A Warm Welcome on World Hepatitis Day May 19, 2010
Posted by Marianne Ruane in : Health , 1 comment so farOver five million Americans are estimated to be living with chronic viral hepatitis. Up to 1.4 million have hepatitis B and over 3 million are infected with hepatitis C. With the observance of World Hepatitis Awareness Day on May 19, I’m reminded of my own screening experience six months ago.
I walked past the tabletop plastic Christmas tree with blinking white lights and sporadic tinsel. Winter decorations always seemed a little out of place to me in sunny southern California. I waited a few minutes at the lobby desk, and eventually I was directed to a woman who spoke English. I asked her where the screening event was.
“It is testing for hepatitis B.”
“Yes, I know. Is it here?”
“You want testing for hepatitis B?”
“Yes. Is this the Herald Community Center?”
She nodded, and with a sigh of resignation, explained that I needed to go out and in the next building. “Hepatitis B!” She called after me, in a last ditch attempt to explain the situation.
I work on the Los Angeles Hepatitis Intervention Project (LA HIP), a project of the Asian Pacific Liver Center (APLC) of St. Vincent Medical Center, so actually, I didn’t need an explanation. I was in San Gabriel, CA, a predominantly Chinese suburb of Los Angeles, attending one of the APLC’s free screening events. I think the woman thought that I didn’t need to be screened, since I’m not Asian. The hepatitis B virus (HBV) disproportionately affects Asians and Pacific Islanders (API) in the U.S. – approximately one in ten has HBV and doesn’t know it. It is a particularly big problem in immigrant populations since many countries do not test for hepatitis B or vaccinate against it. Mothers with chronic HBV unknowingly pass the infection on to their babies whose immune systems are not strong enough to fight it off. The disease often shows no symptoms until middle age when severe liver damage has already set in. If caught early, the infection can be controlled with medication, and those who test negative can be vaccinated to prevent contracting it in the future. The APLC’s senior nurse practitioner, Mimi Chang, MSN, NP, recommends that all Asians and Pacific Islanders who have not built up antibodies to hepatitis B, either through vaccination or previous exposure to the disease, be immunized.
Asians and Pacific Islanders are not the only ethnic groups affected; any immigrant or child of immigrants from a country with a greater than 2% prevalence of HBV should be screened, according to the Centers for Disease Control (CDC). In addition to all of the API countries except Japan, this includes countries from Africa, the Middle East, the former Soviet Union, and Europe, among others. A complete list is included at the end of this article. It is also important to screen and vaccinate babies adopted from any of those countries, even if the adoption organization in the foreign country claims all tests and immunizations are up to date.
The virus is transmitted through blood contact, so household members and sexual partners of those with chronic HBV should be screened and vaccinated, as well as pregnant women, health care workers, homosexual men, intravenous drug users, and anyone traveling to a country with a high prevalence of hepatitis B. I didn’t know about viral hepatitis back in 1992 before I left to work in Russia. Luckily, I didn’t have a problem, but I wish my doctor had recommended that I get vaccinated. Unfortunately, because family doctors in the U.S. are lacking basic knowledge about the disease, testing and vaccination are not recommended as often as they should be for those at risk.
I have very little opportunity now to be exposed to HBV, and as a healthy adult, if I were to contract it, I would probably clear the disease on my own, but I wanted to understand the screening process that is part of our project. I went in to the other building and made my way to the registration table. Everyone was speaking Chinese. I grabbed a survey form and asked one woman where the screening was being set up. She didn’t understand. I asked her if she knew where Mimi or Jason were, two members of the APLC staff. She pointed me to another woman at the end of the table. I asked that woman, and she stared at me silently for a few minutes, shaking her head sideways. “Hepatitis B screening!” she barked at me. I guess she thought I was in the wrong place too.
A third woman approached the second woman and chatted with her loudly in Chinese. People reached around me from behind to grab survey forms, looking askance at me as they left. The new woman asked me what I wanted, and I asked again about Mimi, Jason, or any of the APLC staff setting up to screen. Her face lighted up. “Yes, yes!” she said excitedly. “You go see lady down there.”
I followed the direction of her outstretched arm to a tall blonde woman I had never seen before – the only other white woman in the room. Disheartened, I approached her. It turned out that she was the representative for Gilead, the pharmaceutical company sponsoring the event. While she didn’t know Mimi or Jason and had never heard of the LA HIP project, she did know that the screening would be upstairs, so I headed that way. I needed a familiar face.
I found Jason and the APLC volunteers setting up to screen. On one table there were a few laptop computers for entering basic registration data and preparing a test tube label for each patient. I hadn’t realized that staff was inputting this info twice – once on site and then again into the new data base LA HIP programmers had designed for them. It was good that I learned this; now our programmers are creating a way for the staff to easily upload this registration excel sheet into the data base directly, eliminating the data entry duplication. Other tables were set up with test tubes, rubber gloves, and disposable needles for drawing blood. The screening room was very organized, with signs in English and Chinese.
After taking some photos for the LA HIP Facebook page, I went back downstairs to sit in on the lecture by Tse-Ling Fong, MD, a liver specialist at the APLC. I was very excited to attend his talk; I had read a lot about hepatitis B and was eager to fill in any gaps in my knowledge. Additionally, I was curious to see what kinds of questions the audience members would have. Dr. Fong approached the front of the room and stood under a bright red slide with a large white “B” – part of Gilead’s “B Here” campaign to raise awareness of hepatitis B in the Asian American community (www.willyoubhere.com). Except for that massive B shining brightly above Dr. Fong, the rest of the slide was in Chinese. Then he began speaking in Chinese. He spoke in the same voice, with his usual calm, measured tone, and sounded so like himself that I had to strain to be sure that it wasn’t English. No, he was definitely speaking Chinese.
The experience was a little surreal, like watching a ventriloquist dummy. I was sure that he would switch to English in a few minutes. He didn’t. I turned to the man next to me. “Do you think he is going to do the entire lecture in Chinese?”
“Yes,” he answered. I groaned. “Do you need me to translate for you?” he offered. I smiled, happy to finally feel welcome, but declined. The man pointed to the survey form in my hand. “You know this is a test for hepatitis B?” I explained that I worked on a project doing outreach and designing a data base for Dr. Fong’s group, so yes, I did know. It felt good to finally give an explanation. I reminded him that Asians were not the only ones infected with hepatitis B, but he didn’t seem convinced.
I left my seat and moved up closer, crouching in the aisle to take pictures. When I was done with that, I filled out my survey form, and then I listened to Dr. Fong, trying to pick out Chinese phrases to identify. It was useless. The red slide with the white B stayed up the whole time, taunting me. Many of the audience questions seemed to deal with specific results of previous screenings, which I deduced from the lab reports being waved about as each question was posed. There were probably 70 people or so at the lecture, and on a Thursday afternoon at that, so people were definitely interested in the topic. This presentation had been advertised in Chinese language newspapers and was held at a community center in a predominantly Chinese area; other screenings were often held at local health fairs or churches in API communities.
When the lecture was over, a man with thick glasses made an announcement in Chinese. My neighbor explained the system – a range of numbers would be called out and when the number on my survey form fell into that range, I could go upstairs for the screening. He told me how to say 37 in Chinese so that I could recognize it when it was called. Right. I think it had seven syllables. Luckily Mimi spotted me and brought me upstairs herself. The staff entered my registration data, made a test tube label for my blood, and asked me to verify the information they had printed out.
As Mimi tied the tourniquet on my arm and felt for my vein with her finger, I looked away, slightly light-headed. “You’re not going to faint on me, are you?” Mimi asked loudly. “I’ve never had anyone faint on me.” A number of elderly patients smiled at me and chuckled. My lecture neighbor appeared at the table across from me and rolled up his sleeve for the nurse. “You’ll be fine, won’t you?” I nodded and breathed in deeply, focusing my gaze intently away from my arm. I imagined the hubbub that would ensue if I did pass out. “What was she doing here?” they would cluck at each other. “Didn’t she know this was a hepatitis B screening?”
The blood was drawn without any fainting spells and I gathered my things to leave. A young man offered me a bottle of water on my way out of the screening room, and then downstairs a pair of women handed out bright pink boxes from a local bakery. A present! A completely wonderful, unexpected present! I walked out into the bright sunlight, dumbfounded. An old Chinese man stood by the door with his box, apparently as surprised as I was. We looked at each other and smiled.
“It is nice, yes?” he pointed towards his box.
“It’s great!” I agreed. “I’m starving.”
Excited like a little kid, I tore open the pink box as soon as I reached my car. There was a little custard cup with fruit on top (I ate that right away) and two triangles of a sandwich with the crust cut off. I bit into one and the three layers slid out in succession like a set of stairs. It was white, pink, and gold, the ham all slippery from the mayonnaise and strange, foamy cheese. I ate all of it and loved it. If I’d also had a cup of tea, I think I would have fallen asleep right there, completely content.
Wednesday, May 19, is World Hepatitis Awareness Day. Currently 800,000 to 1.4 million Americans are chronically infected with HBV, a real tragedy since a vaccine does exist. The APLC’s Mimi Chang, MSN, NP, explains that the majority of those infected are foreign-born or the children of recent immigrants who just don’t know that they are at risk. “Hepatitis B is a silent disease. Patients don’t have symptoms until the liver is seriously damaged.” She adds that a bigger problem for the APLC is that many patients who test positive either have no insurance or are underinsured and can’t afford the treatment. “Patients who have HIV automatically get Medi-Cal, but there is no system for that with hepatitis B. They are similar diseases, but one is covered, and one is not. The CDC fund for HIV is much bigger than the one for viral hepatitis.” Patients who avoid treatment until they need liver surgery or a transplant create a much heavier financial burden on the health care system than they would have if their condition had been monitored and controlled.
The U.S. health care system needs to welcome all of its citizens, sick or healthy, recent immigrant or fourth generation American. My neighbor’s offer to translate, Mimi’s joking to relax me, and the pretty boxed lunch went a long way towards making me feel comfortable and, well, wanted. Shouldn’t we do at least that for our fellow citizens – particularly when the financial stability of our country and, even more importantly, lives are at stake? Solid policies to spread awareness and distribute timely treatment instill the warm acceptance that all Americans need to feel good about our country again.
Thankfully, my test came back negative for the hepatitis B antigen and negative for antibodies, which means I have no immunity to the disease and should be vaccinated. It is a series of 3 shots, $17 each at a reduced rate at the APLC. Next time I’ll try to catch the APLC’s other liver specialist, Dr. Ho Bae, when he gives a talk in Korean. I have no doubt that it will go as well as the first time.
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CDC recommends that people born in these countries or born of parents from these countries be tested for hepatitis B.
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.
excerpted from:
http://www3.interscience.wiley.com/cgi-bin/fulltext/122539808/PDFSTART
More information on hepatitis B test results and screening recommendations: http://www.immunize.org/catg.d/p2110.pdf
Information on advocacy efforts to increase funding for viral hepatitis and link to download copy of the IOM report “Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C” www.nvhr.org
Asian Pacific Liver Center www.asianpacificlivercenter.org
LA HIP http://www.facebook.com/home.php?#!/pages/LA-HIP/99719721952
Conference Report: “The Dawn of a New Era: Transforming our Domestic Response to Hepatitis B & C” April 12, 2010
Posted by Marianne Ruane in : Health , add a commentThe conference “The Dawn of a New Era: Transforming our Domestic Response to Hepatitis B & C” was held in Washington, DC from September 10-11, 2009. It was described as “a multi-stakeholder national forum convened to develop a coordinated national response to chronic viral hepatitis through improved prevention, detection, and patient care.” It was the first hepatitis-related professional event to bring together doctors, researchers, pharmaceutical reps, public health officials, outreach and advocacy experts for a discussion of how better to address the issue of viral hepatitis in the U.S. The chance to network with other professionals in the hepatitis outreach field (several of whom I had already corresponded with) was invaluable as was the opportunity to learn more about the extent of viral hepatitis affecting our country. The work done by the Asian Pacific Liver Center (APLC) and the Los Angeles Hepatitis Intervention Project (LA HIP) is incredibly important. I welcomed the occasion to learn more about hepatitis C, since we primarily work with HBV on the LA HIP project, and I was particularly interested to hear speakers from San Francisco talk about the successful Hep B Free/Jade Ribbon Project there.
The Problem of Viral Hepatitis
W. Ray Kim, MD, spoke on the increasing burden of chronic viral hepatitis B and C. From his abstract: “In the United States, since the implementation of universal and retroactive immunization efforts, as well as universal precautions in needle use and in health care settings, acute hepatitis B virus (HBV) infection decreased by as much as 80%. However, these changes in acute infections have not translated into diminished prevalence or burden of chronic HBV infection. While HBV remains uncommon in the general population in the U.S. (prevalence <1%), screening data have identified subgroups with high (sometimes >15%) prevalence: namely, foreign-born minorities from HBV-endemic areas of the world. This trend is reflected in the health care and economic burden associated with HBV infection, which increased at least 4-fold during the 1990s. Most recent data suggest that the introduction of effective antiviral agents may have slowed this rising trend; however, to the extent that available treatments do not eradicate the infection but merely control it; the number of Americans living with chronic HBV continues to grow.”
The increased prevalence of chronic HBV is a result of immigration. According to the abstract of Cindy Weinbaum, MD, MPH, of the Centers for Disease Control (CDC), there are 800,000 to 1.4 million Americans chronically infected with HBV, 47-70% of whom were born in other countries. While immigrants are also a substantial percentage of those affected with hepatitis C, the highest proportion of those infected is intravenous drug users (IDU) (48%). Nine percent of those HCV patients used intravenous drugs only once or twice in isolated incidents (Fasiha Kanwal, MD, MSHS). Approximately 3.2 million people in the U.S. have chronic hepatitis C.
In his talk, “Why Does Hepatitis B Infection Still Occur and How Can We Prevent It?” Dale J. Hu, MD, MPH, of the CDC explained the national policy that reduced the number of acute hepatitis B cases. From his abstract: “A comprehensive strategy for eliminating hepatitis B virus (HBV) transmission in the United States was recommended in 1991. Its 4 elements included 1) universal vaccination of infants, 2) screening of pregnant women, 3) catch-up vaccination, and 4) vaccination of adults at increased risk. Since 1990, the overall incidence of acute HBV has declined by more than 80%. Nevertheless, almost 400 million people worldwide and 800,000 to 1.4 million people in this country have chronic HBV infection. With ongoing immigration from countries with intermediate to high HBV prevalence, approximately 90% of new cases of chronic HBV infection are among foreign-born persons, many of whom are unaware of their infection.” Over 50% of these foreign-born infected patients are Asian or Pacific Islander (API), most of whom received the disease through perinatal transmission.
An explanation of how chronic HBV develops and of who is most at risk for liver disease was presented by Adrian M. Di Bisceglie, MD, FACP. The majority of hepatitis B cases are caused by mother to child transmission at birth, and those infected as neonates have the highest frequency of chronic hepatitis B infection. Some of these infected individuals will not develop liver disease but those with ongoing viral infection and increased viral loads will have the worst outcomes. Screening patients and treating them before liver damage sets in is vitally important. As reported by Dr. Weinbaum, the CDC maintains that “(e)arly identification of HBV or HCV infection enables one to initiate care in order to prevent, delay, or reverse liver disease.” The CDC published updated testing recommendations for hepatitis B in 2008 and updates for HCV screening are expected in 2010-2011.
Willis C. Maddrey, MD, MACP, discussed the barriers to success in eradicating both diseases – lack of awareness; the fear, distrust of and resistance to the prescription drugs that treat the conditions; denial and the difficulty of convincing a person who seems well to get treated; access to health care. The health care reform package will offer some relief to the problem of access, which is a good start. Racial, ethnic, socio-economic, education and language barriers add to the challenge of addressing these diseases. Hepatitis C was officially discovered in 1990 and new techniques for screening (oral samples for example) expected in the next few years will greatly improve outreach.
Even when infected patients are found and treated, several factors, many particularly relevant to the API immigrant population, affect the outcome. A presentation on the difference between efficacy and effectiveness, “When Good Treatments Fail,” was given by Hashem B. El-Serag, MD, MPH. “Efficacy is defined as the extent to which a specific intervention produces a beneficial effect under ideal conditions, usually clinical trials, and is largely determined by the biological effects of a therapy, whereas effectiveness is the extent to which an intervention is beneficial when deployed in a community-based practice setting and takes into account external factors such as patient characteristics, heath system features, or societal influences. In addition to pharmacological and physiological effects, several other issues must be considered for an intervention to be effective: 1) availability to patients who can obtain maximum benefit; 2) identification of patients for whom the intervention is appropriate; 3) provider recommendations; 4) acceptance of the intervention by patients; and 5) adherence to treatment at the recommended dosing. Community effectiveness is calculated by multiplying the probabilities of these parameters and once all factors are considered, the overall community effectiveness of a therapy is typically much lower than its efficacy.”
The issues affecting Asian and Pacific Islander communities in Los Angeles – lack of health insurance and money to pay for medicine and services, the difficulty reaching target populations because of the stigma associated with hep B as well as the reluctance to seek screening and care when there is a lack of symptoms, the poor knowledge of hepatitis B and its disparate effect on these communities by healthcare professionals – are the same issues affecting health outcomes for HBV around the country. In fact, Los Angeles rated as one of the lowest cities on a geographic scale that measures patients’ likelihood of receiving appropriate care. One of the goals of the conference was to address how these disparities could be addressed in the various ethnic communities with a higher prevalence of hepatitis B. The area of community effectiveness could potentially be greatly advanced with health technology innovations in the next few years.
There is considerable economic justification for a national plan to address the problem of chronic hepatitis B, as described by John B. Wong, MD. In 1993, the average lifetime cost of chronic HBV infection was $60,000. In 2003, that number had increased to $88,600. The U.S. spends 17% of its GDP on health care expenditures – an amount that totals 40% more than the expenditures of European countries. On average, Americans now spend 41% of their wages on health care. Patients with chronic HBV spend $4,500-$28,277 per year on antiviral drugs alone. As the cost of health care increases in the U.S., prevention of HBV by screening and vaccination as well as early detection and timely treatment can provide enormous cost savings.
The statistics regarding hepatitis B are presented as ranges, rather than exact numbers, because monitoring and reporting efforts are not comprehensive. As Dr. Hu of the CDC mentioned in his abstract, “…(S)urveillance efforts should be enhanced to ensure complete and accurate reporting so that the impact of strategies for preventing HBV can be monitored and evaluated.” Another speaker from the CDC, John W. Ward, MD, advocated the formation of state registries to track viral hepatitis trends. These profiles on chronic disease would then inform local action, engage a broad array of stakeholders, and encourage the creation of community-based organizations. Over and over during the conference, speakers and participants commented on the lack of surveillance to evaluate the effectiveness of outreach programs. The LA HIP statistics as a result of the online data collection tool, particularly if it is adapted for web use by potential patients before they are screened (eliminating some of the time required for data entry as patients would enter their own data), will be a unique feature among hepatitis B groups that will generate a lot of interest.
Possible Solutions
Many of the hepatologists and other specialists at the conference suggested that primary care physicians take on a larger role in screening and vaccinating patients at risk for hepatitis B and C. Many of them complained that primary care providers were woefully unknowledgeable about the infections and the risk factors. CDC doctors Hu and Weinbaum asserted that official guidelines for identifying and managing people with chronic hepatitis infections had been released and that the CDC encouraged doctors to educate their patients about their conditions so that they could make the necessary behavior modifications to keep from spreading the diseases. Dr. Samuel So, MD, FACS, from Stanford University’s Asian Liver Center, said that every Asian seeing a primary care provider should be tested for HBV, period, the way men over 50 are routinely given a colonoscopy or older women a mammogram. One suggestion was for at-risk women to be screened as part of their yearly gynecological exams.
Others, including Litjen (LJ) Tan, MS, PhD, who spoke on behalf of the American Medical Association, explained that in the ten minutes an overworked physician has to see a patient, there simply isn’t time to review everything or get a detailed history. Son T. Do, MD, explained that physicians often don’t know about the prevalence of hepatitis B in certain ethnic populations and additionally are confused about which tests to order. Screening is inconsistent and practitioners have little time to discuss the condition with their patients or ensure follow up with their family members. Some suggestions he presented were to implement employer screening programs; to educate and train nurse practitioners, nurses, and physician’s assistants in screening and vaccinating; to fund medical assistance for those with low incomes; and to improve the referral network for chronic hepatitis B patients. A coordinated national strategy could greatly reduce the complications of HBV and eventually eradicate the disease entirely.
Though everyone agreed that target populations needed to be better informed, the conference participants did not reach a consensus on how that could best be achieved. One possibility was to screen for HBV and HCV, at least for API-Americans and others in high risk groups, in STD clinics. Those who tested and were shown to be lacking antibodies for hepatitis B could be vaccinated, thus reducing the need for continued testing each year. Dr. Shannon Hader from the HIV/AIDS division of the Department of Health suggested that organizations dealing with hepatitis, HIV, and STDs work together and that hepatitis B groups might benefit by working more closely with those addressing hepatitis C. Another idea was for community clinics to test API Americans or other at-risk immigrants when they came in for any complaint and to vaccinate those who did not already have immunity. The entire medical community needs to be more informed about the problems of viral hepatitis so that the target populations can be better served.
While physicians lack knowledge about hepatitis B, so too do politicians, and additional funding to tackle the problems of viral hepatitis will not be approved until awareness has been increased. Congressman Bill Cassidy, also a physician, opened the conference with a talk on the importance of educating government officials on viral hepatitis. He explained that the majority of public officials really have no idea what hepatitis is or how desperately funds are needed to eradicate the problem.
Another suggestion for improving care for chronic HBV patients was presented by Vernon Smith, PhD. He advocated expanding Medicaid coverage for hepatitis B to all low income adults and eliminating the five year residency requirement. Currently only low income children and their parents, people with disabilities, and senior citizens over 65 are eligible. Medicaid does not cover younger non-disabled adults without children, regardless of income. Increasing Medicaid coverage for those individuals, particularly those infected with hepatitis B, would provide great savings to the federal government by allowing treatment for patients before cirrhosis or other severe liver problems set in, decreasing the need for surgery and liver transplants.
Lester N. Wright, MD, MPH, Chief Medical Officer for the Department of Correctional Services of New York State, proposed an interesting way to reach a badly neglected target population. Since 30% of patients suffering from acute hepatitis B have a history of incarceration, he suggested that public health team up with government institutions to immunize inmates in prisons and jails. “The U.S. Centers for Disease Control and Prevention (CDC) estimates that 2% of inmates have chronic hepatitis B virus (HBV) infection and 15% have antibodies for hepatitis C (HCV). Nearly one-third of cases of acute HBV in the United States occur in people who have previously spent time in correctional facilities. However, most inmates, if offered HBV immunization, will accept it. Thus, collaboration between corrections and public health can facilitate prevention education, HBV immunization, HBV and HCV treatment, and continuity of care on discharge.” And would do much to alleviate the burden of viral hepatitis in the U.S.
As countries with a high prevalence of HBV offer vaccines to their citizens, the problem will decrease around the world. The CDC strongly supports a global immunization program, but in the meantime, the United States needs to come up with a strategy to deal with the burden of viral hepatitis on its own shores.
Case Studies
Dr. Samuel So, the director of the Asian Liver Center at Stanford University, recounted the success of San Francisco Hep B Free, “the nation’s first citywide campaign to test and vaccinate all API adults for hepatitis B.” From 2001-2006, there were 3,163 APIs screened in the Bay area. Nine percent of those tested positive for hepatitis B, and two-thirds of them were unaware that they might be infected. Of the people who claimed to have already been vaccinated, 5% were positive. With a high Chinese population, the Hep B Free Project, along with the Jade Ribbon Campaign (“a culturally and linguistically targeted awareness campaign uniting health care providers, community organizations, policy makers, and the media”), found Chinese newspapers to be the most effective media outlet for spreading the word. The project is helped greatly by the San Francisco Department of Public Health which keeps a registry to track the patients who test positive for hepatitis B. The cost for screening and vaccination of hepatitis B is $60, while receiving vaccines for both hepatitis A and B runs $96. A good place to target seems to be refugee health programs.
Co-director and steering committee member Ted Fang of AsianWeek magazine gave more information about the San Francisco Hep B Free campaign. He said that of the 15.2 million Asian-Americans in the U.S., 32% came to this country as adults; 30% immigrated as children and were raised in the U.S.; and the final 38% were born in America. That meant that 2/3 of the Asian-American population was brought up in the U.S., which made English language materials the logical choice for the San Francisco campaign. While he did not feel that the outreach materials had to be in an Asian language, he did stress creating culturally appropriate materials that would have more resonance with potential patients. Asians have been living in the U.S. for the last 40 years and by 2011 will have amassed $626 million dollars in buying power. Janet Zola, MPH, of the San Francisco Department of Public Health who is also a member of the Hep B Free steering committee talked about the importance of developing local connections to increase awareness. Now in San Francisco, information on hepatitis B is given to every newly married couple along with the marriage license.
Also on the west coast, Kaiser Permanente keeps a Viral Hepatitis Registry of patients infected with HBV and HCV in its Northern California Medical Care Program membership, as described by M. Michele Manos, PhD, MPH, DVM. “This integrated, comprehensive managed care program serves more than 3 million members, who represent about 25% of the insured in the region. Current patients include approximately 14,000 infected with hepatitis B and 20,000 with hepatitis C, most with at least 5 years of plan membership.” Extensive electronic medical records provided Kaiser Permanente with the data needed to assess the current realities of viral hepatitis.
On the other coast, a model that might be worth emulating for the Asian Pacific Liver Center is the Charles B. Wang Community Health Center in New York City. Su Wang, MD, MPH, gave a presentation on the center which sees a high percentage of foreign-born patients, who are twice as likely to be without health insurance. According to her statistics, more than one million HBV-infected patients are hospitalized each year. Her clinic does what it can to address the problem of hepatitis B before patients become extremely ill. The center keeps a HBV disease registry which is tied in to the system of electronic medical records. The registry keeps a flow chart of tests for each patient which greatly aids the doctors. The center staff also educates patients on self-trackers and provides them with an HBV record that allows them to manage their condition, even when they switch providers. This could be employed easily by most healthcare providers.
The clinic puts great emphasis on screening pregnant women and educating them on vaccinations and treatments for their babies. Follow up of infants with HBV-infected mothers is difficult since many of the Chinese mothers send their babies back to China to be cared for. The center advertises its screenings and programs most often on local language radio programs and newspapers. “From 2002-2008, 6600 individuals were screened through these programs. In the two largest efforts, 22% (881) of people tested positive for HBV, 28% (1120) needed HBV vaccination, and nearly 75% (819) of those completed their vaccine series. In one program where comprehensive care services were offered at no cost, 62% (396) accessed free follow-up care and approximately 20% (75) of those needed antiviral medication.”
Conclusion
Despite the large numbers of people in the U.S. infected with viral hepatitis, prevention and clinical care efforts are inadequate. More funding to address these diseases will reduce the economic burden on our country by providing the means to develop and implement a national strategy to improve outreach, testing, vaccination, and treatment programs. Surveillance is key to evaluating the success of new initiatives while accurately assessing the breadth of the problem. Several cities and institutions are employing successful programs that may be applied across the U.S. in a more coordinated effort.
Wireless Solutions in a Brave New World March 25, 2010
Posted by Marianne Ruane in : Health , 2comments“Imagine a world in which everyone has an electric smart car. As drivers are about to leave work, their cars ask them whether they will be making any ancillary stops or going straight home. Based on that answer, the cars will decide whether powering up is necessary, and if so, where the cheapest place is to do that. Perhaps the car has enough energy for the ride, and decides to sell some extra energy to the power company’s grid while prices are high. The car may even decide to buy power back from the grid in the evening when cost is lower and might even negotiate a better price with the power company.” I’m paraphrasing, but he really did use the word “ancillary,” which made me think that the car’s vocabulary might need to be simplified for the general population. My colleagues and I were chatting over lunch with James Avery, Senior Vice President of Power at Sempra Energy. In the current climate of pessimism over seemingly insurmountable economic difficulties, the speakers at Qualcomm’s recent conference offered glimpses into a brave new world full of wireless solutions offering efficiency, savings, and true inspiration.
We attended the Fifth Annual Smart Services Leadership Summit held July 28-29 in San Diego. The conference was hosted by Qualcomm, a leading provider of wireless technology and services. The event was an opportunity for business leaders and technology experts to learn about the development of M2M (machine to machine) and Smart Services across the healthcare, energy, transportation, and consumer industries. With widespread cell phone use (4 billion users out of 6.5 billion total people in the world), almost ubiquitous connectivity, and the technological advances that allow for 3G broadband and smart devices at a lower cost, the world is perfectly positioned for a complete transformation in the way we do everything.
Take reading a book, for example. Russell Baker, the Director for Amazon Kindle, spoke about the business plan for the Kindle, a portable device that allows for reading electronic books. At approximately $10 a pop (at least half the cost of a hard cover book), Kindle owners can download and store thousands of their favorite titles. The wireless component is embedded in the device, so no hook up to a computer or local Internet connection is necessary, and the Kindle ships “hot” (all ready to use). Readers can also download newspapers or magazines, and there is a dictionary feature that allows for an instant definition search of unknown words. The development of the device involved a unique approach that started with the customer and worked backwards to the creation of the hardware and software (press release, FAQ, customer experience mock ups, user manual, and then the business requirements to make the equipment).
While I have a personal fondness for turning the musty yellowed pages of my favorite dog-eared books, it’s easy to see that this technology promotes ease and economy – particularly for the avid reader who travels. Another plus is the concern for the consumer that does not stop at the purchase of the item. The Kindle staff maintains a forum for users’ questions and comments and has initiated a “See a Kindle in Your City” program that allows potential users to join up with current owners to see if they like the device before purchasing. In a world in which technological advances mean fewer interactions with real people and more communication with signals and machines, it is fitting that the business model should allow for social networking. Two-way communication becomes a necessary way for consumers to feel valued and connected to a part of a bigger whole that may be as invisible and ubiquitous as the networks that make it all possible. Will that be enough? With less and less face-to-face contact in the future, will our brains and communication skills develop differently?
With a similarly consumer-driven model is Zipcar, a shared-car subscription service that is bubbling up in large metropolitan areas that have strong transit systems. “Zipsters,” the members of this service, pride themselves on their participation in this socially and environmentally conscious group focused on responsible urban living. Zipcar Chief Technology Officer Luke Schneider calls their business plan “disruptive innovation in personal transportation.” In this new mode of thinking, standard of living is raised by reducing costs, not raising wages. Zipsters save on car payments or purchase costs, maintenance, storage, and insurance premiums by only paying for the time they actually use the car. Congestion and pollution are alleviated in the cities.
Now subscribers are able to reserve online and enter the car with a key card. Upcoming iPhone applications will find the driver’s location, search out the closest Zipcar, give him or her directions to the car, provide maps to the destination – even help the member find a parking spot (several of which are reserved for Zipcar by the city.) The business plan emphasizes periodic surveys and direct communication with members to gauge their opinions and values. Knowing “who is behind the wheel” allows Zipcar to develop a product and service that revolutionize how our society looks at car ownership.
I’ve wondered about the future before – whether gas prices wouldn’t get so high and fuel so scarce that every person would not be able to possess his or her own car. How would Americans feel about this loss of independence? Will there come a time when driving oneself to run errands after work is a luxury? I used to be afraid of a complete change in society’s priorities and modes of life, but Zipcar makes it look fun. Okay, fun might be too strong, but I can certainly entertain the idea of a world without the hassle of car ownership. If I were a subscriber in a car service that took care of all the insurance concerns, maintenance updates, gas filling – would part of my brain atrophy? Would having no responsibility to remember or monitor upkeep on my own make me … Lazy? Entitled? Irresponsible? Or would it leave more time for me to take on other socially conscious roles that I can’t devote time to now? Would I feel pressure from the group to do my part in improving the system – a Marxist version of The Jetsons?
I also question the practicality of these future products and services. The four billion cell phone users on the planet are not all using smartphones. A June 2009 issue of Business Wire predicts that smartphones will make up 38% of all handsets by 2013. A good portion of the other 62% of the population with simpler models cannot afford their more advanced counterparts. Will that create more of a gap between rich and poor? Are the older generations and the less educated going to be afraid of the new technology? Will the ramification be an even more stratified society? Will those countries with a higher percentage of cell phone use due to the lack of land lines surpass the U.S. technologically and economically? Would that be bad? For those customers who are in the market for a smartphone, how do they decide which one to pick? One participant that I spoke to at lunch was concerned that so many services were focusing on the iPhone rather than the Blackberry; apparently applications for one are not compatible with the other. That fact certainly limits the customer’s range of choices, as does allowing one wireless provider to have a monopoly on any particular product (as in the case of AT&T wireless with iPhone).
Despite these concerns, the future of wireless solutions is looking pretty solid, and the possibilities are truly exciting. Dr. Rajit Gadh, PhD, UCLA Professor and Director of its WINMEC partnership, spoke of future energy supplies being maintained by a “smart grid” whose functions and capabilities would resemble a living organism. He said that people would be able to “talk” to appliances in their homes through mobile devices and that those appliances would be able to communicate their status back. Thermostats would become obsolete, as would living, breathing meter readers that currently make a physical trip to every residence to check energy consumption. James Avery of Sempra Energy told us at lunch that despite all the advances his company has made, it still has no way to know of a blackout unless a customer calls to complain.
A smart grid that could work with households and corporate buildings to come up with individual solutions for a more efficient and economical use of power is something I strongly support. I am a little concerned though about those meter readers and other utility company workers who will be out of work. Will they be the ones trained to monitor the new equipment? Do they have the base education they need to succeed? I am particularly worried in California where all of the proposed versions of the still elusive budget call for massive cuts in education spending. If my state is indicative of priorities elsewhere in the country, the U.S. will be sorely lacking the educated work force that it needs to man these new technologies.
Assuming, however, that the American work force is up to the challenge, some innovative wireless solutions are going to be available across industries. Steve Hudson, Vice President for Strategy and Business Development of OmniLink Systems, spoke about location sensors that could be used to keep track of Alzheimer’s patients who might wander out of a set zone. The same sensors could also monitor criminal offenders. With the current budget crisis in California forcing an early release of prisoners, wireless monitoring might be the more cost effective solution that still allows for public safety.
We learned about another interesting use of wireless devices at breakfast one morning with some employees of John Deere. They use various sensors to monitor the “health” of big pieces of equipment, reducing the time mechanics spend in the field doing manual checks. Ben Goldberg, Client Services Manager at Qualcomm, spoke about this tracking of heavy machinery, which can not only indicate physical problems with the equipment, but also supervise preventive maintenance and keep track of time and gas lost by machines standing idle. Companies owning this equipment can use a sophisticated calculator function to figure out their potential savings from installing the sensors, which changes the way the companies think about the investment.
Most fascinating to me personally was the Arizona-based company eSoles which manufactures custom insoles for sports shoes with sensors that measure speed, distance traveled, pressure, and other parameters important to movement and balance, transmitting the details to a web site that can be accessed on a cell phone. A basketball player could find out how high he jumped during a game, and a golfer could determine from swing to swing how her balance was affecting her movements in order to correct it. I’m not sure whether I could get an insole in a pair of socks for beach volleyball (and I don’t suppose I’d need a sensor to tell me that I don’t jump very high), but it’s fun to think of the possibilities – track, analyze, and optimize. Elderly patients with these insoles could be monitored as well; when the movements indicated an off-balance gait, the sensor could send an alert to a caregiver’s wireless device before a fall took place.
My colleague Al Stone and I work on a healthcare consulting team headed up by Steven Stumpf, EdD, and as such, the three of us were most interested in the implications of wireless solutions for healthcare. Dr. Eric Topol, Chief Medical Officer of West Wireless Health, talked about the possibilities for wireless devices in the management of chronic conditions. Though the U.S. spends a large amount on its healthcare system – 16% of the GDP – it is only 19th in the world for quality of care. With such a horribly wasteful system, there is a lot of room for improvement. With the right wireless devices, every person’s home will have the potential to become a wireless ICU, monitoring a patient’s vital signs and transmitting those signals to a caregiver’s cell phone or data hub. The elderly will be able to stay at home as they age, greatly reducing the need for assisted living and nursing homes. Conditions such as asthma, breast cancer, diabetes, obesity, and sleep disorders are just some of those that are managed more easily with wireless devices, diminishing considerably the time spent in doctor’s offices and labs for routine check-ups and tests. Fewer medical visits, especially to hospitals, have the potential to lead to astronomical savings.
Aaron Goldmuntz, the Director of Business Development for Cardionet, explained one wireless solution for healthcare. His company provides heart monitors that transmit ECG data for arrhythmia diagnosis and evaluation of treatment efficacy. Because atrial fibrillation is fairly common in stroke victims, patients who survive one stroke and are found to have an arrhythmia can be regularly monitored, dramatically decreasing the chances that they will suffer another stroke and spend time in the hospital again. Representatives from the company Brainlike explained that their service can minimize the information gathered from the health sensor to its most essential, thus lowering the drain on the battery of the device. Once individual parameters are set, only the data alerting a caregiver to a possible problem needs to be sent.
The medical advances described made me think about our own Los Angeles Hepatitis Intervention Project (LA HIP) in Los Angeles. Patients with chronic hepatitis B need to have their liver enzymes checked every six months for indications of cirrhosis or liver cancer. Compliance is notoriously low, most likely because of the high cost and the target population’s lack of insurance. If the amount of blood needed for the screening was low enough that people could gather a few drops at home, they could test it themselves on a sensor that would send the information directly to a clinic or to the doctor. Only when the tests alerted medical staff to higher than normal levels would the patients need to make a visit in person. This would lower costs, increase compliance, and save doctors and clinical staff valuable time. It may not be feasible now, but it certainly seems like something that may be possible in the future.
I’m fascinated with all of the possibilities for wireless technology, particular in healthcare which is so desperately in need of reform. I’m a recovering control freak who is thrilled with the thought of tossing messy jumbles of cables and wires. I feel relaxed when things are organized and efficient, and I love the thought of saving resources, money, and lives. How quickly will these changes come? I think about my parents who can’t seem to figure out how to program numbers into their cell phone and simply don’t retrieve their voicemail messages. As we brainstormed ideas relevant to our own project on the way back to Los Angeles, my colleagues in the front seat decided to test out the car’s rarely used GPS system, in honor of the future as presented to us at the Qualcomm conference. It took a few tries, but they got it to work. I told them they could change the view to have the arrow pointing straight ahead, the way the car was driving, to more accurately simulate our driving experience and make reading the map easier. “No, no, don’t touch anything!” Steve reprimanded, afraid to lose the settings that had been eluding them. “Leave it the way it is.” Change will come, one step at a time.