Prevalence of chronic viral hepatitis B, D among Mongol migrants in Sweden compared to a sex and age matched native Mongol cohort

Prevalence of chronic viral hepatitis B, D among Mongol migrants in Sweden compared to a sex and age matched native Mongol cohort | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Prevalence of chronic viral hepatitis B, D among Mongol migrants in Sweden compared to a sex and age matched native Mongol cohort Delgersaikhan Zulkhuu, Habiba Kamal, Sanjaasuren Enkhtaivan, Ochirmaa Narantsogt, and 20 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6292867/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 16 Jan, 2026 Read the published version in BMC Infectious Diseases → Version 1 posted 11 You are reading this latest preprint version Abstract Background & Aims Chronic hepatitis B/D is the most severe chronic hepatitis, yet public awareness of its burden remains low. This study examines the prevalence of viral hepatitis B/D among Mongol migrants in Sweden with possible linkage to care. Methods A screening event for viral hepatitis was conducted on the 28th − 29th January 2023 at Karolinska University Hospital, Stockholm for individuals of Mongol descent. Consented participants underwent blood tests and liver stiffness measurements. The prevalence of viral hepatitis was compared to an age, sex-matched general population cohort in Mongolia with blood samples. Results In total, 850 adult Mongols, aged mean (SD) 43·2 ± 8·6 years and 61·9% women were screened. The prevalence of HBsAg+, anti-HDV+, and HDV-RNA + were 4.4%, 2.1%, and 1.3%, respectively. The corresponding figures were 9.8%, 5.1%, and 3.7% in the matched cohort in Mongolia. Persons with anti-HDV + constituted 48.6% of HBsAg+ (18/37), and 61.1% among anti-HDV + were HDV-RNA+ (11/18). Prior HBV infection was seen in 65.8%, 8.7% were vaccinated, and 21.6% were susceptible to HBV infection. In total, 58 (6.8%) persons with chronic viral hepatitis were linked to care. Of HBsAg + or anti-HBc+, 54.1% and 65.8% were aware of current or past HBV infection, respectively. Conclusion Mongol migrants had lower prevalence of hepatitis B, and D compared to Mongolia, but higher than the Swedish general population. More screening efforts are needed to reinforce the awareness, diagnosis, and improve linkage to care of populations at higher risk of chronic viral hepatitis in Sweden and Europe. hepatitis D Mongolia screening HBV HCV prevalence migrants minority Figures Figure 1 Figure 2 Lay summary Infection with hepatitis virus D virus causes a severe liver disease. In this study we screened 850 Mongols living in Stockholm, Sweden and we found a higher prevalence of hepatitis B, D virus and C viral infections compared to that in the general population. One fifth of participants were susceptible to new hepatitis B infection and almost half were unaware of their infection. The screening helped identify 58 persons with viral hepatitis B, D and C and linked them to care. This study supports culturally sensitive and tailored endeavors to raise the awareness and improve the cascade of care of viral hepatitis, especially in vulnerable populations. Introduction Screening for viral hepatitis is the initial step in a continuous process of prevention, diagnosis and care for acute and chronic viral hepatitis as well as related complications.[1] The burden of chronic hepatitis B, C, and D remains high in Asia, Eastern Europe, the Middle East, and Sub-Saharan Africa.[1] Consequently, the top 10 countries with the highest age standardized incidence rate of liver cancer and related mortality are endemic with chronic viral hepatitis B, C, and D.[2] Migrants among other minority groups such as people who use intravenous drugs, and incarcerated individuals have higher prevalence of chronic viral hepatitis B, C and D and are at increased risk of being missed or delayed linkage to care.[3, 4] Additional barriers for migrants might relate to lower disease awareness, language barrier, stigma, and socioeconomic adversities in host countries.[5] These barriers vary across countries emphasizing depending on the specific context and nationwide strategies for addressing viral hepatitis.[3, 5] Chronic hepatitis D virus (HDV) is the most severe form of viral hepatitis that needs hepatitis B virus (HBV) for infection, causing an accelerated progression to cirrhosis and end-stage liver disease. Estimates of the global population chronically infected with HDV vary widely, ranging from 10 to 70 million individuals.[6, 7] In Sweden, the prevalence of HBV and hepatitis C virus (HCV) is 10 to 70 thousand and 35 to 45 thousand persons, respectively.[8] While, it is estimated that around 800 persons lives with chronic HDV infection.[9] Sweden showed a progress towards eliminating viral hepatitis with a 40% decrease in new HBV notifications in years 2015–2018.[8] Similar to other European low-endemic settings, most individuals living with HBV in Sweden are infected perinatally, and originate from high endemic countries, while the majority of individuals with HCV are infected domestically.[8] Mongolia is one of the heavy afflicted countries by viral hepatitis and liver cancer.[10, 11] Despite the introduction of neonatal HBV vaccination in 1991, the prevalences of HBV and HDV infection remain high at 11.1%, 6.6%, respectively and 8.5% are infected with HCV.[10, 12] Prior screening initiatives of Mongol migrants in the United States, revealed a 9.0% prevalence of HCV and HBV infection; of the latter 41.2% were anti-HDV positive.[13] This while recently in Spain, lower estimates were noted at 5.8%, and 3.6% of HCV and HBV infections, respectively.[14] No prior screening for HBV and HDV among Mongol migrants has ever been conducted in Sweden, therefore, this study aims to assess the prevalence of viral hepatitis B, D, and C to identify and link to care those in need among this population. Methods Study design and participants This was a cross-sectional analysis of a population-based screening of Mongol migrants living in Sweden, invited through social media platforms with culturally and linguistically tailored invitations. The event was a collaborative initiative between the Infectious Diseases Clinic at Karolinska University Hospital (KUH); a secondary referral center covering the Southern Stockholm region, the Onom Foundation; an operating family foundation committed to making a tangible difference in lives of Mongols in and outside Mongolia by mitigating early and excess mortalities; the Liver Center; a center of excellence for screening, diagnosis, treatment and research of liver diseases in Ulaanbaatar, Mongolia, and the D-Solve Consortium; a European network coordinated by Hannover Medical School (MHH) and Centre for Individualized Infection Medicine (CIIM) to screen and study HDV infection in large multicenter cohorts[15], and the Onom Institute; a non-profit private research institute in the United States. Applicants were required to fill out a questionnaire involving demographic parameters and other queries (s Table 1 )· On the days of screening, designated the 28th and 29th of January 2023, lectures on viral hepatitis were presented by Swedish and Mongol health care personnel and brochures on the same topic were distributed. All study participants were required to sign an informed consent form, in Mongol language, that explained the procedures included in the screening. Venous blood samples were taken by nurses for virological and laboratory parameters. Liver stiffness (LS) and controlled attenuated parameter (CAP) values were assessed by transient elastography in all participants. LS measurements were considered reliable when success rate of measurements is ≥ 90% and the interquartile range (IQR) was ≤ 30%.[16] The test results were sent to the participants after 2–3 weeks. General population cohort in Ulaanbaatar, Mongolia We selected an age-, sex- (1:1) matched cohort from 2,600 individuals from the General Population STEPS Survey conducted in Ulaanbaatar, Mongolia from December 2017 through January 2018. 413 participants were randomly selected from this cohort and serum samples from those selected particpnats were screened viral hepatitis B and D infection. Definitions and co-variates Persons with no prior immunity against HBV or susceptible to infection defined as absence of serum anti-HBc or anti-HBs or anti-HBs level < 10 IU/ml were identified. Persons with positive HCV antibody were tested for HCV-RNA replication and if chronic infection, they were offered anti-viral therapies with follow-up. LS values < 7.5 kPa were considered homologous to fibrosis stages F0-F1 or no to early fibrosis, values of 7.5–12.4 kPa were considered F2 - F3 or moderate to advanced fibrosis and values ≥ 12.5 kPa were considered as F4 or cirrhosis.[16] Persons with LS between 7.5–12.4 kPa were informed about possible causes of increased LS related to diet, and/or alcohol overconsumption with follow-up referral to their primary care clinics. Persons with LS ≥ 12.5 kPa were subjected to further examination. CAP score values between 291 to 400 decibels per meter (db/m) were considered equivalent to S3 or severe steatosis (> 2/3 steatosis of the liver).[17] Body mass index (BMI) was calculated as weight in kilogram/ (height in meters) 2 and cutoffs of < 23.0 was considered within the normal range, while cutoffs of 23–27.4 and ≥ 27.5 were considered respectively as overweight and obesity per recommendation in Asian population.[18] The permanent identification number (PIN) is obtained by Swedish residents at birth or when immigrating to Sweden.[8] This number is a unique identifier for the entirety of individual’s life and used/linked in all national Swedish registers. Person who lacks a PIN could get temporary registration number(s) at the local level when dealing with health care services.[8] The length of stay in Sweden was calculated by subtracting age at the event from age at immigration. Study outcomes Our primary outcome was to assesses the prevalence of HBV, HCV, HDV and HIV infections. Other parameters of interest were prior HBV vaccination, susceptibility to HBV, self-awareness of viral hepatitis infection and of an infected family member were also sought. The secondary outcomes of the study included the frequency of linkage to care such as the number of patients who initiated anti-HBV or novel anti-HDV therapies or received direct acting anti-HCV (DAA) therapy as well those who initiated HCC surveillance. A comparison of the prevalence of HBV and HDV in a matched general population cohort in Ulaanbaatar, Mongolia was also carried out. Analyses of virological parameters· At KUH laboratory, qualitative detection of HBsAg, anti-HCV, anti-HIV/HIVAg and anti-HBc was performed on a Cobas 8000 e801 instrument (ECLIA; Roche Diagnostics GmbH, Germany) using the Elecsys HBsAg II, Elecsys anti-HCV II, Elecsys HIV Duo and Elecsys anti-HBc II assays (Roche Diagnostics GmbH, Germany). Quantitative detection of anti-HBs and HBsAg was performed using Elecsys anti-HBs II and Elecsys HBsAg II quant II on the Cobas 8000 e801 instrument (Roche Diagnostics GmbH, Germany). The qualitative detection of anti-HDV was performed using the Liaison XL murex Anti-HDV (CLIA) assay on the LIAISON XL instrument (DiaSorin S.p.A., Italy). HDV-RNA, samples were quantified by quantitative real-time PCR (qPCR) using the RoboGene HDV-RNA quantification kit 2.0 (AnalytikJena AG, Germany), with LLoD of 6 IU/ml, following nucleic acid extraction using the MagNA Pure 96 DNA and Viral NA Small Volume Kit using the MagNA Pure 96 instrument (Roche Diagnostics GmbH, Germany). HBV-DNA levels and HCV-RNA levels were quantified using the Cobas HBV and Cobas HCV Quantitative nucleic acid tests on Cobas 6800/8800 (Roche Diagnostics GmbH, Germany). At the Clinical and Molecular Diagnostics Laboratory of the Liver Center, HBsAg was qualitatively tested by rapid diagnostic test (CTK Biotech Inc., USA), while anti-HDV were tested using ELISA (Wantai Co. Ltd., PRC). Quantitative HBsAg was estimated by HISCL-5000 fully automated chemiluminescence analyzer (Sysmex Corporation, Japan). HDV-RNA was quantified using real time reverse transcriptase polymerase chain reaction with LOD of 50 IU/mL (Bioactiva Diagnostica, Germany; Bio-Rad, USA), respectively. Statistical analysis Continuous variables were presented as mean (SD = standard deviation) when normally distributed, and as median (IQR = interquartile range) when skewed. Student-T and Mann-Whitney tests were used for comparison of normal and skewed continuous variables, respectively. Categorical variables were presented as frequencies (numbers) and proportions and were compared using the Chi-Square test or Fisher’s exact test, whenever appropriate. Univariable and multivariable logistic regression analysis generating odds ratio with 95% confidence intervals (CI) were performed testing the association of elevated LS ≥ 7.5 kPa with the following variables: age at the event, sex, BMI, duration of stay in Sweden, positive family history of HBV infection, and positive serological results for viral hepatitis. Statistical significance was considered when P-value < 0·05· All analyses were executed using R and IBM-SPSS, 27 and data handling and figures were done using Microsoft excel 365. Data analysis was performed in January 2024. Power calculation for the native cohort A 1:1 ratio matched for sex and age cohort from the general population in Ulaanbaatar, Mongolia was matched to the Stockholm screened participants (n = 850). This general population cohort included 2,600 individuals who participated in the Ulaanbaatar STEPS Survey. Assuming the prevalence of HDV in the general population at 5.2%, the number needed to screen was 413 individuals with 80% power to detect a difference. This number was randomly selected from the matched cohort. Results Study participants Figure 1 shows the flowchart of the study participants, the baseline characteristics of participants are presented in Table 1 . Briefly, out of 1091 survey applicants, the final cohort constituted 850 individuals; 732 were attendees, and 118 persons attended in January-May 2024 through follow-up calls. Women constituted a majority (n = 526, 61.9%), across all age categories (Fig. 2 a). Women were older than men at migration (mean age 35.2 vs 33.3, p = 0.003) and at the event (mean age 43.9 vs 42.0, p = 0.002). Overall, 79.4% of study participants possessed a PIN, with lower frequency in women (77.2%) compared to men (83·0), (p = 0.04) and 98.6% declared they live in Stockholm (results not shown). Prior screening of HBV infection Only a minority underwent a prior viral hepatitis screening (19.3%), similarly prevalent in men and women (18.2% vs 20.0%, p = < 0·001) (Table 1 ). As shown in Figure S1 a, prior HBV screening showed an increasing trend across years of migration with 14.0% between the years 2000–2005, reaching 27.0% in years 2021–2023 (p = 0.037). Middle age groups: higher proportions of age 40–60 years showed knowledge on prior screening compared to participants less than 30, 30–40 age groups as shown in Figure S1 b (p = 0.003). In 15.5% (72/465) stated the presence of a prior or current infected family member, significantly more reported in women than in men, (18.3% vs 10.9% respectively, p < 0.001), while 39.1% regardless of sex were unaware of this information· For those who have a positive family history (n = 72/465, 15.5%), 68.1% (49/72) stated that a parent is infected, while 38.9% (28/72) stated a sibling, and 5·6% (4/72) stated a child. Younger age groups (< 30, 30–40 years of age) had lower prevalence of infected family members compared to older age groups, with overall 35% − 55% unawareness across all age groups lower in those aged 40 - <50 years of age (Figure S2). Overall, in 819 individuals with successful liver elastography, the median (IQs) value was 4.5 (3.7–5.6) kPa, with men showing higher values vs women (4.8 vs 4.3 kPa, p = 0.002), this difference remained significant across age groups 30–39, 40–49 and 50–59 years of age and CAP score, where 31.3% of men had S3 score compared to 16.7% in women (p < 0.001). Similarly, men had significant higher BMI than women, with 42.8% having BMI ≥ 27.5 contrasted to 29.8% in women (p < 0.001). Study outcome: the prevalence of HBV, HDV, HCV and HIV (Table 1 ) Among all participants, the prevalence of HBsAg+, anti-HDV+, anti-HCV + and anti-HIV/HIV Ag + were n(%), 37 (4.4%), 18 (2.1%), 158 (18.6%) and none, respectively with no sex predilection noted. Persons with anti-HDV + constituted 48.6% of those with HBsAg+. In persons with anti-HDV+, 11 (61.1%) had detected HDV-RNA at a median (IQR) of 4.4 log 10 (1.9–4.8) IU/ml. Among persons with anti-HCV+, 20 (12.7%) had HCV-RNA replication, excluding one patient who had initially borderline value and upon repetition was negative for HCV-RNA replication. Across year of birth, the prevalence of anti-HCV + significantly declined from 34.3% in 1945-<1970 subgroup to 3.5% in 1991–2005 subgroup (a birth cohort effect). A decline also could be seen in those with HBsAg+, anti-HDV + across these birth cohorts, with the least prevalences in 1991- ≤2005 birth cohort (Fig. 2 b), (p = < 0·001). Excluding patients with confirmed HBV infection, almost two-thirds (558) 68·6% of participants had resolved HBV infection. This while 71 (8.7%) had prior vaccination and 184 (22.6%) were susceptible to HBV infection. Younger participants (born 1991-≤2005) had more prevalent HBV vaccination (17.3%), was the least group to have prior HBV infection (17.9%) and 56.7% were susceptible to infection (all p < 0.001), (Fig. 2 c). Only one person of all participants (0.12%) had HBsAg+, anti-HDV + and anti-HCV+. Characteristics of participants with prior or current HBV, HDV and HCV infection (Table 2) Persons with anti-HDV+, and anti-HCV + were significantly older than persons with HBsAg+ (mono-infection) with similar year of migration to Sweden, slightly earlier in anti-HCV+. Women constituted the majority (72.2%) of individuals with anti-HDV+, compared to the HBV mono-infection (42.1%) and anti-HCV (62.7%) (p = < 0·001). Overall, the majority possessed a PIN, more frequent in anti-HCV+ (77.2%). Awareness of current hepatitis infection was higher in individuals with HBsAg + compared to anti-HCV+ (p = 0.01), where awareness was 57.8% and 50.0% among HBV mono-, and HDV infection, respectively. This while approximately, 1 in 10 (10.2%) persons with HCV (current or prior) infection was aware of infection. Participants with viral hepatitis showed a 20–30% unawareness of whether a family member is infected or not. Overall, the mean BMI was similar across the three groups (p = 0.73), individuals with anti-HCV + had more prevalent 38·5% in the obesity range. Persons with anti-HDV + had the highest median (IQR) LS at 6.5 (4.0–8.2) kPa, contrasted to values of 4.5 (3.7–5.5) kPa, and 4.7 (3.8–5.9) kPa in persons with HBV mono-infection and anti-HCV+, respectively (p < 0.001). In the same vessel, 16.7% had LS ≥ 9 kPa in anti-HDV+, the corresponding figures were 5.3% and 7.3% respectively in the other two groups (p < 0·001). CAP score was significantly lower in the anti-HDV + group (p = 0.04), and the prevalence of individuals with steatosis S3 was significantly higher in individuals with HBV mono-infection (30.8%) compared to anti-HDV+ (9.1%), and anti-HCV+ (15.6%) (p < 0.001). Follow-up and linkage to care In 19 individuals with HBV mono-infection, none deemed eligible to start anti-HBV therapy. In patients with anti-HDV + and HDV-RNA+, 2 (11.8%) patients started Bulevirtide, 2 (11.8%) patients started Tenofovir therapy, and 3 (17.6%) patients; two women in age group 50–59 and one man in his fifth decade started surveillance for hepatocellular carcinoma. In two patients with anti-HDV+, one underwent gastroscopy and started non-selective beta blocker, another one started anti-tuberculosis therapy (not shown in Fig. 1 ). All patients with chronic HCV (n = 20) were offered direct acting anti-HCV therapy for 12 weeks, with achieved sustained virological response in all recipients (100%) at follow-up. Prevalence of HBV, HDV in a comparator cohort in Mongolia Among 413 randomly selected individuals screened for general health checkups at primary care, 408 individuals had available samples, mean age 41.3 (8.5), men constituted 43.6% (s Table 2). The prevalence of HBsAg+, anti-HDV + was 9.8%, and 5.1%, respectively. Men were younger and had more prevalent HBsAg + vs women (13.5% vs 7.0%, p = 0.028). Among persons with anti-HDV+, 15 (78.9%) had HDV-RNA replication at a median log 5.9 IU/ml. The mean age of persons with HBsAg+/anti-HDV-, HBsAg+ /anti-HDV+, and those with HDV-RNA+, 39.8 (6.3), 44.2 (8.3) and 42.3 (8.4), respectively. In comparison to the Stockholm cohort, the general population cohort was slightly younger (41.3 vs 43.1, p < 0.001), with numerically higher male proportion (men 43.6% vs 38.1%, p = 0.06). The prevalence of HBsAg+, anti-HDV+, HDV-RNA + was 9.8%, 5.1% and 3.7%, respectively were significantly higher than the Stockholm screened cohort with corresponding 4.4%, 2.1% and 1.3% (all p < 0.05). Compared to Stockholm cohort, the native general population cohort carried a 2.39-higher odds of HBV infection (95% CI 1.50–3.80), a 2.51-odds of anti-HDV+ (1.32–4.76), and 2.91-higher odds of HDV-RNA+ (1.33–6.39). (results not tabulated). The association between baseline characteristics with elevated LS ≥ 7.5 kPa (moderate fibrosis and beyond). In univariable analysis, older age, and presence of any viral hepatitis were associated significantly with higher odds of elevated LS. In multivariable analyses, adjusting for age, sex, BMI, HDV-RNA and HCV-RNA replication, older age showed an aOR = 1.07 (1.02–1.11, p = 0.002), HDV-RNA replication showed aOR = 25.16 (7.17-88·28) and HCV-RNA replication had aOR = 7.20 (2.41–21.47) – remaining significantly associated with LS ≥ 7.5 (s Table 3). Discussion In this first population-based screening of Mongolia-born persons in Sweden, the prevalence of viral hepatitis B, D and C were 4.4%, 2.1% and 18.6%, respectively. None had HIV infection. The prevalence was significantly lower in the birth-cohort born after the year 1990. One in 10 individuals (10%) had a protective anti-HBs titer, while one in 5 (20%) reported a prior screening test for HBV infection. Young individuals (born after year 1990) showed a low HBV vaccine protection rate at 17.3%, and 56.7% were susceptible to HBV infection. Almost half of persons (45.9%) with a current infection were unaware of their status regardless of age group. Persons with HDV-RNA + had more prevalent advanced liver disease compared to HBV mono- and HCV infection. This screening initiative linked 58 (7.5%) people to care, therapies and follow-up per individual eligibility. The prevalences of viral hepatitis B, and D in Mongol migrants in Sweden are lower than the national Mongolian estimates,[10, 12] yet higher than the general population estimates in Sweden.[8] In the age and sex matched cohort from Ulaanbaatar, Mongolia, a higher prevalence was detected, reaching 9.8% HBsAg + and 5.1% anti-HDV+, agreeing with published Mongol general population surveys.[10, 19, 20] Compared to other screening initiatives in Mongols living abroad, a 4.8% prevalence of HBV in our study was lower than 6.8%, 6.2% and 9.9% estimates reported at US events in 2012, 2016 and 2021, respectively.[13, 21, 22] However, our estimated prevalence was comparable to a 3.6% HBV prevalence in a recent community-based screening of 222 Mongols across three Spanish cities.[14] Noteworthy, the prevalence of anti-HDV + among HBsAg + in our study at 48.6% was higher than 41.2% in a US screening study[13], and from a more recent Spanish report where the prevalence of anti-HDV + was 0.9%.[14] A higher prevalence of prior HCV infection in the present study at 18.6% compared to US[13] and Spanish[14] events (9–10% and 5.8% respectively) could also be seen. These variations might be explained by possible differences in sex, age distribution, and time of enrollment across these cohorts.[13, 14, 21, 22] Noteworthy, the varied prevalence of HCV infection in Mongolia reveals a strong age-cohort effect, as also suggested by Dashtseren and colleagues.[10] This agrees with our findings that 72.5% of those with HCV infection were born between 1970–1991, while 25% were born between 1945–1970. The rather high ratio of resolved HCV infection (84.6%) might suggest prior linkage to care, and possible improved survival in the middle-aged cohort. Although the prevalence of chronic HDV (65% with HDV-RNA replication) juxtaposes the Mongolian published estimates[13], but nevertheless less than the matched cohort suggesting a possible healthy migrant effect that might explain the overall lower estimates of hepatitis infection in our cohort.[23] Furthermore, the low prevalence of HBV, HCV and absence of HDV infection in the younger birth cohort agrees with recent Mongolian population screening.[12] Similarly, Colucci and colleagues demonstrated a low prevalence of 2.2%, 1.7%, 0.6% respectively of HBV, HCV and HIV infection in a cohort of newly arriving migrants to Italy.[24] Interestingly, in this young cohort (n = 362, median age 28 years) the prevalence of chronic HCV and HIV was more in those with > 6 months of stay.[24] A possible waning effect of HBV vaccine was suggested by Mongol researchers; Ochirbat and colleagues, reported that only 10% of 438 children aged 5–10 years of age carried a protective anti-HBs titer[25], while another report suggested an overall 41% protection.[12] Dashdorj and colleagues reported anti-HBs titer without indication of prior infection, reflecting vaccination was detected in 33% of 3800 children and young adult participants, declining with increasing age (personal communication, under review).[26] This is in line with our finding of low frequency of detected anti-HBs titer (17.3%) in younger birth cohort. We could not explain these figures in our study, as we did not explore other demographic, and socio-economic factors that might have affected HBV vaccine acquisition and efficacy in Mongol migrants in Sweden. In our data, women constituted 62.7%, and 72.2%, of individuals infected with HCV and HDV, respectively. On the other hand, women constituted 42.1% of the HBV-monoinfection group (not reaching statistical difference), to the contrast of the comparator Mongol cohort where men had 2.1 (95% CI 1.07–4.06, p = 0.03, refer to s Table 2 for proportions) higher odds of HBV mono-infection compared to women. It is unclear the cause of this disparity, nevertheless although women had higher serological evidence of HCV and HDV infection (in our analysis), they showed a trend towards less chronic infections (HCV-RNA and HDV-RNA replication, respectively). In our study, women constituted a majority across all age groups, and by year of migration. Such observation might differ from other populations with viral hepatitis where men constitute a majority.[27] Moreover, women significantly had more prior screening of HBV compared to men, which might be attributed to higher likelihood of screening particularly for women in the reproductive age group (ante-natal screening) and health-seeking behavior possibly lower in men, and women not in this age group or lacked such indication. Unawareness of infection reached 50% in our analysis, mirroring similar figures of screening cohorts in the Mongolian population,[14] with more pronounced unawareness among persons with HDV as reported that 99% of Mongols with HDV infection lacked knowledge of their infection contrasted to 60% in HBV and HCV infection.[12] Nevertheless, the lack of screening in 68–70% in age groups < 40 years demonstrated in our analysis when earlier intervention might affect the risk for liver-related disease progression, hepatocellular carcinoma and survival, need to be further addressed from a public health perspective in populations originating from high endemic regions. A positive remark that HBV screening increased from 14.0% in migration year 2000–2005 to 27.0% in years 2021–2023. Hur and colleagues reported a 2.12 -odds (1.13–3.97) to complete three HBV vaccination doses associated with living more than 10 years in the US.[22] In the current study, we could not note an association between duration of stay in Sweden and prevalence of HBV, HDV, and HCV infections. However, we assume that the low rate of chronic hepatitis C (13.4%) might be related to prior linkage to care and lack of repeated exposure. To date, liver societies recommend screening of persons from high-endemic regions for viral hepatitis (> 2% endemicity), while local guidelines implement different actions according to cost-effectiveness.[28] Although significant improvements have been achieved in timely diagnosis of viral hepatitis. Delayed diagnosis together with low awareness of infection has been associated with liver-related morbidity, especially among patients with CHB in high income settings.[9, 29] With the notion to reduce harm, targeted screening might be helpful in assessing and overcoming gaps and disparities in the viral hepatitis cascade of care. However, it is unclear if screening persons based solely on area of origin (with historical high-endemicity) in the absence of abnormal liver parameters is cost-effective, and the repercussions of such practice on reinforcement of stigma towards migrant communities. In that sense, rapid point-of-care screening services might offer simple, easy to implement and interpret tests that grant faster diagnosis and immediate clinical decision, possibly reducing the loss to follow-up/linkage to care.[30] Recently, Dashdorj and colleagues developed and validated anti-HDV antibody rapid diagnostics test that utilizes a defect-free bi-layer lipid membrane which enhances biofouling resistance, minimizing non-specific binding and significantly increasing the sensitivity of molecular detection (personal communication, under review).[31] These tests showed promising results in target micro-elimination programs, in difficult to reach populations such as people who use intravenous drugs who need frequent testing, and other vulnerable populations such as illegal migrants who might refrain from participating in screening programs in other health care facilities. Whether the use of home-based screening kits might further enhance linking other missed populations to care merits more real-world studies. Our study has limitations. We did not explore other factors such as level of education, area of residence that might not only affect the transmission of viral hepatitis, but also the awareness, and acceptance of health care. However, 70% of survey responders attended the event, reflecting good engagement of this population. Elevated liver stiffness predicted prior or current viral hepatitis in our model, acknowledging that other confounders such as alcohol overconsumption and metabolic dysfunction have not been investigated. Elevated alanine aminotransferase levels or laboratory-based scores such as FIB-4 (fibrosis index score) or APRI (aspartate-platelets ratio index) might be more feasible to detect early liver diseases in healthy individuals, but cutoffs need further validation in populations with CHD.[32] On another aspect, our finding of increased prevalence of overweight and obesity among study participants, particularly in men might be considered for future screening of metabolic-related morbidities in this population. We believe that this screening included 10–20% of the Mongol population living in Sweden, however a selection favoring persons who use social media and having internet access (unknown the extent in this population) could not be ruled out. In the same vein, those who are aware of their disease status (even if not in care) might be less likely to attend such screening. It is unclear if the probability of screening and early diagnosis is higher in Sweden rather than Mongolia. Given that such proactive efforts of population-screening demand will and logistics to implement that might be deficient in low, low-middle income countries in the governmental sector with constrained resources, highlighting the importance of funding governmental and non-governmental organizations/initiatives in resource limited settings. Conclusion Our study revealed a high prevalence of HBV, HDV and HCV infections in Mongols living in Stockholm than the general population estimates. A low rate of awareness especially in younger age groups calls for more tailored, age-adjusted efforts to spread awareness, and engage this population. Nevertheless, the low level of vaccination protection especially among the youngest birth cohort merits further actions. Declarations Ethics approval and consent to participate: The study was approved by the Region Stockholm ethics committee. All screening participants signed a translated informed consent. Clinical Trial: not applicable. Consent for publication: all co-authors approved the final version of the manuscript and consent for publishing. Availability of data and material: All data were anonymized during data handling and analysis. The authors do not have permission to share the data. Competing interests: all co-authors disclose no conflict of interest with the current study. Funding: ALF grant from Region Stockholm, Sweden. Authors' contributions: The following authors have full access to the data set of the study: HK, GJ, SE, ON, NBD, ND and SA. Authors SA and HK are responsible for the integrity and accuracy of the data analysis. Concept and design: SA and ND. Drafting of the manuscript and analysis of the data: HK. Interpretation of data and critical revision of the manuscript: DZ, HK, SE, ON, GJ, MB, BO, MA, KL, MI, NS, AP, GS, NB, SS, SC, AO, AB, ID, DG, AB, ND, DO, SA. DZ and HK share first co-authorship, ND and SA contributed equally as co-last authors. Acknowledgements We express our gratitude to all the participants in this event, and we acknowledge the efforts of all organizers. The Onom Foundation provided a part of the funding to carry out the study. References WHO | Global health sector strategy on viral hepatitis 2016–2021. WHO. 2019. Sung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A, et al. Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. CA Cancer J Clin. 2021;71:209–49. Papatheodoridis G V., Tsochatzis E, Hardtke S, Wedemeyer H. Barriers to care and treatment for patients with chronic viral hepatitis in Europe: a systematic review. Liver International. 2014;34:1452–63. Gahrton C, Westman G, Lindahl K, Öhrn F, Dalgard O, Lidman C, et al. Prevalence of Viremic hepatitis C, hepatitis B, and HIV infection, and vaccination status among prisoners in Stockholm County. BMC Infect Dis. 2019;19:1–9. Mitchell T, Nayagam JS, Dusheiko G, Agarwal K. 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Tables Table 1: Baseline characteristics of participants of the screening event, sub-grouped by sex Parameters** All, n (%) Men, n (%) Women, n (%) p-value Number (%) unless stated otherwise 850 (100) 324 (38·1) 526 (61·9) <0·001 Year of migration, median (IQR) 2015 (2011-2018) 2015 (2011-2018) 2015 (2011-2018) 0·47 Mean age at migration, mean (SD, min-max) 34.4 (8.7, 6-68) 33.3 (8.4, 9-60) 35.2 (8.9, 6-68) 0.003 Mean age at the event, years (SD, min-max) 43.2 (8.6, 18.0-75.8) 42.0 (8.2, 19.2-64.9) 43.9 (8.8, 18.0-75.8) 0.002 Presence of a permanent Swedish personal identification number 675 (79.4) 269 (83.0) 406 (77.2) 0.04 Prior HBV screening Yes 164 (19.3) 59 (18.2) 105 (20.0) 0.52 No 564 (66.4) 225 (69.4) 339 (64.4) Do not know 122 (14.4) 40 (12.3) 82 (15.6) Have you been diagnosed with HBV infection (n=726) Yes 59 (8.1) 24/278 (8.6) 35/448 (7.8) 0.47 No 493 (67.9) 196/278 (70.5) 297/448 (66.3) Do not know 174 (24.0) 58/278 (20.9) 116/448 (25.9) BMI, kg/m 2 , (n=841) Mean (SD) 26.1 (4.3) 26.9 (3.7) 25.7 (4.6) <0.001 <23 183 (21.8) 43/320 (13.4) 140/521 (26.9) <0.001 23-27.5 366 (43.5) 140/320 (43.8) 226/521 (43.4) 0.18 ≥27.5 292 (34.7) 137/320 (42.8) 155/521 (29.8) <0.001 HBV Prior HBV infection (HBsAg-, anti-HBc+, anti-HBs+) 558 (65.8) 223 (69.1) 335 (63.7) 0.19 Vaccinated (HBsAg-, anti-HBc-, anti-HBs+) 71/813 (8.7) 23/308 (7.5) 48/507 (9.5) 0.31 Susceptible to HBV (HBsAg-, anti-HBc-, anti-HBs-) 184/813 (21.6) 61/308 (19.8) 123/507 (24.3) 0.13 HBsAg+ 37 (4.4) 16 (4.9) 21 (4.0) 0.52 HBV-DNA log 10 (IU/ml), median (IQR) 2.4 (1.2–2.9) 2.3 (1.2–3.8) 2.4 (1.0–2.7) 0.27 HBsAg log 10 (IU/ml), median (IQR) 2.6 (1.9–3.7) 3.3 (2.1–3.7) 2.3 (1.1–3.7) 0.06 Knowledge about current infection among HBsAg+ (n=37) (n=16) (n=21) Yes 20 (54.1) 9 (56.3) 11 (52.4) 0.19 No 8 (21.6) 4 (25.0) 4 (19.0) 0.70 Do not know 9 (24.3) 3 (18.8) 6 (28.6) 0.20 HDV Anti-HDV+ 18 (2.1) 5 (1.5) 13 (2.5) 0.36 HDV-RNA+ 11 (1.3) 4 (1.2) 7 (1.3) 0.31 HDV-RNA log 10 IU/ml, median (IQR) 4.4 (1.9–4.8) 4.7 (4.2–5.7) 4.0 (1.7–4.8) 0.12 HCV Anti-HCV+ 158 (18.6) 59 (18.2) 99 (18.8) 0.84 HCV-RNA+ 21 (2.5) 12 (3.7) 9 (1.7) 0.07 HCV-RNA log 10 IU/ml, median (IQR) 6.0 (5.5–6.6) 6.2 (5.5–6.8) 6.0 (5.1–6.5) 0.23 Liver stiffness values, n= 819 LS, median (IQR), kPa 4.5 (3.7-5.6) 4.8 (4.1-5.9) 4.3 (3.5-5.4) 0.002 CAP score¤, median (IQR) dB/m, n=338 236.5 (202.0-277.3) 264.0 (216.8-290.5) 226.0 (193.3-270.8) <0.001 S3 ≥290, n (%) 76/338 (22.5%) 42 (31.3%) 34 (16.7%) 0.001 Abbreviations: n= number; anti-HDV= hepatitis D antibody; HDV-RNA= hepatitis D virus ribonucleic acid; HBV= hepatitis B virus; anti-HCV= hepatitis C antibody; SD=standard deviation; IQR=25 th -75 th interquartile, 25 th and 75 th percentiles are displayed; BMI=body mass index calculated as body weight in kilogram/(height in meters) 2 ; LSM=liver stiffness measurements; kPa= kilopascal; ¤CAP= controlled attenuated parameter score measured in decibels per meter (dB/m); S3=CAP score 290 to 400 dB/m translating to > 2/3 of the liver has steatosis. ¤available in 134 men and 204 women. Table 2: Baseline characteristics of participants according to detected viral hepatitis Parameters, n (%) unless stated otherwise HBsAg+, anti-HDV- HBsAg+, anti-HDV+ Anti-HCV+ p-value Number, % of 850 participants 19, 2.3% 18, 2.1% 158, 18.6% <0.001 Sex, women 8 (42.1) 13 (72.2) 99 (62.7) <0.001 Mean age at the event, years, (SD) 42.2 (9.1) 47.6 (6.7) 47.1 (8.2) 0.039 Year of arrival to Sweden, median (IQR) year 2015 (2010-2018) 2017 (2012-2021) 2015 (2011-2018) 0.092 Presence of permanent Swedish personal number 13 (68.4) 12 (66.7) 122 (77.2) <0.001 Prior test to HBV, n (%) 10 (52.6) 10 (55.6) 30 (19.0) <0.001 Awareness of current hepatitis infection, n (%) Yes 11 (57.8) 9 (50.0) 16 (10.2) 0.011 No 4 (21.1) 4 (22.2) 74 (46.5) <0.001 I do not know 4 (21.1) 5 (27.8) 68 (43.3) <0.001 Awareness of a family or household infected with HBV n=11 n=9 n=82 Yes 2 (18.2) 2 (22.2) 10 (12.2) 0.008 No 6 (54.5) 5 (55.6) 45 (54.9) 0.87 I do not know 3 (27.3) 2 (22.2) 27 (32.9) <0.001 BMI n=19 n=18 n=156 Mean (SD), kg/m 2 26.8 (3.5) 27.5 (9.9) 26.8 (4.4) 0.725 <23 kg/m 2 1 (5.3) 2 (11.1) 25 (16.0) <0.001 23-27.5 kg/m 2 12 (63.2) 13 (72.2) 71 (45.5) <0.001 ≥27.5 kg/m 2 6 (31.6) 3 (16.7) 60 (38.5) <0.001 Virological markers Anti-HCV+ 0 1 (5.6) 158 (100) <0.001 HCV-RNA+ - 0 21 (13.4)^ HDV-RNA + - 11 (61.1) 0 LS n=19 n=18 n=150 Median (IQR), kPa 4.5 (3.7–5.5) 6.5 (4.0–8.2) 4.7 (3.8–5.9) <0.001 LS ≥9.0 kPa 1 (5.3) 3 (16.7) 11 (7.3) <0.001 LS ≥12.5 kPa 0 1 (5.6) 3 (2.0) 0.014 CAP, median (IQR) db/m 239.0 (208.5-308.0) 223.0 (193.0- 271.0) 229.5 (202.0-271.0) 0.04 CAP ≥290 db/m 4/13 (30.8) 1/11 (9.1) 10/64 (15.6) <0.001 Abbreviations: anti-HDV= hepatitis D antibody; HDV-RNA= hepatitis D virus ribonucleic acid; HBV= hepatitis B virus; BMI=body mass index; anti-HCV= hepatitis C antibody; kPa= kilopascal; n= number; IQR= 25 th -75 th interquartile; LS= liver stiffness; CAP= controlled attenuated parameter score measured in decibels per meter (dB/m); S3=CAP score 290 to 400 dB/m translating to > 2/3 of the liver has steatosis. ^patient had repeated HCV-RNA determined negative thereafter. Additional Declarations No competing interests reported. Supplementary Files ScreeningMongolianeventsupplements25.03.24HK.docx Cite Share Download PDF Status: Published Journal Publication published 16 Jan, 2026 Read the published version in BMC Infectious Diseases → Version 1 posted Editorial decision: Revision requested 16 Jun, 2025 Reviews received at journal 06 Jun, 2025 Reviewers agreed at journal 28 May, 2025 Reviews received at journal 20 May, 2025 Reviewers agreed at journal 22 Apr, 2025 Reviewers agreed at journal 20 Apr, 2025 Reviewers invited by journal 15 Apr, 2025 Editor invited by journal 28 Mar, 2025 Editor assigned by journal 26 Mar, 2025 Submission checks completed at journal 26 Mar, 2025 First submitted to journal 24 Mar, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Bungert","email":"","orcid":"","institution":"The Liver Center","correspondingAuthor":false,"prefix":"","firstName":"Andreas","middleName":"S.","lastName":"Bungert","suffix":""},{"id":436113678,"identity":"ca4d09f0-0c10-40f2-8347-12127f07b839","order_by":21,"name":"Nara Bungert Dashdorj","email":"","orcid":"","institution":"The Liver Center","correspondingAuthor":false,"prefix":"","firstName":"Nara","middleName":"Bungert","lastName":"Dashdorj","suffix":""},{"id":436113681,"identity":"e6296458-ee9f-4d81-8d18-f0006fe58084","order_by":22,"name":"Dashdorj Onom","email":"","orcid":"","institution":"The Liver Center","correspondingAuthor":false,"prefix":"","firstName":"Dashdorj","middleName":"","lastName":"Onom","suffix":""},{"id":436113683,"identity":"68d4998e-da8f-4b55-a0e7-4b82b074c762","order_by":23,"name":"Soo Aleman","email":"","orcid":"","institution":"Karolinska University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Soo","middleName":"","lastName":"Aleman","suffix":""}],"badges":[],"createdAt":"2025-03-24 07:53:35","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6292867/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6292867/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12879-025-12506-w","type":"published","date":"2026-01-16T16:29:10+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":80047766,"identity":"8c444715-886c-452e-86ac-3871719f2dc1","added_by":"auto","created_at":"2025-04-07 09:56:52","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":181355,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFlowchart of study participants\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAbbreviations: HBV=hepatitis B virus; HBsAg: hepatitis B surface antigen, HDV= hepatitis D virus; anti-HDV=hepatitis D virus antibody; HDV RNA= hepatitis D virus ribonucleic acid; HCV-ab= hepatitis C virus antibody; HCV RNA= hepatitis C virus ribonucleic acid; anti-HBc= anti-hepatitis B core; anti-HBs=hepatitis B surface antibody; DAA= direct acting antiviral; SVR=sustained virological response defined as undetected HCV RNA ≥ 12 weeks post treatment end; NUC= nucleot(s)ides analogues\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6292867/v1/0abf342347efed036a508076.png"},{"id":80047768,"identity":"d9997c37-cff5-49e4-be54-46529a0ad62d","added_by":"auto","created_at":"2025-04-07 09:56:52","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":100865,"visible":true,"origin":"","legend":"\u003cp\u003ea) Distribution of participants by sex and age categories, b) Prevalence of viral hepatitis by year of birth, c)\u003cstrong\u003e \u003c/strong\u003ePrior HBV exposure or vaccination by year of birth\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6292867/v1/03922a042cd1cdbffb576837.png"},{"id":100614506,"identity":"9b76b6d0-72fd-4aca-9f03-507b34858d7a","added_by":"auto","created_at":"2026-01-19 17:20:59","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1594676,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6292867/v1/da679478-2eab-46e1-b9d1-cb379ce1bc78.pdf"},{"id":80047767,"identity":"893a0c50-13bf-4026-bd46-6f7a8ab34b68","added_by":"auto","created_at":"2025-04-07 09:56:52","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":74667,"visible":true,"origin":"","legend":"","description":"","filename":"ScreeningMongolianeventsupplements25.03.24HK.docx","url":"https://assets-eu.researchsquare.com/files/rs-6292867/v1/79342fc73ee9cf45ad84ecdb.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Prevalence of chronic viral hepatitis B, D among Mongol migrants in Sweden compared to a sex and age matched native Mongol cohort","fulltext":[{"header":"Lay summary","content":"\u003cul\u003e\n \u003cli\u003eInfection with hepatitis virus D virus causes a severe liver disease.\u003c/li\u003e\n \u003cli\u003eIn this study we screened 850 Mongols living in Stockholm, Sweden and we found a higher prevalence of hepatitis B, D virus and C viral infections compared to that in the general population.\u003c/li\u003e\n \u003cli\u003eOne fifth of participants were susceptible to new hepatitis B infection and almost half were unaware of their infection.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eThe screening helped identify 58 persons with viral hepatitis B, D and C and linked them to care.\u003c/li\u003e\n\u003cli\u003eThis study supports culturally sensitive and tailored endeavors to raise the awareness and improve the cascade of care of viral hepatitis, especially in vulnerable populations.\u003c/li\u003e\u003c/ul\u003e"},{"header":"Introduction","content":"\u003cp\u003eScreening for viral hepatitis is the initial step in a continuous process of prevention, diagnosis and care for acute and chronic viral hepatitis as well as related complications.[1] The burden of chronic hepatitis B, C, and D remains high in Asia, Eastern Europe, the Middle East, and Sub-Saharan Africa.[1] Consequently, the top 10 countries with the highest age standardized incidence rate of liver cancer and related mortality are endemic with chronic viral hepatitis B, C, and D.[2] Migrants among other minority groups such as people who use intravenous drugs, and incarcerated individuals have higher prevalence of chronic viral hepatitis B, C and D and are at increased risk of being missed or delayed linkage to care.[3, 4] Additional barriers for migrants might relate to lower disease awareness, language barrier, stigma, and socioeconomic adversities in host countries.[5] These barriers vary across countries emphasizing depending on the specific context and nationwide strategies for addressing viral hepatitis.[3, 5] Chronic hepatitis D virus (HDV) is the most severe form of viral hepatitis that needs hepatitis B virus (HBV) for infection, causing an accelerated progression to cirrhosis and end-stage liver disease. Estimates of the global population chronically infected with HDV vary widely, ranging from 10 to 70\u0026nbsp;million individuals.[6, 7] In Sweden, the prevalence of HBV and hepatitis C virus (HCV) is 10 to 70 thousand and 35 to 45 thousand persons, respectively.[8] While, it is estimated that around 800 persons lives with chronic HDV infection.[9] Sweden showed a progress towards eliminating viral hepatitis with a 40% decrease in new HBV notifications in years 2015\u0026ndash;2018.[8] Similar to other European low-endemic settings, most individuals living with HBV in Sweden are infected perinatally, and originate from high endemic countries, while the majority of individuals with HCV are infected domestically.[8] Mongolia is one of the heavy afflicted countries by viral hepatitis and liver cancer.[10, 11] Despite the introduction of neonatal HBV vaccination in 1991, the prevalences of HBV and HDV infection remain high at 11.1%, 6.6%, respectively and 8.5% are infected with HCV.[10, 12] Prior screening initiatives of Mongol migrants in the United States, revealed a 9.0% prevalence of HCV and HBV infection; of the latter 41.2% were anti-HDV positive.[13] This while recently in Spain, lower estimates were noted at 5.8%, and 3.6% of HCV and HBV infections, respectively.[14] No prior screening for HBV and HDV among Mongol migrants has ever been conducted in Sweden, therefore, this study aims to assess the prevalence of viral hepatitis B, D, and C to identify and link to care those in need among this population.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and participants\u003c/h2\u003e \u003cp\u003eThis was a cross-sectional analysis of a population-based screening of Mongol migrants living in Sweden, invited through social media platforms with culturally and linguistically tailored invitations.\u003c/p\u003e \u003cp\u003eThe event was a collaborative initiative between the Infectious Diseases Clinic at Karolinska University Hospital (KUH); a secondary referral center covering the Southern Stockholm region, the Onom Foundation; an operating family foundation committed to making a tangible difference in lives of Mongols in and outside Mongolia by mitigating early and excess mortalities; the Liver Center; a center of excellence for screening, diagnosis, treatment and research of liver diseases in Ulaanbaatar, Mongolia, and the D-Solve Consortium; a European network coordinated by Hannover Medical School (MHH) and Centre for Individualized Infection Medicine (CIIM) to screen and study HDV infection in large multicenter cohorts[15], and the Onom Institute; a non-profit private research institute in the United States. Applicants were required to fill out a questionnaire involving demographic parameters and other queries (s Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e)\u0026middot;\u003c/p\u003e \u003cp\u003eOn the days of screening, designated the 28th and 29th of January 2023, lectures on viral hepatitis were presented by Swedish and Mongol health care personnel and brochures on the same topic were distributed. All study participants were required to sign an informed consent form, in Mongol language, that explained the procedures included in the screening. Venous blood samples were taken by nurses for virological and laboratory parameters. Liver stiffness (LS) and controlled attenuated parameter (CAP) values were assessed by transient elastography in all participants. LS measurements were considered reliable when success rate of measurements is \u0026ge;\u0026thinsp;90% and the interquartile range (IQR) was \u0026le;\u0026thinsp;30%.[16] The test results were sent to the participants after 2\u0026ndash;3 weeks.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eGeneral population cohort in Ulaanbaatar, Mongolia\u003c/h3\u003e\n\u003cp\u003eWe selected an age-, sex- (1:1) matched cohort from 2,600 individuals from the General Population STEPS Survey conducted in Ulaanbaatar, Mongolia from December 2017 through January 2018. 413 participants were randomly selected from this cohort and serum samples from those selected particpnats were screened viral hepatitis B and D infection.\u003c/p\u003e\n\u003ch3\u003eDefinitions and co-variates\u003c/h3\u003e\n\u003cp\u003ePersons with no prior immunity against HBV or susceptible to infection defined as absence of serum anti-HBc or anti-HBs or anti-HBs level\u0026thinsp;\u0026lt;\u0026thinsp;10 IU/ml were identified. Persons with positive HCV antibody were tested for HCV-RNA replication and if chronic infection, they were offered anti-viral therapies with follow-up. LS values\u0026thinsp;\u0026lt;\u0026thinsp;7.5 kPa were considered homologous to fibrosis stages F0-F1 or no to early fibrosis, values of 7.5\u0026ndash;12.4 kPa were considered F2 - F3 or moderate to advanced fibrosis and values\u0026thinsp;\u0026ge;\u0026thinsp;12.5 kPa were considered as F4 or cirrhosis.[16] Persons with LS between 7.5\u0026ndash;12.4 kPa were informed about possible causes of increased LS related to diet, and/or alcohol overconsumption with follow-up referral to their primary care clinics. Persons with LS\u0026thinsp;\u0026ge;\u0026thinsp;12.5 kPa were subjected to further examination. CAP score values between 291 to 400 decibels per meter (db/m) were considered equivalent to S3 or severe steatosis (\u0026gt;\u0026thinsp;2/3 steatosis of the liver).[17] Body mass index (BMI) was calculated as \u003cem\u003eweight in kilogram/ (height in meters)\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e and cutoffs of \u0026lt;\u0026thinsp;23.0 was considered within the normal range, while cutoffs of 23\u0026ndash;27.4 and \u0026ge;\u0026thinsp;27.5 were considered respectively as overweight and obesity per recommendation in Asian population.[18] The permanent identification number (PIN) is obtained by Swedish residents at birth or when immigrating to Sweden.[8] This number is a unique identifier for the entirety of individual\u0026rsquo;s life and used/linked in all national Swedish registers. Person who lacks a PIN could get temporary registration number(s) at the local level when dealing with health care services.[8] The length of stay in Sweden was calculated by subtracting age at the event from age at immigration.\u003c/p\u003e\n\u003ch3\u003eStudy outcomes\u003c/h3\u003e\n\u003cp\u003eOur primary outcome was to assesses the prevalence of HBV, HCV, HDV and HIV infections. Other parameters of interest were prior HBV vaccination, susceptibility to HBV, self-awareness of viral hepatitis infection and of an infected family member were also sought.\u003c/p\u003e \u003cp\u003eThe secondary outcomes of the study included the frequency of linkage to care such as the number of patients who initiated anti-HBV or novel anti-HDV therapies or received direct acting anti-HCV (DAA) therapy as well those who initiated HCC surveillance. A comparison of the prevalence of HBV and HDV in a matched general population cohort in Ulaanbaatar, Mongolia was also carried out.\u003c/p\u003e\n\u003ch3\u003eAnalyses of virological parameters·\u003c/h3\u003e\n\u003cp\u003eAt KUH laboratory, qualitative detection of HBsAg, anti-HCV, anti-HIV/HIVAg and anti-HBc was performed on a Cobas 8000 e801 instrument (ECLIA; Roche Diagnostics GmbH, Germany) using the Elecsys HBsAg II, Elecsys anti-HCV II, Elecsys HIV Duo and Elecsys anti-HBc II assays (Roche Diagnostics GmbH, Germany). Quantitative detection of anti-HBs and HBsAg was performed using Elecsys anti-HBs II and Elecsys HBsAg II quant II on the Cobas 8000 e801 instrument (Roche Diagnostics GmbH, Germany). The qualitative detection of anti-HDV was performed using the Liaison XL murex Anti-HDV (CLIA) assay on the LIAISON XL instrument (DiaSorin S.p.A., Italy). HDV-RNA, samples were quantified by quantitative real-time PCR (qPCR) using the RoboGene HDV-RNA quantification kit 2.0 (AnalytikJena AG, Germany), with LLoD of 6 IU/ml, following nucleic acid extraction using the MagNA Pure 96 DNA and Viral NA Small Volume Kit using the MagNA Pure 96 instrument (Roche Diagnostics GmbH, Germany). HBV-DNA levels and HCV-RNA levels were quantified using the Cobas HBV and Cobas HCV Quantitative nucleic acid tests on Cobas 6800/8800 (Roche Diagnostics GmbH, Germany).\u003c/p\u003e \u003cp\u003eAt the Clinical and Molecular Diagnostics Laboratory of the Liver Center, HBsAg was qualitatively tested by rapid diagnostic test (CTK Biotech Inc., USA), while anti-HDV were tested using ELISA (Wantai Co. Ltd., PRC). Quantitative HBsAg was estimated by HISCL-5000 fully automated chemiluminescence analyzer (Sysmex Corporation, Japan). HDV-RNA was quantified using real time reverse transcriptase polymerase chain reaction with LOD of 50 IU/mL (Bioactiva Diagnostica, Germany; Bio-Rad, USA), respectively.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eContinuous variables were presented as mean (SD\u0026thinsp;=\u0026thinsp;standard deviation) when normally distributed, and as median (IQR\u0026thinsp;=\u0026thinsp;interquartile range) when skewed. Student-T and Mann-Whitney tests were used for comparison of normal and skewed continuous variables, respectively. Categorical variables were presented as frequencies (numbers) and proportions and were compared using the Chi-Square test or Fisher\u0026rsquo;s exact test, whenever appropriate. Univariable and multivariable logistic regression analysis generating odds ratio with 95% confidence intervals (CI) were performed testing the association of elevated LS\u0026thinsp;\u0026ge;\u0026thinsp;7.5 kPa with the following variables: age at the event, sex, BMI, duration of stay in Sweden, positive family history of HBV infection, and positive serological results for viral hepatitis. Statistical significance was considered when P-value\u0026thinsp;\u0026lt;\u0026thinsp;0\u0026middot;05\u0026middot; All analyses were executed using R and IBM-SPSS, 27 and data handling and figures were done using Microsoft excel 365. Data analysis was performed in January 2024.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003ePower calculation for the native cohort\u003c/h3\u003e\n\u003cp\u003eA 1:1 ratio matched for sex and age cohort from the general population in Ulaanbaatar, Mongolia was matched to the Stockholm screened participants (n\u0026thinsp;=\u0026thinsp;850). This general population cohort included 2,600 individuals who participated in the Ulaanbaatar STEPS Survey. Assuming the prevalence of HDV in the general population at 5.2%, the number needed to screen was 413 individuals with 80% power to detect a difference. This number was randomly selected from the matched cohort.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eStudy participants\u003c/h2\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e shows the flowchart of the study participants, the baseline characteristics of participants are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eBriefly, out of 1091 survey applicants, the final cohort constituted 850 individuals; 732 were attendees, and 118 persons attended in January-May 2024 through follow-up calls. Women constituted a majority (n\u0026thinsp;=\u0026thinsp;526, 61.9%), across all age categories (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003ea). Women were older than men at migration (mean age 35.2 vs 33.3, p\u0026thinsp;=\u0026thinsp;0.003) and at the event (mean age 43.9 vs 42.0, p\u0026thinsp;=\u0026thinsp;0.002). Overall, 79.4% of study participants possessed a PIN, with lower frequency in women (77.2%) compared to men (83\u0026middot;0), (p\u0026thinsp;=\u0026thinsp;0.04) and 98.6% declared they live in Stockholm (results not shown).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003ePrior screening of HBV infection\u003c/h2\u003e \u003cp\u003eOnly a minority underwent a prior viral hepatitis screening (19.3%), similarly prevalent in men and women (18.2% vs 20.0%, p\u0026thinsp;=\u0026thinsp;\u0026lt;\u0026thinsp;0\u0026middot;001) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAs shown in Figure \u003cspan refid=\"MOESM1\" class=\"InternalRef\"\u003eS1\u003c/span\u003ea, prior HBV screening showed an increasing trend across years of migration with 14.0% between the years 2000\u0026ndash;2005, reaching 27.0% in years 2021\u0026ndash;2023 (p\u0026thinsp;=\u0026thinsp;0.037). Middle age groups: higher proportions of age 40\u0026ndash;60 years showed knowledge on prior screening compared to participants less than 30, 30\u0026ndash;40 age groups as shown in Figure \u003cspan refid=\"MOESM1\" class=\"InternalRef\"\u003eS1\u003c/span\u003eb (p\u0026thinsp;=\u0026thinsp;0.003).\u003c/p\u003e \u003cp\u003eIn 15.5% (72/465) stated the presence of a prior or current infected family member, significantly more reported in women than in men, (18.3% vs 10.9% respectively, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), while 39.1% regardless of sex were unaware of this information\u0026middot; For those who have a positive family history (n\u0026thinsp;=\u0026thinsp;72/465, 15.5%), 68.1% (49/72) stated that a parent is infected, while 38.9% (28/72) stated a sibling, and 5\u0026middot;6% (4/72) stated a child. Younger age groups (\u0026lt;\u0026thinsp;30, 30\u0026ndash;40 years of age) had lower prevalence of infected family members compared to older age groups, with overall 35% \u0026minus;\u0026thinsp;55% unawareness across all age groups lower in those aged 40 - \u0026lt;50 years of age (Figure S2).\u003c/p\u003e \u003cp\u003eOverall, in 819 individuals with successful liver elastography, the median (IQs) value was 4.5 (3.7\u0026ndash;5.6) kPa, with men showing higher values vs women (4.8 vs 4.3 kPa, p\u0026thinsp;=\u0026thinsp;0.002), this difference remained significant across age groups 30\u0026ndash;39, 40\u0026ndash;49 and 50\u0026ndash;59 years of age and CAP score, where 31.3% of men had S3 score compared to 16.7% in women (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Similarly, men had significant higher BMI than women, with 42.8% having BMI\u0026thinsp;\u0026ge;\u0026thinsp;27.5 contrasted to 29.8% in women (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eStudy outcome: the prevalence of HBV, HDV, HCV and HIV (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003c/h2\u003e \u003cp\u003eAmong all participants, the prevalence of HBsAg+, anti-HDV+, anti-HCV\u0026thinsp;+\u0026thinsp;and anti-HIV/HIV Ag\u0026thinsp;+\u0026thinsp;were n(%), 37 (4.4%), 18 (2.1%), 158 (18.6%) and none, respectively with no sex predilection noted. Persons with anti-HDV\u0026thinsp;+\u0026thinsp;constituted 48.6% of those with HBsAg+. In persons with anti-HDV+, 11 (61.1%) had detected HDV-RNA at a median (IQR) of 4.4 log\u003csub\u003e10\u003c/sub\u003e(1.9\u0026ndash;4.8) IU/ml. Among persons with anti-HCV+, 20 (12.7%) had HCV-RNA replication, excluding one patient who had initially borderline value and upon repetition was negative for HCV-RNA replication.\u003c/p\u003e \u003cp\u003eAcross year of birth, the prevalence of anti-HCV\u0026thinsp;+\u0026thinsp;significantly declined from 34.3% in 1945-\u0026lt;1970 subgroup to 3.5% in 1991\u0026ndash;2005 subgroup (a birth cohort effect). A decline also could be seen in those with HBsAg+, anti-HDV\u0026thinsp;+\u0026thinsp;across these birth cohorts, with the least prevalences in 1991- \u0026le;2005 birth cohort (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eb), (p\u0026thinsp;=\u0026thinsp;\u0026lt;\u0026thinsp;0\u0026middot;001).\u003c/p\u003e \u003cp\u003eExcluding patients with confirmed HBV infection, almost two-thirds (558) 68\u0026middot;6% of participants had resolved HBV infection. This while 71 (8.7%) had prior vaccination and 184 (22.6%) were susceptible to HBV infection. Younger participants (born 1991-\u0026le;2005) had more prevalent HBV vaccination (17.3%), was the least group to have prior HBV infection (17.9%) and 56.7% were susceptible to infection (all p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003ec). Only one person of all participants (0.12%) had HBsAg+, anti-HDV\u0026thinsp;+\u0026thinsp;and anti-HCV+.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eCharacteristics of participants with prior or current HBV, HDV and HCV infection (Table\u0026nbsp;2)\u003c/h2\u003e \u003cp\u003ePersons with anti-HDV+, and anti-HCV\u0026thinsp;+\u0026thinsp;were significantly older than persons with HBsAg+ (mono-infection) with similar year of migration to Sweden, slightly earlier in anti-HCV+. Women constituted the majority (72.2%) of individuals with anti-HDV+, compared to the HBV mono-infection (42.1%) and anti-HCV (62.7%) (p\u0026thinsp;=\u0026thinsp;\u0026lt;\u0026thinsp;0\u0026middot;001). Overall, the majority possessed a PIN, more frequent in anti-HCV+ (77.2%). Awareness of current hepatitis infection was higher in individuals with HBsAg\u0026thinsp;+\u0026thinsp;compared to anti-HCV+ (p\u0026thinsp;=\u0026thinsp;0.01), where awareness was 57.8% and 50.0% among HBV mono-, and HDV infection, respectively. This while approximately, 1 in 10 (10.2%) persons with HCV (current or prior) infection was aware of infection. Participants with viral hepatitis showed a 20\u0026ndash;30% unawareness of whether a family member is infected or not. Overall, the mean BMI was similar across the three groups (p\u0026thinsp;=\u0026thinsp;0.73), individuals with anti-HCV\u0026thinsp;+\u0026thinsp;had more prevalent 38\u0026middot;5% in the obesity range. Persons with anti-HDV\u0026thinsp;+\u0026thinsp;had the highest median (IQR) LS at 6.5 (4.0\u0026ndash;8.2) kPa, contrasted to values of 4.5 (3.7\u0026ndash;5.5) kPa, and 4.7 (3.8\u0026ndash;5.9) kPa in persons with HBV mono-infection and anti-HCV+, respectively (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). In the same vessel, 16.7% had LS\u0026thinsp;\u0026ge;\u0026thinsp;9 kPa in anti-HDV+, the corresponding figures were 5.3% and 7.3% respectively in the other two groups (p\u0026thinsp;\u0026lt;\u0026thinsp;0\u0026middot;001). CAP score was significantly lower in the anti-HDV\u0026thinsp;+\u0026thinsp;group (p\u0026thinsp;=\u0026thinsp;0.04), and the prevalence of individuals with steatosis S3 was significantly higher in individuals with HBV mono-infection (30.8%) compared to anti-HDV+ (9.1%), and anti-HCV+ (15.6%) (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eFollow-up and linkage to care\u003c/h2\u003e \u003cp\u003eIn 19 individuals with HBV mono-infection, none deemed eligible to start anti-HBV therapy. In patients with anti-HDV\u0026thinsp;+\u0026thinsp;and HDV-RNA+, 2 (11.8%) patients started Bulevirtide, 2 (11.8%) patients started Tenofovir therapy, and 3 (17.6%) patients; two women in age group 50\u0026ndash;59 and one man in his fifth decade started surveillance for hepatocellular carcinoma. In two patients with anti-HDV+, one underwent gastroscopy and started non-selective beta blocker, another one started anti-tuberculosis therapy (not shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). All patients with chronic HCV (n\u0026thinsp;=\u0026thinsp;20) were offered direct acting anti-HCV therapy for 12 weeks, with achieved sustained virological response in all recipients (100%) at follow-up.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003ePrevalence of HBV, HDV in a comparator cohort in Mongolia\u003c/h2\u003e \u003cp\u003eAmong 413 randomly selected individuals screened for general health checkups at primary care, 408 individuals had available samples, mean age 41.3 (8.5), men constituted 43.6% (s Table\u0026nbsp;2). The prevalence of HBsAg+, anti-HDV\u0026thinsp;+\u0026thinsp;was 9.8%, and 5.1%, respectively. Men were younger and had more prevalent HBsAg\u0026thinsp;+\u0026thinsp;vs women (13.5% vs 7.0%, p\u0026thinsp;=\u0026thinsp;0.028). Among persons with anti-HDV+, 15 (78.9%) had HDV-RNA replication at a median log 5.9 IU/ml. The mean age of persons with HBsAg+/anti-HDV-, HBsAg+ /anti-HDV+, and those with HDV-RNA+, 39.8 (6.3), 44.2 (8.3) and 42.3 (8.4), respectively.\u003c/p\u003e \u003cp\u003eIn comparison to the Stockholm cohort, the general population cohort was slightly younger (41.3 vs 43.1, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), with numerically higher male proportion (men 43.6% vs 38.1%, p\u0026thinsp;=\u0026thinsp;0.06). The prevalence of HBsAg+, anti-HDV+, HDV-RNA\u0026thinsp;+\u0026thinsp;was 9.8%, 5.1% and 3.7%, respectively were significantly higher than the Stockholm screened cohort with corresponding 4.4%, 2.1% and 1.3% (all p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Compared to Stockholm cohort, the native general population cohort carried a 2.39-higher odds of HBV infection (95% CI 1.50\u0026ndash;3.80), a 2.51-odds of anti-HDV+ (1.32\u0026ndash;4.76), and 2.91-higher odds of HDV-RNA+ (1.33\u0026ndash;6.39). (results not tabulated).\u003c/p\u003e \u003cp\u003e \u003cem\u003eThe association between baseline characteristics with elevated LS\u0026thinsp;\u0026ge;\u0026thinsp;7.5 kPa (moderate fibrosis and beyond).\u003c/em\u003e \u003c/p\u003e \u003cp\u003eIn univariable analysis, older age, and presence of any viral hepatitis were associated significantly with higher odds of elevated LS. In multivariable analyses, adjusting for age, sex, BMI, HDV-RNA and HCV-RNA replication, older age showed an aOR\u0026thinsp;=\u0026thinsp;1.07 (1.02\u0026ndash;1.11, p\u0026thinsp;=\u0026thinsp;0.002), HDV-RNA replication showed aOR\u0026thinsp;=\u0026thinsp;25.16 (7.17-88\u0026middot;28) and HCV-RNA replication had aOR\u0026thinsp;=\u0026thinsp;7.20 (2.41\u0026ndash;21.47) \u0026ndash; remaining significantly associated with LS\u0026thinsp;\u0026ge;\u0026thinsp;7.5 (s Table\u0026nbsp;3).\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this first population-based screening of Mongolia-born persons in Sweden, the prevalence of viral hepatitis B, D and C were 4.4%, 2.1% and 18.6%, respectively. None had HIV infection. The prevalence was significantly lower in the birth-cohort born after the year 1990. One in 10 individuals (10%) had a protective anti-HBs titer, while one in 5 (20%) reported a prior screening test for HBV infection. Young individuals (born after year 1990) showed a low HBV vaccine protection rate at 17.3%, and 56.7% were susceptible to HBV infection. Almost half of persons (45.9%) with a current infection were unaware of their status regardless of age group. Persons with HDV-RNA\u0026thinsp;+\u0026thinsp;had more prevalent advanced liver disease compared to HBV mono- and HCV infection. This screening initiative linked 58 (7.5%) people to care, therapies and follow-up per individual eligibility.\u003c/p\u003e \u003cp\u003eThe prevalences of viral hepatitis B, and D in Mongol migrants in Sweden are lower than the national Mongolian estimates,[10, 12] yet higher than the general population estimates in Sweden.[8] In the age and sex matched cohort from Ulaanbaatar, Mongolia, a higher prevalence was detected, reaching 9.8% HBsAg\u0026thinsp;+\u0026thinsp;and 5.1% anti-HDV+, agreeing with published Mongol general population surveys.[10, 19, 20] Compared to other screening initiatives in Mongols living abroad, a 4.8% prevalence of HBV in our study was lower than 6.8%, 6.2% and 9.9% estimates reported at US events in 2012, 2016 and 2021, respectively.[13, 21, 22] However, our estimated prevalence was comparable to a 3.6% HBV prevalence in a recent community-based screening of 222 Mongols across three Spanish cities.[14] Noteworthy, the prevalence of anti-HDV\u0026thinsp;+\u0026thinsp;among HBsAg\u0026thinsp;+\u0026thinsp;in our study at 48.6% was higher than 41.2% in a US screening study[13], and from a more recent Spanish report where the prevalence of anti-HDV\u0026thinsp;+\u0026thinsp;was 0.9%.[14] A higher prevalence of prior HCV infection in the present study at 18.6% compared to US[13] and Spanish[14] events (9\u0026ndash;10% and 5.8% respectively) could also be seen. These variations might be explained by possible differences in sex, age distribution, and time of enrollment across these cohorts.[13, 14, 21, 22] Noteworthy, the varied prevalence of HCV infection in Mongolia reveals a strong age-cohort effect, as also suggested by Dashtseren and colleagues.[10] This agrees with our findings that 72.5% of those with HCV infection were born between 1970\u0026ndash;1991, while 25% were born between 1945\u0026ndash;1970. The rather high ratio of resolved HCV infection (84.6%) might suggest prior linkage to care, and possible improved survival in the middle-aged cohort. Although the prevalence of chronic HDV (65% with HDV-RNA replication) juxtaposes the Mongolian published estimates[13], but nevertheless less than the matched cohort suggesting a possible healthy migrant effect that might explain the overall lower estimates of hepatitis infection in our cohort.[23] Furthermore, the low prevalence of HBV, HCV and absence of HDV infection in the younger birth cohort agrees with recent Mongolian population screening.[12] Similarly, Colucci and colleagues demonstrated a low prevalence of 2.2%, 1.7%, 0.6% respectively of HBV, HCV and HIV infection in a cohort of newly arriving migrants to Italy.[24] Interestingly, in this young cohort (n\u0026thinsp;=\u0026thinsp;362, median age 28 years) the prevalence of chronic HCV and HIV was more in those with \u0026gt;\u0026thinsp;6 months of stay.[24]\u003c/p\u003e \u003cp\u003eA possible waning effect of HBV vaccine was suggested by Mongol researchers; Ochirbat and colleagues, reported that only 10% of 438 children aged 5\u0026ndash;10 years of age carried a protective anti-HBs titer[25], while another report suggested an overall 41% protection.[12] Dashdorj and colleagues reported anti-HBs titer without indication of prior infection, reflecting vaccination was detected in 33% of 3800 children and young adult participants, declining with increasing age (personal communication, under review).[26] This is in line with our finding of low frequency of detected anti-HBs titer (17.3%) in younger birth cohort. We could not explain these figures in our study, as we did not explore other demographic, and socio-economic factors that might have affected HBV vaccine acquisition and efficacy in Mongol migrants in Sweden.\u003c/p\u003e \u003cp\u003eIn our data, women constituted 62.7%, and 72.2%, of individuals infected with HCV and HDV, respectively. On the other hand, women constituted 42.1% of the HBV-monoinfection group (not reaching statistical difference), to the contrast of the comparator Mongol cohort where men had 2.1 (95% CI 1.07\u0026ndash;4.06, p\u0026thinsp;=\u0026thinsp;0.03, refer to s Table\u0026nbsp;2 for proportions) higher odds of HBV mono-infection compared to women. It is unclear the cause of this disparity, nevertheless although women had higher serological evidence of HCV and HDV infection (in our analysis), they showed a trend towards less chronic infections (HCV-RNA and HDV-RNA replication, respectively). In our study, women constituted a majority across all age groups, and by year of migration. Such observation might differ from other populations with viral hepatitis where men constitute a majority.[27] Moreover, women significantly had more prior screening of HBV compared to men, which might be attributed to higher likelihood of screening particularly for women in the reproductive age group (ante-natal screening) and health-seeking behavior possibly lower in men, and women not in this age group or lacked such indication.\u003c/p\u003e \u003cp\u003eUnawareness of infection reached 50% in our analysis, mirroring similar figures of screening cohorts in the Mongolian population,[14] with more pronounced unawareness among persons with HDV as reported that 99% of Mongols with HDV infection lacked knowledge of their infection contrasted to 60% in HBV and HCV infection.[12] Nevertheless, the lack of screening in 68\u0026ndash;70% in age groups\u0026thinsp;\u0026lt;\u0026thinsp;40 years demonstrated in our analysis when earlier intervention might affect the risk for liver-related disease progression, hepatocellular carcinoma and survival, need to be further addressed from a public health perspective in populations originating from high endemic regions. A positive remark that HBV screening increased from 14.0% in migration year 2000\u0026ndash;2005 to 27.0% in years 2021\u0026ndash;2023. Hur and colleagues reported a 2.12 -odds (1.13\u0026ndash;3.97) to complete three HBV vaccination doses associated with living more than 10 years in the US.[22] In the current study, we could not note an association between duration of stay in Sweden and prevalence of HBV, HDV, and HCV infections. However, we assume that the low rate of chronic hepatitis C (13.4%) might be related to prior linkage to care and lack of repeated exposure.\u003c/p\u003e \u003cp\u003eTo date, liver societies recommend screening of persons from high-endemic regions for viral hepatitis (\u0026gt;\u0026thinsp;2% endemicity), while local guidelines implement different actions according to cost-effectiveness.[28] Although significant improvements have been achieved in timely diagnosis of viral hepatitis. Delayed diagnosis together with low awareness of infection has been associated with liver-related morbidity, especially among patients with CHB in high income settings.[9, 29] With the notion to reduce harm, targeted screening might be helpful in assessing and overcoming gaps and disparities in the viral hepatitis cascade of care. However, it is unclear if screening persons based \u003cem\u003esolely\u003c/em\u003e on area of origin (with historical high-endemicity) in the absence of abnormal liver parameters is cost-effective, and the repercussions of such practice on reinforcement of stigma towards migrant communities. In that sense, rapid point-of-care screening services might offer simple, easy to implement and interpret tests that grant faster diagnosis and immediate clinical decision, possibly reducing the loss to follow-up/linkage to care.[30] Recently, Dashdorj and colleagues developed and validated anti-HDV antibody rapid diagnostics test that utilizes a defect-free bi-layer lipid membrane which enhances biofouling resistance, minimizing non-specific binding and significantly increasing the sensitivity of molecular detection (personal communication, under review).[31] These tests showed promising results in target micro-elimination programs, in difficult to reach populations such as people who use intravenous drugs who need frequent testing, and other vulnerable populations such as illegal migrants who might refrain from participating in screening programs in other health care facilities. Whether the use of home-based screening kits might further enhance linking other missed populations to care merits more real-world studies.\u003c/p\u003e \u003cp\u003eOur study has limitations. We did not explore other factors such as level of education, area of residence that might not only affect the transmission of viral hepatitis, but also the awareness, and acceptance of health care. However, 70% of survey responders attended the event, reflecting good engagement of this population. Elevated liver stiffness predicted prior or current viral hepatitis in our model, acknowledging that other confounders such as alcohol overconsumption and metabolic dysfunction have not been investigated. Elevated alanine aminotransferase levels or laboratory-based scores such as FIB-4 (fibrosis index score) or APRI (aspartate-platelets ratio index) might be more feasible to detect early liver diseases in healthy individuals, but cutoffs need further validation in populations with CHD.[32] On another aspect, our finding of increased prevalence of overweight and obesity among study participants, particularly in men might be considered for future screening of metabolic-related morbidities in this population. We believe that this screening included 10\u0026ndash;20% of the Mongol population living in Sweden, however a selection favoring persons who use social media and having internet access (unknown the extent in this population) could not be ruled out. In the same vein, those who are aware of their disease status (even if not in care) might be less likely to attend such screening. It is unclear if the probability of screening and early diagnosis is higher in Sweden rather than Mongolia. Given that such proactive efforts of population-screening demand will and logistics to implement that might be deficient in low, low-middle income countries in the governmental sector with constrained resources, highlighting the importance of funding governmental and non-governmental organizations/initiatives in resource limited settings.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eOur study revealed a high prevalence of HBV, HDV and HCV infections in Mongols living in Stockholm than the general population estimates. A low rate of awareness especially in younger age groups calls for more tailored, age-adjusted efforts to spread awareness, and engage this population. Nevertheless, the low level of vaccination protection especially among the youngest birth cohort merits further actions.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e The study was approved by the Region Stockholm ethics committee. All screening participants signed a translated informed consent.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical Trial:\u0026nbsp;\u003c/strong\u003enot applicable.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e all co-authors approved the final version of the manuscript and consent for publishing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and material:\u0026nbsp;\u003c/strong\u003eAll data were anonymized during data handling and analysis. The authors do not have permission to share the data.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u0026nbsp;\u003c/strong\u003eall co-authors disclose no conflict of interest with the current study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e ALF grant from Region Stockholm, Sweden.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions:\u003c/strong\u003e The following authors have full access to the data set of the study: HK, GJ, SE, ON, NBD, ND and SA.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eAuthors SA and HK are responsible for the integrity and accuracy of the data analysis.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eConcept and design: SA and ND. Drafting of the manuscript and analysis of the data: HK.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eInterpretation of data and critical revision of the manuscript: DZ, HK, SE, ON, GJ, MB, BO, MA, KL, MI, NS, AP, GS, NB, SS, SC, AO, AB, ID, DG, AB, ND, DO, SA. DZ and HK share first co-authorship, ND and SA contributed equally as co-last authors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe express our gratitude to all the participants in this event, and we acknowledge the efforts of all organizers. The Onom Foundation provided a part of the funding to carry out the study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWHO | Global health sector strategy on viral hepatitis 2016\u0026ndash;2021. WHO. 2019.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A, et al. Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. CA Cancer J Clin. 2021;71:209\u0026ndash;49.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePapatheodoridis G V., Tsochatzis E, Hardtke S, Wedemeyer H. Barriers to care and treatment for patients with chronic viral hepatitis in Europe: a systematic review. Liver International. 2014;34:1452\u0026ndash;63.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGahrton C, Westman G, Lindahl K, \u0026Ouml;hrn F, Dalgard O, Lidman C, et al. Prevalence of Viremic hepatitis C, hepatitis B, and HIV infection, and vaccination status among prisoners in Stockholm County. BMC Infect Dis. 2019;19:1\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMitchell T, Nayagam JS, Dusheiko G, Agarwal K. Health inequalities in the management of chronic hepatitis B virus infection in patients from sub-Saharan Africa in high-income countries. 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Hepatitis B, C, and D Virus Infection among Population Aged 10\u0026ndash;64 Years in Mongolia: Baseline Survey Data of a Nationwide Cancer Cohort Study. Vaccines 2022, Vol 10, Page 1928. 2022;10:1928.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFong TL, Lee BT, Chang M, Nasanbayar K, Tsogtoo E, Boldbaatar D, et al. High Prevalence of Chronic Viral Hepatitis and Liver Fibrosis among Mongols in Southern California. Dig Dis Sci. 2021;66:2833.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePalom A, Almandoz E, Madej\u0026oacute;n A, Rando-Segura A, P\u0026eacute;rez-Casta\u0026ntilde;o Y, Vico J, et al. Community Strategy for Hepatitis B, C, and D Screening and Linkage to Care in Mongolians Living in Spain. Viruses. 2023;15:1506.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZentrum f\u0026uuml;r Individualisierte Infektionsmedizin: D-SOLVE. https://www.ciim-hannover.de/en/d-solve/. Accessed 8 Jan 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCastera L, Yuen Chan HL, Arrese M, Afdhal N, Bedossa P, Friedrich-Rust M, et al. EASL-ALEH Clinical Practice Guidelines: Non-invasive tests for evaluation of liver disease severity and prognosis. J Hepatol. 2015;63:237\u0026ndash;64.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKamali L, Adibi A, Ebrahimian S, Jafari F, Sharifi M. Diagnostic Performance of Ultrasonography in Detecting Fatty Liver Disease in Comparison with Fibroscan in People Suspected of Fatty Liver. Adv Biomed Res. 2019;8:69.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNishida C, Barba C, Cavalli-Sforza T, Cutter J, Deurenberg P, Darnton-Hill I, et al. Appropriate body-mass index for Asian populations and its implications for policy and intervention strategies. The Lancet. 2004;363:157\u0026ndash;63.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eInoue J, Takahashi M, Nishizawa T, Narantuya L, Sakuma M, Kagawa Y, et al. High prevalence of hepatitis delta virus infection detectable by enzyme immunoassay among apparently healthy individuals in Mongolia. J Med Virol. 2005;76:333\u0026ndash;40.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDambadarjaa D, Mukhtar Y, Tsogzolbaatar EO, Khuyag SO, Dayan A, Oyunbileg NE, et al. Hepatitis B, C, and D Virus Infections and AFP Tumor Marker Prevalence Among the Elderly Population in Mongolia: A Nationwide Survey. Journal of Preventive Medicine and Public Health. 2022;55:263\u0026ndash;72.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHa E, Kim F, Blanchard J, Juon HS. Peer Reviewed: Prevalence of Chronic Hepatitis B and C Infection in Mongolian Immigrants in the Washington, District of Columbia, Metropolitan Area, 2016\u0026ndash;2017. Prev Chronic Dis. 2019;16:180104.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHur K, Wong M, Lee J, Lee J, Juon HS. Hepatitis B infection in the Asian and Latino communities of Alameda County, California. J Community Health. 2012;37:1119\u0026ndash;26.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHelgesson M, Johansson B, Nordquist T, Ving\u0026aring;rd E, Svartengren M. Healthy migrant effect in the Swedish context: a register-based, longitudinal cohort study. BMJ Open. 2019;9:e026972.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eColucci G, Renteria SU, Lunghi G, Ceriotti F, Sguazzini E, Spalenza S, et al. Italian migrants study: An HCV and HBV micro-elimination pilot project. Clin Res Hepatol Gastroenterol. 2022;46.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAssessment of hepatitis B vaccine-induced seroprotection among children 5\u0026ndash;10 years old in Ulaanbaata... https://www.biosciencetrends.com/article/2/2/68. Accessed 30 Jan 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDashdorj ED SKOB et al. Towards Elimination: Hepatitis B and C Among Children and Young Adults in Rural Mongolia.. 2025.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChevaliez S, Roudot-Thoraval F, Brouard C, Gordien E, Zoulim F, Brichler S, et al. Clinical and virological features of chronic hepatitis B in the French national surveillance program, 2008\u0026ndash;2012: A cross-sectional study. JHEP Reports. 2022;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTerrault NA, Lok ASF, Mcmahon BJ, Chang K-M, Hwang JP, Jonas MM, et al. Update on Prevention, Diagnosis, and Treatment of Chronic Hepatitis B: AASLD 2018 Hepatitis B Guidance American Association for the study of liver diseases. 2018.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMnatzaganian G, MacLachlan JH, Allard N, Brown C, Rowe S, Cowie BC. Missed opportunities for diagnosis of hepatitis B and C in individuals diagnosed with decompensated cirrhosis or hepatocellular carcinoma. J Gastroenterol Hepatol. 2023;38:976\u0026ndash;83.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePauly MD, Ganova-Raeva L. Point-of-Care Testing for Hepatitis Viruses: A Growing Need. Life 2023, Vol 13, Page 2271. 2023;13:2271.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDashdorj AN, An K, Ariungerel N, Han S, Kim SA, Kim T, et al. Development and Validation of Streamlined Serodiagnosis of Hepatitis Delta Virus. 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eROULOT D, BRICHLER S, LAYESE R, d\u0026rsquo;ALTEROCHE L, GANNE-CARRIE N, STERN C, et al. High Diagnostic Value of Transient Elastography for Advanced Fibrosis and Cirrhosis in Patients With Chronic Hepatitis Delta. Clin Gastroenterol Hepatol. 2024. https://doi.org/10.1016/J.CGH.2024.08.008.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"681\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" valign=\"top\" style=\"width: 681px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 1: Baseline characteristics of participants of the screening event, sub-grouped by sex\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 287px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eParameters**\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eAll, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eMen, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eWomen, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 287px;\"\u003e\n \u003cp\u003eNumber (%) unless stated otherwise\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e850 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e324 (38\u0026middot;1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e526 (61\u0026middot;9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e\u0026lt;0\u0026middot;001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 287px;\"\u003e\n \u003cp\u003eYear of migration, median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e2015 (2011-2018)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e2015 (2011-2018)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e2015 (2011-2018)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e0\u0026middot;47\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 287px;\"\u003e\n \u003cp\u003eMean age at migration, mean (SD, min-max)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e34.4 (8.7, 6-68)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e33.3 (8.4, 9-60)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e35.2 (8.9, 6-68)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e0.003\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 287px;\"\u003e\n \u003cp\u003eMean age at the event, years (SD, min-max)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e43.2 (8.6, 18.0-75.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e42.0 (8.2, 19.2-64.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e43.9 (8.8, 18.0-75.8)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 287px;\"\u003e\n \u003cp\u003ePresence of a permanent Swedish personal identification number\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e675 (79.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e269 (83.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e406 (77.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e0.04\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 633px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePrior HBV screening\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 287px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Yes\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e164 (19.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e59 (18.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e105 (20.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e0.52\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 287px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;No\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e564 (66.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e225 (69.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e339 (64.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 287px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Do not know\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e122 (14.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e40 (12.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e82 (15.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" valign=\"top\" style=\"width: 681px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHave you been diagnosed with HBV infection (n=726)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 287px;\"\u003e\n \u003cp\u003e\u0026nbsp; Yes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e59 (8.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e24/278 (8.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e35/448 (7.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e0.47\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 287px;\"\u003e\n \u003cp\u003e\u0026nbsp; No\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e493 (67.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e196/278 (70.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e297/448 (66.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 287px;\"\u003e\n \u003cp\u003e\u0026nbsp; Do not know\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e174 (24.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e58/278 (20.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e116/448 (25.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 633px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBMI,\u0026nbsp;\u003c/strong\u003ekg/m\u003csup\u003e2 ,\u0026nbsp;\u003c/sup\u003e(n=841)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 287px;\"\u003e\n \u003cp\u003eMean (SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e26.1 (4.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e26.9 (3.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e25.7 (4.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 287px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;\u0026lt;23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e183 (21.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e43/320 (13.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e140/521 (26.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 287px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;23-27.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e366 (43.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e140/320 (43.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e226/521 (43.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e0.18\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 287px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;\u0026ge;27.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e292 (34.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e137/320 (42.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e155/521 (29.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 633px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHBV\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 287px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Prior HBV infection (HBsAg-, anti-HBc+, anti-HBs+)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e558 (65.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e223 (69.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e335 (63.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e0.19\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 287px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Vaccinated (HBsAg-, anti-HBc-, anti-HBs+)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e71/813 (8.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e23/308 (7.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e48/507 (9.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e0.31\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 287px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Susceptible to HBV (HBsAg-, anti-HBc-, anti-HBs-)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e184/813 (21.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e61/308 (19.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e123/507 (24.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e0.13\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 287px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;HBsAg+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e37 (4.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e16 (4.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e21 (4.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e0.52\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 287px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; HBV-DNA log\u003csub\u003e10\u003c/sub\u003e (IU/ml), median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e2.4 (1.2\u0026ndash;2.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e2.3 (1.2\u0026ndash;3.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e2.4 (1.0\u0026ndash;2.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e0.27\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 287px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; HBsAg log\u003csub\u003e10\u003c/sub\u003e (IU/ml), median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e2.6 (1.9\u0026ndash;3.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e3.3 (2.1\u0026ndash;3.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e2.3 (1.1\u0026ndash;3.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e0.06\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 287px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eKnowledge about current infection among HBsAg+\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e(n=37)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e(n=16)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e(n=21)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 287px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Yes\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e20 (54.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e9 (56.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e11 (52.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e0.19\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 287px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;No\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e8 (21.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e4 (25.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e4 (19.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e0.70\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 287px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Do not know\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e9 (24.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e3 (18.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e6 (28.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e0.20\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 633px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHDV\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 287px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Anti-HDV+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e18 (2.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e5 (1.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e13 (2.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e0.36\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 287px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;HDV-RNA+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e11 (1.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e4 (1.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e7 (1.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e0.31\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 287px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;HDV-RNA log\u003csub\u003e10\u003c/sub\u003e IU/ml, median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e4.4 (1.9\u0026ndash;4.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e4.7 (4.2\u0026ndash;5.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e4.0 (1.7\u0026ndash;4.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e0.12\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 633px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHCV\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 287px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Anti-HCV+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e158 (18.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e59 (18.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e99 (18.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e0.84\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 287px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;HCV-RNA+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e21 (2.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e12 (3.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e9 (1.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 287px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; HCV-RNA log\u003csub\u003e10\u003c/sub\u003e IU/ml, median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e6.0 (5.5\u0026ndash;6.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e6.2 (5.5\u0026ndash;6.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e6.0 (5.1\u0026ndash;6.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e0.23\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 633px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLiver stiffness values, n= 819\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 287px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;LS, median (IQR), kPa\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e4.5 (3.7-5.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e4.8 (4.1-5.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e4.3 (3.5-5.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 287px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;CAP score\u0026curren;, median (IQR) dB/m, n=338\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e236.5 (202.0-277.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e264.0 (216.8-290.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e226.0 (193.3-270.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 287px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;S3 \u0026ge;290, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e76/338 (22.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e42 (31.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e34 (16.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" valign=\"top\" style=\"width: 681px;\"\u003e\n \u003cp\u003e\u003cem\u003eAbbreviations: n= number; anti-HDV= hepatitis D antibody; HDV-RNA= hepatitis D virus ribonucleic acid; HBV= hepatitis B virus; anti-HCV= hepatitis C antibody; SD=standard deviation; IQR=25\u003csup\u003eth\u003c/sup\u003e-75\u003csup\u003eth\u003c/sup\u003e interquartile, 25\u003csup\u003eth\u003c/sup\u003e and 75\u003csup\u003eth\u003c/sup\u003e percentiles are displayed; BMI=body mass index calculated as body weight in kilogram/(height in meters)\u003csup\u003e2\u003c/sup\u003e; LSM=liver stiffness measurements; kPa= kilopascal; \u0026curren;CAP= controlled attenuated parameter score measured in decibels per meter (dB/m); S3=CAP score 290 to 400 dB/m translating to \u0026gt; 2/3 of the liver has steatosis.\u0026nbsp;\u003c/em\u003e\u0026curren;available in 134 men and 204 women.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"686\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 619px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 2: Baseline characteristics of participants according to detected viral hepatitis\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 224px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eParameters, n (%) unless stated otherwise\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 137px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHBsAg+, anti-HDV-\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHBsAg+, anti-HDV+\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAnti-HCV+\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 224px;\"\u003e\n \u003cp\u003eNumber, % of 850 participants\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 137px;\"\u003e\n \u003cp\u003e19, 2.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e18, 2.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e158, 18.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 224px;\"\u003e\n \u003cp\u003eSex, women\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 137px;\"\u003e\n \u003cp\u003e8 (42.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e13 (72.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e99 (62.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 224px;\"\u003e\n \u003cp\u003eMean age at the event, years, (SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 137px;\"\u003e\n \u003cp\u003e42.2 (9.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e47.6 (6.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e47.1 (8.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e0.039\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 224px;\"\u003e\n \u003cp\u003eYear of arrival to Sweden, median (IQR) year\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 137px;\"\u003e\n \u003cp\u003e2015 (2010-2018)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e2017 (2012-2021)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e2015 (2011-2018)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e0.092\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 224px;\"\u003e\n \u003cp\u003ePresence of permanent Swedish personal number\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 137px;\"\u003e\n \u003cp\u003e13 (68.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e12 (66.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e122 (77.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 224px;\"\u003e\n \u003cp\u003ePrior test to HBV, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 137px;\"\u003e\n \u003cp\u003e10 (52.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e10 (55.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e30 (19.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" valign=\"top\" style=\"width: 686px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAwareness of current hepatitis infection, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 224px;\"\u003e\n \u003cp\u003e\u0026nbsp; Yes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 137px;\"\u003e\n \u003cp\u003e11 (57.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e9 (50.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e16 (10.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e0.011\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 224px;\"\u003e\n \u003cp\u003e\u0026nbsp; No\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 137px;\"\u003e\n \u003cp\u003e4 (21.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e4 (22.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e74 (46.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 224px;\"\u003e\n \u003cp\u003e\u0026nbsp; I do not know\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 137px;\"\u003e\n \u003cp\u003e4 (21.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e5 (27.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e68 (43.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 224px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAwareness of a family or household infected with HBV\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 137px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003en=11\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003en=9\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003en=82\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 224px;\"\u003e\n \u003cp\u003e\u0026nbsp; Yes\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 137px;\"\u003e\n \u003cp\u003e2 (18.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e2 (22.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e10 (12.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e0.008\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 224px;\"\u003e\n \u003cp\u003e\u0026nbsp; No\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 137px;\"\u003e\n \u003cp\u003e6 (54.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e5 (55.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e45 (54.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e0.87\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 224px;\"\u003e\n \u003cp\u003e\u0026nbsp; I do not know\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 137px;\"\u003e\n \u003cp\u003e3 (27.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e2 (22.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e27 (32.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 224px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBMI\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 137px;\"\u003e\n \u003cp\u003e\u003cem\u003en=19\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u003cem\u003en=18\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e\u003cem\u003en=156\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 224px;\"\u003e\n \u003cp\u003e\u0026nbsp; Mean (SD), kg/m\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 137px;\"\u003e\n \u003cp\u003e26.8 (3.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e27.5 (9.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e26.8 (4.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e0.725\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 224px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026lt;23 kg/m\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 137px;\"\u003e\n \u003cp\u003e1 (5.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e2 (11.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e25 (16.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 224px;\"\u003e\n \u003cp\u003e\u0026nbsp; 23-27.5 kg/m\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 137px;\"\u003e\n \u003cp\u003e12 (63.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e13 (72.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e71 (45.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 224px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026ge;27.5 kg/m\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 137px;\"\u003e\n \u003cp\u003e6 (31.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e3 (16.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e60 (38.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 224px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVirological markers\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 137px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 224px;\"\u003e\n \u003cp\u003e\u0026nbsp; Anti-HCV+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 137px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e1 (5.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e158 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 224px;\"\u003e\n \u003cp\u003e\u0026nbsp; HCV-RNA+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 137px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e21 (13.4)^\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 224px;\"\u003e\n \u003cp\u003e\u0026nbsp; HDV-RNA +\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 137px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e11 (61.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 224px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLS\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 137px;\"\u003e\n \u003cp\u003e\u003cem\u003en=19\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u003cem\u003en=18\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e\u003cem\u003en=150\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 224px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Median (IQR), kPa\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 137px;\"\u003e\n \u003cp\u003e4.5 (3.7\u0026ndash;5.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e6.5 (4.0\u0026ndash;8.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e4.7 (3.8\u0026ndash;5.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 224px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;LS \u0026ge;9.0 kPa\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 137px;\"\u003e\n \u003cp\u003e1 (5.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e3 (16.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e11 (7.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 224px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;LS \u0026ge;12.5 kPa\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 137px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e1 (5.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e3 (2.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e0.014\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 224px;\"\u003e\n \u003cp\u003eCAP, median (IQR) db/m\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 137px;\"\u003e\n \u003cp\u003e239.0 (208.5-308.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e223.0 (193.0- 271.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e229.5 (202.0-271.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e0.04\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 224px;\"\u003e\n \u003cp\u003eCAP \u0026ge;290 db/m\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 137px;\"\u003e\n \u003cp\u003e4/13 (30.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e1/11 (9.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e10/64 (15.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" valign=\"top\" style=\"width: 686px;\"\u003e\n \u003cp\u003e\u003cem\u003eAbbreviations: anti-HDV= hepatitis D antibody; HDV-RNA= hepatitis D virus ribonucleic acid; HBV= hepatitis B virus; BMI=body mass index; anti-HCV= hepatitis C antibody; kPa= kilopascal; n= number; IQR= 25\u003csup\u003eth\u003c/sup\u003e-75\u003csup\u003eth\u003c/sup\u003e interquartile; LS= liver stiffness; CAP= controlled attenuated parameter score measured in decibels per meter (dB/m); S3=CAP score 290 to 400 dB/m translating to \u0026gt; 2/3 of the liver has steatosis. \u0026nbsp;^patient had repeated \u0026nbsp;HCV-RNA determined negative thereafter.\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-infectious-diseases","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"infd","sideBox":"Learn more about [BMC Infectious Diseases](http://bmcinfectdis.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/infd","title":"BMC Infectious Diseases","twitterHandle":"#bmcinfectdis","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"hepatitis D, Mongolia, screening, HBV, HCV, prevalence, migrants, minority","lastPublishedDoi":"10.21203/rs.3.rs-6292867/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6292867/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground \u0026amp; Aims\u003c/b\u003e\u003c/p\u003e \u003cp\u003eChronic hepatitis B/D is the most severe chronic hepatitis, yet public awareness of its burden remains low. This study examines the prevalence of viral hepatitis B/D among Mongol migrants in Sweden with possible linkage to care.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e \u003cp\u003eA screening event for viral hepatitis was conducted on the 28th \u0026minus;\u0026thinsp;29th January 2023 at Karolinska University Hospital, Stockholm for individuals of Mongol descent. Consented participants underwent blood tests and liver stiffness measurements. The prevalence of viral hepatitis was compared to an age, sex-matched general population cohort in Mongolia with blood samples.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e \u003cp\u003eIn total, 850 adult Mongols, aged mean (SD) 43\u0026middot;2\u0026thinsp;\u0026plusmn;\u0026thinsp;8\u0026middot;6 years and 61\u0026middot;9% women were screened. The prevalence of HBsAg+, anti-HDV+, and HDV-RNA\u0026thinsp;+\u0026thinsp;were 4.4%, 2.1%, and 1.3%, respectively. The corresponding figures were 9.8%, 5.1%, and 3.7% in the matched cohort in Mongolia. Persons with anti-HDV\u0026thinsp;+\u0026thinsp;constituted 48.6% of HBsAg+ (18/37), and 61.1% among anti-HDV\u0026thinsp;+\u0026thinsp;were HDV-RNA+ (11/18). Prior HBV infection was seen in 65.8%, 8.7% were vaccinated, and 21.6% were susceptible to HBV infection. In total, 58 (6.8%) persons with chronic viral hepatitis were linked to care. Of HBsAg\u0026thinsp;+\u0026thinsp;or anti-HBc+, 54.1% and 65.8% were aware of current or past HBV infection, respectively.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusion\u003c/b\u003e\u003c/p\u003e \u003cp\u003eMongol migrants had lower prevalence of hepatitis B, and D compared to Mongolia, but higher than the Swedish general population. More screening efforts are needed to reinforce the awareness, diagnosis, and improve linkage to care of populations at higher risk of chronic viral hepatitis in Sweden and Europe.\u003c/p\u003e","manuscriptTitle":"Prevalence of chronic viral hepatitis B, D among Mongol migrants in Sweden compared to a sex and age matched native Mongol cohort","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-07 09:56:47","doi":"10.21203/rs.3.rs-6292867/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-06-16T12:18:32+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-06T12:21:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"13542756645006636185462013481205846931","date":"2025-05-28T09:31:26+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-20T19:20:49+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"254121214231988896852957198127319792684","date":"2025-04-22T08:13:12+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"55356963988129631272468226050350924521","date":"2025-04-20T13:48:12+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-04-15T12:12:14+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-03-28T08:26:23+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-03-26T09:32:16+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-03-26T09:28:22+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Infectious Diseases","date":"2025-03-24T07:50:43+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-infectious-diseases","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"infd","sideBox":"Learn more about [BMC Infectious Diseases](http://bmcinfectdis.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/infd","title":"BMC Infectious Diseases","twitterHandle":"#bmcinfectdis","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"2f8e2214-68d8-4886-98ac-0dcd75120818","owner":[],"postedDate":"April 7th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-01-19T16:45:46+00:00","versionOfRecord":{"articleIdentity":"rs-6292867","link":"https://doi.org/10.1186/s12879-025-12506-w","journal":{"identity":"bmc-infectious-diseases","isVorOnly":false,"title":"BMC Infectious Diseases"},"publishedOn":"2026-01-16 16:29:10","publishedOnDateReadable":"January 16th, 2026"},"versionCreatedAt":"2025-04-07 09:56:47","video":"","vorDoi":"10.1186/s12879-025-12506-w","vorDoiUrl":"https://doi.org/10.1186/s12879-025-12506-w","workflowStages":[]},"version":"v1","identity":"rs-6292867","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6292867","identity":"rs-6292867","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}