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Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C 3 Knowledge and Awareness About Chronic Hepatitis B and Hepatitis C An estimated 0.8–1.4 million people in the United States are chronically infected with hepatitis B virus (HBV) and 2.7–3.9 million people are chronically infected with hepatitis C virus (HCV). However, there is relatively poor awareness about these infections among health-care providers, social-service providers, and the general public. Lack of awareness about the prevalence of chronic viral hepatitis in the United States and about the proper methods and target populations for screening and medical management of chronic hepatitis B and hepatitis C probably contributes to continuing transmission; missing of opportunities for prevention, including vaccination; missing of opportunities for early diagnosis and medical care; and poor health outcomes in infected people. As discussed in Chapters 1 and 2, surveillance data on the numbers of people acutely and chronically infected with HBV and HCV are imprecise and can be difficult to interpret. The prevalence of chronic infections remains high for several reasons, and the aging of the chronically infected population has contributed to the tripling of liver-cancer incidence during the last three decades (Altekruse et al., 2009; McGlynn et al., 2006). The persistently high prevalence of chronic HBV infection can be attributed in part to immigration of chronically infected people from HBV-endemic regions—including East Asia, Southeast Asia, and sub-Saharan Africa—to the United States. The high prevalence of chronic HCV infection is due in part to the lack of access to preventive measures, such as harm-reduction programs, and lack of access to antiviral treatments in high-risk populations. This chapter is divided into two sections. The first addresses knowledge and awareness about hepatitis B and hepatitis C in health-care providers
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Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C and social-service providers; the second addresses the topic with reference to the general population and at-risk populations. Each section begins by describing what is known about the levels of knowledge and awareness about hepatitis B and hepatitis C and how gaps in education about these diseases are affecting prevention, screening and testing, and treatment opportunities. Those summaries are followed by the committee’s recommendations for addressing the gaps and the rationale and supportive evidence for the recommendations. KNOWLEDGE AND AWARENESS AMONG HEALTH-CARE AND SOCIAL-SERVICE PROVIDERS The committee found that knowledge about chronic hepatitis B and hepatitis C among health-care providers, particularly primary-care providers (for example, physicians, physician assistants, and nurse practitioners), and social-service providers (for example, staff of drug-treatment programs, needle-exchange programs, and immigrant services centers) is generally poor. Although there have been no large-scale, controlled studies of health-care providers’ knowledge about chronic hepatitis B and hepatitis C, it is clear that knowledge has been imperfect among providers in all the surveys whose results have been published. Subjects of deficient knowledge include The prevalence of chronic hepatitis B and hepatitis C in the general and high-risk populations in the United States. The clinical sequelae of chronic viral hepatitis. The characteristics of at-risk persons who should be tested for chronic HBV and HCV infection and vaccinated to protect them from hepatitis B. The approaches to primary and secondary prevention in addition to hepatitis B vaccination. The proper methods of testing and interpretation of test results. The proper followup management for chronic infection. Provider guidelines for hepatitis screening, prevention, treatment, and followup have been in place for decades and are updated regularly (CDC, 1991, 1998, 2005, 2008b, 2008c; Ghany et al., 2009; Lok and McMahon, 2009; Mast et al., 2005, 2006). However, current studies of provider knowledge about chronic viral hepatitis have not identified why health-care providers fail to follow national recommended guidelines.
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Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C Hepatitis B Studies have shown that many primary care providers cannot differentiate between adult populations that should be screened for chronic hepatitis B because of their high prevalence of chronic infection (for example, people born in geographic regions with high HBV endemicity; see Box 3-1) and populations that should be vaccinated against HBV because of their high risk of becoming newly infected (for example, health-care workers, men who have sex with men, prison inmates, and household and sexual contacts of chronically infected individuals) (Euler et al., 2003b; Ferrante et al., 2008; Lai et al., 2007). In a survey of primary care providers in San Francisco, all 91 respondents correctly answered that Chinese immigrants have a higher prevalence of chronic hepatitis B than non-Hispanic white or US-born Chinese people. However, a portion of the same group incorrectly identified HIV-infected BOX 3-1 Geographic Regions That Have Intermediate and High Hepatitis B Virus Endemicity Africa: all countries Asia and Middle East: all countries South and Western Pacific: all countries and territories but only indigenous persons in Australia and New Zealand Eastern Europe: all countries except Hungary Western Europe: Greece, Malta, Portugal, and Spain and indigenous populations of Greenland North America: Alaska natives and indigenous populations of northern Canada Central America: all countries South America: Argentina, Bolivia, Brazil, Ecuador, Guyana, Suriname, Venezuela, and Amazonian areas of Colombia and Peru Caribbean: Antigua and Barbuda, Dominica, Dominican Republic, Grenada, Haiti, Jamaica, Puerto Rico, St. Kitts and Nevis, St. Lucia, St. Vincent and Grenadines, Trinidad and Tobago, and Turks and Caicos SOURCE: Modified from Mast et al., 2006.
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Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C persons (16%), men who have sex with men (18%), and injection-drug users (IDUs; 23%) as having a higher prevalence of chronic hepatitis B than Chinese immigrants (Lai et al., 2007). In the same study, 30% of the respondents were not able to identify the correct test to use for diagnosing chronic HBV infection. A cross-sectional survey conducted among 217 members of the New Jersey Academy of Family Physicians found that a higher proportion of family physicians recommended screening for hepatitis B among men who have sex with men (93%), IDUs (95%), and HIV-infected patients (96%) than for immigrants from Southeast Asia (68%) or sub-Saharan Africa (57%)—areas that are highly endemic for HBV with over 8% seroprevalence of hepatitis B surface antigen (HBsAg) (Ferrante et al., 2008). Only 50% of survey participants recommended screening household contacts of persons who had chronic HBV infection—an established high-risk population. Finally, 21% of the New Jersey family physicians did not know what step to take next if a patient tested positive for HBsAg or would refer such a patient to a specialist for followup (Ferrante et al., 2008). However, 83% of the respondents were interested in receiving education about chronic viral hepatitis. Chu (2009) presented data at the 2009 International Symposium on Viral Hepatitis and Liver Disease that showed that only 18–30% of Asian American primary care providers who treat Asian American adult patients reported routinely testing them for HBV infection in their practice. That finding illustrates the incomplete knowledge even among primary care providers who themselves constitute a group at high risk for chronic HBV infection. At the 2007 Society of General Internal Medicine annual meeting, Dulay et al. (2007) reported on the results of a multiple-choice hepatitis B knowledge survey completed by 196 attendees at a university-based continuing-medical-education conference for primary care providers, including nurse practitioners and physician assistants. Of the respondents, 55% were not able to identify HBsAg as the determinant for chronic HBV infection. Knowledge about the appropriate use of the HBsAg test was substantially higher among primary care providers who were Asian (68%) than those of other ethnicities (43%), among physicians (56%) than nonphysicians (23%), and among providers who had more years of experience or more time spent in the clinic. Some 44% of the respondents did not know that chronic HBV infection could be controlled with medication, and 25% incorrectly responded that chronic HBV infection is curable. Given that the probability of developing chronic hepatitis B is highest when infants are exposed to HBV through their mothers at birth, both the US Preventive Services Task Force and the US Centers for Disease Control and Prevention (CDC) recommend testing all pregnant women for HBsAg
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Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C during an early prenatal visit even if they have been previously vaccinated or tested (CDC, 1991; U.S. Preventive Services Task Force, 2009). Currently, only 27 states have maternal HBsAg screening laws (CDC, 2008c). State screening laws do not necessarily translate into higher testing rates, because they often do not include an enforcement mechanism or sanctions for noncompliance (Euler et al., 2003b). In a study of family physicians in New Jersey, a state with a maternal screening law, Ferrante et al. (2008) found that 22% of respondents indicated that they did not recommend testing pregnant women for HBV infection. At the 2009 International Symposium on Viral Hepatitis and Liver Disease, Chao et al. (2009b) presented results of a study of perinatal health-care providers’ knowledge about hepatitis B and the management of HBsAg-positive pregnant patients recommended by the Advisory Committee on Immunization Practices (ACIP). Questionnaires were mailed or administered to 100 practicing obstetrician/gynecologists (OB/GYNs) and 31 peripartum nurses in Santa Clara County, CA, an area with one of the largest annual numbers of HBsAg-positive pregnant women in the United States. Although most of the OB/GYNs reported that they tested pregnant women for HBsAg and properly advised HBsAg-positive women that their newborns should receive the hepatitis B vaccine and hepatitis B immuno-globulin within 12 hours of birth, overall knowledge about hepatitis B was low. Only 26% of OB/GYNs and 10% of peripartum nurses knew that the prevalence of chronic hepatitis B is higher in Asians than in other ethnic populations; only 33% of OB/GYNs and 17% of peripartum nurses knew that there is a high risk of HBV infection becoming chronic in exposed newborns; and only 22% of OB/GYNs and 37% of peripartum nurses knew about the risk of death conferred by chronic hepatitis B. Only 62% of the OB/GYNs referred their HBsAg-positive pregnant patients for chronic-hepatitis management. Hepatitis C Health-care providers’ knowledge about hepatitis C appears to be similarly insufficient, although there is far less published research on this topic (Ascione et al., 2007; Ferrante et al., 2008; Shehab et al., 1999, 2001; Strauss et al., 2006). In the study of New Jersey family physicians described above, Ferrante et al. (2008) found that although 95% would recommend testing of IDUs for HCV infection, only 81% would recommend HCV testing for people who received blood transfusions before 1992, and only 65% would recommend testing of incarcerated persons—all populations that are at high risk for HCV infection and that fall within national testing guidelines. Although HCV testing of pregnant women is not supported by any evidence-based
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Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C recommendations or guidelines, 34% of family physicians surveyed by Ferrante et al. would nevertheless recommend it. Of the respondents, 31% did not know what to do next or would refer a patient to a specialist after a positive test for HCV antibody, and 2% incorrectly assured patients that those who tested positive were immune to HCV. Physicians in practice for more than 20 years were found to have the lowest level of knowledge about HCV risk factors, whereas those in practice for 5 years or less had the highest knowledge level. A survey of 593 fellows of the American College of Obstetricians and Gynecologists (ACOG), half of whom considered themselves to be primary care providers, assessed screening and counseling practices for HCV infection. About half (49%) reported that they tested for HCV infection in all obstetric and gynecologic patients who self-reported ever having injected illicit drugs, and 35% tested all patients who reported having received blood transfusions before 1992 (Boaz et al., 2003). Nearly half counseled HCV-infected patients to avoid breastfeeding, and 70% counseled HCV-infected patients to use condoms with their steady sexual partners; both kinds of advice are inconsistent with recommendations of CDC (CDC, 1998) and ACOG (2000, as cited in Boaz et al., 2003). Only 64% recommended that patients who had HCV infection avoid alcohol, which has been found to increase the risk of disease progression (Ascione et al., 2007). An earlier mailed survey of 1,412 primary care providers in the United States also assessed knowledge about risk factors for HCV infection and management of hepatitis C (Shehab et al., 2001). Nearly three-fourths (73%) of the respondents had seen fewer than five hepatitis C patients within the preceding year, and almost half (44%) had no experience with treatment for HCV infection. Almost all knew the most common risk factors for HCV infection—injection-drug use, blood transfusion during the 1980s, and multiple sex partners. One-fourth incorrectly indicated that blood transfusion continues to be a risk factor, and 19% erroneously believed that casual household contact is a major risk factor. Some 50% of the providers reported that they routinely ask their patients about risk factors for HCV infection; 78% test for HCV infection among patients who have increased liver enzymes with or without HCV risk factors, and 70% test all patients who have risk factors regardless of liver enzyme levels. When presented with a scenario on how to treat a hypothetical patient for chronic HCV infection, 27% of the respondents did not know which therapy to use. A previous study by the same researchers had also found substantial gaps in primary care providers’ knowledge about hepatitis C (Shehab et al., 1999). The gaps persisted even though 95% of the respondents in the 2001 study reported having used at least one educational tool about hepatitis C in the preceding 2 years; this suggests that primary care providers misreport their
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Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C exposure to educational materials about hepatitis C or that such materials do not communicate accurate information effectively. HCV-positive patients perceive that health-care providers are judgmental toward those with HCV infection because of its association with illicit drug use (Janke et al., 2008). Numerous studies have shown that healthcare workers have extremely negative views of IDUs and characterize them as manipulative, unpleasant, and uncooperative (McLaughlin et al., 2000; Paterson et al., 2007). Such attitudes among health-care providers can have a number of deleterious effects, including discouraging of at-risk persons from accessing testing and other services and reducing the effectiveness of HCV education and counseling messages (Zickmund et al., 2003). Additional research has examined HCV knowledge among drug-treatment providers. Research conducted with 104 members of the staffs of two drug-free and two methadone-maintenance treatment programs (MMTPs) in the New York metropolitan area demonstrated that knowledge about hepatitis C is inadequate (Strauss et al., 2006). Five of 20 items on an HCV knowledge assessment were not answered correctly by the majority of the participating staff, suggesting that staff may be systematically misinformed rather than merely uninformed about some important HCV issues that affect their clients. Total scores on the assessment averaged 70%, 71%, and 45% among the medically credentialed staff, noncredentialed staff in the MMTPs, and noncredentialed staff in the drug-free programs, respectively. The majority of those in the latter group had never participated in training specifically devoted to HCV; these staff may be sharing incorrect information with patients or, aware of their limitations in HCV knowledge, failing to provide patients much needed HCV information. It is critical that both medically credentialed and noncredentialed staff in the programs receive effective HCV training so that they can support their patients’ HCV education and information needs appropriately. Recommendation Many providers are not aware of the high prevalence of chronic hepatitis B and hepatitis C in some populations. Improved understanding of risk factors for acute and chronic HBV and HCV infections and collection of data on them, including country of birth and ethnicity, and the use of risk-factor screening will lead to increased identification of cases, increased provision of preventive resources, increased vaccination to protect those at risk for hepatitis B infection, and reduction in disparities in the burden of chronic viral hepatitis. On the basis of the evidence described above, the committee concludes that insufficient provider knowledge leads to critical missed opportunities for providers to educate patients about prevention of hepatitis B and hepa-
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Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C titis C, to identify patients who may be at risk for these infections, and to test for chronic HBV and HCV infection in patients and their sexual, family, and household contacts in the case of hepatitis B and in drug-use networks in the case of hepatitis C. To address that issue, the committee offers the following recommendation: Recommendation 3-1. The Centers for Disease Control and Prevention should work with key stakeholders (other federal agencies, state and local governments, professional organizations, health-care organizations, and educational institutions) to develop hepatitis B and hepatitis C educational programs for health-care and social-service providers. Educational programs and materials for health-care and social-service providers should focus on improving provider awareness and adherence to practice guidelines for hepatitis B and hepatitis C. The educational programs should be targeted to primary care providers, appropriate social-service providers (such as staff of drug-treatment facilities and immigrant-services centers), and licensed and unlicensed alternative-medicine professionals (such as acupuncturists and traditional Chinese medicine practitioners) that serve at-risk populations. At-risk populations include foreign-born people from HBV- or HCV-endemic countries, clients of sexually-transmitted-disease (STD) clinics and HIV clinics, IDUs, others at risk because of a history of percutaneous exposures, and close contacts of people who have chronic hepatitis B and chronic hepatitis C. The educational programs should include at least the following components: Information about the prevalence and incidence of acute and chronic hepatitis B and hepatitis C both in the general US population and in at-risk populations, particularly foreign-born populations in the case of hepatitis B, and IDUs and incarcerated populations in the case of hepatitis C. Guidance on screening for risk factors associated with hepatitis B and hepatitis C. Information about hepatitis B and hepatitis C prevention, hepatitis B immunization, and medical monitoring of chronically infected patients, specifically, Information about methods of testing and interpretation of results. Information about medical management and long-term care: How to select candidates for antiviral therapy. Importance of liver-cancer screening. When to refer patients to a specialist.
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Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C Information about prevention of HBV and HCV transmission in hospital and nonhospital health-care settings. Information about discrimination and stigma associated with hepatitis B and hepatitis C and guidance on reducing them. Information about health disparities related to hepatitis B and hepatitis C. CDC should examine interventions that target several venues and types of providers, such as educational institutions, health-care facilities, substance-abuse service providers, and alternative-care providers. Educational Institutions Schools of medicine, nursing, physician assistants, complementary and alternative medicine, and public health should develop improved curricula to ensure that their graduates are knowledgeable about chronic hepatitis B and hepatitis C. The curricula should include information on disease prevalence, risk factors, preventive actions, appropriate diagnostics, selection of persons for testing, and appropriate followup for chronically infected patients and those susceptible to infection. Continuing-medical-education courses and activities about viral hepatitis conducted online or at provider meetings should be regularly offered to family-practice physicians, internists, OB/GYNs, pediatricians, nurses, and physician assistants. Drug-treatment counselors’ education and certification examinations should also include hepatitis B and hepatitis C. Questions about chronic hepatitis B should be included on board-certification or recertification examinations for internists, family-practice physicians, pediatricians, and OB/GYNs; and questions about chronic hepatitis C should be included in board examinations for internists and family-practice physicians. Although there has been no systematic effort to determine whether continuing-medical-education courses and certification examinations include questions about hepatitis B and hepatitis C, the shortcomings in knowledge among health-care providers suggest that current efforts are insufficient, and that new approaches are needed to improve knowledge. Educational programs should include targeted outreach to and enrollment of providers who work in high-risk venues (for example, STD and HIV clinics) and in areas where there are many at-risk foreign-born clients, such as hospitals, clinics, and community health centers that serve large populations of Asian and Pacific Islander (API) and foreign-born patients from other highly endemic regions.
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Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C Hospital and Other Health-Care Facilities Health-care workers and their patients are at risk for exposure to infected blood and body fluids and therefore vulnerable to infection with HBV and HCV. As discussed in Chapter 2, there have been several outbreaks of hepatitis B and hepatitis C in health-care settings in recent years (CDC, 2003b, 2003c, 2005, 2008a, 2009a; Fabrizi et al., 2008; Thompson et al., 2009). Hospitals and nonhospital health-care facilities (such as dialysis units, endoscopy clinics, and long-term-care facilities) should develop educational programs to reinforce the importance of adhering to recommended standard precautions and procedures to prevent the transmission of bloodborne infections in both inpatient and outpatient health-care settings (Thompson et al., 2009). Health-care workers should be routinely vaccinated to protect them from hepatitis B. Although the ACIP recommends that health-care workers receive the hepatitis B vaccine, and the Occupational Safety and Health Administration requires employers to offer the hepatitis B vaccine to all health-care workers who may be exposed to blood (29 CFR 1910.1030), about 25% of health-care workers remain unvaccinated (Simard et al., 2007). Successful interventions to prevent exposures known to transmit bloodborne infections have included general safety training; training specific to prevention of needle-stick injuries; modification of practice, staffing, and workload adjustments; and use of protective devices, such as needles that automatically retract (Clarke et al., 2002; Holodnick and Barkauskas, 2000; Hooper and Charney, 2005; Stringer et al., 2002; Trim, 2004). Substance-Abuse–Related Service Providers Staff of drug-treatment programs, needle-exchange programs, and correctional facilities should be participants in viral-hepatitis educational programs. Studies have shown that IDUs who used needle-exchange programs or who had been in drug treatment were more likely than others to report their HCV-antibody status accurately (Hagan et al., 2006). Very high proportions of IDUs have been in jail or prison (Milloy et al., 2008); therefore, periods of incarceration may present a prime opportunity for providing hepatitis C education to this high-risk population. In many communities that have needle-exchange programs, the majority of IDUs have participated in them (Hagan et al., 1999; Lorvick et al., 2006). Over the period during which a person may inject illicit drugs, the likelihood that he or she has been in a drug-treatment program rises (Galai et al., 2003; Hagan et al., 1999). Thus, the committee believes that providing standardized education to staff of drug-treatment and needle-exchange programs and correctional
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Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C facilities will increase the likelihood that at-risk and HCV-infected persons in these settings receive consistent and accurate information. Alternative-Care Providers Alternative-care providers would also benefit from participating in educational programs about viral hepatitis. In California, four annual educational symposia, in 2004–2007, were arranged by a collaboration of academic, professional, and community-based organizations to improve HBV-related knowledge among traditional Chinese medicine practitioners and acupuncturists—providers who serve a largely API population, a patient population that has a high prevalence of chronic hepatitis B and the associated risk of hepatocellular carcinoma (Chang et al., 2007). A precourse survey was administered; about half the participants did not know ways to prevent HBV transmission, the age group most likely to develop chronic infection, which blood test to use to diagnose chronic infection, or the risk of death from liver disease or cancer in people who had chronic hepatitis B. The postcourse survey showed a statistically significant improvement in HBV-related knowledge: about 80% of participants were able to answer questions about prevention and diagnosis of and treatment for HBV infection correctly. COMMUNITY KNOWLEDGE AND AWARENESS The committee has found that knowledge and awareness about hepatitis B and hepatitis C are lacking in members of the public and, most important, in members of specific at-risk populations. Lack of knowledge and awareness about hepatitis B and hepatitis C in the community often leads to misinformation, missing of opportunities for prevention and treatment, and stigmatization of infected populations. The consequences for members of at-risk communities are important in that missing opportunities for prevention can lead to infection of additional people with HBV and HCV. Once infected, they frequently are unaware of their infection and so run the risk of unknowingly infecting others and of not receiving appropriate medical management. Although there have been no large-scale, population-based, controlled studies of community knowledge about hepatitis B and hepatitis C, all published surveys have shown that knowledge about these diseases is sparse. Hepatitis B As mentioned earlier, APIs are at high risk for chronic hepatitis B. A number of studies have assessed awareness and knowledge about hepatitis B
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Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C Encourage notification of household and sexual contacts of infected people to be tested for HBV and HCV and encourage hepatitis B vaccination of close contacts. General Public Awareness and Education Lack of knowledge about HBV and HCV transmission contributes to the stigma of infection and is a barrier to testing, prevention, and care. Public HIV-awareness campaigns led to reduced stigma and discrimination toward patients with HIV infection (Brown et al., 2003). As in the case of HIV/AIDS, increasing general public knowledge about hepatitis B and hepatitis C can be expected to reduce discrimination toward infected people, reduce transmission, and increase early diagnosis and treatment that ultimately save lives. Broader community education should include print and multimedia educational materials about viral hepatitis for the public, large employers, and health insurers. It should work to mobilize and facilitate a grassroots movement among community stakeholders, including health-care providers, employers, mainstream and ethnic media, community-based organizations, and students. Large employers, such as multinational corporations, are potentially important partners in hepatitis prevention and control in that they provide health benefits to about two-thirds of Americans who have health insurance and are commonly employers of foreign-born people from HBV-endemic countries both in the United States and overseas. The lack of knowledge and awareness about hepatitis B and hepatitis C in the general population suggests that integration of viral-hepatitis and liver-health education into existing health-education curricula in schools will help to eliminate the stigma of those chronically infected and improve prevention of viral hepatitis. There is evidence that adolescents are unaware of hepatitis B and hepatitis C risks and how to prevent becoming infected (Moore-Caldwell et al., 1997; Slonim et al., 2005). Many schools already require health education on HIV, which has transmission routes similar to those of hepatitis B and hepatitis C (CDC, 2008b). Several school-based programs have been demonstrated to reduce HIV risk in students and could serve as models for viral hepatitis education initiatives (Gaydos et al., 2008; Kennedy et al., 2000). Community-Based Outreach to Foreign-Born Immigrants from HBV-endemic countries make up the largest population of people who have chronic hepatitis B in the United States, and it is essential that they receive culturally and linguistically tailored information
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Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C about transmission and risks of HBV infection and that it promote testing, vaccination, and medical management. Rein et al. (2009) estimated that there are 55 active community-based hepatitis B outreach programs in the country that were targeting mostly APIs, of which they contacted 31. Although those programs have done much to inform APIs about hepatitis B, there is a need for additional programs that target APIs, given the burden of hepatitis B within that population. There is also a need for education programs that target foreign-born people from other HBV-endemic regions. The models used by programs designed for APIs could be modified to address the needs of other populations. Community-based education and screening programs—including outreach at cultural festivals, health fairs, and places of worship—have been shown to be effective in improving APIs’ knowledge about hepatitis B (Chao et al., 2009a; Hsu et al., 2007; Juon et al., 2008; Lin et al., 2007) and could potentially be effective with other ethnic populations. Each year, around 20,000 people are tested through those programs, and HBsAg is detected in about 8% of the tested population (Rein et al., 2009). Some 30% of the programs were supported by local government funding, 27% by state funding, and 10% by federal funding. Other sources include pharmaceutical and insurance companies, research and service grants, community hospitals, and other private funding sources (Rein et al., 2009). Rein et al. (2009) also found that there were few or no hepatitis B outreach programs in most regions of the United States (the Southeast, the Midwest, and the Southwest outside of California and the Houston area). Education and prevention programs should be expanded to provide services in underserved regions of the United States given that the highest rates of acute hepatitis B incidence are in the south (Daniels et al., 2009). Correctional Facilities About 2 million people are incarcerated in the US correctional system. The major risk factors for viral hepatitis in people in correctional facilities are injection-drug use, tattooing, and sexual activity (see Chapters 4 and 5 for additional information about incarcerated populations). Because people in the correctional system are more likely to be infected or to become infected with HBV and HCV than the US general population, it is important to provide educational opportunities about hepatitis B and hepatitis C in correctional facilities. Increased knowledge and awareness about the diseases will lead to a greater understanding among inmates about how to prevent them, the advantages of hepatitis B vaccination, why they should be tested for chronic hepatitis B and hepatitis C, and what to do about a positive test result for either infection. Niveau (2006) reviewed risk factors
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Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C for acquiring infectious diseases in correctional settings and found that effective preventive measures included information dissemination and education. Inmate peer-based health education has been effective in primary prevention of HIV (Hammett, 2006). The addition of hepatitis education to existing peer-based inmate educational programs is feasible and will probably incur minimal additional cost. Boutwell et al. (2005) called education of prisoners about hepatitis C as part of a larger program of prevention, testing, and treatment a “cornerstone of the public health response to the hepatitis C epidemic in the United States” and recommended research into program implementation. Drug-Treatment Facilities and Needle-Exchange Programs Drug-treatment and needle-exchange programs reach a substantial proportion of active injectors who have HCV infection or are at risk of acquiring it. Because the programs have regular, long-term contact with many IDUs, there are multiple opportunities to disseminate information about hepatitis B and hepatitis C, including the benefits of hepatitis B vaccination, how to avoid reinfection with HCV, and the importance of followup care for those chronically infected. Although education programs developed for needle exchange, drug treatment, and corrections facilities will reach substantial proportions of those at risk, important segments of IDU populations will not be reached by them. Women and young people who inject drugs are less likely than others to attend needle-exchange and drug-treatment programs (Bluthenthal et al., 2000; Miller et al., 2001). Novel programs are needed that will access the hidden injectors, and outreach and peer-education programs are potentially effective ways to achieve this goal. Perinatal Facilities That Care for Pregnant Women The risk of chronic infection after exposure to HBV is highest in early life, and most people who have chronic hepatitis B were infected at birth or during early childhood. Each year in the United States, about 24,000 HBsAg-positive women give birth and about 1,000 newborns develop chronic HBV infection (Ward, 2008). The latter occurs largely because of failure to adhere to ACIP recommendations and timely administration of the birth dose of the hepatitis B vaccine and hepatitis B immunoglobulin. Although it is recommended that household contacts be tested because of high risk of infection, fewer than 50% are tested, and fewer than 50% of those tested and found to be HBV-negative or of unknown status are vaccinated (Euler et al., 2003a). Therefore, perinatal-care facilities and their staffs (including OB/GYNs and their clinic staffs) provide an excellent op-
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Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C portunity to educate pregnant women about the importance of HBsAg testing, interpretation of the results, and the importance of newborn hepatitis B vaccination. The women should be given culturally and linguistically appropriate educational information about the importance of administration of the birth dose of the hepatitis B vaccine and hepatitis B immunoglobulin within 12 hours of birth if needed, completion of the hepatitis B vaccine series by the age of 6 months, and postvaccination testing. There is a need to develop a novel program to educate pregnant women in perinatal-care facilities about hepatitis B to prevent perinatal transmission, to refer women who are chronically infected for medical care, and to refer family and household contacts for testing, vaccination, and care if needed. REFERENCES Altekruse, S. F., K. A. McGlynn, and M. E. Reichman. 2009. Hepatocellular carcinoma incidence, mortality, and survival trends in the United States from 1975 to 2005. Journal of Clinical Oncology 27(9):1485-1491. American College of Obstetricians and Gynecologists. 2007. ACOG practice bulletin no. 86: Viral hepatitis in pregnancy. Obstetrics and Gynecology 110(4):941-956. ———. 2008. Hepatitis B virus in pregnancy. http://www.acog.org/publications/patient_education/bp093.cfm (accessed August 21, 2009). ———. 2009. Protecting yourself against hepatitis B. http://www.acog.org/publications/patient_education/bp125.cfm (accessed October 24, 2009). Ascione, A., T. Tartaglione, and G. G. Di Costanzo. 2007. Natural history of chronic hepatitis C virus infection. Digestive and Liver Disease 39(Suppl 1):S4-S7. Asian Liver Center. 2009. Information resources. http://liver.stanford.edu/Public/index.html (accessed August 21, 2009). Boaz, K., A. E. Fiore, S. J. Schrag, B. Gonik, and J. Schulkin. 2003. Screening and counseling practices reported by obstetrician-gynecologists for patients with hepatitis C virus infection. Infectious Diseases in Obstetrics and Gynecology 11(1):39-44. Bluthenthal, R. N., A. H. Kral, L. Gee, E. A. Erringer, and B. R. Edlin. 2000. The effect of syringe exchange use on high-risk injection drug users: A cohort study. AIDS 14(5):605-611. Boutwell, A. E., S. A. Allen, and J. D. Rich. 2005. Opportunities to address the hepatitis C epidemic in the correctional setting. Clinical Infectious Diseases 40(s5):S367-S372. Brown, L., K. Macintyre, and L. Trujillo. 2003. Interventions to reduce HIV/AIDS stigma: What have we learned? AIDS Education and Prevention 15(1):49-69. CDC (Centers for Disease Control and Prevention). 1991. Hepatitis B virus: A comprehensive strategy for eliminating transmission in the United States through universal childhood vaccination: recommendations of the Immunization Practices Advisory Committee. Mobility and Mortality Weekly Report 40(No. RR-13):1-25. ———. 1998. Recommendations for prevention and control of hepatitis C virus (HCV) infection and HCV-related chronic disease. Centers for Disease Control and Prevention. Morbidity and Morality Weekly: Recommendations and Reports 47(RR-19):1-39. ———. 2003a. Advancing HIV prevention: New strategies for a changing epidemic—United States, 2003. Morbidity and Mortality Weekly Report 52(15):329-332.
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