Immigrant health - acute presentations

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    Key points

    • In the emergency setting, the main issue is the  Febrile recent arrival. Other health screening should be performed in the outpatient setting.
    • An interpreter is usually needed.
    • It is not appropriate to use a family member as an interpreter.
    • Health checks prior to departure are very limited in children.
    • In some states of Australia (including Victoria) there are no routine health checks after arrival.
    • All children and families who have been in Immigration detention should have a medical summary of their health assessment in detention.
    • A verbal history of immunisation is not reliable. If there is no written record presume the child is unimmunised.
    • When discharging patients, provide clear advice about when to return and how/when to access emergency services and ensure contact details are up to date as families often move in the early settlement period.

    Presentations to the Emergency Department

    Current public health considerations

    1. Some types of traditional Burmese medicines have been found to have high levels of arsenic in NSW - the same products are likely to be available in Victoria, although no cases of toxicity have been identified (May 2012). See Immigrant Health Clinic Guideline.
    2. There are current issues with sourcing vaccines in Damascus, Syria; meaning Humanitarian entrants to Australia from this source country are unlikely to have had Mumps-Measles-Rubella vaccine as part of their Departure Health Check (November 2012).
    3. A novel corona virus causing pneumonitis/pneumonia has been identified in the Arabian peninsula (Saudi Arabia and Jordan) although only a small number of cases are confirmed. See WHO update and NSW health release.(December 2012).
    4. There have been confirmed cases of wild-type polio in Syria in October 2013
    5. WHO has made an emergency order about polio in May 2014 under the International Health Regulations. There are two changes relevant to Humanitarian program entrants to Australia:
      • All people departing from Pakistan, Cameroon and Syria will need to have a full course of polio vaccinations certified before they can leave the country.
      • Refugee and humanitarian applicants will have one dose of OPV at the departure health check (and any new applicants referred for initial visa medical examination will also have a dose of OPV) in ten identified countries - Afghanistan, Cameroon, Equatorial Guinea, Ethiopia, Iraq, Israel, Kenya, Nigeria, Pakistan, Somalia and Syria. This will be documented by IOM on the health manifest, so it is clear to all health providers that this has occurred. (May 2014)
    6. There is currently a cholera outbreak in Dadaab, Kenya (November 2015).

    Screening in the emergency department

    Screening for malaria

    • All children < 5 years from malaria endemic areas in Australia < 3 months should have malaria screening (if not already performed) regardless of the reason for presentation.
    • Recent arrivals ( < 3 months in Australia) from malaria endemic areas who are febrile need malaria screening and may need other investigations. Non-falciparum malaria (and very rarely falciparum malaria) may present after a longer duration and should be considered in the febrile child of a refugee background.
    • See  Illness in the returned traveller guideline
    • Malaria screening (thick/thin films and rapid diagnostic test (RDT)) can be done on a fingerprick. The RDT used at RCH gives information on the presence of plasmodium spp and whether it is Pl. falciparum. The test may remain positive up to 4 weeks after elimination of the parasite. Children are still treated for malaria based on a positive test result.
    • All children with malaria should be discussed with infectious diseases
    • For more details see  Immigrant health guideline- malaria screening

    Other screening

    Outpatient follow-up:

    Specific clinics at RCH are available:

    • Immigrant health
    • International adoption

    Common presentations to ED & additional considerations for the new immigrant

    Presentation  Common causes Additional considerations   Links
    Fever

    Viral infections
    Bacterial infections

    Malaria
    Typhoid
    Dysentery
    Dengue and arboviral infections
    Hepatitis

    Fever < 3yo
    Illness in returned traveller
    Immigrant health guideline-malaria

    Respiratory symptoms Refugee children are still most likely
    to have the common causes of respiratory symptoms relevant to their age group, such as viral RTI, pneumonia, asthma, bronchiolitis and croup.
    Whooping cough: pertussis vaccination may not have been available in country of origin.
    Tuberculosis (TB) should be considered in children with chronic cough.
    Parasite infections may (very rarely) cause wheeze/respiratory symptoms.
    Pl. falciparum malaria may cause respiratory symptoms.
    Sickle cell disease may present with acute chest syndrome.
    Pneumonia
    Asthma
    Bronchiolitis
    Croup
    Cough
    Immigrant health guideline-TB screening
    Immigrant health guideline-Malaria
    Sickle cell disease
    Abdominal
    pain
    Consider the usual causes such as
    acute infection, constipation, surgical
    or gynaecological causes.
    Parasite infection (pain, diarrhoea, blood P.R., constipation, hepatic symptoms, haematuria, any screening or medication pre-departure or post arrival).
    Helicobacter pylori gastritis (pain, reflux, early satiety, family history) .
    Abdominalpain
    Immigrant health guideline-parasite
    Diarrhoea Consider the usual viral and bacterial gastroenteritis Bacillary dysentery is more common in the developing world (relevant for very recent arrivals).
    Parasite infection is common.
    Lactose intolerance may be more common in some racial groups.
    Clear instructions (using an interpreter) of oral rehydration and how to maintain fluid intake will be needed (families may not be familiar with local products)
    Diarrhoea and vomiting
    Immigrant health guideline-parasite

    Symptoms of hypocalcaemia

    Tetany, muscle cramps, stridor, siezures

    Vitamin D deficiency

    This is more likely in children aged
    < 6 months.
    These children need admission.

    Look for features of rickets(bossing, swelling of wrists and ankles, bony deformity- which may be in any direction).
    Children with symptoms of low calcium should have screening bloods taken in the emergency department (Vitamin D, calcium, phosphate, ALP, CUE and parathyroid hormone).
    Immigrant health guideline Vitamin D
    Rashes Eczema
    Dermatophyte (Tinea) infection
    Most rashes can be dealt with in the outpatient setting.
    Strongyloides infectionmay cause an intermittent urticarial rash lasting a few days (larva currens). This may be located anywhere including buttocks/perianal region.
    Patients with untreated Strongyloides infections can develop hyperinfection syndrome if given immunosuppressant therapy, including steroids. Hyperinfection syndrome has a high mortality, even with treatment
    Eczema
    Skin infections
    Immigrant health guideline parasite infection

    Children referred for possible tuberculosis

    Background:

    Ask about BCG status, past history of TB and any treatment, contact history, family history, pre-departure screening, health undertakings (in children or in adults in the family).

    Symptoms/ signs:

    Cough, sputum, fevers, night sweats, poor growth and nodal disease or bony pain.

    Management:

    • All children with suspected active disease should be discussed with infectious diseases or respiratory medicine.
    • Children who are unwell with suspected TB disease will need admission.
    • Interpretation of the Mantoux test is complicated and depends on age, BCG status and timing and other risk factors. Mantoux tests are performed by trained providers; they should not be performed within 3 months of a previous test.
    • Children with suspected TB disease should have a CXR or have recent hard copy films reviewed.
    • Microbiological confirmation is sought if TB disease is suspected; discuss with infectious diseases or respiratory medicine. In some cases it may be appropriate to collect specimens using hospital in the home. 
    • Children with TB disease are rarely infectious due to their pattern of disease (lack of cavitating lesions, low bacterial load) and lack of tussive force. They do not usually require protective isolation.
    • For more details see i mmigrant health guideline- tuberculosis screening