Palestinian refugees - key issues

  • This guideline is intended to provide a brief summary of background and health issues for newly arriving Palestinian refugees from Gaza. 

    Background

    • Land and population – Gaza is 41 km long and 6-12km wide, with a total area of 365 km2, divided into five governates – (north to south) North Gaza, Gaza, Deir Al Balah, Khan Younis and Rafah. Gaza contains 8 refugee camps, and has one of the world’s highest population densities, with an estimated population of 2.375 million people. The population is predominantly urban (85%) and young (15% <5 years, 40% <15 years, with around 60,000 births/year). Gaza has some of the world’s highest unemployment (46%) and poverty (53%) rates (2019 and 2017 data).
    • Language - Arabic.
    • Religion - predominantly (99%) Sunni Muslim population, also with a small Palestinian Christian population (<1%).
    • Administration - Hamas won elections in Gaza in January 2006, and assumed administration from June 2007. The United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) was established in 1949, after the 1948 Palestine war and 1948 Arab-Israeli war.  UNRWA maintains active files for 5.9M Palestinian refugees, and an additional 781K people eligible for UNRWA consideration. UNRWA registration is voluntary, and UNRWA records are not considered to be a civil register. 
      • Definitions - Palestinian refugees are defined by the United Nations (UN) as people whose place of residence was Palestine during the period 1 June 1946 to 15 May 1948, and who lost both home and means of livelihood as a result of the 1948 conflict. Palestine refugees, and descendants of Palestine refugee males, including legally adopted children, are eligible to register for UNRWA services. More than 1.7M people in Gaza were classified as refugees prior to the conflict.
      • Historical timeline (UN).
    • Education - pre-conflict Gaza had 737 schools, with 288 run by UNRWA.
    • Healthcare - pre-conflict Gaza had a system of 72 primary care facilities, strong vaccination programs and maternal and neonatal health indicators (see Public Health Situation Analysis for background), and 36 hospitals (24 in the north, 12 in the south).

    Current conflict

    Timelines

    • 7 Oct 2023 - Hamas commits terrorist acts against Israel, killing more than 1200 people, and taking more than 200 hostages.
    • 27 Oct 2023 - Ground invasion of Gaza.
    • 24-30 Nov 2023 - Period of ceasefire brokered by Qatar, Egypt and the United States (US) - Israeli hostages released in exchange for Palestinian prisoners in Israel. 
    • 1 Dec 2023 - Conflict resumes.
    • 6 May 2024 - Ground invasion of Rafah area commences
    • There have been multiple requests for a ceasefire throughout the conflict.

    Current situation

    Australian response

    • See DFAT information on the Occupied Palestinian Territories.
    • Since the beginning of the conflict, more than 1500 Australians have left Israel and the Occupied Palestinian Territories. Currently, exit from Gaza is via the Rafah crossing (into Egypt). Since 1 Nov 2023, more than 17,000 Gazans holding dual nationality have been permitted to evacuate (see media 28 Dec 2023). 
    • Australia has announced $46M in humanitarian assistance, with $25M for civilians affected by the conflict (see media 14 Oct 2023 and 26 Oct 2023) and a further $21.5M announced 16 Jan 2024.
    • By Nov 2023, Australia had granted around 1800 visas to Israeli citizens and 860 to Palestinians (media 23 Nov 2023).  By early February, just over 330 Palestinian refugees had arrived in Australia on visitor visas (see media 27 Mar 2024).
    • Individuals have typically travelled under tourist (visitor) visas, tourist visas do not have access to workrights, Medicare or Centrelink.
    • The Victorian government has enabled free public healthcare for people fleeing the Israel Palestine conflict (see DH advice 22 Dec 2023). 
    • In Feb 2024 the Australian government announced a bridging visa E (BVE, subclass 050) pathway for people arriving on visitor visas from Gaza - this allows access to Medicare, work rights and study rights, but does not provide humanitarian settlement program (HSP) support. Students remain fee liable, and need case-by-case exemption (in Victoria for school age students, contact international Students section of DET). 

    Health screening

    Immediate health triage (for all ages) should assess for acute physical health issues (including malnutrition and injuries), acute mental health issues, disability, frailty/mobility issues in elders, pregnancy and medication type and supply. Children/adults may have acute (and severe) malnutrition and re-feeding syndrome is a consideration in this population. 

    Like any mass migration event, and where people have been living in very crowded conditions, consider outbreak risk and vaccine preventable diseases (VPD), including measles, varicella, hepatitis A, typhoid and other enteric infections. Media in Dec 2023 reported outbreaks of varicella and cases of acute jaundice (likely hepatitis A). UNICEF reported 71,000 cases of diarrhoea in children <5 years in one week (17 Dec 2023; vs 2000/month pre-conflict). Parasite infections are common in Gaza, ask about gastrointestinal symptoms, including abdominal pain and diarrhoea/dysentery. Iron deficiency anaemia and vitamin D deficiency are common, and there are high rates of antimicrobial resistance (antibiotics are sold over the counter).

    Children and families are arriving from a direct conflict situation with acute trauma. They have been displaced, and evacuation orders and search for safety has meant people have been displaced multiple times. They will have witnessed bombs, destruction of cities and houses, injuries and deaths; they may have lost or been separated from family members, or experienced injuries themselves. Clinicians should ensure a supportive approach, following principals of psychological first aid (being mindful of symptoms/signs of psychological trauma, but not exploring trauma directly if people are not ready). Mental health support is available in Victoria, although early information from the Australian Islamic Medical Association (AIMA) suggests the majority of new arrivals have declined mental health services, and there may be cultural stigma around engaging with mental health support.  

    Recommended health assessment Gazan arrivals

    All new arrivals should have an initial health assessment and catch-up vaccination. The same initial health screening investigations are recommended for children and adults from Gaza (based on prevalence data below and 2016 Refugee Guidelines):

    • All: FBE/film, ferritin, vitamin B12, folate, vitamin D, vitamin A, zinc, HAV serology (IgM* and IgG), HBsAg*, cAb, sAb, Strongyloides serology, faecal OCP + PCR.
    • Age/risk based: extended nutritional screening (clinical, low threshold - see guideline), add ALP in children, TB screening (clinical), HCV/HIV (clinical), STI screening (clinical/UHM), consider MMR and varicella serology in adolescents and adults to determine catch-up, offer pregnancy testing to women if relevant, consider H Pylori (if symptoms).
    • Catch-up primary care: see RACGP Red book HPV screen (women 25-74y), Alb:creat/eGFR (30y+ if high risk), BSL/HbA1C (40y+), lipids (45y+), FOBT (50y+), mammogram (women 50-74y)

    *ensure no recent (within 1m) HAV or HBV vaccine - may cause HAV IgM+ or HBsAg+

    Presumptive treatment

    • Albendazole – unless pregnant (class D pregnancy drug) or <6 months age. Dosage is 400mg stat oral for age 12 months or older and weight 10kg+ (or 200mg stat oral for age 6 months and older and weight up to 10kg). 

    • Recommend multivitamin for at least 1st month. 
    • Recommend healthy food intake – vegetables, legumes, fruit, grains, meat and avoid high intake of energy dense foods in days after arrival if acute malnutrition is a consideration (consider re-feeding syndrome).
    • Encourage self-management of low vitamin D for those with ongoing risk factors (multivitamins generally contain vitamin D).

    Catch-up immunisation

    Prior to the conflict, Gaza had a strong immunisation program and high compliance with vaccinations (coverage >95% - see summary). More than 13,700 children received MMR vaccination in Jan 2024 (via UNICEF). The Gaza vaccination schedule includes: DTwP-Hib-HepB, OPV/IPV, rota, 10vPCV, MMR and influenza vaccine, in the following schedule:

    • Birth – HBV
    • 1m - IPV
    • 2m - DTwP-Hib-HepB, OPV, IPV, 10vPCV, rotavirus vaccine
    • 4m - DTwP-Hib-HepB, OPV, 10vPCV, rotavirus vaccine
    • 6m - DTwP-Hib-HepB, OPV, influenza, rotavirus vaccine
    • 12m – MMR, 10vPCV
    • 18m – DTwP, OPV, MMR
    • 6y – DT, OPV
    • 15y – Td
    • 18y+ - annual influenza vaccine

    Missing compared to Australian schedule: meningococcal ACWY, (meningococcal B - risk groups only), varicella, zoster, and HPV. Also note use of 10vPCV (vs 13vPCV in Australia). Also consider both covid (age dependent) and influenza vaccines.

    • Where written records are not available, full catch-up vaccination is recommended - see Catch-up immunisation guidelines
    • Entering information on to the Australian Immunisation Register (AIR) - use 'encounter overseas', schedule = 'other', add dates, and use generic vaccine type where needed (e.g. for pentavalent vaccines, may need to record as DTPa generic, Hib generic and HepB generic). Enter dose numbers accurately, and the record should submit. AIR will not allow entry of the same antigen on the same day, which means overseas schedules with simultaneous OPV and IPV cannot be entered accurately. AIR records can be created for people without Medicare.
    • Note - Abridged catch-up - RCH/MVEC protocols for catch-up vaccination after chemotherapy use infanrix-hexa and MMR-V up to age 18y, this reduces needles required, and we use this in practice. AIR will accept these vaccines for adolescents, **AIR data entry - use other, and enter by antigen, and then accept queries. 
    • Translated catch-up information:  Pre-immunisation checklist, childhood vaccinations, catch-up summary.

    Other

    • Acute malnutrition - ask about pre-morbid weight, seek specialist advice for acute weight loss of 10% or more; healthy diet as above, consider presumptive treatment with 1 week thiamine (10-50mg daily), stoss doses vitamin A (50,000 IU all ages) and vitamin D (150,000 age 12m+), and 1 month vitamin C/zinc supplements (e.g. Vit C 500mg/Zn 20mg combined - 1/2 tablet <5y and 1 tablet 5y+) and multivitamin ongoing.
    • Diarrhoea and parasites (also see Parasite guidelines, Strongyloides guidelines)
      • Treatment for diarrhoea caused by E. histolytica is metronidazole (children 15mg/kg (max 600mg) and adults 600mg tds for 7 days - higher doses for severe disease/confirmed amoebic liver abscess - see eTG), noting that for elimination of luminal carriage - paromomycin is an SAS medication and takes weeks to obtain (also 7-day course). Amoebiasis is a notifiable infection in Victoria.
      • Treatment for Giardia duodenalis - in asymptomatic carriage in immune competent patients usually do not require treatment (eTG). If needed, treatment is metronidazole (children 30mg/kg (max 2g) and adults 2g daily for 3 days OR children 10mg/kg (max 400mg) and adults 400mg tds for 5 days). Tinidazole was discontinued in Australia in 2020;  nitazoxanide 3 days or albendazole 5 days are alternatives as per Sanford guide.
      • Hepatitis A, Salmonella, typhoid and Shigella are notifiable diseases in Victoria (+ others).

    • Confirm birthdate - individuals may have fled without paperwork or identity documents
    • Ensure medication supply and continuity where required - free medications may be available (see resources below).
    • Disability/complex health issues - seek early assistance through specialist services for children or adults with disability and/or complex medical issues. See paediatric refugee health clinic details.
    • Mental health/trauma - refer for mental health support or trauma counselling if required – Foundation House or the multilingual phone hotline Witness to war is available.
    • Education enrolment – for children, seek advice from Language schools and consider grade placement – in general, children should be placed so they are in the older cohort within a given year (e.g. a 6-year old child can be placed in foundation/prep which will have both 5-year-old and 6-year-old children starting school).
      • School enrolment - Contact International Education Division at: international@education.vic.gov.au for enrolment with fees waived for 6 months. Ph: +61 3 7022 1000.
      • Kindergarten enrolment - contact LGA CALD outreach officer.
    • Dental care - see oral health guideline which provides details for community dental clinics and also Dental Health Services Victoria and also Australian Dental Health Foundation (ADHF)
    • Antibiotic resistance - Consider bacterial screening if hospital admission is required.

    Prevalence data for Gaza

    The following summary provides background for the screening investigations recommendations above.

    • Nutrition - as of Mar 2024, the entire population Gaza is experiencing acute food insecurity (see IPC brief 18 Mar 2024). UNICEF (Jan 2024) reports 90% children <2 years are consuming two or fewer food groups, and diarrhoea outbreaks. Pre-conflict surveys also show high prevalence of undernutrition, and food insecurity was 32% in 2020
      • Anaemia has been found in: 59.7% pre-school children (2012), 29.3% children enrolling in UNRWA schools (2017), and 41% pregnant or breastfeeding women (2019).
      • The 2013 Palestinian Micronutrient Survey in Gaza reported the following prevalence of nutritional deficiencies:
        • Pregnant women (2nd - 3rd trimesters, n=587) - anaemia 42.8%, iron deficiency 38.6%, zinc deficiency 84.7%, folate deficiency 10%, vitamin A deficiency 18.6%, vitamin B12 deficiency 51%, vitamin D deficiency (<50nmol/L) 100%, vitamin E deficiency 3.3%.
        • Children 6-59 months (n=582) - mild anaemia 22.9%, moderate anaemia 7.8%, iron deficiency 19.0%, zinc deficiency 70.9%, folate deficiency 1.8%, vitamin A deficiency (<0.7 micromol/L) 35.3%, vitamin D deficiency 65.8%, vitamin E deficiency 32.5%. (B12 not reported in the same survey).
      • UNRWA primary care centres provide 6-monthly vitamin A supplementation for children 6-59m.

    • Non communicable diseases (NCD) - the baseline prevalence of NCD is high (see summary) - health system disruption is likely to result in deterioration.
    • Mental health and intimate partner violence (IPV) -  high prevalence reported pre-conflict (adults - 71% anxiety/depression/both, 7% PTSD; children 24% PTSD, high prevalence IPV) - see summary.

    • Tuberculosis (TB) - lower incidence of TB compared to Australia (<1/100,000 vs 7.3/100,000) - routine TB screening is not indicated.
    • Hepatitis A virus (HAV) - presumed to be a risk with current situation and reporting of acute jaundice outbreaks (Jan 2024 >8000 cases - see media). High baseline seroimmunity likely (93.7% school-aged children in 2001), so cases are more likely in younger children (pre-schoolers) who may also be asymptomatic.
    • Hepatitis B virus (HBV) - 2019 prevalence HBsAg+ 1.5% [1.2-1.7] and higher in haemodialysis centres (8.1% in 2010); Australia - 0.8% in 2021 - recommend HBV screening.
    • Hepatitis C virus (HCV) - low prevalence 0.2% HCV-Ab positiveand higher in haemodialysis centres (22.0% in 2010); Australia 0.8% - routine HCV screening is not indicated.
    • HIV - very low prevalence, with only 98 cases reported between 1988 and 2017; Australia - 0.1% in adults 15-49 years - routine HIV screening is not indicated.

    • Parasite infections - many parasitic infections are reportable diseases in Gaza (92,494 parasite infections reported 2008-17) with a relatively high incidence of amoebiasis (348/100,000 per year), pinworm, Giardia (140/100,000 per year) and scabies, and documented endemic infection with Strongyloides, and Ascaris. Leishmaniasis and hydatid disease are also reported in the West Bank (also see further information), and Toxoplasmosis is reported as an issue in pregnant women.
      • 2006 population study of 1600 children 3-18 years in Northern Gaza (using stool sample) found 75% had parasite infections, including 45.8% with A. lumbricoides and 5.6% with Strongyloides infection.
      • In a 2011 study of 600 outpatients aged 1-69 years, 40.8% had intestinal parasites, 9.1% had more than one parasite (30.5% protozoal parasites, 3.5% helminths).
    • Recommend Strongyloides serology + faecal OCP/stool PCR (which detects E. histolytica) + albendazole dose. 

    Resources

    Immigrant health resources. Author Georgia Paxton, Saniya Kazi 19 Jan 2024. Updated 31 May 2024. Contact georgia.paxton@rch.org.au