Should We Offer Screening for Hepatitis B and Other Infections to Immigrants—Legal or Illegal?

In the paper in this issue of JTM “Point‐of‐care screening, prevalence and risk factors for hepatitis B infection among 3,728, mainly undocumented, migrants from non‐EU countries in northern Italy,” 6% of the migrants were found to be hepatitis B surface antigen (HBsAg)‐positive. 1 Worldwide, 2 billion people have been infected with hepatitis B virus (HBV), 360 million have chronic infection, and 600,000 die each year from HBV‐related liver disease or hepatocellular carcinoma. 2 Approximately one third of all cases of cirrhosis and half of all cases of hepatocellular carcinoma can be attributed to chronic HBV infection. HBV is estimated to be responsible for 500,000 to 700,000 deaths each year. 3 Should immigrants—legal or illegal—be offered screening for hepatitis B and indeed for other infections such as hepatitis C, human immunodeficiency virus (HIV), and tuberculosis (TB)? An editorial in this journal in 2013 strongly argues that immigrants from hepatitis B‐endemic countries, defined as countries with an HBsAg prevalence of ≥2%, should be offered screening for chronic hepatitis B, according to the current Centers for Disease Control and Prevention guidelines. 4 A study from Canada screening immigrants for chronic HBV infection found screening to be cost‐effective and has the potential to reduce HBV‐associated morbidity and mortality. 5 A study from the United States found that screening and vaccination for hepatitis B were low, 36.9 and 26.3% of immigrants, respectively. 6 Another study from the United States found that only 4% to 5% of chronic HBV‐infected patients are screened, enter a health system, and obtain treatment. 7 Travel clinics also care for immigrants returning to their country of origin to visit friends and relatives. A study from a travel clinic in Boston found that of 230 travelers of foreign origin not previously tested for HBV, 7 of 213 (3.3%) were infected with HBV. 8 This demonstrates that the pre‐travel consultation should include a test for HBV preferably with a test for HBsAg in travelers visiting their country of origin if this is a high‐ or intermediate‐endemic area (HBsAg rate ≥2%); however, this will not address the problem in newly arrived immigrants. A European multicenter study mapping screening for infectious diseases in immigrants and other high‐risk groups found that only in Spain was the HBV immunization offered to immigrants and up to half of hepatitis B‐negative immigrants were immunized against hepatitis B. 9 A study of immigrants to Sicily, Italy, found that 9.2% had a liver disease. More than two thirds (67.8%) came from Africa, 15.2% from Asia, and 17.0% from Eastern Europe. In most patients, the disease was related to HBV (44.6%), followed by alcohol (25%), and then hepatitis C virus (HCV) or cryptogenic disease (both 15.2%), concluding that a significant proportion of the immigrant population has liver disease and that the most frequent cause was hepatitis B. 10 A recent study from Germany including people if their parents were not born in Germany found that 87.3% had migrated to Germany from the Eastern Mediterranean area and 12.0% from Eastern Europe. About 32.5% of them tested positive for hepatitis B core protein antibodies. HBsAg were found in 3.6% of patients and HBV DNA was detected in 2.2% of patients. 11 A large screening study in first generation Koreans in Southern California found a lower than expected HBV prevalence (3%), a continued need for vaccination, and a need for screening despite a reported history of vaccination. 12 A study from the Netherlands of selective screening for hepatitis B and C in immigrants from Afghanistan, Iran, Iraq, the former Soviet Republics, and Vietnam found a prevalence of chronic HBV infection of 9.5% in the Vietnamese population. 13 Data from a clinic caring for immigrants in Greece report that 11.1% of immigrants from Africa tested positive for HBsAg, 13% from Asia, and 9.1% from Europe. 14 The conclusion from these studies is that immigrants are a high‐risk population for chronic hepatitis B (and C) because they often come from endemic countries. It seems obvious that immigrants should be offered screening for HBV and followed up if tested positive and immunized if tested negative and not previously immunized. This is simply to avoid a huge unknown reservoir of untreated hepatitis B in Europe resulting in an increased burden of cirrhosis and hepatocellular carcinoma diagnosed in late stages, and the simple decency of offering follow‐up in the health care system and treatment if needed for patients with a lifelong, chronic infection. But why limit screening to hepatitis B? Other obvious infections to screen for are HIV 15 and TB. Again the rationale is to offer treatment to the individual, and not because we should be worried about secondary transmission of these infections. Indeed, the spread of TB from the European populations to immigrants is more likely than the opposite. 16,17 A recent study from Spain describing screening of 3,132 immigrants from low‐ and middle‐income countries for TB, HBV, HCV, HIV, and syphilis found that 1.2% were HIV positive, 3.4% tested positive for syphilis, 2.6% had chronic HBV, and 3.3% tested positive for chronic HCV. 18,19 Active TB was detected in 5.8% and latent TB in 28.1%. 17 The high rate of active TB is especially surprising and emphasizes that screening for TB is needed to identify cases that can further spread the infection. Infections with HIV, HBV, HCV, and TB are chronic infections with a considerable mortality if left undiagnosed and untreated. Therefore, for all infections, the rates were >1%, which strongly suggests that screening immigrants for all these infections will limit both the disease in the immigrants and the transmission to the surroundings. Parasitic infections like strongyloidiasis 18,19 are common, and one study found that looking for eosinophilia and increased total IgE found filariasis, strongyloidiasis, and schistosomiasis. 20 Thus, screening for these helminths could also be considered. It is estimated that there are about 140,000 Filipinos (1.95% of the population) in Hong Kong, most of them being domestic workers. As many Filipino maids have Sunday as their only day off from work, they gather on that day at various spots in Central Hong Kong. Photo Credit: Eric Caumes. The author states that he has no conflicts of interest.

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