Exploring the Link between Migration and the Rise of Hepatitis B in the UK - Essay Example

? EXPLORING THE LINK BETWEEN EAST ASIAN IMMIGRATION AND HEPATITIS B IN THE UNITED KINGDOM March 11, Abstract Table of Contents Table of Contents Primary Investigators 4 Introduction 4 Background - Hepatitis B 4 Study Aims and Objectives 7 Rationale of Study 7 Relevance to Researcher 8 Study Plan 9 Materials and Methods 9 Justification of Approach 10 Ethical and Legal Implications 10 Results and Discussion 11 Conclusions 12 References 15 Primary Investigators [Use this space to give identifying data for yourself (and any others involved)] Introduction As of 2008, nearly three percent of the world's population are immigrants in their current country of residence. By 2050, one estimate suggests that there will be over 250 million people who are permanent residents of a country other than the one in which they were born (Loue, 2008). With such a large amount of movement in the worldwide distribution of people, it is vital that countries are aware of the risks that immigrants may bring. Each region of the world has its own set of endemic diseases, disease-carrying insects and animals, water-borne contamination and chemicals, and issues with access to medical care. For the cause of public health, it must be determined which immigrant groups are high risk, and the magnitude of that risk. Ethnicity, country of origin, and race have all been proven to have at least some effect on the progression and treatment of infectious diseases. Understanding the more concrete links between race and ethnicity to the spread specifically of hepatitis B can give physicians the information they require to treat the unique and specialised needs of each ethnic group (Brant & Boxall, 2009). Background - Hepatitis B Approximately 350 million people worldwide are infected with hepatitis B which is caused by, unsurprisingly, the hepatitis B virus. Hepatitis B is a serious health concern and can greatly reduce the length and quality of a sufferer's life, especially when it is left untreated due to the unavailability of proper medical care, the ignorance of the person to the presence of the infection, or the stigma attached to the disease causing the sufferer not to seek out what care may be available to them. Many lives are lost worldwide every year due to a lack of treatment and vaccination, especially in developing nations (NIDDK, 2009). It is imperative that we understand the workings of this disease, its progression, and its method of contagion, in order to reduce the spread and the worldwide severity of hepatitis B, especially in the case of immigrants. From a public health standpoint, it is thankful that hepatitis B infection is limited to transfer by bodily fluids, such as blood or semen. These fluids may be transferred at any time when two people are in contact with open wounds or mucous membranes, such during unprotected sexual intercourse, during childbirth if the mother is infected, by providing medical care to an infected person without the proper barriers in place to prevent the spread of microbes, and through the reuse of contaminated needles. However, it cannot be transmitted by touch or by air, limiting the speed at which the disease can spread. Therefore, the risk to the general public from an infected person is low; it is those who live in the infected person's household who are most likely to become infected due to accidental contact with bodily fluids (NIDDK, 2009). Infection with the virus may remain undetected for many years after the initial contact, which is why immigrants who seem otherwise healthy may be able to enter the United Kingdom already infected. The disease passes through four phases over about ten to twenty-five years, and remains in the patient's system permanently after the initial infection and disease remission. The first phase is often symptomless and not discovered unless the person is tested for an unrelated reason, and the fourth phase is a marked decrease in viral load, referred to as a period of remission. When the body reaches a high level of viral load, during the second phase, the infected person may finally realise that he or she has been exposed to hepatitis B virus. Pain is often the first noticeable symptom, due to the fact that the infection causes inflammation and fibrosis of the liver. Some patients may experience periods of re-activation and remission for the rest of their lives, greatly increasing their chances of suffering fatal complications with the liver. Chronic hepatitis B can lead to cirrhosis of the liver, liver cancer, and eventually liver failure (Sherman et al., 2007). Even in cases where the disease does not become chronic, there are still long-term risks associated with hepatitis B infection. Primarily, one-time hepatitis B infection can lead to an increased risk of liver cancer, which has high costs in terms of both quality of life and health care funds (Levy, Nguyen, & Nguyen, 2010). Patients are tested for hepatitis using an assay that tests for the presence of hepatitis DNA. This assay can determine the viral load on a patient, helping to determine the efficacy of treatment. The assay also conclusively determines what strain of hepatitis virus has infected the patient, as there are currently eight known strains, of which hepatitis B is the least severe. Hepatitis B is the most common strain found in East Asia, making those patients stand out from the hepatitis A strain usually found in Europe (Sherman et al., 2007). Testing for liver damage caused by chronic hepatitis is done using a blood test to check for elevated levels of alanine aminotransferase, a chemical whose levels in the body usually correlate to levels of liver function. The normal range for alanine aminotransferase is a matter of debate, but the traditional guidelines state that any level above 30 IU/ml should be considered elevated. However, normal alanine aminotransferase levels do not preclude the possibility of liver damage, making treatment decisions for hepatitis patients more difficult (Sherman et al., 2007). Treatment of hepatitis patients is usually performed with antivirals and requires close monitoring. Even patients with infections that are inactive (in remission) must be closely monitored for the possibility of returning symptoms and inflammation. Patients must also be monitored for the possibility of antiviral resistance and non-response. Antiviral resistance can be deadly to patients with an already compromised liver, as it can lead to unexpected increases in viral load and subsequent rapid increase in liver inflammation (Sherman et al., 2007). Study Aims and Objectives The aim of this study is to determine the perceived and actual connections between African and East Asian immigration and a rise in hepatitis B infections in the United Kingdom, and the effect this has on immigrant health care. To achieve this aim, there are three major objectives to reach: 1. An understanding of the nature of endemic hepatitis B in East Asia and Africa 2. Discuss the link or lack thereof between hepatitis B in the UK and relevant immigrants 3. Determine what effect, if any, the perception of a connection has on the health care of the relevant immigrants Indirectly, this study could help show what types of diversity training physicians in the United Kingdom require. If either the immigrant community links to a risk in hepatitis B or not, new policies and guidelines could help to protect both the immigrants and the larger community of the UK (Bentley, Jovanovic, & Sharma, 2008). Rationale of Study The perceived existence of a link between certain immigrant groups and a potentially fatal disease undoubtedly has major repercussions for that immigrant community. There is a definite possibility of racially-driven fear from the population as a whole against the entire immigrant group. As has occurred with homophobia and HIV/AIDS, fear of a disease can cause individuals, including medical professionals, to behave as if everyone in the high-risk group is potentially infected and should be avoided (Elford et al., 2007). This greatly increases the negative stigma associated to anyone belonging to that group (Pardie & Luchetta, 1999). Once this stigma is established, discrimination at the societal and individual level can interfere with the earning potential due to difficulty in finding work. This loss of potential income in turn leads to lower socio-economic status, leaving them without the funds necessary to access to private health care. Even within the national health care system, racial stigma can affect the attitude of and the quality of care provided by physicians (Williams, 2006). Therefore, this study is being undertaken to determine the actual presence of a connection between African and East Asian immigrants and hepatitis B, and the effect this has their health care. Any group that may potentially receive sub-standard care should be considered a serious public health matter. Relevance to Researcher This research project is personally relevant due to its focus on immigrant health. As I am an immigrant of African origin, I am familiar with many of the difficulties faced by the immigrant community. Especially important to me is the factor of being judged by a disease that is common in people of my racial and ethnic background, but from which I do not personally suffer. Being treated as a portion of a group rather than as a separate and unique individual is a very objectifying and demeaning experience. If I cannot stop judgements from being made, I can at least add to the body of knowledge so that it is apparent to the medical and professional community whether such judgements are accurate and correct. Study Plan Materials and Methods Most of the background information on hepatitis B was gathered using a PubMed search for the keywords “Hepatitis B”, as well as a search of the National Health Services website. Other information on immigration statistics was not directly cited in the process of this paper but was useful for background reading. These readings were gathered through a Google Scholar and Google Web search for the keywords “immigration statistics”, “East Asian emigration”, “UK immigration” (with several alternates for “UK”), and “immigrant health”. The last returned data that was directly cited in this paper, primarily the Loue study. Background information was primarily limited to recent (later than 2000) findings, though some exceptions were made. The studies analysed to return the final results for this review were also found using a Google Scholar search. The previously mentioned “immigrant health” search was conducted and the results sorted for relevance. Studies were selected for inclusion in this review if they focused on East Asian emigration, and on the possibility of these subjects carrying disease from their home country to their final country of residence. Preference was given to studies in which the disease of interest was hepatitis B, though this criterion was not exclusive, and other disease models have been referenced in this review. Studies were also included that made mention of the public health implications of such carriers or discussed the reasons why these immigrants might be carriers of contagious disease in the first place. No preference was given to studies for immigrant country of origin, age of subjects, or any other demographic data besides region and quality of health. Studies were also considered irrespective of the results of their findings on the possibility of disease carriage by immigrants or the connotations expressed in the language of the researcher toward immigration. This data set was limited to research studies published in 2005 or later, to ensure that the final result was the inclusion of only current information. Justification of Approach The literature review method has been chosen for this study due to the widespread availability of research studies on immigration and disease transmission that already exists. The rationale for the study still stands, as this data has not previously been collected into a cohesive whole focusing on specifically East Asians and hepatitis B. However, there already exists enough data available in the current literature to make such a determination without the use of any primary research methods or data collection. Ethical and Legal Implications This research is being conducted using a literature search method. This reduces the possibility of ethical and legal implications, since no new or primary research is being conducted, merely a review of the existing data in the field. There is no possibility of injury to the subjects of the original studies, nor can their privacy be any further affected or invaded by the further referencing of the original research findings. The only remaining areas of ethical concern, therefore, are in the researcher's opinion and stance on the topic. It is extremely important to remain unbiased in accumulation of data for a literature review, and not to allow the researcher's personal views to affect the selection or interpretation of the literature. The studies that were included in this review were carefully selected using a systematic method, helping to reduce the possibility of such contamination of the final results (Hart, 2006). Results and Discussion More than half of all Vietnamese-American immigrants quizzed in one study had never had a vaccination or even a screening for hepatitis B in their entire lives, despite the high prevalence of the disease in that population, and this most likely carries over into immigrants to other nations as well (Levy, Nguyen, & Nguyen, 2010). Additionally, the disease is endemic in south-east Asia, with infection rates ranging from seven to fifteen percent of the population (Nguyen et al., 2010; Pollack et al., 2006). The extremely poor health care and living situations in many parts of the world also contributes to contagious disease transfer with emigrants from those countries. For example, infant vaccination for hepatitis B is incomplete in most Asian countries, where it exists at all, and generally began very recently (Nguyen et al., 2010). Matching the proportions for the disease in the general population, approximately fifteen percent of new Korean and Chinese immigrants to the United States have been with hepatitis B (Pollack et al., 2006). More than forty percent of the people currently infected with hepatitis B in the United States are of Asia-Pacific racial heritage, though they make up only approximately five percent of the total population (Lee et al., 2010). This same group also includes more than half of the chronic hepatitis B sufferers in that country (Colvin et al., 2010). These totals do not, however, take country of origin into consideration, only race, and so also include American citizens. Another study did separate American-born from immigrant subjects, and supported the finding of approximately fifteen percent of Asian immigrants to the United States having had a hepatitis B infection (Levy et al., 2010). Since only about five percent of those of Asian heritage born in the United States had ever had a hepatitis B infection, it can be deduced that most of the forty percent of hepatitis B patients from the Lee study are immigrants (Lee et al., 2010; Levy et al., 2010). Assuming that an even cross-section of the population from the Asiatic nations is moving to Western nations, these numbers are likely to be true of Asia-Pacific immigrants in the United Kingdom and Europe as well. Counter-intuitively, the chances are higher that those who emigrated from Asia longer ago will have had hepatitis B infections or be chronic carriers when compared to those with a more recent date of arrival. This is potentially due to the possibility of refugees and Western immigrants being treated at immigrant health centres and refugee camps that understand the necessity of vaccinations (Nguyen et al., 2010). However, unauthorized resident immigrants often forgo medical care, including hepatitis vaccinations and testing, out of fear of their illegal status being revealed to the authorities (Fakoya et al., 2008). An special concern are the chronic hepatitis B sufferers, as they tend to have a higher viral load, which increases the possibility of transferring the infection to another person, and also greatly increases the chance of the originally infected person contracting liver cancer (Colvin et al., 2010). Four percent of the Asian immigrants surveyed in the previously-mentioned Levy et al. study were chronic hepatitis B carriers (2010). The growing nature of this problem is also evidenced by the fact that in the United States, the number of cases of acute hepatitis B infection is dropping, yet the number of people in that country living with chronic hepatitis is actually increasing. That study further suggests that the reason for this increase in chronic cases is the influx of East Asian immigrants to that same country (Colvin et al., 2010). Conclusions Links between rising infection rates of chronic and acute disease and immigrants have already been proven for some other diseases besides hepatitis B. For example, nearly three-quarters of the tuberculosis patients in western Europe are born outside of their current country of residence. This may be due, especially in the United Kingdom, to the disease being endemic in countries from which the United Kingdom receives many of their immigrants (Gilbert et al., 2009). It is possible the same situation is occurring with immigrants who emigrated from countries with endemic hepatitis B. The generally low socio-economic status of such immigrants has also already been proven to have an effect on the health care of the immigrant community, as well as affecting how they are treated by their medical professionals. Much of the blame can be placed on the lack of diversity training and cultural awareness from the physicians. Without an understanding of how foreign cultures work, physicians, in their ignorance, often prescribe courses of treatment that result in low compliance. (Bentley, Jovanovic, & Sharma, 2008). One suggested method for increasing interest of Asian immigrants in screenings and vaccinations for hepatitis B was related to the fear of cancer. Increasing knowledge of the link between hepatitis B infection and liver cancer could help lead more East Asian immigrants to make use of such services (Levy, Nguyen, & Nguyen, 2010). There do seem to be many links between East Asian immigration and hepatitis B infection rates in the United Kingdom. However, these rates seem to be primarily linked to carriers of the infection when they arrive in the country. There appears to be no connection between immigrants carrying the disease and United Kingdom citizens acquiring the infection. This appears to be more of a statistical effect than a true public health concern, and should be treated as such. While it is true that East Asian immigrants are more likely than others to have suffered from hepatitis B in their lifetime, it is a very small percentage of them who are currently carriers of an acute infection or are chronic carriers. They represent a very small risk to the health of the people of the United Kingdom. Medical professionals should attempt to mitigate the concern of the general public that they could contract the disease from such immigrants, while also making sure that the immigrant community is aware of the risks to their health presented by the presence of the infection. A reduction in the stigma attached to the disease may provide an increase in the number of chronic carriers who are willing to seek out treatment. Wider knowledge of the true effects of the disease could help increase compliance with vaccination and testing programs that are already in place in the national healthcare system. References Bentley, P., Jovanovic, A. & Sharma, P. (2008) Cultural Diversity Training for UK Healthcare Professionals: a Comprehensive Nationwide Cross-sectional Survey . IN Journal of the Royal College of Physicians, 8. Brant, L. & Boxall, E. (2009) The Problem with Using Computer Programmes to Assign Ethnicity: Immigration Decreases Sensitivity. IN Public Health, 123. COLVIN, H. M., MITCHELL, A. E., INSTITUTE OF MEDICINE. COMMITTEE ON THE PREVENTION AND CONTROL OF VIRAL HEPATITIS INFECTIONS, INSTITUTE OF MEDICINE. BOARD ON POPULATION HEALTH, PUBLIC HEALTH PRACTICE & NATIONAL ACADEMIES PRESS 2010. Hepatitis and liver cancer: a national strategy for prevention and control of hepatitis B and C, National Academies Press. Elford, J., Ibrahim, F., Bukutu, C. & Anderson, J. 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