Access to Care and Optimal Treatment of Chronic Hepatitis B in Asian Americans: An Evolving Agenda

Abstract

Chronic hepatitis B (CHB) is an important public health problem and a leading cause of liver-related morbidity and mortality worldwide, particularly in the Asia Pacific region [1]. In the US, it has been estimated that 1.25 million individuals, or 0.4% of the population, are infected with the hepatitis B virus (HBV) [2]. However, during the past two decades, a large number of foreign-born persons have immigrated to the US from areas where the prevalence rate of chronic HBV infection is high, including, in particular, Asia, but, also, the middle East and Africa. This pattern of immigration has contributed to an increased prevalence of chronic HBV infection, which is evident in urban areas and communities with a high Asian immigrant population. Screening programs conducted on Asian Americans in San Francisco and New York City showed that approximately 10% of newly tested persons have chronic HBV infection [3, 4], leading to a revised estimate that 2 million people in the US have chronic HBV infection [5]. A recent encouraging study of trends in the prevalence of HBV infection in the US shows that the HBV prevalence rate decreased among children, which reflects the impact of global and domestic vaccination programs; however, the prevalence rate of chronic HBV infection changed little among adults [6]. Many of these adults are Asian Americans whose cumulative rate of morbidity and mortality from cirrhosis and hepatocellular carcinoma (HCC) is high, based on their infection as neonates or in early childhood [1]. Thus, it is timely that two articles in this issue of Digestive Diseases and Sciences address the challenges of increasing the detection rate of HBV infection in Asian Americans and proposes a consensus recommendation for the treatment of Asian Americans with CHB [7, 8]. Hu et al. [7] point out that the Asian American immigrant population is rapidly expanding in the US and is projected to continue this pace of growth. Routine screening for HBV infection can identify those Asian Americans who are infected and potential candidates for antiviral therapy and/or routine surveillance for HCC, as well as those without infection or immunity, who should undergo vaccination. The excellent review by Hu et al. [7] describes a number of factors that are potential obstacles to screening for hepatitis B in the Asian American population, including patient barriers (lack of knowledge of hepatitis B, limited English language proficiency, cultural beliefs, social stigma, and perceived costs), provider barriers (underestimate of the risk of HBV infection in Asian Americans, incorrect use of screening tests, and lack of knowledge regarding the cost-effectiveness of screening and the availability of safe and effective therapy), and healthcare system barriers (difficulty navigating the healthcare system and lack or underutilization of health insurance). This article also coincides with a burgeoning national awareness of the importance of HBV infection to public health that has led to the publication of a national strategy for the prevention and control of hepatitis B (as well as chronic hepatitis C) by the Institute of Medicine [9]. In response to this report, the US Department of Health and Human Services issued on May 12, 2011 its action plan: Combating the Silent Epidemic of Viral Hepatitis. Action Plan for the Prevention, Care and Treatment of Viral Hepatitis [10]. The preamble to this report emphasizes that 65–75% of infected Americans remain unaware of their viral infection, which is largely preventable. For the first E. B. Keeffe (&) Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University Medical Center, 750 Welch Road, Suite 210, Palo Alto, CA 94304-1509, USA e-mail: ekeeffe@stanford.edu