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Abstract

People arriving in Australia by boat without authority are admitted to an immigration reception and processing centre (also known as a "detention centre"), and undergo a protocol-based health assessment. The protocol for entry health assessments at these Department of Immigration and Multicultural Affairs (DIMA) detention centres was devised by a committee with representatives of the Commonwealth Department of Health and Aged Care, DIMA and State and Territory health authorities. The health assessments are concerned with conditions of public health importance only, and identify the minimal health requirements and vaccinations necessary to protect the health of the people detained and the Australian public.

The day-to-day healthcare and continuing medical treatment of the people detained are the responsibility of Australasian Correctional Management (ACM), the company that operates and manages DIMA's detention centres.

All people detained are given medical examinations to satisfy the requirements for visa application. This examination is used for granting visas in those who are assessed as engaging Australia's obligations for protection under the United Nations Convention relating to refugees. By the time that this assessment is complete and the people are released from detention, they will have completed the full, formal medical examination for the granting of a temporary protection visa.¹ An onshore protection visa can be granted even when a medical condition is present.

We describe the conditions of public health importance noted in the health assessment process for the possible granting of visas (Box 1; the tinted entries indicate the health examinations included in our study).

Chest x-ray examinations were performed at Derby Base Hospital, at Port Hedland Hospital and at Woomera Base Hospital, and x-ray films were read either by chest-clinic physicians or by private radiologists, or both. Medical examinations for granting of visas were performed by medical advisers or approved medical practitioners of Health Services Australia (a government business enterprise contracted to DIMA to provide health assessments).

People suspected on clinical or radiological grounds of having tuberculosis underwent full evaluation by sputum-smear and sputum-culture tests. Personnel of State chest clinics were kept informed of all cases of suspected tuberculosis and were involved in the management of all people treated for the disease.

Specimens, including Mycobacterium tuberculosis isolates, were sent for testing to laboratories in the respective capital cities (Adelaide and Perth). Sensitivity testing was to World Health Organization reference standards and included tests to rifampicin, isoniazid, ethambutol and streptomycin, with an indirect test for pyrazinamide. Serological testing for hepatitis B surface antigen (HBsAg) and hepatitis C and HIV infection was by standard methods.

People with non-communicable diseases, such as cardiomegaly or diabetes, identified by chest x-ray or during the medical examinations were referred to doctors employed by ACM for appropriate investigation and treatment. Likewise, people with evidence of sexually transmitted diseases were also referred to ACM doctors for treatment.

All subjects gave their consent to examination and data collection for health assessment purposes.

Seven men and one woman were diagnosed with culture-positive, fully sensitive, pulmonary tuberculosis and treated for infection. Except for one man aged 68 years, all those with active tuberculosis were between 17 and 35 years of age, with five being under 23 years. A 21-year-old man with an abnormal chest x-ray film was found to have peritoneal tuberculosis.

Two other men, both 34 years of age, had radiological and clinical indications of active pulmonary disease and consequently were treated for tuberculosis. Both had very abnormal chest x-ray films; one also had an enlarged cervical lymph node and the other had a strongly positive Mantoux reaction (27 mm). Thus, the prevalence of active tuberculosis in this population was 157 cases per 100 000.

HIV infection was diagnosed in two people. In two others the test results were indeterminate. In one of those with indeterminate results, a subsequently performed polymerase chain reaction test gave negative results and he is thought not to have HIV infection.

In total, 973 people were issued with health undertakings should a visa be granted, with 682 being undertakings to report to a chest clinic for further follow-up of inactive tuberculosis (Box 2).

Other communicable conditions diagnosed and treated that do not require a health undertaking include malaria (average, one case per 200 arrivals), chickenpox and other childhood infectious diseases, scabies, headlice, and one case of cutaneous leishmaniasis. Detainees also consult the doctors employed by ACM for treatment of routine infections, most commonly skin conditions (eczema, impetigo and fungal infections), respiratory tract infections, and urinary symptoms.

In Australia, cases of tuberculosis are generally diagnosed soon after the disease becomes active, so that the incidence and prevalence are similar. It is not strictly correct to compare prevalence with incidence. Nevertheless, to provide some comparison, the rate of active tuberculosis of 157 cases per 100 000 population found in our study is significantly higher than the reported incidence of tuberculosis in Australia in 1998 of 4.93 cases per 100 000 population.²

The case-notification rates of tuberculosis in the principal source countries of our study subjects — Afghanistan, Iraq and Iran — in 1999 were 15 cases per 100 000 population, 142 cases per 100 000 population and 18 cases per 100 000 population, respectively.³ The first and last rates are likely not to represent true incidences in those countries. For example, in 1991, Afghanistan reported a rate of 148.9 cases per 100 000 population. Thus, the prevalence of tuberculosis in the detention population is a reflection of its prevalence in the source countries. Both for treating the people detained and protecting the Australian community, it is important to screen for active tuberculosis among people in detention centres.

As would be expected, the prevalence of currently inactive tuberculosis is also high in this population. One of the strategies used for the control and surveillance of tuberculosis is the issuing of health undertakings to visa applicants with tuberculosis or abnormal chest x-ray films. The applicant signs an agreement to report to a State or Territory government chest clinic for follow-up within a specified period should a visa be granted. Health undertakings to present to a chest clinic for follow-up and surveillance of inactive tuberculosis were required in 9.7% (682/7000) of people, while, of the total group, 13.9% required health undertakings for tuberculosis or other conditions. This proportion is similar to that of overseas visa applicants (14%) who were considered by the Health Assessment Service in 2000-2001 to require health undertakings (unpublished data).

In 1995, visa holders' initial compliance rate with health undertakings was 58% overall.⁴ Changes to the undertakings system foreshadowed in that report have resulted in higher initial compliance rates of around 70% (unpublished data). The tracing system in case of default, also introduced in 1995, has increased final compliance rates to around 75%. State and Territory chest clinics have indicated that compliance rates by people holding temporary protection visas with health undertakings are similar to those of the general population of visa holders with health undertakings.

Procedural changes have recently been introduced to require holders of temporary protection visas to notify DIMA of their current addresses and this should further increase compliance with health undertakings.

Hepatitis B carriage occurred in 2.5% (172/7000) of the population examined. This rate is at the lower end of the expected rate, as most of the people detained come from countries where the prevalence of HBsAg carriage ranges from 2% to 7%.⁵ The prevalence of HBsAg carriage in Australia is less than 2%.⁵ Hepatitis C infection occurred in 1.0% (68/7000) of the population examined. It is also likely that this is a lower rate of infection than might be expected, but there are no data for prevalences of antibody to hepatitis C in Iraq, Iran and Afghanistan.⁶ In Australia, the prevalence of hepatitis C infection is less than 1%.⁶ It is important that people with HBsAg carriage and hepatitis C infection are followed up in the Australian health system and counselled appropriately.

HIV infection was confirmed in two people, giving a prevalence of 0.03%. This rate compares with estimated prevalences of 0.15% for Australia and of less than 0.01% for Iraq, Iran and Afghanistan.⁷

Overall, the health-screening program at the immigration reception and processing centres detects significant numbers of conditions of public health importance, enabling treatment and surveillance to the benefit of the people detained and the Australian community.

1. Department of Immigration and Multicultural Affairs. Guidelines for medical and radiological examination of applicants for onshore protection visas. Canberra: DIMA, 2000.
2. National TB Advisory Committee for the Communicable Diseases Network Australia and New Zealand. Tuberculosis notifications in Australia, 1998. Commun Dis Intell 2001; 25: 1-8.
3. World Health Organization. Global tuberculosis control. WHO report 2001. Geneva: WHO, 2001.
4. King K, Dorner RI, Hackett BJ, Berry G. Are health undertakings effective in the follow-up of migrants for tuberculosis? Med J Aust 1995; 163: 407-411.
5. National Center for Infectious Diseases, Centers for Disease Control. Geographic distribution of chronic HBV infection [modified June 1, 2001]. Available at: http://www.cdc.gov/ncidod/diseases/hepatitis/slideset/ hep_b/slide_9.htm (accessed July 2001).
6. World Health Organization. Hepatitis C: global prevalence (update). Wkly Epidemiol Rec 2000; 75: 3.
7. UNAIDS/World Health Organization. Epidemiological fact sheets on HIV/AIDS and sexually transmitted infections. 2000 Update (revised). Available at: <http://www.who.int/emc-hiv/fact_sheets/All_countries.html> (accessed October 2001).

Authors' details

Reprints will not be available from the authors.
Correspondence: Dr K King, Department of Immigration and Multicultural Affairs, GPO Box 9984, Sydney, NSW 2001.
kathy.kingATimmi.gov.au

©MJA 2001
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