Refugee health

3.14 Refugee health



Georgia Paxton, David Burgner



Introduction


This chapter highlights some of the key health issues commonly encountered in refugee children and their families. The focus is on refugee health in Australia, but the concepts are relevant to refugee children and their families settling in other countries.


The protection of people who have been forced to leave their homes due to armed conflict and human rights abuses is a major global challenge. In 2009, there were approximately 15 million refugees worldwide, 1 million people seeking asylum and 27 million people displaced within their own countries because of conflict. The majority of refugees remain in their area of origin. Only about 1% of all refugees are resettled in a third country, and only about 1% of these are resettled in Australia.


Annually, Australia currently accepts 13 750 people under its humanitarian programme, and New Zealand accepts 750 refugees. In total, more than 140 000 people of a refugee background have arrived in Australia since the mid-1990s, representing a significant population group, with unique health needs. The current Australian humanitarian intake is mainly from Burma (Myanmar), Iraq, Afghanistan, sub-Saharan Africa and Bhutan. Refugee arrivals include a high proportion of children and young people; over half the intake is less than 25  years of age. Families are often large, with women heading the household, and there may be many children within a family group. Some children and young people arrive as unaccompanied humanitarian minors, defined as those aged less than 18 years with no parent to care for them.



Definition of refugee and asylum seeker


A refugee is a person 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 to or, owing to such fear, is unwilling to avail himself of the protection of that country.’


Article 1, The 1951 Convention Relating to the Status of Refugees


An asylum seeker is a person who has left their country of origin, has applied for recognition as a refugee in another country, and is awaiting a decision on their application.


Refugee children, young people and families:



• are usually resourceful and resilient


• will have experienced major transitions with migration and settlement, affecting their family, education and community structure


• may have had inadequate food, water, shelter and safety


• may have spent a prolonged period in refugee camps


• are likely to have come from situations where health care is inadequate


• will have health conditions reflecting their area of origin and country of refuge, with exposure to communicable and vaccine-preventable diseases


• will need catch-up immunization


• may have an incorrect birth date on their paperwork


• are likely to have disrupted education


• may have been separated from their family, or lost family members


• may have experienced physical or sexual violence, including torture and severe human rights violations


• may have mental health problems


• may not be familiar with preventative health care


• may also have more familiar paediatric health issues.



Refugee health assessments




imagePractical points




• Refugee children have usually not had pre-departure health screening in their country of origin.


• Health assessment for refugee children/young people is recommended after they settle in a new country; including an assessment of general health, nutrition, immunization status, infectious diseases (malaria, parasites, hepatitis, tuberculosis risk) and mental health.


• There are additional diagnoses to consider for common presentations in refugee children/young people.


Refugees settling in developed countries should be offered voluntary health screening. Screening protocols vary depending on countries of origin and settlement, and may also vary with refugee/asylum seeker status. Health screening may be completed ‘offshore’ (before leaving the source country) or after arrival in the new country, and may include presumptive treatment for infectious diseases. Many countries use a combination of offshore and post-arrival screening.



Pre-departure screening


In Australia, health screening and treatment prior to departure is limited for children and younger adolescents. The visa health assessment, completed for any permanent arrival to Australia, not just refugee entrants, is directed at excluding active tuberculosis (TB), and includes a physical examination, urine ward test (age ≥ 5  years), chest X-ray (age ≥ 11 years) and human immunodeficiency virus (HIV) serology (age ≥ 15 years). There are no other routine screening tests. Humanitarian entrants may have additional offshore pre-departure medical screening (PDMS). This varies with port of departure, but may include malaria screening (and treatment if needed), empiric antihelminth treatment and a single mumps, measles, rubella (MMR) vaccination (age from 9 months to 30 years). PDMS is a voluntary process and uptake is not complete.



Post-arrival health assessment


It is important to explain the concepts of health assessment, screening and disease prevention; families (and adolescents individually) need to understand the importance and implications of health screening and give informed consent. A professional health interpreter will be needed in the majority of consultations. It is never appropriate to use a family member or friend as an interpreter. It is important to explain the bounds of confidentiality for both the medical consultation and working with an interpreter, and this may help families feel more comfortable. One of the simplest clinical points – often forgotten – is that working with an interpreter takes twice as long: everything is said twice and this needs to be factored into appointment times.


Assessment of newly arrived refugee children and adolescents should focus on:



• parent (or self-identified) concerns


• excluding acute illness


• confirming the reported birth date


• immunization status and catch-up


• screening for TB


• symptoms of parasite infection, including malaria


• nutritional status and growth


• significant developmental issues, including vision and hearing


• dental health


• mental health issues, particularly features of post-traumatic stress disorder (PTSD)


• issues arising during resettlement (housing, financial stress, education).


It is important to take a routine background history, as for any patient, although there are different factors to consider in children from a refugee background. Access to antenatal and perinatal care may have been limited, and child health screening (neonatal, vision, hearing screening) may have been limited or non-existent. Access to health care, dental care and education varies widely. We have found it helpful to ask specifically about chronic diarrhoea and malnutrition in infancy, hospital admissions overseas, episodes of malaria and/or coma, and trauma, as it is surprising how frequently these issues are not revealed initially.


Understanding the migration pathway, together with the language and education transitions, is important in appreciating the child’s and family’s experiences and the effects on health and development. This must be handled sensitively, as there may have been significant trauma. It is not usually appropriate to ask about this directly on the initial visit (unless the family volunteers this history). Useful questions include, ‘Who is in your family in Australia?’ and ‘Do you still have family overseas?’, rather than asking specifically about family members. It is also helpful to ask what people did overseas, recognizing the breadth of occupations/educational levels within refugee cohorts, and acknowledging that people are not simply defined by their refugee experience.


Key points in history and examination related to screening investigations are shown in Table 3.14.1.


Table 3.14.1 Key points in history and examination related to screening investigations











History Examination Suggested initial post-arrival screening investigations


• Fever (malaria, TB, other infections)


• Night sweats/malaise/weight loss/poor growth/chronic cough/contact and family history, health undertakings (TB)


• Low-grade bony and muscular pain, pain with exercise, dairy intake, symptoms of low calcium (muscle cramps), access to outside spaces/time spent outside, skin colour, covering (vitamin D)


• Tiredness, diet (excessive milk, weaning, solids, meat), food access, family history, blood loss (anaemia, iron deficiency)


• Jaundice, RUQ pain, family history, transfusion, shared needles (hepatitis)


• Abdominal pain, diarrhoea, blood PR, macroscopic worms, rashes, skin nodules (parasites)


• BCG status, history of chickenpox, immunization documentation and PDMS (immunization status)


• Epigastric pain, early satiety, poor appetite, family history of ulcer disease (Helicobacter pylori)


• Pregnancy, genital pain, discharge, ulcers, lumps and contact history (STI screening)

 A thorough physical examination of all systems is required:

• Growth parameters


• Nutritional status


• BCG scar


• Pallor (anaemia, haemoglobinopathies)


• Oral health (dentition, periodontal disease)


• ENT (chronic middle ear disease)


• Goitre (unscreened thyroid disease)


• Features of rickets (swelling of wrists/ankles, deformity (which reflects the age/growth of child when low vitamin D status occurred), delayed dentition, late closure of anterior fontanelle, bossing


• Skin, hair, nails (dermatophytes)


• Hepatosplenomegaly (e.g. malaria, Schistosoma, HIV)


• Conditions that would usually be assessed during childhood and may have been missed (e.g. cardiac murmurs, inguinal hernia, undescended testes)


• Culturally specific findings (e.g. uvulectomy, teeth removal, scarification)

• FBE and film


• Ferritin


• Vitamin D, calcium, phosphate, ALP


• Vitamin A


• Malaria screen (thick and thin films, and rapid diagnostic test)


• Hepatitis B screen (HBsAg, HBsAb and HBcAb)


• Hepatitis C serology


• Schistosoma serology


• Strongyloides serology


• Faecal specimen (ideally fixed)


• Mantoux test


• STI screen (Neisseria gonorrhoeae and Chlamydia trachomatis urine nucleic acid detection; syphilis serology (TPHA) – consider in all children, to exclude congenital infection) in sexually active adolescents or if there is a history of sexual violence


• HIV screening – Consider in all children, should be completed in sexually active adolescents, if there is a history of sexual violence, or where parents are deceased/missing/known to be HIV positive, or if clinical symptoms/signs


• Helicobacter pylori faecal antigen testing if suggestive symptoms


ALP, alkaline phosphatase; BCG, bacille Calmette–Guérin; ENT, ear, nose and throat; FBE, full blood examination; HIV, human immunodeficiency virus; HBcAb; hepatitis B core antibody; HBsAb, hepatitis B surface antibody; HBsAg, hepatitis B surface antigen; PDMS, pre-departure medical screening; PR, per rectum; RUQ, right upper quadrant; STI, sexually transmitted infection; TB, tuberculosis; TPHA, Treponema pallidum haemagglutination assay.


Some groups may need additional screening investigations based on prevalence data from their country of origin, or conditions prior to departure. In addition, children with clinical symptoms may require additional investigations. Other differential diagnoses to consider in refugee children are shown in Table 3.14.2.


Table 3.14.2 Common presentations and differential diagnoses to consider in refugee children



























Presentation Common causes Additional considerations
Fever Common viral and bacterial infections (check for localizing features, etc.)

• Malaria*


• Dengue and other arboviral infections*


• Typhoid*


• Dysentery*


• TB in any site, especially if prolonged


• Dental disease (often missed)

Respiratory symptoms Consider the usual causes of respiratory symptoms relevant to the age group, such as viral respiratory tract infection, pneumonia, asthma, bronchiolitis and croup

• Whooping cough – pertussis vaccination may not have been available in country of origin


• TB should be considered in children with cough  >  2  weeks


• Sickle cell disease may present with acute chest syndrome


• Parasite infections may (very rarely) cause wheeze/respiratory symptoms

Abdominal pain Consider the usual causes, such as acute infection, constipation, surgical or gynaecological problems

• Parasite infection – diarrhoea, rectal bleeding, constipation, hepatic symptoms, haematuria


• Helicobacter pylori gastritis – early satiety, anorexia, family history of similar symptoms, nausea/vomiting


• Hepatitis

Diarrhoea Consider the usual causes of viral and bacterial gastroenteritis

• Bacillary* and amoebic dysentery are common in the developing world


• Parasitic infections are common


• Lactose intolerance may be more common in some racial groups

Rashes Eczema; dermatophyte (Tinea) infections

• Strongyloides infection may cause an intermittent urticarial rash lasting a few days (larva currens); this may be located anywhere but is most typically on the buttocks/perianal region


• Skin nodules or a depigmented rash on the lower shins suggest parasite infections; specialist consultation is required

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Aug 4, 2016 | Posted by in PEDIATRICS | Comments Off on Refugee health

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