200  79,900

• Canada  10,800  12,500

• Australia  11,000  11,100

• Germany 2,100

• Sweden  2,200  1,900

• Norway  1,100  1,400

• 358,600 asylum claims Europe, 336,400 Africa 

It’s a long way…

Kakuma

1992, 25 sq km

80,000 people

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Country profiles‐ Sudan

• 2 civil wars

• 1956 (independence)‐ 1972

• 1983‐ 2005 (CPA), also famine• 2 million dead2 million dead

• 4 million displaced

• 2003 – Darfur• 200,000 dead

• 2 million displaced

• Elections 2010

• Referendum January 2011

Burma (Myanmar)

Displaced family living in no mans land, Thai Burma border 2007. Photo: K Sangster

Umpium refugee camp, Thailand. Photo: K Sangster.

Unofficial Chin refugee camps in Malaysia

Country profiles‐ Burma/Myanmar

• Independence 1948

• 1962 Military coup

• 1989 Military junta enforced use of Myanmar

• By end of 2002• By end of 2002• 600,000 IDP

• 500,000 fled as refugees

Country of origin July 1996 – Sept 2010

Source: DIAC settlement reporting facility, accessed 11 Oct 2010

138,881 people

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Australian intake 2009‐10

• Humanitarian 13,770

• Skilled 107,868

• Family 60 254• Family 60,254

• Student 269,828

• Temporary residents (economic) 107,553

• Temporary residents (non economic) 16,953

• Visitors 3,416,575

http://www.immi.gov.au/about/reports/annual/2009‐10/pdf/report‐on‐performance.pdf

Australian intake 2009‐10

• Humanitarian program 13,770• 9,236 offshore

• 4,534 onshore

• 43.6% refugees (13.4% women at risk)

• 23.5% SHP

• 32.9% protection/other onshore

http://www.immi.gov.au/about/reports/annual/2009-10/pdf/report-on-performance.pdf

Australian intake

http://www.immi.gov.au/about/reports/annual/2009-10/pdf/report-on-performance.pdf

Pre‐departure screening process

• 6‐12 months prior to departure: visa medical (all visas)• Public interest criteria: free of

• TB or disease deemed public health risk

• Condition which might result in cost

• Condition which have implications for accessp

• One fails, all fail rule

• 3 days: PDMS (Humanitarian program)• PDMS full

• PDMS short (fitness to fly)

• Uptake 2007/08:  25 – 38% short, 42 – 63% full

Pre‐departure visa medical

Test RecipientChest X Ray (TB)  All applicants > 11 yrs

Younger if there are indications of TB or Hx of contact with TB

HIV serology All applicants >15 yrsInternational adopteesUnaccompanied refugee minorsHistory of blood Tx or clinical indications (parent status)

HBV serology Pregnant womenInternational adopteesUnaccompanied refugee minors ‘High risk applicants’

HCV serology ‘High risk applicants’

Syphilis Serology VDRL     Applicants at risk of STD’sApplicants > 15 yrs lived in refugee camps

Urinalysis All applicants > 5yrs

Exam, height and weight All applicants

Health assessment

• Young person’s/family concern• Excluding acute illness• Immunisation• TB screening• Parasites• Parasites • Nutrition/growth• Dental• Dev’t/vision/hearing• Mental health• Previous severe/chronic illness, physical trauma• Resettlement stressors

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Settlement

SETTLEMENT SUPPORT (0 - 6 months)

BSLBasic

household furniture and

goods placed in accommodation either prior to

arrival or within a week post

arrival

First weeks of Settlement (Month 1)

DIAC INITIAL CONTACT

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

Daily Life

Housing

UNHCR & IOM

Months 7 + onwards

Centrelink

Medicare

Bank Account

Public Transport Training

Supermarket Orientation

Day 1AMES

Emergency Health

Assessment

Long Term Rental Accommodation .

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

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

Day 2

1 month of Free MET

ti k t

Week 1 & 2

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

Emergency Presentation at Hospital

Specialist Refugee

Services at Hospitals

VFST(Foundation

House) Psychiatric screening

assessment, short term

counseling & advocacy

DIAC

Maintains Humanitarian

Entrant Management

System

Sends Arrivals List

to ConsortiumPartners

AMESSettlement

Support Case

Coordinator

Short PDMS

Settlement Consortium

Partners for Victoria

Health (TB) Undertaking Western Hospital / RCH

Red Alert

General (Yellow) Alert

Health

Education

Refugee Health Nurse

Private GP

GP at Community

Health Centre GP On-going Follow-up Medication

and treatment

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

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

Tax File NumberAMES

Community Guide

tickets

Pathology, X-Ray,

Mantoux and other tests

Maternal & Child Health

Other Allied Health

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

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

It’s pretty ID focused really…

The West Australian 11/12/2006

The public health implications of infectious diseases in refugees‐ especially refugee children‐ are relatively minor

Australian prevalence data summary

• Anaemia  10‐30%• Iron deficiency  17‐35%

• Vitamin D  75 ‐ 98% African, • Vitamin A  19 ‐ 38% (2 studies)

• TB screen positive ~ 21 – 63%. (37 ‐ 55% lge studies)

• Hepatitis B  5 ‐ 8% (16% in SA study)

• Pathogenic faecal parasites  20‐40%• Schistosomiasis 2 – 38% (8 studies, 4 > 18%)• Strongyloides 2 – 9%

International prevalence data summary

• TST• Overall 25 – 60%

• 35 – 52% predominantly African

• 20 – 60% South East Asian

• Hepatitis B• 3 – 13% 

• Pathogenic faecal parasites• 17 – 72 % (11 studies, 6 > 30%)

• Malaria • 2 – 64% affected PDMS

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TBMycobacterium tuberculosis complex

• 25‐40% world infected

• 9.27 million new cases 2007

• 55% Asia, 31% Africa• Highest burden 15‐49 year olds• 4.1M smear positive• 1.37M HIV positive (data change)• 1.32 million deaths non HIV. 456,000 HIV +

• http://www.who.int/tb/publications/global_report/2009/pdf/chapter1.pdf

Australian figures 2006 

Overall incidence TB disease 5.8/100,000 (1,201 cases notified)• 20.7/100,000 for overseas‐born• 0.9/100,000 for the Australian‐born population. 

In children aged < 15 (62 cases notified)• 19.8/100,000 overseas born • 1 6/100 000 Australian born1.6/100,000 Australian born 

85% of TB disease notifications were in overseas born people • 14% of notifications in the overseas group (n=68) refugee/humanitarian entrants. • Pulmonary TB 78% of Australian born cases 55% of overseas born

Roche PW, Krause V, Konstantinos A, Bastian I, et al, . Tuberculosis notifications in Australia, 2006. Comm Dis Intell 2008;32(1):1‐11

TB

Latent TB infection = Asymptomatic, not infectious

TB disease (active disease)= Symptomatic

• Primary disease active disease following recent infection (most commonPrimary disease active disease following recent infection (most common form in kids)

• Reactivation disease  active disease following latent infection (most common form in adolescents and adults)

Not usually infectious < 12 yrs even if active

TBOf cases  

Adults • 85% pulmonary

Kids • 75% pulmonary 

• anywhere, 50% symptomaticanywhere, 50% symptomatic

• More likely to have disseminated/meningitis• Nodal (17%)  • Suspicious if LN >1cm Cx, 1.5cm axillary, 2cm inguinal, • No other cause and no change with antistaphylococcal Rx

Immigrants • More likely to have non‐pulmonary

TB

TST• 5 TU PPD, ID injection

• Changed 2007

• Measured 48‐72 hrs (5d)

• Transverse axisTransverse axis

• Induration (not erythema)

• Pen!

• Considerations in repeatingMenzies DJ. 1999. Am J Crit Care Med 159;15‐21

• (Still) not widely used/available in primary care Victoria

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Mantoux interpretation

Interpretation varies with age, BCG, origin

TB screening ‐ IFN γ release assays

Not appropriate initial screen in kids < 13y

• High failure rate QFG (17%)

• Negative in 2/3 kids defined as LTBI by TST, including those who were known household contact

Connell T et al, Thorax, Apr 2006; doi:10.1136/thx.2005.048033    

Difficult to not Rx 15 mm TST from endemic area

Also not Medicare funded‐ potential for patients to get bills

Risk of reactivation TB

Lifetime risk of reactivation TB (%)Age (yrs)

Non-conversion

positive TST

Recent conversion of

TST*

Immuno-suppressive

therapy^Old, healed TB Advanced HIV

infection

100

70

8316-25 8

37

0-5 13

44

17 25

13 17

66

6-15 7 8 14

46-55 3 6 6 17 32

56-65 3 3 5 13 25

66+ 2 2 4 9 18

^infliximab; applicable to other long term immunosuppressive medications

21

73

4036-45 4

39

*applicable to situations where recent infection is likely, eg. migrants from high incidence country within last 5 yrs

7 8

26-35 7 12 15

Horsburgh CR. Priorities in the treatment of Latent Tuberculosis Infection in the United States NEJM 2004; 350(20): 2060-67.

LTBI

Positive Mantoux and exclusion active disease

• Any child/young person with + TST needs: • Careful history (repeat) and exam• CXR (and CT if symptoms and CXR normal)

• Consider prevention Rx with Isoniazid• Protocols vary (and evidence complicated)• Discussion re: risk benefit equation

• Counseling, be wary of GP knowledge/telling school

Vitamin D levels in kids

Normal Vitamin D in kids: Australian consensus statement

• 50 ‐ 160 nmol/l  

• Insufficiency = 25 ‐ 50 nmol/L (mild)

• Deficient = < 25 nmol/L 

• Moderate 12.5 ‐ 25 • Severe < 12.5

Munns C et al. MJA. 2006; 185(5): 268 ‐ 72

Vitamin D reference ranges

• Different to adult reference ranges in Australia• Insufficiency 50‐75 nmol/L

• Mild 25‐50 nmol/L

• Moderate 12.5‐25 nmol/L

• Severe < 12.5 nmol/L/

• Different to American paediatric reference ranges• Sufficient > 50 nmol/L

• Deficient < 37.5 nmol/L

• Severe < 12.5 nmol/L

Misra M et al. Pediatrics 2008; 122:398‐417

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Vitamin D in kids: RDI

• NHMRC: 200 IU daily

• Prevention: if risk factors 400 IU/d or 150,000 IU annually  Munns C et al. MJA. 2006; 185(5): 268 – 72

• AAP: 400 IU daily (as of Nov 2008)• Infants• Children• Adolescents   Wagner CL et al. Pediatrics 2008; 122(5): 1142‐52

Holick, MF. Medical progress: Vitamin D deficiency. NEJM 2007; 357(3):266-81

Vitamin D ‐ physiology

• PTH• Secretion triggered by low Ca

• Bone osteoclasts release Ca (needs 1,25 Vit D)• ↑ hydroxylation Vitamin D kidney• ↑ PO4 excretion, ↓ Ca, Mg excretion

N ff ↑ C ↓ PO4• Net effect to ↑ Ca, ↓ PO4

• 1,25 Vitamin D• 1‐hydroxylation triggered by low Ca, low PO4, high PTH

• ↑ Ca and PO4 absorption gut• ↑ bone dissolution and mineralisation• ↓ PTH 

• Net effect to ↑ Ca, ↑ PO4

Vitamin D ‐ sources

• Most Vitamin D synthesised in skin  • UVB 290 ‐ 315 nm

• Shorter wavelength, scatter

• Little UVB early or late in day

• BCC and melanoma related to UVA

• SCC and actinic keratosis related to UVB

• Melanin protects against skin cancer and stops UVBReviewed in Misra M et al. Pediatrics 2008; 122:398‐417

. 

• 1 MED in bathers = ~ 15,000 ‐ 20,000 IU vitamin D

• 1/3 MED x 15% BSA – 1,000 IU

Vitamin D in dark skin

• 2 Caucasians, 3 African American volunteers• 1 MED Caucasians, 60 fold increase serum Vitamin D• Re‐exposure 1 AA to 6 x UV dose led to similar increase

Clemens et al Lancet 1982; 1(8267):305–308.

• Surgical skin specimens exposed to UV (equator)• Longer time to (same) maximal level• 0.5‐0.75 h for type III a, 3‐3.5 h for type VI

Holick et al. Science 1981; 211:590‐3

• 31 medical students in winter, Philadelphia• 8 white (II/III), 8 black (VI), 8 Asian (III/IV) 7 Indian (V)• Whole body single sub MED dose for whites• All started with baseline < 5 nmol/L• White mean ~30 nmol/L, black mean ~ 10 nmol/L

Matsuoka et al. Arch Dermatol. 1991; 127:536‐8

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Sun exposure times in kids

• Basically unknown• Greater surface area for size

• Greater capacity to produce Vitamin D

• AAP guidelines will still recommend full sun protection for kids• Infants no direct sunlight 1st 6m

• Outdoor activities minimising direct sun exposure

• Full protective clothing and sunscreen

Vitamin D‐ some facts and figures

• Vit D• Formula = 40 ‐ 53 IU per 100 ml• Breast milk = 2.5 IU per 100 ml• Physical™milk = 20 IU per 100 ml (50 IU/cup)• Very little in other foods

• ½ cup margarine/d• 20 eggs/d• 30g fresh herring/d• 60 g pickled herring/d• 8 cups physical/d• 2 cups Anlene/d

Australian and New Zealand nutrient reference values: Calcium

Prevalence of low vitamin D in Melbourne

• Levels < 50 nmol/L

• 87% East African children (n=238, 2000‐02) McGillivray G et al. 2007

• 92% East African adults community health centres inner metro area (n=116, winter 2000) Skull et al, 2003

• 98% dark skinned/veiled women at RWH (n=222, winter 2003) Mulholland N, 2008

• Levels < 25 nmol/L

• 44% East African children (as above)• 80% dark skinned/veiled women at antenatal clinics (n=82, 1999‐2001) Grover R & Morley R, 

2001

• 80% mothers whose infants had rickets (n=31, 1994‐99) Nozza J & Rodda CP, 2001• 53% East African adults community health (as above)• 69% dark skinned/veiled women at RWH (as above)

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Vitamin D deficiency– ask about:

Symptoms• Bone pain

• Exercise tolerance, pain with sport

Risk factors• Dairy intake

• Low Burmese, Somali

• High Dinka, Nuer

S• Delayed motor milestones

• (Headaches) 

• Irritability

• Muscle cramps

• (Seizures)

• Sunscreen

• Covering

• Environment 

Misra M et al. Pediatrics 2008; 122:398-417

Vitamin D a practical approach

• Considerations• Reference range/when test done/where test done

• Any Rx previously

• Time of year

• Skin colour and covering

• Symptoms or Sx low calcium

• Rickets

• Dairy intake, type of feeds

Screening and monitoring (1)

• Screen all kids in the family (and parents)

• Check Vit D, Ca, PO4 and ALP in kids with risk factors

• If initial Vit D normal: repeat at the end of the first winter in A liAustralia

• If clinical rickets: PTH, CUE, X ray, photos

• If low calcium intake or Vit D < 25 nmol/L: check PTH

Screening and monitoring (2)

• Repeat levels 3 m post Rx if Vit D < 25 nmol/L

• Levels start and end of winter

• Clinical photos to monitor

• Limited value rpt XR within 12m

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Management

• Hypocalcaemia and/or symptomatic rickets hospital Ax

High dose Rx: 

• Kids > 12 m 150,000 IU• If rickets or levels < 25 nmol/L – repeat 6 w

• 3 ‐12 monthly depending on situation

• Dose raises levels by ~30 – 50 nmol/L

• All kids together, not in pregnancy

• Adequate Calcium (may need supplement)

Management

• Kids < 12 months• Formula fed always OK (except one 6 weeks ago)

• If on Pentavite – OK in our clinical experience

• Prevention is key

• Higher risk hypocalcaemia

• Lower dose 50,000 or 100,000

Dosing – evidence base

• 2006 National consensus statement recommends • Age > 12m 500,000 IU over 1 – 7 d

• SR literature• Surprisingly little evidenceSurprisingly little evidence

• Methodological issues with studies (timing tests/follow‐up)

• Inadequate evidence to support 500,000 IU oral

• Only one paper using 600,000 IU D3 oral ‐ unsafe

• One paper 600,000 IU D2 oral (n=42, rickets) safe

• One paper on STOSS dosing D2 – excessive

• 3 small series 400,000 IU ‐ variable

• 2 papers 600,000 IU D2 or D3 IM ‐ safe

Pharmacokinetic data RCH Vitamin D

150

26 adults, 150,000 IU at t = 0 and t = 6 weeks

50

Vitamin D‐ catch‐up growth

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Parasite screening

• FBE

• Thick/thin and ICT

• Fixed faecal specimen (protozoa)

• If GIT Sx ‐ ?3 faecal specimens

• Schistosoma serology• Better S haematobium/mansoni (~90%), not great mekongi/japonicum (~50%)/ ( ), g g /j p ( )

• If positive urine and faecal specimens

• Strongyloides serology

• If nothing found and persisting eosinophilia‐ filarial serology

• Occasional more exotic conditions

A call for the faecal specimen…

25

30

35

40

45

%

(Vietnamese (Ref(Vietnamese (ImmLaotianCambodians

Prevalence of Intestinal Parasites, Ryan N et al. 1987

0

5

10

15

20

Opisthorchis Hookworm Trichuris Ascaris Strongyloides

Fairfield Hospital, Victoria Similar studies from US and Canada

Schistosomiasis

• Flukes (Trematodes)• 200 M cases

• >300,000 deaths/year

2/3 Af i• 2/3 Africa

• If infected:

• 60% symptoms 

• 10% severe

Ross et al, NEJM 2002; 346(16):1212‐20

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Schistosomiasis

• 5 spp impt• Haematobium  perivesical • Mansoni • Intercalatum• Japonicum can go to brain• Mekongig

• Infection • Via water‐ from snails • Through skin, lungs, liver, gut vessels• Eggs‐lumen gut/urinary tract‐water• Humans definitive host

Schistosoma• Clinical

• Migratory phenomena: itch, dermatitis, lung, liver• Acute illness immune complex dis 4‐8/52 post exp• Chronic illness chronic granulomatous disease CMI  e.g. hepatic, urinary tract, gut 

Sx

• Diagnosis• urinary spec midday, stool smear• Ab assays more sensitive than Ag/ova detection• Blood eosinophilia more common in active disease

• Rx• Praziquantel 20 mg/kg x 2‐3 doses (4H)

Strongyloides

• Soil transmitted nematode (worm)• Cycle: 

• Larvae in soil‐ filariform, infective form

• Penetrate skin (blood, lungs, upper small intest)

• Mature worms 2.2mm‐ release eggs 4/52 later‐ ‐faeces

• Free living cycle

• Capable of reinfecting host‐

• penetrate intest wall/perianal skin 

• survive years in host 

• mechanism autoinfection

Strongyloides

• 1‐200M infected• Endemic areas‐ 2‐20% prevalence

• Clinical:• Migratory phenomena: dermatitis, larva currens• Abdo pain (often epigastric), • V, D (adult worms in upper SI) or alternating diarrhoea and 

constipation• Blood eosinophilia 50‐90%• Dissemination if immunosuppressed‐

• High CFR

Strongyloides

• Antibody tests not perfect• Faecal specimens: 

• Rx: Ivermectin (> 5 years old)• Ivermectin‐ cure rates ~90% • Albendazole‐ cure rates ~40%

• Be wary if Rx albendazole: may lower serology which will then raise again

• Never give immunosuppression if Strongyloides• Serology becomes negative in 6m w successful Rx

Malaria

• Prevalence rates post arrival ~5‐10%• Higher in some populations e.g. Liberians• Unexplained low in Karen

• Essential screen in any febrile person recently arrived from endemic area• 3 thick/thin films3 thick/thin films• Rapid antigen testing 84‐97% sensitive

• Plasmodium (false + 2‐4 w post Rx)• Falciparum (sensitive 90% + in >100/mcl)

• 98% of symptomatic Pl. falciparum present < 3 m

• 57% of symptomatic non falciparum present < 3 m, 96% < 12 mGriffith K, Lewis L, Mali S, Parise M. Treatment of malaria in the United States. A systematic review. JAMA. 

2007;297(20):2264‐77.

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Immunisation for refugees in Australia

• High risk inadequate immunisation

• Country of origin schedules different 

• Inadequate vaccinations in country of origin

• Catch‐up vaccinations in Australia

• Missed opportunities 

• Funding

• Service delivery issues

• A tendency towards chaos

Country of origin schedules

http://www.who.int/countries/en/

Country of origin schedules

No-one will be up to date

Seroimmunity‐ summary

• Limited information• Measles 

• 9 studies, only 2 cohorts > 90% protected

• Rubella

• 10 studies, 74 – 97%

• Tetanus 

• 5 studies, in 4 cohorts < 65% protected

• Hepatitis B

• 9 studies, 20 – 66% in 7 cohorts

3. Immunity is suboptimal, even for COB schedule vaccines

Hepatitis B infection

• Prevalence in refugee Australian cohorts

• 3 – 8%  in African cohorts 3,5,21‐3 (2000‐05) 

• 3.5 – 9.5% in SE Asian cohorts 5,8 (1998‐2004)

• 2.5% in asylum seekers from Afghanistan and Iraq 24 (2000‐01)

• Prevalence in resettled refugee cohorts overseas

• 4.7 – 6.1% in complete cohorts 12,25 (USA 1993‐95, NZ 1995‐99)

• 4 – 14% in predominantly African cohorts 26‐8 (1994‐1999)

• 5.3 – 9.5% in predominantly Asian cohorts 20,25 (1979 ‐2002)

• 0.5 – 13.6% in European / Middle Eastern cohorts 19,29‐31 (1997‐2000)

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Hepatitis B infection

• Screen (sAb, cAb, sAg)• Immunise if negative• If positive‐ Clinic guideline reasonable summary

• eAg status• LFT• Viral loadViral load• Comorbidity (HCV, HDV, (HAV)) and medication considerations

• Toothbrushes/shaving• Contraception• Vaccinate household/partners and check serology post• Cleaning blood spills• Telling doctors • Not telling schools

Missed immunisation opportunities150 East African children attending RCH Immigrant health clinic November 2000‐January 2002 7

• 98% had incomplete/unknown immunisation status • Children had been resident in Australia up to 4 years. 

156 children RCH Immigrant health clinic over 2002 6

• no child was reported as being up to date for schedule vaccines• 65% (101/156) reported having none of these vaccinations, • 66% of this group had seen a Maternal and Child health Nurse or GP at least once. g p

Community based survey of 70 recently arrived refugee children in English language school, Melbourne 2006 33

• 75% of children had had a post arrival health check and 91% had a family doctor, • 28.6% had immunisation at a GP and 4.8% at a Community Health Centre. • For those in Australia < 6 months (n=30), none had had immunisations in primary care, although 

89.5% of this group had had a post arrival health check at a general practitioner. 

Barriers to immunisation program delivery

• Language and systems literacy• Interpreters

• Handouts

• Print literacy

• Appointment letters 

• Client awareness of services

• Service awareness of clients

• Service awareness of other parts of settlement

Vaccine funding (Victoria)

• MenCCV• Not funded for any child > 8 years

• Hepatitis B• 0 ‐ 9 years free catch‐up • 10 ‐ 11 years wait for high school catch‐up in the future? Stops 2012• 12 years + should receive high school catch‐up

• program targeted year 7

• arrivals year 8 + may miss catch‐up• Adults unfunded, unless household contact

• HPV • Catch‐up program stopped June 2009

Trauma experience ‐ European

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Trauma experience ‐ European Trauma experience

Former Yugoslavia:• Death/loss loved one: 12 studies, 6 > 45% (952/2934; 1 in 3)

• Separation parents: 12 studies, 7 > 60% (1482/2934; 1 in 2)

Trauma experience ‐ Asian Trauma experience – African and UHM

FGM

• All procedures partial/total removal external female genitalia

• 4 types• Clitoridectomy (partial or total removal of the clitoris), 

• Excision (partial or total removal of clitoris and labia minoraExcision (partial or total removal of clitoris and labia minora, with/without excision of labia majora)

• Infibulation (narrowing of the vaginal opening through the creation of a covering seal formed by cutting and repositioning the labia with/without removal of the clitoris)

• Other (all other harmful procedures to the female genitalia for non‐medical purposes) 

FGM

• Quota refugees resettled in New Zealand, 1995‐1999. 

• 346 of 606 women from Congo, Sudan, Ethiopia and Somalia were reported to have had FGM• 43.2% in Ethiopian women

• 71 5% in Somali women71.5% in Somali women

• Found all ages, prevalence greater > 10 years 

• Study of 28,393 women in Africa• 40‐88% in the 6 countries studied Burkina Faso, Ghana, Kenya, 

Nigeria, Senegal, Sudan

6/01/2011

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Adolescent considerations

• All usual adolescent transitions + change in family role + culture + language + education

• Health/wellbeing• Different pre‐departure screening• Different post arrival screening• Higher risk TB reactivation• Hep B STI

Hi h i k d i i d• High risk underimmunised • Different emotional/behavioural issues

• Education• Retain accent• Longer academic language• Different education pathways

• Safety• Environment and interaction with justice system

• Family • Role reversal

• Settlement• No adolescent specific service tension between adult and family models

Birthdate

• ?20%• Usually emerges ~ 2 years after arrival

• Unknown (1/1/xxxx are all younger)• Incorrect DIAC paperwork

/l k f k l d• Fear/lack of knowledge• Better rations if older – changed date• Not person on visa (and not biologically related to family)• Family situation – parent separation/reunions

• Think of implications…• Test validation

Second Language Acquisition

Key variables affecting acquisition• Age

• Cognitive development in first language

• Schooling• Schooling • Duration

• Continuity 

• Type

• Parent education • Higher parental education a/w faster ESL acquisition

Language acquisition

• Conversational proficiency 1 – 2 years

• Preschoolers• Appear quick (simpler language)

• 7 – 10 years if immersiony

• Late primary• Quickest 

• 5 – 7 years

• Adolescents• 6 – 8 years

• Retain accent

Key points

• Big group Australians

• Developing world health issues• Similarities and differences country origin

• Patchy screening (esp 2002 – 06)y g ( p )

• Always need catch‐up immunisations

• Medical issues broader applicability

• Implications education/development

• Developing ?speciality (niche area!)

• Accredited 0.5 mandatory training position!