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To me, health means living your life without concern for your own or loved one's mental, physical, and social health. Health means being in a complete state of happiness, surrounded by healthy, happy people. Being aware of health concerns and taking preventative action against disease and illness.

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One of Australia's native animals is the kangaroo. Kangaroos have short hair, powerful back legs, short forelimbs, big feet, and a large long tail. Kangaroos are known for their muscular tail. They have pouches where the joey is grown and cared for. We Australians share a love for these beautiful animals.

Bush Heritage Australia, (2023), species, Kangaroos https://www.bushheritage.org.au/species/kangaroos#:~:text=Where%20do%20kangaroos%20live%3F,both%20species%20prefer%2

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Principle health issues faced by refugees

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Principle health issues faced by refugees

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Focus country: Afghanistan
Afghanistan has experienced more than 4 decades of conflict and instability leading to about 2 thirds of the population in need of humanitarian and protection assistance from countries such as Australia. Since 2021, more than 1.6 million Afghans have fled the country. (USA for UNHCR 2023).
Mental Health issues-
Trauma, conflict, family separation, and human rights violations are a few of the factors that refugees experience before arriving in Australia leading to high rates of mental health issues. Settlement can be mentally challenging due to experiencing life in a new country, language barriers, housing, accessing employment, loss of community, and cultural differences. A way to reduce the rates of mental illness on arrival to Australia is by trying to keep families and small communities together once they arrive.
Lack of immunizations-  Refugees are at high risk of being unimmunized or under-immunized when arriving in Australia. Humanitarian disasters can disrupt vaccination programs and health services, which can affect the availability and effectiveness of vaccines. A solution for this is to provide catch-up immunizations for these people so their immunization status is equal to Australian-born people of the same age.
Malaria-
Malaria is a mosquito-spread infection that can be brought to Australia via refugees. Australia was declared free from endemic malaria in 1981. Malaria can be treated with prescription drugs which will vary depending on the person's age, place of infection, and type of malaria.

Victorian Foundation for Survivors of Torture, (2023), Australian Refugee Health practice guide, https://refugeehealthguide.org.au/malaria/

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Written by on . Posted in Communicable diseases and immunisation, General population

Christine Phillips, Josh Francis

Recommendations

Investigations for malaria should be performed on anyone who has travelled from/through an endemic malaria area within 3 months of arrival if asymptomatic, or within 12 months if symptoms of fever (regardless of any pre-departure malaria testing or treatment).

Test with both thick and thin blood films AND an antigen-based rapid diagnostic test (RDT), as RDT alone is not significantly sensitive to detect all non P.falciparum infections.

All people with malaria should be treated by, or in consultation with, a specialist ID service. Discuss diagnoses urgently with an infectious disease service. Patients with malaria may deteriorate quickly, especially children, pregnant women and those with low immunity.

Admit all patients with falciparum malaria to hospital, at least for the initial part of their treatment. Experienced clinicians may treat individuals with non-falciparum or non-severe falciparum malaria infection as outpatients if they are in a non-malaria receptive area.

[accordion tag=h3 clicktoclose=true autoclose=false][accordion-item title="+ Overview" state=closed]

Malaria is a mosquito-spread parasitic protozoal infection caused by the genus Plasmodium. Of the five species of human malarial parasites, Plasmodium falciparum is the most common and dangerous. One-third of malaria imported to Australia occurs in migrants coming through Papua New Guinea and India.

Malaria is endemic in many refugee-source countries, and some transit countries (see table 2.1). All refugees to Australia from malaria-endemic regions are offered a voluntary Departure Health Check (DHC), which includes an RDT for malaria (and treatment if positive) in the 72 hours prior to departure. Previous issues with documentation of DHC treatment and sub-optimal anti-malarial therapy have been resolved. Treatment is now with WHO-recommended artemether/lumefantrine and should be documented on a health manifest that accompanies the individual. Diagnoses of malaria in people from refugee-like backgrounds have decreased since the introduction of pre-departure screening for malaria.

A list of countries with significant malaria risk is provided in table 2.1. Detailed, up-to-date information on malaria by country is available from the Malaria Atlas Project.

Australia was declared free from endemic malaria in 1981. However, much of Australia north of latitude 19°S remains receptive to malaria, due to the presence of patent mosquito vectors ( Anopheles spp.). This has been a constant threat to Australia's 'malaria-free' status. Therefore, the detection and treatment of malaria in individuals arriving into Australia from malaria-endemic areas is of significant public health importance.

Malaria has been diagnosed in 4-10% of refugee cohorts from Sub-Saharan Africa in Australian studies, but is uncommon in audits of newly arrived Iraqi or Karen refugees. Malaria has also been diagnosed in people arriving by boat off the coast of Darwin. Thus, there is a rationale for re-screening people from refugee-like backgrounds from malaria-endemic areas on arrival, with enhanced vigilance for malaria in people with a febrile illness.[/accordion-item]

[accordion-item title="+ History and examination" state=closed]

Malaria must be considered in any patient who has visited a malarious area and presents with a febrile illness, even months after arriving in Australia. Other symptoms of malaria include headache, nausea, chills, sweating, diarrhoea and malaise.

Severe malaria requires urgent referral to a hospital. Symptoms, signs and laboratory features of severe malaria include any degree of altered consciousness, jaundice, oliguria, severe anaemia or hypoglycaemia, parasite count >100,000/μL or >2%, or, if patient is vomiting or acidotic. Conversely, individuals with long-term acquired immunity and low-grade parasitaemia may be asymptomatic.[/accordion-item]

[accordion-item title="+ Investigations" state=closed]

The 'gold standard' test for the diagnosis of malaria remains the thick and thin blood film examination for malaria parasites by light microscopy. A combination of blood films and RDT has relatively high sensitivity for the detection of P. falciparum infection. RDTs are frequently used in Australian laboratories to supplement blood film examination. The RDT for falciparum malaria may remain positive up to 28 days post treatment (see 'Patients with pre-departure screening test' below).

Mixed infections with more than one Plasmodium species are not infrequent and can usually be identified from the blood films. Malaria PCR is available in reference laboratories and should be considered to rule out sub-microscopic parasitaemia e.g. such as in patients who may have acquired immunity to malaria and/or in whom the efficacy of treatment given is uncertain. Some individuals can harbour sub-patent infections (i.e. blood film negative) with very low levels of detection for prolonged periods of time; these patients may become febrile as their immunity wanes and PCR-based testing (available in reference laboratories) may be required to exclude sub-patent infection.

If a patient has symptoms consistent with malaria but negative initial blood films and/or RDT result, repeat blood films should be performed in an attempt to demonstrate malarial parasites. Additional investigations in an unwell patient with malaria should be directed to detecting anaemia, acute kidney injury, abnormal liver function, hypoglycaemia or a metabolic acidosis. [/accordion-item]

[accordion-item title="+ Management and referral" state=closed]

Refer to table 2.2 for all management.

Plasmodium falciparum malaria

All patients with falciparum malaria should be referred urgently to a physician with experience in the management of malaria. Children with malaria should be discussed urgently with a paediatric ID physician. Children and people with low immunity who have malaria may deteriorate quickly.

Current Australian recommendations suggest that all patients with falciparum malaria should be admitted to hospital, at least for the initial part of their treatment, although it is possible to treat individuals with non-severe malaria infection entirely as outpatients. Patients with asymptomatic or uncomplicated falciparum malaria who are able to tolerate oral medication should be treated with oral artemisinin-based combination therapy (ACT). The only ACT product available in Australia at present is artemether-lumefantrine (Riamet®), which is available on authority prescription for suspected or proven falciparum infection. For further treatment guidelines refer to table 2.2. For severe malaria refer to hospital immediately and seek expert advice.

Plasmodium Vivax, Malariae or Ovale Malaria

Patients with confirmed vivax, malariae or ovale malaria (or where the parasite cannot be determined) should also have artemether-lumefantrine treatment, although this preparation is only available via the PBS for falciparum malaria and patients should be prescribed the medication via a hospital pharmacy.

Patients with severe non-falciparum malaria should be referred immediately to hospital for expert advice.

In patients with P. vivax or P. ovale infection; hypnozoite eradication therapy (or 'radical cure') should be attempted, to reduce the likelihood of subsequent relapses. Hypnozoite eradication involves a weight-based, generally two-week course of primaquine, available via application through the Special Access Scheme (SAS). Health workers should pay careful attention to adherence, and be aware of the risk of relapse. Before commencing primaquine, all patients should be screened for Glucose-6-Phosphate Dehydrogenase (G6PD) deficiency, because of the risk of haemolysis for these patients. Primaquine is contra-indicated in patients with severe G6PD deficiency, but may be used with caution, and under supervision in those with mild deficiency.

Patients with Positive Pre-departure Screening Test

Refugees with a positive malaria result on pre-departure DHC screening are treated with a three-day course of ACT before departure, according to the protocol of the International Organization for Migration (IOM). This treatment is not monitored, and adherence should be checked with the patient (or their parents, in children). Thick and thin blood film testing after arrival is recommended. The RDT may stay positive for up to four weeks after successful treatment, so is of limited use in this situation. A negative blood film does not exclude sub-patent malaria.

A person who has tested positive at the pre-departure screen but in whom there is uncertainty regarding adherence to pre-departure treatment remains at risk of recurrent symptomatic illness, and should be retreated.

Follow-up

Patients should be assessed one month post treatment and have follow-up blood films performed to ensure that the infection has been successfully treated. Asymptomatic recrudescence and relapse can occur despite initial eradication of infection and full adherence. Artemisinin resistance has been reported in some areas of the Greater Mekong Subregion (Thailand, Vietnam, Cambodia, Laos and Myanmar (Burma)) resulting in reduced efficacy of ACT against P. falciparum. Seek expert advice if ACT resistance is suspected.

For patients with malaria caused by P. falciparum who are being treated in malaria-receptive regions of northern Australia, a single dose of primaquine is recommended to reduce the risk of transmission to local mosquitoes (see table 2.2).

Be aware that delayed relapse for all strains of malaria can occur up to one year after leaving the endemic area. Have a low threshold for re-investigating for malaria in any person with fever. [/accordion-item]

[accordion-item title="+ Considerations in Pregnancy and Breastfeeding" state=closed]

Pregnant women with malaria are at increased risk for severe malaria, severe anaemia, and delivery of a low birth weight infant. Anti-malarials that are considered effective and can be used in all stages of pregnancy include atovaquone-proguanil (category B2), clindamycin (category A) and quinine sulphate (category D, but has been used safely for malaria in pregnancy). We recommend the combination of quinine and clindamycin for pregnant patients. Clindamycin is not subsidised on the PBS for malaria treatment. Treatment should, at least initially, be given as supervised inpatient therapy. Pregnant women with severe malaria may require treatment with intravenous artesunate (as for severe malaria in non-pregnant patients) guided by expert advice.

The above medications are contained in very low levels in breast milk, and are considered safe for infants. Breastfeeding women should receive standard doses of anti-malarial treatment recommended for all adults, with the exception of doxycycline (category D). Before taking primaquine (if required), both the infant and the mother should be tested for G6PD deficiency. [/accordion-item]

[accordion-item title="+ Tables" state=closed]

Table 2.2 Malaria therapy - from Therapeutic Guidelines: Antibiotic v1576

Severe malaria (or if patient unable to tolerate oral therapy)

Refer urgently to ID physician for hospital management.

Uncomplicated malaria

artemether+lumefantrine tablets 20+120mg adult and child more than 34kg: 4 tablets per dose (child 5-14kg: 1 tablet; 15-24kg: 2 tablets; 25-34kg: 3 tablets) orally with fatty food or full-fat milk at 0, 8, 24, 36, 48 and 60 hours, making a total adult dose of 24 tablets in 6 doses

OR

atovaquone+proguanil tablets 250+100 mg (adult formulation) adult and child more than 40kg: 4 tablets per dose (child 11-20kg: 1 tablet; 21-30kg: 2 tablets; 31-40kg: 3 tablets) orally with fatty food or full-fat milk (to ensure adequate absorption of atovaquone), daily for 3 days

OR THE COMBINATION OF

quinine sulfate 600mg (adult less than 50kg: 450mg) (child: 10mg/kg up to 600mg) orally, 8-hourly for 7 days

PLUS EITHER

doxycycline 100mg (child 8 years or older: 2mg/kg up to 100mg) orally, 12-hourly for 7 days (which can start after day 1 of quinine therapy) OR (for pregnant women or children younger than 8 years) clindamycin 300mg (child: 5mg/kg up to 300mg) orally, 8-hourly for 7 days.

For patients with malaria caused by P. falciparum (either alone or with other species) acquired from the Greater Mekong Subregion (Thailand, Vietnam, Cambodia, Laos and Myanmar (Burma)) and who respond slowly to artemether+lumefantrine (ie persisting parasitaemia after 72 hours of therapy), switch to oral quinine sulfate plus either doxycycline or clindamycin as above, for 7 days.

For patients with malaria caused by P. falciparum who are being treated in malaria-receptive regions of northern Australia, a single dose of primaquine is recommended to reduce the risk of transmission to local mosquitoes. Add: primaquine 15mg (child: 0.25mg/kg up to 15mg) orally, as a single dose.

Hypnozoite eradication therapy
First exclude G6PD deficiency in all
For P. vivax infection use concurrently: primaquine 30mg (child: 0.5mg/kg up to 30mg) orally, daily, or if nausea occurs 15mg (child: 0.25mg/kg up to 15mg) orally, 12-hourly. Treat for a minimum of 14 days or, in adults more than 70kg, until a total cumulative dose of 6mg/kg is reached

For P. ovale infection use concurrently: primaquine 15mg (child: 0.25mg/kg up to 15mg) orally, daily for 14 days If a relapse of malaria occurs despite treatment with primaquine, seek expert advice.

[/accordion-item]

[accordion-item title="+ Links" state=closed]

Easidose, a visual prescribing aid [/accordion-item][/accordion]

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Written by on . Posted in Communicable diseases and immunisation, General population Christine Phillips, Josh Francis Investigations for malaria should be performed on anyone who has travelled from/through an endemic malaria area within 3 months of arrival if asymptomatic, or within 12 months if symptoms of fever (regardless of any pre-departure malaria testing or treatment).

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Social determinants of health impact on migrant/refugees

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Social determinants of health impact on migrant/refugees

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Food insecurity-
During the long hard journey for refugees, nutritious food or any food at all is not always available. During this time refugees are forced to live in inhumane living conditions when affording and accessing food is a challenge. Affording food would also be an issue for them.
Early childhood development-
Many families flee their country with young children to get them to a safe place to live and grow up. However, before settling in a new country, the children are forced to live through cruel circumstances for years leading to the children suffering from trauma, stress, lack of education, and isolation.
Access to affordable health services of decent quality-
Refugees are unable to access health services when migrating due to high costs and isolation. It is common for refugees to get sick, not being able to access health care in this time will lead to them getting very sick. Once in Australia, they struggle to access health services due to the high costs that they cannot afford due to unemployment.
World Health Organization (WHO), (2023), determinants of health, https://www.who.int/news-room/questions-and-answers/item/determinants-of-health

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I have read and understood domain 7 of the framework for clinicians and particularly focused on competency standard 12 'Clinicians are committed to cultural responsiveness, reflexivity and self-awareness in all aspects of practice.'
For me, the most important idea in this competency standard is that as a student nurse, I can make people of all cultures feel accepted and safe when receiving care. Previously I did not notice how important it is to be culturally aware when working with people from different upbringings and cultures.
I have developed my knowledge and understanding of culturally insensitive practices that negatively impact health and how to minimize this in the workplace.
Having read and understood this competency standard I will be sure to be aware of myself and other cultures within my work by taking time to educate myself on other cultures through research and conversation with patients and colleagues.

Migrant and Refugee Women's Health Partnership, (2019), Australian Government Department of Health, https:///Culturally-responsive-clinical-practice-Working-with-people-from-migrant-and-refugee-backgrounds-Jan2019.pdf

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Vegemite is an Australian traditional food, made from vegetables, yeast extract, and spice additives, appearing as a dark brown paste (Jeroen Stanff 2017). It is most commonly eaten on toast or in sandwiches with butter although can be enjoyed on crackers with cheese, in pasta, with eggs, and my personal favorite, vegemite scrolls.
Click on the link to see an easy 3-ingredient recipe for vegemite scrolls. https://www.youtube.com/watch?v=vxQMDLRHlLs
My family and I enjoy making these when we go to family and friend gatherings where we all bring our favorite foods to share and catch up with each other.
Jeroen Stanff, (2017), Nomads, Australian Food, the most iconic Australian Cuisine https://nomadsworld.com/australian-food/

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Australians have good health and good access to the health care needed however this varies depending on where in Australia one lives.

in 2016-17 Australia spent nearly $181 billion on health

in 2022, Australians lost 5.5 million years of healthy life

Two in three adults are living with overweight or obesity in 2018

Australian Government, (2023), Australian Institute of Health and Welfare, Australia's health https://www.aihw.gov.au/reports-data/australias-health/summaries

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The Australian flag has 3 symbols each meaning something different and important including the Union Jack, the Commonwealth Star, and the Southern Cross.
The Australian flag is a symbol of the diverse country we are and how welcoming we are to other cultures and beliefs.

Australian Government, (2023), Department of the Prime Minister and Cabinet, Australian Symbols booklet https://www.pmc.gov.au/publications/australian-symbols-booklet/national-symbols/australian-national-flag#:~:text=The%20Commonwealth%20Star%2C%20symbolising%20Australia's,1908%20to%20recognise%20Australia's%20territories.

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Mateship in Australia has its roots in the early years of European colonization. Early explorers in Australia relied on one another to survive in the hostile environment of the outback. They established strong groups founded on cooperation, loyalty, and trust. This has continued into Australian culture today.
Australian's mental and physical health thrive in the company of friends and family. Communities are known for having each other's back when things are tough eg. floods and fires.

Glasshouse Christian College, (2023), Mateship in Australia, https://glasshouse.qld.edu.au/mateship-in-australia/

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Australians are known for playing and supporting many sports that originate from different cultures. More than 90% of adults in Australia have an interest in sport and about 13 million adults take part in sport each year.

We Australians think sport is very important for our physical, mental, and social health. When playing a team sport we bond with new people which can turn into lifelong friends. Australians love to watch a support all types of sport which forms communities of like-minded people.