Refugee Health and Chronic Disease

Refugee Health and Chronic Disease

What is a Chronic Disease? WHO Definitions Cardiovascular Respiratory Cancers Diabetes Other (kidney; neurological; cerebrovascular) Risk Factors in 2014 Alcohol intake Cigarette smoking Hypertension Obesity 2

In Context 3

Causes of Death 2011 vs. 2014 data Country Income group (% total deaths) Injuries (% total deaths) Infectious Maternal Perinatal Nutrition (% total deaths) Total deaths NCD (% total deaths) CVD (% total deaths) Cancer (% total deaths) Resp. (% total deaths) Diabetes Afghanistan Low 8/17 62/46 29/37 15/19 3/6 2/3 1/1 9/8 (% total deaths) Other NCDs Iran Low middle 14/14 13/10 72/76 45/46 12/13 4/4 2/2 10/11 DRC Low 7/10 72/67 21/23 9/9 3/3 2/2 1/1 6/8 Ethiopia Low 9/10 57/60 34/32 15/9 4/6 4/3 2/1 9/11 Australia High 6/6 4/3 90/91 35/31 29/29 6/7 3/3 17/21 4

CVD Risk Factors 2011 vs 2014 data Country Smoking Alcohol L. per head Physical inactivity High BP High blood glucose Obesity Iraq 13.7/18 0.5 55.2 24.4 10.6 27/27 Afghanistan (2008) - 0.7-22.5-2.2 Iran 10.4/14 (2011) 1.0 (2010) 35.7 33.7/ 24.3 8.3 19.4/ 19.4 DRC 4.5/10 (2011) 3.6 (2010) 42.5 37.6/ 29.4 (2008) - 1.7/1.7 (2008) Ethiopia 2.4 4.2 17.9 35.2/ 25.9 Australia 16.8/20 12.2 (2010) 40.3 36.4/ 21.4-1.1/1.1 9.4 26.8/ 26.8

Humanitarian Program (2) Rank 2003-2004 2007-2008 2012-2013 1 Sudan Burma Iraq 2 Iraq Iraq Afghanistan 3 Afghanistan Afganistan Myanmar 4 Ethiopia Sudan Bhutan 5 Iran Liberia Congo (DRC) 6 Liberia Congo (DRC) Iran 7 Fmr Yugoslavia Burundi Somalia 8 Sierra Leone Iran Sudan 9 Congo (DRC) Sierra Leone Eritrea 10 Somalia Sri Lanka Ethiopia 6

Refugee Health Conditions in Post Arrival Screening Problem Prevalence No. Studies Informing Anaemia 9-30% all groups 8 Iron Deficiency 13-34% all groups 6 Low Vitamin D 60-90% African, 37% Karen 6 African, 2 Karen, Low Vitamin A 40% African NT 2, Rohingya in QLD Hepatitis B sag +ve 2-16%, sab ve 60% 12, 5 Hepatitis C 1-3% 8 HIV <1% (0/3 studies) 7 Syphilis 0-5% 9 Other STI Very low 4 Schistosoma 2-39% African, 0-7% Karen 11 Strongyloides 1-21% 8 Malaria 5-10% African, changed with DHC 1 Faecal parasites 16-40% all groups 11 Mantoux positive 17 Australian studies/reports, 3-63%, 18-63% ~ 7000 7 studies people and ~ 7000 detainees; 9,7 4000 children H. pylori 82% African 1 Need for immunisation Close to 100% 7

Nutritional Deficiencies Prolonged deprivation and severe hunger Lack of clean water and nutritious food causes long-term vitamin and mineral deficiency, especially iron. Menstruation and breastfeeding women prone to iron and folate deficiency Diseases endemic eg: malaria, schistosomiasis, strongyloides Micro-nutrient deficiency disorders zinc, manganese, Vitamin A in children 40%), B12 (especially Bhutan/Nepal; no macrocytosis); Vitamin D (90%) Lead toxicity in some children (Burmese dietary supplements) Diet-related disorders eg: non-insulin dependent diabetes mellitus Eating disorders anorexia/obesity/ Western junk food diet 8

Studies have shown African Refugees 2010 (Asia Pacific Journal of Clinical Nutrition, vol. 20, no. 3, pp. 397-403. Prevalence of vitamin D insufficiency and risk factors for type 2 diabetes and cardiovascular disease among African migrant and refugee adults in Melbourne) 62% overweight/obese 47% insulin resistance 16% hypertension Journal of Community Health 2/3/2012 Katherine Yun (2006-2010 NE USA Refugee Clinic): We found that half of the adult refugees in this sample had at least one chronic NCD (51.1%), and 9.5% had three or more NCDs. Behavioral health diagnoses were most common (15.0%), followed by hypertension (13.3%). Half of adults were overweight or obese (54.6%). 9

Noncommunicable diseases among urban refugees and asylum-seekers in developing countries: a neglected health care need Ahmed Hassan Amara1 * and Syed Mohamed Aljunid2 3 Globalization and Health 2014, 10:24 doi:10.1186/1744-8603-10-24 Major search engines and refugee agency websites were systematically searched between June and July 2012 for articles and reports on NCD prevalence among urban refugees. 44,468 refugees and asylum seekers, 75 per cent involved Iraqi refugees. Most studies were conducted in the Middle East and indicated a high prevalence of NCDs among urban refugees in this region, but in general, the prevalence varied by refugees region or country of origin. Hypertension, musculoskeletal disease, diabetes and chronic respiratory disease were the major diseases observed. 10

Prev Chronic Dis. May 2010; 7(3): A51. Apr 15, 2010. Chronic Disease and Its Risk Factors Among Refugees and Asylees Massachusetts, 2001-2005 Nameeta M. Dookeran, MD, MSc, Tracy Battaglia, MD, MPH, Jennifer Cochran, MPH, and Paul L. Geltman, MD, MPH Health screening data from 4,239 adult refugees and asylees who arrived in Massachusetts from January 1, 2001, through December 31, 2005. We determined prevalence of obesity/overweight, hypertension, coronary artery disease (CAD), diabetes, and anemia. Almost half of our sample (46.8%) was obese/overweight, and 22.6% had hypertension. CAD, diabetes, and anemia were documented in 3.7%, 3.1%, and 12.8%, respectively. People from the Europe and Central Asia region were more likely than those from other regions to have CAD. 11

Medical Conditions by Region of Origin of People Who Received Refugee Health Assessment Services, Massachusetts, 2001-2005 (N = 4,239) a Region Obesity % Overwt % HT % CAD % Diabetes % Anaemia % Europe Central Asia (Fmr USSR, Fmr Yugo.; Albania) Africa (Somalia, Liberia, Sudan) East and SE Asia (Viet.; Cambodia; Burma) Nr East South Asia (Afghan.; Iraq; Iran) Latin America and Caribbean (Haiti, Cuba, Colombia) 27.3 31.2 32.2 7.8 3.5 9.5 13.3 24.2 16.4 0.5 2.5 19.6 3.6 21 9.8 0.6 3.6 5.3 13.6 27.2 11.7 0.5 2.8 12.2 18.6 31.2 17.4 0.3 3.3 9.0 All Regions 19.1 27.7 22.6 3.7 3.1 12.8 12

Prevalence: Refugees and Trauma Up to 30% of world s refugee population have had at least one experience of torture (IRCT, 2011) 80% of refugee women have experienced sexual abuse or sexual torture (UNHCR) 7/10 refugees on assessment had experienced physical or psychological violence (Foundation House, 2010)

Prevalence: Refugees and Psychological Suffering PTSD: 32%-100% (various studies 1984-2000: FH) Depression: 47-72% (various studies 1987, 1993: FH) PTSD in up to 20% in children, in some studies Chronic pain in 65% (of 72 clients in Oslo clinic), 72% of those severe. Tidsskr Nor Laegeforen. 2006 Feb 23;126(5):608-10.[Chronic pain in traumatized refugees].dahl S, Dahl CI, Sandvik L, Hauff E.

Cardiovascular Effects of Traumatic Stress PTSD direct relationship to devt of HT (US National Comorbidity Survey) Increased activity of SNS and hyperfn of parasympathetic NS Hyperlipidaemia Brazilian police officers with PTSD; Croatian soldiers Obesity increased BMI in individuals with PTSD Coronary heart disease Dept Vet Affairs USA normative aging study (The Long-term Consequences of Traumatic Stress: Intertwined Physical and Psychological Consequences. Alexander C. MacFarlane World Psychiatry 2010 Feb v 9(1) 3-10. Supported by NHMRC NHF BeyondBlue) 15

Risk Factors Contributing to Chronic disease Australian Institute of Health and Welfare Risk Factors for Chronic Disease 2012 Most Australians have 1 risk factor 90% reduced veg intake 50% reduced fruit 60% reduced physical acitvity (>150mins in 1/52 over 5 sessions) 80% more than 3 hours each day sitting 17% males > 5 risk factors cf 11% females Increased factors associated with lower SES In refugees, changes in diet, physical activity and chronic stress of poverty, low SES, family separation are factors. 16