Tuesday, July 23, 2013

Editorial: How the U.S. Department of Justice Just Might Improve Hepatitis B Care in the United States

By Christine Kukka, Project Manager, HBV Advocate 


While unintended, last month’s U.S. Department of Justice letter to medical schools warning them against discriminating against applicants who are infected with the hepatitis B virus (HBV) may do more to improve the quality of medical care offered to HBV-infected people in the United States than any recent medical initiative.

Despite its judicial origins, this legal warning shot may finally educate medical school teachers about hepatitis B, so they in turn can teach future doctors to screen, immunize and treat the tens of thousands of undiagnosed people with hepatitis B. Because to date, these teachers have failed miserably. An estimated 2 million Americans are infected with hepatitis B and two-thirds do not know it. (1.) Screening and treating chronically-infected people remains poor, with fewer than 10% getting the treatment they need. (1.)

Several years ago, medical practice guidelines were updated so doctors would routinely screen people at risk for hepatitis B, which includes immigrants and their descendants who came from regions with high hepatitis B rates, including Asia, the Middle East, and Africa.

But many doctors have ignored these guidelines and thousands of people remain undiagnosed, untreated, and their family members remain unvaccinated and at risk of infection. Why don’t these guidelines work? They’re not read or followed, studies show, especially among primary care providers who should be the first line of screening and treatment.

Even when doctors know about a patient’s HBV infection, studies show they still fail to effectively treat them and screen and immunize family members. According to a recent report presented at Digestive Disease Week conference (2), only one-quarter to one-half of patients with diagnosed HBV infections who were seen at community clinics were given they treatment they need based on current practice guidelines.

Another recent study also provides insight into how the health care system fails people with hepatitis B. This study documented how pregnant women with hepatitis B were short-changed in getting the screening, treatment, and education they need (3). When interviewed, obstetricians and nurses said they were so poorly informed about hepatitis B that they failed to adequately treat and educate these pregnant women and their families.

Their medical training was inadequate, they reported, and they lacked effective educational materials to help patients understand this complex infection. "The obstetricians and nurses perceived a stigma attached to hepatitis B that made patients reluctant to receive information and/or encourage their sexual contacts and family members to be tested for hepatitis B," researchers reported.

This sense of shame made the providers, "wary of openly discussing hepatitis B with their patients, especially if the patients were accompanied by other people." Would they have avoided talking about HIV with a pregnant woman and her family members if she was infected? No, because there are tremendous training and resources dedicated to training providers about AIDS and the need for education and case management to treat these patients and keep their family members free from infection.

So perhaps the Department of Justice warning letter, backed by medical directives written by the U.S. Centers for Disease Control and Prevention, will be more effective about capturing these institutions' attention. Maybe they will finally learn that not only do HBV-infected health care providers not pose a health risk to patients—but that this is an infection that can be treated and prevented, but only if doctors are trained to heal.

 1. Eradication of Hepatitis B: A Nationwide Community Coalition Approach to Improving Vaccination, Screening, and Linkage to Care by Cohen c, Caballero J, Martin M eta al. J Community Health. DOI 10.1007/s10900-013-9699-4 Source: http://www.hepb.org/pdf/HBU%20Article%20in%20J%20Comm%20Health%20June%202013.pdf 

2. Antiviral Treatment Eligibility and Treatment Rates... by Kim, Nguyen et al. Digestive Disease Week, May 2013. (no url available) 

3. Education and Counseling of Pregnant Patients with Chronic Hepatitis B: Perspectives from Obstetricians and Perinatal Nurses in Santa Clara County, California by Yang, Cheung et al. APJPC vol 14.3, 2013. Source: http://www.apocpcontrol.org/page/apjcp_issues_view.php?pno=4280&gubun=p&s_search=&s_paper_vol=&s_number33=

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