Health Policy Brief – Anthony Guan PA-S Portfolio

Policy Brief : Asian Americans and Pacific Islanders screening and treatment for Chronic Hepatitis B.

To: Senator Charles Schumer and Senator Kristen Gillibrand
From: Anthony Guan
Date: January 20, 2019
Re: Federal Mandate for Asian Americans and Pacific Islanders screening and treatment for Chronic Hepatitis B.

Statement of Issue: Hepatitis B Virus (HBV) is a potentially fatal liver infection caused by a virus and it slowly destroys a person’s liver and can cause cirrhosis, liver failure, or liver cancer. HBV is the leading cause of liver cancer and is transmitted through blood and bodily fluids. In the United States Asian Americans and Pacific Islanders account for less than 5% of the population but more than 50% or about 1 million Americans with chronic HBV are Asian Americans and Pacific Islanders. In the U.S about 1 in every 10 Asian Americans have chronic HBV, which makes it a large racial health disparity in America. This population is 8-13 times more likely to develop liver cancer and their liver cancer death rates are 60% higher than Caucasians. Additionally chronic HBV is known as a silent killer since people with HBV may not show any symptoms, and liver tests may be normal. Since HBV can be spread through birth, blood, and sex people who are unaware of their HBV, can transmit it unknowingly.

After tobacco use, chronic hepatitis B is the next leading cause of cancer globally. The liver performs essential, life sustaining functions. It one of the largest and heaviest organs in the body, which filters toxins from blood, produce bile for digestion, and stores vitamins and minerals. Additionally it regulates hormones and the immune response as well as playing a major role in blood clotting. Contracting HBV can lead to liver cancer, which also leads to a low five-year survival rate.
At least one-third of Asian Americans in the U.S. are unaware of a chronic hepatitis B infection. If they were aware of their chronic Hepatitis B infection they would be able to get necessary care to prevent or delay liver disease as multiple medications have been approved for treatment of adults with chronic Hepatitis B. As those who are chronically infected can live longer lives if they gain medical evaluation and treatment early before symptoms show. Moreover, prompt identification can also get patients to services to prevent the spread of infection to others.
Screening/testing is cost effective and alleviates long term cost of chronic Hepatitis B. Current screening guidelines emphasize a recommended screening for patient population of greater than or equal to 2% prevalence, and studies have also shown that lower-prevalence populations are also likely to be cost-effective. Identifying people with chronic Hepatitis B can allow for primary, secondary, and tertiary prevention. Furthermore patients can benefit greatly from vaccination or medical management with diagnosis of chronic Hepatitis B.

Policy Options

A federal mandate for training and education to healthcare providers for routine testing and follow up for Chronic Hepatitis B Virus Infection. Studies have shown that although screening is shown to be cost effective, many providers are not familiar with basic screening and/or management of chronic HBV.

- Advantages: Provides widespread knowledge to those on the front line of treating these patients. Able to target Asian and Pacific Islander population easier, by focusing efforts of testing and effecting treating those with chronic HBV. Can provide better care coordination and monitor patients.
- Disadvantages: Not all providers would be on board especially if their practice does not involve primary care or hepatology.
A federal mandate to provide screening and vaccination to all U.S. citizens, especially those of Asian and Pacific Islander progeny. Although HBV in the US is less than 1%, it is high, about 10%, amongst Asian Americans. However, screening rates for this population is reportedly low. Additionally, for those who are identified with HBV, testing in family members is a barrier. Thus clinicians must provide testing, follow up and treatment for families of people with HBV.

- Advantages: Improving surveillance to lower the incidence of Hepatitis B in the future. Provides a solution to some barriers of HBV screening and care and possibly improve health outcomes for the disparity that Asian Americans and Pacific Islanders experience with HBV. Early identification can offer better treatment and prevention of disease transmission and progression.
- Disadvantages: Eliminating HBV in the US is feasible but will take considerable will and resources. This mandate would require large resources to provide screening and vaccines, advertising and marketing of awareness and services. Encourages more people to seek treatment, thus increasing costs.
A federal mandate to have people who emigrate to the United States from high prevalence areas to be tested for HBV and provide follow up and education of disease. Asians from China, Korea, Vietnam, and from the Pacific Islands are at high risk for HBV due to low infant immunizations rates. Most Asians and Pacific Islanders contracted the disease during childbirth so it is common to see it amongst family members.

- Advantages: Identification of infected persons allows for primary prevention of ongoing HBV transmission by enabling those with chronic infection to adopt behaviors that reduce the risk of transmission to others and performing safe practices.
- Disadvantages: This option may be costly to implement, as this would cut into the federal budget. Also people who come into this country may find it intrusive, and a violation of their free will because maybe they wouldn’t want to be tested. Opposition from groups that would deem making this a federal mandate unethical because it targets a certain population.

Policy Recommendation:

Hepatitis B is a preventable and treatable disease that can be detrimental to ones health if left untreated. Those who have the virus are unaware of the opportunities to protect themselves and can unintentionally pass it to others. A push towards nationwide vaccination of Hepatitis B has been shown to be effective as it has dropped rates drastically. However, the Asian and Pacific Islander population remains at high risk because many of them are foreign born and may pass it to their children when in the U.S. Community efforts have targeted this population but not everyone is screened or treated for HBV. Thus, the best recommendation would be to educate those who would be interacting with patients and providing the care. As stated, studies have shown that a disparity for this group exists because of barriers such as knowledge from the provider in how to screen and treat, from the patients as denial or lack of communication, and also general resources available. Thus, many are unaware and if primary providers were better well-informed regarding the prevalence in this patient population, it can curtail the incidence of the disease and hopefully it can be removed in the future through promotion of the Hepatitis B vaccine. Through trainings and education programs, the ease of disseminating the information to all providers would benefit the general public, especially those who experience a health disparity such as the Asian and Pacific Islander population.

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