• Migration
• Hepatitis C
• Hepatitis B

The World Health Organization estimates that approximately 350 million people are infected with the hepatitis B virus (HBV)1 and that over 170 million individuals are chronically infected with the hepatitis C virus (HCV).2 The majority of those who are infected live in the developing world and, although the incidence of these infections is declining in many Western countries,3 these viruses continue to spread in many countries. For example in Egypt, parenteral therapy for schistosomiasis administered between 1961 and 1986 led to an epidemic of chronic hepatitis C4 and recent reports suggest that the incidence is increasing once again in Egypt due to the reuse of needles for medical injections and other iatrogenic causes.5 6 It is therefore probable that the current discrepancy between disease burden in developed and developing nations will continue to widen and here we argue that the reduction in disease burden in the developed world should not lead to a reduction in engagement with these viruses.

Migration is one of the defining issues of our times. For example, more than 5 million Canadians were born outside the country and approximately 250 000 new immigrants arrive in Canada each year. With an increasingly interconnected world due to travel and migration, health trends in one location have both local and global implications since infectious diseases do not remain geographically isolated. There is a paucity of data on many migration related health issues but there is a growing body of data demonstrating an increase in the burden of migration-related chronic viral hepatitis in Western societies. The UK Hepatitis Foundation estimated in 2007 that the number of hepatitis B cases in the UK doubled in the previous 6 years chiefly due to migration of infected people,7 many from the new member states of the European Union where the prevalence of viral hepatitis is often high. In a study of infectious diseases in immigrants from sub-Saharan Africa and Latin America in Spain, chronic viral hepatitis (19%) was among the most frequent diagnosis along with tuberculosis, filariasis, intestinal parasites, and malaria.8 In Sweden a high incidence of primary liver cancer was detected in immigrants from hepatitis B endemic regions including East Asia and sub-Saharan Africa as well as an increased incidence in migrants from areas of intermediate HBV prevalence.9 In the UK data from the Health Protection Agency shows that the mortality and morbidity from chronic hepatitis C is rising disproportionately in immigrants10 and the prevalence of viral hepatitis in people born in Pakistan is many fold greater than that seen in the indigenous population.11 Data from the UK Transplant Centre shows that over 20% of transplants for chronic HCV over the last few years were performed in patients belonging to ethnic minorities (data kindly provided by Professor Neuberger, UKTCC). Thus there is abundant data demonstrating a growing disease burden from chronic viral hepatitis in immigrant communities both in Europe and elsewhere.

The long-term costs arising from patients with chronic viral hepatitis are considerable. Effective therapies are expensive and the clinical consequences of advanced liver disease including cirrhosis, end stage liver disease and hepatocellular carcinoma place an enormous burden on healthcare systems. This is a particular concern for countries with socialised healthcare systems, such as the UK, where healthcare is available for all. However, even in other healthcare systems, such as the United States where healthcare reform is currently a contentious political issue, legal and illegal residents without healthcare coverage are often untreated in the early phases of their disease but will eventually require, and be eligible for, expensive therapies when they present with end-stage disease. The costs of managing end-stage liver disease, including liver transplantation, are considerable and likely to increase as advances in available therapies increase the life expectancy of those with advanced cirrhosis. A computer simulated natural history model of hepatitis C in the United States estimated 165 900 deaths from chronic liver disease and 27 200 deaths from hepatocellular carcinoma between 2010 and 2019.12 An estimated $10.7 billion in direct medical expenses would be incurred due to hepatitis C alone and the rise in the disease burden from immigration is likely to increase the costs still further. Furthermore, the societal burden from premature death or disability due to chronic hepatitis and its complications added another $75.5 billion in indirect costs. These staggering figures are despite the remarkable decline in the incidence of hepatitis C in the United States.3 A similar natural history model from Spain demonstrated that despite a decline in the prevalence of hepatitis C, the proportion of patients with cirrhosis will rise, along with the associated costs of treating such patients.13 The Unites States and Spain are not alone in spending large sums of money in treating patients with chronic viral hepatitis, for example Scotland has announced a plan to spend over £40 million on managing hepatitis C over the next few years and Wales recently announced a £1.37 million plan to address hepatitis B and hepatitis C.

Given the high costs of managing patients with chronic viral hepatitis and given that the disease is particularly common in the developing world the costs of managing viral hepatitis are likely to be substantially increased by immigration from areas of high prevalence. There are several possible approaches Western societies could take to this problem. The most extreme is to perform mandatory testing for viral hepatitis on all potential immigrants and bar those who test positive from entry. This policy was debated in the Australian territory of Norfolk Island in 2002 and a number of Middle Eastern countries already practice this form of discrimination. In July 2008, the United Arab Emirates mandated that hepatitis C testing be done at the time of residence visa renewals and added hepatitis C to HIV, tuberculosis, and hepatitis B as diseases warranting deportation. The ethics of mandatory testing and overt discrimination is questionable to say the least (and may not be legal under EU legislation) and discriminating against skilled migrants with a treatable disease may be disadvantageous. An alternative approach is to identify infected migrants as soon as possible and arrange appropriate healthcare. For example The Migrant Clinicians Network in the United States recommends that all primary care and public health clinics should incorporate questions about risk factors for hepatitis, immunisation history, and history of liver disease in their routine medical assessment of migrants.14 They also advise that since immigrants may not develop a long-term continuity of care relationship with a clinician, it is important to offer HBV vaccination at any encounter with such a patient. Acceleration of the HBV vaccination series is also permissible.15 16 These guidelines apply to children, adolescents and adults, in whose home countries routine HBV vaccination may not have been practised when they were young. The Institute of Medicine in the United States recently made recommendations for the prevention and control of hepatitis B and C. Among them was the recommendation for an ‘expansion of community-based programs that provide hepatitis B screening, testing and vaccination services for foreign born populations’.17 In the long term a new approach will be required and the issues of chronic viral hepatitis may be best addressed as a global problem. Strategies to reduce infection, with an emphasis on universal HBV vaccination and policies to reduce the incidence of new infections with hepatitis C, are likely to prove valuable in the long term. In particular, the practice of reusing needles is one of the commonest causes of chronic hepatitis in the developing world and unsafe injection practices are estimated to be responsible for 21 million new hepatitis B virus infections and two million hepatitis C virus infections a year.18 Data from the World Health Organization suggest that the average South Asian receives five injections every year and it is probable that the majority are from inadequately sterilised equipment.19 As a result approximately 80% of hepatitis C infections in Pakistan can be attributed to this practice. Problems with needle reuse are not limited to the developing world as in 2009 it was discovered that at a rural hospital in Alberta, Canada, syringes designed for single use were being reused. The WHO programme on Blood Transfusion Safety monitors key safety parameters to assess the safety of the world's blood supply and, according to their 2007 Blood Safety Survey, 41 of 162 countries were not able to screen all blood donations for at least one transfusion transmissible infection (hepatitis B, hepatitis C, HIV and syphilis).20 In a recent study examining the safety of the blood supply in an area of rural China, the sensitivity of hepatitis screening tests was unacceptably low and could potentially cause a large number of infections in blood recipients.21 In Pakistan's largest city, Karachi, with a population of approximately 13 million, only 23% of blood banks screen blood products for hepatitis C.22 Reducing the prevalence of viral hepatitis in immigrants will require sustained efforts to abolish these unsafe medical practices that, eventually, threaten the developed as well as the developing world.

Another key pathway to prevention is vaccination against HBV. The UK is one of the few countries where selective rather than universal HBV vaccination is practised because of its low endemic infection rate. In an era of mass migration from countries with high prevalence of chronic hepatitis B this policy should be reviewed and reconsidered; the societal consequences of large numbers of acute hepatitis infections resulting from contact with immigrants may be considerable. Perhaps the greatest obstacle to better control of the hepatitis problem is a lack of awareness about the issue amongst both the general public and healthcare providers. As a result adequate resources are not allocated to prevention, control and surveillance programmes.

Global research priorities need to be refocused on ways to reduce the overall chronic viral hepatitis burden through better prevention and treatment. Current research and drug development is geared towards Western markets where the incidence of these diseases is declining. The needs of the developing world are often overlooked and this is where the bulk of infections occur and where most infected patients live, some of whom may present on the shores of Western countries as immigrants. Chronic viral hepatitis is thus a global problem that requires global solutions. The 34 members of the WHO Executive Board recently drafted a resolution on viral hepatitis which is to be debated at the 63rd World Health Assembly in Geneva in May 2010.18 This resolution, among other things, emphasises that viral hepatitis should be a global priority and has to be tackled globally. If adopted, this resolution would, for the first time, offer a framework for international action to prevent, diagnose and treat hepatitis C and B. Western societies can not isolate themselves from these infections and efforts to improve disease control can not be restricted to their borders. Since unsafe healthcare practices are common in many parts of the world, a global focus on safe blood supply and safe injections is needed. The World Health Assembly has already adopted resolutions related to blood supply and injection safety23 24 and the remaining major issues in dealing with the global problem of chronic viral hepatitis are quite clear: improved awareness about the global hepatitis problem, universal vaccination against hepatitis B, ensuring safe healthcare practices including safe injection and blood supply practices, and early diagnosis and treatment of infected patients. Such an approach is both humane and in the long-term self interest of developed nations.