A novel model of screening and management of HBV infection in undocumented immigrants and low-income refugees

Undocumented migrants and low income refugees coming to Europe from countries with high Hepatitis B virus (HBV) endemicity are at risk of carrying an asymptomatic HBV infection. Language and socio-economic barriers limit their access to healthcare and information on HBV. Published today in Infectious Diseases of Poverty, a new study attempts to combat this issue with a novel model of screening and management of HBV infection in Naples, Italy.

Due to socio-economic and political crises in recent decades, Western countries such as Italy have become lands of immigration for citizens of Africa, Eastern Europe, Asia and South and Central America. Many of the immigrants are healthy young males leaving their country to improve their living conditions or for political reasons (dictatorships, persecution, war and genocide).

Once in Italy, the undocumented migrants and low-income refugees … have limited access to healthcare services and lack information on their HBV condition.

The immigrant populations, frequently moving from countries with intermediate or high Hepatitis B virus (HBV) endemicity, are at high risk of carrying an asymptomatic HBV infection (nearly 8%) as a consequence of perinatal transmission, their tribal rituals and of limited knowledge of the routes of HBV transmission.

Italy is a land of immigration, with 5.4 million legal immigrants (8.2% of the resident population) and nearly 500,000 undocumented migrants, prevalently from Sub-Saharan Africa, Eastern-Europe and Central and Eastern-Asia.

Once in Italy, the undocumented migrants and low-income refugees, not socially integrated due to language and cultural and socioeconomic barriers, have limited access to healthcare services and lack information on their HBV condition.

Novel model of screening

My colleagues and I have proposed a novel model of screening and management of HBV infection in undocumented migrants and refugees. Four first-level clinical centers in the Napoletanean area (Italy) and two tertiary units of infectious diseases participated to the study.

All undocumented immigrants and low-income refugees consecutively seen for a clinical consultation at one of the four first-level centers from January 2012 to December 2014 were enrolled in this study.

The first-level clinical centers are hospital centers of the national healthcare system or clinical centers of international charity organizations supported by the national healthcare system, with proven experience in clinical, psychological, and legal management of vulnerable groups, such as undocumented immigrants, low-income refugees, the homeless, and alcoholics.

The most frequent pathological conditions inducing undocumented immigrants and refugees to refer to one of these centers are lumbago, headaches, pruritus, coughs, high blood pressure, and allergy symptoms.

During a clinical consultation, a physician from the clinical center and a cultural mediator explained to the immigrants the importance of testing for HBV, and offered them to be screened free of charge, in anonymity.

An anonymous questionnaire collecting information on the demographics (age, sex, race/ethnicity, place of birth, language); socioeconomic status (education, annual household income); environmental factors (alcohol, diet, etc); and clinical data and risk factors for acquiring HBV (sexual contact, drug, use, surgery, etc) was completed.

Findings

Skilled physicians and cultural mediators operating in the four first-level centers overcame any language and cultural barriers and allowed successful screening and diagnostic and therapeutic management.

Of the 1,331 undocumented immigrants and low-income refugees observed at one of the four first-level clinical units during the study period, 1,212 (91%) subjects agreed to participate in this study, and 116 (9.6%) had HBV infection. The factors associated with HBV infection were male sex, Sub-Saharan African origin, low level of schooling and history of minor parenteral risks for acquiring HBV infection (acupuncture, tattoo, piercing, or tribal practices.

The subjects with HBV infection were referred for further investigation, monitoring, and possible treatment to one of the two tertiary units of infectious diseases. Each HBsAg-positive subject was assigned to the care of a cultural mediator, who, acting as a support, assisted him/her at the third-level clinical center throughout the monitoring and/or treatment period. By this model, of the 116 immigrants with HBV infection, 90 (77.6%) completed their diagnostic itinerary: 29 (32.2%) were asymptomatic non-viremic carriers of HBV, 43 (47.8%) were asymptomatic viremic carriers, 14 (15.6%) had chronic hepatitis, and four (4.4%) had liver cirrhosis, with superimposed hepatocellular carcinoma in two. All the subjects with HBV infection received treatment or remained untreated in accordance with the current international guidelines.

The data of the present study published in Infectious Diseases of Poverty illustrate that HBV infection is frequent in the undocumented immigrants and refugees. The presence of skilled physicians and cultural mediators operating in the four first-level centers overcame any language and cultural barriers and allowed successful screening and diagnostic and therapeutic management.

Overall, the strategies used in this study could be recommended for screening and managing undocumented immigrants and low-income refugees in several clinical settings. In fact, taking care of this vulnerable group of individuals should be a moral duty for every government or national healthcare system in developed countries.

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