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