Hepatitis B testing and access to care among racial and ethnic minorities in selected communities across the United States, 2009-2010

Immigration Factors and Monitoring of Chronic Hepatitis B Infection Among Foreign-Born: The FOCUS-HBV Multicentre Cohort

BACKGROUND

Immigrants are the largest subgroup living with chronic hepatitis B (HBV) infection in the United States. It is not well understood how immigration and associated social and cultural factors impact adherence to HBV monitoring.

METHODS

We conducted a multicentre multilingual survey among foreign-born adults with chronic HBV between 7/2021 and 4/2023. Participants were surveyed regarding (1) immigration factors, (2) acculturation and language preferences, (3) social determinants of health and (4) HBV-related clinical factors. The primary outcome was optimal adherence, defined as 100% of the time with at least annual testing of HBV DNA, ALT and ultrasound while under care. Logistic regression was used to examine survey factors associated with the outcome.

RESULTS

Two hundred and seventy-four foreign-born patients with HBV (median 57 years, 57% male) from 32 birth countries were included. Thirteen per cent had immigrated within the past 10 years, and 62% were US citizens. Nearly all (92%) reported seeing a specialist for HBV, with 72% currently on treatment. 44% of participants had optimal adherence to monitoring over a median of 6 years (2-7) under care. Factors associated with more optimal adherence on multivariate testing included non-English survey language (OR 2.32, 95% CI 1.15-4.66), non-US citizens (OR 2.05, 95% CI 1.01-4.15) and higher education (college vs. high school or less: OR 2.39, 95% CI 1.09-5.24). Medicare insurance (vs. private) was associated with less optimal adherence (OR 0.42, 95% CI 0.19-0.94).

CONCLUSION

Adherence to long-term monitoring is suboptimal among a diverse cohort of immigrants with chronic HBV. More efforts to engage and retain immigrants in care are needed.

HBV Transmission Knowledge Among Korean-American Chronic Hepatitis B Patients in the United States

Chronic hepatitis B (CHB) is a condition that disproportionately affects Asian Americans in the United States. Knowledge of transmission is crucial for CHB patients to practice prevention methods to limit the spread of the hepatitis B virus (HBV), but also live their lives free from unwarranted fears or restrictions. Among Asian CHB patients, several misperceptions about HBV transmission have been identified. This analysis aims to assess the current state of HBV knowledge among a cohort of Korean-American CHB patients. This mixed-methods study includes 363 respondents who completed a survey in either Korean (N = 298) or English (N = 65) at two clinical care settings in Philadelphia (N = 161) and Los Angeles (N = 202); 30 participants also completed in-depth interviews. Knowledge was measured on a 10-point scale, asking patients yes or no transmission questions (n = 10, alpha = 0.87). The average knowledge score was 6.3. In multivariate analyses, older age was associated with lower knowledge (β=-0.25, p < 0.001). More years of formal education (β = 0.09, p = 0.076) and utilizing more sources for health information (β = 0.12, p = 0.023) were both independently associated with higher knowledge scores. Qualitative findings show that misperceptions about transmission through shared food still exist and that provider communication is an important part of knowledge acquisition. These results suggest that despite receiving specialized, culturally concordant medical care for their disease, some Korean-American CHB patients have an inadequate understanding of transmission and that opportunities exist to improve education in this population. Identifying additional factors that influence knowledge acquisition and retention is key to developing culturally effective education interventions for this population.

Significant Disparities in Hepatocellular Carcinoma Outcomes by Race/Ethnicity and Sociodemographic Factors

BACKGROUND

Hepatocellular carcinoma (HCC) disproportionately affects racial/ethnic minorities. We evaluated the impact of income and geography on racial/ethnic disparities across the HCC care cascade in the United States.

METHODS

Using NCI registry data spanning 2000 to 2020, adults with HCC were evaluated to determine race/ethnicity-specific differences in tumor stage at diagnosis, delays and gaps in treatment, and survival. Adjusted regression models evaluated predictors of HCC outcomes.

RESULTS

Among 112,389 adults with HCC, cohort characteristics were as follows: 49.8% non-Hispanic White (NHW), 12.0% African American(AA), 20.5% Hispanic, 16.5% Asian/Pacific Islander, and 1.1% American Indian/Alaska Native. Compared with NHW patients, AA patients had lower odds of localized-stage HCC at diagnosis [adjusted odds ratio (aOR), 0.84], lower odds of HCC treatment receipt (aOR, 0.77), greater odds of treatment delays (aOR, 1.12), and significantly greater risk of death [adjusted hazards ratio (aHR), 1.10]. Compared with NHW patients from large metro areas, AA patients from large metro areas had 8% higher mortality risk (aHR, 1.08), whereas AA patients from small-medium metro areas had 17% higher mortality risk (aHR, 1.17; all P < 0.05).

CONCLUSIONS

Among a population-based cohort of US adults with HCC, significant race/ethnicity-specific disparities across the HCC care continuum were observed. Lower household income and more rural geography among racial/ethnic minorities are also associated with disparities in HCC outcomes, particularly among AA patients.

IMPACT

Our study shows that lower income and less urban/more rural geography among racial/ethnic minorities are also associated with disparities in HCC outcomes, particularly among AA patients with HCC. This contextualizes the complex relationship between sociodemographic factors and HCC outcomes through an intersectional lens.

Gaps and disparities in the treatment of chronic hepatitis B infection in the USA

Chronic hepatitis B (CHB) infection affects nearly 300 million individuals worldwide and is a leading cause of hepatocellular carcinoma and liver-related mortality. However, major gaps in the CHB cascade of care persist, with the majority of individuals with CHB not diagnosed and not linked to care and treatment. Even among individuals with known CHB, existing studies report on major gaps and disparities in timely linkage to care and timely access to CHB therapies. While the momentum to expand and simplify CHB treatment guidelines is promising, access to treatment still relies on individuals being effectively engaged in clinical care and liver disease monitoring. The contributing factors to the observed gaps and disparities in the CHB cascade of care are complex and multifactorial, and there is no one-size-fits-all solution than can be easily applied across all global regions. However, any serious approach towards addressing the existing gaps in the CHB cascade of care to improve patient outcomes requires a concerted investment from healthcare institutions, governments, policymakers, and industry partners to provide the necessary resources to be able to achieve this goal. Anything less than a comprehensive and collaborative approach that engages all stakeholders to invest effort and resources into tackling the global epidemic of CHB will continue to fall short in making progress towards global viral hepatitis elimination goals.

Health disparities in cirrhosis care and liver transplantation

Morbidity and mortality from cirrhosis are substantial and increasing. Health disparities in cirrhosis and liver transplantation are reflective of inequities along the entire spectrum of chronic liver disease care, from screening and diagnosis to prevention and treatment of liver-related complications. The key populations experiencing disparities in health status and healthcare delivery include racial and ethnic minority groups, sexual and gender minorities, people of lower socioeconomic status and underserved rural communities. These disparities lead to delayed diagnosis of chronic liver disease and complications of cirrhosis (for example, hepatocellular carcinoma), to differences in treatment of chronic liver disease and its complications, and ultimately to unequal access to transplantation for those with end-stage liver disease. Calling out these disparities is only the first step towards implementing solutions that can improve health equity and clinical outcomes for everyone. Multi-level interventions along the care continuum for chronic liver disease are needed to mitigate these disparities and provide equitable access to care.

Self-reported hepatitis B testing among noninstitutionalized adults in the United States before the implementation of universal screening, 2013-2017: A nationwide population-based study

In 2023, the US Centers for Disease Control and Prevention recommended universal screening for hepatitis B virus (HBV); however, the proportion of US adults screened before implementing this recommendation is unknown. We analysed nationally representative data from the National Health Interview Survey (2013-2017) on self-reported HBV testing among noninstitutionalized US adults ≥18 years. We employed Poisson logistic regression to identify factors associated with self-reported testing, using a conceptual framework that included four overarching factors: sociodemographic characteristics, healthcare access, health-seeking behaviours and experiences, and access to internet-based health information. Among 149,628 survey respondents, the self-reported HBV testing rate was 27.2% (95% CI 26.2-28.7) and increased by 1.7% from 2013 to 2017 (p = .006). In adjusted analysis, health-seeking behaviours and experiences had the strongest associations of self-reported testing including a history of hepatitis (AOR 2.68, 95% CI 1.92-3.73), receipt of hepatitis B vaccination (AOR 5.11, 95% CI 4.61-5.68) and prior testing for hepatitis C (AOR 9.14, 95% CI 7.97-10.48) and HIV (AOR 2.69, 95% CI 2.44-2.97). Other factors associated with testing included being male (AOR 1.14, 95% CI 1.03-1.26), ages 30-44 years (AOR 1.37, 95% CI 1.17-1.61), 45-60 years (AOR 1.55, 95% CI 1.30-1.80) and ≥60 years (AOR 1.53, 95% CI 1.28-1.84), residence in the Western US region (AOR 1.23, 95% CI 1.06-1.43), and access to internet-based health information (AOR 1.32, 95% CI 1.18-1.47). Being Hispanic was associated with lower odds of testing (AOR 0.80, 95% CI 0.66-0.97). These findings may help guide optimal HBV screening in the universal testing era.

Assessing Physicians' Recommendations for Hepatitis B Virus (HBV) and Hepatitis C Virus (HCV) Testing Among Minority Populations in Greater Philadelphia and New York City

Deaths from liver cancer are on the rise and disproportionately affect minority racial/ethnic groups. In this study, we examined associations between physicians' recommendations for hepatitis B virus (HBV) and hepatitis C virus (HCV) screening and sociodemographic and lifestyle factors among minority populations in the areas of Greater Philadelphia and New York City. Using Poisson regression with robust variance estimation, we evaluated potential associations for 576 Hispanic American (HA), African American (AA), and Asian Pacific American (APA) adults, using blood tests as an outcome measure, with adjustment for sociodemographic factors We found that APAs (34.2%) were most likely to have a physician recommend HBV and HCV screening tests (34.2% and 27.1%, respectively), while HAs were least likely to receive an HBV recommendation (15.0%) and AAs were least likely to receive an HCV recommendation (15.3%). HAs were significantly likely to have never received a blood test for either HBV or HCV (RR = 1.25, 95% CI: 1.05, 1.49). APAs were significantly more likely to receive a screening recommendation for HBV (RR = 1.10, 95%CI: 1.01, 1.20) and to have a blood test (RR = 1.57, 95% CI: 1.06, 2.33). Our findings show that, among HAs, AAs, and APAs, physician recommendations are strongly associated with patients undergoing blood tests for HBV and HCV and that minority populations should increasingly be recommended to screen for HBV and HCV, especially given their elevated risk.

The Role of Culturally Appropriate Mediated Communication Strategies to Reduce Hepatitis B and Liver Cancer Disparities

Asian, Pacific Islander, African, and Caribbean communities in the U.S. are heavily impacted by chronic hepatitis B (HBV) and hepatocellular carcinoma (HCC). Educating these groups about the link between the two diseases is imperative to improve screening rates and health outcomes. This study aims to identify and incorporate preferred mediated communication methods into community-specific educational campaigns which emphasize the connection between the conditions, to promote uptake of prevention and management behaviors for HBV and HCC. Fifteen focus groups and two key informant interviews were conducted with Micronesian, Chinese, Hmong, Nigerian, Ghanaian, Vietnamese, Korean, Somali, Ethiopian, Filipino, Haitian, and Francophone West African communities. Data were analyzed using thematic coding and analysis. Findings demonstrate that all communities preferred materials be offered in both English and native languages and requested that materials highlight the connection between HBV and HCC. Delivery channel preferences and messaging themes varied by group. This study provides insight into community-specific preferences for learning about HBV and HCC. The findings can be used to design culturally and linguistically tailored, multi-platform, health education campaigns to facilitate improved HBV screening and vaccination rates and increase knowledge about HCC risk among highly impacted communities in the U.S.

Existing knowledge, myths, and perceptions about hepatitis B and liver cancer within highly impacted immigrant communities

Background

Immigrant groups from Southeast Asia, the Pacific Islands, sub-Saharan Africa, and the Caribbean bear the heaviest burden of chronic hepatitis B and primary liver cancer in the United States. Educational campaigns to increase knowledge about these diseases and their connection are necessary to promote protective health behaviors within these communities, to ultimately reduce the burden of disease, lessen stigma, and eliminate health disparities.

Objectives

This project sought to engage groups within highly impacted communities to identify existing gaps in hepatitis B- and liver cancer-related knowledge, in order to inform future health education programming that will aim to reduce stigma and promote liver cancer prevention and early detection behaviors within and across groups.

Methods

Fifteen focus groups and two key informant interviews were conducted virtually with participants from Micronesian, Chinese, Hmong, Nigerian, Ghanaian, Vietnamese, Korean, Somali, Ethiopian, Filipino, Haitian, and Francophone West African communities. Qualitative data were analyzed using thematic coding.

Results

There are large gaps in knowledge and awareness of hepatitis B and liver cancer, and the link between these two diseases among Asian, Pacific Islander, African and Haitian immigrant communities. This limited knowledge and misinformation, exacerbated by stigma, hinder these groups' utilization of hepatitis B and liver cancer diagnostic and preventative healthcare services.

Conclusion

To reduce hepatitis B and liver cancer health disparities within heavily burdened groups, health education needs to be community-informed, culturally sensitive, and actionable. Study results can guide the development of culturally and linguistically appropriate education programs that focus on the link between hepatitis B and liver cancer and the need for vaccination and routine screening, and that are responsive to the knowledge gaps and misperceptions of diverse communities. The results also provide valuable insights for healthcare providers to improve the knowledge gaps of the diverse patient populations that they serve.

Association of Baseline Hepatitis B Virus DNA and On-Treatment Risk of Cirrhosis and Hepatocellular Carcinoma

BACKGROUND

Recent studies suggest an inverse relationship between baseline levels of hepatitis B virus (HBV) DNA and on-treatment risk of hepatocellular carcinoma (HCC) in patients with chronic hepatitis B (CHB). However, data are limited to Asian cohorts, and it is unclear if similar associations hold true for non-Asians with CHB. We aimed to evaluate association of baseline HBV DNA with long-term risks of cirrhosis and HCC among a predominantly non-Asian cohort of CHB patients in the USA.

METHODS

Using longitudinal data from the national Veterans Affairs database, we evaluated the risk of cirrhosis or HCC among adults with non-cirrhotic CHB who are on continuous antiviral therapy, stratified by moderate levels of baseline HBV DNA (4.00 - 6.99 log10 IU/mL) vs. high levels of baseline HBV DNA (7.00 log10 IU/mL or higher). Propensity score weighting was applied, and competing risks cumulative incidence functions and Cox proportional hazards models were utilized.

RESULTS

Among 1,129 non-cirrhotic CHB patients (41% non-Hispanic White, 36% African American, mean age 57.0 years, 62.2% hepatitis B e antigen (HBeAg) positive), 585 had moderate levels of baseline HBV DNA and 544 had high HBV DNA. After propensity score weighting, no significant difference in risk of cirrhosis was observed between moderate vs. high baseline HBV DNA (4.55 vs. 5.22 per 100 person-years, hazard ratio (HR): 0.87, 95% confidence interval (CI): 0.69 - 1.09, P = 0.22), but risk of HCC was significantly higher in patients with moderate vs. high baseline HBV DNA (0.84 vs. 0.69 per 100 person-years, HR: 1.33, 95% CI: 1.09 - 1.62, P < 0.01).

CONCLUSIONS

Among a national cohort of predominantly non-Asian US veterans with non-cirrhotic CHB on antiviral therapy, moderate levels of baseline HBV DNA was associated with higher risk of HCC than high HBV DNA.

Screening Practices and Risk Factors for Co-Infection with Latent Tuberculosis and Hepatitis B Virus in an Integrated Healthcare System - California, 2008-2019

BACKGROUND

Hepatitis B virus (HBV) and latent tuberculosis infection are associated with a significant global burden, but both are underdiagnosed and undertreated. We described the screening patterns and risk factors for co-infection with latent tuberculosis and HBV within a large healthcare system.

METHODS

Using data from Kaiser Permanente Southern California during 2008-2019, we described HBV infections, defined as a positive HBV surface antigen, e-antigen, or DNA test, and latent tuberculosis, defined as a positive Mantoux tuberculin skin test or interferon-gamma release assay test. We estimated adjusted odds ratios (aOR) for co-infection among screened adults with either infection.

RESULTS

Among 1997 HBV patients screened for latent tuberculosis, 23.1% were co-infected, and among 35,820 patients with latent tuberculosis screened for HBV, 1.3% were co-infected. Among HBV patients, co-infection risk was highest among Asians compared with White race/ethnicity (29.4% vs 5.7%, aOR 4.78; 95% confidence interval [CI], 2.75-8.31), and persons born in a high-incidence country compared with low-incidence countries (31.0% vs 6.6%; aOR 4.19; 95% CI, 2.61-6.73). For patients with latent tuberculosis, risk of co-infection was higher among Asian (aOR 9.99; 95% CI, 5.79-17.20), or Black race/ethnicity (aOR 3.33; 95% CI, 1.78-6.23) compared with White race/ethnicity. Persons born in high-incidence countries had elevated risk of co-infection compared with persons born in low-incidence countries (aOR 2.23; 95% CI, 1.42-3.50). However, Asians or persons born in high-incidence countries were screened at similar rates to other ethnicities or persons born in low-incidence countries.

CONCLUSIONS

Latent tuberculosis risk is elevated among HBV patients, and vice versa. Risk of co-infection was highest among persons born in high-incidence countries and Asians. These findings support recent guidelines to increase HBV and tuberculosis screening, particularly among persons with either infection.

On-treatment risks of cirrhosis and hepatocellular carcinoma among a large cohort of predominantly non-Asian patients with non-cirrhotic chronic hepatitis B

Background & Aims

The vast majority of studies evaluating differences in on-treatment risks of hepatocellular carcinoma (HCC) in patients with chronic hepatitis B (CHB) have been conducted in Asia. Data on the course of CHB on antiviral therapy among predominantly non-Asian populations is less well described. We aimed to evaluate overall risks of cirrhosis and HCC and the influence of baseline factors on this risk among a predominantly non-Asian cohort of patients with CHB in the US.

Methods

Using longitudinal data from the national Veterans Affairs database, we evaluated the incidence of cirrhosis or HCC among adults with non-cirrhotic CHB on continuous antiviral therapy. Cumulative incidence functions and adjusted Cox proportional hazards models employed competing risks methods and evaluated overall risk and predictors of developing cirrhosis or HCC while on treatment.

Results

Among 2,496 patients with non-cirrhotic CHB (39.1% African American, 38.4% non-Hispanic White, 18.8% Asian, mean age 58.0 ± 13.4 years), the overall incidences of cirrhosis and HCC were 3.99 per 100 person-years (95% CI 3.66-4.35) and 0.43 per 100 person-years (95% CI 0.33-0.54), respectively. The highest incidences of cirrhosis and HCC were observed in non-Hispanic White patients (5.74 and 0.52 per 100 person-years, respectively), which were significantly higher than in Asian patients (1.93 and 0.17 per 100 person-years, respectively, p <0.0001). On multivariate regression, only baseline FIB-4 score was consistently associated with long-term risk of cirrhosis or HCC.

Conclusions

Using a longitudinal cohort of predominantly non-Asian Veterans with non-cirrhotic CHB on antiviral therapy (an understudied population), we provide important epidemiological data to describe long-term risks of cirrhosis and HCC.

Impact and implications

In one of the largest studies to date of a predominantly non-Asian cohort of patients with non-cirrhotic chronic hepatitis B, we provide important epidemiological data describing the long-term risks of cirrhosis and hepatocellular carcinoma among patients on antiviral therapies. Among this understudied population, the overall incidence of cirrhosis was 3.99 per 100-person-years (95% CI 3.66-4.35) and of HCC was 0.43 per 100-person-years (95% CI 0.33-0.54). These data also emphasize the importance of continued monitoring and HCC surveillance among CHB patients who are maintained on antiviral therapies.

Infectious diseases in Indigenous populations in North America: learning from the past to create a more equitable future

The COVID-19 pandemic, although a profound reminder of endured injustices by and the disparate impact of infectious diseases on Indigenous populations, has also served as an example of Indigenous strength and the ability to thrive anew. Many infectious diseases share common risk factors that are directly tied to the ongoing effects of colonisation. We provide historical context and case studies that illustrate both challenges and successes related to infectious disease mitigation in Indigenous populations in the USA and Canada. Infectious disease disparities, driven by persistent inequities in socioeconomic determinants of health, underscore the urgent need for action. We call on governments, public health leaders, industry representatives, and researchers to reject harmful research practices and to adopt a framework for achieving sustainable improvements in the health of Indigenous people that is both adequately resourced and grounded in respect for tribal sovereignty and Indigenous knowledge.

Actionable Solutions to Achieve Health Equity in Chronic Liver Disease

There are well-described racial and ethnic disparities in the burden of chronic liver diseases. Hispanic persons are at highest risk for developing nonalcoholic fatty liver disease, the fastest growing cause of liver disease. Hepatitis B disproportionately affects persons of Asian or African descent. The highest rates of hepatitis C occur in American Indian and Alaskan Native populations. In addition to disparities in disease burden, there are also marked racial and ethnic disparities in access to treatments, including liver transplantation. Disparities also exist by gender and geography, especially in alcohol-related liver disease. To achieve health equity, we must address the root causes that drive these inequities. Understanding the role that social determinants of health play in the disparate health outcomes that are currently observed is critically important. We must forge and/or strengthen collaborations between patients, community members, other key stakeholders, health care providers, health care institutions, professional societies, and legislative bodies. Herein, we provide a high-level review of current disparities in chronic liver disease and describe actionable strategies that have potential to bridge gaps, improve quality, and promote equity in liver care.

Hepatitis B virus screening in Asian immigrants: Community-based campaign to increase screening and linkage to care: A cross-sectional study

Background and Aims

Despite established screening guidelines, many Asian immigrants remain unscreened. Furthermore, those with chronic hepatitis B (CHB) are not linked to care citing multiple barriers. The objective of this study was to determine the role of our community-based hepatitis B virus (HBV) campaign on HBV screening and the success of linkage to care (LTC) efforts.

Methods

Asian immigrants from the New Jersey and New York metropolitan areas were screened for HBV from 2009 to 2019. We started to collect LTC data starting in 2015, and those found to be positive were followed up. In 2017, because of low LTC rates, nurse navigators were hired to aid in the LTC process. Those excluded from the LTC process included those who were already linked to care, declined, and/or had moved or passed away.

Results

Total of 13,566 participants were screened from 2009 to 2019, of which, the results for 13,466 were available. Of these, 372 (2.7%) were found to have positive HBV status. Approximately 49.3% were female and 50.1% were male, and the rest were of unknown gender. A total of 1191 (10.0%) participants were found to be HBV negative but required vaccination. When we started to track LTC, we found 195 participants that were eligible for LTC between 2015 and 2017 after the exclusion criteria were applied. It was found that only 33.8% were successfully linked to care in that time period. After hiring nurse navigators, we saw LTC rates increase to 85.7% in 2018 and to 89.7% in 2019.

Conclusion

HBV community screening initiatives are imperative to increase screening rates in the Asian immigrant population. We were also able to demonstrate that nurse navigators can successfully help increase LTC rates. Our HBV community screening model can address issues with barriers to care including lack of access in comparable populations.

A Comparative Trial of Improving Care for Underserved Asian Americans Infected with Hepatitis B Virus

BACKGROUND

Hepatitis B virus (HBV) is the leading cause of hepatocellular carcinoma (HCC). Asian Americans have the highest incidence and mortality rates of HCC among all US racial/ethnic groups. Inadequate monitoring and treatment of chronic hepatitis B contribute to poor health outcomes and increased healthcare costs among Asian Americans.

AIMS

The goal of this study is to assess the effect of a patient-led strategy on chronic hepatitis B monitoring and treatment adherence specifically among Asian Americans with culturally tailored Patient Navigator-led Intervention.

METHODS

From 2015 to 2018, 532 eligible participants living with chronic hepatitis B in the greater Philadelphia and New York city metropolitan areas were randomly assigned to either the intervention group or the control group. Generalized linear mixed-effects models were used to estimate the odds ratio (OR) for rates of doctor visits for chronic hepatitis B and rates of alanine aminotransferase testing for evidence of liver damage.

RESULTS

Intervention group had higher rates of doctor visits than the control group at both 6-month (77.22% vs. 45.75%) and 12-month assessments (90.73% vs. 60.61%). Significantly more intervention group participants received ALT testing than control group participants at 6-month (52.90% vs. 25.10%) and 12-month (75.40% vs. 46.75%) follow-up.

CONCLUSIONS

Culturally and linguistically appropriate intervention has strong effects on adherence to follow-up care among Asian American hepatitis B patients experiencing challenges to medication adherence and follow up care. These findings further identify opportunities for practical implementation of evidence-based intervention that could lead to reductions in disparities in chronic liver disease and liver cancer among high-risk, underserved populations.

Improving Long-Term Adherence to Monitoring/Treatment in Underserved Asian Americans with Chronic Hepatitis B (CHB) through a Multicomponent Culturally Tailored Intervention: A Randomized Controlled Trial

BACKGROUND

Although Asian Americans make up 6% of the U.S. population, they account for 58% of Americans with chronic hepatitis B (CHB). Yet, adherence to monitoring and antiviral treatment guidelines among Asian American CHB patients remains suboptimal.

METHODS

The purpose of this study was to evaluate the efficacy of a multicomponent intervention on adherence to CHB monitoring among Asian Americans with CHB. The intervention components included virtual patient education, patient navigation, and mobile health reminders delivered by bilingual community health educators. Chi-square test and t-test were used to compare demographic characteristics and two CHB measures: CHB clinical follow-up and CHB laboratory monitoring by the time of the 12-month follow-up assessment. A generalized linear mixed-effects model (GLMM) was fitted to assess the effectiveness of the intervention.

RESULTS

The study sample consisted of 358 Chinese and Vietnamese Americans living with CHB, including 181 in the intervention group and 177 in the control group. The intervention group had a significantly higher rate of CHB clinical follow-up (86.2%) and CHB laboratory monitoring (79.0%) than did the control group (54.2% and 45.2%, respectively). Results of the GLMM showed significant intervention effects on CHB clinical follow-up (odds ratio = 7.35, 95% confidence interval = 4.06-13.33) and CHB laboratory monitoring (odds ratio = 6.60, 95% confidence interval = 3.77-11.56) at the 12-month follow-up assessment.

CONCLUSION

The multicomponent intervention was effective in improving adherence to CHB monitoring among Asian Americans. Additional implementation research is needed to better understand and apply effective interventions to other underserved populations.

Low Rates of Hepatitis B Virus Treatment Among Treatment-Eligible Patients in Safety-Net Health Systems

BACKGROUND

Timely initiation of antiviral therapy in chronic hepatitis B virus (CHB) reduces risk of disease progression. We evaluate overall treatment rates and predictors of treatment among treatment-eligible safety-net CHB patients.

METHODS

We retrospectively evaluated adults with CHB from 2010 to 2018 across 4 large safety-net health systems in the United States. CHB was identified with ICD-9/10 diagnosis coding and confirmed with laboratory data. Treatment eligibility was determined using American Association for the Study of Liver Diseases (AASLD) guidelines. Comparison of CHB treatment rates among treatment-eligible patients were performed using χ2 testing, Kaplan Meier methods and log-rank testing. Adjusted multivariate Cox proportional hazards models evaluated independent predictors of receiving treatment among eligible patients.

RESULTS

Among 5157 CHB patients (54.7% male, 34.6% African American, 22.3% Asian), 46.8% were treatment-eligible during the study period. CHB treatment rates were 48.4% overall and 37.3% among CHB patients without human immunodeficiency virus. Significantly lower odds of treatment were observed in females versus males (odds ratio: 0.40, 95% confidence interval: 0.33-0.49, P<0.001) and patients age 65 years or above versus age below 45 years (odds ratio: 0.68, 95% confidence interval: 0.51-0.92, P=0.012). Conversely, significantly greater odds of treatment were observed in African American and Asians versus non-Hispanic whites, CHB patients with indigent care versus commercially insured patients, and non-English speaking versus English speaking patients.

CONCLUSION

Among a large multicentered, safety-net cohort of CHB patients, 46.8% of treatment-eligible CHB patients overall and 37.3% of treatment-eligible CHB patients without human immunodeficiency virus received antiviral therapy. Improving CHB treatment rates among treatment-eligible patients represents "low hanging fruit," given the clear benefits of antiviral therapy in mitigating disease progression.

Understanding how to live with hepatitis B: a qualitative investigation of peer advice for Chinese people living with hepatitis B in Australia

BACKGROUND

Hepatitis B is a chronic viral infection, a leading cause of primary liver cancer and identified as a major public health priority by the World Health Organization. Despite a high proportion of people in Australia who have been diagnosed with hepatitis B, significant gaps remain in health care access and in accurate knowledge about hepatitis B. Most people with hepatitis B in Australia were born in China, where the infection has an intergenerational impact with significant social implications resulting from the infection. Understanding how people of Chinese ethnicity with hepatitis B understand and respond to hepatitis B is imperative for reducing morbidity, mortality, and the personal and social impact of the infection.

METHODS

Qualitative semi-structured interviews with people with hepatitis B of Chinese ethnicity recruited through a specialist service identified the advice people with hepatitis B thought was important enough to inform the experience of people newly diagnosed with hepatitis B. A thematic analysis of the data privileged the lived experience of participants and their personal, rather than clinical, explanations of the virus.

RESULTS

Hepatitis B infection had psychological and physical consequences that were informed by cultural norms, and to which people had responded to with significant behavioural change. Despite this cohort being engaged with specialist clinical services with access to the most recent, comprehensive, and expert information, much of the advice people with hepatitis B identified as important for living with hepatitis B was not based on biomedical understandings. Key suggestions from people with hepatitis B were to form sustainable clinical relationships, develop emotional resilience, make dietary changes, regulate energy, and issues related to disclosure.

CONCLUSIONS

The study highlights conflicts between biomedical and public health explanations and the lived experience of hepatitis B among people of Chinese ethnicity in Australia. Beliefs about hepatitis B are embedded within cultural understandings of health that can conflict with bio-medical explanations of the infection. Acknowledging these perspectives provides for insightful communication between health services and their clients, and the development of nuanced models of care informed by the experience of people with hepatitis B.

Linkage-to-Care Following Community-Based HBV and HCV Screening Among Immigrants from the Washington–Baltimore Metropolitan Area, 2016–2019

Understanding characteristics that impact linkage-to-care (LTC) among individuals living with HBV and/or HCV can enhance public health efforts to provide tailored care services to prevent and treat viral hepatitis among immigrants. Using HBV/HCV screening and LTC data from immigrants (2016–2019), descriptive and logistic regression analyses were conducted to assess (1) the relationship between LTC and sociodemographic factors and (2) factors associated with HBV/HCV LTC. About 87% of those positive HBsAg had LTC and 52% had LTC among those with HCVAB and confirmed PCR. Access to care was an important LTC predictor for HBV–LTC: those who had neither health insurance nor primary care provider (PCP) were more likely to have HBV–LTC than those who had either health insurance or PCP (aOR = 2.95, 95% CI = 1.32–6.59). It is essential to equally provide HBV/HCV LTC support to all immigrants from countries with high prevalence regardless of access to care.

Ethnic Minorities and Low Socioeconomic Status Patients With Chronic Liver Disease Are at Greatest Risk of Being Uninsured

Background

Chronic liver disease (CLD) predominantly affects ethnic minorities and socially vulnerable populations, who have high prevalence of risk factors (e.g., suboptimal insurance coverage) predisposing to healthcare disparities. We evaluate prevalence and predictors of uninsured status among CLD adults, and secondarily, how this affects documented immunity or vaccination for hepatitis A virus (HAV) and hepatitis B virus (HBV).

Methods

Using 2011 - 2018 National Health and Nutrition Examination Survey data, self-reported insurance status was determined among adults with CLD. Prevalence of uninsured status was stratified by patient characteristics and evaluated using multivariable logistic regression models. Prevalence of self-reported completion of vaccination as well as laboratory value-based documented immunity to HAV and HBV was stratified by insurance status.

Results

Overall, 19.0% of adults with CLD reported having no insurance, which was highest among individuals of Hispanic ethnicity (33.5%), less than high school education (33.7%), and below poverty status (35.3%). On multivariable analyses, significantly lower odds of having any insurance coverage was observed in men, Hispanics, and individuals with lower education and lower household income. Prevalence of documented immunity or vaccination for HAV was low across all insurance categories, ranging from 46.5% to 54.0%. Prevalence of documented immunity or vaccination for HBV was similarly low across all insurance categories, ranging from 24.3% to 40.8%.

Conclusion

Prevalence of uninsured status among CLD was more than twice the US adult population, and lack of insurance particularly impacted Hispanics and individuals with low education and low household income. Low prevalence of documented immunity or vaccination for HAV and HBV across all insurance categories is concerning.

Assessment of Hepatitis B Virus Screening Behaviors among Asian-Americans through the Lens of Social Cognitive Theory

Background and Purpose

Asian-Americans suffer from significant liver cancer disparity caused by chronic hepatitis B virus (HBV) infection. Understanding psychosocial predictors of HBV screening is critical to designing effective interventions.

Methods

Chinese-, Korean-, and Vietnamese-Americans in the Baltimore-Washington metropolitan region (N=877) were recruited from community-based organizations. Applying the Social Cognitive Theory (SCT), three main theoretical constructs (knowledge, outcome expectancy, and self-efficacy) were tested. Descriptive analyses using Chi-square and ANOVA and multivariate logistic regression models were conducted.

Results

About 47% of participants reported ever having screening for HBV. Vietnamese-Americans had the lowest HBV screening rate (39%), followed by Korean-Americans (46%) and Chinese-Americans (55%). Multiple logistic regression analyses showed significant effects of HBV-related knowledge on screening in all three groups, whereas self-efficacy had significant effects in the Chinese and Korean subgroups, but not Vietnamese. HBV outcome expectancy had no effect on the screening outcome in any of the groups. Additionally, consistent in all three groups, those who had lived in the United States longer were less likely to have screening.

Conclusion

HBV screening rates in Asian Americans remain low; targeted interventions need to consider the differences across ethnic subgroups and address the psychosocial risk factors.

Hepatitis B Testing Among Vietnamese in Metropolitan Atlanta: The Role of Healthcare-Related and Acculturation-Related Factors

BACKGROUND

Compared to other racial/ethnic groups, U.S. Vietnamese have higher Hepatitis B infection prevalence, which is a major liver cancer risk factor. Increased testing could reduce this disparity. It is critical to understand subgroups of U.S. Vietnamese least likely to have been tested for Hepatitis B and design appropriate interventions. We examined healthcare- and acculturation-related factors influencing Hepatitis B testing among U.S. Vietnamese.

METHODS

Survey data of 100 U.S. Vietnamese attending health fairs/programs hosted by community-based organizations (2017-2018) were analyzed. Healthcare-related predictors included insurance and past 2-year checkup. Acculturation-related predictors included Vancouver Acculturation Index, percentage of lifetime in the U.S., and Vietnamese and English fluency. We conducted a multiple logistic regression controlling for age, sex, education, and household income.

RESULTS

The sample was an average 37.5 years old and 61.6% female. Insurance coverage was reported by 83.0%. Average percentage of lifetime in the U.S. was 56.8%. Seventy percent reported having received Hepatitis B testing. Hepatitis B testing was associated with health insurance (aOR = 2.61, 95% CI = [1.05-6.47], p = .04) but not any acculturation-related predictors CONCLUSION: Improving insurance coverage and options can be a strategy to increase Hepatitis B testing among U.S. Vietnamese. More education regarding Hepatitis B (e.g., via community-based, culturally-appropriate, lay health worker-led programs) is needed to ensure that individuals are aware of their testing status and pursue appropriate healthcare decisions.

Review article: current gaps and opportunities in HBV prevention, testing and linkage to care in the United States-a call for action

BACKGROUND

The World Health Organization (WHO) has set an elimination goal for hepatitis B virus (HBV) by 2030, so a comprehensive review of current HBV testing and care gaps are needed to help formulate solutions and opportunities for action.

AIMS

To summarise current gaps and barriers, and to propose solutions for HBV prevention, testing and linkage to care in the United States METHODS: Relevant guidelines and studies were reviewed including a systematic review of HCC surveillance adherence.

RESULTS

A total of 64.5 million (95% CI, 61.3-67.5) high-risk US adults had no evidence of HBV immunity. Only 18.6% (95% CI, 13.5-29.9) of privately insured patients with HBV infection have been diagnosed. Among those with known HBV infection, linkage to care rate (33.3%-57%) was poor and the adherence to guidelines regarding anti-viral therapy (30.66% [95% CI, 30.28-31.03]) and HCC surveillance (8%-87%, from a systematic review) were poor with even more concerning data for care and treatment retention. The causes are complex and include lack of access to medical care, lack of physician knowledge, lack of patient health literacy and awareness, linguistic and cultural barriers and fear of stigma.

CONCLUSIONS

A 'scale-up' effort is needed to optimise the care continuum to achieve the WHO 2030 targets. As targeted screening policy has leftover 80% of patients undiagnosed, we advocate for universal screening which can help to remove barriers regarding stigma. More active and system level interventions are also needed to improve linkage to care for patients with HBV infection.

A mixed-methods approach to understanding perceptions of hepatitis B and hepatocellular carcinoma among ethnically diverse Black communities in South Florida

PURPOSE

Hepatitis B (HBV), the leading cause of hepatocellular carcinoma (HCC), disproportionately affects minorities. Compared to other races, Blacks more often present with advanced HCC and have decreased survival. We observed higher HBV-associated HCC rates among Blacks than reported nationally. In our center, Haitian Blacks had the highest rates of HBV-associated HCC and shorter survival compared to other Blacks. We investigated knowledge and perceptions regarding HBV and HCC among Blacks born in the United States or Haiti.

METHODS

Using community partnerships, participants were recruited via word of mouth, email, social media or from Hepatology clinic. Focus groups were conducted in Haitian Creole or English and stratified by birthplace, gender and infection status. Discussions were audio-recorded and transcribed verbatim. A constant comparative method was used for data analysis; themes are based on conversational details.

RESULTS

There were 55 participants; 49% were male and 27% had chronic HBV. Only 42% of Haitian Blacks knew about HBV prior to participation vs. 78% of African Americans, p 0.03. Both groups expressed that fear, mistrust of the medical establishment, denial and stigma might compel persons to avoid seeking care. Both groups attributed higher rates of late stage HCC diagnosis in Blacks to inadequate financial resources and education. Those with HBV reported confusion regarding their infection and suboptimal communication with healthcare providers.

CONCLUSIONS

In two communities disproportionately affected by HBV, misconceptions about disease transmission, stigma, low health literacy and decreased access to care may limit detection for HBV. Culturally relevant community-based interventions are needed to increase HBV detection.

Knowledge and Perceptions of Hepatitis B and Hepatocellular Carcinoma Screening Guidelines Among Trainees: A Tale of Three Centers

BACKGROUND

Hepatitis B (HBV), the leading cause of hepatocellular carcinoma (HCC) worldwide, disproportionately affects minorities in the USA. Undiagnosed HBV precludes HCC screening and contributes to late-stage cancer presentation and decreased survival. Barriers to HBV and HCC screening include lack of insurance and limited diffusion of guidelines. We aimed to assess knowledge about HBV and HCC screening indications and explore barriers to screening.

METHODS

We surveyed trainees from the University of Miami/Jackson Memorial Hospitals, Palmetto General Hospital, and Mount Sinai Medical Center. We assessed knowledge using clinical vignettes. We performed bivariate and Chi-squared analyses.

RESULTS

There were 183 respondents; median age was 31 and 52% were male. The sample was 35% Hispanic, 29% White, 18% Asian, and 9% Black. Training department was Internal Medicine, 71%; Family Medicine, 11%; Infectious Diseases, 6%; or Gastroenterology, 7%. Only 59% correctly estimated national HBV prevalence; 25% correctly estimated global prevalence. In vignettes with behavioral risk factors, trainees correctly advised screening, 63-96%. However, when the risk factor was the birthplace, correct responses ranged from 33 to 53%. Overall, 45% chose an incorrect combination of HBV screening tests. Perceived barriers to screening included limited expertise in screening of immigrants and limited patient education. Respondents were more likely to recommend HCC screening in cirrhotic patients versus non-cirrhotic HBV patients. Key barriers to HCC screening included uncertainty about HCC guidelines and patient financial barriers.

CONCLUSIONS

Knowledge of HBV and HCC screening recommendations is suboptimal among trainees. Efforts to broadly disseminate HBV and HCC guidelines through targeted educational interventions are needed.

Barriers to Disease Monitoring and Liver Cancer Surveillance Among Patients with Chronic Hepatitis B in the United States

Chronic hepatitis B infection (CHB) is a condition that needs ongoing care such as monitoring for liver enzymes (ALT) and HBV DNA tests in treated and untreated patients, and annual imaging evaluation for liver cancer. Although follow-up care and treatment might seem straight forward, an estimated two-thirds of those who are aware of their infection are not seeing a health care provider, and more than half of those who are eligible for treatment do not receive it. This study aimed to compile and examine studies related to the barriers of disease monitoring, treatment, and liver cancer surveillance for CHB patients in the United States (US). A total of 4439 studies on monitoring and surveillance of CHB published between 2007 and 2018 were identified through a search of electronic databases. After critical assessment, the authors included 42 studies, divided into categories: 'patient-related barriers'; 'provider-related barriers'; and 'system-related barriers'. Among the patient-related barriers, one of the most frequent factors invoked in failing to have adequate surveillance was lack of patient's knowledge. In the provider-related barrier category, a lack of disease knowledge and adherence to guidelines was frequently reported. For the system-related barrier category, the only recurrent mention was a lack of clarity in guidelines or lack of guidelines from certain national institutions. This review summarizes and highlights the need for long-term disease management improvement of chronic hepatitis B infection for patients and healthcare providers that care for them.

Disparities in Hepatitis B Vaccine Coverage by Race/Ethnicity: The National Health and Nutrition Examination Survey (NHANES) 2015-2016

Hepatitis B virus (HBV) infection is the most common form of viral hepatitis and remains a global public health problem, even though the HBV vaccine is available. HBV leads to chronic liver disease, including cirrhosis, liver cancer, and death. This study aimed to identify disparities in HBV vaccine coverage with the serological test by race/ethnicity, adjusting for gender and age. In this study, 5735 adult participants were included, obtaining data from the National Health and Nutrition Examination Survey (NHANES), 2015-2016. Proc survey frequency, bivariate- and multivariate logistic regression in the weighted sample were performed due to the complex survey design of NHANES. Data were analyzed using SAS, version 9.2.4. The overall prevalence of HBV vaccine coverage was only 23.3% (95% CI: 20.7%, 25.9%). In a multivariate logistic regression model, data showed that Mexican Americans (OR 0.57, 95% CI: 0.38, 0.86) and African Americans (OR 0.70, 95% CI 0.56, 0.84) had lower vaccine coverage compared to Whites. Females had (OR 1.55, 95% CI: 1.30, 1.85) higher vaccine coverage compared to men. Older age groups (30-49 years) (OR 0.41, 95% CI: 0.32, 0.52) and age group ≥ 50 years (OR 0.18, 95% CI 0.14, 0.23) had lower vaccine coverage compared to younger adults aged 18-29 years.

Prevalence of Trichomonas vaginalis Infection Among US Males, 2013-2016

Background

Trichomoniasis results from adhesion of Trichomonas vaginalis to the mucous membrane of the urethra or vagina. It has been estimated to have a higher incidence rate than both gonorrhea and chlamydia combined. Although females can experience both clinical symptoms and obstetrical complications, male infections are largely asymptomatic and often unreported. We aim to estimate the prevalence of trichomoniasis in US males using the National Health and Nutrition Examination Survey (NHANES) database.

Methods

The NHANES database was queried for all men aged 18-59 years during the years 2013-2016. During these years, the survey included urine testing for trichomoniasis using transcription-mediated amplification. Information was also obtained regarding patient demographics and other sexually transmitted infections.

Results

Overall, 0.49% of men aged 18-59 years tested positive for trichomoniasis. The highest rate was seen in black men (3.6%). There was no significant association with trichomoniasis and age. Higher rates of infection were seen in smokers, those with herpes simplex virus type 2 (HSV-2) infection, men who had sex at an early age, those with less condom usage, and those with more lifetime sexual partners.

Conclusion

The rates of trichomonas infection in US males are lower than in women. Infections are strongly associated with black males, HSV-2 infection, and other factors known to increase rates of sexually transmitted infection. This information may be helpful for counseling, screening, and management of patients.

Chronic Hepatitis B Prevalence Among Foreign-Born and U.S.-Born Adults in the United States, 1999-2016

Hepatitis B virus (HBV) infection remains a major global health problem, exacerbated by poor linkage to care. We aimed to determine the prevalence of HBV infection, exposure, self-reported vaccination, vaccine-induced immunity, disease awareness, and treatment in the United States by birthplace and race/ethnicity during 1999-2016. A total of 47,628 adult participants in the National Health and Nutrition Examination Survey who completed HBV core antibody (anti-HBc) and surface antigen (HBsAg) tests and 47,618 adults who completed HBV surface antibody (anti-HBs) and anti-HBc tests were included in the analysis. HBV infection was defined by positive HBsAg and past exposure by positive anti-HBc. Vaccine-mediated immunity was defined by positive anti-HBs and negative anti-HBc. No significant change in the prevalence of HBV infection was observed between 1999 and 2016 (P = 0.442), affecting 0.35% (95% confidence interval [CI], 0.28-0.45) or 0.84 million adults. In contrast, a significant decrease in HBV exposure and increase in vaccine-mediated immunity was observed. U.S.-born persons had significantly lower prevalence of HBV infection and exposure as well as higher prevalence of vaccine-mediated immunity and self-reported vaccination than foreign-born persons. Prevalence of HBV infection was highest in non-Hispanic Asians in both foreign- (3.85%; 95% CI, 2.97-4.97) and U.S.-born (0.79%; 95% CI, 0.17-3.59) persons during 2011-2016. Among infected persons, liver disease awareness was only 15.19%, and treatment rate was only 4.60%. Conclusion: This study revealed disparities of HBV infection among ethnic/racial groups and between U.S.-born and foreign-born persons. Awareness of liver disease and treatment rate among infected persons was dismal.

Surveillance-Based Estimate of the Prevalence of Chronic Hepatitis B Virus Infection, New York City, 2016

OBJECTIVES

Chronic hepatitis B virus (HBV) infection is a lifelong infection that can cause serious liver damage and liver cancer. The last surveillance-based prevalence estimate of chronic HBV infection in New York City was 1.2% in 2008; however, it did not account for persons with undiagnosed infection. The objective of this study was to calculate the prevalence of chronic HBV infection, including undiagnosed infection, for 2016 by using surveillance data and literature-based information.

METHODS

We calculated the number of persons with diagnosed chronic HBV infection (2000-2016) who were alive and living in New York City in 2016 by using routine surveillance data. We estimated the percentage of persons with undiagnosed chronic HBV infection by using birth region-specific percentages from the literature, weighted by the proportion of the New York City population with diagnosed chronic HBV infection from the same birth region. We identified minimum, maximum, and most likely values for the percentage with undiagnosed chronic HBV infection to generate 95% certainty limits (CLs) of the prevalence estimate.

RESULTS

The prevalence of chronic HBV infection in 2016, including undiagnosed infection, in New York City was 2.7% (95% CL, 2.2%-3.6%), representing approximately 230 000 persons. The prevalence of diagnosed chronic HBV infection was 1.5%. The estimated prevalence among non-US-born residents was 6.9% (95% CL, 5.4%-8.9%).

CONCLUSIONS

The current burden of chronic HBV infection in New York City, especially for non-US-born residents, is substantial. A renewed focus and dedication of resources is required to increase the number of new diagnoses and improve provider capacity to care for the large number of persons with chronic HBV infection.

Low Rates of Linkage and Retention Into Care Among Patients With Chronic HBV Infection

Successful linkage and retention of newly diagnosed hepatitis B virus (HBV) patients is critical for disease monitoring. Existing studies have demonstrated significant gaps in the HBV care continuum among U.S. veterans¹ and have mostly focused on adherence to laboratory testing or initial linkage. However, retention is especially important, given that decisions to start antiviral therapies are often not made until subsequent evaluation, and studies report high rates of becoming treatment-eligible among patients who were not eligible at initial evaluation.² Given the existing system and socioeconomic barriers in access to care, understanding contributors to gaps and delays in HBV linkage and retention among safety-net populations is critical. We aim to evaluate prevalence and predictors of linkage and retention among HBV patients at an urban safety-net hospital.

Population Health And Economic Impacts Of Reaching Chronic Hepatitis B Diagnosis And Treatment Targets In The US

The National Academies of Sciences, Engineering, and Medicine have concluded that eliminating the public health problem of chronic hepatitis B is feasible. We examined the economic and public health impact of reaching the World Health Organization targets of having 90 percent of chronic hepatitis B cases diagnosed and 80 percent being treated by 2030 in the United States with an annual incremental increase in screening and treatment rates. To reach the targets by 2030 would require screening approximately 14.5 million adults in at-risk populations to diagnose an estimated 870,000 undiagnosed cases and would result in substantial health gains: an increase of 16.5 million quality-adjusted life-years (QALYs), and reductions in liver-related deaths of 37 percent and in cases of compensated cirrhosis of 24 percent, decompensated liver cirrhosis of 51 percent, and liver cancer of 35 percent. Achieving the targets by 2030 would be highly cost-effective at $103 per QALY and would be cost-saving if the antiviral drug price were no more than $114 per month. Achieving them by 2025 would be cost-saving and would reduce liver-related deaths by 47 percent.

Mortality Among Patients With Chronic Hepatitis B Infection: The Chronic Hepatitis Cohort Study (CHeCS)

BACKGROUND

According to death certificates, approximately 1800 persons die from hepatitis B annually in the United States; however, this figure may underestimate true mortality from chronic hepatitis B (CHB).

METHODS

We analyzed data from CHB patients seen in the Chronic Hepatitis Cohort Study (CHeCS) between 1 January 2006 and 31 December 2013. We compared overall and cause-specific death rates and mean ages at death between CHeCS CHB decedents and U.S. decedents from the Multiple Cause of Death (MCOD) file.

RESULTS

Of 4389 CHB patients followed for a mean of 5.38 years, 492 (11%) CHB patients died after a mean follow-up of 3.00 years. Compared to survivors, decedents were older, more likely to be White (40.6%), African-American (27.1%), or male (74.2%); and more likely to have had cirrhosis (59.8%), diabetes (27.2%), alcohol abuse (17.7%), hepatocellular carcinoma (17.5%), or a liver transplant (5.7%); whereas survivors were more likely to be Asian (48.8%; all P < .001). CHB patients died at an average age of 59.8 years-14 years younger than the general U.S. population-and at higher rates for all causes (relative risk [RR] = 1.85, 95% confidence interval [CI], 1.851-1.857) and liver-related causes (RR = 15.91, 95% CI, 15.81-16.01). Only 19% of CHB decedents and 40% of those dying of liver disease had hepatitis B reported on their death certificates.

CONCLUSIONS

Compared to the general population, CHB patients die at younger ages and higher rates from all causes and liver-related causes. Death certificates underrepresent the true mortality from CHB.

Sub-optimal Testing and Awareness of HCV and HBV Among High Risk Individuals at an Underserved Safety-Net Hospital

Sub-optimal screening for chronic hepatitis C virus (HCV) and chronic hepatitis B virus (HBV) among high risk groups delays diagnosis and treatment. We aimed to evaluate overall rates of HCV and HBV screening and patient knowledge of their testing result. Adults age ≥18 years undergoing elective outpatient endoscopy at a large, urban safety-net hospital from July 2015 to July 2016 were prospectively evaluated to determine rates of HCV and HBV testing, the results of those completed tests, and patient knowledge of test results among high risk individuals (as determined by U.S. Preventative Services Task Force). Among 1125 patients (52.3% male, 70.4% foreign-born), 66.5% were high risk for chronic HCV; only 30.9% received prior testing. 14.7% had positive chronic HCV infection. Patients born in the 1945-1965 cohort were more likely to have received prior HCV testing compared to those born outside of this cohort (32.7 vs. 16.9%, p = 0.01). Among patients who received HCV screening, 29.3% were aware of test results. Overall, 61.6% were high risk for chronic HBV; only 25.1% received prior testing. 4.1% were positive for chronic HBV. Compared to Caucasians, Asians (19.0 vs. 44.4%, p < 0.001) and Hispanics (20.0 vs. 44.4%, p < 0.001) were less likely to have previous HBV testing. Among patients who received prior HBV screening, 18.4% were aware of test results. Less than one-third of high risk patients received HCV and HBV screening among an ethnically diverse safety-net population. Equally low rates of patient knowledge of testing results were observed.

Racial/ethnic- and county-specific prevalence of chronic hepatitis B and its burden in California

Background

In the United States, the highest burden of chronic hepatitis B (CHB) and CHB-related liver cancer is in the state of California, primarily in the San Francisco (SF) Bay and Los Angeles (LA) areas. The aim of this study was to estimate county-specific hepatitis B surface antigen (HBsAg) prevalence and quantify CHB cases by age, race/ethnicity, nativity, and disease activity status.

Methods

Twelve counties in SF Bay Area and three large counties in LA area were included for this analysis. Race/ethnicity-specific prevalence of HBsAg for each county and the state of California as a whole, was estimated by including prevalence data from the National Health and Nutrition Examination Survey and various studies that estimated HBsAg prevalence in US and foreign-born Asian Pacific Islanders, Hispanic, and Black populations. In addition, clinical data of 2000 consecutive CHB patients (collected between 2009 and 2014) from a large clinical consortium in the SF Bay area were used to calculate the age-specific disease burden.

Results

Of the 15 counties analyzed, SF had the highest HBsAg prevalence (1.78%), followed by Santa Clara (1.63%) and Alameda (1.45%). The majority of CHB cases were estimated to be in LA County (83,770), followed by Santa Clara (31,273), and Alameda (23,764). Among the CHB cases, 12.7% is active HBeAg positive, 24.2% is active HBeAg negative, and 10.6% has cirrhosis.

Conclusion

This study confirms and quantifies the current burden of CHB in high endemic counties in the state of California using population-level estimates combined with clinical data including those from the community.

An expert consensus for the management of chronic hepatitis B in Asian Americans

BACKGROUND

Hepatitis B virus (HBV) infection is common with major clinical consequences. In Asian Americans, the HBsAg carrier rate ranges from 2% to 16% which approximates the rates from their countries of origin. Similarly, HBV is the most important cause of cirrhosis, hepatocellular carcinoma (HCC) and liver related deaths in HBsAg positive Asians worldwide.

AIM

To generate recommendations for the management of Asian Americans infected with HBV.

METHODS

These guidelines are based on relevant data derived from medical reports on HBV from Asian countries as well as from studies in the HBsAg positive Asian Americans. The guidelines herein differ from other recommendations in the treatment of both HBeAg positive and negative chronic hepatitis B (CHB), in the approach to HCC surveillance, and in the management of HBV in pregnant women.

RESULTS

Asian American patients, HBeAg positive or negative, with HBV DNA levels >2000 IU/mL (>104 copies/mL) and ALT values above normal are candidates for anti-viral therapy. HBeAg negative patients with HBV DNA >2000 IU/mL and normal ALT levels but who have either serum albumin <3.5 g/dL or platelet count <130 000 mm3 , basal core promoter (BCP) mutations, or who have first-degree relatives with HCC should be offered treatment. Patients with cirrhosis and detectable HBV DNA must receive life-long anti-viral therapy. Indications for treatment include pregnant women with high viraemia, coinfected patients, and those requiring immunosuppressive therapy. In HBsAg positive patients with risk factors, life-long surveillance for HCC with alpha-fetoprotein (AFP) testing and abdominal ultrasound examination at 6-month intervals is required. In CHB patients receiving HCC treatments, repeat imaging with contrast CT scan or MRI at 3-month intervals is strongly recommended. These guidelines have been assigned to a Class (reflecting benefit vs. risk) and a Level (assessing strength or certainty) of evidence.

CONCLUSIONS

Application of the recommendations made based on a review of the relevant literature and the opinion of a panel of Asian American physicians with expertise in HBV treatment will inform physicians and improve patient outcomes.

A Pilot Program Integrating Hepatitis B Virus (HBV) Screening into an Outpatient Endoscopy Unit Improves HBV Screening Among an Ethnically Diverse Safety-Net Hospital

BACKGROUND

Safety-net hospitals are enriched in ethnic minorities and provide opportunities for high-impact hepatitis B virus (HBV) screening.

AIM

We aim to evaluate the impact of a pilot program integrating HBV screening into outpatient endoscopy among urban safety-net populations.

METHODS

From July 2015 to May 2017, consecutive adults undergoing outpatient endoscopy were prospectively assessed for HBV screening eligibility using US Preventative Services Task Force guidelines. Rates of prior HBV screening were assessed, and those eligible but not screened were offered HBV testing. Multivariate logistic regression models evaluated predictors of test acceptance among eligible patients.

RESULTS

Among 1557 patients (47.1% male, 69.4% foreign born), 65.1% were eligible for HBV screening, among which 24.5% received prior screening. In our pilot screening program in the endoscopy unit, 91.4% (n = 855) of eligible patients accepted HBV testing. However, only 55.3% (n = 415) of those that accepted actually completed HBV testing. While there was a trend toward higher rates of test acceptance among African-Americans compared to non-Hispanic whites (OR 3.31, 95% CI 0.96-11.38, p = 0.06), no other sex-specific or race/ethnicity-specific disparities in HBV test acceptance were observed. Among those who completed HBV testing, we identified 10 new patients with chronic HBV (2.4% prevalence). Only 24.5% of eligible patients received prior HBV screening among our cohort.

CONCLUSIONS

Our pilot program integrating HBV screening into outpatient endoscopy successfully tested an additional 415 patients, improving overall HBV screening from 24.5 to 75.6%. Integrating HBV testing into non-traditional settings has potential to bridge the gap in HBV screening among safety-net systems.

Long noncoding RNA CPS1-IT1 suppresses the metastasis of hepatocellular carcinoma by regulating HIF-1α activity and inhibiting epithelial-mesenchymal transition

Recently, increasing numbers of long noncoding RNAs (lncRNAs), with both oncogenic and tumor-suppressive potential, have been found to be aberrantly expressed in various human cancers. However, the function of lncRNAs in hepatocellular carcinoma (HCC) progression remains largely unknown. In this study, we performed a comprehensive microarray analysis of lncRNA expression using human HCC specimens. After validation in 119 human HCC tissues, we identified a novel tumor suppressor lncRNA, CPS1 intronic transcript 1 (CPS1-IT1). To elucidate the clinical significance of CPS1-IT1 in HCC, correlations between CPS1-IT1 levels, clinical parameters, and survival outcomes were analyzed. In vitro and in vivo functional assays were also performed to dissect the potential underlying mechanisms. Expression of CPS1-IT1 was significantly decreased in 73% of HCC tissues, and patients with low CPS1-IT1 expression had poor survival outcomes. Furthermore, in vitro functional assays indicated that CPS1-IT1 significantly reduced cell proliferation, migration and invasion capacities through reduced Hsp90 binding to and activation of HIF-1α, thereby suppressing the epithelial-mesenchymal transition (EMT). An in vivo animal model also demonstrated the tumor suppressor role of CPS1- IT1 via decreased tumor growth and metastasis. In conclusion, lncRNA CPS1-IT1 acts as a tumor suppressor in HCC by reducing HIF-1α activation and suppressing EMT. The findings of this study establish a function for CPS1-IT1 in HCC progression and suggest its potential as a new prognostic biomarker and target for HCC therapy.

Hepatitis B virus outreach to immigrant population in Greater Boston Area: Key to improving hepatitis B knowledge

AIM

To characterize the understanding of hepatitis B virus (HBV) and determine if outreach improves HBV understanding among Greater Boston Area immigrants.

METHODS

Six outreach sessions were held in various community venues in the Greater Boston Area. Verbal consent was obtained from participants prior to starting each session. Each session included a pre-session questionnaire, followed by a teaching session, and then a post-session questionnaire. In person interpreters were present for translation during the teaching session and assistance for questionnaire completion when needed. The questions were developed based on the HBV clinical experience of physicians who serve largely immigrant populations. Questionnaires included Likert-type scale, open-ended, and true-false questions. All results were anonymous.

RESULTS

One hundred and one people participated in this study. Participants were 30% male with ages ranging from 19 to 87 years. The study population included immigrants from 21 countries, as well as seven United States-born participants. The greatest numbers of participants were from Somalia (44%), Morocco (10%), and Cameroon (8%). Pre session questionnaires revealed that 42% of participants were unaware that HBV can cause cancer, and 50% were unaware that therapies for HBV exist. Our brief teaching intervention led to improved scores on post session questionnaires. For example, at baseline, 58% of participants responded correctly to the question “HBV infection can cause scarring of the liver and liver cancer”, whereas 79% of participants responded correctly after the teaching session (P = 0.01). Furthermore, the mean of total correct answers in the true or false portion of the questionnaire increased from 5.5 to 7.6 (P < 0.001).

CONCLUSION

A teaching session targeting Boston Immigrants at-risk for HBV helped improve scores on HBV knowledge questionnaires. Outreach may empower at-risk patients to pro-actively seek HBV care.

Efficacy of a community-based participatory and multilevel intervention to enhance hepatitis B virus screening and vaccination in underserved Korean Americans

BACKGROUND

The primary objective of the current study was to evaluate the efficacy of a community-based participatory intervention program in improving hepatitis B virus (HBV) screening and vaccination among Korean Americans who were not previously screened.

METHODS

A cluster randomized trial involving 32 Korean church-based community organizations (1834 participants) was conducted. Sixteen churches were randomly assigned to an HBV screening and vaccination multicomponent intervention condition (972 participants) and 16 were assigned to a general cancer education control condition (862 participants). The main components of the intervention program included interactive group education; patient navigation; and the engagement of health care providers, church leadership, and church members in the medical field. The application of community-based participatory research principles was monitored and evaluated. HBV screening and vaccination rates (self-reported and medical record verification) were assessed at 6-month and 12-month follow-ups, respectively.

RESULTS

The results of the current study demonstrated significant efficacy in the HBV screening rate (92.5% in the intervention group vs 5.5% in the control group), 3-series HBV vaccination completion rate (84% in the intervention group vs 17.6% in the control group), and overall screening and vaccination compliance rate (87% in the intervention group vs 3.8% in the control group). Participants in the intervention group were significantly more likely to receive HBV screening (92.5%) compared with those in the control group (5.5%). In multivariate mixed-effect logistic regression analysis, the odds ratio for an intervention effect on HBV screening was 512.3 after adjusting for cluster effect and other demographic variables. With regard to vaccination rates, of the 332 participants who were screened with no immunity in the intervention group, 308 (92.8%) received at least 1 HBV vaccination, 300 (90.4%) received at least 2 shots, and 279 participants (84%) received all 3 shots.

CONCLUSIONS

A combination of community-based participatory research and a multilevel approach may produce the most optimal results and be essential in producing a considerable effect for enhancing HBV screening and vaccination, particularly for Korean American populations with limited language proficiency and insurance coverage. Cancer 2018;124:973-82. © 2017 American Cancer Society.

Melatonin suppresses hepatocellular carcinoma progression via lncRNA-CPS1-IT-mediated HIF-1α inactivation

Melatonin is the primary pineal hormone that relays light/dark cycle information to the circadian system. It was recently reported to exert intrinsic antitumor activity in various cancers. However, the regulatory mechanisms underlying the antitumor activity of melatonin are poorly understood. Moreover, a limited number of studies have addressed the role of melatonin in hepatocellular carcinoma (HCC), a major life-threatening malignancy in both sexes in Taiwan. In this study, we investigated the antitumor effects of melatonin in HCC and explored the regulatory mechanisms underlying these effects. We observed that melatonin significantly inhibited the proliferation, migration, and invasion of HCC cells and significantly induced the expression of the transcription factor FOXA2 in HCC cells. This increase in FOXA2 expression resulted in upregulation of lncRNA-CPS1 intronic transcript 1 (CPS1-IT1), which reduced HIF-1α activity and consequently resulted in the suppression of epithelial-mesenchymal transition (EMT) progression and HCC metastasis. Furthermore, the results of the in vivo experiments confirmed that melatonin exerts tumor suppressive effects by reducing tumor growth. In conclusion, our findings suggested that melatonin inhibited HCC progression by reducing lncRNA-CPS1-IT1-mediated EMT suppression and indicated that melatonin could be a promising treatment for HCC.

Testing and Linking Foreign-Born People with Chronic Hepatitis B Virus Infection to Care at Nine U.S. Programs, 2012-2014

OBJECTIVE

Hepatitis B virus (HBV) infection continues to be a public health threat in the United States. As many as 2.2 million people are infected, approximately 70% of whom are foreign-born, and fewer than one-third are aware of their infection. We launched an HBV testing and linkage-to-care initiative among foreign-born people.

METHODS

As part of the Hepatitis Testing and Linkage to Care (HepTLC) initiative, which promoted viral hepatitis B and hepatitis C screening, posttest counseling, and linkage to care at 34 U.S. sites, nine U.S. programs in seven states conducted HBV screening from October 2012 to September 2014. The nine programs partnered with health-care centers and community-based organizations to recruit foreign-born people recommended for HBV testing. We assessed patient characteristics, region of origin, risk factors, hepatitis B surface antigen (HBsAg) status, and referral to medical care.

RESULTS

Of 23,144 participants tested for HBV, 1,317 (5.7%) were HBsAg positive. Of these, the median age was 47 years, 1,205 (91%) had at least one risk factor for HBV infection, 1,117 (85%) received posttest counseling, 1,098 (83%) were referred to care, and 606 (46%) attended a first medical appointment. The proportion of HBsAg-positive participants by region of origin included Africa (10%, 206/2,129), Western Pacific (6%, 616/9,673), Eastern Mediterranean (5%, 174/3,337), Southeast Asia (5%, 191/3,891), South America (2%, 6/252), Eastern Europe (2%, 6/262), and North America (1%, 17/1,936).

CONCLUSION

Community-based HBV testing initiatives can identify substantial numbers of people with chronic HBV infection, inform them of their infection status, and provide posttest counseling and linkage to care. However, strategies are needed to improve linkage to HBV-directed medical care for foreign-born individuals living with chronic HBV infection.

Ethnic Disparities in Chronic Hepatitis B Infection: African Americans and Hispanic Americans

Chronic infection with hepatitis B affects more than 240 million persons worldwide and is a major public health concern. Despite national and global initiatives to promote hepatitis B elimination, including newborn vaccination, catch up vaccination in adolescents and high-risk adults, screening of the blood supply and treatment of those in need, both new infections and a reservoir of chronic infections continue to result in morbidity and mortality. As with many chronic diseases, racial and ethnic disparities are seen in hepatitis B virus infection.

Purpose of Review

The goal of this review is to synthesize the data concerning the burden of hepatitis B infection in African Americans and Hispanics, two racial/ethnic groups in the United States who encounter barriers in access to care, low engagement in care and low utilization of diagnostic and treatment services.

Recent Findings

Recent data, though sparse in certain areas, continue to suggest differences in rates of incidence and prevalence of hepatitis B virus infection in African Americans, and differences in screening, specialty referral and initiation of therapy for African Americans and Hispanics. Data are lacking about differences in liver disease progression and manifestations in both African Americans and Hispanics.

Summary

Disparities in hepatitis B diagnosis, disease management, treatment and prevention remain for African Americans and Hispanics. These disparities require a commitment from governmental and public health organizations. The efforts should include increasing vaccination in those most susceptible to infection, screening those at highest risk for infection, initiating antiviral therapy in those who require it and monitoring for liver-related complications, such as decompensated cirrhosis and hepatocellular carcinoma in the chronically infected. This multi-pronged approach is necessary to realize hepatitis B elimination.

A Community-Based Randomized Trial of Hepatitis B Screening Among High-Risk Vietnamese Americans

OBJECTIVES

To evaluate the effectiveness of a community-based liver cancer prevention program on hepatitis B virus (HBV) screening among low-income, underserved Vietnamese Americans at high risk.

METHODS

We conducted a cluster randomized trial involving 36 Vietnamese community-based organizations and 2337 participants in Pennsylvania, New Jersey, and New York City between 2009 and 2014. We randomly assigned 18 community-based organizations to a community-based multilevel HBV screening intervention (n = 1131). We randomly assigned the remaining 18 community-based organizations to a general cancer education program (n = 1206), which included information about HBV-related liver cancer prevention. We assessed HBV screening rates at 6-month follow-up.

RESULTS

Intervention participants were significantly more likely to have undergone HBV screening (88.1%) than were control group participants (4.6%). In a Cochran-Mantel-Haenszel analysis, the intervention effect on screening outcomes remained statistically significant after adjustment for demographic and health care access variables, including income, having health insurance, having a regular health provider, and English proficiency.

CONCLUSIONS

A community-based, culturally appropriate, multilevel HBV screening intervention effectively increases screening rates in a high-risk, hard-to-reach Vietnamese American population.

A Novel Strategy to Increase Identification of African-Born People With Chronic Hepatitis B Virus Infection in the Chicago Metropolitan Area, 2012-2014

INTRODUCTION

Most research on hepatitis B virus (HBV) infection in the United States is limited to Asian populations, despite an equally high prevalence among African immigrants. The purpose of this study was to determine testing and detection rates of HBV infection among African-born people residing in the Chicago metropolitan area.

METHODS

A hepatitis education and prevention program was developed in collaboration with academic, clinical, and community partners for immigrant and refugee populations at risk for HBV infection. Community health workers implemented chain referral sampling, a novel strategy for recruiting hard-to-reach participants, targeting African-born participants. Participants were tested in both clinical and nonclinical settings. To assess infection status, blood samples were obtained for hepatitis B surface antigen (HBsAg), core antibody, and surface antibody testing. Demographic information was collected on age, sex, health insurance status, country of origin, and years residing in the United States. Participants were notified of testing results, and HBsAg-positive participants were referred for follow-up medical care.

RESULTS

Of 1,000 African-born people who received education, 445 (45%) agreed to participate in HBV screening. There were 386 (87%) participants tested in clinical and 59 (13%) tested in nonclinical sites. Compared with participants who were tested in clinical settings, participants tested in nonclinical settings were older, were less likely to have health insurance, and had lived in the United States longer (P < .005 for each). Of these, most were from the Democratic Republic of the Congo (14%), Nigeria (13%), Ghana (11%), Somalia (11%), or Ethiopia (10%). There were 35 (8%) HBsAg-positive people, 37% had evidence of past infection, and 29% were immune.

CONCLUSIONS

Chain referral sampling identified many at-risk African-born people with chronic HBV infection. The large proportion of HBsAg-positive people in this sample reinforces the need for health promotion programs that are culturally appropriate and community-driven.

Long non-coding RNA AOC4P suppresses hepatocellular carcinoma metastasis by enhancing vimentin degradation and inhibiting epithelial-mesenchymal transition

Increasing evidence indicates that long non-coding RNAs (lncRNAs) regulate diverse cellular processes, including cell growth, differentiation, apoptosis, and cancer progression. However, the function of lncRNAs in the progression of hepatocellular carcinoma (HCC) remains largely unknown. We performed a comprehensive microarray analysis of lncRNA expression in human HCC samples. After validation in 108 HCC specimens, we identified a differentially expressed novel tumor suppressive lncRNA termed amine oxidase, copper containing 4, pseudogene (AOC4P). The level of AOC4P expression was significantly downregulated in 68% of HCC samples and negatively correlated with advanced clinical stage, capsule invasion and vessel invasion. Low AOC4P expression correlated with poor prognostic outcomes, serving as an independent prognostic factor for HCC. In vitro functional assays indicated that AOC4P overexpression significantly reduced cell proliferation, migration and invasion by inhibiting the epithelial-mesenchymal transition (EMT). RNA immunoprecipitation assays demonstrated that AOC4P binds to vimentin and promotes its degradation. Animal model experiments confirmed the ability of AOC4P to suppress tumor growth and metastasis. Taken together, our findings suggest that AOC4P lncRNA acts as an HCC tumor suppressor by enhancing vimentin degradation and suppressing the EMT. By clarifying the mechanisms underlying HCC progression, these findings promote the development of novel therapeutic strategies for HCC.

Comparison of Demographic and Clinical Characteristics of Hispanic and Asian Chronic Hepatitis B Patients in Southern California

OBJECTIVES

There are few data regarding the clinical and serologic features of chronic hepatitis B (CHB) infection among Hispanics in the United States. The aims of this study were to compare and contrast clinical characteristics of Hispanic and Asian CHB patients.

METHODS

Demographic, clinical, and laboratory data were collected from Hispanic and Asian CHB patients seen between January 2013 and May 2014 at Los Angeles County Hepatitis Clinic.

RESULTS

A total of 55 Hispanic and 342 Asian CHB patients were identified. Almost all were foreign-born. Compared with Asians, Hispanics were more likely to report heterosexual transmission (P<0.0001) and blood transfusion history (P<0.0001) as risk factors. Overall, 31% of Hispanics had HBV>2000 IU/mL compared with 54% of Asians (P=0.004).Significantly more Asian HBeAg-negative/anti-HBe-positive CHB patients had high HBV DNA levels (>2000 IU/mL) with elevated ALT compared with Hispanic patients (P=0.04). Compared with Asians, Hispanic CHB patients were more likely to have elevated ALT and low HBV DNA levels (P=0.001). Among CHB patients who received antiviral therapy, response was comparable among Hispanics and Asians. There were no Hispanic CHB patients who experienced spontaneous reactivation or developed hepatocellular carcinoma.

CONCLUSIONS

There were important differences in the clinical, demographic, and serologic characteristics between Hispanic and Asian CHB. Response rate to antiviral therapy was comparable. Further studies of Hispanic CHB patients in the United States are warranted.