Hepatitis Among Mobile Populations

Viral hepatitis is an infectious disease caused by several different types of viruses that results in inflammation of the liver. Because of the broad array of risks that can result infection with the viruses, health clinics are encouraged to ask annually about hepatitis risks, and history of liver disease and immunization as part of standard medical assessment for mobile patients. Pregnant women are regularly evaluated for and immunized against Hepatitis. Among mobile patients in the US, young low-income men tend to present in clinics only with acute illness or injury, As a result, MCN recommends that, if the client’s condition permits, young men in particular be screened for hepatitis risk factors at any visit, even if they are presenting with unrelated illness or injury.

Hepatitis A

Hepatitis A is transmitted via a fecal-oral route. Though not chronic, hepatitis A can cause serious illness and loss of work time as well as being a more serious health risk to people with chronic liver disease and weakened immune systems. Adults are more likely to show symptoms of illness (jaundice, fatigue, abdominal pain, loss of appetite, nausea, diarrhea, fever) than children.  Mobile working poor persons may be at increased risk for hepatitis A due to lack of access to appropriate water and sanitation facilities while traveling, and substandard housing situations. In addition, hepatitis A is endemic to Mexico, Central and South America, and the Caribbean, and history of exposure is much more common in those countries than in the US. A complete travel history and questions about future travel can help a clinician determine whether a hepatitis A vaccine is warranted. Additionally, people with chronic or long-term liver disease, including hepatitis B or hepatitis C, should be vaccinated for hepatitis A.

Visit the Center for Disease Control and Prevention (CDC) site for further recommendations, resources, and information on hepatitis A and vaccination [1].

Hepatitis B

Hepatitis B is spread through blood or infected body fluids, via unprotected sex, sharing injection equipment, job-related needlesticks, and vertical transmission from an infected mother. In the US, hepatitis B is primarily a sexually transmitted infection. Adults are more likely to show symptoms of illness (jaundice, fatigue, abdominal pain, loss of appetite, nausea, vomiting, joint pain) than children, however, about 30% of those infected show no symptoms. Infection can be acute or chronic and chronic infection is more likely for persons infected in childhood. Chronic infection can lead to cirrhosis, liver cancer, and liver failure.

Vaccinations have reduced rates of hepatitis B throughout the world. By 2015, global coverage with three doses of the hepatitis B vaccine in infancy reached 84 percent.¹ Most people living with hepatitis B infection were born before the vaccination was widely available and administered soon after birth. Many parts of Central America and the Caribbean, where prevalence was once intermediate, are now boasting a prevalence of less than two percent. Africa and the Western Pacific region continue to have highest prevalence of hepatitis B cases. In the US, roughly 50 percent of patients with hepatitis B are Asian.

Vaccinating young adults against hepatitis B and testing persons born in countries that may have high rates of perinatal transmission of hepatitis B continues to be best practice for protecting the health of immigrant patients.

Read the CDC’s page on hepatitis B for health care providers [2] for more information.

Hepatitis C

Hepatitis C virus (similar to Hepatitis B) is typically spread through blood or infected body fluids, via sharing injection equipment, job-related needlesticks, and vertical transmission from an infected mother. Before we had the ability to screen our blood supply for Hepatitis C, patients may have inadvertently received Hepatitis C thru blood transfusions. Currently in the US, hepatitis C is primarily transmitted through sharing of injection drug needles and equipment. Hepatitis C is the most common chronic bloodborne infection in the US. Hepatitis C is often found to be chronic and can lead to liver failure. There is no vaccine against hepatitis C infection.

CDC recommends Hepatitis C testing everyone born between 1945 and 1965, current or former injection drug users, anyone who received clotting factor concentrates made before 1987, recipients of blood transfusions or organ transplants before July 2001, long-term hemodialysis patients, people with HIV, children born to mothers with hepatitis C, and anyone who has had a known exposure to hepatitis C. Additionally, the US Preventive Services Task Force recommends testing for people who are in jail or prison, people who snort drugs, and anyone with an amateur tattoo.

Since 2014, several short-duration, effective antiviral drugs have been in use. While medications are available, they remain expensive, particularly for a population that often is unable to access health insurance. Visit https://www.hcvguidelines.org/ [3] for more on current recommendations or the CDC’s Hepatitis C page [4] for an overview, current statistics, recommendations, and resources.

¹ Global Hepatitis Report 2017. World Health Organization. Available at: https://apps.who.int/iris/bitstream/handle/10665/255016/9789241565455-eng.pdf;jsessionid=F23850265244A5A2180F4671DED4FBE7?sequence=1 [5]