Summary Points
INTRODUCTION
Hepatitis C virus (HCV) infection is a significant public health concern, causing approximately 400,000 deaths annually, primarily due to cirrhosis or hepatocellular carcinoma. While approximately 30% of individuals clear the infection spontaneously, the remaining 70% face the risk of life-threatening outcomes if untreated. Globally, an estimated 58 million people were chronically infected in 2019, with a disproportionate burden in low- and middle-income countries (LMICs). In 2019, approximately 290,000 people died from hepatitis C, mostly from cirrhosis and hepatocellular carcinoma. Limited available data suggested an alarming and unusually high seroprevalence of Hepatitis C (presence of HCV antibodies following HCV exposure) among Rohingya or Forcibly Displaced Myanmar National (FDMN) people residing in densely crowded camps that host nearly one million people located in Cox’s Bazar district, Bangladesh. Médecins Sans Frontières (MSF) is currently the only actor providing limited (quota-based) access to HCV treatment in the camps. Representative data on the prevalence of active HCV infection and risk factors of exposure were urgently needed to inform HCV response in the camps.
METHODS
A cross-sectional point-prevalence survey targeted 680 randomly selected households in seven camps in Cox’s Bazar, covering the catchment area of Médecins Sans Frontières (MSF) Operational Center Paris (OCP). Adults (≥18 y) were randomly selected (one per household) and screened for HCV seropositivity using an antibody rapid diagnostic test (RDT). Active HCV infection was confirmed using Xpert® HCV Viral Load testing, and a structured questionnaire was administered to collect sociodemographic data and identify risk factors.
RESULTS
Between May and June 2023, 641 individuals from 641 households were included, 66.3% female, and a median age of 34 years [IQR 28, 46]. The survey-adjusted estimate of HCV seroprevalence was high at 29.7% (95%CI: 26.0-22.8). Among 637 participants who had completed HCV testing, the survey-
adjusted active infection prevalence was 19.6% (16.4-23.2), with all viremic individuals having a viral load ≥ 1000 IU/ml. The survey-adjusted viremic ratio among HCV seropositives was 66.6 % (58.9-73.6)). About one-third (36.7%) of HCV seropositive participants reported previous HCV diagnosis, and 10.5% reported previous HCV treatment. About half (48.5%) had heard about Hepatitis C, 34.2% indicated that HCV infection can be prevented, 41.8% responded that HCV treatment is available.
Multivariate regression analysis revealed higher odds of HCV seropositivity for women (adjusted odds ratio (aOR)=1.8) and older age groups (aORs ranging from 2.3 to 2.9). Furthermore, associations were identified between HCV seropositivity and reported surgery (aOR=4.7 (95%CI: 1.3-16.7) or medical
injections (aOR=1.7 (95% CI: 1.0-2.6).
Many (70.4%) had reported medical injection(s), while surgery was infrequently reported (3.3%). Few also reported re-use of someone else's needle or blood transfusion, which were found associated with HCV seropositivity but did not remain significant in sensitivity analysis omitting participants with
missing values, refused answers or replies of “don’t know). Camp-specific seroprevalence estimates varied, with a significantly lower seroprevalence specifically in camp 17 (confirmed in multivariate regression analysis). The odds of active HCV infection among HCV seropositive were about 10 times higher among those who did not report previous HCV treatment (aOR= 9.4 (95%CI: 2.2 -40.5)).
The current survey has, for the first time, offered a representative estimate of active HCV infection within the FDMN population in the Cox’s Bazar camps. Limitations stem from a potential bias towards surveying individuals at home during the survey period, evident in a somewhat higher proportion of women included compared to UNHCR camp population statistics for the same period. The assumption of the survey findings' representativeness across all camps in Cox’s Bazar relies on the notion that key camp characteristics—such as adult population demographics, time of arrival in the camps, and access to healthcare—are largely homogeneous. The surveyed camps are those supported by MSF OCP, where MSF provides limited monthly access to HCV treatment for individuals diagnosed at MSF-supported in-and outpatient services. If the surveyed camps were to introduce bias into the overall estimate of active HCV infection prevalence of all camps in Cox’s Bazar, it is more likely to result in an underestimation rather than an overestimation of the overall burden in the camps.
CONCLUSIONS AND RECOMMENDATIONS
The survey disclosed a high prevalence of HCV exposure and active infection among the FDMN population in Cox’s Bazar camps. Approximately one in five adults in the camps is estimated to be living with untreated HCV infection, emphasizing the urgent need for enhanced access to diagnosis and treatment. The burden affects the entire adult population, with women and older age groups being disproportionately impacted. Extrapolating the survey estimates to the entire adult population in the Cox’s Bazar camp (464,324 adults as per UNHCR camp population statistics in 2023) suggests that approximately 86,000 adults currently require treatment, after adjusting for the higher proportion of women included in the survey.
The findings emphasize the pressing need for additional stakeholders in the camps to intervene and support the scale up of access to diagnosis and treatment. Advocacy for the integration of HCV prevention, diagnosis, and care into the comprehensive healthcare package for the entire Cox’s Bazar camp community is crucial. Initiatives for HCV prevention should target identified gaps in awareness and knowledge about Hepatitis C within the population, while infection control efforts must strengthen prevention and safe medical practices across all healthcare sectors in the camps. Given the generalized HCV epidemic among the FDMN adult population in Cox’s Bazar camps, a strongly recommended course of action involves initiating a multi-partner task force and developing a strategic plan to treat all, aiming to prevent disease and halt further HCV transmission in the camps.
