Research Commentary  February 2018
Jan 26, 2018
The focus of this review is on Refugee Health Screening. Refugees arrive in New Zealand from different parts of the world. Refugees undergo health screening at Mangere Refugee Resettlement Centre soon after arrival. Refugee health screening is different from routine patient history taking and examination in several significant ways: 1) They are new migrants from countries where the disease epidemiology is different from New Zealand; 2) Certain infectious disease processes need to be ruled out upon arrival to prevent the spread of communicable diseases; 3) The prevalence of mental health disorders in refugees is higher than the local population; 4) The medical and psychiatric health problems of refugees are often caused or affected by their past experience with trauma and their current acculturation difficulties; and 5) Significant cultural barriers can arise in the evaluation and treatment of refugees.
Commentary provided by Dr Annette Mortensen, eCALD® Services Project Manager: Research and Development
The following articles are reviewed:
Article 1: Systematic health screening of refugees after resettlement in recipient countries: a scoping review.
This article reviews 53 refugee health screening studies in North America, Australia, New Zealand and Europe. The studies demonstrate great variation in who was targeted for screening and how screening was conducted. Generally, screening programmes focus on infectious diseases. Almost half of the studies included screening for tuberculosis and approximately a third of the studies included screening for hepatitis, parasites, helminths and anaemia. Few studies included screening for mental health and non-infectious diseases like diabetes and hypertension.
The refugee health screening offered by the Auckland Regional Public Health Service, Refugee Health Screening Service is internationally unique. Other resettlement countries offer screening through primary health clinics. For example, in Canada only patients seeking medical care are offered screening and the screening tests performed are not consistently offered to the entire population. In New Zealand, refugees spend their first 6 weeks in a resettlement centre where health screening is part of the programme. The screening programme is offered to both quota refugees and asylum seekers.
New Zealand’s refugee health screening process is unique and optimal from a number of perspectives. 1) We offer a systematic public health intervention with 100 percent participation within six weeks of arrival; 2) screening for chronic diseases; 3) mental health screening and intervention 4) immunisations offered to all; 5) health education and an orientation to the New Zealand health system.
Authors: Hvass, A.M.F. & Wejse, C.
Citation: Hvass, A.M.F. & Wejse, C. (2017). Systematic health screening of refugees after resettlement in recipient countries: a scoping review. Annals of Human Biology,44:5, 475-483, DOI: 10.1080/03014460.2017.1330897.
Article 2: A cost-benefit analysis of a proposed overseas refugee latent tuberculosisinfection screening and treatment program.
Refugees to the United States (as with refugees selected for resettlement in New Zealand) are examined for active TB and if diagnosed, treated prior to arriving in the United States. However, refugees are not tested for Latent Tuberculosis Infection (LBTI) overseas. This study explored the effect of the screening and treatment of refugees for latent tuberculosis infection (LTBI) before entrance to the United States as a strategy for reducing active tuberculosis (TB). The purpose of this study was to estimate the costs and benefits of LTBI screening and treatment in United States bound refugees prior to arrival.
The results of the study showed that for a hypothetical 1-year cohort of 100,000 refugees arriving in the United States from regions with high, moderate, and low LTBI prevalence, implementation of overseas screening would be expected to prevent 440, 220, and 57 active TB cases in the United States during the first 20 years after arrival. The cost savings associated with treatment of these averted cases would offset the cost of LTBI screening and treatment for refugees from countries with high (net cost-saving: $4.9 million) and moderate (net cost-saving: $1.6 million) LTBI prevalence. For low LTBI prevalence populations, LTBI screening and treatment exceed expected future TB treatment cost savings (net cost of $780,000).
Implementing LTBI screening and treatment for United States bound refugees from countries with high or moderate LTBI prevalence would potentially save millions of dollars and contribute to United States TB elimination goals. These estimates are conservative since secondary transmission from tuberculosis cases in the United States was not considered in the model.
In New Zealand, all quota refugees are screened at Mangere Refugee Resettlement Centre on arrival and where indicated treated prophylactically for latent TB infection with Isoniazid (McLeod & Reeve, 2005).
References: McLeod, A & Reeve, M. (2005). The health status of quota refugees screened by New Zealand’s Auckland Public Health Service between 1995 and 2000. Journal of the New Zealand Medical Association, 118, (1224). https://www.ncbi.nlm.nih.gov/pubmed/16258577
Authors: Wingate, L.T., Colman, M.S., de la Motte Hurst, C., Semple, M., Zhou, W., Cetron, M.S., Painter, J.A.
Citation: Wingate et al., (2015). A cost-benefit analysis of a proposed overseas refugee latent tuberculosis infection screening and treatment program. BMC Public Health, 15,1201. DOI 10.1186/s12889-015-2530-7.
Article 3: A needs analysis of catch-up immunisation in refugee-background and asylum seeker communities in Victoria.
Refugee communities are strongly supportive of immunisation, and recognise the individual and public health benefits. This report examines catch-up immunisation for people of refugee background in Victoria, Australia and explores effective models of service delivery to complete catch-up vaccinations.
People from refugee backgrounds are at significant risk of being unimmunised or under-immunised on arrival in resettlement countries, due to the circumstances inherent in the refugee and asylum experience. Although people from refugee backgrounds may have received vaccinations overseas, most do not have written documentation, and in this situation, Australian (and New Zealand) guidelines recommend full catch-up vaccination. Unfortunately, there are multiple reasons why people from refugee backgrounds are at significant risk of remaining unimmunised or under-immunised. Catch-up schedules are complex, and change with time. Delivering catch-up vaccinations is complicated, and both time and resource intensive, typically requiring multiple vaccines for numerous family members outside the (National Immunisation Programme) NIP schedule points. People from refugee backgrounds may have difficulty accessing and navigating health and immunisation services, and usually require interpreter assistance for healthcare episodes. Finally, evidence suggests missed opportunities by service providers, including perceptions that catch-up vaccination for people of refugee background is just ‘too difficult’.
Among the recommendations were additional support for providers to deliver catch-up immunisations; the need for a centralised catch-up immunisation guideline, a whole of-life immunisation calculator, and the potential to use a single patient-held record across Victoria. Other gaps identified were the need for specific information on catch-up vaccination, extension of existing immunisation education to include issues for refugee background communities; and the development of service/practice guidelines for general practices; along with translated information.
In New Zealand, the Southern District Health Board’s Programme Leader for Vaccine Preventable Disease Jillian Boniface and Dr Leanne Liggett, a public health analyst involved in the Dunedin resettlement of Syrian refugees are conducting a feasibility study into adapting and piloting the South Australian Immunisation Calculator and ultimately incorporating this into the NIR so that it becomes part and parcel of the national immunisation programme. An online immunisation calculator would simplify data collection, improve workflow efficiencies, support timely clinical delivery and ensure the National Immunisation Register is updated.
Reference: South Australia Immunisation Calculator: https://immunisationcalculator.sahealth.sa.gov.au/ImmuCalculator.aspx.
Authors: Victorian Health Network.
Citation: Victorian Health Network (2014). A needs analysis of catch-up immunisation in refugee-background and asylum seeker communities in Victoria. Melbourne: Victorian Health Network. DOI: 10.13140/RG.2.2.10388.30085
Article 4: Refugee and Asylum Seeker Oral Health Recall tool-Development and Pilot: Final Report. Melbourne: Victorian Refugee Health Network.
The highest rates of hospitalisation for people from refugee backgrounds in New Zealand are for diseases of the oral cavity, particularly ‘dental caries’ (Chan, 2009; Perumal, 2011). A Refugee and Asylum Seeker Oral Health Recall Tool has been developed for use public dental services in Victoria, Australia. The project was funded by Dental Health Services Victoria (DHSV) and conducted over a five-month period from November 2016 to April 2017 by the Victorian Refugee Health Network. The factors associated with poor oral health in refugee and asylum seeker populations are unique and complex, with overall oral health and subsequent access to services impacted by both pre-arrival and resettlement factors. This includes factors such as pre-arrival torture and trauma (including trauma to the outh/teeth), the health impact of periods of deprivation in transit, and the ongoing systemic and social disadvantages related to resettlement, including language barriers, unfamiliarity with the Australian health system.
In 2010, the Victorian Department of Health implemented two policies in regard to oral health; it identified refugees and asylum seekers as a priority access group and provided a fee exemption at public dental services across Victoria. Subsequently, the 2012 Refugee Oral Health Sector Capacity Building Project aimed to support public dental services in Victoria to implement the priority access and fee exemption policies and work with people from refugee backgrounds.
The Model of Care recommends observation and assessment of social and clinical risk factors that impact on oral health care as the basis for continued priority access for individuals from refugee backgrounds. People from refugee backgrounds present with varying degrees of risk of poor health. For this reason oral health practitioners require an approach that differentiates people who require ongoing support to access services from those who may join general waitlists. The development of this evidence-based tool supports oral health practitioners to make these decisions. Systemic changes in the delivery of adult dental services in New Zealand are needed for all high needs oral health populations, with refugee populations a high priority or free or low cost dental care.
Chan, W.C., Peters, J., Reeve, M., Saunders, H. (2009). Descriptive Epidemiology of Refugee Health in New Zealand. Auckland: Auckland Regional Public Health Service. http://nzrefugeeresearch.wikispaces.com/file/view/Descriptive%20epidemiology%20of%20refugee%20health%20in%20New%20Zealand%20%282009%29.pdf
Perumal, L. (2010). Health needs assessment of Middle Eastern, Latin American and African people living in the Auckland region. Auckland: Auckland District Health Board.
Authors: Tyrrell, L., Mansfield, T. & Casy, S.
Citation: Tyrrell, L., Mansfield, T. & Casy, S. (2017). Refugee and Asylum Seeker Oral Health Recall tool-Development and Pilot: Final Report. Melbourne: Victorian Refugee Health Network.