Immigrant Health Service

Overview of health issues in immigrant children

  • Assessment

    In general, health screening in refugee and asylum seeker children should be performed in the outpatient setting. In Victoria, refugee health assessments are often completed in primary care. See initial assessment; a list of suggested initial investigations is included. Children aged < 5 years from malaria endemic areas in Australia < 3 months should have opportunistic malaria screening if they have not had previous screening.

    Immunisation

    No-one arriving as a refugee or asylum seeker will be vaccinated and up to date according to the Australian immunisation schedule, due to differences in country of origin immunisation schedules.

    • People of a refugee background should be vaccinated so they are up to date according to the Australian National Immunisation Program Schedule (NIPS), equivalent to an Australian-born person of the same age
    • Catch-up vaccination is required, unless written documentation of immunisation is provided.
    • Hepatitis B serology is part of initial health screening (and women of child-bearing age should be checked for rubella immunity); otherwise routine serology (for vaccine preventable disease antibody titres) is not recommended
    • Check for a BCG scar (forearm, deltoid region, thighs, other (ask family), either side)
    • Consider live attenuated vaccines (LAV) - Mumps-Measles-Rubella (MMR), Yellow Fever (YF), Oral Polio Virus (OPV) - that may have been given as part of offshore Departure Health Checks (DHC) in Humanitarian entrants or as part of departure protocols (OPV) in relevant source countries. LAV will affect the timing of other vaccines and Mantoux tests. 
    • Provide a written record and a clear plan for ongoing immunisations
    • Immigrant health guideline immunisation

    Anaemia

    Australian data suggest the prevalence of anaemia is 10 - 30% in refugee children, with similar prevalence in children from Africa, Middle East or Asia. Iron deficiency affects a similar proportion. Low B12 and/or folate have recently been reported in refugees from Afghanistan and Sri Lanka; and lead toxicity has been reported in up to 7 - 13% of refugee children from Africa, South Asia and Burma, especially in children < 6 years.

    • Children with symptomatic anaemia will need admission, consider malaria, sickle crisis or other causes of haemolysis, including Glucose-6-Phosphate Dehydrogenase Deficiency (G6PD).
    • Anaemia is usually multifactorial in the paediatric refugee population. Contributors include iron deficiency, malaria infection, and parasite infection/infestation.
      • Iron deficiency is usually nutritional, but may be due to gastrointestinal loss or associated with Helicobacter pylori infection.
      • Consider haemaglobinopathies (more common in African and Asian populations, clinical disease is rare in resettled refugee cohorts in Australia)
      • Blood lead levels are not currently part of initial refugee screening in Australia, although they are recommended in US guidelines for refugee children aged 6 months - 16 years. Consider as second line testing in children with microcytosis, and initially in children with pica, developmental issues, or a history suggesting exposure, including through traditional medicines.
    • Clinical practice guideline Anaemia
    • Immigrant health guideline Anaemia

    Hepatitis B

    Current humanitarian source countries have either intermediate (2 - 7%) or high (>=8%) prevalence of HBsAg. The prevalence of HBsAg in refugee cohorts reflects area of origin prevalence. Both vertical and horizontal modes of transmission are important in the epidemiology of hepatitis B in children, and immunisation of non-immune household contacts is a priority. Household composition may be fluid in the early settlement period, and it is probably safer to assume household contact is the norm, rather than the exception.

    In children diagnosed with hepatitis B infection it is important to:

    • Provide an explanation of the condition and ask the family to let any treating doctors know before starting medications.
    • Refer for specialist advice/care
    • Discuss appropriate infection control measures: cleaning up blood spills, not sharing toothbrushes/razors, use of barrier contraception in sexually active adolescents.
    • Screen family/household contacts and vaccinate non-immune contacts (with serology to confirm seroimmunity 4 - 8 weeks after their final vaccination)
    • Consider comorbidities (other hepatitis, HIV, schistosomiasis)
    • Immigrant health guideline hepatitis B infection.

    The key challenge in management of refugee children/young people with chronic hepatitis B is that they need follow-up/monitoring for years, with transition to adult services. Coordinated care is essential.

    Parasite infection

    Parasites are common in refugee children/young people and are also seen in asylum seeker children. Australian data suggest the prevalence of pathogenic faecal parasites in post arrival refugee health screening is 14 - 42%, Giardia was the most common parasite identified in African cohorts. The prevalence of Schistosoma infection is 12 - 38% in African refugees and 7% in Karen refugees, the prevalence of Strongyloides is 1 - 9% in African refugees and 21% in Karen refugees. Parasite infections may last for years and have sequelae for nutrition, growth and function. In general, treatment is usually short course (often single dose) and well tolerated.

    • Symptoms may be non-specific, macroscopically visible worms are likely to be tapeworms or ascarids
    • Positive Strongyloides serology = active infection (requiring treatment). Strongyloides infection can last decades through a cycle of autoinfection. Patients with untreated Strongyloides infections can develop hyperinfection syndrome if given immunosuppressant therapy, including steroids. Hyperinfection syndrome has a high mortality, even with treatment
    • Albendazole treatment is part of the pre-arrival DHC for refugee entrants and detention health screening for asylum seekers. Albendazole may be recommended as presumptive treatment (see ASID guidelines). It treats some but not all parasites (not Giardia). It may affect serology results for Strongyloides infection, but a single dose is unlikely to treat this infection adequately
    • Specific therapy is needed for Giardia intestinalis, Strongyloides stercoralis, Schistosoma spp, Taenia spp, Rodentolepis (Hymenolepis) nana and amoebiasis
    • Immigrant health guideline parasite infection

    Tuberculosis

    All refugee and asylum seeker children and adolescents should be screened for TB infection. The Mantoux test (Tuberculin Skin Test -TST) is the preferred first line screening test in children aged <5 years, and can be used at all ages. Interferon-gamma release assays (IGRA) such as QFN-GIT® and T-SPOT-TB® can be used in those age >=5 years but are not suitable as first line screening tests in younger children. The prevalence of a positive TST (10 mm or more) in refugees from Africa, Europe and the Middle East is 25 - 55%. Latent TB infection (LTBI) is evidence of TB infection without evidence of active TB disease (based on history examination and a chest x-ray). Children diagnosed with LTBI are not infectious; although their lifetime risk of developing TB disease is around 10%, and may be higher, especially in those aged < 5 years.

    • Ask about BCG status, past history, contact/family history, pre-departure screening/health undertakings and symptoms - cough, fevers, night sweats, poor growth and nodal disease or bony pain
    • A positive TST is >= 10 mm in children from TB endemic areas, or >= 5 mm in children who have a household contact with TB (regardless of BCG status)
    • Children with a positive TST need a CXR and further specialist review to exclude active TB disease and consider preventive therapy for LTBI
    • All children with suspected TB disease should be discussed with infectious diseases or respiratory medicine. Children who are unwell with suspected tuberculosis will need admission
    • Children with TB disease are rarely infectious due to their pattern of disease (lack of cavitating lesions, low bacterial load) and lack of coughing force. They do not usually require protective isolation
    • Immigrant health clinic guideline TB screening

    Vitamin D

    Up to 90% of African-Australians in Melbourne will have low Vitamin D during the winter months. Low vitamin D is also seen in other refugee groups, especially people who have reduced sun exposure, including women who wear covering clothing. Most vitamin D is made in the skin through the action of sunlight, diet is a poor source of vitamin D. Risk factors for low vitamin D include limited sunlight exposure, dark skin, conditions/medications affecting vitamin D metabolism (obesity, liver or renal disease, anticonvulsant, TB medications), and for babies: low maternal vitamin D and breastfeeding with other risk factors.

    • Serum 25-hydroxy vitamin D (25OHD) is used to measure vitamin D stores
    • The recommended level for 25OHD is >= 50 nmol/L
    • Consider vitamin D status in any child with risk factors, especially if there is a history of low-grade bony and muscular pain and fatigue with exercise.Vitamin D deficiency may present with seizures or symptoms of low calcium (tetany, muscle cramps, stridor), this is more likely in children aged < 6 months
    • Measure vitamin D, calcium, phosphate and ALP in children with risk factors, also measure PTH in those with low calcium intake, symptoms/signs or multiple risk factors. See Medicare guidelines for vitamin D testing
    • Children with low vitamin D should be treated to bring their levels to the normal range (see Immigrant health guideline low vitamin D). This should be paired with education and advice on sun protection/exposure
    • Children/young people with ongoing risk factors for low vitamin D require ongoing monitoring, with annual testing and a plan to maintain normal vitamin D through behavioural change where possible and supplementation where this is inadequate. Ensure adequate calcium intake
    • Breast fed infants at risk of low Vitamin D should be commenced on 400 IU vitamin D daily until at least 12 months of age.

    Immigrant health clinic resources Updated April 2016 Contact: georgia.paxton@rch.org.au