DECEMBER 2017 | MÉDECINS DU MONDE BELGIQUE WITH SUPPORT OF UNICEF OFFICE FOR CROATIA

Invisible emergencies?

MdM medical team providing healthcare to a baby in Asylum seekers facility Porin, Zagreb, Croaita. © Renato Pejković

Physical and mental health needs of asylum seekers in Croatia with a special focus on (pregnant) women and children

SOIGNE AUSSI L’INJUSTICE ALSO TREATS INJUSTICE

Providing Health Care Assistance to Refugee and Migrant Women and Children PROJECT SUPPORTED BY UNICEF OFFICE FOR CROATIA/ IMPLEMENTED BY MDM-BE Launched in April 2017, the main goal of the Project “Providing Health Care Assistance to Refugee and Migrant Women and Children” is to ensure primary health and mental health care for asylum seekers in two Croatian AS facilities, with a specific focus on (pregnant) women and children. With a team of two general practitioners, one nurse and one interpreter, “Médecins du Monde-Belgique” (MdM-BE) carries out primary health care consultations in Zagreb and Kutina facilities on a daily basis. The team also conducts official initial medical screening of newly arrived asylum seekers. MdM-BE’s psychologist carries out mental health assessments and individual psychotherapy consultations. In order to ensure provision of an all-inclusive assistance and integrated care, MdM-BE’s community worker offers information, guidance and practical support to asylum seekers/asylees in accessing their rights (accompanying patients to healthcare institutions; accompanying children asylum seekers for vaccination, etc.). Within the framework of the Project, MdM-BE introduced specialised health services in AS facility Porin Zagreb: gynecologist, pediatrician and psychiatrist visit the facility twice a month each. Through workshops or individual counselling, MdM-BE’s medical team also provides information about prevention of infectious diseases, hygiene, access to healthcare and family planning.

© 2017, Médecins du Monde ASBL - Dokters van de Wereld VZW. All rights reserved. The content of this publication represents the views of the author only and his/her sole responsibility: it cannot be considered to reflect the views of UNICEF. Pictures: Renato Pejković. www.medecinsdumonde.be / www.doktersvandewereld.be

INTRODUCTION

Rapid changes requiring geographically and organisationally flexible operational modes

Building of the barrier between Hungary and Serbia and entry into force of the new laws to stop migrants entering Hungary illegally, on 16th of September 2015, resulted in redirection of a refugee/migratory route towards Croatia which became from that date a “transit country”. An official “corridor” was set-up by the Croatian authorities a few days after, and special bus and train services introduced for transportation of refugees and migrants from Serbian to Slovenian border in the days and months that followed. The temporary reception centre was opened in Opatovac on 20th of September 2015, followed by the opening of the so-called Winter Reception Transit Centre in Slavonski Brod, on 3rd of November 2015. In the period from November to December 2016, an average of 6,000 people traversed the Country per day, staying only for a few hours in the Transit Centre in Slavonski Brod. Between mid-September 2015 and March 2016, in total 658,729 people passed through the Country (data: Croatian Ministry of Interior).

the country. These rapid changes in the migratory and national contexts required flexible courses of action, in both geographical and organisational terms. In early October 2015, “Médecins du Monde - Belgique” (MdM-BE) sent a mobile medical team, travelling across seven countries traversed by refugees and migrants in Eastern and Southeast Europe (Bulgaria, Croatia, Greece, Hungary, Macedonia, Serbia and Slovenia). During that time, MdM-BE carried out more than 900 consultations with refugees and migrants, but also accurately assessed their various health and medical needs. Based on this field experience and using the added-value of its partnerships network in most countries of the European Union (EU), MdM-BE decided to deploy a multidisciplinary medical team in Croatia.

Beginning of 2016 was marked by polarized political climate at the European level, and arrival of the new government in Croatia. Along with Austria and Slovenia, Croatia introduced new border restrictions on 9th of March 2016 and migrants remaining in the Country were transferred to one of the two Asylum Seekers (AS) facilities: “Hotel Porin” in Zagreb and Kutinai. In July 2016, there were approximately 300 persons accommodated in AS facilities and 100 in private accommodation. This number remained stable for several months, until September 2016 when it doubled in just a few weeks’ time due to a significant number of people having been deported to Croatia from Austria and other European countries Germany, Sweden, and Switzerland - under the Dublin III Regulation. In November 2017, Croatia counted around 550 asylum seekers in

After signing the Memorandum of Understanding (MoU) with the Ministry of Health and Ministry of the Interior of the Republic of Croatia in August 2016, MdM-BE started to provide direct healthcare in the AS facilities in Zagreb and Kutina. Since April 2017, the work of MdM-BE in Croatia is supported by the UNICEF Office for Croatia.

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INTRODUCTION

Limited access to health care for asylum seekers

Access to health care for asylum seekers in Croatia is limited. According to the Article 57 of the “Law on International and Temporary Protection” which entered into force on 02 July 2015, applicants for international protection have free-of-charge access only to “emergency medical assistance and necessary treatment of illnesses and serious mental disorders”.

tuberculosis and other infectious diseases) and costiii. 

In practice, this limits access to health care for asylum seekers in the following ways: 

If the general practitioner suspects a potential disease during the initial health assessment or during medical consultations, referrals to laboratory tests or specialist examinations are limited to the most (proven) serious cases.



The exercise of the right to “necessary treatment” through referrals implies the continuous presence of a general practitioner within AS facilities especially when, according to medical standards in humanitarian situations, each distance of 1,5 km. reduces the chance by 50% that the patient visits the doctorii.



The need for “necessary treatment” is at the physician's discretion and its definition might differ from one physician to another.



The notion of “necessary treatment” does not include a full scope of primary health care and child, prenatal and post-natal health care. This care, provided by gynaecologists and paediatricians, falls outside the free-of-charge and accessible health care. Additionally, preventive care shows to be poorly covered among migrants, while actually being one of the important components to reduce complications, serious public health problems (for example spread of

Costs of medications which are not on the primary list/list A of the Croatian Health Insurance Fund are not covered by the State meaning that many medications for children/pregnant women - applicants for international protection - are not covered (prenatal vitamins and food supplements, vitamins, syrups, etc.).

Additionally, the Croatian law requires that applicants for international protection undergo an initial health assessment upon their arrival to the AS facilities. At the time of the MoU signing, this service was not available in the AS facilities. Since September 2016, the initial health assessment is being carried out by MdMBE’s general practitioner and psychologist. Lastly, vaccination of children asylum seekers in Croatia started in February 2017 and MdM-BE is supporting this process by accompanying children to officially designated public health institutions for vaccination. Immunization is a proven tool for controlling and eliminating life-threatening infectious diseases and is estimated to avert between 2 and 3 million deaths each year. It is one of the most cost-effective health investments, with proven strategies that make it accessible to even the most hard-to-reach and vulnerable populations.

i

Asylum seekers facility in Zagreb (“Hotel Porin”) was used to accommodate single men but with the raise of number of asylum seekers in the country, some families began to be accommodated also there. Asylum seekers facility in Kutina only accommodates families and vulnerable groups (such as persons with disabilities). ii Gilbert Burnham, Paul Spiegel "Public Health in Humanitarian Crisis", lecture, John Hopkins Center for Humanitarian Health, Baltimore, 2017. iii Anson, 2001.

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PATIENT DEMOGRAPHIC AND HEALTH DATA IN CROATIA Data presented below was collected through the system of electronic patient records (“Dossier de Patient Informatisé”) during the 2855 medical consultations (including initial medical health examination of newly arrived asylum seekers) conducted by MdM-BE in the AS facilities “Hotel Porin” in Zagreb and Kutina, between 01st of April and 31st of October 2017. Records of consultations from both locations were used for the purpose of this analysis. Diagnoses were recorded using the International Classification of Primary Care codes (ICPC-2 codes), based on patient's’ complaints, symptoms and physical/mental health assessments.

Demographic patients

characteristics

Mostly reflecting the overall demographic structure of asylum seekers in Croatia, a majority of medical consultations were carried out with patients from Syria (28,5%), followed by patients from Afghanistan (21,0%) and Iraq (20,5%).

of

The majority of patients were between 18 and 30 years old (40,4% of medical consultations). The average age of the received patients was 27 years old, with the youngest patient being two weeks old and the oldest 65 years old. With regards to women and children: 32 % of the medical consultations were conducted with women, 5,3% with children between 0-3 years and 15,1% with children between 4-17 years old.

Statistics about “the last country traversed/resided in before Croatia” reflect migratory flows observed in Croatia since the fall 2016. They combine the “deportation” flow from the European Union countries to Croatia (35,1% of medical consultations were conducted with patients who were in Austria before Croatia; 16,3% with patients who were in Germany) and the “green-borders” crossing flows from the neighboring countries (mostly from Serbia, with 17,3% of medical consultations carried out with patients who were in this country before they arrived to Croatia). It is to be noted that the data about the last country is missing for 14,5% of the consultations. Through its work and especially initial medical health examinations of newly arrived asylum seekers, MdM-BE noted different cases of patients deported from Austria, Germany and Switzerland with severe disease (cancer and Marfan syndrome, for instance), chronic disease (diabetes, cardiovascular disease, etc.) and pregnancy.

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PATIENT DEMOGRAPHIC AND HEALTH DATA IN CROATIA 

Medical consultations - Age of patients / Medicinske konzultacije - Dob pacijenata 2%

0%

1% Under 1 year / Do 1 godine

3% 12%

4%

1-3 years old / 1-3 godine

4%

4-7 years old / 4-7 godina

7%

8-14 years old / 8-14 godina 4%

15-17 years old / 15-17 godina 18-30 years old / 18-30 godina 31-40 years old / 31-40 godina

23%

41-50 years old / 41-50 godina 51-60 years old / 51-60 godina 61-70 years old / 61-70 godina

40%

71-80 years old / 71-80 godina



Medical consultations - Age and gender of patient / Medicinske konzultacije - Dob i spol pacijenata

More than 80 years old / Stariji od 80 godina 71-80 years old / 71-80 godina 61-70 years old / 61-70 godina 51-60 years old / 51-60 godina 41-50 years old / 41-50 godina 31-40 years old / 31-40 godina 18-30 years old / 18-30 godina 15-17 years old / 15-17 godina 8-14 years old / 8-14 godina 4-7 years old / 4-7 godina 1-3 years old / 1-3 godine Under 1 year / Do 1 godine 0

100

WOMEN / ŽENE

200

300

400

500

600

700

800

900 1000

MEN / MUŠKARCI

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PATIENT DEMOGRAPHIC AND HEALTH DATA IN CROATIA 

Medical consultations - Country of origin / Medicinske konzultacije – Zemlja podrijetla

Other / Ostalo

16% 2%

28%

3%

Serbia / Srbija Turkey / Turska Afghanistan / Afganistan

3%

21%

Islamic Republic of Iran / Islamska Republika Iran Iraq / Irak Pakistan / Pakistan Syria/ Sirija

19% 8%



Medical consultations - Last country before Croatia / Medicinske konzultacije - Posljednja zemlja prije Hrvatske

14% Austria / Austrija Germany/ Njemačka

9%

35% Greece/ Grčka Italy / Italija

17%

Serbia / Srbija Other

2%

6%

Missed data / Bez podataka 16%

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CLINICAL CHARACTERISTICS OF PATIENTS Asylum seekers examined during medical consultations by MdM-BE’s medical team in Croatia suffered mostly from respiratory (1), skin (2), digestive (3) musculoskeletal (4) and psychological pathologies (5) → see details of diagnosis in annex to this report. These pathologies are the same as seen in other countries, where MdM is working. Most of them are related to the migration route and the conditions they have to live in. This population especially women - frequently suffered from headaches, anxiety, insomnia, loss of appetite, abdominal and back pain. Most of these symptoms were of a psychosomatic nature. This is to be expected given the circumstances: uncertain future for them and their families and long waiting time for the processing of the applications, without any possibility to work and integrate into the local community are some examples. Beside the provision of medication, support in form of conversations, listening and counselling was essential.

Absence of, or irregular, menstruation has also been diagnosed largely among women and girls, especially between age 15 and early 20ies, which is likely to be a consequence of stress. Women and girls are among the most vulnerable in the migrant population, and have to bear very difficult and dangerous situations. Other prevailing problems recorded were (mostly upper) respiratory infections, urinary and genital infections, allergies, and digestive problems (constipation, diarrhoea, teeth and gum symptoms). The latter is to a large extent due to the lack of variety of food and an insufficient supply of essential nutrients (as vitamins and minerals) in the diet. There was also a poor oral health recorded in both children and adult population. The children, aside from respiratory infections and diarrhoea, have suffered from various types of scratches, lacerations, fractures, burns/scalds, sprains, strains etc. Most children deported from Austria, Germany and other

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CLINICAL CHARACTERISTICS OF PATIENTS European countries (Dublin III) have developed night-time urination symptoms (secondary enuresis), which is most likely a result of sudden, unexpected and often violent changes in the environment and re-traumatisation. There were also cases of acute stress reaction. Also, injuries to the musculoskeletal system, especially in younger male population, have been the result of a long and exhausting travel in trains, on foot, with smugglers, all in inadequate and often very dangerous conditions. In some cases, there were also injuries caused by physical violence and dog bites. Allergies and digestive problems are partly due to the adaptation of the body to the new environmental factors (vegetation, pollen, air/pollution, etc.) as well as a somewhat new type of a diet with unfamiliar foods and spices. Another reason is a very poor and unbalanced diet, as mentioned above. Skin symptoms were largely recorded, mostly due to a poor hygiene. Cases of chronic illnesses were also recorded, such as diabetes, hypertension, AIDS/HIV and disability.

Through medical examinations or referrals, cases of infectious diseases, such as scabies and tuberculosis were detected. The limited access to an appropriate care during the transit and early arrival phases of migration increases the eventual burden of untreated communicable conditions, like tuberculosis. Most of scabies cases were detected during the initial examination of newly arrived asylum seekers. In cooperation with the epidemiologist from the Teaching Institute of Public Health “Andrija Štampar”, MdM-BE supported the implementation of preventive measures in the AS facility Porin, consisting in accompanying of family members/roommates of infected persons to detailed/follow-up examinations; and delayedtype hypersensitivity (DTH) skin testing of all children in the Facility.

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CLINICAL CHARACTERISTICS OF PATIENTS 

Mental health state of asylum seekers in Croatia

The experiences before, during and after the process of migration highly influence the prevalence of specific mental health problems of asylum seekers. The risk factors are various and include frequently cases of multiple traumatic events that preceded the abandonment of the country of origin, a migration experience that in some cases includes exhausting travel conditions, exposure to violence and risks from various types of exploitation and extortion, uncertainty and the inadequacy of available protection and necessary medical assistance. Post-migration sources of stress include a lengthy processing of application for international protection, with unpredictable outcome (which in most cases results in a sense of helplessness and uncertainty), the relocation of refugees by the application of the Dublin III Regulation, the separation from family members who have remained in their country of origin, migration-related losses, financial difficulties and inadequate living conditions in facilities for asylum seekers, language barriers and cultural differences, legal regulations and the lack of acceptance from the local community that affect the process of employment, integration and the social status of refugees. Migrants and refugees are commonly subject to violence, abuse and human rights violations committed by a range of different actors including smugglers, border guards, the police and security services, traffickers as well as members of local communities and other migrants. Also, events that resemble previous traumatic experiences can result in re-traumatization and the strengthening of the symptoms of depression, anxiety and posttraumatic stress disorder. In Croatia, at the end of 2016, a survey was conducted on a sample of asylum seekers located in the AS facility in Zagreb. During the screening process 80.3% of the participants achieved a result which indicated that they were at risk of developing mental health problems (Stanković, 2017) 1. Mental health problems, for which asylum seekers have requested MdM-BE medical and/or psychological support in Asylum seekers facilities in Zagreb and Kutina, include symptoms of depressive disorder (insomnia, lack of energy, lack of motivation, inability to maintain concentration, hopelessness, negative self-perception, suicidal thoughts), tension, restlessness, high levels of stress, anxiety disorder, panic disorder, posttraumatic reactions (nightmares, mistrust, irritability, recurrent intrusive thoughts and traumatic images). There have also been cases of acute psychosis, postpartum depression, hetero-aggressive outbursts and suicide attempts. Stress and traumatic experiences can also lead to various psychosomatic symptoms such as headaches, digestive problems (i.e. diarrhoea, constipation, nausea), tense muscles, insomnia, skin conditions (i.e. psoriasis, neurodermatitis) or substance abuse in an attempt to cope with high levels of stress. Global estimates published by World Health Organisation (WHO) indicate that about 1 in 3 (35%) women worldwide have experienced either physical and/or sexual intimate partner violence or nonpartner sexual violence in their lifetime. Living in precarious conditions and during the migration route, a woman is much more at risk of becoming a victim of violence. Despite the need and high demand for psychological support, it is still inaccessible to many asylum seekers due to the lack of trained medical staff and qualified translators. Psychotherapeutic work has been found to significantly alleviate the abovementioned mental health problems and therefore it is extremely important to provide access to adequate psychological support to this population.

1

Stanković, N. (2017) It is all good now or maybe not? – Mental health screening of refugees and other migrants. Master’s thesis. Faculty of Humanities and Social Sciences, University of Zagreb.

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CLINICAL CHARACTERISTICS OF PATIENTS When it comes to the beneficiaries accompanied by MdM-BE’s team members for referrals (specialists/hospitals - in total 373), nearly half of them were adult women (47%) which is a considerably higher proportion than the proportion of women in total population of AS facility Porin (approximately 20-30% during the period between April and October 2017). This shows the higher need for adult women to be seen by a specialist. In Zagreb, most of the patients were referred to the KBC Zagreb Hospital (including women and pregnant women), Outpatient Clinic Zagreb Centre (laboratory tests), and University Hospital for Infectious Diseases Dr. Fran Mihaljević (infectious diseases). 

Pregnant women asylum seekers in Croatia

By the Law, pregnant women asylum seekers in Croatia do not benefit from any specific medical treatment based on their condition. They are entitled to emergency care, care at childbirth and postnatal care. Prenatal consultations were not systematically nor regularly implemented until MdM-BE’s care. On average, there were five to six pregnant women in AS facility Porin and Kutina at any given time between April and October 2017. Pregnancy tests were provided by MdM-BE’s medical team to women with delayed menstruation. If the test proved to be positive, the pregnant woman was referred to the MdM-BE gynecologist’s examination and regular ultrasound examination/laboratory tests were ensured as well as the organisation of weekly informative sessions on pregnancy/child healthcare. The most common problem identified among pregnant women asylum seekers was anemia that required provision of iron supplements (provided by MdM-BE through UNICEF support). Anemia is mostly related to the poor and imbalanced food intake. In cooperation with MdM-BE’s psychologist, psychological support was provided to newly identified pregnant women who showed an acute stress reaction to pregnancy (mostly due to uncertain future). Some pregnant women had urinary and vaginal infections which were treated in time in a safe and effective way.

Some MdM-BE’s patients’ stories …. - Deported from Austria to Croatia (under Dublin Regulation), T.A., 24-year-old boy from Syria, has Marfan syndrome (genetic disorder that affects the body’s connective tissue). Before he got deported, he was supposed to have a surgery/different examinations in Austria. Despite official appeal for suspension of decision deportation to Croatia, his health state/disease was not taking into account by the court. MdM-BE in Croatia organized referrals to a range of specialists in order to re-evaluate his health condition before considering surgical procedure. When T.A. received temporary international protection, MdM-BE supported him in registering with the general practitioner and still continues to support him by arranging appointments with specialists and accompanying/translation on the day of specialist examinations. - R. D. is a 25-year-old woman from Syria. She was deported from Switzerland to Croatia (under Dublin Regulation) when she was four-months pregnant. Her husband was not deported with her and they were separated (official reason was that they did not have a “legal” marriage certificate). Suffering from depression and anxiety due to deportation, separation from husband and first pregnancy, psychological support was provided to R.D. by the team of MdM-BE’s psychologist and trained translator. Prenatal consultations were also ensured by MdM-BE.

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CLINICAL CHARACTERISTICS OF PATIENT

700

600

500

400

300

200 Men/ Muškarci 100

0

Women/Žene

Children/Djeca

CONCLUSION - HEALTH NEEDS REQUIRING CONTINUOUS, MULTI-DISCIPLINARY, INDIVIDUALISED AND LINGUISTICALLY ADAPTED CARE Migrants often begin their journey in good health, as such an undertaking requires being in good health. However, the complexity of the migratory journey, the conditions of travel and the absence of, or inadequate access to, health care can result in many migrants experiencing poor physical and mental health outcomes.

Best practices for overcoming language barriers in the provision of health services to migrants: 



Analysis of data on mental and physical health state of asylum seekers in Croatia showed that they suffer from common diseases that can easily be treated in Europe.  The majority of migrants report health needs similar to most EU citizens even though the poor conditions for travel, deportation, sanitation, hygiene and housing pose additional risks and can increase health care needs, particularly for the most vulnerable (women, children, people with disability). Adequate housing conditions, malnutrition prevention, protection measures, adequate sanitary facilities and early access to healthcare are essential to avoid short-term and long-term complications of chronic, infectious, dental and mental health problems. However, data also showed that asylum seekers present higher mental health needs and multi-trauma than an average EU citizen. It is evident that a holistic approach to working with this vulnerable group is essential: a combination of psychosocial assistance and support alongside an early access to healthcare. Health needs of asylum seekers represent invisible emergencies that can easily be treated before they escalate into irreversible complications. The existence of the continuous, multi-disciplinary, individualised and linguistically adapted health monitoring and care within the AS facilities proved to have a positive impact on both asylum seekers and local community.





Professional face-to-face interpretation is the most accurate method, but has many drawbacks, such as organisational requirements, training, and costs. Nevertheless, studies showed that the introduction of interpreters didn’t increase the cost within a health system, but on the contrary reduced. Diagnostic errors and the non-compliance of treatment due to misunderstanding have a much higher cost1. Professional interpretation by telephone or Skype can offer much of the same services at a lower cost, but is associated with a loss of information associated with face-to-face interactions and lower confidence. It can be a good alternative in some circumstances. Bilingual professionals with a command of the migrant’s language can fill in the gaps left by the scarcity of professional interpreters. Cultural mediators are health workers who not only provide linguistic interpretation, but also mediate between health professionals and service users.

This analysis also indicated the fact that early on-site treatment and access to basic primary care is not only beneficial for asylum seekers but also cost-efficient in the long-term as it reduces demand for emergency care by providing cheaper and more effective primary care. Early treatment is also important for tackling and protecting against the deterioration of mental health due to pre-existing traumas from war and conflict as well as from travels and resettlement in Europe. MdM-BE considers that ensuring complete access to healthcare for children and pregnant women asylum seekers should be immediate priority.

1

Bischoff & Denhaerynck, 2004

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

ACRONYMS AND ABBREVIATIONS

AS

Asylum seekers

DTH

Delayed type hypersensitivity

EU

European Union

ICPC

International Classification of Primary Care

MdM-BE

Médecins du Monde - Belgique

MoU

Memorandum of Understanding

NOS

Not Otherwise Specified

UNICEF

United Nations Children’s Fund

WHO

World Health Organization

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ANNEXES - Data for the period between April and October 2017 

MEDICAL CONSULTATIONS - AGE OF PATIENT / MEDICINSKE KONZULTACIJE - DOB PACIJENATA Number / Broj

Under <1 year / Mlađi od 1 godine 1-3 years old / 1-3 godine 4-7 years old / 4-7 godina 8-14 years old / 8-14 godina 15-17 years old / 15-17 godina 18-30 years old / 18-30 godina 31-40 years old / 31-40 godina 41-50 years old / 41-50 godina 51-60 years old / 51-60 godina 61-70 years old / 61-70 godina 71-80 years old / 71-80 godina More than 80 years old / Stariji od 80 godina TOTAL / UKUPNO

32 119 106 201 125 1151 652 338 89 42 0 0 2855

% 1,1 4,2 3,7 7 4,4 40,3 22,8 11,8 3,1 1,5 0 0 100

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ANNEXES - Data for the period between April and October 2017 

MEDICAL CONSULTATIONS - AGE AND GENDER OF PATIENT / MEDICINSKE KONZULTACIJE - DOB I SPOL PACIJENATA

WOMEN / ŽENE Under <1 year / Mlađe od 1 godine 1-3 years old / 1-3 godine 4-7 years old / 4-7 godina 8-14 years old / 8-14 godina 15-17 years old / 15-17 godina 18-30 years old / 18-30 godina 31-40 years old / 31-40 godina 41-50 years old / 41-50 godina 51-60 years old / 51-60 godina 61-70 years old / 61-70 godina 71-80 years old / 71-80 godina More than 80 years old / Starije od 80 godina TOTAL / UKUPNO

Number 20 74 46 92 45 239 209 142 29 22 0 0 918

% 2,2 8,1 5 10 4,9 26 22,8 15,5 3,2 2,4 0 0 100

MEN / MUŠKARCI Under <1 year / Mlađi od 1 godine 1-3 years old / 1-3 godine 4-7 years old / 4-7 godina 8-14 years old / 8-14 godina 15-17 years old / 15-17 godina 18-30 years old / 18-30 godina 31-40 years old / 31-40 godina 41-50 years old / 41-50 godina 51-60 years old / 51-60 godina 61-70 years old / 61-70 godina 71-80 years old / 71-80 godina More than 80 years old / Stariji od 80 godina TOTAL / UKUPNO

Number 12 45 60 109 80 912 443 196 60 20 0 0 1937

% 0,6 2,3 3,1 5,6 4,1 47,1 22,9 10,1 3,1 1 0 0 100

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ANNEXES - Data for the period between April and October 2017 

MEDICAL CONSULTATIONS - COUNTRY OF ORIGIN / MEDICINSKE KONZULTACIJE - ZEMLJA PODRIJETLA

Cuba / Kuba Dominican Republic / Dominikanska Republika Bangladesh / Bangladeš India / Indija Philippines / Philippines Sri Lanka / Šri Lanka Uzbekistan / Uzbekistan Albania / Albanija Belarus / Bjelorusija Bosnia and Herzegovina / Bosna i Hercegovina Russian federation / Ruska Federacija Serbia / Srbija Turkey / Turska Ukraine / Ukrajina Poland / Poljska Algeria / Alžir Libya / Libija Morocco / Maroko Tunisia / Tunis Afghanistan / Afganistan Egypt / Egipat Islamic Republic of Iran / Islamska Republika Iran Iraq / Irak Kuwait / Kuvajt Lebanon / Libanon Pakistan / Pakistan Palestine / Palestina

MEN/MUŠKARCI

Number/ Broj WOMEN/ŽENE

23 1 44 1 1 4 7 6 3 10 9 28 57 4 0 78 20 24 21 413 9 169 312 0 1 99 5

8 0 6 0 1 0 6 12 0 0 0 21 18 0 1 0 0 12 11 180 3 64 232 2 0 0 0

TOTAL/UKUPNO 31 1 50 1 2 4 13 18 3 10 9 49 75 4 1 78 20 36 32 593 12 233 544 2 1 99 5

MEN/MUŠKARCI 1,2 0,1 2,3 0,1 0,1 0,2 0,4 0,3 0,2 0,5 0,5 1,4 2,9 0,2 0 4 1 1,2 1,1 21,3 0,5 8,7 16,1 0 0,1 5,1 0,3

% WOMEN/ŽENE 0,9 0 0,7 0 0,1 0 0,7 1,3 0 0 0 2,3 2 0 0,1 0 0 1,3 1,2 19,6 0,3 7 25,3 0,2 0 0 0

TOTAL/UKUPNO 1,1 0 1,8 0 0,1 0,1 0,5 0,6 0,1 0,4 0,3 1,7 2,6 0,1 0 2,7 0,7 1,3 1,1 20,8 0,4 8,2 19,1 0,1 0 3,5 0,2

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ANNEXES - Data for the period between April and October 2017 Syria/ Sirija Yemen / Jemen Ecuador / Ekvador Stateless / Bez državljanstva Cameroon / Kamerun Congo / Kongo Erithrea / Eritreja Ethiopia / Etiopija Gambia / Gambija Ghana / Gana Nigeria / Nigerija Somalia / Somalija Missed data / Bez podataka TOTAL / UKUPNO

485 8 0 11 11 0 46 1 0 4 16 6 1 1938

311 0 4 0 0 10 2 0 1 0 1 10 1 917

796 8 4 11 11 10 48 1 1 4 17 16 2 2855

25 0,4 0 0,6 0,6 0 2,4 0,1 0 0,2 0,8 0,3 0,1 100

33,9 0 0,4 0 0 1,1 0,2 0 0,1 0 0,1 1,1 0,1 100

27,9 0,3 0,1 0,4 0,4 0,4 1,7 0 0 0,1 0,6 0,6 0,1 100

15

ANNEXES - Data for the period between April and October 2017 

MEDICAL CONSULTATIONS - LAST COUNTRY BEFORE CROATIA / MEDICINSKE KONZULTACIJE - POSLJEDNJA ZEMLJA PRIJE HRVATSKE Number/ Broj

Austria / Austrija Belgium / Belgija Bosnia-and-Herzgovina / Bosna i-Herzgovina Bulgaria / Bugarska Cyprus / Cipar France/ Francuska Germany/ Njemačka Greece/ Grčka Hungary / Mađarska Italy / Italija Malta / Malta Netherlands / Nizozemska Norway / Norveška Poland / Poljska Serbia / Srbija Slovenia / Slovenija Sweden / Švedska Switzerland / Švicarska Missed data / Bez podataka TOTAL / UKUPNO

1001 10 42 4 1 4 465 162 4 65 7 15 17 1 495 33 62 53 414 2855

% 35 0 2 0 0 0 16 6 0 2 0 1 1 0 17 1 2 2 15 100

16

ANNEXES - Data for the period between April and October 2017 

REFERRALS ACCOMPANIED BY MDM-BE’S TEAM - BY AGE AND GENDER / PRATNJA UPUĆENIH NA DALJNJU OBRADU OD STRANE MDMBE-A - PO DOBI I SPOLU Female / Žene

<1 year / godine 1-3 years / godine 4 - 7 years / godina 8 - 14 years/ godina 15 - 18 years / godina Adults/ Odrasli > 18 TOTAL/ UKUPNO

2 3 15 19 1 156 196

Male / Muškarci 3 2 8 16 10 138 177

TOTAL / UKUPNO 5 5 23 35 11 294 373

17

ANNEXES - Data for the period between April and October 2017 

DIAGNOSIS (ICPC)- Medical consultations only (general practitioner) Diagnosis (ICPC) - All asylum seekers/ Dijagnoze - svi tražitelji međunarodne zaštite Women/Žene

Men/ Muškarci

A- General and Unspecified - Opći i nespecificirani             

Diagnosis (ICPC) - Only children asylum seekers under 18/ Dijagnoze - samo tražitelji međunarodne zaštite mlađi od 18 godina

Number/Broj

%

Number / Broj

%

Number / Broj

%

283

8,4

141

7,5

155

13,7

17

0,5

40

2,1

10

0,9

A01 Pain general/multiple sites - Opća bol/multiplih lokacija A03 Fever - Povišena tjelesna temperatura A04 Weakness/tiredness general - Opća slabost/umor A05 Feeling ill - Loše/bolesno osjećanje A08 Swelling - Otjecanje A11 Chest pain NOS - Bol u prsima NS A28 Limited function/disability NOS - Ogranicenje funkcije/onesposobljenost NS A70 Tuberculosis – Tuberkuloza A72 Chickenpox – Varicele A77 Viral disease other/NOS - Virusne bolesti/NS, ostale A87 Complication of medical treatment - Komplikacija medicinskog postupka A92 Allergy/allergic reaction NOS - Alergija/alergijska reakcija NS A97 No disease - Bez bolesti

B- Blood, Blood Forming Organs and Immune Mechanism - Krv, krvotvorni organi i imunološki sustav B02 Lymph gland(s) enlarged/painful - Povećani/bolni limfni čvor(ovi) B25 Fear of AIDS/HIV - Strah od AIDSa/HIVa B28 Limited function/disability (B) - Ograničenje aktivnosti/onesposobljenost B29 Lymph/immune mechanism symptom/complaint other - Simpt/teg limf/imunološkog sustava,ostali  B80 Iron deficiency anaemia - SIderopenična anemija  B81 Anaemia vit B12/folate deficiency - Anemija zbog nedostatka vit. B12/folata  B82 Anaemia other/unspecified - Ostale/nespecificirane anemije    

18

ANNEXES - Data for the period between April and October 2017 D- Digestive - Probavni sustav                  

13,0

228

12,1

95

8,4

54

1,6

55

2,9

20

1,8

D01 Abdominal pain/cramps general - Bol u trbuhu/grčevi općenito D02 Abdominal pain epigastric - Bol u epigastriju D03 Heartburn - Žgaravica D06 Abdominal pain localized other - Lokalizirana abdominalna bol, ostala D09 Nausea - Mučnina D10 Vomiting - Povraćanje D11 Diarrhoea - Proljev D12 Constipation - Konstipacija D13 Jaundice - Žutica D19 Teeth/gum symptom/complaint - Simptomi i tegobe zubi i desni D20 Mouth/tongue/lip symptom/complaint - Simptomi i tegobe usta/jezika/usana D23 Hepatomegaly - Hepatomegalija D27 Fear of digestive disease other - Strah od ostalih bolesti probavnog sustava D29 Digestive symptom/complaint other - Simpt/ tegobe probavnog sustava,ostali D83 Mouth/tongue/lip disease - Bolest usta/jezika/usana D88 Appendicitis - Apendicitis D94 Chronic enteritis/ulcerative colitis - Kronični enteritis/ulcerativni colitis D96 Worms/other parasites - Gliste/ostali paraziti

F- Eye - Oko           

438

F01 Eye pain - Bol u oku F02 Red eye - Crvenilo oka F05 Visual disturbance other - Smetnje vida,ostale F16 Eyelid symptom/complaint - Simptomi/tegobe očne jabučice F28 Limited function/disability (F) - Ograničenje funkcije/onesposobljenost (F) F29 Eye symptom/complaint other - Simptomi/tegobe oka,ostali F71 Conjunctivitis allergic - Alergijski konjunktivitis F73 Eye infection/inflammation other - Infekcije/upale oka,ostale F79 Injury eye other - Ozljeda oka, ostale F92 Cataract - Katarakta F93 Glaucoma - Glaukom

19

ANNEXES - Data for the period between April and October 2017 H- Ear – Uho        

H01 H02 H03 H13 H29 H70 H71 H81

1,8

36

1,9

36

3,2

209

6,2

111

5,9

6

0,5

Ear pain/earache - Bol u uhu Hearing complaint - Smetnje sluha Tinnitus, ringing/buzzing ear - Tinitus, zvonjenje/zujanje u uhu Plugged feeling ear - Osjećaj začepljenosti uha Ear symptom/complaint other - Simptomi/tegobe uha,ostali Otitis externa - Otitis externa Acute otitis media/myringitis - Akutni otitis media/miringitis Excessive ear wax - Cerumen

K - Cardiovascular - Kardiovaskularni sustav          

60

K04 Palpitations/awareness of heart - Palpitacije/osjećaj lupanja srca K05 Irregular heartbeat other - Poremećaji otkucaja srca,ostali K80 Cardiac arrhythmia NOS - Srčana aritmija NS K84 Heart disease other - Srčane bolesti,ostale K85 Elevated blood pressure - Povišeni srčani tlak K86 Hypertension uncomplicated - Hipertenzija - nekomplicirana K88 Postural hypotension - Posturalna hipotenzija K94 Phlebitis/thrombophlebitis - Flebitis/tromboflebitis K95 Varicose veins of leg - Varikozne vene nogu K96 Haemorrhoids - Hemoroidi

20

ANNEXES - Data for the period between April and October 2017 L- Musculoskeletal - Mišićno-koštani sustav                         

12,1

148

7,8

74

6,5

242

7,2

158

8,4

36

3,2

L01 Neck symptom/complaint - Simptomi/tegobe vrata L02 Back symptom/complaint - Simptomi/tegobe leđa L03 Low back symptom/complaint - Simptomi/tegobe križa L04 Chest symptom/complaint - Simptomi/tegobe prsnog koša L07 Jaw symptom/complaint - Simptomi/tegobe čeljusti L08 Shoulder symptom/complaint - Simptomi/tegobe ramena L09 Arm symptom/complaint - Simptomi/tegobe ruku L11 Wrist symptom/complaint - Simptomi/tegobe zapešća L12 Hand/finger symptom/complaint - Simptomi/tegobe ruke/prstiju L14 Leg/thigh symptom/complaint - Simptomi/tegobe noge i bedra L15 Knee symptom/complaint - Simptomi/tegobe koljena L16 Ankle symptom/complaint - Simptomi/tegobe nožnog zgloba L17 Foot/toe symptom/complaint - Simptomi/tegobe stopala i noznih prstiju L18 Muscle pain - Mišićna bol L19 Muscle symptom/complaint NOS - Simptomi/tegobe mišića NS L20 Joint symptom/complaint NOS - Simptomi/tegobe zglobova NS L28 Limited function/disability (L) - Ograničenje funkcije/nesposobnost (L) L29 Musculoskeletal symptom/complaint other- Simpt/teg. miš-košt.sustava,ostali L72 Fracture: radius/ulna - Frakture: radius/ulna L79 Sprain/strain of joint NOS - Istegnuće/distenzija zgloba NS L81 Injury musculoskeletal NOS - Mišićno koštana ozljeda NS L86 Back syndrome with radiating pain - Lumbalni sindrom sa širenjem boli L89 Osteoarthrosis of hip - Osteoartroza kuka L98 Acquired deformity of limb - Stečena deformacija ekstremiteta L99 Musculoskeletal disease other - Mišićno koštane bolesti,ostale

N - Neurological - Neurološki poremećaji     

408

N01 N17 N29 N88 N89

Headache - Glavobolja Vertigo/dizziness - Vertigo/nesvjestica Neurological symptom/complaint other - Neurološki simptomi/tegobe,ostali Epilepsy - Epilepsija Migraine - Migrena

21

ANNEXES - Data for the period between April and October 2017 P - Psychological - Psihološki poremećaji

348

10,4

101

5,4

37

3,3

600

17,8

302

16,0

351

31,0

      

P01 Feeling anxious/nervous/tense - Anksioznost/nervoza/napetost P02 Acute stress reaction - Akutna reakcija na stres P03 Feeling depressed - Depresivnost P06 Sleep disturbance - Poremećaji spavanja P11 Eating problem in child - Problemi sa jelom kod djece P19 Drug abuse - Ovisnost o drogama P22 Child behaviour symptom/complaint - Simptomi/tegobe u vezi dječjeg ponasanja  P23 Adolescent behaviour symptom/complaint - Simpt/teg. u vezi ponašanja adolescenta  P76 Depressive disorder - Depresivni poremećaj  P80 Personality disorder - Poremećaj osobnosti R - Respiratory - Respiratorni sustav                 

R04 Breathing problem other - Problemi disanja, ostali R05 Cough - Kašalj R07 Sneezing/nasal congestion - Kihanje/nazalna kongestija R08 Nose symptom/complaint other - Simptomi i tegobe nosa, ostali R21 Throat symptom/complaint - Simptomi i tegobe ždrijela R29 Respiratory symptom/complaint other - Simp/teg. respiratornog sustava, ostali R72 Strep throat - Streptokokna upala ždrijela R74 Upper respiratory infection acute - Akutna resp.infekcija gornjeg dišnog trakta R76 Tonsillitis acute - Akutni tonzilitis R78 Acute bronchitis/bronchiolitis - Akutni bronhitis/bronhiolitis R80 Influenza - Influenza R81 Pneumonia - Pneumonija R83 Respiratory infection other - Respiratorne infekcije, ostale R90 Hypertrophy tonsils/adenoids - Hipertrofija tonzila/adenoida R95 Chronic obstructive pulmonary disease - Kronična opstruktivna plućna bolest R96 Asthma - Astma R97 Allergic rhinitis - Alergijski rinitis

22

ANNEXES - Data for the period between April and October 2017 S - Skin - Koža                                 

532

15,8

193

10,2

239

21,1

S02 Pruritus - Pruritus S03 Warts - Bradavice S04 Lump/swelling localized - Lokalizirano zadebljanje/oteklina S05 Lumps/swellings generalized - Generalizirano zadebljanje/oteklina S06 Rash localized - Osip lokalizirani S07 Rash generalized - Osip generalizirani S09 Infected finger/toe - Infekcija prsta ruke/stopala S10 Boil/carbuncle - Furunkul/karbunkul S11 Skin infection post-traumatic - Posttraumatska infekcija kože S12 Insect bite/sting - Ugriz insekta S14 Burn/scald - Opeklina S17 Abrasion/scratch/blister - Abrazija/ogrebotina/bula S18 Laceration/cut - Laceracija/posjekotina S19 Skin injury other ostale - Ozljede kože, ostale S20 Corn/callosity klavus - Klavus/kalus S21 Skin texture symptom/complaint - Simptomi i tegobe u vezi strukture kože S22 Nail symptom/complaint - Simptomi i tegobe noktiju S23 Hair loss/baldness - Opadanje kose/ćelavost S29 Skin symptom/complaint other - Simptomi i tegobe kože, ostali S71 Herpes simplex - Herpes simplex S72 Scabies/other acariasis - Skabies/ostale akariaze S73 Pediculosis/skin infestation other - Pedikuloza/ostale infestacije kože S75 Moniliasis/candidiasis skin - Monilijaza/kandidijaza kože S76 Skin infection other - Kožne infekcije, ostale S85 Pilonidal cyst/fistula - Pilonidalna cista/fistula S87 Dermatitis/atopic eczema - Atopijski dermatitis /ekcem S88 Dermatitis contact/allergic - Kontaktni /alergijski dermatitis S89 Diaper rash - Pelenski osip S92 Sweat gland disease - Bolesti žlijezda znojnica S93 Sebaceous cyst - Lojna cista S96 Acne - Akne S98 Urticaria - Urtikarija S99 Skin disease other - Bolesti kože, ostale

23

ANNEXES - Data for the period between April and October 2017 T - Endocrine/Metabolic and Nutritional - Endokrini/metabolički i nutritivni poremećaji      

T03 T08 T71 T85 T86 T90

U05 U07 U13 U29 U70 U71 U72 U78 U95

    

70

3,7

23

2,0

44

1,3

43

2,3

9

0,8

0

0,0

103

5,5

6

0,5

Urination problems other - Smetnje mokrenja, ostale Urine symptom/complaint other - Simptomi i tegobe s mokrenjem,ostali Bladder symptom/complaint other - Simpt/teg. s mokraćnim mjehurom,ostali Urinary symptom/complaint other - Urološki simptomi i tegobe, ostali Pyelonephritis/pyelitis - Pijelonefritis/pijelitis Cystitis/urinary infection other - Cistitis/ostale urinarne infekcije Urethritis - Uretritis Benign neoplasm urinary tract - Benigne neoplazme urološkog sustava Urinary calculus - Urolitijaza

W - Pregnancy, Childbearing, Family Planning - Trudnoća, planiranje obitelji     

2,8

Loss of appetite - Gubitak apetita Weight loss - Gubitak težine Malignant neoplasm thyroid - Maligna neoplazma štitne žlijezde Hyperthyroidism/thyrotoxicosis - Hipertiroidizam/tireotoksikoza Hypothyroidism/myxoedema - Hipotiroidizam/miksedem Diabetes non-insulin dependent - Dijabetes inzulin neovisni

U - Urological - Urološki sustav         

94

W01 Question of pregnancy - Sumnja na trudnoću W05 Pregnancy vomiting/nausea - Povraćanje/mučnina u trudnoći W11 Contraception oral - Peroralna kontracepcija W14 Contraception female - Ostale vrste kontracepcije W18 Post-partum symptom/complaint other - Postpartalni simptomi i tegobe,ostali W27 Fear of complications of pregnancy - Strah od komplikacija trudnoće W76 Congenital anomaly complicating pregnancy - Kong. anomalija koja komplicira trudnoću W78 Pregnancy - Trudnoća W79 Unwanted pregnancy - Neželjena trudnoća W85 Gestational diabetes - Gestacijski dijabetes

24

ANNEXES - Data for the period between April and October 2017 X- Female Genital - Ženski spolni sustav               

0

0,0

145

7,7

24

2,1

15

0,4

0

0,0

3

0,3

18

0,5

13

0,7

8

0,7

3362

100

1887

100

1132

100

X02 Menstrual pain - Menstrualna bol X03 Intermenstrual pain - Intermenstrualna bol X04 Painful intercourse female - Bol kod žene pri spolnom odnosu X05 Menstruation absent/scanty - Izostala /oskudna menstruacija X06 Menstruation excessive - Obilna menstruacija X07 Menstruation irregular/frequent - Neredovita/ česta menstruacija X09 Premenstrual symptom/complaint PMS- Premenstrualni simptomi i tegobe X15 Vaginal symptom/complaint other - Vaginalni simptomi i tegobe, ostali X16 Vulval symptom/complaint - Simptomi i tegobe vulve X18 Breast pain female - Bol u dojkama kod žena X29 Genital symptom/complaint female other - Genitalni simptomi i tegobe žena,ostali X72 Genital candidiasis female - Genitalna kandidijaza žene X78 Fibromyoma uterus - Fibromiom uterusa X84 Vaginitis/vulvitis NOS - Vaginitis/vulvitis NS X91 Condylomata acuminata female - Condylomata acuminate žene

Y - Male Genital - Muški spolni sustav  Y04 Penis symptom/complaint other - Simptomi i tegobe penisa, ostali Z- Social Problems - Socijalni problem  Z02 Food/water problem - Problemi s hranom/vodom  Z03 Housing/neighbourhood problem - Problemi sa stanovanjem/susjedstvom  Z23 Loss/death of parent/family member problem - Gubitak/smrt roditelja/člana obitelji TOTAL

25