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Screening for Hepatitis B Virus Infection Among Refugees Arriving in the United States, 1979-1991

Because hepatitis B virus (HBV) infection is highly endemic in several areas of the world, both the prevalence of and risk for HBV infection are substantially greater among persons emigrating from these areas to the United States than for the overall U.S. population. In 1985, federal funds were made available to supplement ongoing state and local health department refugee-screening programs and to promote serologic screening for HBV infection in pregnant Indochinese women and household contacts of these female HBV carriers among persons identified by the Department of State as refugees entering the United States. This report summarizes data collected during 1979-1991 by selected screening programs that implemented universal hepatitis B (HB) screening at different times.

Health-screening programs established by state and local health agencies for newly arrived refugees generally include tuberculosis screening, stool screening for ova and parasites, and serologic screening for HBV infection; screening is done as soon as possible after arrival. Services may be provided in special refugee-health clinics, local health department clinics, or the offices of private-practice physicians. For this report, programs were selected that 1) screened all incoming refugees and 2) had data on the results of testing for hepatitis B surface antigen (HBsAg) that could be used to calculate nationality-specific estimates of the prevalence of current HBV infection. Because these data did not include more detailed demographic information, neither age- nor sex-specific prevalence estimates could be calculated.

Crude prevalence rates of HBsAg were highest among refugees from countries in Southeast Asia (range: 11.7%-15.5%), intermediate among refugees from Africa, and lower among refugees from other countries in Asia, including Afghanistan (4.1%) and Iran (2.4%) (Table 1). Crude prevalence rates were substantially higher among refugees from Bulgaria (5.3%) and Romania (4.1%) than among refugees from other eastern European countries, who had the lowest rates for all groups tested (Table 1). Reported by: C Crysel, Alabama Refugee Health Screening Program, Bur of Disease Control, Alabama Dept of Public Health. MP Wong, San Francisco General Hospital Refugee Clinic, San Francisco. B Brown, Georgia Refugee Health Program, Div of Public Health, Georgia Dept of Human Resources. J Cochran, Refugee Health Program, Communicable Disease Control, Massachusetts Dept of Public Health. B Morales, Detroit Refugee Health Screening Program, Detroit Health Dept, Michigan. D Peterson, Refugee Health Unit, Acute Disease Programs, Minnesota Dept of Health. S Brooks, New York Refugee Health Program, New York State Dept of Health. D Candow, Refugee Health Program, Ohio Dept of Health. M Hurie, Refugee and Immigrant Health Program, Bur of Public Health, Div of Health, Wisconsin Dept of Health and Social Svcs. Hepatitis Br, Div of Viral and Rickettsial Diseases, National Center for Infectious Diseases; Medical Screening and Health Assessment Br, Div of Quarantine, National Center for Prevention Svcs, CDC.

Editorial Note

Editorial Note: The prevalence of HBsAg among refugees entering the United States reflects the patterns of HBV infection in the countries and regions of origin for these persons. In Southeast Asia, the Middle East, and Africa, the crude prevalence of chronic HBV infection ranges from 5% to 15%, and HBV is a major cause of morbidity and mortality from acute and chronic hepatitis, cirrhosis, and primary hepatocellular carcinoma (2-4). Although less is known about the prevalence of HBV infection in eastern Europe, recent data from other sources are consistent with the high prevalence of HBV infection in Romania reported here (1; CDC, unpublished data) and suggest that levels of HBV infection in parts of eastern Europe may be higher than previously believed.

Although the overall risk for HBV infection is lower in the United States than in many countries, the Immunization Practices Advisory Committee recommends that all pregnant women be screened for HBsAg to identify infants needing specific immunoprophylaxis to prevent HBV infection (5). In addition, universal infant vac cination is recommended in populations with a high prevalence of HBV infection, such as Alaskan Natives, Pacific Islanders, and emigrants from areas with moderate and high levels of HBV infection (5). In these populations, infants not infected at the time of birth may become infected during early childhood through exposure to mothers or siblings who are HBV carriers (6,7). In such groups, vaccination at birth and integration of HB vaccination into the routine infant vaccination schedule are important (8).

The findings in this report identify specific groups at higher risk for HBV infection, including persons emigrating from Afghanistan, Angola, Bulgaria, Cambodia, Ethiopia, Iran, Iraq, Laos, Romania, Thailand, and Vietnam. Although site-specific demographic data were not available for this report, 25.2% of all refugees entering the United States during 1983-1989 were women of reproductive age (15-44 years of age) (CDC, unpublished data). This suggests that U.S.-born infants of women who have emigrated from these countries are at substantial risk for HBV infection through perinatal or early childhood transmission. Therefore, managers of vaccine delivery programs targeted at these groups should recognize the need to screen all pregnant women for HBV infection, appropriately treat infants of HBsAg-positive mothers, and fully vaccinate infants who are at increased risk for HBV infection.


  1. Sobeslavsky O. Prevalence of markers of hepatitis B virus infection in various countries: a WHO collaborative study. Bull WHO 1980;58:621-8.

  2. Sung JL, Asian Regional Study Group. Hepatitis B virus eradication strategy in Asia. Vaccine 1990;8(suppl):S95-9.

  3. Kiire CF, African Regional Study Group. Hepatitis B infection in sub-Saharan Africa. Vaccine 1990;8(suppl):S107-12.

  4. Toukan A, Middle East Regional Study Group. Strategy for the control of hepatitis B virus infection in the Middle East and North Africa. Vaccine 1990;8(suppl):S117-21.

  5. ACIP. Protection against viral hepatitis: recommendations of the Immunization Practices Advisory Committee (ACIP). MMWR 1990;39(no. RR-2).

  6. Franks AL, Berg CJ, Kane MA, et al. Hepatitis B infection among children born in the United States to southeast Asian refugees. N Engl J Med 1989;321:1301-5.

  7. Ko YC, Li SC, Yen YY, Yeh SM, Hsieh CC. Horizontal transmission of hepatitis B virus from sibling and intramuscular injection among preschool children in a familial cohort. Am J Epidemiol 1991;133:1015-23.

  8. ACIP. Hepatitis B virus: a comprehensive strategy for eliminating transmission in the United States through universal childhood vaccination--recommendations of the Immunization Practices Advisory Committee (ACIP). MMWR (in press).

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