The forgotten people: Hepatitis B virus (HBV) infection as a priority for the inclusion health agenda

All-cause mortality significantly increased for inclusion health populations studied:

• Female SMR 11.86 (95% CI 10.42–13.3; I² 91.5%)

• Male SMR 7.88 (95% CI 6.40–9.37; I² 98.1%)

High SMR for infectious diseases:

• 11.43 (95% CI 6.91–15.94; I² 97%)

• High prevalence of hepatitis B

Sex workers contributed only 4.2% datapoints, compared to people with substance use disorders contributing 42.1%

346 participants

Level of self-declared HBV vaccination 52.3%

Being female associated with lower HBV vaccine uptake (OR 2.37, 95% CI 1.23–4.57, p=0.01)

Intravenous drug use protective against incomplete vaccination (OR 0.23, 95% CI 0.08–0.62, p=0.004)

2 or more risk factors associated with protection against incomplete vaccination (OR 0.19, 95% CI 0.09–0.39, p<0.001)

Screening migrants for HBV and other blood borne viruses on arrival to Italy is acceptable to target population (>95% uptake)

Risk of HBV infection was associated with:

• Female sex (aOR 2.47,95% CI 1.90–3.20, p=0.003)

• Physical and/or sexual violence on migration journey (aOR 2.24,95% CI 1.87–3.55,p<0.001)

Migrants appeared to have severe chronic HBV disease requiring intervention:

• >2/3 of migrants with CHB had moderate/ severe liver disease and were eligible for HBV treatment

• >10% diagnosed with HBV had liver cirrhosis

<50% of migrants diagnosed with CHB were retained in care at 1 year

UASC in London (n=101)

16% female, median age 16 (range 14–17)

Physical assault/abuse reported in 67%

13% disclosed sexual assault/abuse (38% of females)

Mental health symptoms in 77%

6% prevalence HBV infection

UASC in London (n=252)

19 countries (majority from Afghanistan, Eritrea, Albania)

4.8% prevalence HBV infection (highest prevalence from Sudan and Afghanistan)

Many co-infections (TB, Schistosomiasis most common)

Very low knowledge and low personal perceived risk of acquiring HBV among migrants

Majority of migrants with positive views around screening for infectious diseases including HBV. Reservations included:

• Concerns over results impacting immigration and/or asylum applications

• Concerns over delay receiving the results

• Language barriers

• Stigma

62 pregnancies, undocumented women

4 women received no antenatal care, 3 denied antenatal care

71% received less that the recommended number of antenatal vistits

3% HBV seroprevalence, significantly higher than all pregnant women (p=0.007)

2/3rds attended first prenatal visit in 2^nd or 3^rd trimester

Migrant pregnant women, northern Thailand

757 knowledge and attitude studies:

• Low knowledge about HBV transmission, infection or vaccination (28% correct response)

Qualitative analysis found counselling should:

Use appropriate language, tailored to local health literacy level, provide pertinent information, be repeated over antenatal period, ensure privacy

HBV seroprevalence higher than in non-PEH

Studies have associated HBV past infection in PEH with: older age, MSM, insertive anal sex, Injecting drug use, alcohol use

Compared to non-homeless individuals, homeless individuals:

More likely to have cardiovascular disease (pooler OR 2.96, 95% CI 2.80–3.13 l p<0.001, I=99.1%)

More likely to have hypertension (pooled OR 1.38–1.75, p=0.007)

Higher cardiovascular mortality (age-standardised SMR range 2.6–6.4)

Estimated global seroprevalence active HBV of 9% (95% UI 5.1–13.2%)

Highest seroprevalence in:

• East and SE Asia (20%)

• Azerbaijan, Egypt, Cote d’Ivoire, Lithuania, Belarus, Czech Republic (>10%)

21.7% (15.8–27.9) recently (within past year) experienced homelessness/ unstable housing

57.9% (50.5–65.2) with history of incarceration

12,204 alcohol users, mostly men

Estimated global seroprevalence of active HBV infection was 20% (95% CI 19–20)

Substantial heterogeneity between studies (I²=96.7%)

Global chronic HBV seroprevalence among incarcerated individuals estimated at 4.8%

Regions with the highest HBsAg seroprevalence were:

West and central Africa (23.5%, 95% CI 19.8–27.5)

Eastern Europe and central Asia (10.4%; 95% CI 1.9–24.6%)

Data from WHO Prison’s European Database and ECDC hepatitis prevalence database

HBsAg seroprevalence ranged from 0% in maximum-security prison in the UK to 25% in two Bulgarian juvenile detention centres

Universal HBV screening on opt-out basis available in 31% of reporting countries

Condoms and lubricants offered free of charge in 46% and 15% of reporting countries, respectively

Universal HBV vaccination available in 85% of reporting countries

25% PWID initiate drug use in prison

Risk factors for HBV: sharing needles, sharing toothbrushes, unsterile tattooing and body piercing

Prevalence of HBV among incarcerated PWID associated with:

• Multiple incarceration (OR 1.43, 95% CI 1.01–2.02)

• Total duration of incarceration (OR 2.70 95% CI 1.94–3.74)

3 cities, southern Brazil

147 SWs (Male 4.5%, female 91.2%, transgender 4.3%)

3.4% HBsAg positive

Baseline prevalence <2% in Brazil

4 cities, northern Brazil

365 FSWs

3.0% HBsAg positive

Use of illicit drugs most strongly associated with exposure to HBV (OR 44.1, 95% CI 12.7–68.6)

One city, mid-western Brazil

402 FSWs

1.6% HBsAg positive

Only 28% serological evidence of HBV vaccination

Exposure to HBV associated with:

• Age >40 (OR 3.5, 95% CI 1.5–7.9, p<0.001)

• Being in education <4 yrs (OR 3.2, 95% CI 1.4–7.4, p<0.009)

• Being single (OR 2.0, 95% CI 1.1–3.8, p<0.028)

• Meeting clients on the street (OR 2.5, 95% CI 1.4–4.4, p<0.003)

129 MSWs

3.3% HBsAg positive

Only 9.1% anti-HBs (i.e. evidence of HBV vaccination)

1096 SWs (97.8% female)

0.6% HBsAg positive

Only 7% anti-HBs (i.g. evidence of previous HBV vaccination)

273 trans female sex workers (TSW), 114 MSW

HBV exposure 40% TSW, 22% MSW

Total HbSAg prevalence 1.6%

HBV infection associated with:

• >= 12 clients monthly (OR 3.30, 95% CI 1.46–7.47)

• Ever using drugs (OR 1.77, 95% CI1.55–2.02) or alcohol (OR 2.96, 95% CI 2.15–4.07)

• Having children (OR 1.52, 95% CI 1.41–1.64)

24% vaccinated against HBV

Only 30% booked in first trimester and attended all antenatal appointments

13% received no antenatal care until admitted

Barriers: waiting times, fear of judgement

1036 female sex workers

HbsAg prevalence 9.9%

HBV infection associated with:

• Recruitment out of the capital city (aOR 6.63; 95% CI 2.51–13.4-, P<0.001)

• Never using condoms for vaginal intervourse (OR 3.14; 95% CI 1.02–8.71)

452 Roma people screened

Increased HBsAg positivity compared to age-matched general population (RR 4.47, 95% CI 2.36–8.42; P<0.001)

1345 Slovak-Roma patients seen in dedicated primary care clinic

9.4% HBsAg positivity (compared to 1% general UK population)

Median number of people in each household 7 (range 1–21 people)

452 Roma people screened, risk factors assessed by questionnaire/interview

Participants who were HBsAg positive had a higher median age compared to those with no evidence of HBV exposure (35.2, vs 30.7, P=0.028)

A higher proportion of male participants were HBsAg positive, compared to those with no evidence of HBV exposure (51% vs 31%, P=0.005)

A higher proportion of incarcerated people, and people with tattoos, had HBV exposure (HBc IgG positive) compared to those with no history of exposure (HBc IgG negative) (14% vs 6%, p 0.016 and 44% vs 32%, p 0.035, respectively)

35,633 individuals tested in Northern Territory between 2007–2011

HBsAg positivity was 3·40% (95%CI 3·19–3·61), being higher in Indigenous (6·08% [5·65%–6·53%]) than non-Indigenous (1·56% [1·38%–1·76%]) Australians, P<0·0001

100 790 individuals were tested (33.4% Indigenous) between 1991 and 2011 (26.1% of the 2011 NT population)

In 2011, the proportion of HBV positive individuals in the NT was 3.17% (5.22% in Indigenous populations) compared to previous 2011 estimates of 1.70% (3.70% in Indigenous populations)

Evidence of suboptimal vaccine efficacy by breakthrough anti-HBc positivity in vaccinated individuals was demonstrated in 3.1% of the vaccinated cohort, of which 86.4% identified as Indigenous (HR 1.17)

558 indigenous and 55 non-indigenous community residence of central Australia

HBsAg more common in indigenous compared to non-indigenous (12.9% vs 6.7%)

Other infections and non-communicable diseases more common in indigenous than non-indigenous population

High prevalence of HBV among indigenous populations (e.g. Inuit of Greenland 3–29% HBsAg positivity, Alsaka Native and Canadian Far North 3–20% depending on community investigated), before introduction of HBV vaccine

Variety of genotype observed which may alter natural history of disease

Genotype B6 (now known as B5) unique to this region, reported to have a more benign disease course

Reviewed 62 studies from 12 countries

High endemicity (>8%) of hepatitis B was found in some indigenous peoples in Mexico (Huichol) (9.4%), Venezuela (Yanomami: 14.3%; Japreira: 29.5%) and among Afro-descendant quilombola populations in Brazil (Frechal: 12.5%; Furnas do Dionísio: 8.4% in 2008, 9.2% in 2003)