See Infectious diseases, chapter 30, p. 405.

Hepatitis B infection is endemic in Africa and south Asia. Hepatitis B vaccination is part of the routine schedule in Australia and many countries of origin including Sudan and Egypt (but not Kenya or Somalia). Hepatitis B vaccination of non-immune children and adolescents is a priority. Chronic infection results in chronic hepatitis, and cirrhosis occurs in up to 1/3 of affected individuals, who have an increased risk of hepatocellular carcinoma. Chronic infection is most likely to occur after exposure in early life.

Screening

• Screen for HBsAg (infection) and HBsAb (immunity – due either to past infection or immunisation).
  
• HBsAb >10 IU/L indicates adequate immunity.
  
• Children who are HBsAg positive need further tests (LFTs, HBcAb, HBeAg, HBeAb) and a screen for hepatitis A and C (immunise against hepatitis A if needed).
  
• STI screening may be needed depending on age and history.

Further management of children with chronic hepatitis B infection

• All acute cases with clinical illness need immediate discussion with gastroenterology.
  
• Explanation/education/counselling:

– Advice about blood spills and infection risk – suggest gloves to clean blood spills and disinfection with diluted (1 : 10) household bleach.

– Advice to notify their treating doctors when starting medications.

– Advice about avoiding excess alcohol consumption.

• Screen and vaccinate household against hepatitis B.
  
• Commence hepatotoxic drugs cautiously – particularly anti-TB therapy.
  
• Hepatitis B is a notifi able disease.
  
• Other management depends on serology, LFTs and clinical status. The primary goal of therapeutic management in the individual is to eliminate or suppress hepatitis B.

• Children are at increased risk for faecal/oral and horizontal transmission.
  
• Symptoms may be non-specifi c:

– Ask about abdominal pain (which may be anywhere), constipation, diarrhoea, bloody diarrhoea and growth.

– Ask about bladder symptoms and haematuria (seen in Schistosoma haematobium infection).

– Macroscopically visible worms are likely to be tapeworms or ascarids.

• Parasite infections may last for years and have sequelae for nutrition, growth and function.
  
• Strongyloides infection should be regarded as persisting lifelong if not treated. Patients with untreated Strongyloides infections can develop hyperinfection syndrome if given immunosuppressant therapy, including short-course steroids. Hyperinfection syndrome has a high mortality, even with treatment.

Management

• Screening should be part of the initial assessment.
  
• In general treatment is usually short course (often single dose) and well tolerated.
  
• The following require treatment, and specialist advice may be helpful: – Ascaris lumbricoides.

– Giardia intestinalis (lamblia).

– Ancylostoma duodenale or Necator americanus (hookworms). – Strongyloides stercoralis.

– Schistosoma spp.

– Taenia solium or T. saginata (tapeworms).

– Trichuris trichuria (whipworm).

– Rodentolepis nana (dwarf tapeworm).

Human immunodefciency virus (HIV)

See Infectious diseases, chapter 30, p. 417.

• Many children come from regions with high prevalence of HIV infection (e.g. sub-Saharan Africa, south-east Asia).
  
• Consider testing:

– Children with symptoms of possible HIV infection (e.g. failure to thrive, chronic respiratory infections, persistent thrush, generalised lymphadenopathy).

– Where parents are known or suspected to be HIV positive, regardless of pre-departure screening results.

– Children with TB disease.

• Pre-test counselling for HIV is legally compulsory.

Dental disease

Assessment of dental health is particularly important in refugee patients, as the patient may have had limited access to dental care services and/or poor diet, or may have sustained injuries. A dental review should be recommended for all recent immigrants.

Development and mental health considerations

Development may be affected by any combination of biological, environmental, social and emotional factors. Considerations in children and adolescents of a refugee background include.

• Biological: Malnutrition, chronic disease, hearing impairment, visual impairment, family history, prematurity.
  
• Environmental: Living conditions, access to schooling, access to food, exposure to communicable diseases, language transitions.
  
• Social: Parenting roles, family disruption, changing roles and responsibilities.
  
• Emotional: Stress, trauma experiences, displacement, uncertainty around future, mental health issues.

Responses to trauma include depression, anxiety, post-traumatic stress, low self-esteem and guilt. These may manifest in a variety of ways including behavioural problems, problems with sleeping and eating, poor school performance, diffi culty making friends and psychosomatic symptoms. Consider mental health in the broad family context, parents with mental health issues themselves will have reduced coping and parenting skills.

A thorough history and examination will establish risk factors and contributors. In reality, developmental and mental health surveillance will usually occur after the initial assessment. If developmental or learning concerns are elicited, organise vision and hearing assessment, screen for thyroid dysfunction and treat iron defi ciency early. Consider mental health issues as a contributing factor or co-morbidity.

Health screening is only one part of promoting health and well-being in new immigrants to Australia. Facilitating resettlement in terms of learning English, educational placement and gaining employment are also priorities and will promote physical and psychological health in families. Parents are likely to have their own health needs and will also warrant appropriate health assessment.