Immunisation issues in refugees & asylum seekers. Dr Mitchell Smith Director, NSW Refugee Health Service

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1 Immunisation issues in refugees & asylum seekers Dr Mitchell Smith Director, NSW Refugee Health Service

2 Overview Background who, what & where What s known Immunity/coverage Access/models of care Community attitudes More to know

3 Australia's Humanitarian Migration Program Increasingly complex Off-shore resettlement refugee status or similar, migrate => permanent residents On-shore Asylum seekers in a range of settings Varied eligibility for health care Some get permanent visas Total visas: up to 20,000 per year

4 Region of origin of refugees settling in Australia

5 off-shore program (DIAC) Iraqi minorities esp. located in Syria Afghans from Iran, Pakistan, Indonesia Burmese from Thai Burma border, Malaysia and India Bhutanese from Nepal Refugees from Dem. Rep. of Congo & Ethiopia

6 Health Screening humanitarian entrants from off-shore Visa medical Departure Health Check (since 2005) - includes MMR vaccine (9 mths to 54 yrs) - vax not always available

7 Immigration Detention Statistics Summary - 31 May DIAC

8 As at 31 May 2013

9 Immunisation in Immigration Detention Health care provided by International Health & Medical Services (IHMS) in detention centres Aim is to provide Australian schedule, including catch-ups Vaccine data given to Immigration Health Advisory Group (IHAG) ACIR for children under 7 Community detention GPs

10 People of refugee background: Risks for inadequate immunisation (G Paxton) Country of origin schedules different eg HIB Disruption to preventive health services by war, chaos Limited access to health care in exile Limited vaccination services esp for adolescents & adults

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12 Total cost of vaccinating 50,787 refugees in 2005: $25,990,579 in US vs $7,706,026 overseas May also reduce importation of VPDs

13 Seroprevalence data Australia (adapted from Paxton G) Study Measles Rubella Tetanus Diphtheria Hepatitis B 136 East African children Immigrant Health Clinic RCH Melb, Nov 2000-Jan 2002 i 90 % 77 % 61 % 45 % 33 % 77 % 88 % 24 % 125 newly arrived youths Intensive English Centre, Fairfield NSW 2005 ii 164 newly arrived children Wollongong NSW 88 % 85 % Jan Dec 2009 iii 187 refugee women arrivals Metro Sydney Nov Apr 2013 iv 710 adult & child refugee arrivals, Metro Sydney Nov Apr 2013 v i Paxton G et al - JPCH 2011 ii Heron L - unpublished data iii Joshua P et al - PIDJ 2013 iv Smith M - unpublished data v Smith M - unpublished data 88 % 33 %

14 Source: Australian Doctor 2011

15 Risks for not catching up General health service access issues Unfamiliarity with system, transport, cost, mistrust Amplified for a/seekers without Medicare Mobility, competing priorities, & lack of constant health provider Language, incl consent Lack of documentation from o/s incl DOB Other provider issues Lack of monovalent vaccines Lack of funding eg HPV vax Difficulties in identifying refugees in data systems

16 Models/access Refugee/Asylum seeker health services Enhanced school-based eg Intensive English Centres in NSW Dedicated clinics eg Adelaide; SVH Enhanced vaccine availability Note varies by jurisdiction

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18 Community Little local research Anecdotally, little opposition to vaccination among refugee groups Sheik-Mohammed et al (2006) found a majority of African families did not perceive measles as serious Hmong study in US significant correlation with years lived in US & opinion that immunisation was not important use of traditional Hmong health care (i.e. shamans & herbalists) associated with perceived barriers to immn (Baker D et al Am J Public Health May; 100(5): ) Note WHO statement re vaccine additives & Islam

19 An example of health education NSW Refugee Health Service Public Health Unit, Sydney South West Fairfield Migrant Resource Centre Anglicare

20 In conclusion Research needs Immunity by: condition / country of origin / age Catch-up programs State-by-state comparison of funding and implementation Policy & funding barriers Coordination mechanisms Feasibility & effectiveness in different settings eg GPs, schools, dedicated clinics, home Attitudes/barriers among various community groups