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by Elsevier B.V. All rights reserved.
Hepatitis B
%
>5
2-5
<2
No data
%
>5
2-5
<2
No data
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during preschool years [2]. HBV is present in blood, saliva, semen dramatically in most Western nations with the institution of rou-
and vaginal secretions, as well as in breast milk of infected per- tine screening of blood products, as well as universal vaccination
sons. HBV exposure can also occur through contaminated needles programs [7]. For example, the incidence of HBV in the US has
and other medical equipment in developing countries. HBV is declined by 80% from 1987 to 2004 [7]. Healthcare workers con-
more infectious through blood-borne exposure than both HCV tinue to be an at risk population, through exposure to infected
and human immunodeficiency virus (HIV). Contaminated needles blood or contaminated medical equipment [8].
alone are thought to be responsible for 8–16 million HBV infec- The route of exposure, and the age of acquisition of the infec-
tions per year [6]. tion are important determinants of the long-term sequelae of
Areas of intermediate prevalence (2–7%) include parts of HBV. Vaccination is a safe and effective way of decreasing the risk
Central and Eastern Europe, the Middle East, Latin America as of neonatal HBV infection, and is especially relevant to the
well as the Indian subcontinent [4]. Once again, perinatal or hor- nations with high HBV prevalence [9]. The WHO recommends
izontal transmission is most common in these regions. universal HBV vaccination at birth in countries with high preva-
In contrast, HBV is lower in prevalence (<2%) in North America lence (>8%) [10]. However, as of 2006, only 38 of 81 (44%) high
and Western Europe [4]. In these countries, infection is usually prevalence countries reported adopting birth-dose vaccination
spread through sexual contact or IV drug use. The risk of HBV as part of the national immunization schedule. WHO estimates
transmission through blood transfusion has decreased show that in 2006, birth-dose coverage was only 36% among
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dence of HCV in both regions [27]. In the USA, HCV incidence 1.3 million foreign-born HBV positive individuals [36].
dropped from an estimated 7.4/100,000 people in 1982–89 to Data from the EU reveal a similar pattern, with regional vari-
0.7/100,000 in 1994–2006. In contrast with the developing world, ations. HBV prevalence is higher in Eastern European nations
iatrogenic outbreaks in North America and Western Europe are such as Turkey (8%), Romania (6%) and Bulgaria (4%), when com-
uncommon, and are typically confined to individual clinics using pared to Western European nations such as Netherlands (<0.5%),
improper sterilization technique [28]. Italy (1%) and Germany (1%) [37]. HBV and HCV seroprevalence
These data reveal large differences in the prevalence of these data is now being collected by the European Centre of Disease
chronic liver diseases among migrant groups and the host Prevention and Control [37], although reporting has been poor
nations. In an era of increasing migration, these differences in from many member countries [38]. Pooled estimates of chronic
HBV and HCV prevalence between regions have important impli- HBV prevalence data from ECDC surveys indicate that 53% of
cations for public health agencies in host nations. HBV carriers were born outside the EU. In the Netherlands, where
robust population level data has been available, 77% of chronic
HBV infections are estimated to originate from outside the EU,
Global migration statistics, countries of origin and destination predominantly from high and intermediate prevalence regions
[39]. Studies from at least seven EU nations have shown that
With the growing ease of air travel, and the globalization of the the prevalence of HBV is higher in the immigrant population than
world economy, mass migration has been on the upswing in in the indigenous population. A meta-analysis on HBV prevalence
the last half of the 20th century. According to UN estimates, the among immigrants found that prevalence rates among migrant
populations mirror the prevalence in the country of origin, with Current standards for screening of immigrants and refugees
particularly high prevalence (>10%) among migrants from East
Asia and sub-Saharan Africa [40]. The American immigration medical exam does not include rou-
The prevalence of HCV antibody in the US may be at least tine testing for viral hepatitis [45]. Importantly, HBV or HCV pos-
5.2 million according to one estimate, when high-risk groups itive serology does not meet grounds for inadmissibility to the
such as incarcerated and homeless individuals are taken into US. Under the current regulations, medical assessment includes
account [26]. However, this estimate did not include immigrants a review of prior medical history, drug and alcohol use as well
with HCV, so that the true prevalence of HCV in the US is likely as a physical examination (Table 1). However, routine HBV and
even higher. Data on the prevalence of HCV among US immi- HCV testing is not required as part of the immigration medical
grants and refugees is sparse. However, small studies of migrant exam. Age-appropriate vaccination recommendations do include
communities have found very high HCV seropositivity rates. For routine HBV vaccination for children below 18 years of age [46].
example, a hepatitis screening program enrolled 283 New On the other hand, the examination of refugees on arrival to
Yorkers from the former Soviet Union, 28.3% of whom were the US includes assessment for the risk of viral hepatitis [47].
anti-HCV positive. In Canada, immigrants are estimated to Current guidelines recommend HBsAg testing for all refugees
account for at least 20% of all cases of HCV, with an estimated arriving from countries with an HBV prevalence of 2% or higher.
prevalence of 3% in this group (general population prevalence In addition, refugees arriving from countries with HBV preva-
estimated at 0.8%) [41]. The prevalence in some groups, such as lence less than 2% are also screened if they have risk factors (such
immigrants from Egypt is reported to be as high as 18%. as homosexual men, IDU, household contacts of known carriers).
HCV prevalence among EU member states is estimated to be HBV vaccination is recommended in non-immune adults.
1% overall [42]. However, some regional differences do exist. Recommendations for HCV testing are similar to the US popula-
Anti-HCV prevalence is lowest in the Scandinavian countries tion, and include universal testing of the 1945–1965 birth cohort,
(<0.5%), but higher in Italy, Greece and Romania (>3%) [37]. as well as testing of individuals with risk factors (such as IDU, HIV
ECDC data on the prevalence of HCV among migrants is limited positive individuals, and recipients of blood products). Patients
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due to incomplete records from many member states. However, found to be positive for HBV or HCV are referred to a physician
studies in individual countries do suggest that immigrants may with expertise in management of viral hepatitis.
constitute a high-risk group. For example, a modeling study from Similar to the US immigration medical exam, universal testing
the Netherlands estimated the 50% of the HCV burden in the for viral hepatitis is not mandated in Canada, even in patients
Netherlands occurred in immigrants, with prevalence 10-fold originating from countries with high prevalence [48]. Rather than
higher than the native population (2% vs. 0.2%) [43]. Data from screening of immigrants based on country of origin, the immigra-
the UK show that HCV prevalence among South Asians, and espe- tion medical exam requires identification of risk factors for viral
cially among migrants from Pakistan may be as high as 2.7%, hepatitis and evidence of liver disease on history and physical
while 0.5% of the general population is estimated to have chronic examination. Patients with positive risk factors, history of liver
HCV [44]. disease, HIV, tuberculosis or syphilis require mandatory HBV
In summary, migrant populations have higher rates of chronic and HCV testing. Refugee claimants are also mandated to
viral hepatitis than the local population in both North America undergo an immigration medical examination with the same
and the EU. These data have prompted various national and standards. A positive HBV or HCV test does not meet grounds
regional guidelines for screening of migrants at high-risk for for inadmissibility into Canada.
HBV and HCV, especially in host nations that attract the largest Immigration medical screening policies in the EU region are
numbers of immigrants globally. The European, Canadian and country-specific. However, hepatitis screening is currently not
American guidelines for HBV and HCV screening will be summa- required as a condition of entry into the EU region. According
rized below. to ECDC statistics, 24 out of 30 EU/EFTA countries have adopted
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HCC [60]. Universal screening of migrants for viral hepatitis has been
Thus, migrants are disproportionately afflicted with both evaluated by several modeling and cost-effectiveness studies
increased mortality and morbidity from chronic viral hepatitis, [37,41,59,80,81]. These studies have shown that screening immi-
and this trend is expected to continue over the next decade with grants from intermediate or high prevalence nations for HBV is
implications for costs to the healthcare system [2]. In the US, likely to be cost effective, and may reduce liver–related mortality
where migrants constitute the majority of people with HBV, out- and morbidity [59,80]. Estimates for the cost per quality adjusted
patient and inpatient visits for HBV have increased 4-fold over the life year (QALY) range from €9000 in a Dutch study proposing one
last two decades [7]. During this period, direct healthcare costs for time screening for immigrants, to $39,000 in an American study
HBV have risen from $350 million in 1990 to over $1.5 billion in proposing screening, treatment and vaccination of contacts
2003. Costs for HBV antivirals have also increased at 50% per year, among Asian migrants [59,80]. Based on these data, experts have
and were estimated at $82 million annually in 2008. made recommendations for the implementation of screening pro-
grams for HBV targeting immigrants and refugees [37,47,59].
However, these recommendations have not yet been adopted
Improving case identification and treatment among migrants by government agencies.
The cost-effectiveness of universal screening of migrants for
Studies have identified patient factors such as lack of knowl- HCV is not as clearly established, since HCV prevalence varies
edge, late presentation and poor adherence to follow-up and widely among host nations and migrant groups. Studies on
fear of the side effects of treatment as major barriers for cost-effectiveness of HCV screening have focused on high-risk
with the challenge will have to address the linguistic, cultural, 1999;31:84–87.
social and medical insurance barriers that are faced by migrants [24] Mühlberger N, Schwarzer R, Lettmeier B, Sroczynski G, Zeuzem S, Siebert U.
HCV-related burden of disease in Europe: a systematic assessment of
with viral hepatitis.
incidence, prevalence, morbidity, and mortality. BMC Public Health
2009;9:34.
[25] Lvov DK, Samokhvalov EI, Tsuda F, Selivanov NA, Okamoto H, Stakhanova
VM, et al. Prevalence of hepatitis C virus and distribution of its genotypes in
Conflict of interest
Northern Eurasia. Arch Virol 1996;141:1613–1622.
[26] Chak E, Talal AH, Sherman KE, Schiff ER, Saab S. Hepatitis C virus infection in
The authors report no conflict of interest with the topics dis- USA: an estimate of true prevalence. Liver Int 2011;31:1090–1101.
cussed in this review. [27] Williams IT, Bell BP, Kuhnert W, Alter MJ. Incidence and transmission
patterns of acute hepatitis C in the United States, 1982–2006. Arch Intern
Med 2011;171:242–248.
[28] Fischer GE, Schaefer MK, Labus BJ, Sands L, Rowley P, Azzam IA, et al.
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