There are food security risks in many refugee-source countries,²⁵² as prolonged food deprivation and inadequate access to nutritious food and clean water are common. After arrival in Australia there still may be issues of food insecurity, ^253,254 poor access to healthy foods and consequent under-nutrition. Specific issues include: low weight and/or height-for-age in children, vitamin deficiencies, iron deficiency and anaemia. As well as the potential for under-nutrition, there are increasing problems with dyslipidaemia and obesity and the associated risks of developing non-communicable diseases (NCDs chapter 14). The period of early settlement is a window for health promotion about nutrition.

Anaemia (defined as a low blood haemoglobin concentration with ‘normal’ ranges depending on gender, age and pregnancy status) has been reported in adults from refugee-like backgrounds in Australia. The prevalence is estimated at 7–20%, ^39,43,45,255 but is greater in young children (23–39%)^43,255 (see prevalence tables for more information). Anaemia is a major cause of, or a contributor to, morbidity and mortality worldwide. In some settings up to 50% of patients with anaemia are iron deficient.²⁵⁶ Iron deficiency in children from refugee backgrounds in Australia and New Zealand ranges from 17% (36/216)⁴⁵ to 33% (113/343).⁵¹

Iron deficiency anaemia occurs after iron stores become severely depleted. As well as the common causes in the Australian population such as pregnancy, breast feeding, menstrual blood loss, inadequate iron intake, and gastrointestinal blood loss,²⁵⁷ chronic infections such as hookworm, strongyloidiasis, Helicobacter pylori infection and chronic malaria can contribute. Iron deficiency, even without associated anaemia, may cause fatigue and hence affect productivity. Women of reproductive age and children are at particular risk of iron deficiency and iron deficiency anaemia because of greater iron requirements. It is important that women have adequate iron stores during their reproductive years, as iron deficiency in pregnancy increases maternal and perinatal mortality, and can cause cognitive and motor delays in children. Side effects of iron supplementation include gastrointestinal symptoms such as nausea, constipation or abdominal pain as well as the potential for overdose in children.^258–262 In view of the high prevalence of anaemia and iron deficiency in people from refugee-like backgrounds, the fact that iron deficiency is easily treated, as well as published evidence for possible improvements in symptomatic fatigue in women ²⁶³ and for psychomotor development in children,²⁶⁴ we recommend screening for anaemia with full blood examination (FBE) in all patients and to consider excluding iron deficiency by determining serum ferritin concentrations in women of child-bearing age, children, and those with fatigue. FBE, rather than purely haemoglobin (Hb), is recommended because red cell characteristics may be useful in determining the type of anaemia, and differential white cell concentrations (e.g. eosinophils) are included.

Other haematological conditions

Congenital neutropenia. Neutrophil concentrations below normal Australian reference ranges occur in 25–50% of persons of African descent and in some groups from the Middle East.²⁶⁵ This is not a pathological condition but rather reflects a different ‘normal’ range. If the person seems well and has no associated clinical features like fever, gingivitis or skin infections, no further investigation is indicated.

Eosinophilia is defined as an absolute eosinophil count exceeding 0.6 x 109 eosinophils/mm3 and is apparent on FBE. Eosinophilia in this population may indicate the presence of a parasitic infection (see schistosomiasis, strongyloidiasis, and other intestinal parasites). Note: single-cell intestinal parasites (e.g. giardia) do not cause eosinophilia. Other causes of eosinophilia include allergies and medications.

Inherited anaemias. These include thalassaemias, G6PD deficiency and haemoglobinopathies. These are more common in people from Africa, Asia and the Middle East. Carriers are usually asymptomatic but often have mild microcytic hypochromic anaemia.

Lead toxicity. Elevated serum lead concentrations have been reported in up to 7–25% of people of African refugee-like background^266,267 and in children from the Thai-Burma refugee camps^267–270 especially in those aged < 6 years, although rarely to a level requiring chelation therapy. Screening for lead toxicity in Australian refugee populations is not recommended routinely but should be considered if there are symptoms of lead toxicity such as learning, memory, behavioural or cognitive dysfunction in children²⁷¹ and when anaemia is unexplained.

Coeliac disease. Although there are no Australian data available in people from refugee-like backgrounds, the rates of coeliac disease in North Africa and the Middle East are apparently similar to rates in Western countries. The disease is rare in Sub-Saharan Africa and in East Asia.²⁷²

Vitamin B12 deficiency has been reported in refugees from Bhutan, Iran, Afghanistan, Iraq and the Horn of Africa in Australia ^156,273,274 especially when there is poor access to food. This does not necessarily correlate with symptoms or even with macrocytosis, and the significance of such apparent deficiency, the requirements for replacing borderline deficiency, the effects of post-migration diets and possible impacts on long-term health in those from refugee-like backgrounds are currently unclear.²⁷⁵

Folate deficiency is uncommon in those from refugee-like backgrounds in Australia ^43,273 but should be considered in new arrivals with food insecurity. As folate deficiency is uncommon in Australia due to the availability of fresh foods and vegetables, and the fortification of some foods, testing is not recommended.

Symptoms of anaemia may be subtle. They include lethargy, irritability, shortness of breath, poor growth, weakness and signs of cardiac failure. There may be a past history of malaria, worm infestations, Helicobacter pylori infection, haematemesis or malaena and patients may have occult chronic diseases, such as renal failure. The family history may indicate a predisposition to haemoglobinopathy.

Consider folate or B12 deficiency in those with a history of food insecurity, vegan diets or with symptoms suggestive of cognitive deficit, neurological or neuropsychiatric problems, developmental delay, and, if FBE indicates macrocytic anaemia.

Full blood examination (FBE) in all. This is to screen for anaemia, eosinophilia and thrombocytopenia.

Serum ferritin for children and for women of childbearing age, people with vegetarian, especially vegan diets, those with a history of food insecurity, if anaemia is unexplained, and when iron deficiency is suspected clinically or from FBE results. Note: in patients with acute and/or chronic inflammatory and some other conditions, serum ferritin levels of up to 60-100µg/L²⁵⁷ do not exclude iron deficiency.

Consider B12 screening in those with suggestive symptoms, macrocytosis, or deemed at risk (e.g. vegan diet). Screening is generally not required for asymptomatic individuals with an adequate diet, or for those living in Australia for >6 months and who consume meat. Request serum B12, if this is abnormal or low a serum active B12 (holotranscobalamin) should be ordered.

If FBE shows microcytic anaemia and/or low ferritin consider and treat underlying causes. Consider common parasitic infections and Helicobacter pylori infection. Educate patients and families about iron-rich diets.

Replace iron as per published guidelines.^257,276 There are a number of formulations of iron and the dosage depends on weight in children. Intermittent oral iron (e.g. once or twice-weekly) is also an option and may reduce side-effects. Discuss side-effects (e.g. dark stools, constipation, gastrointestinal upset), safety and storage with patients and families. Use Easidose for picture-based dosing, if needed.

If iron-deficiency anaemia does not resolve within three months of oral iron supplementation and in those without a clear explanation for their anaemia, consider gastroscopy and colonoscopy especially in men and post-menopausal women, to exclude occult gastrointestinal bleeding associated with peptic ulceration, polyps, cancers etc.

B12 deficiency. In those with low or equivocal serum B12 concentrations, confirm deficiency by measuring active B12 (serum holotranscobalamin), and treat if the concentration is <35 (pmol/L).²⁷⁷ When B12 supplementation is indicated, consider and treat concomitant folate deficiency. Consider testing for helicobacter pylori infection.^278,279 Replacement can be oral (cyanocobalamin 50–200 mcg daily, given between meals) or intramuscular (cyanocobalamin or hydroxycobalamin, IM 1000mcg given once.²⁷⁶ Dietary B12 intake following settlement in Australia is usually adequate and so it seems unlikely that ongoing supplementation is required, although this has not yet been studied.

The principles of healthy eating are universal and should be discussed with patients and their families.

Be aware of concurrent micronutrient deficiencies. These are outside the scope of this document but are summarised in the RCH guidelines.

Refer to Australian antenatal care guidelines 2015.

Refer to a paediatrician if there malnutrition is suspected. Consider hospital admission if there is anaemia is severe (e.g. Hb < 6g/dl). Severely malnourished children should have anthropometry performed by a dietitian. Once the initial screen has been completed and treatment initiated, growth-monitoring should be offered.
http://www.rch.org.au/uploadedFiles/Main/Content/immigranthealth/TE%20V2.htm 

Easidose, a visual prescribing aid
http://www.rch.org.au/immigranthealth/clinical/Iron_deficiency_and_anaemia/
Translated information on iron
Healthy lifestyle resources 

Non-communicable diseases (NCDs) include CVD, diabetes, respiratory diseases such as chronic obstructive pulmonary disease (COPD), musculoskeletal diseases and some cancers. There are few published data on the prevalence of NCDs in people from a refugee-like backgrounds in Australia. Some studies report a higher rate of NCDs in some refugee populations.²⁸⁰ There is published evidence that people from refugee-like backgrounds may have an increased prevalence of diabetes,^280–282 hypertension,^282–285 dyslipidaemia,^156,282 musculoskeletal disease, chronic respiratory disease,²⁸⁰ obesity or overweight^{274,280,283,284,286} and CVD,^282,287 compared to the population of country of settlement.

Conversely, some studies show a reduced prevalence of NCDs in some groups of immigrants living in high-income countries (HICs) compared to the long-term residents: the ‘healthy migrant effect.’^288,289

The rates of death related to NCDs are increasing in Australia^290,291 and internationally particularly in low- and middle-income countries (LMIC), including refugee-source countries.^292,293 Premature death attributable to NCDs in LMIC occurs at a far higher rate than in Australia.²⁹⁴

The major potentially treatable risk factors for the development of NCDs are poor nutrition and low physical activity, which pre-dispose to obesity, excessive alcohol intake, cigarette smoking and hypertension.

There may be additional explanations for the increased prevalence of NCDs. For immigrants moving from a low- or middle-income country to a high-income country (including people from a refugee-like background) these include abdominal obesity, dyslipidaemia, genetic and environmental factors.^295–297 Experiences of prolonged poverty, forced migration, time spent in refugee camps or similar circumstances may also be potential risk factors for developing NCDs. For example, perinatal deprivation or malnutrition is considered to pre-dispose to diabetes and to other NCDs. ^298,299 Post-traumatic stress disorder (PTSD) and depression are associated with hypertension and hyperlipidaemia.³⁰⁰ People from refugee-like backgrounds with NCDs may also be at risk of complex and multiple comorbidities due to poor socioeconomic conditions and concomitant mental illness, as well as inadequate access to preventive and chronic disease care.

Nutrition and obesity

There are few studies investigating risk factors for obesity in people from refugee-like backgrounds specifically but low socioeconomic status, food insecurity, high intake of sugar-sweetened drinks, body image and inappropriate beliefs related to food, stressful family life and depression are all risk factors for obesity in the general community, including those from refugee-like backgrounds.^288,301,302 Some refugee-background children reportedly assimilate quickly to less healthy Australian diets,³⁰³ and cultural groups may value childhood obesity as a sign of health and success.³⁰⁴ Other refugee-background communities feeling overwhelmed by food choices³⁰⁵ and have limited knowledge and access to information about healthy food options in Australia.³⁰¹

Physical activity

There are few published data on physical activity in people from refugee-like backgrounds. Amongst culturally and linguistically diverse communities, some refugees were less likely to be active or to consider physical activity due to PTSD.³⁰⁶

Diet and exercise requires individualised and culturally sensitive approaches.³⁰⁶

Tobacco, alcohol and other substances

Little is known about the use of substance in refugee-background communities in Australia.^307,308 A recent review of substance use in people from refugee backgrounds in the USA suggested a ‘refugee paradox’ much like the ‘healthy migrant effect.’³⁰⁹ Nevertheless drug, tobacco and alcohol issues have been identified as specific health issues of concern following consultations with refugee groups in Australia.^15,310 There are no data on the prevalence of smoking in people from a refugee-like background, and reported prevalence in immigrants varies according to gender, time since migration and country of origin.³¹¹ There are reports of increased smoking behaviour and heavy alcohol use in people from a refugee-like background who experience PTSD.³⁰⁸ Tobacco intake via a water pipe has been reported in those from the Middle East and Africa and has been shown to potentially increase nicotine dependence.³¹² Certain ethnic groups may also use other addictive substances, such as betel nut in Burmese³¹³ and khat in Somali communities.³¹⁴

There are few data on the use of complementary and alternative medicines by people from a refugee-like background.³¹⁵ Over-the-counter medications within some refugee communities have been linked to potential lead poisoning.²⁷¹ As with any patient, obtain detailed history of complementary and alternative medicine use.

• Evaluate for NCDs at initial assessment, then annually, or as opportunities arise.
• Consider prevalence of NCDs in country of origin.²⁹⁴ These may be underestimates in some refugee-source countries, because of infrequent screening and adequate data collection.
• Family history may be unknown; many people from refugee-like backgrounds have experienced family separation and loss.
• Ask about:
  • diet and nutritional status, including the amount of sugar-sweetened drinks (see ‘nutrition and obesity’ above) processed food and other carbohydrates
  • smoking, alcohol, other substances, prescribed and non-prescribed medications
  • physical activity
  • chest symptoms. e.g. consider COPD in those > 35 years with breathlessness, cough and/ or sputum production (after active TB is excluded). Biomass fuel cooking, common in many LMIC is associated with COPD³¹⁶
  • over-the-counter medications, alternative medications and herbal products (e.g. betel nut, khat), illicit substances.
• Examine:
  • weight, height and waist circumference. Calculate BMI. It should be noted that ‘normal’ values vary between ethnic groups and gender^317,318
  • blood pressure
  • nutritional status
  • signs of CVD, COPD, alcohol use, tobacco use.

At present there is no evidence to support screening for NCDs in refugee-background people earlier than current Australian guideline recommendations.

We recommend diabetes and CVD risk assessment from age 35 years in patients from high prevalence countries and with risk factors such as obesity or hypertension.

• Screen patients without risk factors for diabetes every 3 years from age 40 years using the AUSDRISK calculator and with a fasting blood sugar or HbA1c.

In people who are obese and/or with high-risk ethnicity (Asian, Middle Eastern, Pacific Islander, Southern European, North or Sub-Saharan African) calculate AUSDRISK and undertake testing earlier.

• Calculate absolute cardiovascular risk, serum cholesterol and other lipids: for patients >45 years, or earlier if risk factors.

Cardiovascular risk may be increased in South East Asians and southern Europeans. Those with co-morbid PTSD and depression may have dyslipidaemia. These groups may warrant earlier screening.

• Screen for chronic renal disease if at increased risk (e.g. because of smoking, hypertension, CVD, obesity, family history, diabetes) with a urine albumin:creatinine ratio and UEC (urea electrolytes and creatinine) with calculated glomerular filtration rate.
• Offer screening for breast, cervical cancer, colorectal cancer and osteoporosis as per the RACGP red book 
• See Low Vitamin D.

Manage possible or established NCDs and according to current Australian guidelines, as indicated in the links below. Use tailored, patient-centred, explanatory models.

Educate regarding lifestyle risk factors:

• Provide dietary advice, including recommending tap water as the main drink to all patients, irrespective of age.
• Consider discussions about NCDs in all individuals including adolescents especially in unaccompanied or separated minors.
• Take note of cultural and religious impact on diet e.g. Ramadan and diabetes.
• Consider referrals to diabetes nurse educators and dietitians to assist patients to understand and manage their chronic conditions.
• Consider and address social and emotional wellbeing and psychiatric co-morbidities (see Mental Health).

Refer to the Australian antenatal care guidelines 2015 

Although this chapter does not specifically refer to children we recommend recording weight and height, calculating body mass index (BMI) and recording blood pressure (BP) in all children and adolescents and offering management if abnormal.

RACGP
Australian Heart Foundation
Diabetes calculator
Nutritional guidelines (includes patient resources)
Chronic obstructive airways disease
Physical activity guidelines 
Physical activity assessment 
Health Translations
Health Information in Multiple Languages
The Australian Guide to Healthy Eating 

People from refugee-like backgrounds may not have had an assessment of hearing, vision and oral health in their country of origin.

Hearing

An estimated 80% of people in the world with moderate to profound hearing impairment are from low and middle income countries (LMIC).³⁴¹ Eighty per cent of hearing impairment worldwide is due to chronic suppurative otitis media (CSOM), and 90% of such cases are in the developing world.³⁴² In Australia, rates of CSOM and cholesteatoma in the adult refugee population are much higher than that documented in broader Australian population.³⁴³

Vision

Low vision and blindness are recognised as one of the major public health problems worldwide. Eighty per cent of visual impairment, including blindness, is avoidable. Uncorrected refractive errors and cataract are the leading causes of visual impairment. Other causes of visual impairment include glaucoma, age-related macular degeneration, corneal opacities, diabetic retinopathy, childhood blindness, trachoma and onchocerciasis. Cataract, trachoma, onchocerciasis and glaucoma occur at increased rates in Sub-Saharan Africa and in the least developed countries.³⁴⁴

Oral health

Poor oral health is a significant public health issue and can cause long-term morbidity. Common oral health problems among people from refugee-like backgrounds include dental caries, missing teeth and peridontal disease; less common issues include orofacial trauma or oral cancers.³⁴⁵ Rates of dental caries vary from region of origin; however, a number of studies have reported much poorer oral health for some groups of newly arrived adults and children from refugee-like backgrounds compared to the general population.^345–349

Oral health may be affected by a number of pre-arrival issues including low fluoride in the country of origin, low socioeconomic status, malnutrition, damage caused to teeth and gums by torture or trauma, and, poor access to dental care and oral health education.³⁴⁹ Post-arrival issues include low oral health literacy, the competing priorities of settlement, suboptimal understanding of dental service access, and the availability of low-cost sugar-rich food. Long waiting lists, costs of private dental service and suboptimal referral processes are also significant barriers to assessment and care. There may also be a discrepancy between self-reported and clinically determined need for dental care.^349,350

Miswak, a traditional chewing stick, is a commonly used oral health product in the Middle East and Sub-Saharan Africa. The efficacy of such products has not yet been established, but the healthcare provider should be aware of the potential oral healthcare differences between cultures.³⁵¹ 

Hearing

Ask the client if they have any concerns about their hearing or problems with their ears including chronic otitis media or discharge. Assess for a family history of deafness, and any exposure to extreme noise, including during conflict situations. Examine the external auditory canals and tympanic membranes. Further examination should be based on the client’s presenting symptoms. Hearing impairment may be a cause of, or contributor to learning difficulties.

Vision

Ask the client if they have any concerns about their vision or any other problems with their eyes. Check visual acuity for each eye, using an eye chart. The E Logmar Chart may be used for clients who cannot read English and the LEA Symbols Chart may be used for children.

Children rarely complain of low vision; therefore, all children should be assessed using StePs or a similar programme. Again, visual issues can contribute to learning problems in children and adolescents.

Refer all people of African descent >40 years and all others >50 years for ocular health checks for glaucoma.³⁴⁰ All people with diabetes require an eye examination. People from Pacific Island countries are at increased risk of diabetes.

Oral health

Ask the client if they have any concerns about their teeth and gums. Inspect the oral cavity with a good light, looking for dental caries, missing teeth, gum disease and other potential problems. Ask parents if children have difficulty sleeping or chewing hard foods, as this may be an indicator of chronic pain.

Hearing

Refer children and adults with hearing concerns for audiology testing. Access to this will depend on state and territory legislation. Australian Hearing offer hearing checks and other services (see eligibility requirements).

Referral to an ENT surgeon or audiology service can be made through a public hospital.

Vision

Ensure adults at risk, (e.g. from Sub-Saharan Africa or Pacific Island countries), and all individuals with visual concerns have had their vision tested through referral to bulk billing optometrist. Spectacle prescriptions can be filled by a subsidised eyewear service. See the Vision Australia website for referral options.

Some states and territories provide subsidised optometry services and glasses for refugees and asylum seekers.

Oral health

Regardless of reported symptoms, refer all people from refugee-like backgrounds to a public dental service for review. Provide basic oral health promotion including informing clients of the importance of a healthy diet, twice daily brushing of teeth, flossing to prevent tooth decay, and regular dental review. Discuss the use of age-appropriate toothpaste (0–6 years) with brushing advice. There may be significant difficulties accessing dental services. Some states and territories currently identify people from a refugee-like background as a priority access group, allowing fee exemption and next available appointment for general and denture care.

Low vitamin D is a public health issue across the lifespan, and is prevalent in refugee and asylum seeker populations in Australia. Vitamin D is essential for bone and muscle health, and there is increasing evidence of an association between vitamin D status and a range of non-bone health outcomes, despite a relative lack of robust randomised controlled supplementation trials.

Vitamin D refers to both D3 (cholecalciferol) and D2 (ergocalciferol). D3 is produced in the skin through the action of ultraviolet-B radiation (UVB) in sunlight; it is also the most common form in food and the form available in supplements. Small amounts of D2 are found in some plant- based foods. Vitamin D undergoes stepwise hydroxylation in the liver (forming 25OHD), then³¹⁹ kidneys (forming the active 1,25(OH)2D). 25OHD is the major circulating form and index of vitamin D input, and is used to assess vitamin D status. Normal vitamin D levels are defined as >50 nmol/L at all ages, and during pregnancy and lactation. This level may need to be 10–20nmol/L higher at the end of summer to maintain levels >50nmol/L over winter and spring.^320,321

Sunlight exposure is the most important source of vitamin D, and is estimated to provide over 90% of vitamin D in humans.³¹⁹ Skin synthesis varies with skin colour, ultraviolet radiation (UVR) protection (e.g. clothing, shade, sunscreen), time spent outside, latitude, season, time of day, and atmospheric conditions.^322–327 Adults with dark skin are likely to require three to six times the amount of UVB (compared to someone with light skin) to produce similar amounts of vitamin D, as the skin pigment, melanin, absorbs UVB.³²⁸ There are no data on skin synthesis in children.³²¹ Diet is a poor source of vitamin D for most Australians (limited amounts in some fatty fish, liver, eggs).³²⁰ Neonatal vitamin D levels reflect maternal vitamin D status, and cord blood levels are approximately 65% of maternal levels.³²⁹ Infants also depend on skin synthesis, as breast milk, despite its other benefits, contains very little vitamin D.³³⁰

Risk factors for low vitamin D can therefore be divided as follows:³²¹

• Lack of skin exposure to sunlight, e.g. lifestyle factors, chronic illness, covering clothing, southerly latitude
• Dark skin (Fitzpatrick types V or VI)³³¹
• Conditions affecting vitamin D metabolism and storage (including obesity)
• In infants – maternal vitamin D deficiency, and exclusive breastfeeding combined with at least one other risk factor.

People from a refugee-like background frequently have risk factors for low vitamin D, including dark skin, covering clothing and reduced exposure to sunlight through migration to temperate latitudes.

Available prevalence data show 61–100% in African refugees in Melbourne, Adelaide and Sydney have low vitamin D (<50nmol/L).^{45,155,255,332,333} Low vitamin D is also common in other refugee cohorts wearing covering clothing (Afghani, Iraqi; prevalence 50–70%),^71,156 and has been found in 33% of Karen refugees.⁴³ Three Australian case series of rickets found 96–98% of children were migrants or born to migrant parents, and almost all children in these series had ethno-cultural risk factors (dark skin, maternal covering clothing).^334–336 See prevalence tables for more information.

Vitamin D screening^321,337 is recommended in people with one or more risk factors for low vitamin D – and is therefore recommended as part of initial refugee and asylum seeker health screening where risk factors are present.

People with low vitamin D should be treated to restore their levels to the normal range with either daily dosing or high dose therapy, ^321,337 ensuring adequate calcium intake paired with advice about sun exposure and self-management. People with ongoing risk factors should be aware this is a lifelong health issue, requiring ongoing monitoring and management.

History

• Non-specific bony and/or muscular pain; fatigue with exercise
• Irritability, delayed motor milestones (young children)
• Dairy intake, symptoms of low calcium (muscle cramps). Hypocalcaemic seizures are rare beyond 12 months of age
• Sunscreen use, time outside
• Previous vitamin D levels, previous/current treatment (especially with the increased availability of supplementation)
• Family understanding.

Examination

• Rickets — deformity in growing bones due to failure of mineralisation of osteoid. Peak incidence during infancy, although deformity reflects age/growth (and can be in any direction).³³⁸ Consider other causes if asymmetrical. Long bone deformity, splaying (wrists, ankles), bossing, delayed fontanelle closure (normally closed by 18 months, 100% by 23-26 months), rachitic rosary
• Other — delayed dentition (no teeth by 9 months, no molars by 14 months),³³⁸ enamel hypoplasia.³³⁹ 

Screen people with serum Vitamin D if with one or more risk factors for low vitamin D.^321,337

• In adults — measure 25OHD
• In children — measure 25OHD, calcium, phosphate and ALP. Also measure parathyroid hormone (PTH) in those with low calcium intake, symptoms/signs or multiple risk factors.

In recent arrivals: if the initial vitamin D level is normal, repeat at the end of the first winter in Australia. Levels at the start and end of winter can be useful to make a clinical judgement on frequency of dosing.

From 2014, Vitamin D testing only attracts a Medicare benefit if the patient meets certain criteria (these include dark skin and severe lack of sun exposure for cultural/residential/medical reasons, children <16years with rickets, sibling <16 years with vitamin D deficiency, and infants whose mothers have vitamin D deficiency) – these criteria need to be specified on test requests.

People with low vitamin D should be treated to restore their levels to the normal range with either daily dosing or high dose therapy. ^321,337 D3 is the only form currently available in supplements.

Adults

• Mild deficiency (30–49nmol/L) 1000–2000IU daily for 3 months
• Moderate to severe deficiency (<30nmol/L) 3000–5000IU daily for 6–12 weeks, then 1000– 2000IU daily for a further 6–12 weeks (or 50,000IU monthly for 3–6 months).

Children

• There is inadequate evidence to support high dose therapy in children age<3 months, or during pregnancy or lactation³²¹
• Mild deficiency (30–49nmol/L) age ≥1 year 1000-2000IU daily for 3 months (or high dose 150,000IU stat in age 1–18 years)
• Moderate to severe deficiency (< 30nmol/L) age ≥1 year 1000-2000IU daily for 6 months or 3000-4000 IU daily for 6–12 weeks, (or high dose 150,000IU stat and repeat in 6 weeks in age 1–18 years).

Ensure adequate calcium intake. Calcium supplements may be needed if dietary intake is poor (<2 serves dairy daily). See recommended daily intake of calcium for age.

Treatment should be paired with health education and advice about sun protection/sun exposure – encouraging outside activity. People with dark skin can tolerate intermittent sun exposure without sunscreen. Hats/sunglasses are still recommended.

Follow-up bloods at 3 months (earlier in infants with moderate – severe deficiency – at 1 month³²¹). Follow-up bloods should include 25OHD, Ca, PO4 and ALP. Further management may be required if 25OHD is still low.

People with ongoing risk factors for low vitamin D need to understand this is a lifelong health issue. They will require ongoing monitoring, with annual testing and a plan to maintain vitamin D and calcium status through behavioural change where possible, and supplementation where this is inadequate. They may require high dose vitamin D more than once a year. Avoid very frequent testing.

Ongoing vitamin D intake to prevent deficiency

• Infants and children: 400-600IU daily in the absence of sun exposure – in those with ongoing risk factors it is useful to suggest daily supplements over the winter months or consider high dose vitamin D (150,000IU oral) each 6–12 months depending on levels and risk factor profile
• Adults: 600 IU daily for age <70 years, 800IU daily for those aged ≥70 years.

Women with one or more risk factors for low vitamin D should have their serum 25OHD levels measured at the first antenatal visit. Women with low levels should be treated to achieve 25OHD levels >50nmol/L

• 25OHD levels between 30–49nmol/L – 1000IU vitamin D3 daily
• 25OHD levels <30nmol/L – 2000IU vitamin D3 daily.

Testing should be repeated at 28 weeks’ gestation; in women whose 25OHD levels have corrected to >50nmol/L, a minimum of 600IU vitamin D3 daily should be given throughout the remainder of pregnancy. There is inadequate evidence to support high dose vitamin D during pregnancy.

Lactation:³²¹ breastfeeding women with low 25OHD levels should be started on 2000IU vitamin D3 daily. There is inadequate evidence to support high dose vitamin D during lactation.

Screening and treatment for children also follows the guidelines above.

Other considerations:

• Dosing tables are available for children, including infants
• In exclusively breastfed infants with at least one other risk factor it is usually more practical to start supplements without screening with 400IU daily for at least the first 12 months of life
• Babies on full formula feeds should receive adequate vitamin D from this source. There is inadequate evidence to support high dose vitamin D in children age 3 months
• Children with rickets require the above tests (25OHD, Ca, PO , ALP) as well as UEC, X-ray wrist, clinical photos. Also consider Mg, 1,25(OH)2D and urinary Ca/PO4/Creatinine
• Clinical photography is useful to monitor bony deformity in children (nutritional rickets usually corrects after treatment of low vitamin D provided the child has adequate calcium and phosphate intake).

Admission/specialist referral

Symptomatic rickets/hypocalcaemia (including tetany, stridor, seizures) requires hospital admission for intravenous calcium infusion with cardiac monitoring and vitamin D. Do not give high dose Vitamin D in the outpatient setting to this group

Children with clinical rickets or abnormal serum calcium require specialist assessment.

http://www.rch.org.au/immigranthealth/clinical/Low_Vitamin_D/

https://www.nps.org.au/data/assets/pdf_file/0020/265322/Fact-sheet-vitamin-D-tests.pdf

https://www.nrv.gov.au/nutrients/calcium

Easidose, a visual prescribing aid 

Female adolescents and women from refugee-like backgrounds may have had limited access to women’s healthcare services prior to arrival in Australia, either due to lack of availability in their countries of origin and transit or because of prolonged periods spent in transit camps. Depending on their country of origin, the concept of women’s health screening and perinatal care may be unfamiliar, and the rationale, benefits and processes thus may need to be explained with a professional interpreter to enable informed consent.

A comprehensive women’s health assessment should be offered respectfully and sensitively. This is an opportunity to build trust and to create a safe environment. Similar to other communities, sensitive aspects of history may not be volunteered by patients until rapport is established, and may not be raised in the presence of other family members. Interpreter rapport is a further factor in building trust in the consultation. It is essential to clearly define the routine role of confidentiality in consultations, including defining interpreter confidentiality. Female adolescents should be seen alone for part of their health consultations once rapport is established. Explaining this is routine in the Australian healthcare system and seeking permission from both the adolescent and her parent/carers is helpful to facilitate this aspect of adolescent healthcare.

It is rarely necessary to perform a breast or pelvic examination at the first visit, unless there is an issue of immediate concern to the patient. It may be appropriate to see the patient over several visits in order to establish trust, to adequately explain the reason for women’s health screening and to ensure understanding and informed consent. Practitioners should always offer and provide a female interpreter, or, if requested by the individual, a chaperone for these consultations.

Cultural pressures and expectations as well as additional vulnerabilities related to migration status may influence the health consultation. As an example, women who are seeking asylum who are victims of IPV, as well as facing the many barriers common to all women who are victims of family violence, may struggle to disclose their traumatic experiences because of concerns about potential impacts on their asylum claim.

Confidentiality within the consultation should be emphasised as well as the fact that resources and support are available if violence is disclosed.³⁵⁵ Re-establishing trust is essential to emotional recovery for women who have experienced pre and/or post-migration trauma. Development of a quality therapeutic relationship with a primary care provider can be an important part of this recovery process.

Preventive health

Many women from refugee-like backgrounds are unfamiliar with pap smears and mammography, as well as other aspects of preventive health. Women with a first language other than English in Australia have been found to have lower health screening access rates and poorer quality of health outcomes compared to English speakers.^358,359

Explain the benefit and mechanism of these investigations to ensure an informed choice. Use health promotion material such as multilingual patient information sheets, flip charts, anatomical models and diagrams to explain screening tests, basic anatomy and physical functions such as menstruation.³⁶⁰

Women from refugee-like backgrounds may be at increased risk of osteoporosis due to prolonged poor nutrition and/or low vitamin D levels. Standard national guidelines apply for chronic disease (such as type 2 diabetes, ischaemic heart disease and osteoporosis), cervical, breast and bowel cancer screening.³⁴⁰

Screening for STIs also needs to be considered for women at risk, particularly for women who have come from a high-risk environment for, or disclosed exposure to sexual violence or unprotected sex (See Sexually Transmissible Infections).

Fertility and contraceptive choices

A comprehensive contraceptive and obstetric history is essential. Avoid making assumptions when providing sexual and reproductive healthcare. Some women may have limited knowledge and experience of contraception and are consequently at greater risk of unplanned pregnancy.³⁶¹

Contraceptive choices may be a responsibility shared by both partners. Offer information sensitively and clarify and enhance existing knowledge of emergency, reversible and irreversible contraception. Multilingual resources are available.³⁶²

Avoidance of assumptions is particularly pertinent to the management of unplanned pregnancy. Some women may decline a termination of pregnancy for religious and/or cultural reasons, others will make use of the opportunity; in any case, information regarding referral and clinical options, including medical abortion, should be provided so women can make an informed choice.

Female genital mutilation/cutting

Female genital mutilation/cutting³⁶³ is practised in many humanitarian source countries, although there are no prevalence data on how many women have undergone the procedure prior to arrival in Australia. It is estimated that over 125 million women worldwide have been affected by FGM/C,³⁶⁴ and in some countries the prevalence in women is up to 90%.

FGM/C involves removing normal, healthy genital tissue. The procedure is typically performed in young girls, from infancy to 15 years of age. It is medically unnecessary and has many potential physical and psychological consequences. The risks are related to the type of FGM/C that a woman has undergone. It is important that all primary care providers who see women from countries where this practice is performed are aware of the facts on the procedure, and potential consequences for women and girls.

It is important to be aware that use of the term FGM/C can be offensive to women. This issue should be explored respectfully, ascertaining what term the patient prefers. Other suggested terms such as ‘female circumcision’, ‘traditional cutting’ or ‘female ritual surgery’ may be perceived as being more respectful.³⁶³ For many women, FGM/C is a normal part of their life experience and thus they may be surprised when concerns are raised. Adolescent girls may not be aware that they have undergone the procedure.

There are four different types of FGM/C, ranging from excision of the prepuce to removal of the majority of the external genitalia and narrowing of the introitus (infibulation).³⁶³ Potential consequences depend on the type of FGM/C performed. Many women do not experience difficulties; however some may suffer from difficulty voiding, frequent UTIs, obstructed urinary flow, incontinence, sexual difficulties, urinary and/or faecal fistulae, obstruction during miscarriage and childbirth, intra-partum vaginal and perineal damage, chronic pain and psychological sequelae. Refer to an experienced female GP or sexual health nurse for gynaecological examination, including for pap smears. If women request de-infibulation (surgical opening of a narrowed introitus), facilitate expert gynaecological review – this is considered an urgent rather than routine referral.

Respectful, non-judgemental explanation of medical concerns about risks of FGM/C is important, particularly during pregnancy. Women and their families need to be aware of Australian law concerning FGM/C. It is particularly important that women understand that it is illegal in Australia for their daughters or other female relatives or friends to have this procedure, either in Australia or while overseas. Some families may want their daughters to undergo FGM/C and may wish to take them out of Australia to facilitate the procedure, this is an issue to consider when families seek travel advice for other reasons. Mandatory child protection reporting is required if there is any concern that girls aged less than 18 years of age are at risk of undergoing FGM/C.³⁶⁵ Education programmes to inform and support communities about the negative health consequences of FGM/C are available in several states in Australia.³⁶⁶

Pregnancy care

Women who have a positive pregnancy test or who are planning pregnancy should be offered screening consistent with Australian antenatal care guidelines.³⁵²

Pregnancy planning, preferably in the prenatal period, is very important in women who have had FGM/C, to ensure that health outcomes of both mother and baby are optimised. Assess the type of FGM/C and refer appropriately to ascertain if de-infibulation is required. The external appearance of genitalia is not necessarily an accurate representation of internal narrowing due to the procedure, which may complicate labour. Understanding and managing expectations, which may be divergent from obstetric practice in Australia, such as expectation of re-infibulation following delivery, is important; these concerns should be recognised and addressed as soon as they arise.

Many women from refugee-like backgrounds come from countries where there are high fertility rates and poor access to antenatal and prenatal care. Consequently, pregnancy complications and fetal loss are not uncommon.³⁶⁷ The sense of loss experienced by women from refugee-like backgrounds may increase during pregnancy. Many women are distressed at not being able to follow their traditional cultural practices at this time, where supporting women through pregnancy and childbirth, and raising children is a shared responsibility. Women often feel the absence of relatives acutely and some studies suggest a higher risk of postnatal depression.³⁶⁸

Menopause

Menopause should be considered when taking a history from women aged over 40 years. Menopausal symptoms may be masked by, or attributed to the difficulties of resettlement. Prolonged periods of amenorrhoea due to malnutrition or stress may be mistaken for premature menopause, or mask a slowly returning and/or unexpected fertility. This presentation provides a good opportunity to talk about contraception and preventive health, including the importance of weight-bearing exercise.

Intimate partner violence³⁵⁵

Refugee women often lack knowledge of laws about IPV in Australia, particularly knowledge of what constitutes family violence, and how to access help for this issue. Women can face multiple barriers to disclosing their experience of violence.

Family violence in Australia is not confined to particular socioeconomic or cultural groups – it is pervasive.³⁶⁹ Recognised correlating factors for risk of violence in women include exposure to child abuse or violence as a child, alcohol or drug dependency issues, financial or personal stress and lack of social support. IPV is more common in countries experiencing war, conflict or social upheaval. Some women are more vulnerable to violence, or less able to leave violent relationships, based on factors such as age, rural and remote location, disability, ethnicity, English language ability and being pregnant.

As is the case with any women presenting for healthcare in Australia, the possibility of IPV should always be considered in women from refugee-like backgrounds, sensitively explored, level of safety assessed and managed empathically.^354,355

It is useful to screen discreetly for family wellbeing and to interview the woman separately from her partner where possible, giving her an opportunity to raise concerns. Useful questions include: ‘Is there a lot of tension in your relationship at the moment?’, ‘How do you solve arguments if they happen?’, ‘Do arguments ever get physical at home?’, ‘Do you feel safe at home?’. Assessing safety is important, as is providing support to develop a safety plan for women and children at risk.

The majority of women who are victims of IPV do not readily disclose their traumatic experiences due to a number of factors including:

• fear of reprisal/worsening violence
• social isolation and financial dependence
• poor self-esteem as a consequence of the violence
• emotional dependence
• being unable to recognise the cycle of abuse/self-blame
• fear of loss of custody of children.

For women from refugee-like backgrounds, disclosure rates are believed to be lower than the rest of the population, and they may face additional complexities such as concerns about potential impact on immigration status, and cultural and religious factors, including risk of social ostracism if disclosure occurs.^370,371

Healthcare providers need to be aware of these issues, to approach concerns about IPV sensitively and to review regularly and invest time in the therapeutic relationship as the development of trust is imperative. When a woman is ready, referral to culturally appropriate advocacy, support and legal services can be facilitated.

RACGP White book Abuse and violence – working with our patients in general practice Feb 2014.

Australian antenatal guidelines (contains information on culturally sensitive care and on specific needs of women from refugee-like backgrounds)

The National Education Toolkit for FGM/C awareness

Female genital mutilation Information for health professionals booklet

Hach M. Multicultural centre for womens health. Common threads, common practice. Working with immigrant and refugee communities in sexual and reproductive health.

Family planning NSW multilingual audiovisual resource for patients explaining importance of cervical screening

Cohealth. Helping health professionals to start conversations about female circumcision website.

Jean Hailes Multilingual womens health resources including menopause and PCOS.

Women from culturally and linguistically diverse backgrounds
https://www.beyondblue.org.au/resources/for-me/multicultural-people

http://www.health.gov.au/internet/publications/publishing.nsf/Content/clinical-practice-guidelines-ac-mod1~part-a~population-groups~diverse-backgrounds

https://www.beyondblue.org.au/resources/health-professionals/perinatal-mental-health 

Many adults and children from refugee-like backgrounds have experienced trauma, conflict, family separation and significant human rights violations, including torture and physical and sexual violence. A meta-analysis found the population prevalence of reported torture was 21% in refugee adults,³⁷² and available Australian data suggest a high proportion of asylum seekers in detention disclose a history of trauma and torture.³⁷³ Unaccompanied and separated children are recognised as having specific risks and vulnerabilities.^374–378

While pre-arrival trauma is well recognised in refugee populations, settlement may also contribute to mental illness, and is often associated with multiple stressors. Navigating life in a new country, language barriers, housing and financial instability, difficulty accessing employment, changes in family roles, and loss of community, country and cultural connections can have additive impacts in terms of risk for mental health. A meta-analysis of risk factors affecting mental health outcomes in refugee groups³⁷⁹ found poorer outcomes were associated with institutional or temporary housing after settlement, restricted economic opportunity after settlement, ongoing conflict in the country of origin, higher education level and higher socioeconomic status pre-arrival, and coming from a rural area. Child and adolescent refugees had relatively better mental health outcomes than adults in this analysis, although parent mental health has a strong influence on child wellbeing.

Asylum seekers may face additional stressors related to their asylum experience – through perilous journeys, time in immigration detention, and living in a state of prolonged uncertainty. There is clear evidence that Australian immigration detention, especially long-term detention, is detrimental to health and mental health at all ages, in the short and long term.^380–400 Additionally, Australian temporary protection visas have been shown to be associated with worse mental health status when compared to permanent protection visas,^{387,392,401–404} due to restrictions on family reunion, access to employment and/or Medicare, and exposure to ongoing uncertainty.⁴⁰⁴

Widely variable rates of mental health issues are reported in refugee children (reviewed in,⁴⁰⁵ also^406,407 and adults,^{372,391,408–412}) although there is more information available on the prevalence of Post Traumatic Stress Disorder (PTSD), depression, and anxiety than other mental health diagnoses, and findings are typically specific to cohorts, conflicts and countries of settlement. Like any population, people from refugee-like backgrounds may have conditions such as schizophrenia or bipolar disorder; although, there is little evidence to suggest that these diagnoses are more frequent in refugee-like populations.

The validity of mental health screening in refugee groups has been questioned.⁴¹³ Existing assessment tools, diagnostic approaches and psychological interventions may have limited applicability to refugees and asylum seekers, and caution is required with mental health diagnoses; however, evidence suggests that therapy is beneficial in these groups.^414–416

We advise clinical screening for emotional wellbeing and mental disorders as part of the post-arrival screening, and ongoing review for stressors related to the refugee and resettlement experience over time.

Available evidence suggests that both refugees^{405,417–423} and asylum seekers^424–427 face significant barriers to accessing health and mental health services. A comprehensive post-arrival health assessment offers an opportunity to build trust and rapport, consider risk and resilience, and raise awareness of mental health and supports in Australia. Understanding mental health is also essential to address other health problems, and support adherence to medication and management.

A complete history and examination is outlined in Promoting Refugee Health.²¹

Health consultations and discussion about mental health may be a source of significant anxiety for some individuals. Past experiences influence people’s understanding and access to healthcare, and it is important to recognise that people may not had prior experience of mental health care. Furthermore, in some source countries, authority figures, including health professionals, may have been complicit in torture or other form/s of persecution. It is also important to consider the presence of family members in the room, and issues specific to working with interpreters.

The following areas are useful to explore during initial consultations:

• Migration history. Some useful general (and sensitive) questions include:
  • When did you leave your country?
  • Were you forced to leave?
  • What was the situation that led you to leave?
  • What countries were you in before you came to Australia?
  • What were conditions like in those countries?
  • Have you spent time in a refugee camp or a detention centre?
• Migration status (asylum seekers). Asylum seekers in Australia experience prolonged delays (i.e. years) in processing their claims for refugee status, which includes frequent changes to immigration policies that directly impact on their day-to-day lives. An insecure and temporary visa status is associated with feelings of powerlessness and inability to plan for the future,^401,403 with the additional burden of stringent code of conduct requirements,⁴²⁸ denial of work rights⁴²⁹ and/or Medicare, and restrictions on family reunion.⁴³⁰
• Family composition. Useful questions include: ‘Who is in your family in Australia?’ and ‘Who is in your family overseas?’ rather than trying to construct a genogram. Concern for remaining family overseas may be overwhelming, with significant effects on settlement and wellbeing.
• Settlement experience, social connections, resources and support.
• Current functioning. It is often useful to ask about appetite, energy, daily activities, memory and concentration, sleep and plans for the future as an entry to more specific mental health symptoms. Asking about approaches to stress management, and coping strategies can also be useful, as it can indicate the extent of the person’s (internal and external) resources, and utilisation of these resources.
• Trauma screening. It is rarely necessary to ask in detail about a client’s trauma and torture history, and it is important to consider the potential for triggering a trauma response. Useful screening questions include:
  • Terrible things have often happened to people who have been forced to leave their countries. I do not need to know the details about what you have been through, but is there anything that has happened that might be affecting you now?
  • Do you think a lot about these things that you’ve been through?
  • Is it hard to concentrate on other things in your life, or is it hard to get to sleep because of these memories or thoughts, or because of bad dreams or nightmares?
  • Do you worry about going crazy or ‘losing your mind’?
• More specific mental health symptoms. Enquire about symptoms such as current mood, irritability or anger, sadness, hopelessness, guilt and worthlessness, loss of interest in (previously) enjoyable activities, social withdrawal, anxiety symptoms, panic symptoms/panic attacks, rumination, and intrusive thoughts.
• Self-harm/suicide risk assessment. Suicidality can occur independently of mental illness,⁴³¹ and hopelessness has been found to be a stronger predictor of suicidal ideation than a diagnosis of depression.^432–434 Furthermore, suicidality may present differently in those from diverse refugee-like backgrounds.^435,436 Religious beliefs and a strong sense of responsibility to one’s family can be particularly potent protective factors, which often precludes intentional and planned acts of self-harm. It is worth noting that asylum seekers are likely to be at greater risk of suicide after a negative refugee determination decision.^437,438 Therefore in addition to the usual risk assessment questions (i.e., Does the individual have thoughts of harming themselves? Do they have intent, a plan and means to do so?), the following questions may also be useful: ‘Do you ever wish you were dead?’; ‘How often do you have these thoughts… and how long have you been having them? Have they increased or lessened over time?’; ‘Do you worry that you might hurt yourself impulsively, without planning to (e.g. walking in front of a car or train)?’ ‘Do you sometimes find yourself doing things that put you at risk without realising, such as walking across the road without checking to see if there is traffic?’.

Other common presentations in adults include:

• Somatization of psychological symptoms including chronic and regional pain syndromes. Pain syndromes, particularly neuropathic pain, can also be the consequence of previous torture and thus should be comprehensively assessed.
• Concerns about memory and concentration.
• Complicated grief,^439–441 prolonged grief/bereavement,^439,442 and traumatic grief.⁴⁴³ Common – even adaptive – traumatic/complicated grief reactions in this population may be mistaken for psychotic symptoms, such as visual or auditory hallucinations,^444,445 and must be considered and assessed carefully within this context.
• Relationship difficulties (including family violence, parenting issues). Refer to Women’s health for further exploration of family violence identification and management.
• Disorders of addiction, including gambling or substance abuse.

Culture, mental health literacy, education, language proficiency, education and perceptions of stigma also have profound effects on presentation and access to mental health services.

The Cultural Assessment Tool⁴⁴⁶ is a useful framework that encourages a narrative approach to exploring people’s beliefs and cultural interpretation of illness. Questions from this tool include:

• Why do you think the problem started when it did?
• What do you think your illness does to you?
• What are the main problems it has caused for you?
• How severe is your illness?
• What do you most fear about it?
• What kind of treatment/help do you think you should receive?
• Within your own culture how would your illness be treated?
• How is your community helping you?
• What have you been doing so far?
• What are the most important results you hope to get from treatment?

Patients with mental health issues related to torture and trauma should be referred to a specialised torture and trauma service.

Where there is no torture or trauma history, referral to mainstream mental health services may be more appropriate. There are a number of ways to provide assistance while people await review. These include:

• Regular review and providing support to reduce feelings of isolation.
• Exploring and identifying strengths and evidence of resilience.
• Advice regarding regular exercise and good nutrition.
• Advice on sleep hygiene and relaxation strategies.
• Psycho-education about common mental health symptoms and conditions (e.g. social withdrawal, anhedonia, and disturbance of mood, sleep, appetite for depression; intrusive symptoms, avoidance and hyper-arousal for PTSD; physiological responses during panic attacks; transient cognitive difficulties due to anxiety/depression/chronic stress). Normalising symptoms can help to de-stigmatise perceptions of mental illness, and individuals may prefer to manage symptoms themselves unless, or, until, significant psychosocial functional impairment and/or subjective suffering is encountered.
• Explaining what is meant by counselling, which may increase the likelihood of the individual accepting a referral in the future. Counselling may be normalised by framing it as a way to help problem-solving processes and increase coping strategies, in addition to it being a confidential space to release ‘emotional pressure’ independent of family and community relationships.
• Introducing the concept of talking with others – e.g. friends, religious figures, or a counsellor as a way to releasing pent up emotions and stress. Useful analogies can be to get things ‘off one’s chest’ or a pressure cooker valve ‘letting off steam’, rather than ‘bottling things up’. Explaining that counselling may not suit everyone, but that it may help provide strategies to reduce further build up of emotional stress, strengthen emotion regulation, and increase social connectivity, can be a useful strategy.
• Teaching structured problem-solving, and identifying and challenging negative core beliefs using simple cognitive behavioural therapy strategies. Technology such as mobile phone applications may be useful. Whilst most applications are in English, there is at least one (‘New Roots’) that has been translated. (Refer to Links at the end of this chapter).
• Excluding possible medical contributors to mental health symptoms where relevant (e.g. low B12, thyroid dysfunction).

A list of services for each state and territory is available in the Foundation House Promoting Refugee Health Guideline.²¹

The methods of documenting (and managing) physical and psychological findings of torture and trauma are outside the scope of these guidelines. Please refer to the Istanbul protocol for further details.

The sense of disconnection and loss relating to separation from key family members, supports and culture can be exacerbated during pregnancy and the perinatal period. It is common for women to be distressed by differences between mainstream ante and perinatal care and their traditional cultural practices during this time. Many women of refugee-like background are from cultures where supporting a new mother and raising children is a shared responsibility. Pregnancy and the post-partum period are often times where the sense of loss related to absence of friends and relatives is heightened and thus there is a higher risk of anxiety and postnatal depression.³⁶⁸ This risk appears to be extreme for women who are pregnant and give birth while they are in immigration detention.

Women who have experienced FGM/C face specific physical and psychological risks in pregnancy, which need to be recognised early and addressed (see Women’s Health).

Pregnancy is a time where women at risk of family violence may be particularly vulnerable to harm. Women of refugee-like background are not immune to these risks and thus this needs to be considered and sensitively managed^355,369 (see Women’s Health).

Recognition of the risks which women of a refugee like background face during this vulnerable time is important, to enable appropriate screening, to facilitate access to care with early referral to culturally and linguistically appropriate services, to enhance social supports and enable access to appropriate health promotion and education resources to optimise outcomes.³⁵² 

Children and young people of refugee-like background are likely to have been exposed to significant trauma prior to their arrival in Australia, and may have additive risk for mental health and developmental concerns through parent mental illness, disrupted family functioning, periods of separation, and the timing of trauma in relation to developmental milestones. Unaccompanied and separated minors have specific vulnerabilities, including increased risk of experiencing violence, sexual abuse or sexual violence, and they may have cumulative risk for mental illness. Children and adolescents experience a similar range of psychological reactions to trauma to adults; however, their clinical presentation reflects their age and development.

Parent mental health influences child mental health, and the impacts of parental distress and/or mental illness on children are significant. For asylum seeker children and adolescents, Australian immigration detention has been found to have profound negative impact on parenting and family functioning,^{209,390,391,395,447,448} and children frequently witness adult distress, mental illness and self-harm in detention.⁴⁴⁹ Children and adolescents in detention are at high risk of mental health problems, including PTSD, anxiety and depression, sleep and behavioural disturbances, and enuresis. Infants born in detention may have severe attachment issues in association with maternal postnatal depression.

Parental well-being is also identified as a key factor in optimising a child’s ability to recover from adversity.⁴⁵⁰ Children and adolescents experience settlement through their family circumstances, but also through their interaction with peers, community and education in their new country, and there is increasing recognition of the role of education and schools in supporting child wellbeing.^451–454
In addition to the areas of history suggested in the earlier section, other points to consider in children and adolescents include:⁴⁵⁵

• Attachment to parents/caregivers.
• Behavioural difficulties, including irritability or aggression.
• Play and peer relationships, including emergent themes in games or drawing, any difficulties making friends, engaging in play, or joining group activities.
• Difficulties with attention or concentration, hyperactive behaviour, learning difficulties.
• Withdrawal or lack of interest in normal activities; retreating into screen-based play is common.
• Separation issues, including school refusal, watchfulness, and co-sleeping.
• Sleep-related symptoms, including nightmares, intrusive worries or thoughts, disordered sleep routine and fatigue.
• Enuresis and encopresis.
• Difficulties with self-esteem.
• Developmental delay, lack of expected developmental progress or regression.
• Sexualised behaviour, which may indicate that a child or young person has witnessed or been exposed to sexual abuse. Seek advice on child protection concerns and consider reporting requirements.
• Risk taking behaviour in adolescents.

Self-harm or suicidality are extremely rare in younger children, but require urgent review if present at any age.

Consider use of a screening tool for children such as the Strengths and Difficulties Questionnaire (SDQ). HEADSSS screening is useful to elicit key aspects of psychosocial history in adolescents. See below for links.

Management and referral (children and adolescents)

Management and referral of children with mental health concerns follows similar principles to adults. Where mental health difficulties relate to torture/trauma experience, a torture trauma service is an appropriate referral, and in most states and territories these services will provide services for children. Seek specialist paediatric advice early; referral to generalist mental health services may also be appropriate. Also consider (and screen where relevant) for treatable conditions that may cause or exacerbate mental health or behavioural problems, including hypothyroidism, vitamin B12 deficiency and iron deficiency.

General principles of managing children/adolescents experiencing trauma reactions and/or other mental concerns include:

• Addressing mental health issues in the whole family.
• Supporting primary attachments with significant people.
• Maintaining routine and preparing for changes, reassuring children about the future.
• Addressing sleep issues, and maintaining a healthy age-appropriate sleep routine, and limiting screen time.
• Encouraging play in younger children (between children, and between parents and children) and enjoyable activities in older children/adolescents, including sport and exercise.
• Encouraging them to express emotions and asking what they are thinking/feeling.
• Setting realistic goals for behaviour and avoiding overreacting to difficult behaviour during transition periods.
• Promoting engagement with school and community, and also promoting maintenance of first language alongside English language learning.

A brief assessment of developmental milestones should be included as part of a comprehensive assessment in children of refugee-like background, specifically eliciting parent concern, excluding sensory impairment (vision and hearing), and ensuring children are linked with age-appropriate services such as Maternal and Child Health Nursing and kindergartens early in the settlement period. Assessment of children with developmental delays or disability will usually require specialist child health input, by paediatricians or through paediatric allied health professionals.

There are limited prevalence data on developmental issues or disability in children of refugee- like background, although they may have multiple risk factors for developmental concerns, and the aetiology of developmental issues is typically multifactorial. Routine neonatal, early childhood, vision and hearing screening are unlikely to have been completed, and children may arrive with significant developmental delays or disability.

Psychological and developmental assessment can be complex, requiring an understanding of second (or later) language acquisition, language transitions in relation to development, relevant medical conditions, the impact of forced migration, trauma, and settlement, and support services available. There are specific challenges with the use of developmental screening tools, language assessments and cognitive assessments for children with English as an Additional Language (EAL). Developmental assessments take time and require close liaison with families and the help of a skilled interpreter. They are usually completed in the specialist child health setting, after referral from primary care. Service guidelines are available.⁴⁵⁶

Adolescence is a developmental stage, for which milestones include emergent autonomy and independence, personal identity and body image, peer relationships and recreational goals, educational and vocational goals, and sexuality. Adolescents of a refugee background face all these transitions in addition to the transitions of resettlement. They are faced with balancing the values/expectations of their parents/cultural background with those of their new peers, while developing their own identity and learning a new language in a new schooling and social system. Adolescents may also make new meaning from past trauma, and present with mental health concerns in relation to trauma in early childhood.

Promoting refugee health: a guide for doctors, nurses and other health care providers caring for people from refugee backgrounds.

Mental health in multicultural Australia

Forum of Australian Services for the Survivors of Torture and trauma services (listed by state and territory)

Health Translations Mental Health

Beyond Blue Resources Health Professionals Clinical Practice Guidelines

Refugee Health Network Mental Health Resources

Refugee Health Network Mental Health Referrals

New Roots smartphone app

Children and young people

ANU Australian child and adolescent trauma, loss and grief network – refugee children and families information

Royal Children’s Hospital Melbourne. Immigrant Health service. Developmental assessment page.

Transcultural Mental Health Centre & NSW Centre for the Advancement of Adolescent Health. Adolescent Health: Enhancing the skills in caring for young people from culturally diverse backgrounds. 2nd edn. 2008 

Strengths and Difficulties Questionnaire

HEADSSS screening 

Approximately 1% of the Australian population – 220,000 people – are living with chronic HBV; however, it is estimated nearly half remain undiagnosed. People born overseas represent the majority of individuals with hepatitis B in Australia. Approximately 90% of the world’s population live in areas where the prevalence of chronic HBV in the population is 2% or higher, including the majority of source countries for Australia’s humanitarian intake.

A number of studies have assessed the prevalence of chronic HBV in refugees based on routine screening. Rates vary, but are significantly higher than the prevalence in the Australian population. Examples include predominantly Sub-Saharan African refugee cohorts in Melbourne (22%¹⁰⁷ and 8%¹⁰⁸) and Sydney (4%⁴⁵), and from the Migrant Health Unit in WA (5%⁴¹). High prevalence has also been found among Burmese refugees (14%⁴⁸ and 10%⁴³), and those from the Mekong region (8–9%¹⁰⁹). See prevalence tables for more information.

Since chronic HBV is a) generally asymptomatic; b) endemic in nearly all current countries of origin of people from refugee-like backgrounds, and c) has effective treatment and vaccination available, we have recommended universal testing.

Figure 4.1: Global Prevalence of Hepatitis B, 2012

Source: B Positive: All you wanted to know about hepatitis B¹¹⁰

*   For multiple countries, estimates of prevalence of hepatitis B surface antigen (HBsAg), a marker of chronic HBV infection, are based on limited data and might not reflect current prevalence in countries that have implemented childhood hepatitis B vaccination. In addition, HBsAg prevalence might vary within countries by subpopulation and locality. Adapted from: World Health Organisation, Introduction of hepatitis B vaccination into child immunization services. WHO. 2001.

Chronic HBV is usually asymptomatic; however, if left undiagnosed and unmanaged it can cause advanced liver disease and/or liver cancer in up to 1 in 4 people. Appropriate management and treatment significantly reduces these risks; and diagnosis also provides an opportunity to offer vaccination to contacts at risk of exposure.

Serology testing for HBV infection should include hepatitis B surface antigen (HBsAg), hepatitis B surface antibody (HBsAb or anti-HBs) and hepatitis B core antibody (HBcAb or anti-HBc). All three tests are rebatable by Medicare if the request specifies ‘query chronic HBV’ (or similar). Testing all three markers allows a complete picture of hepatitis B status, including clarification of infection, and immunity, and whether immunity has developed in response to vaccination or infection. All tests should be performed with the informed consent of the individual, or their legal guardian where relevant (e.g. parents providing consent for children).

Figure 4.2: Serology interpretation for hepatitis B

Source: Decision Making in Hepatitis B (ASHM resource)

Further testing and management is required for all people diagnosed with chronic HBV, alongside culturally appropriate counselling about their diagnosis, treatment options, and ways to minimise the impact of HBV on their health and reduce transmission to others. There is no such thing as a ‘healthy carrier’. All people with chronic HBV infection need lifelong monitoring, as HBV infection is a dynamic process. Consultation with a clinician experienced in the management of viral hepatitis is recommended. Consider the patient’s language proficiency and the use of an interpreter when discussing HBV diagnosis, management and treatment. Use visual material if the patient has low literacy skills (see resources below).

All those who are HBsAg positive should have:

1. Counselling regarding the natural history, how to protect others from infection, the need for lifelong monitoring and the avoidance of hazardous alcohol consumption.
2. A targeted history and physical examination, looking for symptoms or signs of chronic liver disease.
3. Baseline LFTs, HBV viral load, HB eAg and eAb, FBE, iron studies, INR, UEC and upper abdominal ultrasound.
4. Serology for hepatitis A virus (HAV), hepatitis C virus (HCV), hepatitis delta virus (HDV) and HIV if not already completed.
5. A repeat consultation once these results are available, to decide on a management plan, and whether specialist referral is needed.
6. The following patients should be referred to a specialist (ID physician, gastroenterologist or GP with accreditation to prescribe HBV medications):
   1. anyone suspected to have cirrhosis (based on clinical signs of chronic liver disease, imaging findings, low platelets or albumin, high bilirubin or INR)
   2. raised ALT (>19IU/L for women or >35IU/L for men, > reference range for children) AND HBV viral load >2,000 IU/ml
   3. current pregnancy
   4. those with co-infection with HIV, HCV or HDV (in addition to HBV)
   5. those with extra-hepatic manifestations of HBV (such as vasculitis or glomerulonephritis).
7. All others with HBV should have a management plan made, which should include a clinical review and a blood test for LFTs every 6 months and HBV viral load every 12 months.
8. The following patients with chronic HBV infection should be offered surveillance for hepatocellular carcinoma (HCC), with 6 monthly ultrasound and serum Alpha Fetoprotein (AFP):
   1. African people over age 20 years
   2. Asian females over age 50 years
   3. Asian males over age 40 years
   4. anyone with proven or suspected cirrhosis
   5. anyone with a family history of HCC in a first or second-degree relative.
9. People with HBV who are non-immune to hepatitis A should be vaccinated against HAV.

For people from refugee-like backgrounds who remain susceptible to HBV infection (i.e. negative serology for HBsAg, HBsAb and HBcAb), vaccination against hepatitis B is recommended at all ages.

Household and sexual partners of people with hepatitis B infection should be tested for HBV and vaccinated if they are susceptible to HBV infection. Serological testing (to confirm HBV immunity) is recommended for sexual partners and household or other close household-like contacts of people who are infected with hepatitis B, 4–8 weeks after completion of the primary vaccination course.

Figure 4.3: Testing algorithm for hepatitis B

All pregnant women should be screened for hepatitis B, and if they are HBsAg positive, they should be appropriately assessed, including hepatitis B viral load testing, ideally at 18–24 weeks of pregnancy. It is important that women who are diagnosed with hepatitis B antenatally are referred to a viral hepatitis specialist during pregnancy and that they engage in ongoing monitoring and care following delivery.

If a woman is HBsAg positive, her infant should receive hepatitis B immunoglobulin (HBIG) in addition to standard birth dose of monovalent hepatitis B vaccination, to reduce the risk of HBV transmission. HBIG and hepatitis B vaccination can be given concurrently to the infant (administered in different sites). HBIG should preferably be given within 12 hours of birth, and should be given within 48 hours. Hepatitis B vaccination should preferably be given within 24 hours and should be given within 7 days. Infants should go on to complete routine hepatitis B vaccination. Antiviral treatment to further reduce risk of vertical transmission is increasingly used in pregnant women with a high viral load (>107 IU/ml). Caesarean section is not recommended as an intervention to reduce the risk of perinatal hepatitis B transmission.

Breastfeeding is safe in women with chronic HBV, and does not increase the risk of transmission to the infant.

All children born in Australia should receive a full course of hepatitis B immunisation, which includes a dose within 24 hours of birth, and subsequent vaccinations at 2, 4 and 6 months (i.e. four doses of hepatitis B vaccine within the first year of life).

Children born to mothers with chronic HBV should have hepatitis B immunoglobulin (HBIG) at the time of birth in addition to the routine hepatitis B immunisation schedule as above. All children whose mothers have chronic HBV should subsequently be tested for HBsAg and HBsAb to determine if they have been infected, at 3–12 months after their vaccination is complete (i.e. after 9 months of age). Serology should not be checked before 9 months of age (to avoid detection of HBsAb from HBIG given at birth.

Children with chronic HBV typically have minimal liver damage and rarely require treatment; however, this is not always the case. All children with chronic HBV should therefore be referred to a paediatric viral hepatitis specialist for ongoing assessment and management. Children typically have very high viral load. Basic advice about preventing transmission related to normal childhood activities (e.g. cleaning blood spills, covering scrapes and scratches, not sharing toothbrushes) and immunising household contacts (and checking seroimmunity) is essential.

The Hepatitis B Story (a pictorial guide aimed at those from culturally and linguistically diverse backgrounds)

National Hepatitis B Testing Policy

HepBHelp

Decision making in HBV

B Positive 2014

CDC Yellow Book – Hepatitis B

ASID Management of Perinatal Infections 2014

Australian Immunisation Handbook 

Background

Intestinal parasite infections are common in low resource and rural communities. The largest disease burden is caused by the soil-transmitted helminths (STH), with an estimated 2 billion people, or 30% of the world’s population, infected globally.¹⁵⁰ Infections are common in tropical and subtropical areas, especially in Sub-Saharan Africa, the Americas, China and East Asia. The main species are Ascaris lumbricoides, Trichuris trichiura and the hookworms (Necator americanus and Ancylostoma duodenale). Giardia lamblia is a protozoan parasite that also commonly causes infection in these settings.

The prevalence of pathogenic stool parasites in people from refugee-like backgrounds reflects their socio-demographic and environmental circumstances, their countries of origin and transit, and availability of therapy.^151,152

In a study of 26,956 African and South East Asian refugees between 1993 and 2007, at least one nematode was found on stool microscopy in 20.8% of 4,370 people who had not received pre-departure albendazole.¹¹⁷ In the 22,586 people who received pre-departure albendazole, only 4.7% had nematode infection.^117,153 In 99 recent immigrants in New York, 40% had pathogenic parasites detected in stool.¹⁵⁴ Australian prevalence data are summarised here, most studies have found the prevalence of pathogenic stool parasites is between 15–40%^{39,41,43,48,51,108,135,155– 159} and the most common pathogen is Giardia.

Screening

Previous ASID guidelines recommended stool microscopy if this was readily obtainable, or where symptoms were present.¹²⁴ One stool sample will detect 90% of parasites.¹⁶⁰

The voluntary Departure Health Check (DHC) has been implemented since 2005, and is now in place for most source countries¹⁹ for Australia’s offshore Humanitarian Programme intake. The uptake of the DHC is unclear; however, many offshore arrivals will have received albendazole as part of the DHC. The current guidelines consider the introduction of the DHC and recent data on the impact of albendazole on the prevalence and patterns of intestinal parasites.^117,153 [/accordion-item]

Most patients are asymptomatic.¹³⁶ Symptoms due to intestinal parasites may include diarrhoea, cramping and abdominal pain.

Offer all an FBE to look for eosinophilia.

People with documentation of pre-departure albendazole treatment do not require screening for faecal parasites unless they are symptomatic or if they have eosinophilia.

In people with no documentation of pre-departure albendazole there are two acceptable options, depending on local resources and practices:

• Give empiric single-dose albendazole therapy (>6 months, <10kg; 200mg; ≥10kg; 400mg). This will be effective against many of the common parasites (see below). If they have eosinophilia at base line, re-check at 8 weeks post treatment. If eosinophilia unresolved, refer to specialist.

OR

• Perform stool microscopy for OCP. Obtain at least one fresh or fixed specimen delivered promptly to the laboratory. If there is a delay with delivery, stool should be in preservative (SAF). Laboratories are funded through Medicare for one OCP exam in seven days.

Common pathogenic parasites

For further information about individual parasites refer to the Centers for Disease Control and Prevention (CDC) website.

Common non-pathogenic parasites

Note: Albendazole is available at some refugee health and specialist hospital clinics, or on the PBS via streamlined authority for treatment of tapeworm and hookworm.

Hookworm (Ancylostoma duodenale, Necator americanus)

Albendazole 400mg daily for three days orally if weight ≥10kg (200mg daily if >6 months and <10kg).

Albendazole has been shown to be superior to mebendazole, but single dose treatment has suboptimal efficacy for hookworm infection.^161–164 Treat any concurrent iron deficiency (see Anaemia, Iron Deficiency and Other Blood Conditions).

Round worm (Ascaris lumbricoides)

Albendazole 400mg orally if weight ≥10kg (200mg >6months weight <10kg) as a single dose.^161,162 Corticosteroids are occasionally required in pulmonary ascariasis.

Whipworm (Trichuris trichiura)

Albendazole 400mg orally for three days orally if weight ≥10kg (200mg daily if >6 months and <10kg).

A three-day treatment regime had an efficacy of 83% in an RCT involving 175 children in Gabon.¹⁶³ Single dose therapy has low efficacy for trichuriasis.^161,164

Giardia lamblia

Treatment is with tinidazole 2g orally as a single dose (50mg/kg in children, maximum 2g), or metronidazole 2g daily for three days (30mg/kg in children, maximum 2g) (efficacy >90%).^136,148
Albendazole 400mg daily for five days is probably as efficacious as metronidazole 500mg three times daily for five days, with fewer side-effects.¹⁶⁵

Caution: Albendazole

Albendazole should be used with caution in patients who have symptoms and/or a travel history compatible with neurocysticercosis (such as epilepsy, central nervous system (CNS) symptoms, subcutaneous nodules, Taenia solium positive in faeces or serology) as treatment with albendazole alone can exacerbate CNS disease.

Follow-up

Repeat stool microscopy for OCP 2–4 weeks post therapy. Retreat if ova still present. Refer refractory cases for specialist management.

Albendazole is a class D drug. It should not be used in the 1st trimester of pregnancy. WHO recommends use in 2nd and 3rd trimester.¹⁶⁶ In women who are breastfeeding pyrantel is an alternative to albendazole.

Avoid albendazole in children ≤6 months, and give 200mg dose if >6months and <10kg. Avoid mebendazole in pregnancy (class B3).

Australian therapeutic guidelines state both albendazole and mebendazole can be used during lactation.⁷⁶

Seek specialist advice if uncertain, and refer children <2 years for specialist review if concerned.

World Health Organisation

Antimicrobial Therapy

Sheorey H, Biggs, BA. Clinical Parasitology: a Practical Handbook for Medical Practitioners and Microbiologists. Melbourne: Erudite Medical Books 2nd ed. 2014. 

Easidose, a visual prescribing aid

Skin infections may be common in some groups of people from refugee-like backgrounds. There are limited prevalence data, but skin complaints were the sixth most frequent problem amongst newly arrived African refugee patients less than 15 years old in Melbourne in 2005, affecting 10% of patients in that group.¹⁰⁸

Non-infectious conditions may have skin manifestations (e.g. nutrient deficiency, inflammatory conditions (eczema/dermatitis), insect bites, pigmentation changes (vitiligo, post inflammatory hypo/hyperpigmentation), psychodermatoses, medication side effects). Also consider skin manifestations of traditional medicine procedures (cupping, coining) and scars from injury or torture.

Common rashes and skin infections may have a different appearance in dark skin compared to light skin. Erythema may be subtle or not visible in dark skin.

The following table lists skin presentations, and outlines infectious and other diagnoses to consider along with associated findings, investigations and management.^219,220 Many of these diagnoses are extremely rare; they are included as a reference base for this reason. Inspection of skin is part of routine post arrival health screening examination. Investigations are guided by the clinical presentation.

Key points to note with drug treatment are:

• Albendazole is pregnancy category D – exclude pregnancy prior to use and provide advice about contraception prior to therapy. Dosage for albendazole changes for young children (200mg for patients >6months and <10kg).
• Ivermectin is not used in children <15kg and is relatively contraindicated in pregnancy (category B3).
• Griseofulvin is only used in children >2years and is relatively contraindicated in pregnancy (category B3).

See Table 11.1: Skin Infections for further detail on diagnosis and treatment of common skin infections

(A) Scabies: therapy details

>6 months old:

permethrin 5% cream to dry skin from the neck down especially hands, genitalia; apply under nails with a nailbrush.

Note- In central and northern Australia and in infants and the elderly, scabies above the neck is common and in these populations treatment should also be applied to face and hair (avoiding eyes and mucous membranes).

Leave for >8 hours (e.g. overnight) or 24 hours if previous treatment failure. Reapply to hands if washed. Repeat in 7 days.

OR

benzyl benzoate 25% emulsion (if allergic/permethrin failure) – apply as per permethrin for 24 hours.

For children dilute prior to application 6 months-2 years 1:3 parts water; 2 years-12 years 1:1 part water; If skin irritation occurs in adults dilute as for child 2-12 years.

OR

consider oral ivermectin for crusted scabies and/or treatment in immunocompromised or for treatment of widespread infection in crowded institutional settings.

<6months old:

permethrin is not approved in this age group but this must be balanced against the morbidity of untreated scabies, therefore recommended treatment is: permethrin 5% to entire body (including scalp but not eyes/mouth); Cover hands (e.g. mittens) so child doesn’t suck medication. Leave 8 hours. Repeat in 7 days.

OR

sulphur 10% in white soft paraffin (<2months: sulphur 5% in white, soft paraffin) topically, once daily 2-3 days

OR

crotamiton 10% cream topically daily 2-3 days.
During pregnancy/breastfeeding: permethrin 5% cream is the recommended treatment

(B) Tinea: diagnosis and management

Confirm diagnosis by microscopy and culture prior to treatment with antifungals, particularly systemic agents. Diagnostic samples include skin scrapings, subungual debris, clipped nail or plucked hair. False negative results are common especially with nail clippings due to insufficient specimens, recent antifungals and overgrowth. A trial of therapy may be appropriate.

Topical therapy is appropriate for localized infection (body, limbs, face, interdigital) with: terbinafine 1% cream/gel daily 1 week

OR bifonazole 1% daily 2-3 weeks

OR clotrimazole 1% bd for 2-4 weeks (continue 2 weeks after symptoms resolve)

OR econazole 1% bd continued 7 days after symptoms resolve

OR ketoconazole 2% topically daily continued 14 days after symptoms resolve

OR miconazole 2% bd for 4 weeks.

Use oral therapy for tinea capitis, palmar or solar tinea or if widespread, unresponsive to topical therapy, recurrent or previously treated with steroids. Tinea unguium usually requires oral treatment.

>40kg: Terbinafine 250mg daily OR fluconazole 150mg once weekly OR itraconazole 200mg oral, twice daily for 1 week (feet/hands) or daily for 1 week (elsewhere). Continue until clinical resolution (2-6 week course).

20-40kg: Terbinafine 125mg/d 2-4 weeks OR Itraconazole 3-5mg/kg daily 4-6 weeks OR fluconazole 6mg/kg/day for 3-6 weeks.

10-20kg: Terbinafine 62.5mg daily 2-4 weeks

Alternatively: Griseofulvin 20-25mg/kg/day for 6-12 weeks.

Easidose, a visual prescribing aid