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A summary of special issues for refugees is presented in TABLE 135.2.
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Predictably these traumatised people experience a wide range of psychological sequelae, particularly loneliness/isolation, post-traumatic stress disorder with anxiety and depression. They experience the whole gamut of the usual life-stage conditions, financial concerns and gender-related issues that we encounter in everyday general practice. However, these problems are compounded possibly by cultural differences and poor language skills if they come from a non-English-speaking background. Effective communication and counselling skills are required to tease out, identify and manage any psychological disorders. Psychological distress often presents as physical symptoms such as headaches, chest pains and upper gastrointestinal discomfort.
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Many refugees seem to manage very well with the transition, feeling relief to be in a safe and supportive environment.
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According to one refugee children’s group, children and adolescents may exhibit disorders such as:5
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behavioural problems
aggression
acting out
running away
poor concentration and school performance
somatic complaints
self-harming or suicidal ideation
anxiety, phobias or depression
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A recommended tool for assessing children’s psychological well-being is the Strength and Difficulties Questionnaire, available online at <www.sdqscore.org>.
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This is a prevalent problem, particularly in children, for a variety of reasons, including poor dietary intake, dark skin, relocation to higher latitudes and low levels in breast milk. Those undergoing rapid growth, particularly infants and adolescents, are at greatest risk of insufficiency. Most children will be asymptomatic but check for signs of rickets (see CHAPTER 9) and deficiency such as leg bowing, delayed walking, bone and muscle aches and weakness. Blood levels of 25-OH vitamin D <50 nmol/L require treatment—a particular problem for families in meeting the costs of treatment.
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Vitamin B12 deficiency8
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It is important to recognise and treat vitamin B12 deficiency early to prevent permanent neurological changes. The problem can get overlooked in the complexity of multiple issues in refugees. It should be considered in the same context as any other vitamin and mineral deficiency such as vitamin D.
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Helicobacter pylori infection
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Besides dietary deficiency the other major risk factor in developing countries is Helicobacter pylori infection with figures indicating that up to 90% of the population is infected5 (see CHAPTER 47). This infection should be considered in any adult with symptoms suggestive of peptic ulcer disease or any child with chronic abdominal pain, other GIT symptoms and failure to thrive. Consider a helicobacter breath test and triple therapy.
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Genetic disorders such as sickle-cell disease (Africa), α and β thalassaemia and glucose-6-phosphate dehydrogenase (G6PD) (latter two Mediterranean, Africa and South-East Asia in particular) are over-represented in refugee populations (see CHAPTER 18). Affected people may be asymptomatic carriers or symptomatic, with symptoms including haemolysis precipitated by infection, cold, hypoxia, drugs and antioxidants. Look for skeletal abnormalities and hepatosplenomegaly on examination and screen with appropriate tests if clinically indicated.
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Routine hepatitis B vaccination does not occur in endemic areas of Asia and Africa. The rate of infection there is at least eight times higher than the background infection rate of 0.9% in the general Australian population.5 In particular, those coming from refugee camps are highly susceptible to the spread of hepatitis B. Those with active infection may be asymptomatic, so screening (HBsAg, HBsAb, HBcAb) and subsequent management are important health issues for the refugees and the community. See CHAPTER 58.
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Malaria is a common infection in endemic regions where most African and South-East Asian refugees originate. Children under 5 years are at most risk and although predeparture testing should detect infected people, some may manifest the disease after arrival. The diagnosis is made on three separate thick and thin blood films but one single test supplemented with a rapid antigen test may be a practical way of detecting the disease (see CHAPTER 15). Treatment should be directed by an experienced consultant.
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Schistosomiasis (see CHAPTER 15) is a blood trematode often encountered in African refugees; it is usually acquired in childhood from swimming in contaminated freshwater. Approximately 200 million people are infected worldwide. Many of those infected are asymptomatic while chronic infection may manifest as gastrointestinal symptoms (e.g. diarrhoea, nausea, abdominal pain), failure to thrive/weight loss, respiratory symptoms such as chronic cough, and urinary symptoms that include haematuria. Detecting eggs in the stool or urine may be difficult but serology has high sensitivity and specificity. Eosinophilia, which often correlates with duration, is a feature. If positive, a renal tract ultrasound is advisable and the patient should be referred to a renal physician. Treatment of the infection is with praziquantel.
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Strongyloides (human threadworm)
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Strongyloides (see CHAPTER 15) is a common infestation in refugees with a prevalence of up to 11% in some groups.5 It can survive asymptomatically for decades but may present with recurrent abdominal pain and watery diarrhoea, failure to thrive/weight loss, and skin and respiratory symptoms (similar to schistosomiasis). Diagnosis is by identifying larvae in concentrated stool (see FIG. 135.3), which can be elusive, and by eosinophilia and serology, which has good sensitivity and specificity. Treatment with ivermectin or albendazole can be complex and consultant help is advisable.
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Tuberculosis (see CHAPTER 29) is a major health problem in the countries of origin of refugees. Most of those infected are asymptomatic and may go undiagnosed unless properly screened. It is important to detect those (particularly children) with latent infection and non-pulmonary disease. Investigations include a chest X-ray, tuberculin skin test (Mantoux) and an IGRA (check if Medicare rebatable). It is recommended that all refugees should have a clinical assessment by a specialist chest clinic within 2 months of arrival. Special issues include:
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Both TB and HIV are reportable conditions in Australia and their management is specialised.
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Immunisation catch-up is a difficult area of management for all doctors treating refugees. Written records are the only reliable form of documentation but immunity from past immunisations cannot be taken for granted. It is advisable to follow formal catch-up guidelines, which are summarised in TABLE 135.3.
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These guidelines are available in the latest edition of The Australian Immunisation Handbook (see Resources).
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A huge challenge facing refugees is the so called ‘settlement issue’ as they confront the complexities of adjusting to a totally new way of life with their various physical, psychological and social problems. The settling process is a source of considerable stress as new arrivals, many with large families, are likely to move house several times in their first few years.
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The general practitioner is ideally placed to act as an advocate for the rehabilitation of his or her patients and family. Of course, GPs from a similar background have an advantage, but special skills are required to understand the issues and to gain access to available rehabilitation and support services (see Resources). Resources are also provided by the RACGP.
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Key recommendations (Australasian Society for Infectious Diseases)6
All refugees should be offered a comprehensive health assessment, ideally within 1 month of arrival in Australia.
This should include:
– screening for and treatment of the following conditions: tuberculosis, brucellosis, malaria, blood-borne viral infections, schistosomiasis, helminth infection and sexually transmitted infections
– testing for and treatment of other infections (e.g. Helicobacter pylori) as indicated by clinical assessment
– assessment of immunisation status, and catch-up immunisations where appropriate.
The assessment can be undertaken by a GP or within a multidisciplinary refugee health centre.
An appropriate interpreter should be used when required.
The initial assessment should take place over at least two visits: the first for initial assessment and investigation, and the second for review of results and treatment/referral.
Psychological, dental, nutritional, reproductive and developmental health issues should also be addressed at the post-arrival health assessment.
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Practice tips
It is helpful to become familiar with the clinical features of the relevant tropical diseases.
It is also advisable to learn about the significant cultural and religious customs of the ethnic groups you are likely to encounter.
Important diseases that ‘must not be missed’ include malaria, tuberculosis, schistosomiasis, HIV, typhoid fever, meningoencephalitis and severe psychological illness such as psychosis and major depression, especially with suicide risk.
Be aware of pseudo ‘neutropenia’ since some people, especially of African origin, have a different reference range for neutrophil counts.4
Doctors should consider their own safety in dealing with people coming from a theatre of violence who may be subject to vicarious trauma (also known as secondary traumatic stress).4
The use of professional interpreter services is a vital component of sound communication skills.
A multidisciplinary health care team will help meet the needs of practitioners in addressing most problems, especially complex ones.
Practitioners have a useful range of resources including refugee clinics in each state, chest clinics, torture and trauma services, and immunisation advice.