Refugees with HBV Infection Often Do Not Link with Appropriate Long-Term Care

Refugees entering the US who are infected with hepatitis B virus (HBV) often do not connect with appropriate long-term follow-up care after they arrive in the country, according to a new report.

Chronic HBV infection affects an estimated 257 million people around the world, and those patients face increased risks of a number of serious complications, including cirrhosis and hepatocellular carcinoma, if left untreated.

Many refugees who are resettled in the US come from countries with intermediate or high prevalence of the disease. The US Centers for Disease Control and Prevention (CDC) already recommends universal HBV screening for refugees from these countries, but Janine Young, MD, of the University of Colorado School of Medicine, said despite a tight screening regime, the rest of the patient journey was unclear.

She and colleagues decided to study the matter in hopes of providing clarity.

“Our question was: what happens to refugee patients after diagnosis?” she told Contagion®. Young said she and her team feared many of these patients are being lost to follow-up. In the May 29 edition of the CDC’s Morbidity and Mortality Weekly Report, she and her co-authors report that their fears proved well-founded.

To get to those results, Young and colleagues worked with 3 urban health clinics that provide care to refugees. The centers were located in Denver; St. Paul, MN; and Philadelphia.

The sites looked back at the medical charts of patients presumed to be infected with HBV during their domestic medical evaluations. They then performed prospective outreach.

The study found that at the Denver and Philadelphia sites, just 29% and 53% of infected patients were linked to HBV care, respectively (data were not available for the St. Paul site).

Only a fraction of patients were retained in a physician’s care for HBV, ranging from 11% in Philadelphia to 21% in St. Paul. Furthermore, the Denver clinic eventually could not locate 71% of its HBV patients, Philadelphia could not locate 69% of patients, and St. Paul could not locate 28%.

“This QI (quality improvement) collaboration clearly showed that more supports need to be provided for newly arriving refugees diagnosed with hepatitis B,” Young said. “There are many barriers to healthcare for new refugees and immigrants; our health systems are complex, appropriate language access is often difficult to negotiate for non-English speakers (including access to appointment centers, nurse advice, and pharmacy refill lines), and transportation to appointments and appointment times might be difficult to negotiate.”

Young said all refugees resettled in the US are given a health orientation soon after their arrival, with state-specific information about the healthcare system. However, she said these orientations are not standardized and thus may vary from one location to another.

“There are ongoing efforts to coordinate and standardize messaging around diseases such as hepatitis B, from the initial medical screening examination performed by the International Organization of Migration, to the US-based resettlement agencies, and to the US-based medical screening provider,” she said.

At the clinic level, Young said culturally matched patient navigators may be able to address many of the barriers outlined in the study.

“Health literacy may also play a significant role and there is a need to develop and evaluate teaching tools to explain hepatitis B as a chronic condition needing continued, lifelong, close follow-up,” she said.

In their report, Young and colleagues concluded that clinics must do more to facilitate better care for new HBV-infected refugees, and noting that care for these patients not only will improve their long-term health outcomes, but will also curb domestic transmission.