Screening immigrants for tuberculosis—why not for HBV infection?

[joebloggs]

In May 2012, the then Immigration Minister Damian Green announced a new scheme for the screening of immigrants to the UK from countries with a high incidence of tuberculosis before they are granted a visa for entry into the UK. The new measures were brought in as figures for 2011 showed over 9000 new cases of active tuberculosis in the UK, with non-UK born people accounting for three quarters of them.


If the government considers pre-entry screening to be worthwhile for tuberculosis, why not for hepatitis B virus (HBV) infection, the frequency of which has risen substantially in the UK as a consequence of immigration? The numbers involved are comparable with an estimated 6500 new cases of chronic HBV infection entering the UK each year. Over 90 000 immigrants have come from countries with high HBV prevalence (>8% HBsAg positivity, whereas prevalence in the UK is 0·25%).1 In 2007, 193 888 of the estimated total of 326 338 chronically infected people in the UK were born in other countries, double that in 2007 and today's figure is likely to be significantly higher.2 Eight of the ten top non-EU countries from which immigrants come are countries of high or intermediate (2—8%) HBV seroprevalence according to the UK Council for International Student Affairs. The CUSHI-B study—a survey of chronic HBV infection comprising patients in active follow—up attending 15 UK liver centres—showed that 81% of the 1 147 patients registered were born outside the UK.3 Individuals from Pakistan accounted for the highest number (15%) with persons born in Hong Kong and in China only a short way behind (11% and 12%, respectively). The Liver Unit in Birmingham, a city with a large immigrant population, has seen an almost five-fold increase in the number of new HBV referrals between 2001 and 2010.4 Resurgence of supra infection with the delta virus in HBsAg positive individuals is another important public health problem (especially in areas with substantial numbers of immigrants from Africa and Eastern Europe)5 because it creates a pool of infection resistant to antiviral therapy, and one associated with more rapid disease progression to cirrhosis.

read more here .. http://www.thelancet.com/journals/la...lltext?rss=yes

[Dedworth]

There should be a stringent screening process as in Australia

http://www.immi.gov.au/media/fact-sheets/22health.htm

[grahamw48]

I agree....also criminal record checks, including police clearance from country of origin, although admittedly, such documents from countries like Pakistan may as well be sheets of bog paper.

[Doc Alan]

The British experts writing in “ The Lancet “ make a valid case, in my opinion .


As with TB, a majority of UK people with chronic HBV infection were born in other countries. The Philippines is one country where HBV is much commoner than in the UK - at least 1/10 are “ carriers “ of HBV, meaning they could infect others ; compared to around 0.25% here. There are blood tests to detect HBV antibodies ( and antigens ).


Hepatitis ( liver inflammation ) can be caused by viruses ( A – E ), alcohol, or ( auto- ) immune reaction.


Hepatitis A results from poor sanitation / sewage disposal and while usually mild, can be prevented by vaccination, and usually recommended for travellers ( free on NHS ).


Hepatitis C is serious in most people, usually results from infected blood by needle-sharing when injecting drugs, and there is no vaccine.



Hepatitis B is transmitted through contact with blood or other body fluids of an infected person. This may include :- mother to baby; close contact in childhood ; unsafe injection practices / blood transfusion ; and unprotected sexual contact. Infants and children are most likely to develop chronic HBV infection ( with the risk of adult cirrhosis / cancer ). 9/10 healthy adults who are infected will recover. The pattern of transmission is different in high-incidence areas, like the Philippines and other Asian countries, compared to UK ( where injecting drug and sexual activity are the main risks ).



A safe vaccine is available for HBV ( with or without HBA ). HBV infection can be prevented if babies are vaccinated at / within 2 months of birth ( two “ jabs “ ) and 6-18 months ( 1 “ jab “ ) and is available free – to my knowledge, at least to 1 year old - in the Philippines. The vaccine is not routinely given in the UK – although there is now a case for vaccinating here, even if not travelling to high incidence countries.



Chronic HBV infection may need expensive antiviral drugs if investigations like biopsy show liver disease – the Lancet article quotes up to £5000(+) annually per patient.



Of course pre-entry screening for HBV would have cost implications for the country of origin, and therefore immigrants applying for visas - as with TB. But around 6,500 new cases of chronic HBV infection entering the UK each year is not far short of the 9,000 TB cases.


It’s illogical not to consider such screening. As the experts point out, it’s less efficient, and more expensive, to screen and treat migrants once they’re in the UK. Unfortunately the Philippines is one country which would be included in the list for pre-entry screening.


http://www.who.int/mediacentre/factsheets/fs204/en/

http://www.nhs.uk/conditions/Hepatit...roduction.aspx



For those who are interested, the discoverer of HBV, which ultimately resulted in a vaccine ( 1982 ) was Baruch Bloomberg. When I worked at Glasgow University, he visited us and we took him up Ben Lomond . Luckily he survived the climb , and received a Nobel Prize in 1976.
Blumberg is in the foreground and I’m behind him, wearing shades !

[Terpe]

Very interesting thread this.

Well done joebloggs for find this report

And well done Doc Alan for the very informative follow-up post
BTW Doc, interesting story and Photo.

I was not aware of the degree of prevalence of HBV either here in UK or in Philippines

[gWaPito]

In May 2012, the then Immigration Minister Damian Green announced a new scheme for the screening of immigrants to the UK from countries with a high incidence of tuberculosis before they are granted a visa for entry into the UK. The new measures were brought in as figures for 2011 showed over 9000 new cases of active tuberculosis in the UK, with non-UK born people accounting for three quarters of them.


If the government considers pre-entry screening to be worthwhile for tuberculosis, why not for hepatitis B virus (HBV) infection, the frequency of which has risen substantially in the UK as a consequence of immigration? The numbers involved are comparable with an estimated 6500 new cases of chronic HBV infection entering the UK each year. Over 90 000 immigrants have come from countries with high HBV prevalence (>8% HBsAg positivity, whereas prevalence in the UK is 0·25%).1 In 2007, 193 888 of the estimated total of 326 338 chronically infected people in the UK were born in other countries, double that in 2007 and today's figure is likely to be significantly higher.2 Eight of the ten top non-EU countries from which immigrants come are countries of high or intermediate (2—8%) HBV seroprevalence according to the UK Council for International Student Affairs. The CUSHI-B study—a survey of chronic HBV infection comprising patients in active follow—up attending 15 UK liver centres—showed that 81% of the 1 147 patients registered were born outside the UK.3 Individuals from Pakistan accounted for the highest number (15%) with persons born in Hong Kong and in China only a short way behind (11% and 12%, respectively). The Liver Unit in Birmingham, a city with a large immigrant population, has seen an almost five-fold increase in the number of new HBV referrals between 2001 and 2010.4 Resurgence of supra infection with the delta virus in HBsAg positive individuals is another important public health problem (especially in areas with substantial numbers of immigrants from Africa and Eastern Europe)5 because it creates a pool of infection resistant to antiviral therapy, and one associated with more rapid disease progression to cirrhosis.

read more here .. http://www.thelancet.com/journals/la...lltext?rss=yes

Put simply, anyone can catch TB walking down the street minding their own business.
Folks partaking in consensual sex should use their commonsense especially with new partners. ..One should always assume they have something unless proven otherwise. Only the foolish dive in.

Do agree. ..screening for all nasties should be obligatory. ..those carrying should be shipped back until deemed fit and clean for British occupation.

[joebloggs]

thanks for the further info doc Alan

[raynaputi]

Very interesting thread this.

Well done joebloggs for find this report

And well done Doc Alan for the very informative follow-up post
BTW Doc, interesting story and Photo.

I was not aware of the degree of prevalence of HBV either here in UK or in Philippines

When I was younger, probably grade school to high school years, there was an outbreak of Hepatitis (I'm just not sure which type exactly). I remember it was a big issue during those years. My dad has always been concerned with our health and he is the one who would usually take notice of health issues of me and my siblings. Anyway, what I remember was he prevented us from buying street food and would always insist of using our own stuffs at school (i.e. utensils for our "baon" or food for lunch that we bring at school, or glass/mug for water and drinks). I think after all those years, the time that I started buying street food again was when I was in college. Hahaha

[Doc Alan]

Thanks for the responses ! For those interested here is a little more information.


There should not necessarily, in my opinion, be a stigma or shame attached to a diagnosis of hepatitis ; HIV/AIDS ; TB, or other illness in which the frequency varies in different parts of the world.


HIV/AIDS is thankfully uncommon in the Philippines and UK, compared to sub-Saharan Africa – and is by no means confined to homosexual males.


Poor health and living conditions increase the risk of TB – while healthy people are at far less risk.


The variation in frequency of Hepatitis B is because causal factors vary in importance. All three are underdiagnosed.


Baruch Blumberg was fascinated by inherited variations in illnesses, and collected thousands of blood samples from around the world. While investigating " yellow jaundice " he discovered a protein in the blood of an Australian aborigine. He called it " Australia antigen " – and later realised this was the surface antigen ( immune response trigger ) for Hepatitis B. We owe him a huge debt of gratitude for work which resulted in the first ever " cancer vaccine " – preventing not only liver cancer, but also the more common hepatitis, resulting from HB infection. By coincidence Australia now has a strict immigrant screening programme.


" Outbreaks " of hepatitis – as described by Rayna, with sensible precautions taken by her Dad – are due to the A ( or E ) virus. This is more likely with poor food hygiene, sanitation, and sewage disposal. After 2-6 weeks it usually presents with flu-like symptoms and jaundice, but most people soon fully recover. The HA vaccine may be given in two doses, with a further booster dose 20 years later if necessary.


HBV takes 2-6 months to incubate and it is often not diagnosed because symptoms may not appear, if at all, for years. Only a small proportion develop chronic hepatitis ; perhaps a fifth of these develop cirrhosis ( liver scarring ) ; and only a tenth of those, cancer. Blood tests can diagnose HBV, and also liver function ( if abnormal, a biopsy is taken for diagnosis by microscopy ).


There are other causes of hepatitis – said to be chronic if lasting over 6 months, diagnosed by blood tests / liver biopsies. Alcohol is a commoner cause in the UK ( and there is also “ non-alcoholic “ hepatitis which may be related to obesity ). Only some of these go on to cirrhosis and cancer. By far the commonest cause of liver cancer in the UK is spread from elsewhere, such as lung.



The HBV vaccine is the solution for prevention of HBV and its consequences. Treatment is very expensive and not curative. The only other “ cancer vaccine “ is for human papilloma virus ( HPV ) affecting cervix ( and other ) sites.


Hepatitis C virus / HCV is another topic; there’s no vaccine ; treatment is also expensive.


HBV is roughly 30X more infectious than HBC and 100X more infectious than HIV.