  |
|
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Journal of the New Zealand Medical Association,
28-October-2005, Vol 118 No 1224
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
The health status of quota refugees screened by
New Zealand’s Auckland Public Health Service between 1995 and
2000
Alison McLeod, Martin Reeve
Each year, New Zealand takes a quota of 750 refugees from
overseas; about 10 other countries also take a quota of refugees. These refugees
have been mandated by the United Nations High Commission for Refugees (UNHCR),
and have often lived in refugee camps for many years. New Zealand also accepts
asylum seekers, about whom there is a separate report.1 The invited or
‘quota’ refugees are selected by the New Zealand Immigration Service
(NZIS), and come to New Zealand in groups of about 130, and on arrival, stay at
the Mangere Refugee Resettlement Centre (MRRC) in Auckland for 6 weeks. MRRC,
which started receiving refugees in 1979, is possibly unique in the world
because of its collection of agencies on the one site, the agencies being:
During their stay at MRRC, the refugees
are prepared for their new life in New Zealand, and among the preparations are
medical screening and treatment. Any treatment needed is either started at MRRC,
or the refugee is referred to the appropriate clinic. Adverse medical findings
do not have any effect on the refugees right to resettlement.
On leaving MRRC, all the refugees are given a copy of their
medical records, and part of the resettlement process involves a support worker
from RMS helping the refugee to register with a GP.
We report here key findings, mainly from the period of
1995–2000, but also including historical data from the opening of the
clinic. Some comparisons are made with asylum seekers.
MethodsMedical records have been kept since the clinic first
opened in 1979. An annual medical report was written every year from 1979 until
1992. Since July 1995, the records have been computerised, initially shelf
general practice patient management system, Medtech-32. The main data is derived
from analysis of the Microsoft Access software program from July 1995 until the
end of 1999. The screening programme is evolving; so over time, some procedures
are introduced and others dispensed with. In addition, some refugees do not
receive all the tests. In most cases this occurs in young children in whom for
technical reasons not enough blood is obtained to carry out all the tests.
The data includes stated nationality, age, and sex; the
screening process includes a chest X-ray for all those 16 years and over; and
for all ages, a Mantoux test, full blood count, haemoglobinopathy screening,
iron studies, liver function tests; serology for HIV antibodies, Hepatitis B
surface antigens, and antibodies, Hepatitis C antibodies, morbilli and rubella
IGG; one urine test; and 3 stool tests for
Salmonella and
Shigella bacterial species, and all
other faecal parasites. Women are offered cervical smears and gynaecological
bacteriological screening. The clinical medical examination is standardised, and
includes a psychosocial assessment.
Historical data before 1995 are taken from the annual
reports, and is presented for tuberculosis, HIV, and some faecal pathogens.
Where data are missing, it is because it is not available, usually at times of
restructuring when lack of continuity of staffing made collection of data
difficult.
Laboratory parameters from the testing laboratories as
printed with each result were used to determine the normality of blood tests.
Data were analysed using Epi Info 2000 software. Relative risks (RR) and 95%
confidence intervals (CI) were calculated, with corresponding p values.
ResultsDemographics2992 refugees received health screening at the MRRC
between July 1995 and the end of 1999. Their age and sex demographics are
presented in Figure 1; Tables 1 indicates their nationalities. Figure 2 and
Table 2 compare the age/sex and nationalities, respectively, of quota refugees
compared with asylum seekers. Of the 2992 refugees, 1403 (46.9%) were female and
1589 (53.1%) were male; 34 different nationalities were recorded.
Table 1. Demographic characteristics of quota refugees
screened at Mangere Refugee Resettlement Centre (1995–1999)
Figure 1. Demographic characteristics of quota refugees
screened at the Mangere Refugee Resettlement Centre, Auckland, New Zealand
(1995–1999)
Figure 2. Demographic characteristics of screened
asylum seekers in Auckland, New Zealand (1999–2000)
 Table 2. Demographic characteristics of quota refugees
1995–1999, compared with asylum seekers 1999–2000
Infectious diseasesThe four most prevalent infectious diseases in the World
(excluding upper respiratory tract infections) are:
Tuberculosis—Figure
3 shows the outcome of screening from July 1995 until July 1998 (1405 refugees).
After that time, the management of Mantoux positive refugees has devolved to the
public health units in the areas in which the refugees have settled.
Figure 3. Outcome of tuberculosis testing in quota
refugees screened at Mangere Refugee Resettlement Centre
(1995–1999)
 CXR=serial
chest X-ray; TB=tuberculosis; Prophylaxis=treatment for latent TB infection with
Isoniazid; Unresolved=generally those refugees whose Mantoux test is positive,
but who are undergoing further investigation at the time they left the
Centre—e.g. awaiting sputum culture for tuberculosis, and who were
followed up outside the Centre.
For the population under consideration, all 2992 had a
mantoux test, of whom 995 (34.3%) had a result of 10mm or more.
Malaria—Many
refugees come from an area in which malaria is endemic (e.g. Sub-Saharan
Africa). There is no test for quiescent malaria, but all refugees are asked if
they have had malaria, and if they come from a malaria endemic area; 26% of all
the refugees questioned report that they have had malaria in the past.
HIV
infection—Testing for HIV infection started at the Centre in 1994,
but reliable data exists from computerisation of the data in mid-1995. The data
has been grouped to avoid the risk of identifying individuals.
Table 2. Prevalence of positive HIV tests among quota
refugees screened at Mangere Refugee Resettlement Centre
(1995–1999)
Table 3. Serology of infectious diseases other than HIV
among quota refugees screened at Mangere Refugee Resettlement Centre
(1995–1999)
†Testing started in
1997.
Intestinal
parasites—Each refugee is requested to give three stool samples. In
the population studied, all 2992 refugees gave at least one sample. If every
refugee had given three samples as requested, there would have been 8976
samples. In fact there were 8485 samples examined, (of which 45 were
insufficient for analysis). Thus 8440 samples were analysed, 94% of the possible
total.
Table 4 lists the number of individuals affected by each
intestinal pathogen. Any given individual may be affected by more than one
pathogen.
A previous study of the Mangere refugees showed an overall
prevalence of 31%2 of individuals with one or more parasites; of which 7% had
two parasites detected, 1% had three, and 0.1% had four.
Table 4. Prevalence of selected intestinal
pathogens/parasites among quota refugees screened at Mangere Refugee
Resettlement Centre (1995–1999)
*One recorded case of
S.
typhi; unusual pathogens included 2
individuals with Sarcocystis and 9 with Trichostrongylus.
Other health parametersBlood-related
pathology—None of the study subjects was affected by a
haemoglobinopathy to the extent they had clinical disease. However, the carrier
state for various haemoglobinopathies and iron-related disorders were found as
recorded in Table 5.
Table 5. Blood related pathology in among quota
refugees screened at Mangere Refugee Resettlement Centre
(1995–1999)
*Hb Stanleyville II, HbO
Arab, HbE+HbF; †Iron therapy is prescribed for ferritin levels below
normal (ferritin levels not recorded).
Nutrition—The
body mass indices (a measure of relative body fatness) of the adult refugees are
presented in Figure 4.
Figure 4. Body Mass Index (BMI in kg/m2) of adult
(>17 years) quota refugees screened at Mangere Refugee Resettlement
Centre (1995–1999)
 Table 6. BMI statistics of adult (>17 years) quota
refugees screened at Mangere Refugee Resettlement Centre
(1995–1999)
Chronic
illness—ICD-9 coding of significant illnesses was started on 4
September 1997; the population affected by this coding was 1796 individuals, or
60.0% of the study total.
Table 7. ICD-9 coded chronic illnesses/conditions among
quota refugees screened at Mangere Refugee Resettlement Centre
(1995–1999)
NOS=not otherwise
specified.
Diseases with low
prevalence—Some conditions (particularly those associated with
atopy) typically have a low prevalence among refugees. For instance, there were
no recorded refugees with eczema or otitis media with effusion (glue ear).
Asthma, confirmed or suspected, had a recorded prevalence of only 0.8%.
Tobacco and alcohol
intake—All adult refugees are asked if they drink alcohol and/or
use tobacco. Prevalence is shown in Table 8.
Table 8. Prevalence (%) of tobacco and alcohol intake
among quota refugees screened at Mangere Refugee Resettlement Centre
(1995–1999), by sex
Psychosocial
issues—The onsite Torture/Trauma Counselling Service is responsible
for the screening and treatment of quota refugees, hence data for psychosocial
trauma is confined to a study group in MRRC before the RAS Service opened. This
study2 showed that about 20% had been subjected to some form of significant
mistreatment in the form of detention and/or physical mistreatment.
About 14% reported some form of significant psychological
symptoms, while about 7% were diagnosed as having suffered post traumatic stress
disorder. A greater proportion of females reported psychological symptoms, but a
greater proportion of males reported mistreatment. As noted below, referral for
counselling and psychological services is one of the more frequent reasons for
refugees requiring referral to secondary services.
Referrals to secondary servicesOn leaving the Refugee Centre, all refugees are given a
printed copy of the records, with a covering letter, and requested to register
with a general practitioner in the area in which they are settling.
Referrals are made to secondary services, mostly hospital
outpatient clinics. The referrals are detailed in Table 9. (Note that any
individual may be referred to more than one clinic.) A total of 2189
referrals were made, representing 1423
individuals, being 47.6 % of the total
population.
Historical issues in refugee healthIs the health of the refugees becoming worse? Apart from
the appearance of HIV infection, this appears not to be the case. Historical
data for separate conditions are presented below. Missing data points indicate
where data is not available, usually at the times of restructuring.
Table 9. Referrals to services other than a GP among
quota refugees screened at Mangere Refugee Resettlement Centre
(1995–1999)
*Dermatology 21 (0.9%),
Family Planning: 21 (0.9%); Plastic Surgery: 18 (0.8%); Neurology 15 (0.7%);
Dental 15 (0.7%) plus Audiology, Concussion, Genetics, Geriatrics, Haematology,
Nephrology, Neurosurgery, Oncology, Prosthetics, Rheumatology, Vascular Surgery
(all less than 0.5%). ENT=Ear Nose Throat.
Figure 5. Tuberculosis (TB) rates among adult quota
refugees screened at Mangere Refugee Resettlement Centre
(1979–1998)
 Figure 6. HIV infection among quota refugees screened
at Mangere Refugee Resettlement Centre (1995–1999)
 SSA=Sub-Saharan
Africa.
Figure 7. Rates of presumptive hepatitis B virus (HBV)
carriers among quota refugees screened at Mangere Refugee Resettlement
Centre (1979–1999)
 Figure 8. Rates of selected intestinal
pathogens/parasites among quota refugees screened at Mangere Refugee
Resettlement Centre (1979–1999)
 Gender issues in refugee healthWomen’s health
Table 10. Contraceptive and associated status among
quota refugee women screened at Mangere Refugee Resettlement Centre
(1995–1999)
Oral=combined oral or
progesterone only; DPV=progesterone depot injection; IUD=any form of
intrauterine device; Natural=rhythm, or other non-interventional methods;
Operative=hysterectomy or tubal ligation.
Gender
disparities—The male vs female disparity in the use of alcohol and
tobacco has been noted above. As might be expected, there are statistically
significant disparities in the prevalence of diseases with a sexually
transmitted component, although notably not in the case of HIV infection. In
recent intakes of refugees, the prevalence of HIV infection among women has
exceeded that of men.
Table 11. Prevalence (%) of selected diseases by gender
among quota refugee women screened at Mangere Refugee Resettlement Centre
(1995–1999)
DiscussionThe results outlined above can be described individually,
in relation to asylum seekers screened by the Auckland Health Service, and for
refugees in general. The results demonstrate a well-known fact: Refugees and
asylum seekers resettled in countries of second asylum have high health needs.
Using referrals to secondary services as an index of health
needs, a paper from Ireland compares the rates of referral for refugees with
those of a usual general practice population, and found that 16% of refugees
were referred, compared to 5% of general practice population.3. However, refugee
health needs may be less than those of certain at-risk groups of the resident
population. For example, in a New Zealand study examining the financial health
costs of refugees compared with Pacific Island People, Maori, and
‘other’ populations, the health costs per capita are in descending
order, with Pacific Island populations incurring the greatest costs. That study
found that refugee health costs lay between those of Maori and Pacific Island
People.4
Perhaps the most obvious difference between refugees and
asylum seekers in New Zealand lies in the differing demography of the two
groups, in particular the differences in sex and ethnicity.
A commonly repeated statement is that, worldwide, 80% of
refugees are women and children, and two-thirds are women and girls.5 UNHCR
figures show that among mandated refugees, worldwide, the proportion of adult
males and females is about equal.6. Yet the majority of asylum seekers in
developed countries are male, as is seen in the asylum seekers screened in
Auckland,1 and also, for example, in the United Kingdom, where, in one study,
less than one-fifth of the asylum-seeking population were women.7 The reasons
for this discrepancy between refugees and asylum seekers have been described as
being due to ‘lack financial resources, held back by childcare
responsibilities and cultural and other restrictions.’ Services for women
refugees are described as being ‘gender-blind,’ in spite of the
greater obstacles that women face.8
The barriers to women refugees being resettled are well
known to UNHCR and NZIS. The latter has policies which seek to redress this
problem, including a special ‘women at risk’ category for quota
refugees. The success of these policies is represented in the more
gender-balanced demography of the quota refugees. A notable feature of the quota
refugees admitted under the ‘Pacific Solution’ (mainly Afghani boat
people attempting to reach Australia) was a reversion to the asylum-seeker
pattern of male dominance. In one intake, for example, from a total of 136
refugees, 117 (86%) were male. A predominance of single males brings with it a
range of problems, for example housing, family re-unification, well known to the
agencies supporting refugees and asylum seekers.
The different mix of nationalities between quota refugees
and asylum seekers is also noteworthy. The motives for those seeking asylum in
the UK have been recorded, including local knowledge of asylum receiving
countries.9,10 (Whether these motives are different from mandated refugees, and
hence contributes to the different nationality mix is not certain.) Other
reasons may relate to the length of time it takes for a quota refugee to leave
their country and finally reach New Zealand, compared with the immediacy of the
asylum-seeking process. In other words, the nationality of quota refugees
represents past conflicts, while that of asylum seekers represents present
problems.
The different pathway between quota refugees and asylum
seekers also has an impact on the prevalence by nationality of disease,
particularly for acquired diseases. By definition, a refugee does not come to
New Zealand from his or her country of origin. Many have complex travel
histories, and an attempt to relate prevalence to nationality is generally
unrewarding or even misleading. However there are some exceptions, particularly
the prevalence of HIV infection in those from Sub-Saharan Africa, and also a few
notable diseases, for example the prevalence of Clonorchis among the Lao, due to
their habit of eating uncooked fish.
Even for non-acquired disease, for example
haemoglobinopathies in relatively high prevalence among all nationalities of
refugees, makes detailed listing by nationality a hardly worthwhile exercise.
Some tailoring of refugee screening by area of origin may be worthwhile, and has
been suggested.11 In the past, some tailoring has been done at MRRC;
particularly the refugees from the southern Yugoslav province of Kosovo who were
not screened for schistosomiasis (as they came directly from Europe where it is
not prevalent) but were instead screened for active hepatitis A. In the main,
however, for screening refugees it is better to offer a comprehensive set of
tests rather than attempt to modify the tests by ethnicity.
The screening process at Mangere is constantly evolving. A
recent change is that asymptomatic refugees no longer have their stools examined
for any bacterial pathogen. The only pathogen of importance,
Salmonella typhi (or
S.
paratyphi) was found only once in over
8000 specimens, hence testing for bacterial pathogens was not considered a
worthwhile use of health funds. Other matters at present under review include
the cost-benefit analysis of routine Mantoux testing; Vitamin D deficiency;
diabetes and hyperlipidaemia screening in older refugees; and tailoring
screening for children, particularly those related to vaccination preventable
diseases, where routine vaccination might be a better option than testing.
As far as practitioners involved in screening those of a
refugee background are concerned, it is suggested that the battery of tests
offered at MRRC is a good starting point, and in a large population, the tests
will reveal disorders in a worthwhile proportion.
The data also shows that health concerns traditionally found
in the population of resettlement countries also occur in refugees, for example
diabetes and hypertension, hence the possible need to include appropriate
screening among refugees, as well as screening for more unusual diseases. The
prevalence of excess weight among quota refugees may also be surprising: The
lack of correlation between iron deficiency and low weight shows that quota
refugees are generally malnourished rather than undernourished. The high
prevalence of smoking, particularly among males, also offers an area where
health education should offer significant benefits.
By contrast, some diseases common in the New Zealand
population, particularly those associated with asthma and atopy, are uncommon
among refugees. The probable reasons for this are not entirely clear, but
probably relate to the ‘hygiene hypothesis’.12
The data also draw attention the health needs (reproductive
and otherwise) of refugee women, although the rates of sexually transmitted
infections and cervical smear abnormalities appear to be low compared with the
host population.13,14. In Auckland, at least, there are now specific services
for those whose health is adversely affected by FGM. Practitioners involved with
services for refugees should make particular provision for the health needs of
refugee women, bearing in mind the greater than usual need for these services to
be gender sensitive.
Among the infectious diseases, there are no unexpected
findings when comparing refugees in resettled in other parts of the World and
asylum seekers screened in Auckland. The cost-benefit utility of routine Mantoux
testing has been questioned,15 and (as noted above) is under review.
Interestingly, overseas screening of refugees,16 or indeed screening on
arrival,l17 appear to have little impact on the subsequent incidence of TB among
the resettled refugees. Hence the fact that although refugees and asylum seekers
have been screened for TB it does not mean that practitioners should relax their
vigilance for this disease.
According to published UNHCR data, only 3 countries (Canada,
USA, and Australia), among the 12 quota-accepting countries, routinely carry out
comprehensive pre-screening of quota refugees.18,19 This screening is generally
not done for the refugees’ benefit, but, for example, to exclude those
with ‘communicable diseases of public health significance, current or past
physical or mental disorders that are or have been associated with harmful
behaviour, and drug abuse or addiction.’ 20
According to published information,21 general
practitioners in Australia do not know the results of the overseas screening of
refugees presenting to them as patients. At the time of writing, the only
overseas screening carried out for quota refugees destined for New Zealand is
for active tuberculosis and HIV infection. Tuberculosis must be treated before
travel to New Zealand, and the number of quota refugees with HIV infection
accepted for resettlement is limited to 20 per year.
Alleviation of psychological upset is an important health
need among quota refugees, although it appears to be a greater concern in asylum
seekers; this may be due to the uncertain state in which asylum seekers find
themselves. Nevertheless, for quota refugees, it still represents one of the
most common reasons for referral to secondary services.
Is screening of refugees and asylum seekers worthwhile? The
literature refers to the health screening of refugees in different countries as
being ‘a confusing blend’22. Indeed, it has been questioned whether
routine screening is needed at all for any immigrants,23 and it is not carried
out for some countries, notably the United Kingdom. The ‘confusing
blend’ probably arises because of confused motives for screening.
The reasons for screening may include all or some of the
following:
A valuable paper by Reid et al examines
the relationship between public health risk and personal health benefit in
screening refugees.24 Refugee health screening programmes are generally set up
to minimise public health risk, but evolve to serve the personal health of
refugees, as exemplified by the formation of torture/trauma counselling services
for refugees.
There are well-defined criteria for the effective
implementation and management of screening programmes. These criteria refer to
screening programmes which look for asymptomatic diseases, disease precursors,
or disease surrogates (such as cervical screening), but they can, where
relevant, also be applied to mass medical-screening programmes such as refugee
health screening.25,26
No studies appear to look at the effectiveness of refugee
health screening, although certain components of the screening (e.g. intestinal
parasites) have been examined.27 Given the diverse reasons why refugee health
screening is carried out, an assessment of effectiveness is likely to be
complex.
Refugee health screening in the sheltered environment of the
Mangere Refugee Resettlement Centre is only a small first step in the
resettlement of refugees. Of greater importance is the ongoing use that
resettled refugees and asylum seekers make of primary and secondary medical
services, and finding ways that this use can be enhanced by refugee and medical
provider.
Author information:
Alison McLeod, Public Health Medical Officer, Auckland District Health Board,
Auckland (and Medical Clinic, Mangere Refugee Resettlement
Centre, Auckland); Martin Reeve, Public
Health Medical Officer, Auckland District Health Board, Auckland (and Medical
Clinic, Mangere Refugee Resettlement Centre,
Auckland)
Correspondence:
Martin Reeve, Medical Clinic, Mangere Refugee Resettlement Centre, PO Box 22315,
Otahuhu, Auckland. Fax: (09) 276 6836; email: MartinR@adhb.govt.nz
References:
|
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| | Current
issue | Search journal |
Archived issues | Classifieds
| Hotline (free ads) Subscribe | Contribute | Advertise | Contact Us | Copyright | Other Journals |
|