Family Physicians' Knowledge and Screening of Chronic Hepatitis and Liver Cancer

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• Open Access
• Published: 15 August 2016

Chronic hepatitis B in Korean Americans: decreased prevalence and poor linkage to care

BMC Infectious Diseases volume sixteen, Article number:415 (2016) Cite this article

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Abstract

Groundwork

Chronic hepatitis B virus(HBV) infection is a major cause of liver related morbidity and mortality. HBV infection remains largely underdiagnosed in Asian American population, and information technology is also poorly linked to clinical care. We, therefore, assessed the HBV prevalence and evaluated linkage to care among Korean Americans in order to develop strategic plans to reduce the impact of HBV in a high take a chance customs.

Methods

Serologic screening and survey were provided to 7157 Korean American adults (age 21–100) in New Bailiwick of jersey between December 2009 and June 2015. All participants were tested for hepatitis B surface antigen (HBsAg), hepatitis B surface antibody (anti-HBs), and hepatitis B core IgG antibody (anti-HBc). Additional survey was conducted on the subjects chronically infected with HBV on their history of infection. Self-administered questionnaires were employed to evaluate demographic and epidemiologic characteristics.

Results

Of those 7157screened, 171 (2.4 %) were HBV infected, 2736(38.two %) were susceptible to HBV, and 4250(59.4 %) were immune. The prevalence of chronic HBV varied between the age groups: 1.18 % (age21-thirty); 2.53 % (age 31–xl); 2.76 % (historic period 41–50); ii.90 % (age 51–60); 2.06 % (historic period 61–70); and 1.37 % (age 71–100). The charge per unit of HBsAg was significantly college in males (3.04 %) every bit compared to females (one.93 %). At to the lowest degree 75 % of these HBV infected subjects had been previously diagnosed, but were not engaged in care.

Decision

This screening written report suggests that the HBV prevalence in Korean Americans is significantly lower than currently understood. On the other hand, many of the individuals chronically infected with HBV cannot access care, suggesting a poor linkage-to-care (LTC). Further, a large percentage of the population is still susceptible to HBV. Report findings volition be used to develop strategies to tailor community-based HBV screenings and LTC to the high chance populations.

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Background

Chronic hepatitis B (CHB) is a serious global health consequence affecting more than 240 million people. Approximately 25 % or more of these CHB patients may eventually suffer from liver cirrhosis, primary liver cancer or other complications of CHB [ane–4]. In that location are three major issues regarding CHB today. First, numerous people have not been screened and thus are not aware of the fact that they are infected [5, 6]. Second, despite the availability of vaccine since early 1980s, many are notwithstanding at risk and require vaccination [6, vii]. Third, even with the availability of constructive antiviral treatment for CHB, a majority of the CHB treatment candidates are non linked to acceptable care [viii–eleven].

There is a marked disparity between different racial and ethnic groups in the prevalence of CHB and its complications. For instance, 5–10 % of all Asian Americans take HBV infection every bit compared with 0.2 % of Caucasian Americans [3, five]. In the United States lonely, an estimated two million people are chronically infected with HBV. Nigh 70 % of these HBV infected individuals are unaware they have the virus. Furthermore, less than 10% of patients who may demand treatment in the United States are currently receiving antiviral medication. Thus, hepatitis B is non merely significantly underdiagnosed, only it is also undertreated [half-dozen, 7].

The fact that the majority of the people chronically infected with HBV are not enlightened of their infection clearly demonstrates that there are barriers to screening in the Usa. The barriers to screening are multi-factorial. Patient-related obstacles are mostly consisted of lack of sensation well-nigh the affliction, language and cultural barriers, and financial problems [8, 12]. Additionally, providers and healthcare organization currently available in the US lack the understanding of the significance of CHB. To be specific, there is a lack of public health systems to come across the needs of multicultural populations [9, 13]. There is likewise a poor communication betwixt providers and patients of dissimilar racial, indigenous, or cultural backgrounds. Last but not to the lowest degree, there is a significant lack of cross-cultural training in health professionals [xi, 14, 15]. As a result, in that location is a serious lack of adequate health access models bachelor for minority populations.

New Jersey and its vicinity are heavily concentrated with Asian Americans, many of whom are currently infected with HBV. Despite a rapidly growing population of Korean Americans in New Jersey, a majority of these people accept non been accessed past the currently available HBV screening program. During the flow betwixt Dec 2009 and June 2015, Eye for Viral Hepatitis (CVH) and Asian Liver Center (ALC) of Holy Name Medical Center carried out a total of 128 community outreach HBV screening events in Cardinal and Northern New Jersey. Serologic screening and survey were provided to a full of 7199 Korean American adults (mean age 52) throughout these events. All the participants were tested for hepatitis B surface antigen (HBsAg), hepatitis B surface antibiotic (anti-HBs), and hepatitis B core IgG antibody (anti-HBc).

This report and the results of other recent studies conspicuously suggest that the reported prevalence of hepatitis B among Koreans in both Korea and the United States may be college than the true prevalence [16, 17]. The results of the current report too indicate an urgent demand to meliorate vaccination and LTC to prevent HBV- related liver disease and cancer.

Methods

Study design

A large scale customs-based Hepatitis B Screening and Awareness Entrada was led by CVH and ALC of Holy Proper name Medical Centre in the country of New Bailiwick of jersey. CVH and ALC are ii major not-profit organizations devoted to promoting CHB screening and linkage to intendance in Asian American community. All our staff were consisted of community physicians with expertise in the field of CHB, nurses, and community volunteers. CVH and ALC have collaborative human relationship with local hospitals, community organizations and physicians to work cooperatively in a multidisciplinary manner to ensure the highest quality of care for screening, education, vaccination, and linkage to care for the individuals chronically infected with HBV.

Our hepatitis B campaign consisted of a total of 128 community outreach screenings and education seminars at various locations throughout Key and Northern New Bailiwick of jersey during the period between Dec 2009 and June 2015. CVH and ALC organized and hosted all the entrada events. A total of 7199 Korean American immigrants were screened for hepatitis B in 98 churches, 12 community centers, and xviii health fairs in five unlike counties of New Bailiwick of jersey. All the HBV infected subjects were referred to specialists inside the community, and those who were not allowed to HBV were vaccinated.

Participant characteristics

All the participants were Korean Americans currently residing in New Jersey. 99.v % of the participants were born in Korea. Their ages ranged from 21 to 100, with a hateful age of 52. A vast bulk (>85 %) of the participants were reported to having lived in the Us for a minimum of ten years. More than than 99 % of the participants preferred Korean as the language for advice.

Serological screening and survey

Hepatitis B Screening included the three following tests: HBsAg, anti-HBs, and anti-HBc (IgG). The claret cartoon and processing were conducted by phlebotomists or registered nurses, and all the results were reviewed by physicians. All the participants who had screening tests were contacted by the following means of communication: telephone and mail service. The participants who did not respond, for instance, were tracked down and were persistently contacted through the means of telephone calls and certified mails.

Self-administered questionnaires were employed to evaluate demographic and epidemiologic characteristics. At the fourth dimension of the screening, participants completed a survey written in both English language and Korean. The items in the survey included gender, date of birth, country of birth, years in the United states of america, and preferred language of communication. All participants provided written informed consent. Some of the screening events also included Hepatitis B sensation seminars and question and answer sessions to accost numerous questions the participants had.

Data analysis

Exact binomial 95 % conviction intervals (CIs) were calculated for prevalence of HBsAg seropositivity. A 2-tailed Fisher'southward exact exam was used to test for differences between frequencies.

Results

Sample demographics

Nosotros conducted a total of 128 screening events in Central and Northern New Jersey between December 2009 and June 2015. Figure 1 shows the age and gender distribution of 7095 participants. Of 7199 screened, 104 were unspecified. The average historic period was 52 years, and 58.iii % were females. Approximately half of the participants belonged to the age grouping of 41–sixty.

Fig. 1

Distribution of the study sample past historic period and gender

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Serological data

Of 7199 Korean Americans screened, the results for 7157 participants were available. Of 7157 participants, 171 (two.4 %) were HBV infected, 4250 (59.iv %) were immune, and 2736 (38.2 %) were susceptible to HBV (Fig. 2). Of 4250 (59.4 %) allowed subjects, 2319 (32.7 %) were recovered from past infection, and 1931 (26.7 %) were vaccinated.

Fig. ii

Hepatitis B status in a Korean American population in New Jersey

Total size image

The prevalence of HBV varied significantly between age groups: 1.18 % (age21-30); 2.53 % (historic period 31–40); ii.76 % (age 41–50); ii.90 % (age 51–60); two.06 % (historic period 61–70); and 1.37 % (age 71–100). The highest HBsAg positive rates are found in the group between age 41 and threescore. To determine a statistical difference between age groups, nosotros compared the HBV prevalence in the youngest age group (historic period 21–thirty) with older age groups. The HBV prevalence in the age grouping of 21–thirty years was significantly dissimilar but from two other age groups (age 41–50 and age 51–60) with the p-values of 0.0436 and 0.028, respectively (Table one).

Tabular array 1 Prevalence of HBsAg seropositivity by age

Full size table

Of 171 HBV infected subjects, all but 3 were built-in in Korea. At that place were 88 males, 81 females, and two unknown. Every bit shown in Fig. 3, the rate of HBsAg is significantly higher in males (iii.04 %) as compared to females (1.93 %) (p = 0.003).

Fig. 3

The prevalence charge per unit by gender

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Infection history of the HBsAg-positive subjects

A survey was carried out to determine how many of these HBsAg-positive subjects might have known their infection condition prior to the current screening (Fig. 4). It showed that out of 171 HBV infected subjects, 128 knew that they were chronically infected prior to the screening, 33 just learned that they were infected, and the remaining 10 were not sure of their hepatitis B status. Of those 128 previously diagnosed subjects, at least 105 accept reported of having immigrated to the Usa before 2000. Most 10 % of these HBV infected subjects take seen physicians for hepatitis B, but none of them engaged in any further work up. A vast majority (>95 %) of these subjects had no symptoms or were non aware of potential complications of hepatitis B such as cirrhosis and liver cancer.

Fig. 4

History of HBV infection in the HBsAg-positive subjects

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Acquisition of immunity

Of 7157 participants screened, a total of 4250 were immune, showing 59.iv % immune rate (Fig. 2). We looked into acquisition of immunity from vaccination versus past infection. Of 4250 immune participants, 1931 participants developed immunity from vaccination, and the remaining 2319 participants developed amnesty from past infection. The ratio of the conquering of amnesty from vaccination to the acquisition of immunity from past infection varied in different age groups. Equally shown in Fig. 5, the bulk of immunity came from vaccination in younger historic period groups (age 21–xl) while the majority of amnesty came from previous infection in older age groups (51–100).

Fig. 5

Conquering of immunity in all age groups. The percentage values correspond pct of participants in each age group

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Lack of immunity in all age groups

Despite the availability of vaccine for over three decades, there were still many subjects who were non allowed to HBV. Of 7157 screened in this report, 2736 participants (38.2 %) lacked protective antibiotic to HBV (Fig. 2). This lack of immunity was apparent in all age groups (Fig. 5).

Discussion

In the current study of our community-based hepatitis B screening entrada, we performed an epidemiologic evaluation on hepatitis B in Korean Americans. On a total of 7157 participants screened between December 2009 and June 2015 from New Bailiwick of jersey, this study shows that the prevalence of CHB in Korean American adults is 2.4 %, which is significantly lower than currently understood [16, 17]. Surprisingly, a bulk of the HBV infected subjects (80.7 %) had non been linked to adequate care for monitoring and handling. In addition, nosotros found 59.4 % every bit allowed and 38.2 % equally susceptible to HBV infection.

Ane noteworthy attribute of this written report is the sit-in of a HBV prevalence of 2.4 % among Korean American immigrants, which is substantially lower than currently believed. The prevalence of chronic hepatitis B infection for Koreans in Republic of korea has been also reported to be equally high as viii % until recent years [16, 17]. In a review of the studies on the Korean American population, nosotros find a trend of decreasing prevalence rates of hepatitis B over the by three decades. A community-based Hepatitis B screening campaign by Hann et al. have evaluated 6130 Korean Americans in eastern United States between 1988 and 1990 and showed a HBsAg positive charge per unit of 6.1 %, with 8 % for males and four.4 % for females [18]. Another customs- based study on 609 Korean Americans in Colorado betwixt 2004 and 2007 revealed a HBV prevalence of iv % [nineteen]. It as well revealed 55 % immune and 41 % susceptible to infection. More recently, a written report on 973 Korean American residents from California, which took place between 2009 and 2010, demonstrated a 3.0 % HBV prevalence rate [xx]. In this study, the allowed rate was higher at 76 %, and only 20 % were susceptible to infection.

The relatively low HBV prevalence constitute in the current written report is coinciding with the results of the recent studies from Korea. In an evaluation of 50,140 Korean participants for HBsAg positivity over a period of 12 years between 1998 and 2010, investigators plant a decreasing rate of HBsAg positivity: 4.61 % in 1998; three.69 % in 2005, and 2.98 % in 2010 [21]. They besides showed that the percentage of HBV infected individuals in the age grouping of ten–twenty years decreased from 2.2 % in 1998 to 0.12 % in 2010. In addition, the per centum of the HBV infected in the age grouping 10–39 years decreased from iv.72 % in 1998 to ii.29 % in 2010. Co-ordinate to these studies, South Korea may belong to low intermediate owned (2-4 %) area as recently reported by CDC Health Information for International Travel 2016 [22].

The decreasing HBV prevalence in Koreans in the United States and Korea may exist largely attributed to HBV immunization programs and other preventive strategies [23]. Korean national Immunization Plan for all neonates began in 1995 to include universal vaccination, regardless of maternal HBsAg status, which helped to forestall both vertical and horizontal manual [23, 24]. Likewise, universal vaccination programs take contributed to the marked decline in HBV prevalence charge per unit in people younger than twenty years of age worldwide [eighteen, 23]. A similar decline in HBV prevalence was reported in Taiwan following its neonatal vaccination program [25]. These are coinciding with results of the electric current study, which show an increased vaccination rate and a decreased HBV prevalence in younger population.

At that place are of import limitations to consider in this study. First, the participants, namely Korean American residents in New Jersey may not exist representative of the overall Korean population in the Us. Education level and socioeconomic condition, for instance, are of import factors known to touch on HBV prevalence [26, 27]. How these factors might have influenced the results of the electric current written report are unknown. Secondly, the age distribution in our study population may not correspond the unabridged population. For example, our study sample under-represents younger age groups relative to the older age groups. Youngest historic period group beneath twenty, who are known to accept a very low HBV prevalence, for instance, are not represented in our study population. Thirdly, information technology is difficult to make up one's mind how the screening rates would have affected the prevalence. For example, many of our study subjects underwent screening knowing their hepatitis B status. If a greater number of HBV infected subjects in proportion to non-infected subjects underwent the screening in this campaign, the HBV prevalence would have been overestimated. Finally, differences in the settings for screening could have affected the prevalence. It should be noted, however, that the non-clinical community settings for screening employed in this study were like to the community settings for screening employed in previous studies which had demonstrated significantly higher HBV prevalence [eighteen, xix].

Although the HBV prevalence is significantly declined, the percentage of the Korean American population susceptible to HBV infection remains high. More than than one 3rd of the participants were susceptible, and this lack of immunity was evident throughout all the age groups (Fig. 5). It is also remarkable to note that a substantial percentage of a younger age grouping (age 21–30) still remains susceptible to HBV infection. In this age grouping, approximately 3.ane % had hepatitis B infection previously, and 59.3 % had detectable anti-HBs level as result of vaccination. Since 5-ten % of the persons vaccinated against hepatitis B may not respond [28], we can estimate that approximately one third of the subjects in this age group are not vaccinated.

Some other noteworthy aspect of this study is the demonstration that a majority of the HBV infected subjects constitute in the electric current campaign had been previously diagnosed (Fig. four). These individuals chronically infected with HBV are not engaged in any care, reflecting a poor hepatitis B LTC in Korean American community. Other investigators have also reported that only a minority of HBV infected people can access care [nine-xi]. In fact, information technology was estimated that only 40 % of the HBV infected subjects screened in community setting were successfully linked to care [10, 11]. These challenges met in LTC are nigh often related to finding qualified providers inside the community, who can provide intendance in a linguistically and culturally sensitive manner. Improvements in patient teaching, counseling, and navigation efforts may likewise be an effective strategy to improve linkages from community-based testing sites to HBV-directed medical care. Considering routine and ongoing monitoring is the foundation for an effective HBV medical management, future efforts to improve outcomes amongst HBV infected people should provide a greater accent on LTC.

This study illustrates how Community-based screening tin can provide an effective screening for CHB in indigenous minority populations, where linguistic communication, civilisation, and financial barriers may foreclose them to access advisable care. At that place are more than several ways community-based health initiatives can be achieved, depending upon who initiates, drives and carries out these initiatives and the degree of their input [29, xxx]. In the current community-based campaign for hepatitis B, individual leaderships and customs organizations carried out the unabridged project with an external fiscal support. We offered comprehensive services including screening programs, educational outreach, vaccination, and a link to community physicians with expertise in hepatitis B care. Of note, our entrada also included instruction seminars and forums for physicians who had greatest contacts with the Asian American customs. In addition to updating physicians on the effective HBV prevention, antiviral treatments and monitoring, these educational activities helped motivate providers to get involved in community outreach. Secondly, nosotros fostered strategic partnerships with cardinal community organizations which promoted customs ownership and sustained engagement of the campaign. As a effect, a full of 160 subjects chronically infected with HBV identified in this campaign were referred to specialists for confirmatory testing, monitoring, and antiviral treatments. Among these HBV infected subjects referred to specialists, 76 % had initial consultations within a 6 calendar month period.

Conclusion

The electric current study on 1 of the largest HBV screening campaigns among Korean Americans demonstrates a significantly decreased HBV prevalence of 2.4 %. The study also reveals a poor LTC for those HBV infected subjects, who require monitoring and/or medical treatments. A comprehensive, community-based screening and evaluation program described in this report may be effectively implemented in other indigenous populations to facilitate hepatitis B care.

Abbreviations

anti-HBc, hepatitis B core IgG antibiotic; anti-HBs, hepatitis B surface antibody; CHB, chronic hepatitis B; HBsAg, hepatitis B surface antigen; HBV, hepatitis B virus; LTC, linkage to care.

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Acknowledgements

The authors acknowledge the work past members and volunteers of the Center for Viral Hepatitis and the Asian Liver Center of Holy Proper noun Medical Center.

Funding

This study was supported by a grant from Gilead Foundation. The fund was used for collection and analysis of the samples.

Availability of data and materials

The information volition not exist made available in club to protect the participants' identity.

Authors' contributions

CSH conceived of the study, participated in the design of the study, and drafted the manuscript. SK and SYK participated in the design of the study and performed statistical analysis. SJ and SL participated in its coordination and helped with the literature review. All authors read and canonical the final manuscript.

Competing interests

The authors declare that they take no competing interests.

Consent for publication

Not applicable.

Ideals blessing and consent to participate

All procedures performed in studies involving man participants were in accordance with the ethical standards of the institutional and/or national enquiry committee. The Investigative Committee on Clinical Research (ICCR), IRB of Holy Name Medical Middle, Teaneck, NJ, canonical this report with a waiver of informed consent.

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Affiliations

1. Holy Proper name Medical Middle, Teaneck, NJ, Us

   Chul S. Hyun & Sue Kim

2. Center for Viral Hepatitis, 35 Van Nostrand Avenue, Englewood, NJ, 07631, USA

   Chul S. Hyun, Seung Y. Kang, Seo Jung & Seulgi Lee

Respective author

Correspondence to Chul S. Hyun.

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Hyun, C.S., Kim, Due south., Kang, S.Y. et al. Chronic hepatitis B in Korean Americans: decreased prevalence and poor linkage to care. BMC Infect Dis sixteen, 415 (2016). https://doi.org/10.1186/s12879-016-1732-7

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• Received: 22 February 2016

• Accustomed: 22 July 2016

• Published: 15 August 2016

• DOI : https://doi.org/10.1186/s12879-016-1732-vii

Keywords

• Hepatitis B screening
• Korean Americans
• Linkage to care

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