Author: Lorenzo De Min
Last update: 01/10/2019
The word ‘hepatitis’ literally means inflammation of the liver. An inflammation of the liver can be triggered by several causes, which may be infectious or non-infectious in nature. Most frequently, hepatitis is infectious in nature and caused by viruses (CDC, 2018). This article will focus on viral hepatitis among migrant populations, a group that may be exposed to higher risk of disease transmission and complications of hepatitis (Greenaway et al., 2018; Myran et al., 2018).
Vulnerability of migrant populations
Migrant populations’ vulnerability to viral hepatitis has been linked with several factors. Low health literacy (i.e. lack of knowledge of the disease, low familiarity with the organisation of the health system), together with language and cultural barriers, play a key role in exposure to and poor management of the disease. Fear of being reported to state authorities (particularly among irregular migrants), the stigma associated with the disease, and socioeconomic status are other factors that can lead affected individuals to delay seeking treatment. Other obstacles and barriers within the health system can also challenge detection and treatment of hepatitis among migrants: among doctors, for example, lack of awareness of the epidemiology of hepatitis contributes to underdiagnoses; at health system level, lack of translators and cultural mediators are common challenges that contribute to poorer treatment outcomes among migrants (Greenaway et al., 2018). As a result, a higher prevalence of hepatitis-related morbidity and mortality among migrant populations is widely reported in Europe, North America and Australia (Owiti, Greenhalgh, Sweeney, Foster, & Bhui, 2015).
Hepatitis B Virus and Hepatitis C Virus
Viral hepatitis is a major public health problem and can be broken down into different forms based on the underlying causal virus. Among the most common are hepatitis B virus (HBV) and hepatitis C virus (HCV), which are responsible for the majority of the cases of hepatitis worldwide and affect an estimated 257 million people (HBV) and 71 million people (HCV), respectively (WHO, 2017). The prevalence of HBV and HCV is unevenly distributed. Sub-Saharan Africa – in particular the Western region – is the area with the highest prevalence of HBV, followed by Central and Eastern Asia (Locarnini, Hatzakis, Chen, & Lok, 2015); HCV is more prevalent in the Eastern Mediterranean and Eastern European regions. However, both the conditions are diffused worldwide (WHO, 2017). Chronic infection of the liver through HBV and HCV can lead to life-threatening complications (Greenaway et al., 2018; Myran et al., 2018), in particular cirrhosis (advanced scarring of the liver) and hepatocellular carcinoma (a common type of liver cancer), which are responsible for more than one million deaths every year (Sharma, Carballo, Feld, & Janssen, 2015). Transmission of HBV occurs through blood-to-blood contact, sexual contact, and from mother to child during birth. Hepatitis C virus is transmitted through exposure to contaminated blood, in particular through the use of contaminated needles, unsafe medical procedures, and mother to child transmission during birth (Sharma et al., 2015; WHO, 2017). Different forms of hepatitis require different means of prevention and treatment: HBV infection can be prevented through a safe and effective vaccine (Mipatrini, Stefanelli, Severoni, & Rezza, 2017), whereas there is currently no vaccine to prevent HCV. In recent years, a highly effective treatment for HCV has been developed, but its availability has been limited by its high costs (Greenaway et al., 2018).
HBV and HCV among migrant populations
Among migrants, HBV is often acquired at birth (Castelli & Sulis, 2017), while HCV is more frequently contracted through unsafe injections or medical procedures in the country of origin (Greenaway et al., 2018). Studies conducted in the European region indicate that migrants have a lower vaccination rate compared to the general population due to low coverage in the country of origin and to limited access to vaccination in the country of arrival (Mipatrini et al., 2017). Migrants coming from regions where hepatitis viruses are endemic have a higher prevalence of chronic hepatitis compared to the general population in countries of destination (Myran et al., 2018), yet the risk of immigrants supporting transmission of the disease to the native population is low due to the transmission modalities (WHO, 2017). Chronic liver infection is often asymptomatic, which makes case detection more complex and contributes to a delay in infected persons seeking healthcare, which often occurs after complications have already occurred (Myran et al., 2018). A major challenge is that asymptomatic individuals can still spread the virus. Within immigrant cohorts, complications related to hepatitis infection tend to occur at a younger age – since within this subgroup infection is more commonly acquired during childhood – and contribute to higher mortality rates compared to the general populations (Myran et al., 2018; Sharma et al., 2015). Early detection is therefore crucial to prevent both the progression of the disease its spread, and it represents a challenge for the health systems in countries of migrant destination (Sharma et al., 2015). Screening focused on migrant populations would allow susceptible individuals to be screened for vaccination (for HBV) and affected ones to treatment (Greenaway et al., 2018; Myran et al., 2018), but such screenings are not routinely performed in most destination countries (Sharma et al., 2015). Furthermore, while therapy for HCV has become more accessible in the past years, with differences from country to country, the above-described barriers reduce access to treatment for migrants. More efforts to promote access to screening and treatment for migrants populations are required and could reduce the health disparities (Greenaway et al., 2018). Hepatitis A Virus (HAV) [Hepatitis among internally displaced / refugee camps] Unlike HBV and HCV, hepatitis A does not cause chronic liver disease but results most frequently in an acute infection with gastrointestinal symptoms. The hepatitis A virus is transmitted by food, drinks, and objects contaminated by faecal matter from infected individuals, which relates directly to poor hygiene and sanitation standards. In western countries, children of migrants have been found to be at risk of contracting the disease when travelling back to their countries of origin (Khyatti et al., 2014). Due to the role played by lack of hygiene in transmission, the risk of HAV infection is particularly high is crowded settings, for example during humanitarian emergencies and in refugee camps. Measures to prevent HAV morbidity are particularly important to reduce the burden of the disease in such contexts and include improvement of sanitation, health education, screening and vaccination (Lam, Mccarthy, & Brennan, 2015).
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