The Patient with Hepatitis B

Issue: June 2016

The Case: A 26-year-old Cambodian female is being evaluated after a routine screening for viral hepatitis. She is symptomatic and works in a nail salon. She has three older siblings with hepatitis B virus (HBV) infection. She takes no medications and denies drug or alcohol use. Her liver enzymes, bilirubin, and international normalized ratio (INR) are normal. HBV serology is as follows:

HBV surface antigen: positive
HBV surface antibody: negative
HBV core antibody: positive
HBV e antigen: positive
HBV e antibody: negative
HVB DNA: 200,000 units/mL

Key Supporting Information

In May 2014, the US Preventative Services Task Force updated its hepatitis B screening guidelines to recommend screening for high-risk groups, including many foreign-born populations. This recommendation carries a grade B, and thus under the Affordable Care Act, all insurance plans must cover this service without cost-sharing to the patient (unless they have grandfather status).

Providers should be familiar with HBV endemic regions because they represent much of the world, including all of Asia, Africa, much of Latin America, the Caribbean, and Eastern Europe. Given the diversity this represents, cultural and linguistic barriers can be significant challenges in the implementation of these recommendations and in the optimal care of such at-risk populations.

The Office of Minority Affairs has developed national Culturally and Linguistically Appropriate Services (CLAS) standards that are a blueprint for organizations to implement cultural and appropriate services. The goal is to advance health equity, improve quality, and help eliminate health care disparities. Many federal and state medical mandates now incorporate these principles, and a growing number of states require cultural competency training as part of physician licensure. Because those at risk of HBV are so culturally diverse, these standards can help improve the care of those at risk of HBV.

The various subgroups of patients with HBV infection are indicative of the natural history of this disease and include the immune-tolerant patient, the inactive carrier, and the patient in the phase of immune clearance or immune active state. Immune-tolerant HBV is defined by a high viral load, e-antigen positivity, and normal liver enzymes. Immune-active individuals have surface and e-antigen positivity, with high viral load DNA and elevated liver enzymes. The inactive HBsAg carrier is e-antigen and antibody negative, DNA viral load is typically less than 10, and the transaminases are normal.

This article will focus on the cultural and linguistic gaps in the care of Asian Americans and Pacific Islanders (AAPIs) and offer tools that may be employed to bridge those gaps. AAPIs make up 5.8% of the U.S. population, but alone represent more than 50% of those with chronic hepatitis B (CHB) infection, thus making it one of the largest ethnic health disparities in our country. As the fastest growing group in the U.S., and with 36% of all immigrants reportedly Asian, the burden of CHB on the AAPI group will continue to grow.

Awareness and Education

Successful screening, vaccination, and linkage-to-care campaigns in AAPI communities have shown that up to two-thirds of those infected are unaware of their diagnosis. Lack of HBV awareness is one obstacle to screening in the community. There is general lack of knowledge about HBV, including transmission methods, disease manifestations, its asymptomatic nature, and its consequences of cirrhosis and liver cancer. Many may not be aware that liver cancer is actually preventable or that hepatitis B is treatable. “Knowing someone with liver cancer” is often cited as a motivator for getting screened, thus the connection between HBV and liver cancer should be a key component in any education.

Understanding HBV also requires a basic understanding of certain medical concepts that may be limited in individuals with lower educational attainment. Patients may not understand that HBV is transmitted by blood and may think that it is genetic because it is passed on to family members. Also, people often do not understand that vaccines cannot protect those who are already infected. Finding individuals who were vaccinated but already infected is not uncommon — they may have been vaccinated without being screened.

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Lack of physician awareness in screening and treatment is a significant reason for underscreening in the Asian-American population. Physicians who do not see many AAPIs may not recognize the risk in their patients. Even Asian-American physicians who see a significant number of Asian patients have reported not consistently screening their patients.

Linguistic Barriers

Linguistic barriers create a difficulty with accessing health care; 1 out of 2 Asian Americans report linguistic isolation, defined as living in a household where all members of the household who are over 14 years of age have at least some difficulty with English. Those with limited English proficiency (LEP) suffer from lower patient engagement in the health care relationship and these barriers are known to contribute to poor health outcomes.

Identifying providers or staff with language concordance with patients is ideal and HBV screening programs should seek to identify health care providers who share the language of Asian-American communities. Directories or maps can be made as a resource for the community. Studies in the Asian-American community show that patient return rates and linkage to care were much better with providers and organizations who worked consistently with the target population. Social service organizations dedicated to AAPI populations are good partners in health care delivery and may be able to assist in education and patient navigation to help reduce linguistic and cultural barriers.

In-language materials are very important to providing accessible and effective health education to those with LEP. There are many HBV resources easily accessible online in many Asian languages.

Because language concordance between patients and providers is not always possible, translation services are another method to help bridge language gaps. There are federal mandates for language rights in health care and clinicians must ensure equal treatment to individuals who are LEP. Language lines are available and more hospitals are providing translators who are certified. Providers who give care to those HBV at-risk populations may want to encourage translators to take those courses. Reliance on family members for translation should be discouraged because they are not trained and this can become an issue of medical liability. States differ in their policies, but many do require health insurers, including Medicaid, to cover interpreting service for patients.

Click here to see this Education Lab Activity.

Learning Objectives:

Upon successful completion of this educational activity, participants should be better able to assess obstacles in screening high-risk groups for hepatitis B infection.

Overview

Author(s)/Faculty: Ronald A. Codario, MD, FACP, FNLA, RPVI, CCMEP
Source: Healio Gastroenterology Education Lab
Type: Monograph
Articles/Items: 4
Release Date: 7/15/2015
Expiration Date: 7/15/2016
Credit Type: CME
Number of Credits: 0.25
Cost: Free
Provider: Vindico Medical Education

CME Information

Provider Statement: This continuing medical education activity is provided by Vindico Medical Education.
Support Statement: No commercial support for this activity.
Target Audience: The target audience for this activity is gastroenterologists and other health care professionals with an interest in the treatment of patients with gastroenterological disorders.