Refugee Health Infectious Diseases, Age Determination and other health problems Dr. Jill Benson Senior Medical Officer Migrant Health Service and Director, Health in Human Diversity Unit Discipline of GP, University of Adelaide
Nutritional deficiencies – Vitamin D, A, B12, folate, and Iron
Injuries from pre-migration torture & trauma
Rheumatic heart disease
Childhood development problems
Low immunisation rates
Serious mental health problems
Thick and thin films, antigen
Abs, stools &/or urine
especially if anemia or eosinophilia
Other nutritional deficiencies eg Vitamin A
Hepatitis B and C status
Hep B surface antigen indicates infectivity & further tests needed to assess risk (Hep B eAg and Ab)
Iron studies +/- haemoglobin variant analysis
especially if pre-departure screening has been a long time before and patient is from high-risk area
Children not tested before arrival
must be appropriate pre- & post-test counselling
Mental health problems
symptoms may not appear until a long time after arrival (honeymoon period)
Look for other signs eg eneuresis (up to 50%)
Other sequelae of torture and trauma
e.g. physical injuries; behavioural problems in children.
Schistosomiasis (bilharzia) infects humans when skin comes into contact with water contaminated with certain snails
Asymptomatic in up to 80%
Most common cause of massive splenomegaly
Schistosomal portal hypertension occurs in only a minority with normal liver function tests until very late.
The initial presentation even in the young may be with bleeding oesophageal varices
300-500 million cases/year
Mortality of 3 million/year , 89% of these in Africa
Children most at risk
Of the 13000 refugees each year, about 70% are from areas where malaria is endemic
A ‘fitness to fly’ assessment includes a rapid diagnostic test
If positive, given a 3 day course of treatment
Sensitivity of the test is only 95-98% so will miss those with early infection, a low parasite count or who contract the infection between the health assessment & leaving the country
Malaria in refugees is 8% in WA, 5% in SA, 10% in Hobart and 16% in Newcastle.
Symptoms of malaria
Not the traditional pattern of periodic fever with paroxysms of cold, hot and sweating
Usually fever, vomiting, diarrhoea, headache, muscle pain.
Older patients may have developed partial immunity to malaria and may not be symptomatic on arrival
Can be treated as an outpatient if:
Asymptomatic or minimal symptoms
Over 10kg, and/or 12 months old
Parasitaemia of less than 1%.
WHO estimates that more than 1/3 of the world’s population is infected with TB
Africa high prevalence >300/100,000 cf Aus 5.8/100,000
90% of those with TB in Australia are born overseas
20/100,000 in overseas-born cf 0.9/100,000 for Aus-born
Culture for AFBs in the sputum is the gold standard
High prevalence country
Crowded living conditions
Poor general health
Tuberculosis in refugees
Up to 50% of refugees have positive Mantoux
indicates 10% lifetime risk of TB in adults
40% risk of progression to TB if < age 1
20-30% risk of progression to TB if age 1-15 years
Latent TB common, active TB rare
Most risk in first 2 years after arrival
Non-pulmonary TB more common, especially in children
Not usually infectious if <12 years of age
Some will have had BCG
Chest Clinic does Mantoux on children through schools
HBV 2.2 per 100,000 in 2001 cf 1.5 in 1997 with consequent increase in hepatocellular carcinoma
70% of those with chronic HBV in Australia born overseas
Approximately 20% of refugees from some countries are hepatitis B sAg positive
90% of those infected perinatally will have chronic infection with
25% risk of cirrhosis or
Vitamin D deficiency in refugees
Vitamin D deficiency in 40-80% of refugee patients
Women who wear veils for cultural reasons and dark-skinned migrants from Africa
May have seizures, rickets or chronic non-specific
Treatment with megadose of cholecalciferol such as 100,000 IU in 1ml flaxseed oil
W and CH Vit D protocol
5000 IU daily for 3 months if > 12 months
3000 IU if <12 months
Most have had minimal immunisation
May be forged or incomplete records
Important that vaccines are age-appropriate eg Prevenar and Pneumovax
Little or no knowledge of vaccine preventable diseases and the Australian schedule
At risk of diseases eg measles and pertussis
At risk of over immunisation if multiple providers involved
Special NARI clinics in Council areas for newly arrived refugees
Most cultural practices are not harmful but important to ask as some might be eg
Not giving certain foods if a child is sick eg protein
‘ Cupping’, scratching or rubbing with kerosene
Female and male circumcision by inexperienced people
Children should not be fasting in Ramadan but some do
Fear of becoming addicted to
Massaging broken limbs
Review social parameters of illness
Education (?prioritised over health)
Housing (several kids in same bed)
Transport (kids find their own way)
Language and literacy
Cultural communication skills
The Importance of knowing correct age
Taught at a suitable educational level
Correct medication and dose
Developmental milestones eg urinary incontinence
Determining potential emotional resources for dealing with stressful life events
Get married, join the army, drive, receive Centrelink payments or vote
Local authorities fulfil their obligations in providing support and services to vulnerable groups, such as unaccompanied minors aged less than 18 years
Why don’t we know the correct age?
The significance of birthdates tends to be cultural and many may know the year of birth but not the day or month
Banning of calendars (eg in Afghanistan)
Chaotic circumstances surrounding the time of birth
Child and parents may have been separated for some time
Child is the child of only one parent (eg one wife may come with the children of other wives)
Child may be adopted from another family
Visa authorities made an inappropriate estimate of the child’s age
Many other systemic or administrative errors or mishaps.
How can we assess a child’s age?
Wide range of normal even if a child has good health, adequate nutrition and a stable environment
If there is illness, undernutrition, extreme stress and disrupted socialization, any tools used to assess age are likely to be even less reliable
Use narrative accounts, physical assessment of puberty and growth, and cognitive, behavioural and
X-rays should be used as a last resort
Assessing age by ‘medical’ means
Left wrist X-ray standards developed in white north Americans in 1942 are not applicable in 2008 or for other geographical locations, climates, ethnicities or socioeconomic groups
Bones, teeth and sexual maturation affected by:
general health and illnesses
nutrition or malnutrition
climate and altitude
Vitamin D and calcium levels
Original records such as ‘road to health cards’ and immunisation documents
Recording an accurate narrative account requires time and patience, a good interpreter and a non-judgemental approach
Where the family was at time of birth
the time of year of birth (winter, summer, wet, dry)
when the child first walked (approx one year)
when the child was dry in the day (approx 3 years)
age in relationship to other children
The following assessment tool should be used to confirm age estimates in the absence of correct legal documentation. Accuracy of the final assessment will be within a range of approximately two years and should be expressed as an estimate for educational purposes only. This estimate is not legally binding.
If estimated age (age stated by parents and others) of child is less than 18 months different to the age on the visa, do clinical history and assessment.
If estimated age is more than 18 months different to the age on the visa add X-ray of left wrist.
Questions which may be useful in helping parents remember the child’s date of birth:
Are there any other records which may show child’s age – immunisation/ health records?
Where the family was at the time of birth.
Time of year of birth (winter, summer, wet, dry).
Walking (approx one year) – how long ago?
Toilet trained i.e. dry in the day (approx 3 years) – how long ago?
Age in relationship to other children in the family.
According to MHS Age Assessment protocol - which includes the above criteria, the age is assessed as: X-ray left wrist: Health professional’s estimate of age on the basis of maturity and relationships with other people. <11 or >13 <13 or >15 Puberty (if appropriate and with consent) : Girls - periods commenced (usually around age 11-13 yrs) Boys - noted voice change (usually around age 13-15 yrs) Assessment of child’s current developmental stage: http:// www.health.qld.gov.au/child&youth/factsheets / Assessment of child’s date of birth according to parent’s story* Height : plot on 50 th percentile and find age to match Weight : plot on 50 th percentile and find age to match Parents initial estimate of age: Child’s age according to other documentation e.g. early child hood immunisation records, passport . Date of Birth on visa: Assessed age Questions / Observations:
Relationship the most important tool for healing
Long-term treatment may be a very unusual thing
Multidisciplinary team approach esp with school
Try to work with family’s expectations as well as your own
Important to estimate age
Be prepared for unusual
Remember, every encounter with a refugee is an opportunity to heal the past and bring hope for the future.