Communicable Diseases

Infectious Hepatitis

Chronic hepatitis B virus (HBV) infection is prevalent worldwide, particularly in Asia and sub-Saharan Africa, where many US-bound refugees originate. Between 15% and 40% of those infected with chronic HBV infection develop long-term sequelae; however, the majority of infections are asymptomatic [39]. CDC reports that East Africa, including Somalia and countries where Somali refugees are being processed, has a high intermediate prevalence of HBV (5%–7%) [40]. In one study of adult Somali Bantu refugees (n=707) living in Kakuma, Kenya, PCR analysis detected HBV DNA in 5.5% of serum samples [41].

Among 1,234 adult refugee patients screened in Washington State, HBV infection prevalence was substantially higher among Somali speakers (12.4%, n=386) than in other refugee groups [39]. Similarly, high HBV infection prevalence has been observed among Somali refugees in Minnesota. From 1999 to 2016, 18,422 Somali refugees received a domestic medical screening, of whom 7% (n=1,240) tested positive for HBsAg, indicating HBV infection [42]. Notably, prevalence was highest among adults 45–64 years of age (14%) and lowest among children under 5 (1%) [42]. Approximately 42% of those not infected with HBV were immune, due to either natural infection or vaccination. A recent study of refugee children from Somalia (n=2,878) found that 3.6% had HBV infection [43]. Additionally, researchers found that the majority of cases were in children over 5 years of age, likely reflecting increasing childhood vaccination rates [43].

Hepatitis C virus (HCV) infection is also a concern for some US-bound refugees. East Africa, including Somalia, has a moderate prevalence of HCV (1.5%–3.5%) [40]. However, refugees processed in Yemen may be at increased risk, as Yemen has a high prevalence of HCV (>3.5%) [40]. Among Somali Bantu refugees residing in Kakuma, Kenya, 0.85% of those tested (n=707) were found to have HCV DNA in their serum [41]. Similarly, among Somali refugees resettled in Minnesota between 2004 and 2016, 44 individuals, or roughly 1% of those tested during the domestic medical screening (n=2,978), were positive for HCV [42]. Additionally, refugees ≥45 years of age had the highest prevalence, while those <25 years of age had the lowest prevalence [42].

Tuberculosis

Somalia and countries where Somali refugees are being processed for resettlement to the United States have a high TB burden. Depending on the country, between 1.3% and 5.2% of all new cases are multidrug-resistant, with up to 41% of previously treated TB cases classified as multidrug-resistant. Table 1 describes, in detail, the TB burden in Somalia and key countries of asylum for Somali refugees.

Table 1: Select Data Describing National Tuberculosis Burden in Somalia and Countries of Asylum, 2015

Select Data Describing National Tuberculosis Burden in Somalia and Countries of Asylum, 2015
Country Incidence Rate (cases per 100,000 population) Multi-drug-resistant TB
% of new cases % of retreatment cases
Somalia 274 5.2 41
Djibouti 378 4.3 34
Ethiopia 192 2.7 14
Kenya 233 1.3 9.4
Uganda 202 1.6 12
South Africa 843 3.5 7.1
Yemen 48 2.3 18

Source: World Health Organization Tuberculosis Country Profiles, 2016 [44]

For additional information regarding TB burden estimates and data in Somalia or countries where Somali refugees have sought asylum or are being processed, please see the WHO Tuberculosis Country ProfilesExternal.

Before departing for the United States, all refugees are screened for TB and receive treatment, if necessary. As part of the recommended domestic medical screening, newly arrived refugees are also screened for TB. Among 18,308 Somali refugees screened for TB in Minnesota from 1999 to 2016, 43% (7,850) were diagnosed with latent TB infection (LTBI), with prevalence increasing with age. Only 2% (287) were diagnosed with active TB disease (Table 2) [42]. Overall, the prevalence of active TB disease diagnosed during the domestic medical screening has decreased since 1999 and has remained below 1.0% since 2007 [42].

Table 2: Tuberculosis Screening and Infection among Somali Refugees to Minnesota, 1999–2016

Tuberculosis Screening and Infection among Somali Refugees to Minnesota, 1999–2016
Age at US Arrival Screened for TB Infection*
Number Screened Diagnosed with LTBI Diagnosed with Active TB Disease**
N N (%) N (%)
<5 years 1,317 146 (11%) 3 (<1%)
5–14 years 4,081 859 (21%) 39 (1%)
15–24 years 7,370 3,624 (49%) 145 (2%)
25–44 years 2,891 1,678 (58%) 45 (2%)
45–64 years 2,048 1,226 (60%) 39 (2%)
≥65 years 601 317 (53%) 16 (3%)
Overall 18,308 7,850 (43%) 287 (2%)

*Tuberculin skin test (TST) or interferon-gamma release assay (IGRA)
**Active TB disease classified as either pulmonary or extrapulmonary
Source: Minnesota Department of Health [42]

Clinicians should approach TB diagnosis with sensitivity and confidentiality. Individuals who have been diagnosed with active TB disease often face a lifetime of stigma, even after successful treatment completion. Some Somalis may associate TB with stress, loss of faith, God’s will, or sorcery. Standard antibiotic treatments for TB are often combined with traditional remedies, as well as prayer [45].

References

  1. Terasaki G, Desai A, McKinney CM et al. Seroprevalence of hepatitis B infection among immigrants in a primary care clinic: a case for granular ethnicity and language data collection. J Immigr Minor Health 2017 August;19(4):987–90.
  2. Centers for Disease Control and Prevention. CDC Health Information for International Travel . 2016; Available from: https://wwwnc.cdc.gov/travel/page/yellowbook-home.
  3. Mixson-Hayden T, Lee D, Ganova-Raeva L, et al. Hepatitis B virus and hepatitis C virus infections in United States-bound refugees from Asia and Africa. Am J Trop Med Hyg 2014 June;90(6):1014–20.
  4. Minnesota Department of Health. Domestic Medical Screening Data, 1999–2016 (unpublished data). 2017.
  5. Yun K, Matheson J, Payton C, et al. Health profiles of newly arrived refugee children in the United States, 2006–2012. Am J Public Health 2016 Jan;106(1):128–35.
  6. World Health Organization. Tuberculosis country profiles. 2016; Available from: http://www.who.int/tb/country/data/profiles/en/External.
  7. Citrin D, Somali Tuberculosis Cultural Profile. 2006.