Hepatitis B Prevalence High in Refugees in Germany

The ongoing refugee crisis facing European countries as a result of conflicts in the Middle East presents a potential public health challenge—in addition to political, economic, social, and security issues—to governments already struggling with the influx of hundreds of new migrants on a daily basis.

A study presented April 16 at The International Liver Congress in Barcelona, Spain found that there is a higher prevalence of hepatitis B among refugees, when compared to German controls, and a low level of immunity to the disease within this population overall. Additionally, fewer than 20 percent of the refugees assessed had been immunized for hepatitis B.

“[Our study has] helped to characterized this vulnerable population, but further analysis and follow ups of the coming refugees are necessary in order to give sound recommendations [for the management of hepatitis B in this population],” study lead author, Philipp Solbach, MD, Department of Gastroenterology, Hepatology and Endocrinology, Medizinsche Hochschule, Hannover, Germany told Contagion. “Although we do not feel the incidence [of hepatitis B] is alarmingly high, we would stress the importance of looking carefully for clinical signs of infection and risk factors demanding testing on an individual basis.”

According to the Office of Migration and Refugees in Germany, nearly one million refugees from the Middle East applied for asylum in 2015 alone. The World Health Organization (WHO), meanwhile, reports that health needs from humanitarian emergencies are at an all-time high, with more than 11.5 million people in Syria, the nation of origin for many of the refugees arriving in Europe, and 5 million displaced persons in neighboring countries requiring medical care, including vaccines for infectious diseases. WHO estimates that more than $2 billion (US) will be required to fund this desperately needed care this year.

For their study, Dr. Solbach and his team tested 793 patients from all age groups for serological markers of hepatitis B virus infection (HBsAg and anti-HBc) and performed liver enzyme tests (ALT, AST, bilirubin, gGT, alkaline phosphatase) in refugee reception centers in northern Germany in August of last year. In addition, 258 patients were tested for anti-HBs antibodies.

The authors noted the presence of Hepatitis B, as measured by HBsAg, in 2.3 percent of people tested and, as measured by anti-HBc, in 14 percent of the study subjects. In all, there was a higher prevalence of hepatitis B within the study population than in German controls; however, the prevalence was comparable to other migrant populations in Germany, Dr. Solbach reported.

In addition, the group found that prevalence of HBsAg was higher in male patients (2.5 percent) and middle-aged to older patients (3.1 percent) than in female and younger patients. Male patients were also more likely to exhibit anti-HBc than female patients (14.5 percent vs. 13.5 percent), but those over the age of 50 were even more likely to be anti-HBc positive (38 percent). Furthermore, elevated ALT and AST were recorded in 15.9 percent and 5.8 percent, respectively, of the refugees studied, and 62 percent of the study subjects had no immunity to Hepatitis B. Only 18.6 percent of the study population had been vaccinated against the disease at the time of the study.

At present, according to Dr. Solbach, the German Standing committee on vaccination (STIKO) recommends vaccination for every refugee against hepatitis B following analysis of their serostatus. As a result, he added, every refugee seeking medical care at a reception center in the northern part of Germany was offered a blood testing for vaccination preventable infectious diseases, including seromarkers of hepatitis B infection and liver enzymes.

“When the results were available, we tried to re-identify the refugees and… offer vaccination or further diagnostics. One problem included the follow up of the patients, as in the meantime some were transferred to other locations and many have left the camp on their own,” Dr. Solbach said. “In Summer 2015, Germany was flooded by refugees in desperate need of medical care. We were asked to face this challenge, but did not know which infectious diseases to expect as data was scarce.”

“This new research demonstrates the potential impact of health policy across Europe,” Professor Tom Hemming Karlsen, Vice-Secretary, European Association for the Study of Liver, said in a statement. “Understanding the potential health implications of large scale migratory trends like the one Europe is currently experiencing can be challenging, however it is urgently needed. While this study looks at hepatitis B markers in isolation, there are potential implications for surveillance of communicable diseases across the board.”

Brian P. Dunleavy is a medical writer and editor based in New York. His work has appeared in numerous healthcare-related publications. He is the former editor of Infectious Disease Special Edition.