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Ukrainian refugees - key issues

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

    Background 

    Russian troops had been located along the Ukrainian border from March 2021, with estimates of 100,000 troops in place by December 2021. On 24 February 2022 Russia invaded Ukraine from the north (Belarus), east (Donetsk and Luhansk regions) and south (Crimea).  More than a million people left Ukraine within the first week of the conflict, and by 15 Mar 2022 (19 days later), more than 3 million people had fled. Current (7 Jul 2022) UNHCR estimates more than 5.6 million Ukrainian refugees have fled into European countries and are now dispersed widely. Current figures include 1.2 million people in Poland,  867,000 in Germany, 388,097 in Czech Republic, 145,000 in Turkey, 141,562 in Italy, 125,757 in Spain, and around 85,000 in each of France, UK, and Bulgaria. There are also 1.58 million Ukrainians displaced into the Russian Federation.  See summary, including maps.

    • Population - Ukraine had a population of around 44 million people.
    • Ethnic groups - Ukrainian, Russian, other.
    • Languages - the official language is Ukrainian, which is first language for two thirds of the population, the remaining third have Russian as first language.
    • Religion - the main religion is Orthodox Christian, also with Catholic, Protestant, Muslim and Jewish populations.

    Australia has now granted more than 8000 visas for people from Ukraine. As of 13 Jun 2022, around 3200 Ukrainian nationals have arrived in Australia (900 to Victoria).  This is a situation of hyper-acute displacement, with differences to other humanitarian cohorts:

    • Individuals from Ukraine have typically travelled under tourist (visitor) visas - these visas do not have access to Medicare or Centrelink.
    • The subclass 786 Temporary Humanitarian Concern (THC) visa was available until July 2022 for all Ukrainian nationals who are in Australia on temporary visas. This is a two-step process which involves issuing a Humanitarian Stay (Temporary) (subclass 449) visa followed by the 786 visa (3-years duration).
    • Individuals will have had continuous access to healthcare and education, and thus fewer untreated/under-treated conditions might be expected.  

    There are around 46,000 Ukrainian Australians (2016 Census), predominantly living in Melbourne and Sydney, also with communities in other areas. See DHA community information summary.

    Medicare, AIR records and NDIS

    • The 449 visa for Ukrainians does not carry access to Medicare (this is different to Afghan arrivals in 2021, where 449 visa holders did receive Medicare)
    • Ukrainian refugees granted a 786 visa are eligible for Medicare from the date of visa grant. Medicare enrolment takes 4-6 weeks, and after this, it takes up to 10 weeks to obtain a Medicare card. Individuals can call Services Australia to obtain their card number before their Medicare card arrives. Health providers can look up HPOS (with consent) to obtain patient's Medicare numbers (and are able to bill for services before a physical Medicare card is issued)
    • The September 2022 Federal Budget included provisions for Medicare access for Ukrainian refugees on bridging visas, and an additional allocation of 3-year 786 visas (Paper 2, p85)
    • If children's AIR records are created prior to Medicare, Centrelink requires parents to call the multilingual line (131202) for confirmation - so AIR records can be matched to Centrelink. Services Australia have advised they are experiencing name matching issues (which may affect Centrelink payments)
    • Neither the 449 nor the 786 have access to NDIS.

    Medicare fact sheet (available in Ukrainian)

    Covid related

    Management of covid-related risk remains a priority in the post-arrival period. Ukrainian covid vaccination coverage was low in early 2022 (~ 35%), and early covid vaccination should be prioritised. Overseas vaccines should be recorded on AIR (this is possible without Medicare) and vaccine certificates organised.

    Quarantine requirements for new arrivals to Victoria ceased in April 2022 (including for unvaccinated arrivals).

    Covid vaccination

    • Ukrainian covid vaccination coverage (2 doses) was ~ 35% in early 2022
    • Covid vaccines used in Ukraine - Pfizer, Moderna, Astra Zeneca, Johnson and Johnson, Sputnik V and Sinopharm. All these vaccines are recognised in Australia by the TGA and can be registered on AIR.  
    • Covid vaccination is an urgent priority for any group accomodation situation. 
      • For unvaccinated individuals - please follow local guidelines - e.g. Victoria, also see Immigrant Health Covid-19
      • For partially vaccinated individuals (see ATAGI clinical advice)
        • Pfizer or Moderna - use same as second dose unless not available  - either Pfizer 3-6 weeks after dose 1, or Moderna 4-6 weeks after dose 1
        • J&J vaccine - if vaccinated x 1 dose - consider complete primary course
        • AZ vaccine -  AZ second dose 4-12 weeks after dose 1, unless contraindicated (anaphylaxis/serious adverse event, or condition listed as precaution for AZ (precautions = cerebral-venous-sinus thrombosis, heparin induced thrombocytopenia, idiopathic splanchnic thrombosis, antiphospholipid syndrome with thrombosis) - give mRNA vaccine instead) 
        • Sinopharm/Sputnik/other covid vaccine requiring 2 doses for primary- either AZ or mRNA vaccine (use mRNA <60 years unless contraindication, no preference on type of mRNA, 4-12 weeks after dose 1)
      • Covid digital certificates and Proof of covid vaccination (Services Australia).

    Health screening

    Onshore immigration screening (BUPA)

    The onshore immigration medical examination (IME) for Ukrainian arrivals applying for a 786 visa is limited, related to the 786 being a temporary visa (noting the IME is more comprehensive for the Afghan arrivals who are transitioning onto permanent visas). It consists of:

    • (501) Medical examination
    • (502) CXR age 11 years and older (unless pregnant) or if requested by Commonwealth Medical Officer
    • Check for special circumstances - intending healthcare worker, close household TB contact within last 5 years, pregnant and will deliver in Australia - in which case other tests are required - including (708) Hepatitis B screen if pregnant

    Other considerations

    • Individuals are advised of their HAP numbers in their initial visa 449 grant letter. It is unclear whether the HAP number has always been on the 449 grant letter - but worth asking.
    • Ukrainian arrivals have to pay for their own IME - clinicians report this is a substantial barrier to completion of both IME and any subsequent assessment, and we have not seen this before in humanitarian cohorts.
    • Existing processes have been challenging in clinical practice. Individuals are not told of their results unless they are positive, and while a 'duty of care' letter can be sent to the HSP agencies (who typically hold the HAP number), many of the Ukrainian cohort do not have HSP support. This, combined with difficulties clarifying the HAP number, has made BUPA IME screening very difficult to find for this cohort. 

    Recommended health assessment

    All new arrivals should have an initial health assessment and catch-up vaccination. Timing may be affected by access to Medicare. This assessment should occur even if they have had the (limited) BUPA IME assessment.

    • Immediate health triage (i.e. for all ages) should assess for acute physical or mental health issues, disability, frailty/mobility issues in elders, pregnancy and medication type and supply.
    • 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 and typhoid.
    • Prevalence data for Ukraine show: 
      • Tuberculosis - 10-fold higher incidence of TB compared to Australia (73/100,000 vs 7.3/100,000) with higher prevalence of MDR (13.3% of cases) and XDR (3.7% of cases) - TB screening is a priority
      • Hepatitis C - moderate to high prevalence - 3.6% HCV-Ab positive, and 2.7% HCV RNA positive (Australia 1.7%, 1.5%) - include HCV screening for children and adults
      • Hepatitis B - lower prevalence compared to Australia - 1.3% HBsAg positive (Australia modelled - 2.14%)
      • HIV - higher prevalence compared to Australia in adults (predominantly in people with history of injecting drug use)  - 1.0% in age 15-49 years, very low in children (comparison - Australia - 0.1% in adults 15-49 years). Excellent access to treatment and high rates of viral suppression noted. HIV screening in age 15 years and older is part of normal refugee screening.

    Screening tests

    • Children
      • All: FBE/film, ferritin, IGRA or TST, HBsAg, cAb, sAb, HCV
      • Age/risk based: HIV 15y+/clinical/UHM, STI screening, syphilis (clinical/UHM), varicella 14y+ if no Hx, consider faecal OCP and H Pylori (if symptoms)

    • Adults 
      • All: FBE/film, IGRA, HBsAg, cAb, sAb, HCV, HIV
      • Age/risk based: ferritin (women, men with RF), rubella (women), varicella (if no Hx), STI screening, syphilis, H pylori (Sx)
      • Catch-up primary care: HPV screen (women 25-74y), Alb:creat/eGFR (30y+ if high risk), BSL/HbA1C (40y+), lipids (45y+), FOBT (50y+), Mammogram (women 50-74y) 

    Catch-up vaccination

    The Ukrainian vaccination schedule includes: BCG, DTwP, Hib, Hepatitis B, OPV/IPV, MMR and influenza vaccine

    • Missing compared to Australian schedule: rotavirus (usually not relevant for catch-up because of age restrictions), pneumococcal, meningococcal ACWY, varicella, zoster, and HPV. 
    • Where written records are not available, full catch-up vaccination is recommended - see catch-up immunisation guidelines. 
    • Many new arrivals have travelled with detailed overseas vaccination records - in our experience, there are a few differences to be aware of:  
      • The format of the records is by antigen - thus the same vaccine is recorded under different antigens (e.g. the same hexa dose is recorded under DTPa, Polio, Hib and HBV categories (this makes it much quicker to interpret! and much easier to enter into AIR). 
      • The Pentaxim formulation is DTPa-IPV-Hib (whereas infanrix penta is DTPa-IPV-HepB). 
      • Families have indicated that vaccine supply was difficult 5-10 years ago, and many children appear to have had vaccines on many different dates and often only 1 or 2 vaccines at a time. This sometimes seems to make it difficult to enter vaccines onto AIR. 
      • AIR records have been difficult to obtain for individuals without Medicare, and there is a delay of ~ 1 week between submitting vaccination information and the record being available on AIR. 
      • When entering information on to 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, IPV generic and Hib 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 that include simultaneous OPV and IPV cannot be entered accurately. These schedules typically include many more doses of polio vaccination than the Australian schedule, so this will not affect up to date status. 

    Translated catch-up information Pre-immunisation checklistVaccine safety - UkrainianVaccine side effectsCatch-up summary (City of Melbourne resource, informal translation - but excellent interim resource),

    Other

    • Confirm birthdate - individuals may have fled without paperwork or identity documents (although 3-months in, we have not seen this).
    • Prioritise education enrolment in children, and actively consider grade placement - when children are learning new languages, we suggest they are placed with the same age children in younger grade levels - e.g. a 6-year-old child can be placed in foundation (prep) with other 6-year olds in this level (many children start school age 6 years in Victoria), and a 5-year-old child can complete a year of kindergarten before commencing school. This cohort may also enter into local Catholic or Jewish education systems.
    • Ensure medication supply and continuity where required (this may be challenging without medicare - we will provide information as it becomes available).
    • 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.

    Resources

    Immigrant health clinic resources. Author Georgie Paxton, 24 Nov 2022 - Contact: georgia.paxton@rch.org.au