Activity 5: Achieving health equity to eliminate racial, ethnic, and socioeconomic disparities in HBV-and HCV-associated liver disease

Professor of Medicine, Baylor College of Medicine, Chief of Gastroenterology and Hepatology, Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, Texas

Senior Investigator, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, Maryland

Deputy Assistant Secretary for Minority Health, Office of Minority Health, Department of Health and Human Services, Rockville, Maryland

Director, Asian Liver Center, Director, Liver Cancer Program, The Lui Hac Minh Professor of Surgery, Stanford University School of Medicine, Stanford, California

Professor of Medicine, Director, Hepatology Research, University of Maryland Medical Center, Baltimore, Maryland

Director, Asian Week Foundationm Steering Committee Member, San Francisco Hep B Free, San Francisco, California

Cocoordinator/Secretary, National Task Force on Hepatitis B; Focus on Asian Americans and Pacific Islanders, St Paul, Minnesota

Chair and CEO, Hepatitis Foundation International, Silver Spring, Maryland

Despite the overall success in the fight against viral hepatitis, there remain racial, ethnic, and socioeconomic disparities in the incidence and prevalence of acute and chronic viral hepatitis, the outcomes of chronic viral hepatitis, and health care access and quality. Numerous federal and community initiatives are aimed at overcoming these discrepancies.

  Disparities in disease outcomes and treatment of viral hepatitis

Minority populations in the United States are disproportionately affected by acute and chronic viral hepatitis.¹ For example, African Americans bear a disproportionate burden of new hepatitis B virus (HBV) infections, with an incidence of 2.2 cases/100,000 population in 2007. This is higher than all other racial and ethnic groups.² The prevalence of HBV infection among African Americans is also higher than among whites, while the prevalence of hepatitis C virus (HCV) infection is higher among African Americans than among non-Hispanic whites and Mexican Americans.³

Of the roughly 4 million noninstitutionalized/nonhomeless Americans infected with HCV, 920,000 are African American,³ accounting for 23% of the disease burden, while representing approximately 13% of the population. There is less information available regarding incidence and prevalence of viral hepatitis among Hispanic Americans, but 260,000 Mexican Americans are infected with HCV, accounting for about 6% of the disease burden.³ The strongest risk factor for HCV infection is injection drug use.³

Outcomes

Although mortality rates from chronic liver disease and cirrhosis have declined since 1985, they remain the ninth leading cause of death in the United States. The highest mortality rate from liver disease resulting from all causes occurs in American Indians and Alaska Natives (22.6/100,000), followed by Hispanics (13.9/100,000), white non-Hispanics (9.2/100,000), African Americans (7.7/100,000), and Asians or Pacific Islanders (3.6/100,000).⁴ Regardless of racial or ethnic group, mortality rates from chronic liver disease are twice as high among males than among females.⁴

Chronic HCV. A study of HCV mortality (ie, deaths related to HCV as a contributing or underlying cause) found that the overall mortality rate among HCV-infected individuals more than doubled from 1995 to 2004, and that the greatest increases in mortality occurred among non-Hispanic blacks and American Indians/Alaska Natives (FIGURE 1).⁵

Hepatocellular carcinoma (HCC). Cirrhosis, chronic HBV infection, and HCV-related cirrhosis are the major risk factors for the development of HCC, the most common type of liver cancer.⁶ Incidence rates of HCC have tripled from 1975 to 2005, with marked recent increases among middle-aged African American males, Hispanic males, and white non-Hispanic males.^7,8 Asians/Pacific Islanders had a higher incidence rate and mortality rate than other racial and ethnic groups but experienced a smaller annual percent change in HCC incidence rates, compared with other racial ethnic groups.⁸ Moreover, while Asians and Pacific Islanders make up approximately 5% of the total population, this group accounts for 24% of all HCC cases in the United States.⁹

FIGURE 1 Annual age-adjusted HCV mortality rates and 95% confidence intervals by race/ethnicity, 1995-2004

AI/AN, American Indian/Alaska Native; HCV, hepatitis C virus; PI, Pacific Islander; PY, per year. Wise M, et al. Hepatology. 2008;474:1133. Reprinted with permission.

There is considerable variability in the etiology of HCC among different racial and ethnic groups. In a study of the Medicare population, the dominant risk factor for HCC for Asians was HBV infection, for African Americans it was HCV infection, and for non-Hispanic whites it was diabetes mellitus.⁹ With the exception of Asians, alcohol-related conditions were the second leading factor (FIGURE 2). Attributable risks may explain about two-thirds of HCC cases, but this proportion varies by race and ethnicity. Almost half of the cases of HCC occurring among African Americans and about one-third found among Asians are not explained by known risk factors.

Figure 2 Attributable risks of HCC factors by racial/ethnic group: Seer-Medicare, 1991-2005

HBV, hepatitis B virus; HCC, hepatocellular carcinoma; HCV, hepatitis C virus; SEER, Surveillance, Epidemiology, and End Results Program. McGlynn, KA. Presented at: The Dawn of a New Era: Transforming Our Domestic Response to Hepatitis B&C; September 10-11, 2009; Washington, DC.

Health care access and quality

Disparities in health care access and quality based on race, ethnicity, and socioeconomic status persist¹⁰ and have been documented for African Americans and Hispanics, compared with non-Hispanic whites.¹¹

Hepatitis treatment. African Americans infected with HCV genotype 1 are less likely to receive treatment than their white counterparts.¹² Disparities in the evaluation and management of HCV infection based on race are independent of the health care system and payer status.^12,13 For example, African Americans and whites evaluated at Veterans Affairs Medical Centers were equally likely to be referred for HCV treatment and to have biopsies, but African Americans were less likely to actually receive treatment.¹⁴ Nontreatment was also associated with increasing age, alcohol dependence, drug use, and medical and psychiatric comorbid illness.

HCC and liver transplantation. African Americans have a more advanced HCC tumor stage at diagnosis and are less likely to receive local or surgical therapy than whites, even when the tumor is localized to the liver.¹⁵ Researchers have also cited a large number of disparities in access to and outcomes of liver transplantation between African Americans and whites. African Americans are underrepresented on the United Network for Organ Sharing liver transplantation waiting list.¹⁶ When they are listed, African Americans have more advanced disease than whites, suggesting a delay in referral.^16,17 In addition, African Americans are less likely to receive live-donor transplantation, have a lower survival rate after transplantation, and experience a higher rate of graft loss.¹⁸ More studies are needed to evaluate medical center and geographic effects on racial and ethnic variation in survival, graft failure, and quality of life. Racial and ethnic variation in posttransplant outcomes may be related in part to differences in immunosuppression pharmacokinetics and adherence.¹⁹

At-risk populations

There are insufficient data to fully explain the racial and ethnic disparities in hepatitis infection and outcomes. It is clear that many interrelated factors are involved. One reason for the racial disparity in HBV disease is high rates of exposure and low rates of immunization among African Americans at high risk. Thus, while universal vaccination of children and adolescents is closing the HBV gap between African Americans and other racial and ethnic groups, current immunization strategies have not sufficiently penetrated the populations at highest risk,²⁰ which include injection drug users.

Similarly, the risk of HBV (and HCV) infection is high among the incarcerated. African Americans and Hispanics are overrepresented in the incarcerated population.²¹ Young adults (25-45 years old) who have been incarcerated or who engage in high-risk behavior are the cohort that needs to receive HBV vaccination.²² Socioeconomic status also impacts the epidemiology of viral hepatitis. Lower income levels have been associated with a greater likelihood of infection with HBV or HCV.²³

There are also differences in the natural history of chronic hepatitis and the efficacy of therapy among minorities. For example, Hispanics have a higher frequency of cirrhosis than African Americans and trend toward more cirrhosis than non-Hispanic whites.²⁴ The need for more effective HCV treatments is pressing, especially in minority populations, because the response to combination therapy of pegylated interferon and ribavirin (standard therapy for HCV infection) is lower for African Americans and Hispanics compared with non-Hispanic whites.^25,26 Also, African Americans and Hispanics are underrepresented in clinical trials for novel antiviral therapies.

Eliminating disparities

Disparities in morbidity and mortality associated with HBV and HCV infections according to race, ethnicity, and socioeconomic status must be recognized by primary care providers. Government and community initiatives are also crucial for overcoming these disparities. While the following discussion focuses on HBV infection, the need to address HCV infection is no less important. Screening of individuals at risk for HCV infection, followed by evaluation of and care for those infected, is the central secondary prevention strategy for HCV infection.

Government initiatives

Federal agencies are working to address the disproportionate burden of viral hepatitis, liver disease, and liver cancer among patient subgroups. The Office of Minority Health (OMH) advises the Office of the Secretary of the US Department of Health and Human Services and the Office of Public Health and Science on public health program activities that affect minority populations. In addition to racial and ethnic minorities, the OMH serves a broad cross section of underserved populations, including those with limited English proficiency.

In 2007, the Centers for Disease Control and Prevention (CDC), in collaboration with state and local health agencies, launched the Adult Hepatitis B Vaccination Initiative. The initiative targets high-risk individuals and vaccination clinics in high-risk areas and supports increased education of health care providers.²⁰

Community initiatives

Community HBV initiatives play an important role in increasing grassroots and health care provider awareness of HBV disease by offering the opportunity for screening, vaccination, and referral for care. They also play an important role in advocacy at the local, state, and national levels.

Within the Asian/Pacific Islander communities, several initiatives have demonstrated success in increasing HBV awareness, screening, diagnosis, and treatment, in addition to effecting change at the legislative level.

The Jade Ribbon Campaign. The Jade Ribbon Campaign, launched in 2001 by the Asian Liver Center (ALC) at Stanford University, is a culturally and linguistically targeted awareness campaign that unites health care providers, community organizations, policy makers, and the media. From 2001 to 2006, 3163 Asian/Pacific Islander adults were screened at community centers for hepatitis B surface antigen (HBsAg) and its antibody (anti-HBs).²⁷ Of the 8.9% who were HBsAg-positive, two-thirds were unaware of their infection. Of those who said that they had been vaccinated, 5.2% were HBsAg-positive.²⁷ The efficacy of the Jade Ribbon Campaign was studied in a group of 476 Chinese Americans who attended a 5-hour screening and education event. Even though 80% of the participants reported attaining a college degree or higher, 45% reported that the Jade Ribbon Campaign was their only source for learning about HBV disease.²⁸ Although 86% had health insurance and 74% had a regular physician, 71% of attendees said that their physicians had never spoken to them about HBV.²⁸ A 1-year follow-up survey of 309 of the 476 participants showed that two-thirds of HBsAg–positive individuals had received care for chronic HBV or were screened for liver cancer, and 78% heeded the recommendation to have family members tested.²⁸

The Hepatitis B initiative. The Hepatitis B Initiative is an outreach program that has partnered with 9 Asian churches in the Baltimore and Washington, DC, metropolitan areas to provide faith-based HBV education, testing, and vaccination. As part of the program, 1775 people were tested for HBsAg and anti-HBs from 2003 to 2006; of those, 2% were found to be HBsAg–positive, and 61% were unprotected. Of those unprotected, 79% completed the 3-shot HBV vaccine.²⁹

San Francisco Hep B Free. San Francisco Hep B Free is the nation’s first citywide campaign to test Asian/Pacific Islander adults for HBV infection and offer vaccination. During its first 18 months, approximately 3000 people were screened, and 663 health care providers attended continuing medical education courses.³⁰

Asian American Hepatitis B Program/BFreenYC. New York City funded the Asian American Hepatitis B Program, which provided $9 million in grants over 3 years. Among 925 new participants screened during a 6-month period, 14.8% were HBsAg-positive.³¹ The program was expanded and renamed BFreeNYC to serve other populations at risk for HBV, including recent immigrants from Eastern Europe, Africa, the Caribbean, and Latin America. Since 2004, the program has screened over 8000 people and vaccinated approximately 2000.

3 For Life. Community outreach programs do not have to be free to be effective. A fee-for-service, community-based pilot program (a partnership between the ALC, the San Francisco Department of Public Health, and a community YMCA) called 3 For Life targeted Chinese Americans and attracted 1206 participants. Of unprotected adults, 85% were vaccinated as a result of the program.³²

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