Screening, Vaccination, and Referrals as Viral Hepatitis Elimination Triad Among Internally Displaced Persons in Edo State, Nigeria

Abstract

Watch a video presentation of this article Hepatitis B virus (HBV) and hepatitis C virus (HCV) infections are major global health problems, causing 887,000 and 399,000 deaths, respectively, each year. In addition, 247 million people with HBV and 71 million with HCV are at risk for premature mortality from liver failure and cancer.1 Routine hepatitis B (HepB) vaccination of children beginning at birth reduces HBV transmission, and long-term antiviral treatment for HBV infection and curative antiviral therapy for HCV reduce mortality. In 2016, with the availability of these effective strategies, the World Health Organization (WHO) issued a global strategy with goals for HBV and HCV elimination defined as a 90% reduction in incidence and 65% reduction in mortality by 2030.2 A key feature of the global strategy is health equity for all persons to benefit from hepatitis elimination. Migrants can be at increased risk for HBV and HCV infection and often relocate to settings (e.g., camps) where hepatitis prevention and care services are limited. In 2018, there were more than 41 million internally displaced persons (IDPs) worldwide, including more than 2 million in Nigeria.3 The key drivers of internal displacement are civil unrest (e.g., Boko Haram insurgency), natural disasters, political persecution, and economic deprivations. In Nigeria, an estimated 142,000 new displacements were recorded in the first half of 2019.4 The outcomes of mass movement, overcrowding, economic and environmental degradation, and other factors compromise opportunities for hepatitis elimination as the result of poor access to HepB vaccination and heightened barriers to HBV and HCV testing and linkages to care.5 In 2004, the Nigerian National Program on Immunization began routine HepB vaccination for children ≤5 years old, with 57% HepB immunization coverage nationally but lower rates in some areas, especially in northern Nigeria.6 With these large displacement numbers, more comprehensive studies of viral hepatitis are needed among IDPs in Nigeria. The aim of this study, therefore, was to determine the prevalence and risk factors for viral hepatitis among IDPs in Edo State, Nigeria. This study was conducted in a camp in Benin City, Edo State, Nigeria, that hosted approximately 3000 IDPs. The basic health facility at the camp provided no viral hepatitis care. Individuals within the camp who were between the ages of 15 and 49 years were randomly recruited by the research team. Individuals who stayed in the camp but were not IDPs were excluded from the study. Ethical approval was obtained from the Research Ethics Committee, University of Medical Sciences, Ondo City, Nigeria. All subjects agreed to participate after adequate explanation before inclusion into the study. After adequate health education and informed consent, an interviewer administered a semistructured questionnaire to collect basic sociodemographic data and risks for hepatitis from each IDP. Approximately 5 mL of blood was aseptically collected, and serum samples were processed within 24 hours for hepatitis B surface antigen (HBsAg) and antibody against HCV (anti-HCV) using BeSure, a third-generation enzyme-linked immunosorbent assay kit, which is manufactured in China. Paired sera technique was used. The methodology described in the manufacturer’s manual was strictly followed, and individuals received prescreening and postscreening counseling. Those with HBsAg were interpreted as positive (HBsAg+). Patients seropositive for hepatitis B and C were referred for treatment, and those negative for HBsAg were referred for vaccination. Statistical Product and Service Solutions (SPSS) Statistics software, version 23.0, was used, as well as the Χ2 test, to demonstrate statistically significant results, and binary logistic regression, to test the strength of these associations. A P value <0.05 was considered significant. A total of 346 IDPs took part in this study. The mean age of respondents was 18.5 ± 6.7 years, with the adolescent age group (15-19 years) constituting 273 (78.9%) of respondents; 111 (32.1%) were male, 307 (88.7%) were single, and 130 (37.8%) had up to a secondary level of education (Table 1). The majority of the respondents were displaced within the 5 years preceding the study. A total of 200 individuals were referred and received at least one dose of the HepB vaccine during the study. Among the 346 IDPs tested, 55 (15.9%) were HBsAg+ (Fig. 1), whereas only 4 (1.1%) were positive for anti-HCV. All those with HBsAg+ results had no history of HepB vaccination. A total of 285 (82.4%) had no history of infant HepB vaccination. Other risk factors included a previous prick injury (28 [8.1%]), scarification marks (20 [5.8%]), unprotected sexual intercourse (11 [3.2%]), previous blood transfusion (8 [2.3%]), previous surgery (7 [2.0%]), and multiple sexual partners (4 [1.2%]) (Table 2). Among these, 42 (12.2%) had one other risk, 19 (5.5%) had two other risks, and 5 (1.4%) had multiple other risks for HBV infection. The group of subjects at greater risk for HBV infections included those ≥19 years of age and male (1.4 times higher each). Respondents with first sexual intercourse when 15 years old or younger were 2.5 times more likely to have a positive HBV laboratory result than those with first sexual intercourse when older than 15 years (Table 3). This study found an HBsAg+ seroprevalence rate of 15.9% among IDPs in Benin City. This exceeds the national prevalence rate of 12.2% but is lower than the 21.05% reported from a similar study of IDPs in 2011,7, 8 in which the mean age of HBsAg+ IDPs was 18.5 years, suggesting that a considerable number of the IDPs were adolescents. This is expected because young people often bear the brunt of displacement, especially during wars and conflicts in which their parents may have been killed. The anti-HCV seroprevalence rate of 1.1% seen in this study is lower than Ejiofor et al.’s9 finding in which the prevalence rate ranged from 4.7% to 5% in Ilorin, 5.3% to 6.6% in Enugu, 11% in Ibadan, and as much as 20% in Benin. The finding from our study reporting that male respondents had a higher prevalence than female respondents supports similar studies among IDPs7 and a stable population.10 The management of the disease is cumbersome and difficult to afford in a developing country such as Nigeria that has a high prevalence. In the IDP camp where our study was located, there is no testing, immunization, or treatment for HBV despite the high risks for the disease among this population. It is therefore important to emphasize prevention of the disease among those who are negative and ensure treatment for infected individuals. The fear of viral hepatitis observed among some of the IDPs, which could have been a limitation to the success of this study, was removed by general health conversations before sample collection, as well as group counseling by our research team. In this study, all those with HBsAg+ results had not received the HepB vaccination as infants. The risks for HBV transmission among adolescents underscores the need for “catch-up” HepB vaccination for this age group. This intervention is feasible but may be difficult in Nigeria, where mass HepB screening is not readily available except as a specific recommended project or intervention by governments. A potential cost-effective approach is providing HepB vaccine to all adolescent IDPs. More efforts are also needed to ensure improved coverage of routine HepB immunization and to remove physical and cultural barriers to infant immunization. In conclusion, the prevalence of HBV infection is high among IDPs in Nigeria. Many in this mostly adolescent population were not vaccinated and remain at risk for HBV infection. We recommend health education and HBV testing, catch-up vaccination for adolescents in IDPs, and referral for HBV treatment as pillars for elimination of viral hepatitis in this highly endemic migrant population. We thank the management of the IDP camp at the Christian Resource Center, Benin City, Edo State, Nigeria, and Virology Education for the travel grant to Amsterdam, the Netherlands, to present this study at the International Viral Hepatitis Elimination Meeting (IVHEM) 2019.

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