Detecting Mycobacterium tuberculosis Infection in Children Migrating to Australia.

In 2015, Australia updated premigration screening for tuberculosis (TB) disease in children 2-10 years of age to include testing for infection with Mycobacterium tuberculosis and enable detection of latent TB infection (LTBI). We analyzed TB screening results in children <15 years of age during November 2015-June 2017. We found 45,060 child applicants were tested with interferon-gamma release assay (IGRA) (57.7% of tests) or tuberculin skin test (TST) (42.3% of tests). A total of 21 cases of TB were diagnosed: 4 without IGRA or TST, 10 with positive IGRA or TST, and 7 with negative results. LTBI was detected in 3.3% (1,473/44,709) of children, for 30 applicants screened per LTBI case detected. LTBI-associated factors included increasing age, TB contact, origin from a higher TB prevalence region, and testing by TST. Detection of TB and LTBI benefit children, but the updated screening program's effect on TB in Australia is likely to be limited.

Etiology, Comorbidities, and Health Service Use in a Clinical Cohort of Children With Hearing Loss.

OBJECTIVE: To examine etiology, comorbidities, and health service use in a cohort of children with permanent hearing loss. Receiving an etiological diagnosis can inform reproductive planning, rehabilitation outcomes, predict additional disabilities, and direct intervention or management decisions. DESIGN: Retrospective audit of 518 deaf/hard-of-hearing children attending a tertiary pediatric outpatient clinic (2016-2019) using descriptive statistics. We used linear regression to investigate the relationship between degree of hearing loss, comorbidities, and health service use. RESULTS: Of the 518 children who attended the clinic, 481 (92.9%) proceeded with testing for etiology. Most children (399/518, 77.0%) were diagnosed with hearing loss by 3 mo of age. Of the children tested, the cause of hearing loss was confirmed in 234/481 (48.6%), suspected in 113/481 (23.5%), and unknown in 134/481 (27.9%); 17/341 (5.0%) had congenital cytomegalovirus (CMV), 17/320 (5.3%) had enlarged vestibular aqueducts, 67/213 (31.5%) of children with bilateral hearing loss had connexin mutation, and 25/72 (34.7%) of children with unilateral loss had hypoplastic/absent cochlear nerve on imaging. The odds of having a definitive/suspected diagnosis were twice as likely for indivduals with profound hearing loss than mild hearing loss (OR 2.1; 95% CI, 1.2-3.9; P = 0.02). The majority (348/518, 67.2%) of children had medical comorbidities, and most children attended otolaryngology (453/518, 87.5%), early intervention (358/518, 69.1%), and genetic (287/518, 55.4%) services. CONCLUSIONS: Children with hearing loss have diverse etiologies, most have comorbidities, and attend multiple services. Most families elected to proceed with diagnostic testing for etiology. Current guidelines and expanded access to genetic testing identified a confirmed/suspected etiological diagnosis in 72.1% of children tested. The number of comorbidities correlated with service use, regardless of hearing loss severity.

Schistosoma serology after praziquantel treatment of Schistosoma infection in refugee children resettled in Australia: A retrospective analysis.

BACKGROUND: This study aimed to document changes in serological response before and after treatment of Schistosoma infection in resettled refugee children from endemic countries in Australia. Current Australian guidelines recommend serological screening for Schistosoma infection in children and adults from endemic countries. Data on the utility of follow-up serology after treatment is limited. METHODS: We undertook a retrospective audit of Schistosoma serology in refugee-background children presenting to a specialist paediatric refugee health clinic in Melbourne, Australia, between January 2005 and December 2014. Patients were included with positive Schistosoma serology, documented treatment with praziquantel; clinical and serological followup data after treatment, and no return to endemic areas. RESULTS: Fifty-one refugee-background children were included. Overall, 40/51 (78.4%) children had serology that decreased after treatment, 25/51 (49.0%) had a greater than twofold decrease and 22/51 (43.1%) reverted to negative serology. Six (11.8%) children showed an increasing serology titre and 5/51 (9.8%) had unchanged serology after treatment. CONCLUSIONS: This is the first study describing the changes in Schistosoma serological titres following treatment in immigrant children in a non-endemic country. We observed a majority downward trend in antibody titres after praziquantel treatment, suggesting follow-up serological testing may be useful in children to monitor treatment response.

Catching up with catch-up: a policy analysis of immunisation for refugees and asylum seekers in Victoria.

This study examines catch-up immunisation for people of refugee-like background in Victoria, exploring effective models of service delivery to complete catch-up vaccinations. The analysis is based on: (i) review of the medical literature, Commonwealth and Victorian government immunisation policy and immunisation patient information; (ii) review of vaccination coverage and service delivery data; and (iii) stakeholder interviews completed in 2014 with 45 people from 34 agencies, including 9 local government areas in Victoria. Although refugees and asylum seekers all need catch-up vaccinations on arrival, they face significant barriers to completing immunisation in Australia. Analysis suggests missed opportunities by service providers and perceptions that catch-up vaccination is time-consuming, difficult and resource-intensive. Service delivery is fragmented across primary care and local government, and pathways depend on age, location and healthcare access. There are strengths, but also limitations in all current service delivery models. Gaps in vaccine funding for refugee-like populations have now been addressed through Commonwealth initiatives, however migration is still not well considered in immunisation policy, and existing systems for notification payments do not capture catch-up vaccination for these groups. Providers identify areas for improvement in professional development and support, patient information, patient-held records and immunisation surveillance data.

No jab, no record: Catch-up vaccination of children in immigration detention.

International Health and Medical Services (IHMS) are contracted to provide health services, including catch-up vaccination, for individuals in immigration detention. Our audit of catch-up vaccination in asylum seeker children who spent time in held detention demonstrates inadequate and suboptimal vaccine delivery in this setting, and no evidence that IHMS recorded vaccines on the Australian Childhood Immunisation Register at the time. We also found substantial shortfalls in vaccination for these children after they were released from detention. Immunisation in this cohort falls well below Australian community standards, does not demonstrate assurance in IHMS provision of care, and has implications for similar asylum seeker cohorts nationally as well as people in held detention.

The Australasian Society for Infectious Diseases and Refugee Health Network of Australia recommendations for health assessment for people from refugee-like backgrounds: an abridged outline.

INTRODUCTION: In 2009, the Australasian Society of Infectious Diseases published guidelines on the post-arrival health assessment of recently arrived refugees. Since then, the number of refugees and asylum seekers reaching Australia has increased substantially (17 555 refugees in 2015-16) and the countries of origin have changed. These groups are likely to have had poor access to health care pre-arrival and, consequently, are at risk of a range of chronic and infectious diseases. We established an advisory group that included infectious diseases physicians, general practitioners, public health specialists, paediatricians and refugee health nurses to update the 2009 guidelines.Main recommendations: All people from refugee-like backgrounds, including children, should be offered a tailored comprehensive health assessment and management plan, ideally within 1 month of arrival in Australia. This can be offered at any time if initial contact with a GP or clinic is delayed. Recommended screening depends on history, examination and previous investigations, and is tailored based on age, gender, countries of origin and transit and risk profile. The full version of the guidelines is available at http://www.asid.net.au/documents/item/1225.Changes in management as a result of this guideline: These guidelines apply to all people from refugee-like backgrounds, including asylum seekers. They provide more information about non-communicable diseases and consider Asia and the Middle East as regions of origin as well as Africa. Key changes include an emphasis on person-centred care; risk-based rather than universal screening for hepatitis C virus, malaria, schistosomiasis and sexually transmissible infections; updated immunisation guidelines; and new recommendations for other problems, such as nutritional deficiencies, women's health and mental health.

Gaps in smiles and services: a cross-sectional study of dental caries in refugee-background children.

BACKGROUND: Refugees are reported to experience high rates of dental disease, although there are limited data on refugee children. The aim of this study was to report on oral health in refugee-background children in Australia, and to assess their follow-up at dental services. METHODS: Cross-sectional study of opportunistic oral health screening and subsequent dental service use in refugee-background children attending a refugee health clinic in Victoria, Australia, between November 2006-November 2010. RESULTS: 350 patients (0-18 years, mean age 8 years 7 months) had oral health screening; 241 (68.9%) were born overseas, (176 Africa, 65 other countries) and 109 (31.1%) were born in Australia to African-background families. Parents were concerned about oral health in 65/341 (19.1%) children, with specific concern about caries in only 9/341 (2.6%). On assessment, 155/336 (46.1%) had visible caries and 178/345 (51.6%) had caries experience (dmft/DMFT > 0). Where parents were concerned about caries, they were likely to be present (positive predictive value = 100%), however absence of parent concern about caries was not reassuring (negative predictive value = 56.1%).Compared to Australian-born children of African background; African-born children were more likely to be referred for further dental care (adjusted PR 1.33, 95% CI [1.02-1.73]), although there was no statistically significant difference in caries prevalence. African-born children were less likely to have caries compared to other overseas-born children (adjusted PR 0.73, 95% CI [0.58 - 0.93]). Overall 187/344 (54.4%) children were referred for further dental care; 91/124 (73.4%) attended any dental appointment. Attendance rates were 90% with a phone reminder system for appointments, attendance reduced when this system lapsed. CONCLUSIONS: Oral health is an important public health issue in refugee-background children, despite low levels of parent concern and very few parent reported caries. Routine direct oral health assessment is important in refugee-background children and co-ordinated health systems may help improve their attendance at dental services.

Vitamin D and health in pregnancy, infants, children and adolescents in Australia and New Zealand: a position statement.

• The recommended level for serum 25-hydroxyvitamin D (25(OH)D) in infants, children, adolescents and during pregnancy and lactation is ≥ 50 nmol/L. This level may need to be 10-20 nmol/L higher at the end of summer to maintain levels ≥ 50 nmol/L over winter and spring. • Sunlight is the most important source of vitamin D. The US recommended dietary allowance for vitamin D is 600 IU daily in children aged over 12 months and during pregnancy and lactation, assuming minimal sun exposure. • Risk factors for low vitamin D are: lack of skin exposure to sunlight, dark skin, southerly latitude, conditions affecting vitamin D metabolism and storage (including obesity) and, for infants, being born to a mother with low vitamin D and exclusive breastfeeding combined with at least one other risk factor. • Targeted measurement of 25(OH)D levels is recommended for infants, children and adolescents with at least one risk factor for low vitamin D and for pregnant women with at least one risk factor for low vitamin D at the first antenatal visit. • Vitamin D deficiency can be treated with daily low-dose vitamin D supplements, although barriers to adherence have been identified. High-dose intermittent vitamin D can be used in children and adolescents. Treatment should be paired with health education and advice about sensible sun exposure. Infants at risk of low vitamin D should be supplemented with 400 IU vitamin D3 daily for at least the first year of life. • There is increasing evidence of an association between low vitamin D and a range of non-bone health outcomes, however there is a lack of data from robust randomised controlled trials of vitamin D supplementation.

Post-arrival health screening in Karen refugees in Australia.

OBJECTIVE: To document the prevalence of nutritional deficiencies, infectious diseases and susceptibility to vaccine preventable diseases in Karen refugees in Australia. DESIGN: Retrospective audit of pathology results. SETTING: Community based cohort in Melbourne over the period July 2006-October 2009. PARTICIPANTS: 1136 Karen refugee children and adults, representing almost complete local area settlement and 48% of total Victorian Karen humanitarian intake for the time period. MAIN OUTCOME MEASURES: Prevalence of positive test results for refugee health screening, with breakdown by age group (<6 years, 6-11 years, 12-17 years, 18 years and older). RESULTS: Overall prevalence figures were: anaemia 9.2%, microcytosis 19.1%, iron deficiency 13.1%, low vitamin B(12) 1.5%, low folate 1.5%, abnormal thyroid function tests 4.4%, vitamin D<50 nmol/L 33.3%, hypocalcaemia 7.4%, raised alkaline phosphatase 5.2%, abnormal liver transaminases 16.1%, hepatitis B surface antigen positive 9.7%, hepatitis B surface antibody positive 49.5%, isolated hepatitis B core antibody positive 9.0%, hepatitis C positive 1.9%, eosinophilia 14.4%, Schistosoma infection 7%, Strongyloides infection 20.8%, malaria 0.2%, faecal parasites 43.4%. Quantiferon-gold screening was positive in 20.9%. No cases of syphilis or HIV were identified. Serological immunity to vaccine preventable diseases was 87.1% for measles, 95% for mumps and 66.4% for rubella; 56.9% of those tested had seroimmunity to all three. CONCLUSIONS: Karen refugees have high rates of nutritional deficiencies and infectious diseases and may be susceptible to vaccine preventable diseases. These data support the need for post-arrival health screening and accessible, funded catch-up immunisation.

East African immigrant children in Australia have poor immunisation coverage.

AIM: To provide data on the immunisation status of recently arrived East African children and adolescents in Australia. METHODS: A prospective audit was conducted at a hospital-based paediatric immigrant health clinic, in Melbourne, Australia, over the time period November 2000-January 2002. Study subjects were consecutive children and adolescents born in East Africa, arriving in Australia after January 1998. Vaccination status was ascertained by parent report and review of patient-held records where available, and by serological testing for immunity to hepatitis B, tetanus, diphtheria, rubella and measles. RESULTS: Among 136 participants, 132 (97%) had incomplete or unknown immunisation status based on parent report and vaccination records; written records were available for 5/136 (4%) of participants. Only 21/136 (15%) had serological immunity to all five of measles, rubella, tetanus, diphtheria and hepatitis B, despite a total of 395 visits to vaccine providers by participants since migration. A higher proportion of children had serological immunity to measles (90%) compared to the proportion with serological immunity to rubella (77%), tetanus (61%), diphtheria (45%) and hepatitis B (33%). The predictive value of parent-reported vaccination status for serological immunity was poor. CONCLUSIONS: Paediatric East African immigrants in Victoria are very likely to be inadequately immunised and parent-reported vaccination status does not predict serological immunity. Full catch-up immunisation is recommended where immunisation status is unknown and written records are unavailable. Consideration should be given to policy and program development to provide timely and complete immunisation coverage in this group after arrival in Australia.

A three-way comparison of tuberculin skin testing, QuantiFERON-TB gold and T-SPOT.TB in children.

BACKGROUND: There are limited data comparing the performance of the two commercially available interferon gamma (IFN-gamma) release assays (IGRAs) for the diagnosis of tuberculosis (TB) in children. We compared QuantiFERON-TB gold In Tube (QFT-IT), T-SPOT.TB and the tuberculin skin test (TST) in children at risk for latent TB infection or TB disease. METHODS AND FINDINGS: The results of both IGRAs were compared with diagnosis assigned by TST-based criteria and assessed in relation to TB contact history. Results from the TST and at least one assay were available for 96 of 100 children. Agreement between QFT-IT and T-SPOT.TB was high (93% agreement, kappa = 0.83). QFT-IT and T-SPOT.TB tests were positive in 8 (89%) and 9 (100%) children with suspected active TB disease. There was moderate agreement between TST and either QFT-IT (75%, kappa = 0.50) or T-SPOT.TB (75%, kappa = 0.51). Among 38 children with TST-defined latent TB infection, QFT-IT gold and T-SPOT.TB assays were positive in 47% and 39% respectively. Three TST-negative children were positive by at least one IGRA. Children with a TB contact were more likely than children without a TB contact to have a positive IGRA (QFT-IT LR 3.9; T-SPOT.TB LR 3.9) and a positive TST (LR 1.4). Multivariate linear regression analysis showed that the magnitude of both TST induration and IGRA IFN-gamma responses was significantly influenced by TB contact history, but only the TST was influenced by age. CONCLUSIONS: Although a high level of agreement between the IGRAs was observed, they are commonly discordant with the TST. The correct interpretation of a negative assay in a child with a positive skin test in clinical practice remains challenging and highlights the need for longitudinal studies to determine the negative predictive value of IGRAs.