Hepatitis B and Liver Cancer in Asian Americans
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Hepatitis B and Liver Cancer in Asian Americans
Hepatitis B virus (HBV) can cause an acute or chronic infection with high morbidity and mortality from liver disease. Its spread is geographically diverse, with some populations or ethnic groups and endemic areas having a relatively high HBV prevalence. Chronic HBV infection is among the leading etiologies of cirrhosis and the majority of liver cancers in such populations. Disparities continue to exist in tackling HBV infections among Americans of Asian descent thus targeted approaches and culturally appropriate interventions are needed to alleviate the burden of morbidity and mortality from liver pathology.
Epidemiology of HBV Infections among Asian Americans
The spread of HBV infections in America is diverse but a high prevalence exists among minority communities such as immigrant populations. Globally, more than 250 million people are estimated to be HBV infected with approximately two-thirds of this living in the Asia‐Pacific region (Torre et al, 2016). Tang et a (2018), describes this as a racial disparity since Asian Americans and Pacific Islanders constitute more the 50% of those with HBV infection. About 10% of this population has chronic HBV infection, a figure which is way above the estimate of 0.3% in the overall US population (Tang et al, 2018). According to Strong et al (2015), Vietnamese Americans in Baltimore–Washington metropolis showed a higher prevalence of HBV than the Hepatitis C virus (HCV) at 9 % and 5 % respectively. This study also revealed that the prevalence of HBV was highest among the productive age group below 50 years who are at risk of sequale of chronic infection which could emancipate the problem (Strong et al, 2015). Strong et al (2015) did not find any association between the rate of HBV infection and gender. The sociodemographics of HBV infection in Asian Americans reflect the true burden of this disease which is far-reaching beyond the health of individuals.
Why the High Prevalence of HBV among Asian Americans
The fact that Asian Americans have a high prevalence of HBV infections despite existent barriers to screening, prevention, and treatment led to a lot of research to understand this disparity. Many regions have witnessed sharp reductions in HBV infections and increasing immunity since the inception of the Universal Childhood Hepatitis B vaccination, however, Asian Americans continue to experience a disproportionately higher number of cases (Wong et al, 2019). Asian Americans, the fastest-growing racial group, have the highest prevalence of HBV despite living in developed regions with rather low endemicity such as North America. This is due to a large proportion of this population being immigrants as opposed to being the USA born (Torre et al, 2016). Immigrants from Asian countries have poor access to healthcare and a high prevalence of HBV infection compared to the rest of the population and other ethnic groups in the United States (Vedio et al, 2017).
Most of these people originate from areas of high HBV prevalence in East Asia such as China and Malaysia or South‐East Asia such as Vietnam and Laos. The prevalence of HBV among these immigrant populations has very little variation from that of their countries of origin (Vedio et al, 2017; Tong et al, 2018). The high global immigration of people from Asia to countries like the USA in the past few decades could be implicated in this finding. Asian Americans have generally low screening rates for HBV and the fact that screening is focused mainly among pregnant women to reduce vertical transmission leaves men out in this regard. According to Tang et al (2018), a family history of HBV was also associated with high odds of having HBV infection in the closely-knit and reserved Asian Americans communities. These findings indicate that the high prevalence of HBV among Asian Americans could largely be due to the importation of the virus and its circulation within this population.
Issues affecting care and prevention of HBV in the Asian American community
A lot of inequities continue to plague minority populations in the United States. Poor access and lack of culturally sensitive healthcare services among migrants have been recognized as a complex issue. Immigrants in America of Asian origin have different cultural backgrounds and circumstances surrounding their immigration into the United States. This population consists of diverse ethnic subgroups who speak one of more than 30 different languages, thus highlighting language as the most glaring cultural barrier in the fight against HBV. According to Tang et al (2018), immigrants who could not speak English at all were less likely to get screened than fluent English speakers. The degree of acculturation, such as language acquisition, is one factor that affects the health-seeking behaviors among these immigrants.
Lack of awareness is also another issue derailing the prevention of HBV and the provision of care in Asian American communities. According to Owiti et al (2015), a majority of immigrants lacked adequate knowledge and information concerning HBV infection symptoms, transmission risk factors, treatment, and prevention strategies. Misunderstanding around the transmission of HBV being food-borne rather than a possible sexually transmitted infection is prevalent among Vietnamese Americans and this warrants the effort to enhance public education programs in this population (Strong et al, 2015; Freeland et al, 2020). The casual association of HBV to social determinants of health has also been linked to interfering with health education about the transmission of this blood-borne virus. According to Owiti et al (2015), the majority of people in this population lack access to the already limited opportunities thus the lower education levels, low-income, and live without medical insurance. Ethnic differences in perceptions about preventive strategies such as vaccinations and the role of religious groups have also been highlighted (Owiti et al, 2015). Other than leading to poor help-seeking behavior, these mutually interdependent factors predispose the Asian American community to greater HBV infection and transmission.
Linking HBV Infection and Liver Cancer
HBV is a hepatotropic DNA virus that has several modes of transmission. According to Owiti et al (2015), most transmissions in minority groups and developing countries occur vertically (infected mother to baby during birth) and horizontally (through sexual contact). Sexual contact may account for up to 10% of all HBV carrier states in Asian adults and adolescents (Tong et al, 2018). Minor modes of transmission include early childhood exposure to infected children, transfusion of infected donor blood, and unsafe therapeutic procedures or injection.
HBV infection has a wide spectrum of clinical outcomes ranging from asymptomatic chronic carriers, mild to moderate hepatitis, fulminant hepatitis to late-onset cirrhosis, and hepatocellular carcinoma (HCC). Generally, Asian Americans and Pacific Islanders have a relatively lower risk of cancer except for few infection‐related cancers such as stomach and liver malignancies (Torre et al, 2016). HBV is strongly associated with HCC which accounts for more than three-quarters of all liver cancer cases worldwide due to a persistent chronic infection established through causing immune anergy (Yuen et al, 2018). About 25 % of patients who are chronic carriers fail to clear the disease and could develop cirrhosis or HCC later in life. Also, those who get infected earlier such as infants born to HBsAg and HBeAg positive mothers with high viral loads and miss the birth dose immunization are at higher risk of becoming chronic carriers (Inoue & Tanaka, 2016). Other established risk factors for liver cancer include toxins such as aflatoxins, schistosomiasis, alcoholic liver disease, metabolic syndrome, and tobacco smoking (Wong et al, 2019). With all this knowledge the sequale of cancer from chronic HBV infections is for sure an avoidable consequence.
The possibility of reactivation among persons who recovered and the risk of fulminant liver failure in immunocompromised cases pose an unforeseen challenge more so in highly endemic areas. A range of factors such as the viral genotype, individual immunity, concomitant pro-oncogenic-viral infections, and other etiologies of liver disease determines the outcomes in HBV infected patients (Sarin et al, 2016). HCV is a pro-oncogenic virus that lacks licensed vaccines and has been found to have high co-infection rates in HBV positive adult patients (Strong et al, 2015). Approximately 1 in 4 patients with chronic HBV infection die prematurely from liver failure or liver cancer (Tang et al, 2018). The best way to reduce a significant percentage of liver malignancies such as HCC is through the eradication of chronic HBV infections in high-risk populations.
Possible Solution
The statistics concerning HBV infection among Asian Americans highlight the need for tailored solutions. Multi-pronged efforts are essential to address patient, provider, and system huddles in service provision to this special community. Scale-up of disease surveillance and testing is required to ensure appropriate care is given to infected people (Vedio et al, 2017). Stigma should be tackled at the community level through communication strategies that are aimed at breaking the silence, disclosure, and normalizing talking about HBV. Interventions that are focused on increasing the understanding of this population about HBV can have a positive impact in the long term. Outreach campaigns and public sensitization is one approach that can improve awareness among difficult-to-reach populations (Zacharias et al, 2015). The role education has to play, is central in handling the menace HBV infections have caused in the Asian American population.
Lastly, it suffices to say that all solutions aimed at solving the whole problem require to be communicated in a language that many people can understand. This can be achieved through the use of language-concordant staff, translating information into native languages using interpreters, and partnering with community-based organizations to address linguistic and cultural barriers (Tang et al. 2018). Clinicians form an important entity in implementing initiatives aimed at ensuring uptake of missed opportunities in vaccination, screening, and treatment. Ultimately, these approaches could have implications not only for HBV but also for other stigmatized health issues in the Asian American community.
Conclusion
The fact that Asian Americans have a higher prevalence of HBV infections and that they remain vulnerable within their ethnic communities cannot be overlooked. This significant racial health disparity should prompt an assessment of the effectiveness of current public health interventions. Among the critical steps needed, includes scaling up of screening, vaccination programs, and provision of essential treatment to those who are infected. Immediate attention should be accorded to the implementation of new structures and policies designed internationally using strategies that help minority and disadvantaged groups in facing the threat of HBV infection. Intervention programs should also incorporate community contexts, ethnic and cultural sensitivity factors such as language concordance to ensure the Asian American community is served effectively. Coordinated and culturally appropriate approaches are essential to ensure the successful provision of holistic HBV infection-related health services to this population who continue facing a lot of disparities.
References
Freeland, C., Huynh, T., Vu, N., Nguyen, T., & Cohen, C. (2020). Understanding Barriers and Knowledge Related to Hepatitis B for Vietnamese Nail Salon Workers in the United States.
Inoue, T., & Tanaka, Y. (2016). Hepatitis B virus and its sexually transmitted infection-an update. Microbial cell, 3(9), 420.
Owiti, J. A., Greenhalgh, T., Sweeney, L., Foster, G. R., & Bhui, K. S. (2015). Illness perceptions and explanatory models of viral hepatitis B & C among immigrants and refugees: a narrative systematic review. BMC public health, 15(1), 151.
Sarin, S. K., Kumar, M., Lau, G. K., Abbas, Z., Chan, H. L. Y., Chen, C. J., ... & Dokmeci, A. K. (2016). Asian-Pacific clinical practice guidelines on the management of hepatitis B: a 2015 update. Hepatology International, 10(1), 1-98.
Strong, C., Hur, K., Kim, F., Pan, J., Tran, S., & Juon, H. S. (2015). Sociodemographic characteristics, knowledge, and prevalence of viral hepatitis infection among Vietnamese Americans at community screenings. Journal of immigrant and minority health, 17(1), 298-301.
Tang, A. S., Lyu, J., Wang, S., He, Q., Pong, P., & Harris, A. M. (2018). Disparities in hepatitis B virus infection and immunity among New York City Asian American Patients, 1997 to 2017. American journal of public health, 108(S4), S327-S335.
Tong, M. J., Pan, C. Q., Han, S. H., Lu, D. K., Raman, S., Hu, K. Q., ... & Min, A. D. (2018). An expert consensus for the management of chronic hepatitis B in Asian Americans. Alimentary pharmacology & therapeutics, 47(8), 1181-1200.
Torre, L. A., Sauer, A. M. G., Chen Jr, M. S., Kagawa‐Singer, M., Jemal, A., & Siegel, R. L. (2016). Cancer statistics for Asian Americans, Native Hawaiians, and Pacific Islanders, 2016: Converging incidence in males and females. CA: a cancer journal for clinicians, 66(3), 182-202.
Vedio, A., Liu, E. Z. H., Lee, A. C., & Salway, S. (2017). Improving access to health care for chronic hepatitis B among migrant Chinese populations: A systematic mixed-methods review of barriers and enablers. Journal of viral hepatitis, 24(7), 526-540.
Wong, M. C., Huang, J. L., George, J., Huang, J., Leung, C., Eslam, M., ... & Ng, S. C. (2019). The changing epidemiology of liver diseases in the Asia–Pacific region. Nature Reviews Gastroenterology & Hepatology, 16(1), 57-73.
Yuen, M. F., Chen, D. S., Dusheiko, G. M., Janssen, H. L., Lau, D. T., Locarnini, S. A., ... & Lai, C. L. (2018). Hepatitis B virus infection. Nature Reviews Disease Primers, 4(1), 1-20.
Zacharias, T., Wang, W., Dao, D., Wojciechowski, H., Lee, W. M., Do, S., & Singal, A. G. (2015). HBV outreach programs significantly increase knowledge and vaccination rates among Asian pacific islanders. Journal of community health, 40(4), 619-624.