Surveillance for Chronic Hepatitis B Virus Infection — New York City, June 2008–November 2009

Chronic hepatitis B virus (HBV) infection is a leading cause of cirrhosis and liver cancer worldwide (1); the estimated prevalence in the United States is 0.3%–0.5% (2). Each year, approximately 11,500–13,000 persons are newly reported with a positive HBV test to the New York City (NYC) Department of Health and Mental Hygiene (DOHMH) (3). To characterize chronic HBV patients, DOHMH began ongoing enhanced chronic HBV surveillance, selecting a random sample of newly reported cases and collecting more detailed information from the patients' clinicians. This report summarizes investigations of 180 randomly selected HBV cases reported during June 2008–November 2009. Approximately two thirds (67%) of patients were Asian, and the most commonly reported reason for HBV testing was the patient's birth country or race/ethnicity (27%). In 70% of cases, the clinician did not know of any patient risk factors. Sixty-nine percent of clinicians stated that they counseled their patients about notifying close contacts about their infection, and 75% counseled about transmission and prevention. Sixty-two percent did not know their patient's hepatitis A vaccination status despite recommendations. This surveillance effort provided quantitative data on health disparities useful for identifying opportunities for outreach and education, and it showed that not all patients received recommended prevention and treatment services. In response to these findings, DOHMH now routinely distributes HBV patient education materials to populations in need.

DOHMH requires clinicians and laboratories to report positive results of tests for hepatitis B surface antigen (HBsAg), e antigen (HBeAg), and HBV DNA for all NYC residents. The CDC and Council of State and Territorial Epidemiologists (CSTE) case definition for confirmed chronic HBV infection requires two positive tests at least 6 months apart or one positive test and a negative test for immunoglobulin M (IgM) antibodies to HBV core antigen.* This project included all patients with a positive HBsAg, HBeAg, or HBV DNA as long as there was no evidence of acute infection (IgM or case reported as acute by clinician). All data from reports were either directly entered into a DOHMH database or imported from DOHMH's electronic laboratory reporting system and deduplicated automatically. In 2009, a total of 84,659 reports were received; for the same year, 11,589 persons were newly reported with chronic HBV infection. As a result of the large volume of reports, investigation of each patient was not feasible.

To learn more about HBV patients in NYC, every 2 months persons newly reported to DOHMH 2–3 months earlier with a positive HBV test were selected from the HBV surveillance database. Patients without a recorded date of birth were excluded (<3% of reports). From this dataset, a simple random sample of 20 patients was created using a SAS survey selection procedure.† Investigators telephoned the clinician who ordered the HBV test, then faxed a standard questionnaire, and followed-up by telephone as needed. If the clinician mentioned another clinician who knew the patient better, staff members contacted this clinician as well. In cases in which clinicians were unable or unwilling to provide information by telephone or fax, DOHMH staff members reviewed medical charts. Data collected included demographics, reasons for HBV testing, hepatitis A vaccination status, and HBV-related risk factors, care, and patient counseling (e.g., modes of transmission and contact notification). Patients' most recent positive HBV test results were obtained to confirm HBV infection status. When clinicians did not report the patient's country of birth, staff members contacted patients directly for that information. Frequency tables were generated using statistical software. Fisher's exact test was used to assess relationships between variables. Statistical significance was defined as p<0.05.

From September 2008 to January 2010, a total of 180 patients were selected and investigated for enhanced surveillance; their report dates ranged from June 2008 to November 2009. From these 180 patients selected, completed questionnaires were obtained for 156 (87%) and these 156 were included in this analysis. Among the 24 patients excluded, five questionnaires could not be completed, five were laboratory reporting errors, two had acute HBV, four were not NYC residents, and eight did not have HBV infection confirmed by additional laboratory results. For the 156 included patients, 135 (86%) questionnaires were completed by fax, 15 (10%) by chart review, five (3%) by telephone, and one (1%) by both fax and telephone. Also, 12 patients were contacted by DOHMH staff members to ascertain birth country. Chi-square analysis showed that sampled patients were not statistically significantly different from all patients in the HBV surveillance database for the same surveillance period in terms of age, sex, and borough of residence (3). Sixty-one percent of patients were male, 67% were Asian, and the median age was 38 years (range: 2–91 years) (Table 1). Birth country was China for 56% of patients and unknown for 14%. No risk factor was reported by clinicians for 70% of patients; of those with a risk factor reported, perinatal exposure and heterosexual contact were most common.

Reasons for HBV testing were not mutually exclusive. The most commonly reported reason was birthplace in a high-prevalence country (27%). Two percent of patients were tested because of hepatitis signs and symptoms, and 12% because of elevated liver function test results. Seventy-five percent of clinicians reported counseling the patient about transmitting HBV to others, and 69% had counseled the patient on notifying close contacts. Five to seven percent of the clinicians stated that they would counsel about these topics during the next visit. Non-Asian patients were significantly less likely to have been counseled (Table 2). Sixty-two percent of clinicians did not know their patients' hepatitis A vaccination status.

Reported by

Emily McGibbon, MPH, Erlinda Amoroso, Alice Baptiste-Norville, MPH, Sharon Balter, MD, Jennifer Baumgartner, MPH, Alison Bodenheimer, MPH, Katherine Bornschlegel, MPH, Cherylle N. Brown, MPH, Fazlul Chowdhury, Carolyn Cokes, MPH, Ellen T. Gee, MPH, Yin Ling Leung, MPH, Michelle Middleton, Daniel Osuagwu, Jose Poy, MPH, Meredith M. Rossi, MPH, Sara Sahl, MPH, Rajmohan Sunkara, MPH, Bur of Communicable Diseases, New York City Dept of Health and Mental Hygiene. Corresponding contributor: Emily McGibbon, elumeng@health.nyc.gov, 347-396-2631.

Editorial Note

This investigation showed that the majority of persons reported with chronic HBV in NYC from June 2008 to November 2009 were Asian and male, which is consistent with previous findings (4–6). In 2006, the San Francisco Health Department found that 84% of patients reported with confirmed chronic HBV infection were Asian/Pacific Islanders (5); chart reviews conducted in Olmsted County, Minnesota, indicated that approximately half of chronic HBV patients in that locality were Asian (6). These findings validate the need for continued efforts to educate clinicians and patients in Asian-American communities about HBV screening recommendations (2,7). High-prevalence birth country was the most common reason for HBV testing; 119 (76%) patients were born in countries where HBV prevalence exceeds 2%. CDC recommends HBV screening for persons born in countries with HBV prevalence ≥2% (2). Despite the emphasis on birth country as a screening criterion, 14% of clinicians in this analysis did not know where their patients were born, suggesting that clinicians do not consistently ask patients about birth country.

The small proportion of patients tested because of hepatitis signs and symptoms or elevated liver function test results suggests that most clinicians are considering the screening recommendations and diagnosing HBV before symptoms of chronic infection develop. Consistent with this observation, none of these newly reported patients were hospitalized for HBV during the preceding year, and only 4% were waiting for a liver transplant.

Seventy percent of clinicians did not know their patients' risk factors for HBV infection. Interviewing patients instead of clinicians might have provided more complete information. Nearly two thirds of clinicians did not know their patient's hepatitis A vaccination status, despite recommendations to vaccinate HBV patients against hepatitis A (infection with hepatitis A can be severe in those with chronic HBV infection) (2). This finding suggests that educational efforts directed to clinicians are warranted.

Most clinicians reported appropriately counseling patients about key issues for patients with HBV infection: transmission and contact notification. Five to seven percent of clinicians indicated that they intended to provide counseling during the patient's next visit, suggesting that the questionnaire might have served to remind clinicians about the importance of such counseling. In a 1997 telephone survey in San Diego, California, only 43% of clinicians reported counseling their HBV-infected patients about transmission, suggesting that many clinicians might be unaware of the need for such counseling (8). The analysis described in this report indicated that Asians were more likely than non-Asians to have been counseled. Asians in NYC might more often be cared for by clinicians who are more familiar with HBV.

The findings in this report are subject to at least two limitations. First, information was collected from clinicians only (with the exception of birth country information for 12 patients). Although more accurate clinical information might be supplied by clinicians, patient interviews might have added information about risk factors and receipt of counseling messages (8). Second, despite efforts to interview all relevant clinicians, investigators might not have identified the clinician most familiar with certain aspects of each patient's care.

These data show the utility of a chronic HBV infection surveillance system. When caseloads are high and staffing is limited, investigating all reports of HBV infection might not be possible. In such situations, investigating a representative sample provides useful data to describe the affected population and identify unmet needs. By investigating only a sample of patients, DOHMH was able to achieve a high response rate (97%). This project was conducted, in part, with CDC grant funds for hepatitis surveillance. Some health departments conduct limited hepatitis surveillance or none at all because of limited funding.

This enhanced surveillance effort described NYC's newly reported chronic HBV population, determined whether patients received recommended prevention and treatment services, and identified potential areas for clinician education. Health departments can use these findings to develop educational materials for clinicians on HBV screening guidelines, vaccination recommendations, and counseling. These data also can guide efforts to prevent HBV transmission and prevent disease progression in persons living with chronic HBV infection. Health departments, community-based organizations, clinicians, and patient educators can consider these findings when developing outreach, advocacy, and educational initiatives.

DOHMH developed multiple initiatives as a result of this surveillance project. Clinicians who had indicated that their patients were not immune to hepatitis A were mailed a reminder that hepatitis A vaccination is recommended, along with information about locations where vaccination is available free of charge. DOHMH developed a booklet for patients called How to Tell Others You Have Chronic Hepatitis B (9) for distribution through clinicians and community groups. In addition, DOHMH sends patient health education booklets called Hepatitis B: the Facts (10) to all clinicians who participate in enhanced HBV surveillance and to newly-reported HBV patients. These booklets (available in five languages) can be ordered in bulk and free of charge within NYC by calling 311 and also are available online at http://www.nyc.gov/html/doh/downloads/pdf/cd/cd-hepB-chronic-telling-others.pdf and http://www.nyc.gov/html/doh/downloads/pdf/cd/cd-hepb-bro.pdf.

References

1. Custer B, Sullivan SD, Hazlet TK, Iloeje U, Veenstra DL, Kowdley KV. Global epidemiology of hepatitis B virus. J Clin Gastroenterol 2004;38(10 Suppl):S158–68.
2. CDC. Recommendations for identification and public health management of persons with chronic hepatitis B virus infection. MMWR 2008;57(No. RR-8).
3. New York City Department of Health and Mental Hygiene. Hepatitis A, B, and C surveillance reports. New York, NY: New York City Department of Health and Mental Hygiene; 2012. Available at http://home2.nyc.gov/html/doh/html/cd/cd-hepabc-reports.shtml. Accessed January 5, 2012.
4. Ioannou G. Hepatitis B virus in the United States: infection, exposure, and immunity rates in a nationally representative survey. Ann Intern Med 2011;154:319–28.
5. CDC. Characteristics of persons with chronic hepatitis B—San Francisco, California, 2006. MMWR 2007;56:446–8.
6. Kim WR, Benson JT, Therneau TM, Torgerson HA, Yawn BP, Melton LJ 3rd. Changing epidemiology of hepatitis B in a U.S. community. Hepatology 2004;39:811–6.
7. Chao SD, Chang ET, So SK. Eliminating the threat of chronic hepatitis B in the Asian and Pacific Islander community: a call to action. Asian Pac J Cancer Prev 2009;10:1–6.
8. Weinberg MS, Gunn RA, Mast EE, Gresham L, Ginsberg M. Preventing transmission of hepatitis B virus from people with chronic infection. Am J Prev Med 2001;20:272–6.
9. New York City Department of Health and Mental Hygiene. How to tell others you have chronic hepatitis B. New York, NY: New York City Department of Health and Mental Hygiene; 2011. Available at http://www.nyc.gov/html/doh/downloads/pdf/cd/cd-hepB-chronic-telling-others.pdf. Accessed January 5, 2012.
10. New York City Department of Health and Mental Hygiene. Hepatitis B: the facts. New York, NY: New York City Department of Health and Mental Hygiene; 2007. Available at http://www.nyc.gov/html/doh/downloads/pdf/cd/cd-hepb-bro.pdf. Accessed January 5, 2012.