Is Hepatitis B Under-treated in U.S.?

Hepatitis B Virus

Chronic hepatitis B virus (HBV) infection is a major risk factor for liver cirrhosis, hepatocellular carcinoma, and end-stage liver failure. Disease progression typically takes decades, however, and many people show no symptoms until they develop advanced disease.

While there are now 5 antiviral drugs, plus interferon alfa, approved in the U.S. for chronic hepatitis B treatment, much remains to be learned about who accesses therapy and the types of outcomes they achieve.

As described in the June 2011 Journal of Viral Hepatitis, Chari Cohen from the Hepatitis B Foundation and colleagues from the Centers for Disease Control and Prevention and other public health agencies and treatment facilities reviewed data about how many people are living with chronic hepatitis B and how many are screened and treated, with an emphasis on disparities between segments of the U.S. population.

Findings

	Between 1.4 and 2 million people in the U.S. have chronic hepatitis B.
	Data suggest that only 20% to 30% of individuals with HBV - about 600,000 - have been diagnosed.
	Studies indicate that a majority of Asians and Pacific Islanders, gay and bisexual men, and injection drug users are unaware of their HBV status.
	" Fewer than half of people diagnosed with chronic hepatitis B, or approximately 200,000 to 300,000 patients, are referred for appropriate care.
	An estimated 300,000 to 500,000 individuals with chronic HBV infection are eligible for treatment according to current guidelines.
	However only 50,000 people -- or about 10% of those eligible -- are currently receiving prescription drugs for hepatitis B.
	Preliminary findings from a Hepatitis B Foundation study suggest that no more than 80,000 people have been treated with FDA-approved HBV drugs over the past 10 years in the U.S.
	Taken together, only an estimated 4% to 5% of people with chronic hepatitis B are screened, get into care, receive prescription drugs, and are successfully treated or remain in treatment.

Looking at possible reasons for the wide gap between the number of people with chronic hepatitis B and the number who receive treatment, the study authors found that explanations include the large proportion of infected individuals who have not been screened and therefore remain undiagnosed, as well as lack of access to care. Many people with hepatitis B have inadequate health insurance, insufficient education about hepatitis B, and do not receive referrals to appropriate medical care -- problems that appear to especially impact populations with a disproportionately high burden of HBV infection.

With only about 50,000 people receiving treatment, "the largest barriers to care are most likely at the level of patient awareness, diagnosis, and access to care," the researchers wrote. "These appear to be the 'slow' steps in the process; once a patient is diagnosed and able to access caregivers, they appear to have a fairly good chance of receiving appropriate treatment."

Many people are unaware of their risk factors for HBV infection -- such as belonging to a high-risk ethnic group -- and providers also lack knowledge about which groups to screen and treat, they continued. In addition, some individuals are reluctant to undergo long-term treatment, with its high cost and risk of side effects, especially when they feel healthy. In general, the authors noted, Asians/Pacific Islanders report lower use of most health care services and are less likely to have a source of ongoing health care, a situation exacerbated by limited English proficiency.

"[W]hile our proposed estimates rely upon limited data and assumptions, the overwhelming body of evidence suggests that only a minority of chronic HBV-infected patients in the United States are being diagnosed and receiving appropriate treatment," the researchers concluded. "As chronic HBV infection and primary liver cancer rates in the United States continue to rise, research and intervention efforts that explore and reduce barriers to care and improve rates of diagnosis, management, and treatment are necessary to reduce the morbidity and mortality associated with this serious liver infection in the United States."

Investigator affiliations: Hepatitis B Foundation, Doylestown, PA; Centers for Disease Control and Prevention, Epidemiology and Surveillance Branch, Division of Viral Hepatitis, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Atlanta, GA; Alaska Native Medical Center, Liver Disease and Hepatitis, Anchorage, AK; Children's Hospital and Research Center, Oakland, CA; California Pacific Medical Center, Liver Transplant Program, San Francisco, CA Fox Chase Cancer Center, Philadelphia, PA.

5/20/11

Reference
C Cohen, SD Holmberg, BJ McMahon, et al. Is chronic hepatitis B being undertreated in the United States? Journal of Viral Hepatitis 18(6):377-383 (abstract). June 2011.