Addressing Hepatitis B: Community Health Centers, Partnerships and the Affordable Care Act

Abstract

Addressing Hepatitis B:Community Health Centers, Partnerships and the Affordable Care Act Corinna Dan, RN, MPH (bio), Kenneth Tai, MD (bio), Su Han Wang, MD, MPH (bio), Jeffrey Caballero, MPH (bio), Melinda Martin, MPH (bio), Stacy Lavilla, MS (bio), and Nina Agbayani, RN (bio) Hepatitis B virus (HBV) infection is a major preventable health problem in the U.S. and the most pronounced health disparity disfavoring Asian Americans and Pacific Islanders (AAPIs). Despite constituting only 5% of the U.S. population, AAPIs account for at least 50% of all individuals with chronic HBV infection. Additionally, rates of liver cancer, often caused by chronic HBV are up to 13 times higher in some AAPI subgroups than average.1 Vaccination, testing, and treatment tools needed to eliminate new HBV infections and prevent liver disease and liver cancer caused by chronic HBV infection exist, but these tools are inadequately implemented. Uncoordinated programs, sparse federal funding, high rates of uninsurance, language barriers, and low levels of awareness among the public and health care providers, are all barriers preventing effective implementation of these tools in AAPI communities. A limited number of programs demonstrating effective public health and primary care collaborative efforts also exist, but support to replicate these programs is needed. Asian Americans and Pacific Islander communities with high rates of hepatitis B infection must mobilize, work with public health and primary care systems, and capitalize on opportunities such as the new Viral Hepatitis Action Plan (Action Plan) and the Patient Protection and Affordable Care Act (ACA) to eliminate HBV and liver cancer. It is estimated that two billion people worldwide are exposed to HBV and 350 million are chronically infected.2 In the U.S., the Centers for Disease Control and Prevention (CDC) estimate that 800,000-1.4 million people (or up to 0.4% of the total population) [End Page 507] are chronically infected. Chronically infected individuals often have no symptoms until they are diagnosed with liver disease or cancer. U.S studies show that in AAPI communities, 4-25% are chronically infected with HBV, with variation depending on country of birth and age;3 these are rates 10-62 times higher than the general population. Exposure to the virus through contaminated blood or bodily fluids can lead to acute or chronic infection. Perinatal transmission from an infected mother to her infant at the time of birth accounts for a majority of infections in countries with high rates of infection including a majority of countries in Asia. In the United States, new infections have dropped significantly since universal perinatal HBV screening and infant vaccination was recommended in the early 1990s. Hepatitis B vaccine is also recommended for adults at risk including household and sexual contacts of chronically infected individuals. Despite these effective interventions, some 1,000 infants and 43,000 adults are newly infected every year.4 In addition, an estimated 40,000-45,000 chronically infected individuals migrate to the U.S. from HBV endemic countries every year3 increasing the number of infected individuals in the U.S. A 2010 Institute of Medicine report, Hepatitis and Liver Cancer, A National Strategy for Prevention estimated that 65% of people with chronic HBV are unaware of their status and that ring vaccination (vaccination of close contacts of those infected) is cost-effective.5 Hepatitis B is an infectious disease, a public health problem, and an issue for health care providers. Despite notable strides in children vaccination and efforts to prevent transmission to infants, much needs to be done for chronically infected mothers and other adults. Dedicated funding is still needed for adult vaccination, testing, management or treatment for HBV. Because public health has ineffectively tested or cared for chronically infected people, it is clear that additional partnerships and collaboration are needed to eliminate HBV. Opportunities. In recent years, there has been greater recognition of HBV and a range of opportunities that can lessen its impact on AAPI communities. National laws such as the ACA, as well as new studies and renewed commitment from federal agencies such as the U.S. Department of Health and Human Services (HHS) are promising developments that could change how HBV is prevented and treated. The ACA overall...