Ton Duy Tran, M.D. and Binh Nhung Tran, Pharm.D.
The hepatitis B virus is the leading cause of acute and chronic liver disease and liver cancer worldwide. In the United States, acute and chronic HBV infections are a major cause of morbidity and mortality.1 Each year, 80,000 persons in the United States become infected, and 5,000 die from liver disease or liver cancer caused by HBV. Health care and work loss costs for these conditions total more than $700 million per year. Infection with HBV is often asymptomatic, and an estimated 1.2 million Americans are chronic carriers of HBV, which means they are potentially infectious to others.
BACKGROUND
Prevalence of Hepatitis B in Asian and Pacific-Islander Americans: The prevalence of HBV is four times higher among Asians than any other race/ethnicity. It is commonly quoted that 12% of Asian American and Pacific Islander children and 14% to 20% of API adults are carriers. Much higher rates are found in some API communities. According to Samuel So, M.D., Director of the Stanford Asian Liver Center, “The greatest single health disparity between Asian Americans and white Americans is liver cancer. The incidence of liver cancer in men is seven to 13 times higher in Asian and Pacific-Islander Americans than in white Americans. This incidence is directly correlated to the disproportionately high rate of chronic hepatitis B in the Asian and Pacific-Islander American populations.” 2
While HBV can be transmitted by blood transfusions, sharing needles, and unprotected sex, most API individuals become infected as infants or young children. According to the National Health Nutrition Examination Survey II, prior to the implementation in the early 1990s of successful perinatal and routine infant hepatitis B vaccination programs in the United States, HBV infection rates among API infants and children were 5 to 26 times greater than among non-API infants and children. 3
Hepatitis B Immunization: Immunization, in three doses, is the most effective means to prevent HBV-related liver disease. Since HBV can lead to liver cancer, the vaccine is considered the first “anti-cancer vaccine.” The immunization strategy to eliminate HBV transmission in the United States is to:
· Screen all pregnant women to prevent infection of infants
· Routinely vaccinate all infants
· Provide catch-up vaccination for children and adolescents. Hepatitis B vaccination is especially important for adolescents because approximately 9% of hepatitis B occurs in adolescents and an additional 45% in persons aged 20 to 29 years. 4
In California, prenatal testing of mothers and immunization of newborns are required. Since 1999, all California children entering seventh grade have been required to receive the hepatitis B immunization series. Children under age 19 are eligible to receive federally-provided vaccine.
While immunization rates in California are increasing, many target groups have not been immunized. Surveys performed in 1999 in San Diego County indicated that over 68% of seventh graders had received the recommended three doses of hepatitis B vaccine.1 However, just 33% of students in eighth through twelfth grade had completed the hepatitis B series. Because of the potential for infection transmitted from infected household members, unvaccinated API children remain at higher risk compared to non-API children for HBV infection into adolescence.
The Hepatitis B Prevention Project will provide HBV testing and vaccination for San Diego’s Asian and Pacific Islander adolescents and young adults who have not been vaccinated under recent school immunization requirements.
PROJECT GOAL AND OBJECTIVES
The goal of the Hepatitis B Prevention Project is to decrease the incidence of hepatitis B and resulting liver disease in San Diego Asian and Pacific-Islander communities. The objectives of the project are to:
1. Increase community awareness of the importance of hepatitis B immunization in the target communities, as determined by pre and post community survey.
2. Improve the knowledge of physicians and other health professionals about hepatitis B, especially as related to high-risk populations such as Asians and Pacific Islanders, through clinic inservices and two educational symposia for physicians in the target areas.
3. Test API adolescents and young adults ages 12 to 25, and provide the vaccine series as appropriate to those not infected or naturally immune.
4. Identify infected persons in the target group who will receive appropriate treatment or health education through referral and provider education programs.
Specific project activities to be carried out by staff and partners are:
1. Increasing Community Awareness of Hepatitis B Immunization. Project staff and partners will coordinate to promote awareness in the target communities of the importance of hepatitis B testing and immunization. Outreach will be conducted by the Union of Pan Asian Communities. The Outreach Coordinator will work with Asian and Pacific Islander community organizations to reach parents of children over age 12 as well as young adults.
2. Improving the Knowledge of Physicians and Other Health Professionals. A critical component of project success will be to educate physicians and other health care providers about hepatitis B testing and immunization, especially as related to the high-risk status of their Asian and Pacific Islander patients. The Project Coordinator will work with health plans, health systems and provider networks to reach providers with brief, focused information bulletins on recommended testing and immunization practices. The San Diego County Division of Sexually Transmitted Diseases (STD) and Hepatitis Prevention will distribute a Physicians Bulletin for countywide distribution.
In addition, a two-hour seminar will be presented to physicians, nurses, and other providers who have Asian and Pacific Islander patients. The seminar will feature Son Do, M.D., Chair of the Hepatitis B Task Force, Focus on Asian Pacific Islanders, who will present an overview of hepatitis B epidemiology, health education, treatment options, and current research.
3. Testing and Immunizing API Adolescents and Young Adults. The hepatitis B vaccine provides protection to those who are not infected. In the high-risk API population, hepatitis Bprevention must include specific blood testing to screen for those already infected. Administration of the anti-HBc as the initial single marker test will determine if a person needs to complete the hepatitis B series. On individuals who have anti-HBc positive tests, the HBsAg and anti-HBs tests will be ordered (possibly on the same blood sample). Test results will indicate if they need to be referred to health centers or private physicians. Testing is less expensive than immunization, so identification of those not needing vaccine can be cost-effective. In addition, federally-provided vaccine is available at no cost for children up to age 19, approximately 50% of the target group.
Public education and outreach efforts will guide the target population to access testing and vaccination through their primary care providers, the participating community clinics, or the Asian Pacific Health Center. Many of the uninsured can be tested and immunized under California’s Family PACT (Planning, Access, Care, Treatment) family planning program. (The PACT program serves low income, uninsured clients at risk for pregnancy or causing a pregnancy. Its services include prevention and treatment of sexually transmitted diseases, including hepatitis B.)
4. Treatment or Health Education for Infected Persons. Based on incidence data, it is expected that up to 15% of those tested will be found to be infected with hepatitis B. These persons will be referred for follow up, treatment and health education to their primary care physician. Those who have no primary care physician or health insurance will be referred to a community health center, a health care provider in the targeted communities, or the Asian Pacific Health Center. Some of them will be appropriate for referral to the University of California, San Diego, Liver Center, for enrollment in clinical trials.
ORGANIZATION AND PARTNERSHIPS
- The Asian Pacific Health Center will be responsible for project implementation and coordination. APHC, located in the mid-city area of San Diego, provides low-cost, family-centered health services to persons who may not otherwise have access because of financial, language, cultural or psychological barriers. APHC’s services include primary medical care, minor surgery, health education, acupuncture, and laboratory services. In addition to acting as lead organization for the project, APHC will provide testing, immunization, health education and treatment for those without another source of health care. Project staff will be located at the APHC facility. Ton Tran, M.D., will direct clinical and provider education activities and interact with physicians for patient referral. Binh Tran, Pharm.D., will provide administrative oversight of project operations and supervise staff.
- The Community Health Group Foundation, a 501(c)(3) organization, will be fiscal agent for the project. The purpose of the CHG Foundation is to provide care and services to the community that supplement or complement services provided through traditional health insurance. Glenn Perelson, M.D. will be medical liaison between the project and Community Health Group. He will assist with use of CHG personnel resources (such as public relations, network relations, and provider education) and will oversee the CHG Foundation’s fiscal agency for the project.
Other Project Partners: The Hepatitis B Prevention Project will bring together the resources of a variety of community and health agencies. Although they share common missions and serve many of the same communities, many of these agencies have not worked together before. An important capacity-building benefit of the project will be to combine resources and strengthen working relationships, forming the basis for other future partnerships.
- Community Health Group: While its foundation will be fiscal agent, CHG has also pledged to share its organization resources for project support. These resources include public relations, media relations, outreach, public education, provider education, and linkage to traditional and safety net providers, county health collaboratives and school health programs. CHG has provided financial support to project planning.
- Community Health Improvement Partners: CHIP is a collaboration of San Diego health care systems, hospitals, community clinics, insurers, physicians, schools, universities, community benefit organizations and the County of San Diego formed to increase awareness of and responsiveness to community health needs and expand coordination among health improvement projects throughout the San Diego region. CHIP will assist with community and provider awareness and information on healthcare resources.
- Pharmaceutical Companies: Financial support, particularly for provider education and possibly for vaccine, will be solicited from pharmaceutical companies producing hepatitis B vaccines or treatments.
- San Diego County Department of Health, Division of STD and Hepatitis Prevention: Physicians’ Bulletins will be a broad communications channel for messages about HBV immunization. In addition, the County is a means of obtaining free vaccine for children under age 19 through the Vaccine for Children program.
- San Diego Hepatitis Community Consortium: The Consortium is a group of professionals working to address the prevention and treatment of viral hepatitis in San Diego County. Its members include public health officers, liver disease specialists, researchers, epidemiologists, and representatives of alcohol, drug and STD treatment programs. Participant agencies will be enlisted to coordinate services and education efforts for the project.
- Stanford Asian Liver Center: The Center’s Jade Ribbon campaign and community awareness materials, available in Asian languages, will be used for public education and distributed to project partners.
- Union of Pan Asian Communities: Since 1974, UPAC has been the primary provider of human care services to San Diego’s Asian and Pacific Islander communities. UPAC’s mission is to meet the social, psychological, physical, and economic needs of San Diego’s population. UPAC will conduct project outreach to promote awareness of the special importance of hepatitis B testing and immunization for Asians and Pacific Islanders.
- University of California, San Diego, School of Medicine Liver Center: The UCSD Liver Center offers specialized care in the treatment of acute and chronic liver disease, managing the full scope of liver disorders from early stages through transplantation. The Center is actively involved in clinical and basic research projects for a wide variety of liver diseases, including viral hepatitis, liver failure and liver cancer. Patients with liver disease identified through the Hepatitis B Prevention Project may benefit from referral to the Liver Center for enrollment in appropriate clinical studies.
- Vietnamese Physicians Association and Other Asian Providers: Because the project focuses on Asians and Pacific Islanders, Asian providers will be especially targeted for provider education, community education, and patient referral activities.
RELEVANCE OF PROJECT TO COMMUNITY PRIORITIES
The Hepatitis B Prevention Project addresses the communities main objectives:
· Access: The project will outreach to community members to bring them into an entry point (APHC, community health centers, or private physicians) for testing and immunization, and referral to care if appropriate. For many of them, access to testing will link them to a medical home. As indicated by the list of project partners, a wide variety of existing public and private resources will be brought together to focus on the problem of hepatitis B in the target populations.
· Health and Well-Being: The project is designed to reduce the impact of hepatitis B and the chronic liver disease that it causes. Those who are found to be already infected will be referred for health education to address behavioral issues. The project will replicate the successful Jade Ribbon Campaign to increase community awareness of the importance of hepatitis B immunization.
· Multicultural Health: The project uses existing culturally competent resources (the Asian Pacific Health Center, Community Health Group, the community health centers, the Union of Pan Asian Communities, Asian student groups, etc.) to address the health disparity of hepatitis B and resulting liver disease in Asians and Pacific Islanders. The implementation of the project will strengthen working relationships among the partners for future collaboration to address the health of these communities.
CONCLUSION
REFERENCES
1. Much of the data presented in this background discussion was provided by the National Task Force on Hepatitis B Immunization: Focus on Asian Pacific Islanders. www.aapihp.com/hepbtf
2. Stanford Medical Staff Update: June 2001, pp. 5, 10.
3. National Task Force on Hepatitis B Immunization: Focus on Asian Pacific Islanders. www.aapihp.com/hepbtf
4. Hepatitis Surveillance Report. US Department of Health and Human Services, Public Health Service, 2000 (no. 57). Quoted in MMWR Weekly, August 10, 2001, 660-3.
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