This guideline is intended to provide a summary of background and health issues for newly arriving Afghan refugees, noting the additional complexity of Covid lockdowns at the time of the initial uplift in August 2021. 

Useful Afghan calendar converter and UNHCR situation report

Background

In late August 2021, the Taliban returned to power in Afghanistan - see summary of events. More than 120,000 people were evacuated over 10 days to 31 August 2021, by many different nations (see media). Evacuees included foreign nationals and around 65,000 Afghans. Australia evacuated 4100 people (see Prime Minister's press conference and media), with 3500 travelling on to Australia, including 2500 women and children. 

UNHCR reports more than 1.6M people have left Afghanistan for neighbouring countries since August 2021, with 5.3M registered Afghan refugees in neighbouring countries (Iran, Pakistan, Tajikistan, Uzbekistan, Turkmenistan). UNHCR estimates there are 4.5M Afghans in Iran, and 3.2M in Pakistan (at Dec 2023), and millions of these cohorts do not have documentation.

• On 3 Oct 2023, Pakistan announced plans to repatriate more than 1M undocumented migrants, predominantly Afghans (see DHA information, DFAT information Nov 2023 and media summary). The initial announcements provided a 4-week deadline (later extended until end 2023), despite UNHCR concerns and a non-return advisory in place. More than 500,000 people have returned to Afghanistan from Pakistan between Sep 2023 and Jan 2024.
• This situation has implications for Afghan Australian visa applicants/holders residing in Pakistan without valid residency status in Pakistan - who are subject to new exit permission requirements and costs, and risk deportation. The Australian government is working to expedite visa processing (see updates). 

Demography

• Population - Afghanistan has a population of around 42.8M people. After 40 years of conflict, Afghans make up one of the largest refugee populations globally, with UNHCR reporting 6.1M registered Afghan refugees by mid 2023. The country continues in a state of humanitarian emergency, with more than 90% of the population living in poverty, severe food shortages, and 30% acute food insecurity. Afghanistan is the lowest ranking country globally for the status of women (177/177).
• Ethnic groups - the main ethnic groups are Pashtun, Tajik, Uzbek and Hazara, other groups include Nuristani, Aimak, Turkmen and Baloch.
• Languages - official languages are Pashto and Dari, although there are more than 30 languages spoken and multilingualism is common.
• Religion - majority Sunni Islam (including Pashtun and Tajik populations), followed by Shi'a Islam (including Hazara populations).
• Naming conventions - Afghan names typically consist of a first/personal name alone, which may be a compounded name. Female names are usually a single name. Surnames/family names are not customary, but are becoming more common in educated/wealthier groups. When used, surnames often represent tribal/ethnic affiliation or area of origin, and children will take the surname of their fathers. Women do not traditionally adopt their husbands surnames when they marry. 
  

Australian response

Australia allocated 3000 places from the existing humanitarian intake for the initial uplift; many agencies urged an additional intake of Afghan refugees - see Refugee Council of Australia. Australia (then Minister Alex Hawke) announced an Advisory Panel on Australia's Resettlement of Afghan Nationals in August 2021, and then $27.1M in funding for an Afghan Settlement Support package in October 2021. In January 2022, Minister Hawke announced a further allocation of 15,000 places within the existing humanitarian (10,000 places) and family visa programs (5000 places) over the next 4 years, and on 29/3/22, the federal budget allocated an additional humanitarian intake (above the existing humanitarian intake) of 16,500 Afghan refugees over 4 years (funding of $666M).

By end 2022, 31,500 places for Afghan nationals had been allocated over 4 years - 26,500 places under the humanitarian program (10,000+16,500) and at least 5000 places under the family migration stream.

Entry visas

• In the initial uplift, some new arrivals had Australian citizenship/permanent residency, others travelled under Australian refugee visas, and many arrived on Temporary Humanitarian Stay (449) visas - related to the speed of the uplift/evacuation.
  • The 449 visa did not carry Medicare initially, arrangements were made facilitating Medicare access for 449 visas by 16/9/21 (~30% had Medicare by 15/10/2021, 75% by 11/11/2021). In practice there were delays in new arrivals getting their Medicare details. 
    • The 449 is a temporary visa. Initial duration was 3m, with an assumption of renewal (to 12m) and transition to permanency. 
      • The 449 is not eligible for the MBS refugee health assessment item (707); or NDIS (it is a temporary visa).
      • Temporary visas do not carry rights to family sponsorship. 
        
• Within the cohort, there were a small number of unaccompanied humanitarian minors (UHM) - see media. All UHM are eligible for the UHM Program.
• Contact xb@homeaffairs.gov.au and the Humanitarian Settlement Program (HSP) provider (Victoria - hspintake@ames.net.au) where individuals details are incorrect, expedited access to permanent visas is required, or for Medicare issues.
• Future entrants are anticipated to arrive on offshore refugee visas (with permanent residency).

Health screening

Unlike other humanitarian arrivals, very few Afghan refugees in the uplift had an offshore Immigration Medical Examination (IME). IME are recorded on the offshore Health Assessment Portal (HAP) system. It is plausible the same situation may occur again for Afghan arrivals from Pakistan. Check HAP for all offshore refugee visas and humanitarian arrivals - the HSP provider can access the HAP number (but not the HAP system) - contact hspintake@ames.net.au. BUPA completed IME for new Afghan arrivals in late 2021 and early 2022 (details included for historical reference at the bottom of the page). The IME was required for transition onto substantive visas, but is different to a recommended post-arrival refugee health assessment.

Recommended health assessment Afghan arrivals

All new arrivals should have an initial health assessment after arrival. In 2021, assessments were affected by health service access due to Covid and delays in Medicare, it is worth confirming Afghan arrivals have completed a refugee health assessment, even if they arrived some time ago.

Screening tests children

• All: FBE/film, ferritin, active B12, folate, vit D/ALP, IGRA or TST, HBsAg, cAb, sAb, Strongyloides, malaria, faecal COP 
• Age/risk based: HCV, HIV (15y+/clinical/UHM), STI screening, syphilis (clinical/UHM), consider MMR and varicella serology adolescents, H pylori (symptoms)

Screening tests adults

• All: FBE/film, active B12, folate, IGRA, HBsAg, cAb, sAb, HIV, Strongyloides, malaria, consider MMR and varicella serology, faecal COP
• Age/risk based: ferritin (women, men with RF), vit D, rubella (women), HCV, STI screening, syphilis, H pylori (Sx)
  
• Catch-up primary care: HPV screen (women 25-74y), Alb:creat/eGFR (30y+ if high risk), BSL/HbA1C (40y+), lipids (45y+), FOBT (50y+), Mammogram (women 50-74y)

Note screening for Schistosoma and HCV* is not routinely required for people from Afghanistan (*screen for HCV if risk factors identified). We suggest routine screening for malaria and for B12 deficiency in people from Afghanistan. 

Special note: B12 screening and preventive treatment in Afghan cohorts

We have seen widespread B12 deficiency in children and adolescents from Afghanistan, despite regular reported meat/milk intake.

• Suggest FBE, ferritin, B12 and folate screening for all new arrivals from Afghanistan. 
• In infants, and anyone with poor nutrition, disability or neurological symptoms (all ages) - prioritise early screening, and also check serum homocysteine, and urine methylmalonic acid (Note - these tests may not be possible, and also may be billed outside the hospital setting).
• Where screening will be delayed, commence 3m oral B12 supplements (100 mcg oral daily, all ages), or give 1000 mcg IMI if possible.
  • When screening is later completed: if B12 levels are replete - stop supplements and repeat levels in 3-6 months, if levels remain low, complete serum homocysteine & urine methylmalonic acid, and seek specialist advice.
• Provide appropriate dietary advice.
• In breastfeeding infants with low B12 - seek specialist advice, and ensure their mothers also have screening for B12 and treatment if deficiency identified. 

Catch-up immunisation

Catch-up immunisation is required for all new arrivals, including full catch-up for anyone without a written record of vaccination, Covid vaccination remains a priority and can be given with other vaccines.

• The immunisation schedule in Afghanistan includes: BCG, rotavirus, DTwP-Hib-HBV, Td, IPV/OPV, measles, conjugate pneumococcal (i.e. no mumps, rubella, meningococcal ACWY, varicella/zoster, HPV or influenza).
• Note - RCH/MVEC protocols for catch-up vaccination after chemotherapy use infanrix-hexa and MMR-V up to age 18y, this reduces needles required, and we use this in practice. AIR will accept these vaccines for adolescents, **AIR data entry - use other, and enter by antigen, and then accept queries. 
• We have seen many families with excellent quality overseas vaccination records - these can be entered on AIR - you will need an Afghan calendar converter (!).
  

Other considerations

• Covid remains a health consideration after arrival, especially for large families/group accomodation.
• A number of children had diarrhoeal illnesses - also consider hepatitis A in the differential diagnosis.
• Measles was reported in Afghan arrivals to the US as of 11 Sep 2021 - see media, there were no cases in Australian arrivals.
• Emergency department presentations - a number of new arrivals required ED care (higher than clinical experience for other cohorts). In this situation, note:
  • Individuals may not yet have Medicare, ensure local billing processes record them as refugees/asylum seekers rather than international arrivals.
  • Individuals may not yet have any phone or address details or may be in the process of moving accomodation.
  • Liaise early with the HSP provider (Victoria = AMES, and at RCH, contact Immigrant health if needed).
• Disability and equipment needs -  multiple individuals within the cohort had disability/equipment needs, equipment access was/is difficult.
• Medications - individuals who have had an offshore IME should arrive with 1 month supply of medications.
• Mental health - individuals may have been separated from immediate family, and there has been wide ranging impact on other Afghan-background populations in Australia. Distress may be amplified by separation and the current situations in Afghanistan and Pakistan. Refer for mental health support or trauma counselling if required e.g. Foundation House.

Settlement

Immediate priorities for large new arrival cohorts include:

• Immediate (and subsequent) material needs
• Identifying any UHM
• Interstate movement
  
• Short-term and then longer-term accomodation - often involving movement across LGAs and services in the early period of settlement
• Casework - community and household orientation 
  • Centrelink access - for difficulties with Centrelink access contact hardship.assistance@servicesaustralia.gov.au 
  • Finalising Medicare access - this process was delayed, but Medicare cards are backdated to arrival, hence billing can be completed retrospectively
• Linking with primary care, and where needed, specialist and/or mental health care
• Health assessments and catch-up vaccinations
• Education enrolment (children and young people)  - NB assess age, prior schooling and grade level placement. 
  

There has been wide ranging impact on Afghan-Australian communities in recent years, including those who arrived seeking asylum - this is an active consideration in clinic reviews of any new/existing patients. The current situation in Afghanistan and recent events in Pakistan will continue to affect wellbeing of this cohort. Legal support is available through ASRC and a network of legal providers - Afghanistan clinic - 9252 2534, also see information sheet.

Historical reference

Covid, hotel quarantine, and covid vaccination at the time of the uplift

Due to the Covid pandemic, new arrivals from the uplift were subject to hotel quarantine (HQ) after arrival in WA, SA, Vic, NSW, Qld and NT. HQ arrangements (and healthcare available in HQ) varied across the jurisdictions. In Melbourne, the process of commencing case work support, Centrelink/Medicare access, and finding accomodation was complicated because of HQ and lockdowns, and most arrivals spent some time in short term accomodation close to the CBD. Many interstate Afghan arrivals subsequently moved to Victoria, often to City of Greater Dandenong.

Covid vaccination was limited in Afghanistan at the time of the uplift, 2.0% were partially and 1.1% were fully vaccinated, although a number of new arrivals had been vaccinated.

BUPA IME assessment (2021-22)

• BUPA completed IME for new Afghan arrivals, screening for this cohort has now ended. BUPA declined to accept local pathology results, resulting in duplication of testing. The BUPA contact email is BupaMedicalOfficerOnshore@bupamvs.com.au. 
• BUPA test protocols for Afghans were: (as of 30/9/21 and confirmed 24/11/21) by age:
  • <2 years - medical exam (no blood tests)
  • 2-10 years - medical exam, IGRA or TST
  • 11-15 years - medical exam (no blood tests), CXR
  • 15 years and older - medical exam, HIV, HBsAg, HCV, HIV, syphilis screening, CXR
  • UHM - HIV, HBsAg (all ages), + age based as above. UHM status was missed in a number of cases resulting in repeat assessment.
• Key points
  • Positive TB screening or blood-borne virus tests were disclosed to the client (who was called back for an appointment) and referred to local TB services/health service.
  • Clients got a 'duty of care' letter with limited clinical information and the HSP was notified. There was inadequate information in the 'duty of care letter' for the HSP provider to communicate concerns to the client's GP. 
  • There was no medical referral process or handover for any other findings on the IME (raised with DHA).  There were multiple clinical risk situations (where individuals were not referred for care).
    
  • Clients did not get a copy of their test results unless they requested them (BUPA request form (in English) & emailing the local pathology provider (Victoria = Dorevitch - RequestforMedicalRecords@Dorevitch.com.au).
  • Screening results were uploaded onto the HAP system - although there were delays, and HAP numbers were difficult to identify. 

_{Immigrant health clinic resources. Author Georgie Paxton, Jen Schaefer, Sep 2021, last update January 2024  - Contact: georgia.paxton@rch.org.au}