Keeping Refugees With Hepatitis B in Care: A Three-City Evaluation, 2006–2018

An estimated 257 million people worldwide live with chronic hepatitis B virus (HBV) infection. Untreated, it leads to liver cirrhosis or liver cancer (hepatocellular carcinoma) in 15% to 25% of adults who were infected as infants or children, so people with chronic HBV need regular, lifelong monitoring. CDC recommends HBV testing for people from countries where 2% or more of the population is infected, including newly arriving refugees. But what happens after a refugee tests positive? Three urban clinics that perform refugee medical examinations evaluated how many patients got into care and stayed there. (The report was later corrected by an erratum; this page follows the corrected version.)

How the clinics checked

Each clinic reviewed the charts of refugees who tested positive for hepatitis B surface antigen (HBsAg) at their domestic medical examination, treating that result as a sign of presumed chronic infection. Patients not receiving what the clinic considered optimal care were called, using standardized scripts and certified medical interpreters, given information about HBV, urged to follow up, and advised to reconnect with a primary care provider if they had moved away. Clinics also sent messages on HBV best practice to primary care providers in their health systems.

The three clinics

Clinic A, Denver, Colorado (examinations 2006–2012). A state public health refugee screening clinic referred all HBsAg-positive patients to a gastrointestinal specialist and in 2016–2018 reviewed charts and called patients.

• Of 306 refugees who tested positive, 204 were evaluated.
• 29% (60) had initial linkage to care, 12% (24) were retained in care, and 84% (172) were not receiving optimal care.
• Despite outreach, 71% were lost to follow-up, and one patient was confirmed to have died of liver cancer.

Clinic B, St. Paul, Minnesota (examinations 2008–2017). This clinic gave primary and ongoing HBV care to some patients and ran all follow-up blood tests as standard, so initial linkage was not measured.

• Of 310 who tested positive, 137 adults with recent care in the health system were included, and 21% (29) were retained in care.
• Of the 108 not in optimal care, some were current on tests and ultrasound but had not seen a specialist, some agreed to come back, and some reported getting care elsewhere. 28% could not be reached by phone, and one person declined follow-up because they had no health insurance.

Clinic C, Philadelphia, Pennsylvania (examinations 2007–2018).

• 53 refugees tested positive. 53% were initially linked to care, 11% were retained, and 47 (89%) were not receiving optimal care.
• Of the 42 of these whom staff tried to reach, 69% could not be located, 10% were not in care, 14% were seeing an outside provider and 7% had moved away.

What it shows

Although HBV screening of new refugees is recommended, there is no mechanism to make sure those who test positive get counseling and evaluation for treatment. Few attended initial hepatitis B appointments at the two clinics that measured it, and retention was low everywhere, from 11% to 21%, much like a study of mostly Asian immigrants that also found chronic HBV poorly managed. Chasing patients years later proved labor-intensive and low-yield.

The authors suspect — though they did not measure it — that the reasons include too little counseling at diagnosis, difficulty navigating the U.S. health system with limited English, transportation problems, lack of insurance, and competing needs such as work and income. They call for thorough, standardized counseling at diagnosis and every follow-up visit, removing barriers to care, and tracking patients' follow-up in real time.

Limitations

• Each clinic used its own definitions of linkage and retention.
• Patient populations, community support, education and cultural views of health care differed by site.
• Clinics could see only their own records, so some refugees may have been in care elsewhere.
• A single positive HBsAg test may overstate the number with chronic infection.

Sources

• Janine Young, Colleen Payton, Patricia Walker, Daniel White, Megan Brandeland, Gayathri S. Kumar, Emily S. Jentes, Ann Settgast and Malini DeSilva, "Evaluation of a Program to Improve Linkage to and Retention in Care Among Refugees with Hepatitis B Virus Infection — Three U.S. Cities, 2006–2018," Morbidity and Mortality Weekly Report, CDC, with its published erratum: https://www.cdc.gov/mmwr/volumes/69/wr/mm6921a2.htm
• The source's summary range for patients who could not be located does not match the clinic figures in its results; this page gives only the clinic figures.