In the tropical state of Hawaii, the sunlight is shining on a potentially deadly virus living quietly within many of its inhabitants. Hawaii’s diverse population1 makes chronic hepatitis B, a largely asymptomatic condition and leading cause of liver cancer, a common, albeit unknown, burden.2 But primary care physicians (PCPs) in the “Aloha State” are taking the lead in bringing the disease into the open with preventative screening measures and slowing its progression with appropriate patient care.

Approximately 1.4 to 2 million people in the United States are infected with the hepatitis B virus (HBV) and because many experience few or no symptoms, two-thirds do not know they have it.2,3 The disease is especially prevalent among individuals who immigrated to the United States from Asia or are of Asian descent; 1 in every 12 Asian Americans has chronic hepatitis B.2 An ethnically heterogeneous population, more than 38% of Hawaiians identify themselves as Asian, 10% consider themselves native Hawaiian and Pacific Islander, and more than 17% are foreign-born.1

Philip Suh, MD, who has a busy primary care practice in urban Honolulu, has joined a growing number of PCPs who are diagnosing and treating people with HBV. Like many PCPs, however, he was initially reluctant and did not realize how much of a difference he could make.

“I used to be one of those people who said it’s too complicated. I thought it would take a lot of time but it doesn’t,” said Dr. Suh, who grew up in and completed his medical training in Hawaii.

In his first decade or so of private practice, Dr. Suh came across a handful of patients infected with HBV, whom he would refer to specialists at a local liver center. “However, the liver center started getting busier and busier, and the referrals became harder to do,” he said.

It was then, 3 or 4 years ago, that his PCP friend told him of his experience screening and treating patients with HBV. He suggested that Dr. Suh could manage these patients himself but Dr. Suh remained reluctant. “I said, ‘Oh no, that’s way too hard, that’s way too complicated.’ And I kind of left it at that.”

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“What I found in my practice is that I had a lot of patients who were affected by hepatitis B, but I didn’t know because I wasn’t checking.”

Philip Suh, MD

Nevertheless, Dr. Suh agreed to participate in a lecture series sponsored by Gilead Sciences to educate physicians about the diagnosis and treatment of hepatitis B in the office. “By going through that whole process, I recognized that there was a lot to learn and there were many ways that I could help my patients.”

 

Although he was still unconvinced that hepatitis B was an issue in his practice, he began screening and found that the statistics bore true among his patients, the majority of whom are Asian and Asian American. Many of them were in fact unknowingly harboring this disease. “What I found in my practice is that I had a lot of patients who were affected by hepatitis B, but I didn’t know because I wasn’t checking.”

The most common route of transmission in the Asian American community is from a woman to her newborn baby.2 This cycle of transmission from generation to generation in families can be broken in the United States, where pregnant women are now routinely screened for HBV and their newborns are immunized, preventing chronic infection 90% of the time.2,4

Unfortunately, many adults with HBV are never screened and diagnosed—published data on screening is limited.3 Treatment guidelines are recommended for the subpopulation of HBV carriers who present with biochemical and histological features of moderate or severe liver disease.3 If left unmonitored and unmanaged, the virus is free to attack liver cells and up to 25% of infected people may develop serious complications, including hepatocellular carcinoma and decompensated cirrhosis.2 Antiviral therapy can be used to slow progression of the disease.2 Currently, approximately 350,000 to 500,000 people per year in the United States are potentially eligible for HBV treatment.3

As they often are the first and sometimes only clinicians to see patients who may be infected with HBV,5 PCPs have the greatest opportunity to catch the disease in its early stages and potentially help keep the most serious of its complications at bay. PCPs are also well equipped to manage these patients without specialist intervention, for the most part.5

“The treatment methods and the diagnostic tests available made things much simpler than I had imagined in the past,” Dr. Suh said. He now routinely screens all of his at-risk adult patients for HBV, just as he checks for other issues, such as cholesterol, blood sugar, blood count, and thyroid. Especially considering the ethnically diverse Hawaiian population his practice serves, he said it can sometimes be difficult to tell who may have an Asian family member somewhere in their lineage, placing them at risk for HBV infection. “You’re seeing a lot of racial diversity, a lot of mixed ethnic families, a lot of multigenerational families. Some of the patients that I’ve actually found to be positive are ones that I wouldn’t have expected and ones that I wouldn’t necessarily have tested if I were just looking for a specific patient type.”

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Figure. Rates of HBV infection, eligibility for treatment, and diagnosis in the United States. The number of people currently eligible for treatment for hepatitis B virus in the United States is approximately 350,000 to 500,000.
Adapted from reference 3.
The tests are fairly straightforward and results are returned within a few days to a week, Dr. Suh said. Insurance coverage for HBV diagnostic tests and care has not been difficult to obtain, in Dr. Suh’s experience. “The treatment coverage has been good. The diagnostic coverage has been good. And so, it’s another one of those things where I thought it was going to be a barrier but actually, it isn’t.”

 

Dr. Suh still refers some patients to the local liver center, if there is advanced disease, any mass that requires a biopsy, or suspicion of hepatocellular carcinoma, along with patients with hepatitis C.

After learning about HBV and now regularly managing these patients in his practice, Dr. Suh likens screening for and treating HBV to doing the same for high cholesterol, asthma, or diabetes. “If I can check and treat from my background, [other PCPs] can do it too. After the first couple of patients, I realized that the early stages of hepatitis B are just like the early stages of any other disease, where I can check, I can get a baseline, I can identify, and I can treat it in the office. And, from there, I can manage patients. If I run into a more challenging case, I can refer them to the local liver center.”

When asked what barriers PCPs may face when deciding whether to screen and treat patients with HBV, Dr. Suh suggested that many PCPs may think they are too busy. “I used to be one of those people who thought it was too complicated. I thought [screening and managing] would take a lot of time but it doesn’t. Overall, it gives me a better feeling because I know I’m giving more comprehensive care. And when you look at it, one of the ultimate goals to treat is to prevent hepatocellular carcinoma,” concluded Dr. Suh.4

References

     

  1. US Census Bureau: state and county quickfacts. http://quickfacts.census.gov/​qfd/​states/​15000.html. Accessed September 12, 2012.
  2. Ward J. CDC expert commentary: screening Asian patients for chronic hepatitis B. http://www.medscape.com/​viewarticle/​729610. Accessed September 12, 2012.
  3. Cohen C, Holmberg SD, McMahon BJ, et al. Is chronic hepatitis B being undertreated in the United States? J Viral Hepat. 2011;18(6):377-383.
  4. Mast EE, Weinbaum CM, Fiore AE, et al. A comprehensive immunization strategy to eliminate transmission of hepatitis B virus infection in the United States. MMWR Recomm Rep. 2006;55(RR-16):1-33.
  5. McHugh JA, Cullison S, Apuzzio J, et al. Chronic hepatitis B infection: a workshop consensus statement and algorithm. J Fam Pract. 2011;60(9): E1-E8.