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Submission to the National Inquiry into Children in Immigration Detention from
the Department of Health and Ageing
ROLE OF THE DEPARTMENT AND THE CHIEF MEDICAL OFFICER
The Department's role in the setting of standards in relation to public and other health issues.
Health and aged care are shared responsibilities: all levels of government have roles in funding, administering or providing services.
The Commonwealth has some statutory obligations to set standards: eg, under the Quarantine Act 1908 (see below), and the Therapeutic Goods Act 1989 (to provide a national framework for the regulation of therapeutic goods in Australia and ensure their quality, safety and efficacy).
In other areas, the Commonwealth has a policy interest but responsibility for service delivery rests with the States and Territories, or involves an industry sector for which the Government sees self-regulation as appropriate. In these cases, the Commonwealth (through the Department of Health and Ageing) has a leadership role in facilitating the setting of standards: eg, the National Standards for Mental Health Services; the Australian Standard Vaccination Schedule; and the Standards Framework of Accreditation and Certification for residential care.
The process by which health undertakings negotiated with Health Services Australia are monitored.
The term "Health Undertaking" has a specific meaning in migration legislation and policy, to do with post visa issue monitoring of (mainly) tuberculosis by state health chest clinics. The process does not involve Health Services Australia (HSA) as it is an arrangement made between the visa issuing officer, the visa applicant, the Medical Officer of the Commonwealth (appointed by the Minister for Immigration for immigration purposes) based in the Health Assessment Service and the state-based chest (or other) clinic director.
DIMIA can provide detail on the operation of health undertakings.
What is the role of the Department in monitoring major communicable diseases?
Under the Quarantine Act 1908 the Commonwealth Department of Health and Ageing has responsibility for human quarantine policy in Australia. The policy enables the identification and surveillance of persons who have been potentially exposed to a quarantinable disease, the provision of appropriate medical treatment if necessary, and the application of public health measures to prevent the outbreak of any of the quarantinable diseases in Australia.
Five human diseases are subject to quarantine controls: plague, rabies, cholera, yellow fever and viral haemorrhagic fever. The only vaccination requirement for entry to Australia is for yellow fever. Any person over one year of age is required to hold an international yellow fever vaccination certificate if, within the six days prior to their arrival in Australia, they have stayed overnight or longer in a declared yellow fever infected country in Africa or South America. Any such person who does not posses a valid vaccination certificate on arrival in Australia, is placed under a quarantine surveillance order by an officer of the Australian Quarantine & Inspection Service. A surveillance order allows a person to enter Australia on the basis that they report to a health authority if they develop symptoms of yellow fever infection within the surveillance period (up to a maximum period of six days).
The Department is also a member of, and provides the Secretariat for, the Communicable Diseases Network Australia. The network:
- comprises state and territory representatives as well as representatives from key laboratory, academic and other institutions with expertise in the public health management of communicable diseases;
- develops protocols, discusses information in immediate disease threats, etc, and contributes data on communicable diseases to the National Notifiable Diseases Surveillance System (see further below); and
- can be convened at short notice to handle an acute situation.
Can a copy of the public health protocol referred to in DIMIA's submission (p.61) be provided?
A copy of the 'Interim Protocol for public health management at DIMA detention environments' is attached (Appendix A). This protocol, endorsed by the Commonwealth Chief Medical Officer, is still operational. Negotiations on finalising guidelines are continuing with DIMIA.
IMMUNISATION
Are there national standards of required immunisation, and are these determined by the Department?
National standards are set out in the Australian Standard Vaccination Schedule, but there is no legal requirement for immunisation. The Department facilitates the development of the standards through the Australian Technical Advisory Group on Immunisation (ATAGI). The Schedule, produced by ATAGI and endorsed by the National Health and Medical Research Council, outlines all immunisations recommended by the ATAGI.
Does the Department or any agency have a role in providing or assessing data about arrivals who have not had required immunisations in country of origin or residence?
The Department has a role only in relation to yellow fever (as above), in conjunction with the Australian Quarantine & Inspection Service.
What are the appropriate levels of immunisation of adults from countries where diseases such as polio are common?
The Australian Immunisation Handbook (7th edition) recommends that all adults have three doses of diphtheria, tetanus, and polio vaccines and two doses of measles, mumps and rubella (MMR)vaccine. Some extra vaccinations (such as those against influenza and pneumococcal disease) are recommended for older adults and persons with particular medical conditions. The standards relate to all people: they do not vary according to a person's place of origin.
What is the role of the States and Territories in immunisation services generally?
The States and Territories are responsible for the purchase, administration and delivery of vaccines to the public. Funds for the purchase of vaccines on the Australian Standard Vaccination Schedule are provided by the Commonwealth.
Is there a national database of immunisation records?
The Australian Childhood Immunisation Register (ACIR) is a national database containing information on the immunisation status of children living in Australia who are under the age of seven years. Only vaccines given in Australia are recorded on the ACIR and those given to children in detention may be included. The ACIR is administered by the Health Insurance Commission.
COMMUNICABLE AND NOTIFIABLE DISEASES
What is the role of the Commonwealth, the states and territories, and/or individual medical providers in notifications?
The States and Territories:
- are responsible for legislation requiring the notification of certain diseases to health authorities by medical practitioners and some others (such as pathology laboratories and hospitals). Different diseases may be notifiable by different mechanisms depending on the jurisdiction and/or the circumstances (eg, Detention Centre Service Provider staff are required to make notifications in relation to detainees); and
- analyse and act on notifications data for their own jurisdiction, and each fortnight forward their data for inclusion in the National Notifiable Diseases Surveillance System.
The Commonwealth:
- maintains the national database for the National Notifiable Diseases Surveillance System to which covers more than 50 communicable diseases or disease groups endorsed by the National Health and Medical Research Council; and
- undertakes national analysis for policy purposes, and for publication on the Internet and in the Communicable Diseases Intelligence journal.
- (see http://www.health.gov.au/pubhlth/cdi/cdihtml.htm)
PSYCHIATRIC HEALTH
Are there national standards in relation to the provision of psychiatric care, including special needs of people who have experienced torture and trauma?
National Standards for Mental Health Services were endorsed by the Australian Health Ministers Advisory Council National Mental Health Working Group in 1996.
Standard 7 of the National Standards addresses issues of cultural awareness and sensitivity, and a broad recognition that treatment and support should be delivered in a manner that is sensitive to the unique social and cultural needs and beliefs of population groups within the community (See http://www.health.gov.au/hsdd/mentalhe/resources/index.htm).
The role of the Commonwealth in the development and implementation of improved mental health care for at risk groups in the community (which would include people who have previously been in immigration detention)
The planning and delivery of mental health and related services, and the enactment of legislation pertaining to the treatment of people with a mental illness, are State and Territory responsibilities.
The Commonwealth's role is principally to provide leadership and coordination, and to support national-level activities. However, the Commonwealth has contributed substantial funds for activities which support the mental health and related care for at-risk groups; eg:
- The Program of Assistance to the Survivors of Torture and Trauma assists people who have experienced traumatising events in their home countries, and supports their integration into mainstream medical and mental health services ($5.84 million (indexed) over four years from1999-2003. The client group for this program includes people granted Permanent Protection and Temporary (Humanitarian Concern) Visas.
- Under the National Mental Health Strategy, a national transcultural mental health program helps to improve community knowledge and understanding about mental health, and the quality and accessibility of mental health services available to Australians from diverse cultural and linguistic backgrounds (around $2.58 million funding since 1995.
Are there Australian standards or guidelines on the special needs of children from countries significantly affected by warfare?
There are no specific standards or guidelines for the special needs of children in this circumstance.
However, the National Action Plan for Promotion, Prevention and Early Intervention for Mental Health 2000 recognises that adverse life events such as experiencing warfare may impact upon, and increase the risk of, children experiencing mental health and related problems. It allows for national activities to enhance community capacity to provide support during adverse life events, and increase use of evidence-based prevention and early interventions for high-risk individuals who have experienced adverse life circumstances.
FOOD AND NUTRITION
Does the Department have a role in research, monitoring or provision of information on:
- Nutritional standards for people who are from very disadvantaged backgrounds, and education on the provision of appropriate nutrition and food services;
- Availability of national/international measurements of nutritional health to determine if particular groups or individuals need supplements etc?
- Cross-cultural nutrition and food information;
- Special needs of babies and pregnant women spending long periods in institutions such as immigration detention?
No. The Department aims to improve the nutrition and healthy eating patterns of Australians through the development of dietary guidelines that target the general public, rather than specific population groups such as those in institutions.
PREGNANCY, BIRTH AND POST-NATAL CARE
Information on cross-cultural training, and information in community languages on birth options.
Standards for post-natal care.
These are State and Territory responsibilities
PRIVACY
Are there any standards developed that ensure that appropriate privacy is guaranteed to patients in hospitals, or is this a state matter.
This is largely a state matter. However, under the Australian Health Care Agreements, each State and Territory has developed a public hospital charter and these cover commitments to treating consumers with respect, dignity, privacy and with consideration for religion and cultural background. The charters apply only to public hospitals within the State or Territory.
RESEARCH AND FUNDING
Has the Commonwealth provided funding, including for research, for any of the above areas?
Health care for children in detention is provided and paid for by DIMIA.
The Department has no direct funding role in relation to health services for children in detention:
- unauthorised arrivals who are in immigration detention are not eligible for Medicare;
- the Department has not funded research around any of the matters above in as much as they directly relate to children in detention; and
- nor has DIMIA provided the Department with any funding to undertake research or projects relating to detainees.
However, the National Health and Medical Research Council has funded one three year project to investigate 'The impact of the refugee application process on the psychiatric status of traumatised asylum seekers'. This project is due to be completed later in 2002.
Further, people who arrive illegally but are issued visas in the following categories are eligible for Medicare under special provisions in legislation:
- Temporary Protection;
- Temporary (Humanitarian Concern);
- Offshore Entry; and
- Relocation Secondary Movement.
In addition, as the responses to the questions above show, some funds from the Department support a range of initiatives and programs that may, indirectly, affect detainees.
Attachment A
Interim Protocol for public health management at DIMA detention environments
Rationale
This interim protocol addresses public health issues relevant to detention environments and is not intended to cover all health management issues. It identifies the minimum health requirements and vaccination to protect the health of detainees and the Australian public (see footnote).
This interim protocol will be in place while awaiting final deliberations of the Committee.
Tuberculosis (TB)
Screening for active TB should be undertaken in all persons aged 12 years and over, and for children under 12 who are symptomatic or are family contacts of active cases. Screening will be by history, physical examination and chest x-ray (PA film initially).
Chest x-rays should be taken as soon as possible, and within two weeks of arrival at the detention centre. Chest x-ray films must be read by a radiologist and the report sighted by the relevant medical officer before the examination is considered complete.
Pregnant women who have not had a chest x-ray will be monitored by the medical staff and have a chest x-ray performed after delivery.
Mantoux (tuberculin) testing is indicated as a screening test for children under 12 years of age (see Vaccination). The Mantoux test must be administered by clinical staff specifically trained in its administration and reading. Interpretation of the Mantoux result may require the expert advice of the relevant State based tuberculosis service.
Regardless of screening results, any person with symptoms suggestive of TB, or who develops symptoms of TB after initial screening, should be investigated promptly and/or referred to the relevant State based tuberculosis service.
The detention centre service provider, contracted medical staff and the HSA should develop strong links with the State based tuberculosis service to ensure staff remain up to date on TB issues and to expedite diagnosis and management of detainees with TB.
HEPATITIS B
HBsAg blood testing on all pregnant women and/or where there are clinical indications of hepatitis.
HIV antibody testing
HIV testing should be carried out when there are clinical and/or epidemiological indications of disease or infection. Pre- and post-test counselling is required for all persons undergoing HIV testing and/or for the legal guardian in the case of a symptomatic child.
Confirmed HIV positive persons should be referred to the State AIDS/STD service for management and contact tracing upon discharge from detention.
Malaria
Malaria screening by thick and thin film should be performed on persons who have come from, or transited through, a malaria endemic country and who present with a febrile illness, report fever in the previous week and/or are pregnant.
Other infectious diseases
Routine screening for other infectious diseases, including gastrointestinal parasites and typhoid, should not be undertaken unless clinically indicated. Health care providers should maintain a high level of suspicion of communicable diseases and investigate accordingly.
Vaccination
The following minimum schedule is recommended for all children aged 0-15 years unable to provide a documented history of prior vaccination.
MMR
Two doses of MMR spaced one month apart should be administered to all children aged 12 months to 15 years who are unable to provide documentation of vaccination. MMR should not be given to an immunocompromised child. To protect the health of Australians and to minimise the possibility of an outbreak in the detention centre, MMR should be administered as soon as possible after arrival in Australia, preferably within the first week.
Polio vaccine
Three doses of oral polio vaccine (OPV) spaced 2 months apart should be administered to all children aged 2 months to 15 years who are unable to provide documentation of vaccination. Inactivated polio vaccine (IPV) should be substituted for OPV if the person or a member of their family is immunocompromised.
BCG
All neonates born in Australia, and tuberculin negative children up to 5 years of age, should receive BCG except for those previously vaccinated or for TB contacts for whom preventive treatment is being considered. BCG should not be given to an immunocompromised child.
Notification of State Health Authorities
In the event of a Notifiable Disease or disease cluster
Where a notifiable disease is diagnosed in a detainee, the case must be notified to the relevant State Health Authority in accordance with normal disease notification protocols. HSA, the detention service provider and contracted medical staff should be familiar with local notification requirements, including the procedure for urgent notifications. Maintaining close liaison at all times with the State Health Authority should be encouraged.
Any unusual increase in the occurrence of a disease (cluster), even for diseases not usually notified, must be reported to the relevant State Health Authority as a matter of urgency and all health staff must cooperate with the disease control measures required by that Authority. Outbreaks likely to occur in camps and institutions include measles, hepatitis A, influenza, meningitis, acute gastrointestinal disease and skin infestations such as scabies.
In the event of discharge from detention
On discharge, detainees should be referred to the relevant State Health Authority for follow up of infectious diseases such as TB, and in order to facilitate access to public health and clinical services, including completion of vaccination schedules as above. Pregnant women who were not x-rayed should be referred to the relevant State Health Authority.
Medical records
To facilitate subsequent health care arrangements, a copy of the medical discharge summary and vaccination record should be kept at the detention centre and copies given to each person (or their legal guardian) on discharge.
Occupational Health and Safety
As a minimum, all detention centre staff should be fully vaccinated in accordance with the Australian Standard Vaccination Schedule. Staff in specific occupational groups may require additional vaccinations as recommended in the current edition of the Australian Vaccination Handbook.
Footnote: This protocol has the endorsement of the Commonwealth Chief Medical Officer although it will be further developed in consultation with State and Territory Health Authorities, DIMA, the detention service provider and HSA.
Last Updated 10 October 2002.
