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

4

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

(% total deaths)

Other NCDs

Afghanistan Low 8/17 62/46 29/37 15/19 3/6 2/3 1/1 9/8

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

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

- 1.1/1.1

Australia 16.8/20 12.2 (2010) 40.3 36.4/

21.4

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

17 Australian studies/reports, ~ 7000 people and ~ 7000 detainees; 4000 children 7

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 3-63%, 18-63% 7 studies 9,7

H. pylori 82% African 1

Need for immunisation Close to 100%

8

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”

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

12

Region Obesity % Overwt % HT % CAD % Diabetes % Anaemia %

Europe

Central Asia (Fmr USSR, Fmr

Yugo.; Albania)

27.3 31.2 32.2 7.8 3.5 9.5

Africa (Somalia, Liberia,

Sudan)

13.3 24.2 16.4 0.5 2.5 19.6

East and SE

Asia (Viet.; Cambodia;

Burma)

3.6 21 9.8 0.6 3.6 5.3

Nr East South

Asia (Afghan.; Iraq;

Iran)

13.6 27.2 11.7 0.5 2.8 12.2

Latin America

and Caribbean (Haiti, Cuba,

Colombia)

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

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

In refugees, changes in diet, physical activity and chronic

stress of poverty, low SES, family separation are factors. 16

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