Why do more HCV-infected immigrants, rather than non-immigrants, end up hospitalized for liver problems? Inadequate screening and longer infection duration are likely reasons.
More than 700,000 people worldwide die every year from chronic hepatitis C (HCV). In addition to the death toll, the disease is a huge drain on healthcare finances. In fact, by 2024, total annual spending on HCV is projected to rise to $9.1 billion in the United States and $258 million by 2032 in Canada. Rates of hospitalization among people infected with chronic HCV are on the rise in those two countries; however, the underlying reasons for admittance often differ between immigrants and non-immigrants. A recent retrospective cohort study aims to shed some light on why HCV-infected individuals, whether native-born or not, might end up in a hospital bed—and how these findings might possibly translate into reduced HCV-associated healthcare expenses and death rates in the years to come.
Following previous studies revealing that immigrants who leave countries with moderate to high prevalence of HCV represent an outsize percentage of the HCV-infected population in host countries, a group of researchers in Quebec decided to conduct a study of their own. Obtaining records of all HCV cases in the Quebec Ministry of Health and Social Services database from 1998 to 2007, the team parsed the records of 20,139 participants. Of these, 9% were immigrants, with the largest share coming from East Asia and the Pacific (23.4%), followed by Latin America and the Caribbean (13.3%), and then sub-Saharan Africa (12.2%). Although the average age of study participants was 43.2 years, the portion of the population who were immigrants proved to be slightly older, with an average age of 47.6 years.
The researchers tracked the number of hospitalizations as well as the average number of in-hospital days per participant. In addition, they noted each patient’s primary diagnosis upon admittance to determine whether it was liver-related or due to something else. The results were intriguing: immigrants were two to 10 times less likely than non-immigrants to be admitted to a hospital as a result of substance abuse or mental-health problems. They also had a significantly lower rate of HIV infection (0.88%) than non-immigrants (3.2%). However, they were more likely to have diabetes and hypertension (11% and 17.1%, respectively) than non-immigrants (6% and 9.7%, respectively). Additionally, immigrants were more likely to have chronic hepatitis B virus (1.5% versus 0.62% in non-immigrants) and decompensated cirrhosis and/or hepatocellular carcinoma (0.93% versus 0.31% in non-immigrants).
About 28% of all immigrants had at least one hospital stay on record, compared with 42% of non-immigrants. The mean hospital stay in this population was 7.3 in-hospital days, shorter than non-immigrants’ 15.7 in-hospital days. However, interestingly, the proportion of overall hospital stays directly related to liver problems was much higher in the immigrant group than the non-immigrant group (27.6% versus 18.2%). Those liver-related stays were longer than non-liver-related stays and were often linked to hepatocellular carcinoma and decompensated cirrhosis. Also, a full 15% of immigrants’ liver-related hospital stays resulted in their deaths, while just 10.1% of non-immigrants’ liver-related stays resulted in death.
What’s behind the greater likelihood that immigrants will be hospitalized for liver problems that may be quite serious, or even fatal? The authors attribute the higher average age of the immigrant population as one key reason for this. In addition, the researchers believe that immigrants are likely to have become infected in their home countries as a result of unsafe medical procedures. The authors surmise that after acquiring the infection, they then enter their host countries without being screened, which can result in delayed HCV diagnosis. By the time they receive this diagnosis, they carry a high disease burden that has already taken its toll on the liver. Similarly, comorbidities such as diabetes and hypertension, both of which appear at higher rates in immigrants than non-immigrants, could also contribute to liver problems. As the average infected immigrant is diagnosed with HCV a full 9.8 years after coming to Canada, this assumption of longer infection duration resulting in poorer liver outcomes seems likely. Non-immigrants, by contrast, are known to have more behavioral risk factors that can lead to mental-health emergencies, accidents, and poisonings; so, those “other” factors are often what lead to hospital stays.
The researchers hope that awareness of the possibility that those immigrating to Canada will already be infected with HCV upon arrival will translate into more comprehensive screening. This way, effective treatment can be started earlier and possibly prevent the costly, and possibly deadly, liver problems that so many immigrants experience as a result of late diagnosis.
Laurie Saloman, MS, is a health writer with more than 20 years of experience working for both consumer and physician-focused publications. She is a graduate of Brandeis University and the Medill School of Journalism at Northwestern University. She lives in New Jersey with her family.