Refugee Health Screening Guidance
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Domestic Refugee Health Screening Guidance
Viral Hepatitis Screening
Last updated: July 2022
Minnesota viral hepatitis screening recommendations
Hepatitis B (HBV)
- All newly arriving refugees should be tested for HBV infection regardless of overseas medical examination results. Serologies for hepatitis B should include HBsAg, hepatitis B surface antibody (anti-HBs), and total hepatitis B core antibody (anti-HBc).
- Those who do not have HBV infection or immunity should be offered hepatitis B vaccination series according to the ACIP-recommended schedule. Partial vaccine series should be completed regardless of immunity status, as long as the patient does not have HBV infection.
- Clinicians should provide further evaluation and management for people whose serologic testing indicates prior or current HBV infection, through continuing care or referral. In this case, hepatitis B vaccination is not indicated.
- Screen all household and sexual contacts of HBsAg-positive arrivals.
- Those who are HBsAg positive should be tested for Hepatitis D.
- Follow reporting guidelines and hepatitis B management best practices.
Hepatitis C (HCV)
- Universal hepatitis C screening should be implemented for all new adult arrivals (≥18 years of age). Testing should consist of anti-HCV and, if positive, HCV RNA testing.
- Hepatitis C screening is recommended for all pregnant women during each pregnancy.
- Hepatitis C screening is not routinely recommended for children <18 years old but is recommended for unaccompanied refugee minors, children with risk factors, and children born to HCV-positive mothers.
Other forms of viral hepatitis
- Routine screening for hepatitis D virus (HDV) infection is not recommended. Testing is recommended for those who are HBsAg-positive.
- Routine screening for hepatitis A virus (HAV) infection is not recommended. HAV vaccination is recommended for children in accordance with ACIP recommendations, as well as select adults.
- Routine screening for hepatitis E virus (HEV) infection is not recommended.
Microlearning series: Viral hepatitis
This video (under 5 minutes) is meant to serve as a summary of viral hepatitis screening guidance and resources for providers completing the refugee health screening and all those serving new arrivals.
- If the last recorded dose of hepatitis B vaccine was given less than 30 days before the refugee is screened for hepatitis B infection, the HBsAg result might reflect the vaccine antigen. If positive, the HBsAg test should be repeated once 30 days have passed from the last hepatitis B vaccine dose.
- Hepatitis C screening for children born to HCV-positive women should be performed after 18 months of age, due to the presence of maternal antibodies. If earlier testing is desired, HCV RNA testing can be considered as early as 2 months of age.
- Because anti-HCV testing in children younger than 18 months may be falsely positive due to detection of passively acquired maternal antibody, testing prior to age 18 months should consist of HCV RNA testing.
Best practices in management of chronic hepatitis
- Diagnoses of acute or chronic hepatitis should be clearly indicated in the patient’s electronic medical records and reported to MDH (Reporting Hepatitis). Please note that submission of the refugee health screening result form does not replace mandatory disease reporting forms.
- It is important for patients to be connected to care beyond their initial screening if they are found to be living with viral hepatitis. Consider clinic workflows and patient support that may be available to ensure patients are not lost to follow up. Care managers or community health workers can help patients to ensure continued access to and utilization of care.
- Hepatitis C is curable. Discuss treatment options with the patient. As refugees generally have access to insurance coverage upon arrival and may not have consistent access to insurance over time, it is appropriate to prioritize timely treatment.
- There are treatments for hepatitis B that can improve long-term outcomes. Because refugee patients have generally had very limited access to primary and preventative health care, careful patient education regarding the need for on-going monitoring is important. Providers should discuss the chronic diagnosis of hepatitis B and make clear recommendations for lifelong screening for hepatocellular carcinoma even though patients may be asymptomatic. It is helpful to explain clearly the benefit of early detection. Culturally sensitive patient education should be provided. Written materials should be in the refugee’s preferred written language and should supplement (not replace) other mediums of communication.
Background and epidemiology
Each type of viral hepatitis may cause illness during acute infection (two weeks to six months following exposure). Although acute viral hepatitis can be severe or fatal, it is often asymptomatic. HAV and HEV cause predominantly acute hepatitis and are the leading causes of symptomatic viral hepatitis infections globally. Acute infections caused by HBV and HCV commonly become chronic, persisting for decades and often silently damaging the liver. Chronic HBV and HCV infections result in a high disease burden and are leading causes of cirrhosis (late-stage scarring of the liver) and hepatocellular carcinoma (liver cancer) in the United States and globally. As chronic HBV and HCV infections are frequently asymptomatic and refugees often come from settings where these viruses are endemic, it is important to consider these infections during the domestic medical screening for newly arrived refugees.
In many parts of the world, perinatal and neonatal transmission is a primary driver of hepatitis B infection rates. Early exposure to HBV is particularly problematic as the risk of chronic hepatitis B virus infection is higher when infection occurs at an early age. Thus, universal screening for hepatitis B is appropriate and important, regardless of the age and vaccine status of the individual or clinical assessment of other exposure risks rooted on the epidemiology in the U.S.
The areas with the highest prevalence of hepatitis C are in Western Africa, Russia, and portions of the Middle East. Worldwide, hepatitis C is most commonly transmitted through injection drug use and unsafe medical practices.
Prevalence of HBV among Primary Refugees to Minnesota, 2009-2019
|Age at RHA||Received RHA*||Tested for HBV (%)**||HBV+ at RHA (%)|
|Under 5||2,584||2,410 (93%)||9 (<1%)|
|5-14||5,076||4,910 (97%)||88 (2%)|
|15-24||4,491||4,345 (97%)||295 (7%)|
|25-44||5,563||5,409 (97%)||429 (8%)|
|45-64||1,914||1,850 (97%)||160 (9%)|
|65 and older||439||419 (95%)||29 (7%)|
|Total||20,067||19,343 (96%)||1,010 (5%)|
|Region of Origin***||Received RHA||Tested for HBV (%)**||HBV+ at RHA (%)|
|East Asia/Pacific||38||37 (97%)||0 (0%)|
|Eastern Europe||778||706 (91%)||15 (2%)|
|Latin America/Caribbean||223||214 (96%)||1 (<1%)|
|North Africa/Middle East||1,368||1,340 (98%)||4 (<1%)|
|South/Southeast Asia||8,531||8,378 (98%)||594 (7%)|
|Sub-Saharan Africa||9,129||8,668 (95%)||395 (5%)|
|Total||20,067||19,343 (96%)||1,010 (5%)|
*Refugee Health Assessment (RHA): health screening done in U.S., usually within 90 days of U.S. arrival
**Tested for HBV using Hepatitis B Surface Antigen (HBsAg) test during post-arrival RHA; % among those who received RHA
***Based on MDH's world regions
Minnesota hepatitis surveillance data, provider resources, serology interpretation guides, and provider best practices.
- Reporting Hepatitis
Hepatitis (all primary viral types including A, B, C, D, and E) must be reported to MDH within one working day.
- Reporting Hepatitis
- CDC: Division of Viral Hepatitis
National data on hepatitis, hepatitis outbreak information, provider and patient resources, and the Division of Hepatitis Strategic Plan.
- MedlinePlus: Health Information in Multiple Languages
- The Refugee Patient Education Project of CNY: Hepatitis B
- Refugee Health Technical Assistance Center: Health Education
- Hep B United: Hep B Education Materials