Closing the Gap in Managing Viral Hepatitis Infections in Refugees and Immigrants

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Viral hepatitis is responsible for 1.46 million deaths worldwide annually.
Viral hepatitis is responsible for 1.46 million deaths worldwide annually.

While progress in curing viral hepatitis and hepatitis C virus (HCV) infection in particular has been robust in first-world nations, the forecast is bleak for refugees and economic migrants.1 The World Health Organization (WHO) estimates that between 2015 and 2030, 19 million deaths from 7.2 million HCV infections and 11.8 million hepatitis B virus (HBV) infections will occur globally.2 Such dire projections challenge the WHO's target of a 90% reduction in new viral hepatitis infections and a 65% reduction in mortality by 2030.

Reaching Marginalized Populations

Adding to this challenge are millions of refugees, economic migrants, and people who inject drugs (PWID).1 Recently Italy has experienced a large influx of immigrants fleeing economic and political instability.

Sagnelli and colleagues sought to determine whether a screening program for HCV in Italy would be well received by recent refugees and undocumented immigrants.3 A study of 2032 newly arrived immigrants found that 85% were receptive to HCV screening. Of those who tested positive for HCV-RNA, 84% received treatment. The researchers deemed the study a success as they had not anticipated that so many would opt for testing. Moreover, the researchers were able to diagnose HCV in those who were unaware of their status. The study also confirmed that HCV prevalence would be higher in a highly mobile population (4.1%) vs that of the Italian population (1.2%).1,3

The type of marginalization is often a matter of geography; PWID tend to be found in high- and middle-income countries, while marginalized people in low-income countries  are those living in poverty and political instability.1,4 In a systematic review of 1147 records, Degenhardt and colleagues estimated that there were 15.6 million PWID worldwide aged 15 to 64 years.4 Of these PWID, the researchers estimated that 52.3% would test positive for HCV, 17.8% for HIV, and 9% for infection with HBV.4 In the time that elapsed since a previous review, 31 more countries were added to the PWID prevalence list; many of them were in sub-Saharan Africa and the Pacific Islands, which already accounts for many of the world's viral hepatitis infections.4

“This work demonstrates the considerable heterogeneity in terms of the burden of HCV infection among PWID among countries and regions globally, highlighting that different responses will be required in different settings,” said Louisa Degenhardt, PhD, professor and senior principal research fellow at the National Drug and Alcohol Research Centre at the University of New South Wales in Sydney, Australia. “Globally, given that 23% of all new HCV infections occur among PWID, increased efforts to enhance HCV prevention, linkage to care and treatment will be important to achieve the WHO targets to eliminate HCV as a major public health threat by 2030.”

Educating Immigrants About Viral Hepatitis Risk

In an attempt to determine the baseline knowledge of HBV in a predominantly immigrant population, and to thwart the spread of the virus, Djoufack and colleagues offered community-based classes with interpreters to a mostly immigrant population (N=101) in and around Boston, Massachusetts.5 Prior to the participants' attending classes, 42% of them did not know that HBV could cause cancer, and 50% did not know that HBV treatment was available. Posttest results revealed the effectiveness of the classes: while <60% of participants correctly answered a question about whether HBV could cause liver scarring and cancer, 79% answered correctly after they had taken the class (P=.01).5

Two concepts that the participants did not fully comprehend were that HBV treatment is not curative and must be taken indefinitely and that vaccination does not protect against HBV if the participant had already been infected. A slight increase in before- and after-questionnaire answers indicated that the participants still did not know that HBV therapy exists (50% vs 66%, respectively).5

In just a matter of months since the study's publication, co-author Dahlene N. Fusco, MD, PhD, from the Massachusetts General Hospital, in Boston, explained: “Informal discussions have revealed that more clinicians are asking their patients whether they are aware of HBV risk and are performing HBV testing. Our understanding is that community outreach liaisons are also encouraging persons at risk to seek testing for HBV, SAb [surface antibody], SAg [surface antigen], and total core antibody proactively. A major teaching point we are trying to communicate is that every single person from an at-risk population should be tested, regardless of vaccination status.”

In the Netherlands, HBV prevalence is 0.20%; however, it is 3.77% in first-generation immigrants from endemic countries.6 To determine what barriers immigrants had encountered in testing for HBV, Hamdiui and colleagues interviewed first- and second-generation Moroccan-Dutch immigrants, among the largest immigrant groups in the country.  

Though most of the participants (N=19) were receptive to testing for HBV, they cited reasons why some in their community may not be so eager to be tested: lack of awareness about HBV, fear of cancer, lack of symptoms, reduced testing urgency, and fear of a positive result. Cultural barriers to testing included shame, stigma, and fatalism. The researchers suggested that outreach to influential religious leaders, who might impart knowledge about the importance of HBV testing, might spur more immigrants to be screened.6

 “Whether this compilation of different theoretical models can be applied for other populations has to be investigated further,” said lead author Nora Hamdiui, MSc, epidemiologist at the National Coordination Centre for Communicable Disease Control, National Institute for Public Health and the Environment, in Bilthoven, the Netherlands.

Summary and Clinical Applicability

Viral hepatitis is responsible for 1.46 million deaths worldwide annually. To meet the goals of the World Health Organization for reducing new infections and decreasing HBV and HCV deaths by 2030, people on the margins of society will need to be tested and treated, including refugees and migrants from endemic regions as well as people who inject drugs.

References

  1. Feld JJ. Extending a helping hand: addressing hepatitis C in economic migrants and refugees. Ann Hepatol. 2018;17(1):8-10.
  2. World Health Organization. Combating hepatitis B and C to reach elimination by 2030. May 2016. http://apps.who.int/iris/bitstream/10665/206453/1/WHO_HIV_2016.04_eng.pdf?ua=1. Accessed March 27, 2018.
  3. Sagnelli E, Alessio L, Sagnelli C, et al. Clinical findings of HCV chronic infection in undocumented immigrants and low-income refugees in three areas of southern Italy. Ann Hepatol. 2018;17(1):47-53.
  4. Degenhardt L, Peacock A, Colledge S, et al. Global prevalence of injecting drug use and sociodemographic characteristics and prevalence of HIV, HBV, and HCV in people who inject drugs: a multistage systematic review. Lancet Glob Health. 2017;5(12):e1192-e1207.
  5. Djoufack R, Cheon SSY, Mohamed A, et al. Hepatitis B virus outreach to immigrant population in Greater Boston area: key to improving hepatitis B knowledge.World J Gastroenterol. 2017;23(42):7626-7634.
  6. Hamdiui N, Stein ML, van der Veen YJJ, van den Muijsenbergh METC, van Steenbergen JE. Hepatitis B in Moroccan-Dutch: a qualitative study into determinants of screening participation [published online January 15, 2018]. Eur J Public Health. doi: 10.1093/eurpub/cky003
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