Hepatitis B Virus (HBV)is a leading cause of chronic liver diseases, causing cirrhosis and hepatocellular carcinoma (HCC). Approximately 296 million people are chronically infected with HBV worldwide, with 1.5 million new infections each year, and it is estimated that up to a quarter of infected persons may develop severe complications of the infection. HBV is responsible for 30% of all deaths from cirrhosis and 40% of all deaths from HCC globally. In 2019, chronic hepatitis B (CHB) resulted in 820,000 deaths, mostly from cirrhosis and HCC.
The most significant percentage of hepatitis B is found in Asia and Africa, followed by the Eastern Mediterranean regions, Europe, and America. While the World Health Organization (WHO) aims to eliminate viral hepatitis by 2030 by minimizing new infections and deaths, many challenges highlight the need for innovative initiatives consisting of primary prevention, screening, and the earliest possible intervention for infected individuals.
Although it has been reported in the US that an estimated 880,000 to 1.89 million people are chronically infected with HBV, a recent study has suggested that the number may be as high as 2.4 million. This apparent increase in chronically infected people living in the US may be multifactorial. First, there has been a continuous influx of immigrants from countries with moderate and high prevalence levels. Secondly, the CHB prevalence of naturalized US citizens might have been underestimated. Thirdly, diagnosis and treatment rates have not improved significantly during the past decade. These facts underscore the importance of raising awareness of CHB and the need for more effective implementation of screening and linkage-to-care programs in the US, thus calling for a strategy for CHB eradication efforts.
HBV is a public health issue historically underprioritized in the United States. Many barriers have hindered the development and success of interventions. In the US, about 75% of chronic HBV infections occur in immigrants born in countries where HBV is endemic. More than half of the individuals living with chronic hepatitis B (CHB) in the US are Asian Americans. Not only are immigrant populations more significantly infected with HBV, but they are also more susceptible to poor health outcomes resulting from CHB.
New CDC recommendation- Improvement but still falls short of achieving the UN’s 2030 goal
CDC reported in 2023 new recommendations on screening for Hepatitis B Virus Infection, which includes hepatitis B screening using three-panel tests (Hepatitis B surface antigen, Hepatitis B surface antibody, and Hepatitis B core antibody) at least once during a lifetime for adults aged ≥18 years. The updated recommendation also includes the following individuals: those who request HBV testing, persons who have been incarcerated in a jail or other detention setting, persons who have had HCV infection in the past, and persons who have or had STIs or multiple sex partners.
The new recommendations from the CDC are expected to aid in reducing the current challenges in diagnosing and treating CHB in the US. However, it may require additional measures to eliminate CHB by 2030 as the United Nations General Assembly has set the control and eradication of viral hepatitis as its target for that year.
1. Universal HBV screening in the US.
Recent research suggests that the number of people with HBV in the US may be significantly underestimated due to the inaccurate assessment of HBV-infected immigrant populations. Since risk-based screening often fails to identify people living with HBV and is also not efficient for healthcare providers to implement, it is crucial to screen everyone regardless of age, including all immigrants and their families, irrespective of age.
2. Reevaluation of antiviral treatment guideline
Antiviral therapy, while not curative in most cases, is safe and inexpensive and can control viral replication, prevent mother-to-child transmission, and lower the risk of developing cirrhosis and HCC. All individuals infected with HBV and a detectable viral load are at risk of complications and can potentially spread the virus. Expanding the indications for HBV treatment to include all individuals with detectable HBV DNA could be considered an effective strategy for reducing morbidity and mortality associated with HBV as well as controlling the spread of HBV and bringing us closer to achieving the UN’s 2030 goal.
3. Community approach to effectively screen and facilitate linkage-to-care (LTC)
Current levels of diagnosis and treatment of hepatitis B are inadequate. The cost of antiviral agents is not a barrier. Lack of access to community and referrals presents a more significant obstacle than the low cost of drugs.
There are numerous and complex obstacles to screening and treatment for CHB. These include a lack of awareness about the disease, language and cultural barriers, and financial challenges. Additionally, US public health systems often struggle to cater to the needs of diverse populations. Poor communication between healthcare providers and patients from different cultural, ethnic, or racial backgrounds is another issue, which results in inadequate healthcare access for minority groups.
There are evidence-based initiatives that aim to improve health outcomes and reduce health disparities by using community-level approaches. Many large-scale community-based hepatitis B initiatives have shown that campaigns to educate and screen at-risk communities are effective. These community programs can help overcome many barriers to reduce the significant burden of disease.
References
Baeyens, A.; Goffin, T. Transforming Our World: The 2030 Agenda for Sustainable Development. 2015. Available online: https: //documents-dds-ny.un.org/doc/UNDOC/GEN/N15/291/89/PDF/N1529189.pdf?OpenElement
Dusheiko, G.; Agarwal, K.; Maini, M.K. New Approaches to Chronic Hepatitis B. N. Engl. J. Med. 2023, 388, 55–69.
Fan P, Li LQ, Chen EQ. The urgency to expand the antiviral indications of general chronic hepatitis B patients. Frontiers in Medicine. 2023 May 19. doi: 10.3389/fmed.2023.1165891
Hepatitis B Basic Information. https://www.hhs.gov/hepatitis/learn-about-viral-hepatitis/hepatitis-b-basics/index.html
Hu KQ, Pan CQ, Goodwin D. Barriers to screening for hepatitis B virus infection in Asian Americans. Dig Dis Sci. 2011; 56:3163–71.
Hyun CS, Ko O, Lee, S, McMenamin J. Long term outcome of a community-based hepatitis B awareness campaign: eight-year follow-up on linkage to care (LTC) in HBV infected individuals. BMC Infectious Diseases (2019) 19:638 https://doi.org/10.1186/s12879-019-4283-x.
Polaris Observatory Collaborators. (2018). Global prevalence, treatment, and prevention of hepatitis B virus infection in 2016: a modelling study. The Lancet Gastroenterology and Hepatology, 3 (6), 383-403. DOI:10.1016/S2468-1253(18)30056-6
Screening and Testing for Hepatitis B Virus Infection: CDC Recommendations — United States, 2023. Recommendations and Reports / March 10, 2023 / 72(1);1–25. https://www.cdc.gov/mmwr/volumes/72/rr/rr7201a1.htm
WHO News. (2019). Hepatitis B. https://www.who.int/news-room/fact-sheets/detail/hepatitis-b.
Wong, RJ, Brosgart, CL, Welch S., Block T. et al. An Updated Assessment of Chronic Hepatitis B Prevalence Among Foreign-Born Persons Living in the United States. 2021 Hepatology 74(2):607-626. DOI: 10.1002/hep.31782.
January 8, 2024
Chul S. Hyun, MD, PhD
Chairman, New York Health Forum
President, Stomach Cancer Task Force
Chul S. Hyun received his B.A. from Johns Hopkins University, M.D. from the University of Miami School of Medicine and completed his Internal Medicine Internship and Residency at Georgetown University Medical Center. Subsequently, he pursued a Gastroenterology and Liver Fellowship at Yale University School of Medicine. He holds a Ph.D. in Biophysics from the University of Rochester School of Medicine and an MPH from Columbia University. He furthered his research with a postdoctoral fellowship in Physiology at the University of Chicago School of Medicine. He is Board-certified in Gastroenterology and has been a faculty in the Division of Gastroenterology and Hepatology at Weill Cornell Medical College since 1996. Dr. Hyun has served as a Board Member of the New Jersey State Board of Medical Examiners (2017- 2018). He has also served as the president of the Korean American Medical Association (2011-2013) and is the founding President of the World Korean Medical Organization (2012-2015). He has founded several nonprofit health organizations such as the Center for Viral Hepatitis and Asian American Stomach Cancer Task Force, and published articles on ethnic health disparities in the US. He is currently the chair of the New York Health Forum (NYHF).