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The patient, the doctor, and the system:
Underdiagnosis and undertreatment of hepatitis B
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Tram T. Tran M.D.1,2,
Luis H. Ocampo Jr M.D.2

Hepatology August 2012

Cohen C, Holmberg SD, McMahon BJ, Block JM, Brosgart CL, Gish RG, et al. Is chronic hepatitis B being undertreated in the United States? J Viral Hepat 2011;18:377-383. (Reprinted with permission.)

Hepatitis B in the united states: a major health disparity affecting many foreign-born populations - (06/03/12)


Chronic infection with the hepatitis B virus (HBV) is a major risk factor for the development of end-stage liver disease, including cirrhosis, liver failure, and primary liver cancer. There are now 7 antiviral agents approved by the US Food and Drug Administration for the management of chronic HBV infection. Despite the fact that there are between 1.4 and 2 million chronic HBV infections in the United States, fewer than 50,000 people per year receive prescriptions for HBV antiviral medications. This report discusses possible explanations for the disparity between the number of people who are chronically infected and the number of people who receive treatment. Explanations for this incongruence include the potentially large number of infected persons who are unscreened and thus remain undiagnosed, and lack of access, including insurance, education, and referral to appropriate medical care, particularly for disproportionately infected populations.


The incidence of acute hepatitis B (HBV) infection has decreased since the implementation of universal screening of pregnant women and vaccination of newborns.1 However, there still exists a substantial number of Asian Americans, Africans, and other groups immigrating from areas of high prevalence, men who have sex with men (MSM), and IV injection drug users (IVDU) who are already infected or are at risk of infection. Once chronic, HBV increases the risk of cirrhosis, as well as hepatocellular carcinoma (HCC). Unfortunately, even with the success of preventative strategies there still exist 730,000 to 2 million people in the United States who are already chronically infected with HBV,2 with the largest proportion being MSM, IVDU, and Asian Americans. Of the chronically infected, Cohen et al. suggest only 50,000 patients are receiving antiviral treatment.3 Although not all infected persons require therapy, understanding why this large disparity exists requires understanding the individual, specific community, health care provider-related, and health care systems-based barriers that may exist.

One group affected by HBV infection is the Asian American/Pacific Islanders (AAPI), who comprise approximately 4% of the US population and are expected to be 9.2% of the population by 2050.1 This group is disproportionately affected by chronic HBV compared to the rest of the US population as an estimated 1 in 10 AAPIs have chronic HBV. Of new cases of chronic HBV diagnosed in the United States, approximately 24% of those cases are found in AAPIs.4 This is in contrast to the prevalence of chronic HBV among whites, which is estimated at 0.2%.5 Many of these chronically infected AAPIs are immigrants from countries where the prevalence of hepatitis B surface antigen positivity may be as high as 10% to 20% of the population, which is seen in many parts of Southeast Asia.5 Contributing to the issue is that two-thirds of immigrants from high-prevalence areas such as Southeast Asia do not know they are infected.1 Many of the countries with the highest prevalence of HBV worldwide are also countries with limited resources for mandatory screening programs; therefore, increasing opportunities for screening this population are critical to decreasing the impact of chronic HBV infection.

Other populations at risk include MSM and intravenous drug abusers. These 2 groups have the highest incidence of acute HBV infection in the United States,6 which equates to an annual incidence of chronic HBV infection within these groups of 1.1% and ~2.4% to 11%,7 respectively. Although some of these individuals may have access to the health care system, studies have shown that these groups may also be underscreened for HBV.

The reasons for the lack of screening and treatment in high-risk groups often involve a patient's educational status, belief systems, and cultural barriers to screening. These factors can influence the willingness of an individual to seek screening or comply with screening recommendations. Philbin et al. recently surveyed immigrant and native-born Chinese, Vietnamese, and Korean individuals about their knowledge of hepatitis and associated liver diseases. In this study, the responses showed that many individuals felt that lack of education about the disease, as well as limited access to health care were barriers to screening.8 Studies among AAPIs who have lower levels of education and socioeconomical status revealed that they were the least likely to be vaccinated and screened.1, 9 These patients were asked about their health care in a questionnaire, which showed that health care provider recommendations as well as family suggestion were the leading reasons for a person to seek screening.9 Overcoming these barriers as well as the social stigma of infection and treatment will be essential in improving screening and treatment acceptance.

The MSM community is often perceived as having a higher socioeconomic status than AAPIs; however, when this community was studied by the Young Men's Survey Phase II, Weinbaum et al. reported the prevalence of immunization at only 17.2% among MSM surveyed. Many of these individuals had access to health care or had been screened for HIV, another commonly associated disease among MSM, but many had no knowledge they were susceptible to HBV or that a vaccine existed.6

Aside from individual patient factors, the health care practitioner's role in screening, diagnosis, and treatment of HBV is of obvious importance. With the expansion of the treatment armamentarium and the effectiveness of vaccination, it would be expected that physicians would be highly proactive in screening and treating those meeting treatment guidelines. Unfortunately, this has not been the case as data published on physicians' adherence to The Centers for Disease Control and Prevention guidelines for screening showed that only 60% of physicians correctly screened at-risk patients.10 In fact, many physicians who practice in areas with large at-risk populations such as AAPIs actually underestimate the impact of HBV on this population. Misidentifying the population to screen was determined to be the main reason for lack of screening among physicians in a recent survey.1 Many clinicians feel they only need to screen those with abnormal liver tests, such as transaminitis or when presenting with symptoms, when in fact many patients may not have symptoms or abnormal lab tests.

The approval of new first-line oral therapies have shown effective viral suppression, low resistance, and good safety profiles with evidence of biochemical normalization and moderate rates of hepatitis B e antigen seroconversion.11 The result of decreasing disease activity with antiviral suppressive therapy is decreased risk of cirrhosis and theoretical decrease of HCC risk as well.12, 13 Despite the availability of these medications, recent interviews with physicians who treat patients in AAPI populations show that close to 60% of these physicians are not aware of current treatments.14

In the article by Cohen et al.-"Is Chronic Hepatitis B Being Undertreated in the United States?"3-the authors show how patients, doctors, and health care systems are the primary factors for the lack of screening and treatment of HBV. Screening is cost effective even in population centers with as little as 0.3% prevalence when the expense of hospitalizations for cirrhosis and transplantation are considered.15 The authors make the case that only 4% to 5% of chronic HBV-infected patients are screened, enter into a health care system, and obtain treatment. So what can we do? One large AAPI community intervention in San Francisco using a comprehensive citywide program utilizing HBV education, screening, and treatment showed that within 1 year of being screened, the individual diagnosed with chronic HBV (67%) had accessed health care, and many (78%) have encouraged family members to undergo screening.1 This article makes a point that we probably all know: that hepatitis B is underdiagnosed and undertreated. The more difficult task will be how to mobilize stronger and more persistent patient, physician, and community advocacy to increase the numbers of patients screened, diagnosed, and treated.

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