Eliminating Hepatitis amongst Migrant Population
HepBClink is a micro-elimination project to improve diagnosis of viral hepatitis B and C, and provide linkage to care and treatment among Barcelona-based adult migrants from hepatitis-endemic countries. The initiative makes use of decentralised community-based interventions and applies the lessons of a previous pilot targeting hepatitis C elimination among migrants from Pakistan (HepClink; Martró E, et al. Liver Int 2022).
HepBClink is led by the Research Group on Clinical Virology and New Diagnostic Tools at the Germans Trias i Pujol University Hospital and Research Institute (IGTP) – Microbiology Department (LCMN), and carried out together with the Community and Public Health Team (ESPiC) at the Drassanes-Vall d’Hebron Centre for International Health and Infectious Diseases. Additionally, the research team counts with hepatologists at Germans Trias i Pujol and Vall d’Hebron hospitals, epidemiologists from the Center for Epidemiological Studies of Sexually Transmitted Diseases and AIDS in Catalonia (CEEISCAT) and policymakers from the Public Health Agency of Catalonia.
Viral hepatitis B and C prevalence in the general population of Catalonia is low (0.52% for HBsAg, 1.02% for anti-HCV antibodies and 0.49% for HCV RNA ) but there is a high proportion of adult migrants from endemic countries residing in Barcelona. The actual prevalence of HBV and HCV amongst this sub-population is mostly unknown. Healthcare access for Senegalese, Pakistani or Romanian adult migrants is often adversely affected by cultural/language barriers, social vulnerability, and a fragmentation in the health services which makes them difficult to navigate. Decentralized community-based screening strategies in collaboration with community organizations have been shown to overcome these barriers, increasing testing and simplifying access to treatment, enabling a more equitable approach. Such projects are more pertinent than ever in view of the COVID-19 pandemic, which has been associated with lower diagnosis and treatment rates for viral hepatitis.
Community-based interventions are carried out by individuals of the same origin as the target population, either individually or in small groups, as well as in collaboration with community organizations, consulates and churches. Initially, participants are educated on viral hepatitis with the help of an interactive and multi-lingual tool (HEPARJOC) installed on a tablet. Rapid tests for hepatitis B (HBsAg) and C (HCV antibody) are then distributed and, from those who test positive, dried blood spot (DBS) samples are collected for a confirmatory diagnosis in a laboratory. Those infected are linked to care and treatment via the International Health Unit with direct referral to an hepatologist (reference hospital), which is a simplified procedure from the normal primary care route. Additionally, HBV vaccination is recommended to patients’ close contacts, such as household members, and to those participants who tested negative and are not yet vaccinated. To ensure treatment initiation and follow-up, participants are accompanied to their appointment with a physician by community health agents when required.
Since the outbreak of the COVID-19 pandemic, over 490 adult migrants have participated. Whilst around 60% had no awareness of viral hepatitis B and/or C, the initial information session convinced all (100%) to agree to testing (previously, only around 10% reported having been screened). Six individuals were diagnosed with hepatitis C and 22 have tested positive for hepatitis B. As regards hepatitis B vaccination, 9% reported having been vaccinated and 40% did not know their vaccination status. Altogether, preliminary prevalence data based on rapid tests in Romanian and Senegalese adult migrants is estimated at 2% and 7.7% respectively for hepatitis B, and at 1% and 0.4% for hepatitis C. These are provisional results as the project is still ongoing.
Community-based interventions by individuals of the same origin as the target population are an effective tool to improve education, diagnosis and linkage to care for hepatitis B and C among adult migrants from endemic countries. Such interventions are especially relevant in view of the low awareness of viral hepatitis and the observed higher prevalence than in the general population, which justify such targeted outreach. The Public Health Agency of Catalonia is scaling the model to accelerate viral hepatitis elimination by 2030.
The HepBClink project (PI19/0568) is co-funded by Instituto de Salud Carlos III and the European Regional Development Fund “A way to make Europe”. A. Not, one of the researchers, holds a PFIS predoctoral grant (FI20/00211) from Instituto de Salud Carlos III, co-funded by Fondo Social Europeo.