Author Archive

Intestinal Parasites

Beverley-Ann Biggs, Margaret Kay, Aesen Thambiran

Recommendations

  • Check for eosinophilia
  • If documented pre-departure albendazole therapy:
    • no eosinophilia and no symptoms – no investigation or treatment required.
    • eosinophilia – perform stool microscopy for ova cysts and parasites (OCP) followed by directed treatment.
  • If no documented pre-departure albendazole therapy, depending on local resources and practices there are two acceptable options:
    • empiric single-dose albendazole therapy (age >6 months, weight <10kg; 200mg; ≥10kg; 400mg). If eosinophilia at baseline re-check in 8 weeks. If eosinophilia persists perform stool microscopy for OCP

OR

    • perform stool microscopy OCP followed by directed treatment. Recheck eosinophils and stool microscopy OCP at 8 weeks after directed treatment.
  • Refer if unable to find cause of eosinophilia.
  • Treat pathological helminths with albendazole (age > 6 months, weight <10kg; 200mg; ≥10kg; 400mg) for three days, except for Ascaris lumbricoides, which only requires 400mg as a single dose (200mg in children >6 months and <10 kg). Mebendazole is an option for some parasites.136
  • Treat giardiasis with tinidazole 2g as a single dose, (50mg/kg in children, maximum 2g), or metronidazole 2g daily for three days (30mg/kg in children, maximum 2g).148
  • In people with positive stool microscopy, follow up with stool microscopy at 2-4 weeks after treatment and re-treat if necessary.
  • Refer refractory cases to an ID specialist.

Avoid albendazole (class D) and mebendazole (class B3) in pregnancy, both can be used during lactation.149

Schistosomiasis

Joshua S Davis, Christine Phillips, Vanessa Clifford

Recommendations

  • Offer blood testing for schistosomiasis serology if people have lived in/travelled through endemic countries (including Africa, parts of South East Asia and the Middle East, see text).
  • If serology is negative, no follow up is required.
  • If serology is positive or equivocal:
    • Treat with praziquantel in two doses of 20/mg/kg, 4 hours apart, orally. (40mg/kg total, no upper limit) (EBR – A)
    • Perform stool microscopy for ova.
    • Perform urine dipstick for haematuria, and end-urine microscopy for ova if haematuria.
  • If positive for ova on urine or stool, evaluate further for end-organ disease with ultrasound and LFTs. See flow-chart for further details.
  • Seek advice from a paediatric specialist on treatment of children <5 years.

Anaemia, Iron Deficiency, and Other Blood Conditions

Nadia Chaves, Georgia Paxton

Recommendations

  • Offer screening to all people from refugee-like backgrounds for anaemia and for other blood conditions with a full blood examination (FBE).
  • Offer screening for iron deficiency with serum ferritin to all children and to women of childbearing age and consider this in patients with unexplained fatigue.
  • Replace iron if ferritin <15µg/L and/or when clinical and haematological features indicate iron deficiency anaemia.
  • Educate about iron-rich diet and avoid excessive dairy intake in children
  • Investigate and treat causes of anaemia
  • Consider screening for vitamin B12 deficiency if arrival <6 months with a history of at least several years of significantly restricted food (especially meat) access e.g. patients from Bhutan, Afghanistan, Iran or the Horn of Africa; or if vegan diet.
  • Treat B12 deficiency if serum active B12 <35pmol/L or <reference range for children with oral or IM supplementation. Exclude concomitant folate deficiency. Consider Helicobacter pylori infection.

Asylum seekers

Key points

  • Asylum seekers are people who arrive in Australia and subsequently apply for protection as refugees
  • Depending on the person’s mode and date of arrival in Australia, living arrangements and service eligibility will vary
  • Visas and entitlements, including eligibility for Medicare, can change during the protection visa application process
  • All people found to be refugees in Australia undergo a Visa Health Check which is performed by a provider contracted by the Commonwealth Department of Immigration and Border Protection
  • Do not provide legal advice unless you are qualified to do so – if a person asks questions about their asylum claim, health professionals should refer them to a legal clinic or to advice and resources that have been prepared by legal services

Overview

Protection visa applications that are made in Australia are assessed by the Department of Immigration and Border Protection (DIBP) to determine whether the person legally engages the Australian Government’s protection obligations. Over recent years there have been multiple changes to how this processing occurs, and depending on the mode and date of arrival, different groups of asylum seekers have been and are processed under different systems, with different entitlements to have DIBP decisions reviewed. 

Flowchart of refugee process 

Mode of arrival and entitlements

Asylum seekers arriving with a valid visa (usually by plane)

Those arriving with valid entry documentation (e.g. a student visa or visitor visa) are permitted to reside in the community while their application is considered and are often provided with a Bridging Visa for this purpose (e.g. Bridging Visa A, Bridging Visa E). This group of asylum seekers are Medicare eligible even though  if they may not have work rights.

Asylum seekers arriving without a valid visa (usually by boat)

Asylum seekers who come by boat on or after 1 January 2014 are transferred offshore to either Nauru or Manus Island, Papua New Guinea, to have their protection claims assessed by those countries. 

Immigration detention (including alternate places of detention, immigrant transit accommodation, and immigration detention facilities)

Asylum seekers who arrived without a valid entry visa are subject to periods of immigration detention. Those who arrived before 31 December 2013 were usually detained on Christmas Island in the first instance, and then moved to mainland immigration detention facilities. While in detention facilities, healthcare is facilitated by the DIBP contracted service International Health and Medical Services (IHMS). Contracted hospitals that have reimbursement arrangements with the DIBP also provide care to people in immigration detention. People in detention are accompanied by guards to all appointments outside of the detention facility. After release from a detention facility, asylum seekers are allocated a Status Resolution Support Service Caseworker (SRSS provider). They  are given a detention health discharge summary prepared by IHMS. If this is misplaced, health professionals may request a copy from the SRSS provider. 

Find the SRSS providers in your state. 

Community placement (previously known as community detention)

Some asylum seekers are released from immigration detention facilities into the community under residence determination arrangements. Placement in the community allows people to move about without being accompanied. DIBP have contracted service providers under the SRSS program to provide housing, case management support and, where appropriate, counselling for pre arrival experiences of  torture and trauma. Community placement clients are not eligible for Medicare, instead IHMS is contracted by the DIBP to facilitate and pay for a specified range of health services for this group.

Living in the community post-detention

Asylum seekers may be released from detention facilities on a Bridging Visa E (BVE) to live in the community. This group are reliant on the private rental market, and receive housing and case work support from SRSS providers after they exit detention. Holders of BVEs waiting for the outcome of their protection visa application are eligible for Medicare and may have associated work rights. Some asylum seekers who have appealed a negative decision and whose case is at judicial review may be living in the community without Medicare and work rights. Medicare validity and expiry is also linked with the BVE. In circumstances where a BVE has expired due to DIBP administrative processing delays, a client remains in the community without a valid Medicare card. In these instances payment for medical services may be arranged in advance with SRSS providers through a letter of supply. 

Code of behaviour

People who arrived by boat and are 18 years of age or older must sign the DIBP Code of Behaviour before they are considered for the grant of a Bridging E visa. The Code of Behaviour makes certain kinds of behaviour (over and above Australian criminal laws) potentially punishable by cancellation of that Bridging Visa, and therefore detention. The Code includes a requirement to ‘comply with any health undertaking provided by the Department of Immigration and Border Protection or direction issued by the Chief Medical Officer (Immigration) to undertake treatment for a health condition for public health purposes’.

Protection visas (permanent and temporary)

People who arrive in Australia with a valid visa then apply and are found to be owed protection, are entitled to a Permanent Protection Visa, subclass 866. This entitles holders to permanent residency and a pathway to citizenship and the ability to apply to sponsor their family.  

People who arrive in Australia without a valid visa, then apply and are found to be owed protection, are entitled to a Temporary Protection Visa (TPV, subclass 745) for up to 3 years or a Safe Haven Enterprise Visa (SHEV, subclass 790) for up to 5 years. TPV and SHEV holders are eligible for Medicare for the duration of their visa. On either form of temporary visa, it is not possible to become a citizen, or to sponsor overseas family members to come to Australia. The Safe Haven Enterprise Visa allows you to then apply for a limited range of other kinds of visas if you work or study for 3.5 years in designated regional areas.

Important considerations for the health care of people seeking asylum

  • Some asylum seekers living in the community are ineligible for Medicare.  Asylum seekers may be eligible for assistance with health care and income support through the Status Resolution Support Services (SRSS) program. Those who are Medicare ineligible and not eligible for SRSS rely on specialist asylum seeker health services and other, often pro bono, services.
  • Containing the cost of care will be important as asylum seekers may face restrictions on their rights to employment, income support and other benefits.
  • Asylum seekers may not have undergone the Immigration Medical Examination offshore, but will do so in Australia as part of their application for permanent protection.Practice tips and considerations for working with people seeking asylum 

Mental distress and suicide risk 

“Asylum seekers can spend years in the community awaiting final determination of their case. The fear of being returned home, coupled with isolation and destitution, can be overwhelming. Statements of suicidal thought by an asylum seeker should always trigger an action response plan, which may include provision of enhanced support or calling in the specialist mental health crisis team.”1

Impact of poverty

“Many asylum seekers may eat poorly and frugally. Over winter, almost all asylum seekers economise on heating, and in summer on cooling. GPs should be aware of food banks in their community and the local charities that provide clothing and other essential items.”1 

Affordability of medications

“Asylum seekers with chronic diseases are often faced with choosing between medications. GPs should assist them in decision-making about which medications to prioritise and, where possible, should prescribe the cheapest medication in its class or for the therapeutic purpose.”1

Confidentiality and interpreters

  • Be aware that a telephone interpreter may be preferred by the patient for confidentiality reasons – especially if they are from a small community or language group
  • The patient’s name does not need to be given to interpreting services.  You can state that this is confidential and this can speed up the process.  In circumstances where the client is extremely concerned about confidentiality, offer to call the client by another name during the consultation and book an interstate interpreter if possible.

Links

See your state referral page for:

  • Immigration legal service providers
  • Status Resolution Support Services (SRSS) Programme
  • Pro-bono medical services

References

  1. Phillips, 2014, ‘Beyond Resettlement: Long-term care for people who have had refugee-like experiences’, Australian Family Physician, Volume 43 Issue 11

Chronic Non-Communicable Diseases in Adults

Kate Walker, Nadia Chaves

Recommendations

  • Offer screening for non-communicable diseases (NCDs) as per the RACGP red book including screening for:
    • smoking, nutrition, alcohol and physical activity (SNAP) risk factors
    • obesity, diabetes, hypertension, cardiovascular disease (CVD), chronic obstructive pulmonary disease (COPD) and lipid disorders
    • breast, bowel and cervical cancer.
  • Assess diabetes and CVD risk earlier for those from regions with a higher prevalence of non-communicable diseases (NCDs) or an increased BMI or waist circumference.
  • Although this chapter does not specifically refer to children we recommend recording body mass index (BMI) and blood pressure (BP) in all and offering management if abnormal.

Hearing, Vision and Oral Health

Shanti Narayanasamy, Joanne Gardiner, Nadia Chaves

Recommendations

  • A clinical assessment of hearing, visual acuity and dental health should be part of primary care health screening for all.
  • Test visual acuity for each eye in all people. For people who do not speak English, test visual acuity with E Logmar chart. For children, use LEA symbols chart.
  • Children may be referred to StEPS or similar programme, if available
  • Refer all people of African descent >40 years and all others >50 years for ocular health checks for glaucoma.340
  • Refer all for dental review.

Helicobacter Pylori

Thomas Schulz, Margaret Kay, Sarah Cherian

Recommendations

  • Routine screening for Helicobacter pylori (H. pylori) infection is not recommended (EBR – C3).167
  • Screening with either stool antigen or breath test is recommended in adults from high-risk groups. High-risk groups include those with a family history of gastric cancer168,169 (EBR 1a, B), or, symptoms and signs of peptic ulcer disease, or dyspepsia (for both adults and children) (EBR 1b, A).167
  • Patients with H. pylori infection and dyspepsia who are aged over 50 years, or who have anorexia, weight loss, dysphagia, vomiting, GI bleeding or an abdominal mass could be considered for further assessment, including endoscopy irrespective of H. pylori status.
  • Treat as per Australian Therapeutic Guidelines Gastrointestinal.30
  • Follow up at least 4 weeks after treatment with repeat diagnostic test.
  • Patients with unsuccessful first line therapy need referral to a specialist to access second line medications.

Low Vitamin D

Georgia Paxton, Gillian Singleton

Recommendations

  • Check vitamin D status as part of initial health assessment if there are one or more risk factors for low vitamin D.
  • People with low vitamin D should be treated to restore their levels to the normal range with either daily dosing or high dose therapy, ensuring adequate calcium intake, paired with advice about sun exposure and self-management.

Skin Infections

Kasha Singh, Rebecca Dunn, Gillian Singleton, Georgia Paxton

Recommendations

  • The skin should be examined as part of the initial physical examination.
  • Management will depend on findings; differential diagnoses will depend on area of origin.

Hepatitis B Virus (HBV)

Jennifer Maclachlan, Benjamin Cowie, David Isaacs, Joshua S Davis

Recommendations

  • Offer testing for hepatitis B virus (HBV) infection to all.
  • A complete HBV blood test includes HB surface antigen (HBsAg), HB surface antibody (HBsAb), and HB core antibody (HBcAb).
  • If HBsAg is positive, further assessment and follow up with clinical assessment, abdominal ultrasound and blood tests is required (see text).
  • Household and sexual partners of people who are HBsAg positive should be offered testing, and vaccination if they are susceptible to HBV.
  • If HBsAg positive, test for and vaccinate against hepatitis A

Produced by

in consultation with

                  Refugee Health Network of Australia

Endorsed by

Funded by

The Australian Refugee Health Practice Guide was produced with funds from the Australian Government Department of Health.

Disclaimer

The information set out in the Australian Refugee Health Practice Guide (“the Guide”) is current at the date of first publication and is intended for use as a guide of a general nature only and may or may not be relevant to particular patients or circumstances. Nor is the Guide exhaustive of the subject matter. Persons implementing any recommendations contained in the Guide must exercise their own independent skill or judgement or seek appropriate professional advice relevant to their own particular circumstances when so doing. The statements or opinions that are expressed in the Guide reflect the views of the contributing authors and do not necessarily represent the views of the editors or Foundation House. Compliance with any recommendations cannot of itself guarantee discharge of the duty of care owed to patients and others coming into contact with the health professional and the premises from which the health professional operates.

Whilst the information is directed to health professionals possessing appropriate qualifications and skills in ascertaining and discharging their professional (including legal) duties, it is not to be regarded as clinical advice and, in particular, is no substitute for a full examination and consideration of medical history in reaching a diagnosis and treatment based on accepted clinical practices.

Accordingly, Foundation House and its employees and agents shall have no liability (including without limitation liability by reason of negligence) to any users of the information contained in the Guide for any loss or damage (consequential or otherwise), cost or expense incurred or arising by reason of any person using or relying on the information contained in the Guide and whether caused by reason of any error, negligent act, omission or misrepresentation in the information. Although every effort has been made to ensure that drug doses and other information are presented accurately in the Guide, the ultimate responsibility rests with the prescribing clinician. For detailed prescribing information or instructions on the use of any product described herein, please consult the prescribing information issued by the manufacturer.