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Community-based hepatitis B screening programs in the United States in 2008: CDC recommends HBsAg testing to identify HBV-infection for foreign-born persons from areas with HBsAg prevalence 2% or greater
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CDC recommendations to expand routine screening to include immigrants from most African and Asian countries.
"In the current post-vaccination era, the majority (47-70%) of HBV-infected individuals in the United States were born in other countries, primarily Asia and Africa [3]. Because HBV infection can remain asymptomatic for years, many U.S. residents who were born in intermediate and high HBV-endemic countries are unaware of their infection and their risks of transmitting the virus to others and/or developing serious liver disease. Improving the identification and public health management of persons entering or living in the United States with chronic HBV infection is the next step in the strategy to eliminate HBV transmission and ultimately HBV-related liver disease in the United States.....Currently, infrastructure exists to test pregnant women for HBsAg, which has been recommended since 1988, but federal resources are lacking to fund and track screening of other adults, including persons from highly endemic countries"
"Policy makers should consider methods to fund the continued operation of these screening programs and to expand HBsAg testing to make it available in other regions such as the Southeast and Midwest, to ethnic populations at high risk for HBV, and to U.S.-born groups with identified behavioural risk factors."
Journal of Viral Hepatitis Early view Aug 6 2009
D. B. Rein 1 , S. B. Lesesne 1 , P. J. Leese 1 and C. M. Weinbaum 2
1 RTI International, Atlanta, GA, USA ; and 2 Division of Viral Hepatitis, Centers for Disease Control and Prevention, Atlanta, GA, USA
Correspondence to David Rein, RTI International, 2951 Flowers Road, Suite 119, Atlanta, GA 30341. E-mail: drein@rti.org
"In the United States, 800 000 to 1.4 million persons are chronically infected with HBV"........"more than 16 million persons from these countries reside in the United States with more arriving each year, and there may also be as many as 5 million U.S.-born persons at high risk for hepatitis B infection due to behavioural factors [11-13]. Although the programs identified by this study are actively working to meet the need for HBV screening, their efforts are likely insufficient to meet the national need for testing high prevalence populations in the United States. Policy makers should consider methods to fund the continued operation of these screening programs and to expand HBsAg testing to make it available in other regions such as the Southeast and Midwest, to ethnic populations at high risk for HBV, and to U.S.-born groups with identified behavioural risk factors."
We conducted this study to identify and geographically locate community HBV screening programs in the United States and to collect information on the number of people each program screened, the types of HBV services beyond screening provided by these programs, the populations/ethnic groups targeted for screening, and the prevalence of HBV infection identified among those screened
To increase identification of HBV-infected individuals, in September 2008, CDC published updated recommendations for HBV screening among population groups in the United States with recognized high rates of infection [3]. Most notably, CDC now recommends routine hepatitis B surface antigen (HBsAg) testing to identify chronic HBV infection among foreign-born persons from areas with HBsAg prevalence of ≥2%
Although refugees (those fleeing to the United States because of persecution or fear of persecution) entering the United States are systematically screened for HBV infection, other U.S. resident populations born in high and intermediate HBsAg prevalence countries are not; these individuals are offered screening by a number of independent, voluntary, not-for-profit organizations. Conducting snowball sampling of known HBV screening organizations and a structured search of the Internet, we located 55 such organizations
Although the HBV screening programs identified were geographically dispersed, several areas of the country with 'intermediate or large target populations' had no screening programs....five in New York City
ABSTRACT
Summary. The Centers for Disease Control and Prevention (CDC) recommends hepatitis B surface antigen (HBsAg) testing to identify hepatitis B virus (HBV) infection for foreign-born persons from areas with HBsAg prevalence of ≥2%. Currently, most HBsAg screening in the United States is performed by independent community organizations. For these HBsAg screening programs, we collected information about the location, number of people screened, other services beyond screening provided, the population/ethnicity groups targeted for screening, and the prevalence of HBsAg among those screened. We identified programs offering screening by contacting programs known to us, from interviews with identified programs, and from structured Internet searches, and collected information using a simple e-mail survey with follow-up phone calls. We identified 55 possible community HBsAg screening programs, of which we successfully contacted 31 programs. In the past year, contacted programs screened an estimated 21 817 patients with an 8.1% average HBsAg prevalence. The majority of programs screened persons born in Asia and their children, and a small number of programs screened persons from Africa or Eastern Europe; very few programs screened U.S.-born persons at risk of HBV infection due to behavioural factors. We identified few or no programs in the American Southeast, the Midwest, and the Southwest outside of California and the Houston area. The HBsAg screening programs that we contacted were effective in identifying and screening patients at risk of HBV as evidenced by the high prevalence observed among those screened. However, their efforts alone are likely insufficient to meet the need for screening recommended by CDC.
Article Text
Chronic infection with hepatitis B virus (HBV) is a common, preventable cause of death from decompensated cirrhosis and hepatocellular carcinoma. Worldwide, an estimated 350 million persons are chronically infected with HBV, leading to approximately 620 000 annual deaths from HBV-related chronic liver disease [1,2]. In the United States, 800 000 to 1.4 million persons are chronically infected with HBV [3]. New HBV infections have declined substantially in the United States since the Centers for Disease Control and Prevention's (CDC's) recommendation in 1991 to integrate hepatitis B vaccination into the childhood immunization schedule [4-7]. In the current post-vaccination era, the majority (47-70%) of HBV-infected individuals in the United States were born in other countries, primarily Asia and Africa [3].
Because HBV infection can remain asymptomatic for years, many U.S. residents who were born in intermediate and high HBV-endemic countries are unaware of their infection and their risks of transmitting the virus to others and/or developing serious liver disease. Improving the identification and public health management of persons entering or living in the United States with chronic HBV infection is the next step in the strategy to eliminate HBV transmission and ultimately HBV-related liver disease in the United States. Identification of infected individuals will allow for the [1] identification and vaccination of susceptible household contacts and sex partners of HBV-infected individuals to prevent ongoing transmission, [2] education and medical management of patients to decrease the risk of liver disease progression, [3] referral of infected patients for antiviral therapy and other treatment when indicated, and [4] development of financing strategies to pay for the treatment of medically indicated individuals.
To increase identification of HBV-infected individuals, in September 2008, CDC published updated recommendations for HBV screening among population groups in the United States with recognized high rates of infection [3]. Most notably, CDC now recommends routine hepatitis B surface antigen (HBsAg) testing to identify chronic HBV infection among foreign-born persons from areas with HBsAg prevalence of ≥2% and children of persons born in areas with HBsAg prevalence ≥8%; if carried out, these recommendations would expand routine screening to include immigrants from most African and Asian countries.
Currently, infrastructure exists to test pregnant women for HBsAg, which has been recommended since 1988, but federal resources are lacking to fund and track screening of other adults, including persons from highly endemic countries. However, many community organizations, particularly in Asian-American communities, independently conduct screening activities to identify foreign-born persons with chronic HBV infection. Little is known about the scope of these voluntary networks of community hepatitis B screening and prevention programs and the role they could play in a national strategy to decrease the sequelae of chronic HBV infections.
We conducted this study to identify and geographically locate community HBV screening programs in the United States and to collect information on the number of people each program screened, the types of HBV services beyond screening provided by these programs, the populations/ethnic groups targeted for screening, and the prevalence of HBV infection identified among those screened. This information can be used to understand the level of current national HBV screening coverage provided by voluntary and primarily charity-financed organizations. Policy makers who wish to develop new national efforts to screen for asymptomatic chronic HBV infection or to enhance existing community screening efforts can reference this information as a baseline for future comparison.
Materials and methods
Inclusion criteria
We attempted to contact and survey all identifiable community-based HBV screening programs in the United States. Any U.S. nongovernmental program that systematically offered HBsAg testing to all members of a population group based on country of birth or participation in high-risk behaviour was eligible for inclusion in the current study. For this analysis, we excluded screening conducted by state and local public health departments, including screening performed by refugee health programs.
Identification of programs
We employed three methods to identify screening programs. First, we contacted programs that collaborate with the National Task Force on Hepatitis B, a nonprofit organization committed to hepatitis B awareness and prevention. To augment this initial list of sites, we conducted a structured Internet search to identify additional organizations that met the inclusion criteria using the search terms 'hepatitis B community screening program,''immigrant hepatitis screening', 'Asian hepatitis B screening', and 'immigrant community health hepatitis B', as well as a number of variations on these search terms. Finally, we asked each screening program we contacted to identify other screening programs.
Data collection
We conducted the study in the spring and summer of 2008. We asked programs to report the following: whether they were screening any populations at the time of the inquiry; the specific risk populations screened; the estimated number of people screened in the past 12 months and the anticipated number to be screened in the following 12 months; the proportion of their total screened population that was positive for HBsAg or antibody to hepatitis B core antigen (anti-HBc) (stratified by place of birth or risk group when possible); the type of additional services beyond screening, if any, they provided, such as hepatitis B vaccination or referrals to medical care for participants with positive test results; and the source(s) of funding for the screening. We contacted programs by e-mail and by telephone with frequent reminders (up to five) for nonresponders. Several programs required multiple subsequent contacts to supplement incomplete data.
Data analysis
All data were entered, stored, and analyzed using Microsoft Excel. We calculated the proportion of programs that provided each service, the proportion of programs that targeted each population group, the reported number of patients screened, the mean HBsAg prevalence across all programs weighted by the number of individuals screened, and the estimated number of infected persons identified. For ethnic groups that were screened by four or more different programs, we estimated the mean HBsAg prevalence as the average prevalence weighted by the number of patients tested in each program that screened patients of that ethnic group.
We mapped all identified community-based HBV screening programs (including those we were unable to contact) onto a map of the United States, after shading individual states based on their proportion of individuals who were born in countries covered by the current CDC screening recommendation (regional prevalence of 2% or higher). We used the American Community Survey to estimate the proportion of each state's population that was born in one of 130 foreign countries (see Appendix) [3]. We then classified states as having a small target population when their percentage of population born in the above countries was between 0.0% and 2.0%, a small to intermediate target population when their percentage of population born in the above countries was between 2.0% and 3.9%, an intermediate to large target population when their percentage of population born in the above countries was between 4.0% and 5.9%, and a large target population when their percentage of population born in the above countries was 6.0% or greater. Where data were available, we shaded the map based on target population category.
Results
We identified 55 programs. Of these, 31 (56%) programs were currently screening or had screened patients in the last year, three programs had not screened in the past year, and 1 program was screening but was too new to provide information. Twenty of the 55 programs did not respond to inquiries and may no longer be operational.
Programs were geographically dispersed (Fig. 1). Of the 55 programs identified, 23 were located in California (19 in the greater San Francisco Bay Area, three in Los Angeles, and one in San Diego, CA, USA). A large number of programs were in the mid-Atlantic region: five in New York City; five in the greater Washington, DC area; and four in New Jersey or the greater Philadelphia area. In addition, we identified six programs in the northern Midwest states of Ohio, Michigan, Illinois, and Wisconsin. The remaining programs were located in New England [3]; Honolulu, HI [2]; Texas [2]; Denver, CO [1]; Seattle, WA [1]; and New Orleans, LA [1]. Two of the programs we identified screened in multiple states. Based on data from the American Community Survey, we identified 11 states as having large target populations, 3 states and the District of Columbia as having intermediate to large target populations, 13 as having intermediate to small target populations, and 8 as having small target populations. The remaining 15 states were not included in the American Community Survey data.
Of the programs who responded, 90% were screening individuals for HBV at the time of the contact, 90% offered hepatitis B vaccination, 74% provided HBV education, 71% coordinated or provided referrals to treatment, and 29% provided HBV treatment themselves. All together, the 31 contacted programs screened 21 817 individuals for HBV in the 12 months preceding their interview. The programs predicted that they would increase their screenings to 24,880 individuals in the upcoming 12 months (Table 1).
Thirty programs provided information regarding the specific populations they targeted for HBV screening. Of these, 83% screened Chinese and/or Taiwanese; 63% screened Vietnamese; 50% screened Koreans; 27% screened members of various non-Vietnamese Southeast Asian ethnicities, including Filipino, Malaysian, Thai, Laotian, Cambodian, and Burmese; 7% screened persons of Indian or African descent; 7% screened U.S.-born high-risk populations (homeless, HIV positive, commercial sex workers, injection drug users, and newly released inmates); and 3% screened Japanese.
Many programs (40%) reported receiving most of their funding from pharmaceutical or insurance companies. Other sources of funding included research or service grants (37%); community hospitals (37%); private funding (23%); and federal (10%), state (27%), or local (30%) government funding.
The mean HBsAg prevalence among all screened individuals was 8.1% (95% CI: 7.9-8.2%). Multiplying this prevalence by the reported number of individuals screened yielded an estimate of 1,745 HBsAg-positive persons identified by these screening programs.
Chinese, Koreans, and Vietnamese were screened in four or more programs. For these groups, we calculated an HBsAg prevalence among those screened of 8.0% (3.1-12.9%) among Chinese, 5.7% (3.3-8.0%) among Koreans, and 9.7% (4.4-14.0%) among Vietnamese.
Discussion
Although refugees (those fleeing to the United States because of persecution or fear of persecution) entering the United States are systematically screened for HBV infection, other U.S. resident populations born in high and intermediate HBsAg prevalence countries are not; these individuals are offered screening by a number of independent, voluntary, not-for-profit organizations. Conducting snowball sampling of known HBV screening organizations and a structured search of the Internet, we located 55 such organizations that screened for HBV currently or at some time in the past, with 31 of these able to respond to specific inquiries about their services.
Despite the challenges of maintaining daily operations, we found that these programs screened a large number of people with a high estimated prevalence of 8.1%, approximately 15 to 25 times the prevalence of HBsAg in the United States (0.3-0.5%) [3]. Estimates of HBsAg prevalence for Chinese (8.0%), Koreans (5.7%), and Vietnamese (9.7%) from this study are consistent with estimates of HBV prevalence found in other reports from screening projects [8-10].
The voluntary screening programs were likely also successful in preventing new cases of HBV and its sequelae. Most programs offered vaccination to persons who were HBsAg-negative and/or to family contacts of infected persons and health education to at-risk populations about HBV transmission, disease progression, and treatment options. Most of the organizations were able to provide patients who tested positive with referrals to appropriate specialist care, but far fewer organizations (29%) offered medical care for patients. This in part reflected the community-based, nonclinical character of most of these organizations, but it also reflects the high costs and difficulties of managing antiviral treatment for hepatitis B. At least one clinical setting that performed routine screening was unable to offer treatment to patients who tested positive, due to a lack of clinical specialists and a lack of sources of reimbursement for care.
Although the HBV screening programs identified were geographically dispersed, several areas of the country with 'intermediate or large target populations' had no screening programs. In the southeastern United States, the only program identified was in Virginia. Florida, Georgia, Minnesota, and Nevada lacked screening programs and were geographically distant from any states that had screening programs. We identified no programs in large areas of the central United States with small to intermediate target populations.
Further, the vast majority (83%) of programs we identified focused on screening Asian populations, whereas only 7% of programs screened patients of African, Indian, Latin American, or Eastern European origin. Likewise, only 7% of programs screened other high-risk patients, such as the homeless, HIV-positive patients, commercial sex workers, newly released inmates, and intravenous drug users. These data suggest that some high prevalence populations are being systematically overlooked, and expansion of HBV screening services may be warranted.
Funding for programs identified in this survey was derived from multiple sources, and the large majority of programs funded their activities using two or more sources of revenue. Nearly all programs described future screening plans as contingent on identifying and securing new sources of funding. Potentially, lack of funding may have led at least some of the programs we were unable to contact to cease operations.
Limitations
This study was intentionally limited to outreach screening programs and therefore does not quantify HBsAg testing being done for high-prevalence populations in hospitals, in clinics, and by private physicians. In addition, although we attempted to identify all programs that systematically screened for HBV, we likely missed independent programs not affiliated with other HBV screening programs and lacking an Internet presence. Other health care providers, such as federally qualified health centers located in areas with high concentrations of at-risk patients, may routinely screen targeted populations for HBV but may not identify themselves as screening programs. This likely led to an underestimate of the true number of voluntary programs currently screening and persons tested for HBsAg through targeted screenings each year.
Further, our estimates of the numbers screened and HBsAg prevalence depend on information reported by the screening programs that cooperated with our study. Although some programs were able to provide actual counts of persons screened and calculated their program's prevalence based on reviews of test results, other programs only provided more general estimates of numbers of persons screened and prevalence observed based on the program manager's best recollection. While the concordance of our prevalence estimates with those observed in previous studies supports the general validity of our findings, these data should be interpreted within the context of their collection.
Implications
Charitable and voluntary organizations conducting targeted screening currently provide HBsAg testing to at least 20 000 people born in countries where HBsAg prevalence exceeds 2%. These programs are successful in identifying high-prevalence populations, exhibited by the mean prevalence rate of 8.1% among tested persons. However, more than 16 million persons from these countries reside in the United States with more arriving each year, and there may also be as many as 5 million U.S.-born persons at high risk for hepatitis B infection due to behavioural factors [11-13]. Although the programs identified by this study are actively working to meet the need for HBV screening, their efforts are likely insufficient to meet the national need for testing high prevalence populations in the United States. Policy makers should consider methods to fund the continued operation of these screening programs and to expand HBsAg testing to make it available in other regions such as the Southeast and Midwest, to ethnic populations at high risk for HBV, and to U.S.-born groups with identified behavioural risk factors.
Authors' declaration of personal interests: Authors have no personal interests to declare.
Declaration of funding interests: This study was funded in full by the Centers For Disease Control and Prevention's Division of Viral Hepatitis through contract #200-2002-00776, Task Order 65.
APPENDIX: LIST OF COUNTRIES WITH 2%
HBSAG PREVALENCE
Afghanistan, Albania, Algeria, Angola, Armenia, Azerbaijan, Bahrain, Bangladesh, Belarus, Benin, Bhutan, Bosnia and Herzegovina, Botswana, Brunei, Bulgaria, Burkina Faso, Burundi, Cambodia, Cameroon, Cape Verde, Central African Republic, Chad, China, Comoros, Congo, Croatia, Cyprus, Czechoslovakia (including Czech Republic and Slovakia), Democratic Republic of Congo (Zaire), Djibouti, East Timor, Ecuador, Egypt, Equatorial Guinea, Eritrea, Estonia, Ethiopia, Europa Island, Gabon, Gambia, Ghana, Glorioso Islands, Guatemala, Guinea, Guinea-Bissau, Guyana, Haiti, Honduras, Hong Kong, India, Indonesia, Iran, Iraq, Ivory Coast, Jamaica, Japan, Juan de Nova Island, Kazakhstan, Kenya, Korea, Kuwait, Laos, Latvia, Lebanon, Lesotho, Liberia, Libya, Lithuania, Macedonia, Madagascar, Malawi, Malaysia, Maldives, Mali, Mauritania, Mauritius, Mayotte, Moldova, Montenegro, Morocco, Mozambique, Myanmar (Burma), Namibia, Nepal, Nigeria, Oman, Pakistan, Philippines, Poland, Qatar, Reunion, Romania, Russia, Rwanda, Sao Tome & Principe, Saudi Arabia, Senegal, Seychelles, Sierra Leone, Singapore, Slovenia, Somalia, South Africa, Spain, Sri Lanka, St. Helena, Sudan, Swaziland, Syria, Taiwan, Tajikistan, Tanzania, Thailand, Togo, Tomelin Island, Tunisia, Turkey, Turkmenistan, Uganda, Ukraine, United Arab Emirates, Uzbekistan, Venezuela, Vietnam, Western Sahara, Yemen, Yugoslavia, Zambia, Zimbabwe.
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