Refugee health

Most Australian refugees come from southern and south-east Asia, the Middle East and Saharan Africa. Most, especially children, arrive with a variety of medical problems.

Predeparture screening

History and examination; chest X-ray if ≥11 years; HIV and syphilis tests if ≥15 years; hepatitis B surface antigen if pregnant, an unaccompanied minor, or on an onshore protection visa/health care worker; hepatitis C antibody for onshore protection visas/health care workers; malaria rapid antigen test and treatment, and helminth testing plus albendazole, for humanitarian entrants; MMR if age <30 for humanitarian entrants. Depending on how they arrived, this may not have been done (a boat arrival may have had it completed at the immigration detention centre; a plane arrival may not have).

Barriers to seeking healthcare

Language, financial stress, competing priorities in the settlement period, and difficulties understanding and navigating the healthcare system.

Medical assessment

Ideally within 1 month of arrival.

Common presenting problems: psychological and behavioural disorders, anaemia (especially iron deficiency), oro-dental disease, intestinal parasites, malaria, Helicobacter pylori infection/peptic ulcer disease, vitamin deficiencies (especially D and B12), disorders of the skin/eyes/ears, chronic disease.

History: presenting problem(s); family history including haemoglobinopathy/genetic disorders; migration history (time in refugee camps, exposure to violence/torture/trauma); past history including tropical diseases; developmental history; immunisation; diet (vitamin intake); drug history including IV drug use/smoking; mental health, trauma history, behavioural issues in children; appetite, weight, energy, sleep, mood, sex.

Examination: growth/weight/BMI (percentile charts); skin (rash, BCG scars, pallor, jaundice); hearing and vision; oro-dental; cardiovascular; respiratory; lymphadenopathy/hepatosplenomegaly; genital mutilation; urinalysis.

Investigations: FBC, ESR, CRP; UEC, LFT; TB (chest X-ray, Mantoux, IGRA); malaria (thick and thin films, rapid antigen test); blood-borne viruses (HIV, HBV, HCV); STIs (syphilis, PCR for chlamydia/gonorrhoea); helminths (strongyloides serology, stool microscopy for ova/cysts/parasites); schistosomiasis serology; consider iron studies, vitamin A/D/B12, and haemoglobinopathy electrophoresis screen.

Specific common issues

Social isolation and displacement; tropical/developing-world diseases (helminths, malaria, schistosomiasis); infections (TB, HBV, HCV, HIV); sexual and reproductive health; female genital mutilation; dental health; nutritional deficiencies (e.g. rickets, B12); childhood growth and development; immunisation status; chronic medical problems; specific genetic disorders.

Psychological issues

Trauma background and cultural differences are common. Psychological distress often presents as physical symptoms — headaches, chest pain, upper GI discomfort. Children/adolescents may show behavioural problems, aggression, acting out, running away, poor concentration/school performance, somatic complaints, self-harm/suicidal ideation, or anxiety/phobias/ depression — the “strengths and difficulties questionnaire” is a useful screening tool.

Vitamin D deficiency

A prevalent problem, especially in children; most are asymptomatic. Look for signs of rickets: limb pain, stunted growth, teeth deformities, fractures, skeletal deformities (e.g. leg bowing).

Helicobacter pylori

Up to 90% of the population in developing countries are infected. Consider a breath test and treatment, especially with symptoms of peptic ulcer disease.

Haemoglobinopathies

Sickle cell disease (Africa), alpha/beta thalassaemia and G6PD deficiency (Mediterranean, Africa, south-east Asia) are over-represented in the refugee population — have a low threshold to screen. Look for skeletal abnormalities and hepatosplenomegaly.

Malaria

Children under 5 are at most risk.

Schistosomiasis

A blood trematode often encountered in African refugees; many infected are asymptomatic. Chronic infection can cause GI symptoms (diarrhoea, nausea, abdominal pain), failure to thrive/weight loss, chronic cough, or haematuria. Serology has high sensitivity. If positive: treat with praziquantel, arrange a renal tract ultrasound, and refer to a renal physician.

Tuberculosis

All refugees should have a specialist chest clinic assessment within 2 months of arrival.

Immunisation

A formal catch-up schedule is recommended.

Preventative health

Should align with standard Australian screening/red book recommendations.