Chronic Hepatitis Infection

Hepatitis is a general term referring to inflammation of the liver. This term also refers to a group of viral infections that affect the liver, including, hepatitis A, B, C, D and E. Two hepatitis viruses, hepatitis B (HBV) and hepatitis C (HCV), are the most important viruses causing chronic liver infection in humans. Chronic infection is associated with the development of liver cirrhosis, failure and cancer.

Globally, more than 350 million people are chronically infected with hepatitis B, leading to more than 500,000 deaths annually.[1] In fact, approximately 25% of those who become chronically infected with HBV during childhood, and 15% of those who become chronically infected during adulthood, will die prematurely from complications of the disease.[2] In the U.S. alone, where rates of HBV infection rates are relatively low, it is estimated that 2,000 to 4,000 people die every year due to associated complications.[2]

Hepatitis C in increasingly recognized as an important cause of morbidity and mortality globally. HCV prevalence rates vary greatly between populations and may range from well below 1% to exceeding 30%.[3] An estimated 70% of HCV-infected persons will develop liver disease. Faster progression of liver disease is associated with infection acquired at an older age, high alcohol intake and co-infection with HIV.  In Egypt, schistosomiasis co-infection has been also associated with more severe disease.[4]

Refugees and Chronic Viral Hepatitis
It was recently estimated that ~3% of all refugees arriving in the U.S. are chronically infected with HBV.[5] However, refugees originating from countries considered highly endemic for HBV (≥8%) frequently have prevalence rates exceeding 10%. [6]

Prevalence of hepatitis C virus in refugees is not well documented but appears to be low (<1%) in most refugee populations (unpublished data). Evidence is clear that in certain countries where refugees originate, especially where parenteral iatrogenic spread is thought to have occurred, rates may exceed 5% [7,8,9].  The CDC currently does not have formal recommendations for screening newly arrived refugees for hepatitis C, but based on available data, it is reasonable to screen refugees according to current CDC recommendations for the U.S. general population.

Hepatitis B Screening
During the domestic health assessment, screening for chronic HBV infection should be routinely performed on all refugees who are from or have resided in countries with intermediate (≥ 2% to 7%) or high (≥ 8%) prevalence of chronic HBV infection (see the CDC guidelines on the geographic distribution of chronic HBV infection). Screening tests include hepatitis B surface antigen (HBsAg), hepatitis B surface antibody (anti-HBs), and total hepatitis B core antibody (anti-HBc). Refugees who are non-immune (negative anti-HBs) should be immunized. Although the anti-HBc test alone does not indicate immunity, it may be a useful test in distinguishing refugees with immunity from prior infection from those who have immunity from partially completed vaccine series.

Those who have initiated a vaccine series prior to arrival in the U.S. should complete the series according to ACIP guidelines even if there is already serologic evidence of immunity. Refugees found to be chronically infected (positive HBsAg) should be evaluated in order to assess if they are candidates for treatment.  Those who are not treated for HBV should undergo periodic screening for early detection of liver cancer.  Lastly, refugees with HBV infection and their household contacts should be counseled regarding prevention of transmission. All susceptible household contacts should be immunized. Further information regarding HBV may be found at:

Hepatitis C Screening
Due to the lack of data and the preliminary findings of low hepatitis C rates in most refugee populations, the CDC currently recommends that refugees should be screened according to current U.S. recommendations.  This includes screening any person considered at risk. Risk factors most likely to be encountered in refugees include being born to a mother who is HCV positive, previous work as a health care provider, history of illicit injection drug use, hemodialysis or blood transfusion (see CDC guidelines for full recommendations). In addition, the CDC recently recommended all persons born in the U.S. between 1945 and 1965 should be screened.

There are other factors that might influence a provider’s decision to screen for HCV such as multiple tattoos, known co-infections such as HIV, and if a refugee originated from or resided in a country with a higher baseline prevalence of HCV. Clinicians should keep in mind that screening populations that have a low prevalence rate of HCV (low pre-test probability) will lead to excessive false-positive test results.

Although successful vaccination campaigns have decreased global prevalence, chronic viral hepatitis remains a leading cause of morbidity and mortality worldwide. In the last decade great strides have been made in the treatment and management of hepatitis. Early detection of complications is key to preventing morbidity and mortality. The domestic health assessment offers the opportunity to identify those who would benefit from vaccinations as well as those who are chronically infected.

Contributed by William Stauffer M.D., M.S.P.H., University of Minnesota

1. World Health Organization. Immunization, vaccines and biologicals, hepatitis B.
2. Centers for Disease Control and Prevention. Guidelines for viral hepatitis surveillance and case management.
3. World Health Organization. Global Alert and Response. Hepatitis C.
4. Strickland GT. Liver disease in Egypt: hepatitis C superseded schistosomiasis as a result of iatrogenic and biological factors. Hepatology 2006;43(5):914-22.
5. Rein DB, Lesesne SB, O’Fallon A, Weinbaum CM. Prevalence of Hepatitis B surface antigen among refugees entering the United States between 2006 and 2008. Hepatology 2010;51(2):431-4.
6. Museru OI, Vargas M, Kinyua M, et al. Hepatitis B virus infection among refugees resettled in the U.S.: high prevalence and challenges in access to health care. J Immigr Minor Health 2010;12(6):823-7.
7. Pawlotsky JM, Belec L, Gresenguet G, et al. High prevalence of hepatitis B, C and E markers in young sexually active adults from the Central African Republic. J Med Virol 1995;46:269-72.
8. Caruana SR, Kelly HA, De Silva SL, et al. Knowledge about hepatitis and previous exposure to hepatitis viruses among immigrants and refugees from the Mekong Region. Aust N Z J Public Health 2005;29:64-8.
9. Frank C, Mohamed M, Stickland G, et al. The role of parental antischistosomal therapy in the spread of hepatitis C virus in Egypt. Lancet 2000;355:887-91.