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Recommendations on the prevention and control of hepatitis B in migrant populations (September 1999)

Mass migration and increased mobility are modern phenomena that are having a tremendous impact on the epidemiology of hepatitis B infection and on national prevention programmes. Mobile populations are heterogeneous and include people from all walks of life and backgrounds. In addition, the speed and efficiency of modern transportation systems make it a challenge to introduce health interventions to mobile populations and to monitor the effectiveness of these programmes.

At the September 1999 meeting in Venice, the VHPB examined the current situation, taking particular note of the immigration trends in Europe, put forward recommendations on how to define the healthcare problems brought about by mass migration and to formulate national healthcare policy that will protect the individual and the society. What follows are definitions of different migrant populations and recommendations on what elements need to be included in successful hepatitis B prevention programmes aimed at migrant populations.

Migrant populations

Migrant populations are diverse. Those who would be considered as risk groups for hepatitis A and/or B would include:

• asylum seekers and refugees
• internal migrants moving from rural to urban areas and back, migrating because of:
• economic considerations
• natural disasters and political upheaval
• development projects
• international guest workers, both seasonal and long-term
• frequent travellers
  • businessmen
  • professionals
  • air crews
  • seamen
  • truck drivers
  • civil servants
• military personnel
• tourists
• immigrants/permanent migrants
• unofficial migrants
• students
• spouses of international marriages
• children adopted internationally

All of these groups have specific healthcare and psycho-social needs which should be addressed. The VHPB proposes that routine immunization remains the best tool for the long-term prevention of HBV and HAV, together with education and counselling of migrants and the healthcare workers who serve these populations.

Recommendations

• HBV vaccination should be offered to all migrants coming from high prevalence areas to low prevalence areas. Immunization programmes should include screening and counselling.
• Migrants should be screened for HBsAg and anti-HBc. All susceptible persons should be immunized against HBV.
• When HBV carriers are identified, they should be offered:
  • counselling
  • an evaluation of the possible treatments available
  • follow-up for chronic liver disease
  • benefit of confidentiality
• New-borns of HBV carrier mothers should be immunized at birth, or as soon after as possible.
• HAV vaccination should be given to frequent travellers at risk and to all military personnel.
• Providing the blood supply is safe, migrants are not a risk for community-wide transmission of HCV.

Immigrant workers

• All incoming healthcare workers should be vaccinated, as is the recommendation for all healthcare workers. Screening healthcare workers for chronic HBV and HCV is not indicated.

Adopted children

• Candidate adoptive parents should receive counselling so that they understand fully the issues of international adoption.
• Candidate adoptive parents should have access to reliable information on the hepatitis B status of the perspective adopted child before the adoption takes place. However, they should be aware that not all screening information is reliable.
• The VHPB recommends that the adopted child be re-tested as soon as possible after arriving in the home country of the parents.
• All household contacts should be vaccinated if the adopted child is HBsAg-positive.
• All children in foster care or in institutional care should receive HB immunization.

Refugees and asylum seekers

Refugees and asylum seekers fall into two categories: those who are relocated by government programmes and are living in organized camp settings; and those who have moved on their own under no organized programme.

Management in camps

• It is imperative that all relief workers and staff of refugee camps be immunized for hepatitis A and hepatitis B, ideally, before arriving in the camps or alternative, immediately upon arrival.
• Immunization of all refugees for hepatitis A to prevent outbreaks of infection in the camps is recommended in low endemic countries. Good general hygiene is also a necessary preventative measure. Vaccination for hepatitis A is not a priority in high endemic countries, but is recommended in countries of intermediate endemicity for hepatitis A.
• As HBV and HCV are also sexually transmitted, information about transmission and prevention should be made available as part of any prevention programme.
• All injections should be delivered according to safe medical practice.

Refugees identified for resettlement and asylum seekers

• HB immunization should be carried out:
• without anti-HBc screening of children in recipient countries where routine infant immunization is in place;
• after anti-HBc screening for all age groups in recipient countries where routine HB immunization is not yet implemented.
• Anti-HBc screening and vaccination should be performed in adults.
• Testing should not be related to the outcome of the integration process, but should be performed in the interest of individual and public health.
• Refugees should receive culturally appropriate information on screening and vaccination.
• All countries are strongly encouraged to exchange epidemiological information on refugees.

Sex workers

Sex workers include men, women and transgender persons who provide sex for money or remuneration. Immigrants have rapidly become a major proportion of the sex worker population in many countries. In the EU, an average of 40% of sex workers are foreign born. Immigrant sex workers bring the viral hepatitis epidemiology of their country of origin, although in some cases the prevalence rates of HBV and HCV may be higher or lower than that found in their countries of origin.

Although sex work is illegal in many countries, the goal of disease prevention is to ensure that these people are served by the public health authority and that they have access to healthcare services.

Sex workers are at occupational risk of sexually transmitted diseases, including hepatitis B and, to a lesser extent, hepatitis A. Drug use among sex workers may increase the risk of infection by blood-borne pathogens, particularly hepatitis C.

Clients of sex workers are at increased risk of HBV infection and this risk is highest from those immigrant workers from countries with a high endemicity of infection. The limited data available suggest that legal residents of a country working in the sex trade are more likely than illegal immigrant workers to practice safe sex. However, it is essential that the extent of these practices be determined.

Recommendations

• Routine immunization of all sex workers should be carried out, irrespective of the person’s legal status. Vaccination programmes should be adapted to meet the needs of these diverse populations in order to achieve high levels of coverage.
• As many sex workers have no insurance coverage and limited access to healthcare, hepatitis B immunization should be available at no charge. Clients should also receive vaccination at no charge.
• Vaccination should be initiated irrespective of whether completion of the three-dose series can be ensured.
• There is a need to extend currently existing outreach and prevention programmes for sex workers to include immigrant sex workers.
• Health education messages should be directed at both the sex workers and the clients.

Confidentiality and appropriate counselling are essential to the success of any prevention programme targeting sex workers.