Health and Chronic Disease

What is a Chronic Disease?

 WHO Definitions

 Cardiovascular  Respiratory  Risk Factors in 2014  Cancers  Alcohol intake   Cigarette smoking  Other (kidney;  neurological;  Obesity cerebrovascular)

2 In Context…

3 Causes of Death 2011 vs. 2014 data

Country Income (% total (% total (% total (% total (% total (% total (% total (% total deaths) group deaths) deaths) deaths) deaths) deaths) deaths) deaths) Other NCDs Injuries Infectious Total CVD Cancer Resp. Diabetes Maternal deaths Perinatal NCD Nutrition Afghanistan Low 8/17 62/46 29/37 15/19 3/6 2/3 1/1 9/8

Iran Low 14/14 13/10 72/76 45/46 12/13 4/4 2/2 10/11 middle

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

4 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 Physical High BP High blood Obesity head inactivity glucose

Iraq 13.7/18 0.5 55.2 24.4 10.6 27/27 Afghanistan - 0.7 - 22.5 - 2.2 (2008) Iran 10.4/14 1.0 35.7 33.7/ 8.3 19.4/ (2011) (2010) 24.3 19.4 DRC 4.5/10 3.6 42.5 37.6/ - 1.7/1.7 (2011) (2010) 29.4 (2008) (2008)

Ethiopia 2.4 4.2 17.9 35.2/ - 1.1/1.1 25.9 Australia 16.8/20 12.2 (2010) 40.3 36.4/ 9.4 26.8/ 21.4 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 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 2-39% African, 0-7% Karen 11 Strongyloides 1-21% 8 5-10% African, changed with DHC 1

Faecal parasites 16-40% all groups 11 Mantoux positive17 Australian studies/reports,3-63%, 18- 63%~ 7000 7 studiespeople and ~ 7000 detainees;9,7 4000 children 7 H. pylori 82% African 1 Need for immunisation Close to 100% 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- dependent diabetes mellitus . Eating disorders – anorexia/obesity/”Western junk food diet”

8 Studies have shown…

 African 2010 ( Pacific Journal of Clinical Nutrition, vol. 20, no. 3, pp. 397- 403. Prevalence of vitamin D insufficiency and risk factors for and 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, (CAD), diabetes, and . 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 27.3 31.2 32.2 7.8 3.5 9.5 Central Asia (Fmr USSR, Fmr Yugo.; Albania)

Africa 13.3 24.2 16.4 0.5 2.5 19.6 (Somalia, Liberia, Sudan) East and SE 3.6 21 9.8 0.6 3.6 5.3 Asia (Viet.; Cambodia; Burma)

Nr East South 13.6 27.2 11.7 0.5 2.8 12.2 Asia (Afghan.; Iraq; Iran) Latin America 18.6 31.2 17.4 0.3 3.3 9.0 and Caribbean (Haiti, Cuba, Colombia)

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