Hepatitis B infection is a leading cause of liver cancer and is preventable with vaccination and treatable with antiviral medications, but many people in the United States are already infected with the virus and don’t know it.
The U.S. Centers for Disease Control and Prevention (CDC), in collaboration with researchers at UC Davis and two other sites, led an initiative to screen people at risk of hepatitis B and treat those infected. They determined that health system and community-based efforts were successful, but that more needs to be done to prevent the deadly impact of hepatitis B.
The CDC effort resulted in the publication of an article in today’s issue of Morbidity and Mortality Weekly Report, the CDC’s primary vehicle for scientific publication of timely, objective and useful public health information and recommendations.
Christopher Bowlus, a liver disease specialist and principal investigator on the initiative at UC Davis, said it has long been a challenge to get people at risk of infection with hepatitis B virus (HBV) into medical care.
“Most people with chronic hepatitis B infection do not have symptoms, and in many cases their doctors are not aware that they are at risk of infection, most of which is acquired at birth,” said Bowlus, chief of the Division of Gastroenterology and Hepatology.
Bowlus added that stigma and cultural barriers can hamper efforts to get people screened and into care.
“People with hepatitis B fear that they will be seen as being dirty,” Bowlus said. “And there is often a sense of fatalism – if you tell them it is very important to get treatment because the virus can cause cancer, they don’t want to know.”
Chronic HBV infection affects 257 million people worldwide and an estimated 850,000-2.2 million people in the U.S. Of those, about 70 percent were not born in the U.S., and about two-thirds do not know they are infected, according to the researchers. Many of those infected acquired the virus as children; as many as one in four people with chronic infection will die prematurely.
The CDC initiative aimed to improve hepatitis B testing and link those found to have chronic HBV infection to care. Between October 2014 and September 2017 the CDC funded three programs in partnership with primary care centers, community-based organizations and public health departments. In all, 10,152 people were tested and 757, or 7.5 percent, tested positive for HBV. Of those, 17 were cases of newly diagnosed liver cirrhosis.
The majority of those who tested positive for HBV were from China (32 percent). Others were from Vietnam (16 percent), Myanmar/Burma (8 percent), Taiwan (7 percent) and Laos (3 percent). Only 2.1 percent were born in the U.S.
HBV-positive individuals were provided counseling (84 percent), HBV-directed care (76%), and, when indicated, were prescribed antiviral therapy (18%). Each site used a different approach to improve testing and linkage to care. UC Davis, for example, initiated the Sacramento Collaborative To Advance the Testing and Care of Hepatitis B (SCrATCH B) in which students worked with community groups to organize testing events and help people access health-care services through their primary care providers, the Paul Hom Asian Clinic, or one of the other UC Davis student-run clinics. Within UC Davis Health, use of electronic medical record alerts and care managers worked to enhance testing and assist with patient navigation. The other study sites were in Livingston, N.J. and Chicago.
“This community-based public health initiative demonstrated that it is feasible to implement the CDC’s HBV testing recommendations and link non-U.S.-born individuals with chronic HBV infection to high quality care through community screening events, patient navigation, utilization of the electronic health record, and provider education and feedback,” the researchers concluded.
Bowlus said additional research, including a study led by UC Davis gastroenterologist Eric Chak, will determine the effectiveness of medical record alerts for providers by comparing the rate of hepatitis B screening and follow-up care for patients who have been tagged in the electronic system for alerts with those patients who have not.
“What we hope comes of this is awareness on both sides of the health system – the patients and the providers – who need to understand this is a significant disease and we can smartly use technology and community outreach to try to identify those at risk, get those identified effective treatment, prevent cirrhosis and reduce the risk of liver cancer.”
Other authors of the MMWR paper included Erik Chak and Moon Chen, Jr. of UC Davis; Aaron M. Harris, Ruth Link-Gelles and Noele Nelson of the CDC and the U.S. Public Health Service, Perry Pong of the Charles B. Wang Community Health Center in New York, NY, and Su Wang of the Saint Barnabas Medical Center, Center for Asian Health in Livingston, N.J. The study was funded with a CDC grant #NU51PS004633.