Monday, August 19, 2013

The Other Forgotten Hepatitis B Minority—African-Americans

 —Christine. M. Kukka, Project Manager, HBV Advocate

Which racial/ethnic group in the United States had the highest rate of acute (new) hepatitis B infections in 2010?

You might assume Asian-Americans who have high chronic infection rates had this distinction, but think of another racial group facing similar cultural and economic barriers to health careAfrican-Americans.

According to a study by University of Pennsylvania researchers, African-Americans make up the largest percentage of people who are newly infected with hepatitis B today.

In 2010, African-Americans had the highest rate of acute HBV infection with 1.7 cases per 100,000 people. In contrast, Asian-Americans had an acute infection rate of 0.6 per 100,000. Asian-Americans may have a higher rate of chronic infection due to infection at birth, but most of the new infections occurring in the United States today happen to African-Americans.

In America, being black means you have a 3.9-fold chance of being infected with hepatitis B, compared to whites.

According to the study, published in the August issue of the Journal of Clinical Gastroenterology and Hepatology, African-Americans tend to be infected with HBV genotype A (84%), which is associated with a 4-  to 5-fold increase in liver cancer compared to other genotypes. In contrast, Asian-Americans are often infected with less virulent genotypes B and C.

To make matters worse, the few hepatitis B studies that have been performed in African-Americans and immigrants from Africa found that liver cancer occurs at a younger age in these populations than in other ethnic groups. African-Americans may have genetic risk factors that predispose them to developing chronic hepatitis B following exposure to the virus that other ethnic groups do not face. Yet, few doctors know to screen their African-American clients for hepatitis B.
 
If little is known about the progression of liver disease in HBV-infected African-Americans, even less is known about the effectiveness of treatment.

A long-term follow-up study of patients treated with interferon found that African American patients were, "... much more likely to respond to therapy," researchers wrote. "Of note, all African American responders not only cleared the hepatitis B "e" antigen and (achieved undetectable) HBV DNA ... but all cleared HBsAg, a relatively rare milestone with HBV therapy that (usually) occurs in (only) 7.8% of patients on therapy."

Unfortunately, this was a small study and no additional research into African-Americans' remarkable ability to reportedly clear hepatitis B infection after interferon treatment has been repeated to verify these results.

When it comes to the effectiveness of antivirals in African-Americans, few clinical trials have examined their impact in this population. "...There are inadequate data about the efficacy and safety of these agents in African American patients with chronic HBV infection," researchers added.

As with Asian-Americans, few African-Americans who qualify for treatment ever receive it. A small study that included patients from an urban medical center found that only 7% of a predominantly African-American and Hispanic population had been initiated on therapy.

The study cited lack of health insurance, failure to take medication as prescribed and ongoing drug and alcohol use as possible reasons for poor access to treatment. Not surprising, access to liver transplants was also far lower among African-Americans than whites.

"Continued research is needed to identify and address areas of disparity in chronic HBV infection and treatment, and an improvement in enrollment of African Americans in clinical trials is essential for achievement of this goal," the researchers noted.


Abstract:Hepatitis B and C in African Americans: Current Status and Continued Challenges

Forde KA, Tanapanpanit O, Reddy KR.
Division of Gastroenterology and Hepatology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.

Viral hepatitis remains a public health concern in the United States, resulting in excess morbidity and mortality for the individual and representing a burden to societies as evidenced by billions of dollars in healthcare expenditures.

As with many chronic diseases, race and ethnicity influence various aspects of disease pathogenesis including mechanisms of persistence, disease progression, disease sequelae, and response to therapy. For hepatitis B and C infections, African Americans disproportionately bear a large burden of disease in the United States. The role and importance of African American race, however, have been less well characterized in the literature among the population of viral hepatitis-infected individuals.

The differences in epidemiology, manifestations of liver disease, response to therapy, and differential trends in liver transplantation in African Americans compared with other racial and ethnic groups deserve special attention. This review will address the current status of hepatitis B and C infection in African Americans in the United States and identify some of the remaining challenges in diagnosis, characterization of natural history, and treatment. 

For purposes of this review, the terms African American and black will be used interchangeably throughout the text.

Clin Gastroenterol Hepatol. 2013 Jun 28. pii: S1542-3565(13)00865-3. doi: 10.1016/j.cgh.2013.06.006.

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