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

  1. Emily Martyn
  2. Sarah Eisen
  3. Nicky Longley
  4. Philippa Harris
  5. Julian Surey
  6. James Norman
  7. Michael Brown
  8. Binta Sultan
  9. Tongai G Maponga
  10. Collins Iwuji
  11. Stuart Flanagan
  12. Indrajit Ghosh
  13. Alistair Story
  14. Philippa C Matthews  Is a corresponding author
  1. The Francis Crick Institute, United Kingdom
  2. London School of Hygiene & Tropical Medicine, United Kingdom
  3. Hospital for Tropical Diseases, Division of Infection, University College London Hospitals NHS Foundation Trust, United Kingdom
  4. Department of Infectious Diseases, University College London Hospitals NHS Foundation Trust, United Kingdom
  5. Find & Treat Service, Division of Infection, University College London Hospitals NHS Foundation Trust, United Kingdom
  6. Institute of Global Health, University College London, United Kingdom
  7. Universidad Autonoma de Madrid, Ciudad Universitaria de Cantoblanco, Spain
  8. Mortimer Market Centre, Central and North London NHS Foundation Trust, United Kingdom
  9. Stellenbosch University, Faculty of Medicine and Health Sciences, South Africa
  10. Department of Global Health, Brighton and Sussex Medical School, University of Sussex, United Kingdom
  11. Africa Health Research Institute, South Africa
  12. Collaborative Centre for Inclusion Health, University College London, United Kingdom
  13. Division of Infection and Immunity, University College London, United Kingdom
2 figures and 2 tables


Characteristics of HBV in inclusion health populations.

(A) Illustration of the overlapping characteristics that may be present among different inclusion populations and people living with HBV infection. (B) Relationship between migrancy and asylum-seeking status as a risk factor for HBV infection. (C) Representation of complex relationship between HBV infection and PEH, where other factors include for example injecting drug use, transactional sex, mental illness (Freeland et al., 2021; Ly et al., 2021a). HBV – hepatitis B virus; PEH - People experiencing homelessness. Figure created in with a licence to publish.

Solutions for service development to overcome barriers for people living with hepatitis B virus (HBV) infection in inclusion health populations, applying framework suggested by Charania et al., 2020.

Figure created in with a licence to publish.


Table 1
Top 20 origins of international migrants in 2020 (millions), HBV prevalence and progress towards SDG 30 goals for elimination of HBV as a public health threat.

Data - United Nations Department of Economic and Social Affairs, Population Division (2020b). International Migrant Stock 2020.; The Polaris Observatory, CDA Foundation; HBV – Hepatitis B virus. SDG – Sustainable Development Goal.

Country of OriginNumber of International Migrants (millions)HBV Prevalence*90% Diagnosed80% Treated65% Reduction in MortalityReduced Prevalence in 5 year olds
United Kingdom4.71%2051205120512020
  1. *

    Green -Low HBV prevalence (<2%); Amber - intermediate HBV prevalence (2–8%); Red - high HBV (prevalence >8%).

  2. Green - HBV SDG reached before 2030; Amber - SDG reached 2031–50; Red - SDG reached >2050.

Table 2
Key review and study observations pertinent to HBV infection among inclusion health populations.
Inclusion health populationCitationStudy typeCountryKey observations
PEH, PWID, Incarcerated individuals, sex workersAldridge et al., 2018Systematic Review and Meta-analysisHigh-income countries
  • 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%

PWID, PEH, Previous incarcerationTaylor et al., 2019Cross-sectionalUK
  • 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)

MigrantsPrestileo et al., 2022Cross-sectionalItaly
  • 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)

Colucci et al., 2022Cross-sectionalItalyIncreased risk of BBV acquisition persisted after arrival in Italy, possibly due to living conditions, sex work, lack of access to healthcare and social support
Mazzitelli et al., 2021Cross-sectionalItaly
  • 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

Armitage et al., 2022Cross-sectionalUK
  • 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

Williams et al., 2020aCross-sectionalUK
  • 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)

Eborall et al., 2020QualitativeUK
  • 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

Tasa et al., 2021Retrospective cohortFinland
  • 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 2nd or 3rd trimester

Bierhoff et al., 2021Mixed-methodsThailand
  • 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

PEHLy et al., 2021aNarrative reviewGlobal
  • 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

Al Shakarchi et al., 2020Systematic review and meta-analysisGlobal
  • 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)

PWIDDegenhardt et al., 2017Multistage systematic reviewGlobal
  • 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

People who misuse alcoholMagri et al., 2020Systematic review and meta-analysisGlobal
  • 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%)

Incarcerated peopleDolan et al., 2016Systematic review and meta-analysisGlobal
  • 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%)

Nakitanda et al., 2021Descriptive analysisEurope
  • 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

Kamarulzaman et al., 2016Narrative reviewGlobal
  • 25% PWID initiate drug use in prison

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

Dana et al., 2013Cross-sectionalIran
  • 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)

Sex workersSchuelter-Trevisol et al., 2013Cross-sectionalBrazil
  • 3 cities, southern Brazil

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

  • 3.4% HBsAg positive

  • Baseline prevalence <2% in Brazil

Miranda et al., 2021Cross-sectionalBrazil
  • 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)

Matos et al., 2017Cross-sectionalBrazil
  • 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)

Leuridan et al., 2005Cross-sectionalBelgium
  • 129 MSWs

  • 3.3% HBsAg positive

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

Mak et al., 2003Cross-sectionalBelgium
  • 1096 SWs (97.8% female)

  • 0.6% HBsAg positive

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

Dos Ramos Farías et al., 2011Cross-sectionalArgentina
  • 273 trans female sex workers (TSW), 114 MSW

  • HBV exposure 40% TSW, 22% MSW

  • Total HbSAg prevalence 1.6%

Todd et al., 2010Cross-sectionalAfghanistan
  • 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)

Jeal and Salisbury, 2004Cross-sectionalUK
  • 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

Bitty-Anderson et al., 2021Cross-sectionalTogo
  • 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)

Roma and Traveller populationsMacejova et al., 2020Cross-sectionalSlovakia
  • 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)

Gregory et al., 2014Cross-sectionalUK
  • 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)

Veselíny et al., 2014Cross-sectionalSlovakia
  • 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)

Indigenous PopulationsDavies et al., 2019Cross-sectionalAustralia
  • 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

Qama et al., 2021Retrospective cohortAustralia
  • 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)

Einsiedel et al., 2013Retrospective cohortAustralia
  • 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

Osiowy et al., 2013Narrative reviewUSA, Canada, Greenland
  • 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

Russell et al., 2019Systematic reviewLatin America
  • 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)

  1. SMR Standardised Mortality Ratio; aOR adjusted odds ratio; OR odds ratio; RR relative risk; CI confidence interval; HBV hepatitis B virus; UI Uncertainty Interval; MSM men who have sex with men; PEH people experiencing homelessness, PWID people who inject drugs; UASC unaccompanied asylum-seeking children; HBsAg Hepatitis B surface antigen (active HBV infection); HBc Hepatitis B core antibody

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  1. Emily Martyn
  2. Sarah Eisen
  3. Nicky Longley
  4. Philippa Harris
  5. Julian Surey
  6. James Norman
  7. Michael Brown
  8. Binta Sultan
  9. Tongai G Maponga
  10. Collins Iwuji
  11. Stuart Flanagan
  12. Indrajit Ghosh
  13. Alistair Story
  14. Philippa C Matthews
The forgotten people: Hepatitis B virus (HBV) infection as a priority for the inclusion health agenda
eLife 12:e81070.