HB and HC contribute significantly to the global burden of disease, with Pakistan being among the countries most affected by these infections. The situation is especially dire among the high-risk populations, one of them being the refugee population. Our study revealed that the seroprevalence of HBsAg (5.82%) and anti-HCV (4.73%) was higher among the refugee population compared to the general population globally and that of Pakistan [9]. Our study findings are comparable to the 2024 study by Kazmi et al., reported a seroprevalence of 7% for HBsAg and 17.5% for anti-HCV among the refugee population of Kashmir, Pakistan [11].
Similar to our study the seroprevalence of HBsAg and anti-HCV reported by Kazmi et al., is higher than the general population. A clear trend can be seen of higher seroprevalence of the infections in Kashmiri refugee population in Pakistan. Higher prevalence of HB was also observed among other refugee populations in Pakistan. The study by Quddus et al., found that the seroprevalence of HBsAg was 8.3% among Afghan refugees settled in Balochistan [17]. The 2025 study by Akhtar et al., conducted in Neelum Valley, Kashmir among the general population of Kashmir, The study recorded that the seroprevalence of HBsAg was 2.4% and the seroprevalence of anti-HCV was 1.3% among the participants [18]. The study shows that the seroprevalence of HBsAg and anti-HCV among the general population of Kashmir is similar to the seroprevalence in the general population of Pakistan and that the problem of higher seroprevalence of HbsAg and anti-HCV is among the refugee population in Kashmir.
Age was a significant determinant of HBsAg and seroprevalence. In our study, an increase in seroprevalence of both HBsAg and was observed with increase in age. The previously discussed study conducted among the Kashmiri population Pakistan by Kazmi et al., reported that highest seroprevalence of HBsAg (23.5%) and anti-HCV (41.1%) was noted among the age group 62–75 [11]. The study by Samo et al., reported a higher seroprevalence of HBsAg and anti-HCV recorded in the age group above 30 in Nawabshah, Sindh, Pakistan. The seroprevalence of HBsAg (13%) was higher among the age groups 41–50 and 51–60, compared to 7% in individuals younger than 30 years. Similarly, anti-HCV seroprevalence in age group under 30 was 13%. Likewise, anti-HCV seroprevalence was 18.7% and 18.5% in the 41–50 and 51–60 age groups, respectively, compared to 13% in those under 30 [19]. Although the study by Samo et al., was not conducted among the refugee population it highlights the impact of age on the prevalence of HBV and HCV.
We studied HBsAg and anti-HCV seroprevalence in different gender groups. Previous studies have suggested a higher seroprevalence of HB among males, while HC is more common among women [20, 21]. The study by Kazmi et al., reported a higher prevalence of both HBsAg (4.4%) and anti-HCV (10.8%) among females compared to males (2.6% and 6.7%), respectively [11]. A 2022 study in a large Taiwanese cohort showed similar trends to previous studies with higher prevalence of HB in males and higher prevalence of HC in women [22]. Understanding these differences is crucial for developing targeted interventions to reduce transmission and improve prevention strategies. Given these findings, it is essential to implement gender-sensitive approaches in hepatitis awareness campaigns, screening programs, and treatment initiatives to address the specific risks and barriers faced by both males and females [23].
In our study, education level emerged as one of the factors impacting seroprevalence of HBsAg and anti-HCV. A 2024 study by Alula et al., conducted in Northern Ethiopia reported similar trends, with HBsAg and anti-HCV seroprevalence of 9% among illiterate individuals. The prevalence declined as education levels increased, with rates of 8% among those with elementary education and 0% among individuals with college-level education or higher [20]. Similarly, a 2022 study by Mohammed et al., in Ethiopia found a higher prevalence of HBsAg (14.8%) among illiterate individuals, which progressively declined with higher education levels: 6.4% at the primary level, 4.6% at the secondary level, and 1.6% at the higher education level [24]. This disparity may be associated with lower awareness among uneducated and less-educated individuals regarding safety practices, prevention methods, and modes of transmission. Additionally, fear and stigma surrounding hepatitis screening and treatment in healthcare settings may further contribute to the higher prevalence in these groups [25].
Over the past decades, some progress has been made in raising awareness and improving treatment of hepatitis in Pakistan; however, these efforts remain inadequate. This has resulted from a critical gap in high-quality data on the prevalence of hepatitis hindering the ability to track progress effectively [26]. Our study findings provide critical data regarding the seroprevalence of HBsAg and anti-HCV among the high-risk refugee population of Muzaffarabad. It is crucial that high-quality data is available for governmental institutions and stakeholders for appropriate allocation of resources and development for public health action to combat the challenge posed by HB and HC. A well-coordinated national level campaign is essential to educate people about hepatitis, its risk factors, and preventative measures. Additionally, strong political and financial commitments are required to achieve hepatitis elimination in Pakistan. Figure 1 illustrates the distribution of awareness brochures to children at the refugee camp.
Distribution of hepatitis awareness brochures among people at a refugee camp
Limitations
Our study had some limitations that need to be addressed in future research to gain a deeper understanding of the critical burden of hepatitis diseases. Our study focused solely on demographic and educational risk-factors influencing the seroprevalence of HBsAg and anti-HCV among the Kashmiri refugees. There is a need for a nuanced examination into various other factors, including vaccination history, unprotected sexual contact, injection use, occupational hazards, tattoos, piercings, blood transfusions, household contact and others. Additionally, future research needs to examine the underlying causes for variable seroprevalence of HbsAg and anti-HCV in individuals of different age groups, gender, and educational levels. The study employed convenience sampling which can introduce selection bias and can reduce the generalizability of the study. Due to financial constraints in Pakistan, we utilized rapid ICT kits to detect HBsAg and anti-HCV in the serum. While these kits are useful in identifying seroprevalence trends, are easy to use, and low in cost, future research should utilize more accurate diagnostic techniques such as polymerase chain reaction (PCR) and enzyme-linked immunosorbent assay (ELISA) to accurately determine the prevalence of HB and HC among the study population.
HBsAg and anti-HCV positive participants were referred to Hepatitis control program for PCR test and start of treatment for confirmed positive patients.