karen e. kim, md professor of medicine dean for faculty ... · karen e. kim, md professor of...

Karen E. Kim, MDProfessor of Medicine

Dean for Faculty AffairsDirector, Center for Asian Health Equity

University of Chicago

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• 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/index.htm.

2. Perz. J Hepatol 2006;45(4):5293. McGlynn. Clin Liv Dis 2015;19(2):223

4. McMahon. Hepatol 2009;49(Suppl 5):S455. Beasley. Hepatology. 1982;2(5):5536. Qian. Cancer Epidemiol Biomarkers Prev 1994;3(1):3

Race/Ethnicity 2010 Rate

2011 Rate

2012 Rate

2013Rate

White, non-hispanic 0.34 0.32 0.31 0.33Black, non-Hispanic 0.94 0.98 0.81 0.98Hispanic 0.43 0.48 0.39 0.39Asian/Pacific Islander 2.95 2.72 2.93 2.64American Indian/Alaskan Native

0.73 0.38 0.74 0.55

Overall 0.52 0.52 0.50 0.52

2.95

2.72

2.93

2.64

1. CDC. Surveillance for Viral Hepatitis – United States, 2013.

HBV-RELATED DEATHS BY RACE/ETHNICITY

CDC, 2006

Hepatitis B Incidence Among Persons ≥19 YrsBy Race/Ethnicity, 1990-2004

0

5

10

15

20

19

90

19

91

19

92

19

93

19

94

19

95

19

96

19

97

19

98

19

99

20

00

20

01

20

02

20

03

20

04

Year

Ca

se

s/1

00

,00

0

Asian/Pacific Islander

AI/AN

Black

Hispanic

White

Overall decline ~ 75%Decline among API ~ 85%

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: FUNDINGVIRUS Prevalence

(millions)% unaware

Deaths 2006

Vaccine CDC budget 2010

$ per pt

HBV 0.8-1.4 65% 3,000 YES

HCV 2.7-3.9 75% 12,000 NO

HBV/HCV

3.5-5.3 15,000 24Million

$4/pt

HIV 1.1 21% 14,016 NO 1.2Billion

$1000/pt

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Disproportionate disease burdenLack of data

Lack of awarenessLack of Resources

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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.

• Multisector Partnership– Local government– Providers– Community based organizations– Academic centers– Ethnic media

• Evidence based interventions and strategies

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Provided funding for community-based 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

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Collaborations with local, city and state government agencies

• CDC (funded since 2008)• Beijing center grant• CDC Conference Grant• AHRQ R24-Partnership for Healthier Asians• NCI P20

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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 56 49 32 47 47 33 264

Number of Health Fair Events 0 9 8 12 15 19 63

Number Referred for Screening/ Immunization

1,432 3,770 3,318 5,672 3,105 197 17,494

Adults Screened 405 601 576 370 611 676 5,139

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• In 2012, AHC awarded CDC Cooperative Grant to conduct HBV surveillance and screening in Chicago Metropolitan area.

Project Phoenix

Screenings performed

1174

Screeningsavailable for

analysis

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)

Community-based Organizations (CBOs)

HPNs

CHWs

• 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 PercentNotified 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

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DIALOGUE FOR ACTION