Screening for Hepatitis B Virus Infection
Among Refugees Arriving in the United States, 1979-1991
Because hepatitis B virus (HBV) infection is highly endemic in
several areas of the world, both the prevalence of and risk for HBV
infection are substantially greater among persons emigrating from
these areas to the United States than for the overall U.S.
population. In 1985, federal funds were made available to
supplement ongoing state and local health department
refugee-screening programs and to promote serologic screening for
HBV infection in pregnant Indochinese women and household contacts
of these female HBV carriers among persons identified by the
Department of State as refugees entering the United States. This
report summarizes data collected during 1979-1991 by selected
screening programs that implemented universal hepatitis B (HB)
screening at different times.
Health-screening programs established by state and local
health agencies for newly arrived refugees generally include
tuberculosis screening, stool screening for ova and parasites, and
serologic screening for HBV infection; screening is done as soon as
possible after arrival. Services may be provided in special
refugee-health clinics, local health department clinics, or the
offices of private-practice physicians. For this report, programs
were selected that 1) screened all incoming refugees and 2) had
data on the results of testing for hepatitis B surface antigen
(HBsAg) that could be used to calculate nationality-specific
estimates of the prevalence of current HBV infection. Because these
data did not include more detailed demographic information, neither
age- nor sex-specific prevalence estimates could be calculated.
Crude prevalence rates of HBsAg were highest among refugees
from countries in Southeast Asia (range: 11.7%-15.5%), intermediate
among refugees from Africa, and lower among refugees from other
countries in Asia, including Afghanistan (4.1%) and Iran (2.4%)
(Table 1). Crude prevalence rates were substantially higher among
refugees from Bulgaria (5.3%) and Romania (4.1%) than among
refugees from other eastern European countries, who had the lowest
rates for all groups tested (Table 1).
Reported by: C Crysel, Alabama Refugee Health Screening Program,
Bur of Disease Control, Alabama Dept of Public Health. MP Wong, San
Francisco General Hospital Refugee Clinic, San Francisco. B Brown,
Georgia Refugee Health Program, Div of Public Health, Georgia Dept
of Human Resources. J Cochran, Refugee Health Program, Communicable
Disease Control, Massachusetts Dept of Public Health. B Morales,
Detroit Refugee Health Screening Program, Detroit Health Dept,
Michigan. D Peterson, Refugee Health Unit, Acute Disease Programs,
Minnesota Dept of Health. S Brooks, New York Refugee Health
Program, New York State Dept of Health. D Candow, Refugee Health
Program, Ohio Dept of Health. M Hurie, Refugee and Immigrant Health
Program, Bur of Public Health, Div of Health, Wisconsin Dept of
Health and Social Svcs. Hepatitis Br, Div of Viral and Rickettsial
Diseases, National Center for Infectious Diseases; Medical
Screening and Health Assessment Br, Div of Quarantine, National
Center for Prevention Svcs, CDC.
Editorial Note
Editorial Note: The prevalence of HBsAg among refugees entering the
United States reflects the patterns of HBV infection in the
countries and regions of origin for these persons. In Southeast
Asia, the Middle East, and Africa, the crude prevalence of chronic
HBV infection ranges from 5% to 15%, and HBV is a major cause of
morbidity and mortality from acute and chronic hepatitis,
cirrhosis, and primary hepatocellular carcinoma (2-4). Although
less is known about the prevalence of HBV infection in eastern
Europe, recent data from other sources are consistent with the high
prevalence of HBV infection in Romania reported here (1; CDC,
unpublished data) and suggest that levels of HBV infection in parts
of eastern Europe may be higher than previously believed.
Although the overall risk for HBV infection is lower in the
United States than in many countries, the Immunization Practices
Advisory Committee recommends that all pregnant women be screened
for HBsAg to identify infants needing specific immunoprophylaxis to
prevent HBV infection (5). In addition, universal infant vac
cination is recommended in populations with a high prevalence of
HBV infection, such as Alaskan Natives, Pacific Islanders, and
emigrants from areas with moderate and high levels of HBV infection
(5). In these populations, infants not infected at the time of
birth may become infected during early childhood through exposure
to mothers or siblings who are HBV carriers (6,7). In such groups,
vaccination at birth and integration of HB vaccination into the
routine infant vaccination schedule are important (8).
The findings in this report identify specific groups at higher
risk for HBV infection, including persons emigrating from
Afghanistan, Angola, Bulgaria, Cambodia, Ethiopia, Iran, Iraq,
Laos, Romania, Thailand, and Vietnam. Although site-specific
demographic data were not available for this report, 25.2% of all
refugees entering the United States during 1983-1989 were women of
reproductive age (15-44 years of age) (CDC, unpublished data). This
suggests that U.S.-born infants of women who have emigrated from
these countries are at substantial risk for HBV infection through
perinatal or early childhood transmission. Therefore, managers of
vaccine delivery programs targeted at these groups should recognize
the need to screen all pregnant women for HBV infection,
appropriately treat infants of HBsAg-positive mothers, and fully
vaccinate infants who are at increased risk for HBV infection.
References
Sobeslavsky O. Prevalence of markers of hepatitis B virus
infection in various countries: a WHO collaborative study. Bull WHO
1980;58:621-8.
Sung JL, Asian Regional Study Group. Hepatitis B virus
eradication strategy in Asia. Vaccine 1990;8(suppl):S95-9.
Kiire CF, African Regional Study Group. Hepatitis B infection in
sub-Saharan Africa. Vaccine 1990;8(suppl):S107-12.
Toukan A, Middle East Regional Study Group. Strategy for the
control of hepatitis B virus infection in the Middle East and North
Africa. Vaccine 1990;8(suppl):S117-21.
ACIP. Protection against viral hepatitis: recommendations of the
Immunization Practices Advisory Committee (ACIP). MMWR 1990;39(no.
RR-2).
Franks AL, Berg CJ, Kane MA, et al. Hepatitis B infection among
children born in the United States to southeast Asian refugees. N
Engl J Med 1989;321:1301-5.
Ko YC, Li SC, Yen YY, Yeh SM, Hsieh CC. Horizontal transmission
of hepatitis B virus from sibling and intramuscular injection among
preschool children in a familial cohort. Am J Epidemiol
1991;133:1015-23.
ACIP. Hepatitis B virus: a comprehensive strategy for
eliminating transmission in the United States through universal
childhood vaccination--recommendations of the Immunization
Practices Advisory Committee (ACIP). MMWR (in press).
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