This guideline is intended to provide a brief summary of background and health issues for new arrival Ukrainian refugees.  See UNHCR situation report Ukraine for background. Please also see: DH guidance - Displaced Ukrainian nationals in Victoria without Medicare (June 2022) - free hospital care for this cohort (also in Ukrainian).

Background 

Russian troops had been located along the Ukrainian border from March 2021, with estimates of 100,000 troops in place by December 2021. On 24 February 2022, Russia invaded Ukraine from the north (Belarus), east (Donetsk and Luhansk regions) and south (Crimea).  More than a million people left Ukraine within the first week of the conflict, and by 15 Mar 2022 (19 days later), more than 3 million people had fled. Current (Jan 2024) UNHCR records more than 6.36M Ukrainian refugees globally, with most in Europe. Current numbers of displaced Ukrainians by country are: Russian Federation 1.2M, Germany 1.12M, Poland 957K,  Czech Republic 376K, UK 250K, and Spain 186K; at least 18 other European countries have >50,000 people from Ukraine.  See summary, including maps.

• Population - Ukraine had a population of around 44 million people pre-conflict.
• Ethnic groups - Ukrainian, Russian, other.
• Languages - the official language is Ukrainian, which is first language for two thirds of the population, the remaining third have Russian as first language.
• Religion - the main religion is Orthodox Christian, also with Catholic, Protestant, Muslim and Jewish populations.
  

Australian response

Australia has granted more than 11,500 visas for people from Ukraine, and nearly 11,400 have arrived in Australia (as of Jan 2024). By end 2022, around 1100 Ukrainians had arrived in Victoria (no more recent information available). This has been a situation of hyper-acute displacement, with differences to other humanitarian cohorts: 

• Individuals from Ukraine typically travelled under tourist (visitor) visas - these visas do not have access to Medicare or Centrelink.
  
• The subclass 786 Temporary Humanitarian Concern (THC) visa was available until July 2022 for Ukrainian arrivals and all Ukrainian nationals in Australia on temporary visas (using a two-step process of a Humanitarian Stay (Temporary) (subclass 449) visa followed by the 786 visa (3-years duration).
  • 449 visa Ukraine arrivals - includes:work rights, eligible for special benefit, Humanitarian Settlement Program (HSP) and AMEP, no Medicare/NDIS
  • 786 visa - includes: Medicare, full work rights, study rights, special benefit, childcare benefits, HSP and AMEP. No NDIS
• The Sep 2022 budget included an additional allocation of 3-year 786 visa places (Paper 2, p85) and provisions for Medicare access for Ukrainian refugees on bridging visas. 
• Multiple visa pathways are now available, including 866 (PPV) visas and 'no further stay' waivers for those who arrived on temporary visas. 

There were around 46,000 Ukrainian Australians (2016 Census), predominantly living in Melbourne and Sydney, also with communities in other areas. See DHA community information summary.

Medicare, AIR records and NDIS

• The 449 visa for Ukrainians did not carry access to Medicare (different to Afghan arrivals in 2021, where 449 visa holders did receive Medicare)
  
• Ukrainian refugees granted a 786 visa are eligible for Medicare from the date of visa grant. Medicare enrolment takes 4-6 weeks, and after this, it takes up to 10 weeks to obtain a Medicare card. Individuals can call Services Australia to obtain their card number before their Medicare card arrives. Health providers can look up HPOS (with consent) to obtain patient's Medicare numbers (and are able to bill for services before a physical Medicare card is issued).
  
• If children's AIR records were created prior to Medicare, Centrelink requires parents to call the multilingual line (131202) for confirmation - so AIR records can be matched to Centrelink. Services Australia have advised they have experienced name matching issues (which may affect Centrelink payments)
• Neither the 449 nor the 786 visas have access to NDIS.

Medicare fact sheet (available in Ukrainian)

Health screening 

All new arrivals should have an initial health assessment and catch-up vaccination. Timing may be affected by access to Medicare. This assessment should occur even if they had the (limited) BUPA IME assessment (see below). Immediate health triage (i.e. for all ages) should assess for acute physical or mental health issues, disability, frailty/mobility issues in elders, pregnancy and medication type and supply. 

Recommended health assessment Ukrainian arrivals

Screening tests children

• All: FBE/film, ferritin, IGRA or TST, HBsAg, cAb, sAb, HCV
• Age/risk based: HIV 15y+/clinical/UHM, STI screening, syphilis (clinical/UHM), consider MMR and varicella serology in adolescents, consider faecal OCP and H Pylori (if symptoms)

Screening tests adults 

• All: FBE/film, IGRA, HBsAg, cAb, sAb, HCV, HIV
• Age/risk based: ferritin (women, men with RF), rubella (women), consider MMR and varicella serology, 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) 

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 age 5 years and older.

• The Ukrainian vaccination schedule includes: BCG, DTwP, Hib, Hepatitis B, OPV/IPV, MMR and influenza vaccine. Missing compared to Australian schedule: rotavirus (usually not relevant for catch-up), pneumococcal, meningococcal ACWY, varicella, zoster, and HPV. Ukrainian covid vaccination coverage was low in early 2022 (~ 35%). 
  
• Our clinical experience has been widespread issues with vaccine hesitancy in this cohort (the first time we have seen this in refugee health). 
  
• Many new arrivals travelled with detailed overseas vaccination records - in our experience, there are a few differences to be aware of:  
  • The format of the records is by antigen - thus the same vaccine is recorded under different antigens (e.g. the same hexa dose is recorded under DTPa, Polio, Hib and HBV categories (this makes it much quicker to interpret! and much easier to enter into AIR). 
  • The Pentaxim formulation is DTPa-IPV-Hib (whereas Infanrix-penta is DTPa-IPV-HepB). 
  • Families have indicated that vaccine supply was difficult 5-10 years ago, and many children appear to have had vaccines on many different dates and often only 1 or 2 vaccines at a time. This sometimes makes it difficult to enter vaccines onto AIR. 
• AIR records were difficult to obtain for people without Medicare, with a delay of ~ 1 week between submitting vaccinations and the record being available on AIR. 
• Entering information on to AIR - use 'encounter overseas', schedule = 'other', add dates, and use generic vaccine type where needed (e.g. for pentavalent vaccines, may need to record as DTPa generic, IPV generic and Hib generic). Enter dose numbers accurately, and the record should submit. AIR will not allow entry of the same antigen on the same day, which means overseas schedules that include simultaneous OPV and IPV cannot be entered accurately. These schedules typically include many more doses of polio vaccination than the Australian schedule, so this will not affect up to date status. 
• 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. 
  

Translated catch-up information:  Pre-immunisation checklist, Vaccine safety - Ukrainian, Vaccine side effects, Catch-up summary (City of Melbourne resource, informal translation - but excellent interim resource),

Other considerations

• Birthdate - now 2-years in, we have not seen issues with birthdates in this cohort.
  
• Prioritise education enrolment in children, and actively consider grade placement - when children are learning new languages, we suggest they are placed with the same age children in younger grade levels - e.g. a 6-year-old child can be placed in foundation (prep) with other 6-year olds in this level (many children start school age 6 years in Victoria), and a 5-year-old child can complete a year of kindergarten before commencing school. This cohort may also enter Catholic or Jewish education systems.
• Ensure medication supply and continuity where required.
• Disability/complex health issues - seek assistance through specialist services for children (or adults) with disability and/or complex medical issues. See paediatric refugee health clinic details. 
• Mental health/trauma - refer for mental health support or trauma counselling if required.

Prevalence data for Ukraine

Prevalence data for Ukraine show: 

• Tuberculosis - 10-fold higher incidence of TB compared to Australia (73/100,000 vs 7.3/100,000) with higher prevalence of MDR (13.3% of cases) and XDR (3.7% of cases) - TB screening is a priority
• Hepatitis C - moderate to high prevalence: 3.6% HCV-Ab positive & 2.7% HCV RNA positive (Australia 1.7%, 1.5%) - include HCV screening for children and adults
• Hepatitis B - higher prevalence compared to Australia - 1.3% HBsAg positive; Australia - 0.8% in 2021. HBV screening is part of post-arrival refugee screening
• HIV - higher prevalence compared to Australia in adults (predominantly in people with history of injecting drug use)  - 1.0% in age 15-49 years, very low in children (comparison - Australia - 0.1% in adults 15-49 years). Excellent access to treatment and high rates of viral suppression noted. HIV screening in age 15 years and older is part of post-arrival refugee screening.

Onshore immigration screening (BUPA)

The onshore immigration medical examination (IME) for Ukrainian arrivals applying for a 786 visa is limited, related to the 786 being a temporary visa (noting the IME was more comprehensive for the Afghan arrivals transitioning onto permanent visas). It consists of:

• (501) Medical examination
  
• (502) CXR age 11 years and older (unless pregnant) or if requested by Commonwealth Medical Officer
  
• Check for special circumstances - intending healthcare worker, close household TB contact within last 5 years, pregnant and will deliver in Australia - in which case other tests are required - including (708) Hepatitis B screen if pregnant

Other considerations

• Individuals HAP numbers were listed in their initial visa 449 grant letter. It is unclear whether the HAP number has always been on the 449 grant letter - but worth asking.
• Ukrainian arrivals had to pay for their own IME - clinicians reported this was a substantial barrier to completion of IME and any subsequent assessment - we have not seen this before in humanitarian cohorts.
• Existing processes were challenging in clinical practice. Individuals were not told their IME results unless they are positive, and while a 'duty of care' letter can be sent to the HSP agencies (who typically hold the HAP number), many of the Ukrainian cohort did not have HSP support. This, combined with difficulties clarifying the HAP number, made BUPA IME screening very difficult for this cohort. 

Resources

• DHA Ukraine visa support and Humanitarian Settlement Program
• DH Circular - Displaced Ukrainian nationals in Victoria without Medicare -  interim guidance (June 2022) (June 2022)
• Medicare fact sheet (available in Ukrainian)
  
• United resource for Ukrainians in Australia (excellent)
• Vaccination: Pre-immunisation checklist, Vaccine safety - Ukrainian, Vaccine side effects, Catch-up summary

_{Immigrant health clinic resources. Author Georgie Paxton, Initial March 2022, last updated January 2024 - Contact: georgia.paxton@rch.org.au}