Post on 30-Mar-2020
6/01/2011
1
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
17
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!