Hepatitis B Prevention for Asian Americans in New York City

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Hepatitis B Prevention for Asian Americans in New
York City

• Charles B. Wang Community Health Center
• Thomas Tsang, MD, MPH

Hepatitis B Training for Substance Abuse and
Social Service Providers, October 26th 2006
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Agenda

• Demographics
• Epidemiology
• Community Prevention Models
• Results
• Lessons/Challenges/Barriers

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Asian American Communityin New York City

• 787,047 Asians in New York City
• 75 of all AAPI in NY State
• 54 increase since 1990
• 78 foreign born
• 46 (361,531) Chinese
• 31 of all Chinatown residents lived below the
  poverty line
• 60 of Chinatown adults ( 25yrs) do not have a
  high school diploma
• 45 have less than 9th grade education
• 60 of Asian adults in NYC are limited-English
  proficient

Source US Census Bureau 2000. The Asian
Population 2000. Website http//www.census.gov/
prod/2002pubs/c2kbr01-16.pdf Asian American
Federation of New York. New York City Asian
American Census Brief. Website
http//www.aafny.org/cic/briefs/newyorkbrief.pdf
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Burden of Disease

• Prevalence rates of HBV among Asians around
  10-15 compared with less than 1 among
  mainstream US population
• Of the 1.5 million hep B carriers in US, about
  half are Asian
• Rate of hepatocellular carcinoma (HCC) in APIs
  was 5-11 fold higher than for other ethnic groups
  (data from Surveillance, Epidemiology and End
  Results)

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Community Need

• 800,000 Asian Americans in NYC (Census 2000)
• Of these, 90 are immigrants and a large
  percentage is uninsured
• Most persons do not know their HBV status
• Persons who test positive often do not
  subsequently receive proper evaluation and
  treatment

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Community Need (cont)

• High rates of HBV and HCC in API population
  underscore need to implement programs to prevent
  new HBV infections and detect chronic HBV
  infection and HCC at an early stage when it is
  amenable to treatment
• We felt it was necessary to develop a
  comprehensive program to include education,
  screenings, evaluation and treatment

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Innovative ServiceDelivery Models

• Asian American Hepatitis B Project

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Project Conception Realization

• Development of a coalition of New York City
  institutions, physicians, citizens, academicians
  and community partners
• Making the case selling the project,
  cost-benefit analysis and strong written proposal
• Building broad coalition of support within the
  funding agency (NYC Council)

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Project Components

• Outreach and education
• Screening
• Follow-up and Counseling
• Clinical Evaluation and Treatment

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Education Media Campaign

• Developed and translated numerous educational,
  advertising and clinical materials

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Media Campaign Banners

• Launched culturally sensitive citywide outreach
  and media campaigns that include ethnic
  newspapers and radio stations

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Media Campaign Print Ad
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Education Workshops

• Developed slide presentation for all screening
  sites to use
• Encouraged all screening participants to sit in
  on workshop
• Developed educational video in English, Korean,
  Chinese Mandarin, Cantonese and Vietnamese for
  patients to watch in waiting room

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AAHBP Screening Sites

• Charles B. Wang Community Health
• Gouverneur Hospital
• Bellevue Hospital
• New York Downtown Hospital
• Korean Community Service
• American Cancer Society Asian Unit
• Community Health Network

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AAHBP Screening Site Locations
As Reflection of Distribution of API populations
in NYC
AAHBP Screening Site
Source US Census 2000
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Program Accomplishments

• Educational workshops for almost 4500 individuals
• Screened more than 4000 individuals
• Vaccinated more than 1000 individuals (more than
  1800 vaccine doses)
• Identified over 900 HBV-infected patients and
  provided about 700 initial evals and 1000 follow
  up visits

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Program Challenges

• Developing an effective coalition involves trust
  and overcoming many potential obstacles,
  including
• Coordination between different institutions
• Communication between institutions
• Reaching new immigrants
• This required a collaborative effort involving
  health specialists, community-based
  organizations, local governments and health
  departments

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Program Innovations

• Identified new funding source
• Developed new comprehensive model
• Invested heavily in collection of data that
  permitted sophisticated analysis and new
  observations
• High-impact by publication of results and media
  exposure

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Addendum

• Project funded for Program Year 3
• Expand target populations to include South Asians
  and Southeast Asians
• Focus on young adult high-risk populations

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Asian American Hepatitis B Program funded by the
City Council of New York. The following is a
partial list of partners and contributors to the
AAHBP program

• American Cancer Society Ming-Der Chang, PhD, Li
  Ma
• Bellevue Hospital William Bateman, MD, Chris
  Cho, Edith Davis, Judy Aberg, MD, Scott Fuller,
  Janice Charles, Thomas Jasper, Robert Boyd
• Charles B. Wang Community Health Center Thomas
  Tsang, MD, Alan Tso, MD, Christina Lee, Regina
  Lee, Esq, Phyllis Kwok, MD
• Community Healthcare Network Kameron Wells, RN,
  Catherine Abate, ED, Gloria Leacock, MD
• Korean Community Services Jinny Park, Shin Son,
  PhD
• Gouverneur Healthcare Services Pearl Korenblit,
  MD, Lily Yiu, L Chiang, PA, S Shi, MD
• NY Downtown Hospital William Wang, Waiwah Chung,
  RN, Charles Ho, Eric Poon, MD
• NYU School of Medicine Kejia Wan, MPH, John
  Nolan, Paige Baker, Rona Luo, Jenny Bute, Gemma
  Rochford, Ming Xia Zhan, Ruchel Ramos, MPA, Alex
  Sherman, MD, Hillel Tobias, MD, Helene Lupatkin,
  MD, Chau Trinh,DrPH, Henrietta Ho-Asjoe, Gerald
  Villaneuva, MD, Mariano Rey, MD, Henry Pollack,
  MD.

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Charles B. WangCommunity Health Center

• Mission
• To be a leader in providing quality, culturally
  relevant, and affordable health care and
  education, and advocate on behalf of the social
  needs of underserved Asian Americans.
• History and Description
• Established in 1971
• Federally Qualified Health Center
• 2 locations in Manhattan, 1 in Flushing
• Total of 140,000 patient visits annually
• 70 of patients insured though federal programs
  (Medicaid, Medicare, CHP), 28 are uninsured, 2
  have private insurance
• Bilingual and bicultural services
• Comprehensive Primary and Specialty Care

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Community-Based Hepatitis BScreening Program
(2000)

• Public Private collaboration with Oxford Health
  Plans, CAIPA / CAMS and Glaxo SmithKline
• Program Goals
• To raise awareness of hepatitis B infection
• To screen for patients with CHB (HBsAg )

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Lessons Learned

• From a community perspective
• PublicPrivate collaboration provided efficiency
  and necessary resources
• From a provider perspective
• How can we better ensure that carriers return
  for follow-up care?
• How can we provide hepatitis B vaccinations for
  patients at risk for infection?

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Community-Based Hepatitis BScreening Program
(2001)

• Same public private collaboration (Oxford
  Health Plans, CAIPA / CAMS and Glaxo SmithKline)
• Program Goals
• To follow-up on CHB patients identified in year
  2000 screenings
• To conduct individual screenings in provider
  offices to ensure better follow-up

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Lessons Learned

• From a community perspectiveNeed for increased
  community support and involvement in the
  screenings
• From a provider perspective
• 13 of uninsured patients specifically indicated
  that lack of insurance was a barrier to seeking
  F/U care at MD office
• Need to vaccinate at risk patients

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DOH Program ScreeningHousehold Contacts
(2002Current)

• New collaboration with NYC Dept of Health and
  Mental Hygiene
• Program GoalTo provide education, screening and
  vaccination to household members of pregnant
  women who tested positive for HBsAg
• Targeted group of high-risk individuals that is
  often hard to reach
• Over last 4 years
• Among pregnant women at CBWCHCHBsAg positive
  rate consistent at about 16
• Total of 1,823 household contacts screenedHBsAg
  positive rate consistent at about 20

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Lessons Learned

• From a community perspective
• How can we maintain resources (e.g., vaccines)
  and support for the program?
• Need to increase marketing and outreach
• From a provider perspectiveHow can we improve
  F/U for CHB patients?
• Lack of insurance continues to be a barrier to
  seeking F/U care

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B Healthy Model Care Program(2006)

• Partnership with the Association of Asian Pacific
  Community Health Organizations (AAPCHO)
• Chronic Care Model applied as conceptual
  framework to a largely immigrant community that
  faces social, cultural, linguistically, and
  financial barriers to quality care
• Designed to serve as a model for a multifaceted
  approach to hepatitis B intervention
• 3 Areas of Focus, 4 Primary Objectives
• Comprehensive care management for CHB patients
• Outreach and education to a community with
  limited English proficiency
• Increasing awareness of the impact of hepatitis B
  in the AAPI community through local, regional,
  and national advocacy efforts (AAPCHO)
• Supported by BMS

Wagner EH. Chronic disease management What
will it take to improve care for chronic
illness?Effective Clinical Practice. 199812-4.
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B Healthy Model Care Program5 Primary
Objectives

• Comprehensive care management for CHB patients
• Objective 1 To train primary care physicians
  on new management issues related to hepatitis B
  infection
• On-site provider training seminars conducted by
  various leaders in hepatitis B management
• Objective 2 To encourage high-quality CHB care
  at CBWCHC
• Hepatitis B flow sheets

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B Healthy Model Care Program5 Primary
Objectives

• Comprehensive care management for CHB patients
• Objective 3 To develop an enabling service to
  improve access to hepatitis B treatment and
  management services for AAPIs with CHB
• Bilingual case managers
• Availability of social workers
• Availability of mental health services
• Referrals to diagnostic tests and specialists

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B Healthy Model Care Program5 Primary
Objectives

• Comprehensive care management for CHB patients
• Objective 4 To provide education and support
  for hepatitis B carriers and their families and
  the community
• Developed culturally and linguistically
  appropriate educational materials
• Brochure focusing on importance of screening,
  vaccination, and risk of perinatal transmission
• Two 10-minute videos perspective of a patient
  with CHB, perspective of a family member of a
  patient with CHB
• Monthly radio programs were aired on popular
  Chinese stations

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B Healthy Model Care Program5 Primary
Objectives

• Comprehensive care management for CHB patients
• Objective 4 (contd)
• Support groups
• Three sessions (90 minutes each)
• 1, patients only (5) Overview of Hepatitis B
• 2, patients only (5) Living with Chronic
  Hepatitis B
• 3, patients and family (8) Family Life Coping
  with Hepatitis B
• Patients encouraged to gain knowledge from
  speakers, facilitators and other patients
• Assist in developing and improving coping skills
• Increase confidence and acceptance of patients
  liver disease through the knowledge that they are
  not alone

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Perceptions of Hepatitis B in the Chinese
Community

• Awareness of hepatitis B but many underestimate
  the severity
• Link between hepatitis B infection and liver
  cancer liver damage is not clear
• Many myths regarding transmission
• Spread by sharing food or chopsticks
• Vaccine can transmit hepatitis B infection
• Cure for hepatitis B exists
• Observations by CBWCHC staff from past hepatitis
  B programs

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Educating Empowering Patients

• Importance of education
• Many misperceptions about hepatitis B
• Many unaware of the seriousness of a chronic
  infection
• Importance of empowerment
• Self-management greatly affects disease control
  and outcomes
• Empower the patient through information,
  emotional support and strategies for living with
  chronic illness

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Conclusions

• An unmet need in large-scale hepatitis B
  screenings remains within the Asian community
• Community-based, collaborative prevention
  strategies allow for increased outreach into the
  community, access to resources and public support
• Targeted clinical and educational interventions
  should be created for high risk populations that
  face barriers to access
• Education module must be developed to accommodate
  low literacy patients
• Care and support for chronic hepatitis B patients
  involves the collaboration of multiple disciplines