Characteristics of Persons with Chronic Hepatitis B - San Francisco, California

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From Morbidity & Mortality Weekly Report

Characteristics of Persons with Chronic Hepatitis B --- San Francisco,

California, 2006

Posted 06/07/2007

S. Huang, MD; S. Shallow, MPH; D. Stier, MD; P. Shiono, PhD; A. Nishimura,

MPH; I. Bihl; S. Bialek, MD; I. , PhD

Content

Chronic hepatitis B is the most common cause of cirrhosis and liver cancer

worldwide. Approximately 45% of the world's population lives in regions

where chronic hepatitis B virus (HBV) infection is endemic, including most

of Asia and the Pacific Islands, Africa, and the Middle East.[1] Nearly one

fourth of the population of San Francisco was born in Asia and the Pacific

Islands.* In 2006, the San Francisco Department of Public Health (SFDPH)

received reports consistent with probable chronic HBV infection for 2,238

persons. To characterize persons with reported confirmed chronic HBV

infection in San Francisco in 2006, SFDPH collected additional data on a

subset of 567 cases reported to the SFDPH chronic hepatitis B registry.

Eighty-four percent of the persons were Asians/Pacific Islanders (A/PIs),

80% of whom were foreign born. Fewer than half had been referred to a

gastroenterologist/hepatologist for evaluation at the time of reporting.

Persons with chronic HBV infection can benefit from medical care by

providers with expertise in viral hepatitis. In addition, close contacts of

infected persons should be screened and offered vaccination if found to be

susceptible to HBV infection. Culturally appropriate counseling for and

follow-up of persons with chronic HBV infection and their contacts could

help reduce the transmission of HBV infection.

Hepatitis B surface antigen (HBsAg), hepatitis B e antigen (HBeAg), HBV DNA,

and immunoglobulin M antibody to hepatitis B core antigen (IgM anti-HBc) are

detectable during acute HBV infection. The presence of HBsAg, HBeAg, or HBV

DNA for more than 6 months is evidence of chronic infection. The California

Code of Regulations† requires laboratories to report all positive test

results for HBsAg to local health departments. Health-care providers also

are required to report cases of acute and chronic hepatitis B. Reporting

requirements for both laboratories and providers include supplying the name,

age, sex, and contact information of persons with positive tests and the

contact information for the associated health-care provider, although not

all reports contain this information. SFDPH has maintained a registry of

persons with positive HBsAg test results reported to SFDPH since 1984; the

registry contains HBsAg test results for approximately 25,700 persons. Based

on the standard case definitions approved by state epidemiologists for 2007,

a confirmed case of chronic HBV infection is defined as an infection in a

person who tests HBsAg positive, HBV DNA positive, or HBeAg positive two

times at least 6 months apart.§ A probable case is defined as an infection

in a person with a single HBsAg-positive, HBV-DNA-positive, or

HBeAg-positive laboratory result with either a negative IgM anti-HBc or no

IgM anti-HBc test reported.

To further characterize persons with known chronic HBV infection, in January

2006, SFDPH began requesting data from health-care providers on persons who

met the case definition for confirmed HBV infection for whom a second

positive HBsAg result was reported to SFDPH during 2006. SFDPH formed an

advisory panel of clinicians from public, private, and academic settings,

who provided input into the development of the supplemental data collection

form and endorsed the activity in a letter mailed by SFDPH to local

health-care providers. SFDPH faxed supplemental data forms to the providers

who had ordered the most recent positive HBsAg test, requesting information

on patient race/ethnicity, primary language, reasons for HBsAg testing, risk

factors for HBV infection, referral for specialist care, and treatment

history. Providers used information obtained from a chart review or during

patient visits to complete the form. Providers who did not respond were sent

faxes two more times and then contacted by telephone one time.

During 2006, SFDPH received reports of 2,238 persons with test results

consistent with probable chronic HBV infection; all were reported by

laboratories. Of these, 1,156 (52%) were male, and 1,090 (49%) were aged

30--49 years ( Table 1 ). Among the 714 women of childbearing age (i.e.,

aged 12--45 years) for whom a positive HBsAg test result was reported to

SFDPH, 170 (24%) were pregnant when follow-up was conducted by the perinatal

hepatitis B coordinator.

Of the 2,238 positive HBsAg reports received by the registry in 2006, a

total of 1,162 (52%) met the case definition for confirmed chronic HBV

infection. Of these, 736 had available health-care provider contact

information. Supplemental data forms were faxed to these providers; 567

forms were returned to SFDPH with at least partial information. Of persons

for whom place of birth was reported, 84% were foreign born ( Table 2 ); of

persons for whom both race/ethnicity and place of birth were reported, 80%

were foreign-born A/PIs. Cantonese Chinese was reported to be the primary

language of 52% of persons. Reasons for HBsAg testing included screening

(43%), follow-up of a history of hepatitis B (41%), or evaluation of

abnormal liver enzymes (9%). The most frequently reported risk for HBV

infection was birth in an HBV-endemic region (74%); male-to-male sexual

contact accounted for 12% ( Table 2 ). A total of 21% of persons were

reported to have been treated for chronic HBV infection, and 32% were

reported to have been referred to a gastroenterologist/hepatologist at the

time of reporting.

* US Census Bureau. American fact finder. Available at

http://factfinder.census.gov.

† California Code of Regulations. 17 CCR §2500. Reportable diseases and

conditions. Available at

http://www.dhs.ca.gov/ps/dcdc/disb/pdf/Title%2017%20lab%20reportable%20condition\

s.pdf.

§ CDC. National notifiable diseases surveillance system. Chronic hepatitis B

virus. Available at

http://www.cdc.gov/epo/dphsi/casedef/hepatitisbcurrent.htm.

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Editorial Note:

The findings in this report suggest that, in 2006, nearly 85% of persons

with confirmed chronic HBV infection in San Francisco were A/PIs, 80% of

whom were born outside the United States. These persons likely acquired

their infections in their countries of origin, countries where HBV infection

is endemic and infections usually are acquired at birth or during early

childhood. Of persons who acquire chronic HBV infection when they are aged

<5 years, an estimated 15%--40% will eventually have chronic liver disease,

including cirrhosis and liver cancer.[2] Treatment for chronic hepatitis B

is increasingly effective and can prevent or slow the development of these

sequelae.[2] However, fewer than one third of persons with chronic HBV

infection in San Francisco in 2006 had been referred to a specialist for

evaluation or undergone treatment at the time of reporting.

Persons from countries where HBV infection is endemic might be unaware of

their increased risk for hepatitis-B--related liver disease.[3,4] Hepatitis

B screening programs in A/PI communities in the United States can be an

effective means of identifying persons with chronic HBV infection and

encouraging them to seek medical care.[5-7]

Health departments and large health systems can use electronic disease

registries to characterize and provide services for persons with chronic HBV

infection and their close contacts. Persons with chronic HBV infection

should receive referrals for appropriate medical care, which can include

treatment for HBV infection. Their close contacts should undergo screening

for HBV infection and, if found to be susceptible, should receive hepatitis

B vaccination. Registries also can provide local population-based data on

the epidemiology of chronic HBV infection.

At least five factors are critical to ensuring that registry data are

representative and complete. First, legally mandated laboratory reporting of

test results is essential for complete ascertainment of cases. Second,

electronic information systems are needed to promote efficiency, allowing

the registry to receive data securely, account for duplicate case reports,

and merge data from multiple reporting sources. Third, collaboration with

laboratories is needed so that health departments can obtain additional

patient demographic information and clinician contact information through

laboratory reports. Fourth, communication with and timely feedback of

surveillance data to clinicians are needed to increase cooperation with

health departments that are requesting supplemental information on cases.

Finally, because the majority of infected persons and their contacts might

not speak English as their primary language, multilingual staff and

culturally appropriate health education materials are needed to support

these activities.

The findings in this report are subject to at least three limitations.

First, the results are limited to persons who received medical care, who

were tested for chronic HBV infection, and whose laboratory results or

diagnoses were reported to SFPDH. Therefore, these findings do not represent

the actual number of persons with chronic HBV infection in San Francisco,

especially among those who do not have regular access to medical care.

Second, persons included in the analysis of confirmed cases were limited to

those for whom provider contact information was available. Although the

California Code of Regulations mandates reporting of provider name and

contact information for all notifiable diseases and conditions, this

information is not reported frequently. Finally, the findings are based on

data collected from persons with confirmed chronic HBV infection. Because

the case definition for confirmed cases requires additional laboratory

testing, the 567 persons described in this analysis might represent a subset

of patients with greater access to care or those who were more likely to

have undergone follow-up and treatment.

During 2007, local organizations in San Francisco are planning low-cost,

community-based HBV screening and vaccination activities targeted to A/PIs

and educational outreach to promote awareness of HBV screening, prevention,

and treatment guidelines (http://www.sfhepbfree.org). SFDPH plans to provide

persons newly reported to the registry with information on how to reduce the

risk for transmission to others and the need for medical monitoring. SFDPH

also will explore different approaches to identifying persons who are

household and sex contacts of infected persons to inform them of their

potential exposure to HBV, to recommend testing and vaccination, and to

better understand the barriers to obtaining HBV preventive services.

With proper resources, chronic hepatitis B registries can help health

departments characterize the burden of chronic HBV infection. Such

registries also enable health departments and health-care providers to link

HBV-infected persons and their contacts with recommended prevention and care

services.

Acknowledgements

This report is based on contributions by L. Afu-Li and S. Rose, MPH, San

Francisco Dept of Public Health; N. Bzowej, MD, L. , MD, M. Khalili,

MD, A. Li, MD, K. Man, MD, K. Shafer, PhD, J. Sun, MD, N. Terrault, MD, and

H. Yu, MD, San Francisco Chronic Viral Hepatitis Registry Advisory Panel;

reporting laboratories; and San Francisco clinicians.

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