Community-Based Strategies to Improve Screening, Diagnosis and Linkage to Care for Patients with Chronic Hepatitis B
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Purpose of Review
Chronic hepatitis B (CHB) places 3.5% of the world population at risk of dying from liver failure or liver cancer. Effective antiviral therapies can change disease outcomes, provided that CHB screening and linkage to care can be delivered at population level, to reach the vast numbers of undiagnosed people. We therefore reviewed the experience of community-based CHB screening programs reported in the English literature since 2014.
Twenty papers met eligibility criteria and only one originated from a low-income country. The two randomised studies found that culturally tailored hepatitis education increased hepatitis testing. Successful linkage to care was facilitated by partnerships with community-based organisations and the use of bilingual patient navigators. Point of care testing and chain referral sampling were successfully tested in two programs.
These studies demonstrated that community-based interventions can screen large numbers of people and could deliver the population-level outcomes required to meet the WHO targets of hepatitis B elimination.
KeywordsChronic hepatitis B Immigrants Screening Liver cancer prevention Antiviral treatment
Compliance with Ethical Standards
Conflict of Interest
Monica Robotin and Jacob George each declare no conflicts of interest.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
- 1.World Health Organization, Global Hepatitis Report 2017. https://www.who.int/hepatitis/publications/global-hepatitis-report2017/en/, W.H. Organization, Editor. 2017, World Health Organization: Geneva. Accessed 15 May 2019.
- 4.World Health Organization, Global Health Estimates 2015: deaths by cause, age, sex, by country and by region, 2000–2015. Geneva: World Health Organization; 2016. https://www.who.int/healthinfo/global_burden_disease/estimates/en/index1.html, W.H. Organization, Editor. 2016, World Health Organization: Geneva. Accessed 15 May 2019.
- 5.Stanaway JD, Flaxman AD, Naghavi M, Fitzmaurice C, Vos T, Abubakar I, et al. The global burden of viral hepatitis from 1990 to 2013: findings from the global burden of disease study 2013. Lancet. 2016;388(10049):1081–8.Google Scholar
- 8.Trinh-Shevrin C, Pollack HJ, Tsang T, Park J, Ramos MR, Islam N, et al. The Asian American hepatitis B program: building a coalition to address hepatitis B health disparities. Prog Community Health Partnersh. 2011;5(3):261–71.Google Scholar
- 9.Supramaniam R, et al. Cancer incidence in New South Wales migrants 1991 to 2001. Sydney: The Cancer Council NSW; 2006.Google Scholar
- 11.McDermott S, DesMeules M, Lewis R, Gold J, Payne J, Lafrance B, et al. Cancer incidence among Canadian immigrants, 1980-1998: results from a national cohort study. J Immigr Minor Health. 2011;13(1):15–26.Google Scholar
- 14.Chang TT, Liaw YF, Wu SS, Schiff E, Han KH, Lai CL, et al. Long-term entecavir therapy results in the reversal of fibrosis/cirrhosis and continued histological improvement in patients with chronic hepatitis B. Hepatology. 2010;52(3):886–93.Google Scholar
- 15.Papatheodoridis GV, Manolakopoulos S, Touloumi G, Nikolopoulou G, Raptopoulou-Gigi M, Gogos C, et al. Hepatocellular carcinoma risk in HBeAg-negative chronic hepatitis B patients with or without cirrhosis treated with entecavir: HepNet.Greece cohort. J Viral Hepat. 2015;22(2):120–7.Google Scholar
- 17.Nayagam S, Thursz M, Sicuri E, Conteh L, Wiktor S, Low-Beer D, et al. Requirements for global elimination of hepatitis B: a modelling study. Lancet Infect Dis. 2016;16(12):1399–408.Google Scholar
- 18.IOM (Institute of Medicine), Hepatitis and liver cancer: a national strategy for prevention and control of hepatitis B and C., IOM, Editor. 2010, Institute of Medicine: Washington DC.Google Scholar
- 19.Cowie, B. and H.Kelly, Outcomes of a complex dynamic mathematical model of hepatitis B virus in Australia. (PP-027), in 20th Conference of the Asian Pacific Association for the Study of the Liver (APASL); . 2010, Hepatology International Beijing, China p. 27.Google Scholar
- 20.Hatzakis A, Wait S, Bruix J, Buti M, Carballo M, Cavaleri M, et al. The state of hepatitis B and C in Europe: report from the hepatitis B and C summit conference. J Viral Hepat. 2011;18(Suppl 1):1–16.Google Scholar
- 21.Cohen C, Holmberg SD, McMahon BJ, Block JM, Brosgart CL, Gish RG, et al. Is chronic hepatitis B being undertreated in the United States? J Viral Hepat. 2011;18(6):377–83.Google Scholar
- 25.Xu K, Watanabe-Galloway S, Rochling FA, Zhang J, Farazi PA, Peng H, et al. Practice, knowledge, and barriers for screening of hepatocellular carcinoma among high-risk Chinese patients. Annals of Global Health. 2017;83(2):281–92.Google Scholar
- 26.Zhou K, Fitzpatrick T, Walsh N, Kim JY, Chou R, Lackey M, et al. Interventions to optimise the care continuum for chronic viral hepatitis: a systematic review and meta-analyses. Lancet Infect Dis. 2016;16:1409–22.Google Scholar
- 30.Status of Vietnamese Health: Santa Clara County, California, 2011, C.o.S.C.P.H. Department, Editor. 2011, Public Health Department Santa Clara.Google Scholar
- 33.Zuure FR, Bouman J, Martens M, Vanhommerig JW, Urbanus AT, Davidovich U, et al. Screening for hepatitis B and C in first-generation Egyptian migrants living in the Netherlands. Liver Int. 2013;33(5):727–38.Google Scholar
- 35.Bailey MB, et al. San Francisco Hep B free: a grassroots community coalition to prevent hepatitis B and liver Cancer. J Community Health. 2010;36(4):538–51.Google Scholar
- 45.World Health Organization, Global health sector strategy on viral hepatitis, 2016–2021., in http://apps.who.int/iris/bitstream/10665/246177/1/WHO-HIV-2016.06-eng.pdf?ua=1, W.H. Organization, Editor. 2016, World Health Organization: Geneva. Accessed 12 Apr 2019.
- 47.• Chandrasekar E, et al. A Novel Strategy to Increase Identification of African-Born People With Chronic Hepatitis B Virus Infection in the Chicago Metropolitan Area, 2012–2014. Prev Chronic Dis. 2016;13:E118 Trialled chain referral sampling to encourage testing and engagement in care of uninsured and marginalised African-born people; used patient navigators. CrossRefGoogle Scholar
- 49.• Ma GX, et al. A Community-Based Randomized Trial of Hepatitis B Screening Among High-Risk Vietnamese Americans. Am J Public Health. 2017;107(3):433–40 Cluster RCT of multilevel intervention offering interactive in-language education and patient navigators vs. general information; outcomes: screening rates. Used a participatory approach to enhance intervention effects and enhance its sustainability. CrossRefGoogle Scholar
- 50.Nguyen K, van Nguyen T, Shen D, Xia V, Tran D, Banh K, et al. Prevalence and presentation of hepatitis B and C virus (HBV and HCV) infection in Vietnamese Americans via serial community serologic testing. J Immigr Minor Health. 2015;17(1):13–20.Google Scholar
- 53.Stornaiuolo G, Cuniato V, Cuomo G, Nocera E, Brancaccio G, de Rosa M, et al. Active recruitment strategy in disadvantaged immigrant populations improves the identification of human immunodeficiency but not of hepatitis B or C virus infections. Dig Liver Dis. 2014;46(1):62–6.Google Scholar
- 57.•• Harris AM, et al. Testing and Linking Foreign-Born People with Chronic Hepatitis B Virus Infection to Care at Nine U.S. Programs, 2012–2014. Public Health Rep. 2016;131(Suppl 2):20–8 Summary results from a prospective cohort drawn from population groups with a HBV prevalence>2%, based on their country of birth. Nine pilot sites conducted targeted screening of 23,144 participants; linkage to primary care providers was achieved in 83% of HBsAg+ve people. Data collected using a common dataset. Authors provide insights into success factors and recommendations for how to increase testing uptake. CrossRefGoogle Scholar
- 58.• Hyun CS, et al. Chronic hepatitis B in Korean Americans: decreased prevalence and poor linkage to care. BMC Infect Dis. 2016;16(1):415 Summarises findings of a large-scale screening and awareness campaign targeting Korean Americans. Through 128 separate community events, tested 7,199 people, with HBV prevalence of 2.4%. Identified role of education and navigation in facilitating linkage to care. CrossRefGoogle Scholar
- 60.Navarro N, Lim N, Kim J, Joo E, Che K, Runyon BA, et al. Lower than expected hepatitis B virus infection prevalence among first generation Koreans in the U.S.: results of HBV screening in the Southern California Inland Empire. BMC Infect Dis. 2014;14:269.Google Scholar
- 61.• Shankar H, et al. A Novel Collaborative Community-Based Hepatitis B Screening and Linkage to Care Program for African Immigrants. Clin Infect Dis. 2016;62(Suppl 4):S289–97 Novel partnership involving a community-based organisation, an academic medical center and community health centers to provide comprehensive screening and linkage to care of underserved / unisured people from African countries. Used culturally targeted patient navigators. CrossRefGoogle Scholar
- 63.•• Coenen S, et al. Clinical impact of five large-scale screening projects for chronic hepatitis B in Chinese migrants in the Netherlands. Liver Int. 2016;36(10):1425–32 First large-scale community based screening and treatment intervention in high risk Chinese residents in a European country. Combination of outreach with direct clinic referal ensured high referral and treatment rates. CrossRefGoogle Scholar
- 65.•• Lemoine M, et al. Acceptability and feasibility of a screen-and-treat programme for hepatitis B virus infection in The Gambia: the Prevention of Liver Fibrosis and Cancer in Africa (PROLIFICA) study. Lancet Glob Health. 2016;4(8):e559–67 First large-scale screen-and-treat program in the general population in a low-resource country in Africa. Used point-of-care testing and trained fieldworkers and achieved high screening coverage and linkage to care. Google Scholar
- 66.•• Robotin MC, et al. Using a chronic hepatitis B Registry to support population-level liver cancer prevention in Sydney, Australia. Clin Epidemiol. 2018;10:41–9 Established a disease Registry enrolling patients with CHB diagnosed in primary care. Specialist referral based upon risks stratification by primary care providers, which reduced unnecessary specialist referrals. Validated assumptions of the economic level, including antiviral treatment in 18% of those enrolled. Google Scholar
- 69.Perumalswami PV, Factor SH, Kapelusznik L, Friedman SL, Pan CQ, Chang C, et al. Hepatitis outreach network: a practical strategy for hepatitis screening with linkage to care in foreign-born communities. J Hepatol. 2013;58(5):890–7.Google Scholar
- 70.Veldhuijzen IK, Wolter R, Rijckborst V, Mostert M, Voeten HA, Cheung Y, et al. Identification and treatment of chronic hepatitis B in Chinese migrants: results of a project offering on-site testing in Rotterdam The Netherlands. J Hepatol. 2012;57(6):1171–6.Google Scholar
- 71.Robotin M, et al. Characteristics of chronic hepatitis B infection in SW Sydney: clinical correlates and policy implications. In: in 9th Australasian Viral Hepatitis Conference. Australia: Alice Springs; 2014.Google Scholar
- 72.World Health Organization, Guidelines on hepatitis B and C testing. 2017, World Health Organization Geneva.Google Scholar
- 74.Veldhuijzen IK, Toy M, Hahné SJM, de Wit GA, Schalm SW, de Man RA, et al. Screening and early treatment of migrants for chronic hepatitis B virus infection is cost-effective. Gastroenterology. 2010;138(2):522–30.Google Scholar
- 75.Robotin MC, Kansil M, Howard K, George J, Tipper S, Dore GJ, et al. Antiviral therapy for hepatitis B-related liver cancer prevention is more cost-effective than cancer screening. J Hepatol. 2009;50(5):990–8.Google Scholar
- 77.Zhou K, Fitzpatrick T, Walsh N, Kim JY, Chou R, Lackey M, et al. Interventions to optimise the care continuum for chronic viral hepatitis: a systematic review and meta-analyses. Lancet Infect Dis. 2016;16(12):1409–22.Google Scholar
- 79.Hermann K, van Damme W, Pariyo GW, Schouten E, Assefa Y, Cirera A, et al. Community health workers for ART in sub-Saharan Africa: learning from experience--capitalizing on new opportunities. Hum Resour Health. 2009;7:31.Google Scholar
- 80.Dunbar EL, Wroe EB, Nhlema B, Kachimanga C, Gupta R, Taylor C, et al. Evaluating the impact of a community health worker programme on non-communicable disease, malnutrition, tuberculosis, family planning and antenatal care in Neno, Malawi: protocol for a stepped-wedge, cluster randomised controlled trial. BMJ Open. 2018;8(7):e019473.Google Scholar
- 81.Busza J, Dauya E, Bandason T, Simms V, Chikwari CD, Makamba M, et al. The role of community health workers in improving HIV treatment outcomes in children: lessons learned from the ZENITH trial in Zimbabwe. Health Policy Plan. 2018;33(3):328–34.Google Scholar
- 82.Nayagam S, Conteh L, Sicuri E, Shimakawa Y, Suso P, Tamba S, et al. Cost-effectiveness of community-based screening and treatment for chronic hepatitis B in the Gambia: an economic modelling analysis. Lancet Glob Health. 2016;4(8):e568–78.Google Scholar
- 84.Glasgow RE, Askew S, Purcell P, Levine E, Warner ET, Stange KC, et al. Use of RE-AIM to address health inequities: application in a low-income community health center based weight loss and hypertension self-management program. Transl Behav Med. 2013;3(2):200–10.Google Scholar