Karen E. Kim, MD Professor of Medicine Dean for Faculty Affairs Director, Center for Asian Health Equity University of Chicago 1
2 billion people have been exposed to HBV 350-400 million people chronically infected Over two thirds are from China Cirrhosis, liver failure, HCC develop in 15-25% of chronic HBV patients WHO. Hepatitis B. Fact Sheet Lavanchy D. J Viral Hepat. 2004;11:97-107 Lok AS. N Engl J Med. 2002;346:1682-3.
It is estimated that up to 2.2 million persons in the United States are chronically infected with HBV. Foreign-born Asian and African individuals in the U.S. are disproportionately affected by chronic HBV Foreign-born Asian individuals make-up nearly 60% Foreign-born African individuals account for nearly 12% 1. CDC. MMWR 2008;57(No. RR-08) 2. Knowdley. Hepatology 2012;56(2)422
The prevalence of chronic HBV infection in API Americans is as high as 15% in some studies. Almost two-thirds of chronically infected API Americans are unaware of their infection status because they have not been tested for HBV Less than 5% are in treatment IOM. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C. http://www.nap.edu/catalog/12793.html
HBV is responsible for 75-80% of virus-associated HCC (compared to 10-20% for HCV) 2 HBV carries a lifetime risk HCC of 10-25% 3 Worldwide, Asian have the highest rates of liver cancer 1. CDC. http://www.cdc.gov/hepatitis/statistics/2013surveillance/ 4. McMahon. Hepatol 2009;49(Suppl 5):S45 index.htm. 5. Beasley. Hepatology. 1982;2(5):553 2. Perz. J Hepatol 2006;45(4):529 6. Qian. Cancer Epidemiol Biomarkers Prev 1994;3(1):3
1. CDC. Surveillance for Viral Hepatitis United States, 2013. HBV-RELATED DEATHS BY RACE/ETHNICITY Race/Ethnicity 2010 Rate 2011 Rate 2012 Rate 2013 Rate White, non-hispanic 0.34 0.32 0.31 0.33 Black, non-hispanic 0.94 0.98 0.81 0.98 Hispanic 0.43 0.48 0.39 0.39 Asian/Pacific Islander 2.95 2.72 2.93 2.64 American Indian/Alaskan 5 0.73 0.38 2 0.74 3 0.55 4 Native Overall 0.52 0.52 0.50 0.52
Hepatitis B Incidence Among Persons 19 Yrs By Race/Ethnicity, 1990-2004 20 Black Cases/100,000 15 10 5 Asian/Pacific Islander AI/AN Hispanic White Overall decline ~ 75% Decline among API ~ 85% 0 1990 CDC, 2006 1991 1992 1993 1994 1995 1996 1997 Year 1998 1999 2000 2001 2002 2003 2004
Rationale for Hepatitis B Screening Early Rx and risk based treatment likely to reduce chronic complications from HBV RCT shows that CHB treatment leads to lower HCC Cost effective to treat Greater than 65% of those with CHB don t know it!
Policy: FUNDING VIRUS Prevalence (millions) % unaware Deaths 2006 Vaccine HBV 0.8-1.4 65% 3,000 YES HCV 2.7-3.9 75% 12,000 NO CDC budget 2010 $ per pt HBV/ HCV 3.5-5.3 15,000 24 Million HIV 1.1 21% 14,016 NO 1.2 Billion $4/pt $1000/ pt
Disproportionate disease burden Lack of data Lack of awareness Lack of Resources 11
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Build the infrastructure and capacity of pan-asian communities for hepatitis education and prevention. Provide targeted outreach and health education through community health workers (CHWs). Increase hepatitis screening rates for at-risk Asian populations. Provide appropriate linkage to care for Asians for either the hepatitis vaccine or medical follow-up for chronic infections. 13
Multisector Partnership Local government Providers Community based organizations Academic centers Ethnic media Evidence based interventions and strategies 14
Collaborations with local, city and state government agencies Provided funding for communitybased hepatitis education and outreach Provided local-level hepatitis surveillance data for community mapping Invited local officials to speak at hepatitis advocacy events Advocate for a new line item for at risk AAPI and African immigrants for HBV-$500,000K RFA 15
CDC (funded since 2008) Beijing center grant CDC Conference Grant AHRQ R24-Partnership for Healthier Asians NCI P20 16
ACTIVITY 2006 2007 2008 2009 2010 2011* Total People Educated 3,495 4,787 7,800 6,029 8,031 2,743 32,885 Number of Group Educations Number of Health Fair Events Number Referred for Screening/ Immunization 56 49 32 47 47 33 264 0 9 8 12 15 19 63 1,432 3,770 3,318 5,672 3,105 197 17,494 Adults Screened 405 601 576 370 611 676 5,139 17
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Project Phoenix In 2012, AHC awarded CDC Cooperative Grant to conduct HBV surveillance and screening in Chicago Metropolitan area. Screenings performed Screenings available for analysis 1174 1158 (98.6%) HBsAg + 69 (6%) Anti-HBc + 444 (18%) Country of Origin # Screened # Positive Carrier Rate China 59 8 13.60% Africa 131 14 10.7% Laos 144 12 8.30% Cambodia 51 4 7.80% Nepal 28 2 7.10% Tibet 18 2 7.10% Other 84 6 7.10% Philippines 114 5 4.40% Korea 239 9 3.80% Vietnam 170 6 3.50% Mongolia 52 1 1.90% India 29 0 0.00% Burma 22 0 0.00% USA 17 0 0.00% TOTAL 1158 69 6.00%
Primary Care Providers (PCPs) HPNs CHWs Communitybased Organizations (CBOs) CHWs and HPNs will have joint: Reciprocal site and facility visits Cultural competency training Translation phone line training HBV education and training Medical Process and Linkage-to-care training
Number Percent Notified of Result 46 100% Referred for Medical Care 34 73.9% Visit Attended/In Progress 24 52.2% Sought care through PCP 6 13.0% TOTAL IN CARE 65.2%
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Opportunity To eliminate a cause of Disparity and Death Evidence based strategies Education Vaccination Screening Treatment
DIALOGUE FOR ACTION 25