Hepatitis B Prevention for Asian Americans in New York City

1. Hepatitis B Prevention for Asian Americans in New York City Charles B. Wang Community Health Center Thomas Tsang, MD, MPH Hepatitis B Training for Substance Abuse and Social Service Providers, October 26th 2006

2. Agenda • Demographics • Epidemiology • Community Prevention Models • Results • Lessons/Challenges/Barriers

3. Asian American Communityin New York City • 787,047 Asians in New York City • 75% of all AAPI in NY State • 54% increase since 1990 • 78% foreign born • 46% (361,531) Chinese • 31% of all Chinatown residents lived below the poverty line • 60% of Chinatown adults (≥ 25yrs) do not have a high school diploma • 45% have less than 9th grade education • 60% of Asian adults in NYC are limited-English proficient Source: US Census Bureau 2000. The Asian Population: 2000. Website: http://www.census.gov/prod/2002pubs/c2kbr01-16.pdf Asian American Federation of New York. New York City Asian American Census Brief. Website: http://www.aafny.org/cic/briefs/newyorkbrief.pdf

4. Burden of Disease • Prevalence rates of HBV among Asians around 10-15% compared with less than 1% among mainstream US population • Of the 1.5 million hep B carriers in US, about half are Asian • Rate of hepatocellular carcinoma (HCC) in APIs was 5-11 fold higher than for other ethnic groups (data from Surveillance, Epidemiology and End Results)

5. Community Need • 800,000 Asian Americans in NYC (Census 2000) • Of these, >90% are immigrants and a large percentage is uninsured • Most persons do not know their HBV status • Persons who test positive often do not subsequently receive proper evaluation and treatment

6. Community Need (cont) • High rates of HBV and HCC in API population underscore need to implement programs to prevent new HBV infections and detect chronic HBV infection and HCC at an early stage when it is amenable to treatment • We felt it was necessary to develop a comprehensive program to include education, screenings, evaluation and treatment

7. Innovative ServiceDelivery Models: Asian American Hepatitis B Project

8. Project Conception & Realization • Development of a coalition of New York City institutions, physicians, citizens, academicians and community partners • Making the case: selling the project, cost-benefit analysis and strong written proposal • Building broad coalition of support within the funding agency (NYC Council)

9. Project Components • Outreach and education • Screening • Follow-up and Counseling • Clinical Evaluation and Treatment

10. Education & Media Campaign • Developed and translated numerous educational, advertising and clinical materials

11. Media Campaign: Banners • Launched culturally sensitive citywide outreach and media campaigns that include ethnic newspapers and radio stations

12. Media Campaign: Print Ad

13. Education Workshops • Developed slide presentation for all screening sites to use • Encouraged all screening participants to sit in on workshop • Developed educational video in English, Korean, Chinese Mandarin, Cantonese and Vietnamese for patients to watch in waiting room

14. AAHBP Screening Sites • Charles B. Wang Community Health • Gouverneur Hospital • Bellevue Hospital • New York Downtown Hospital • Korean Community Service • American Cancer Society: Asian Unit • Community Health Network

15. AAHBP Screening Site Locations As Reflection of Distribution of API populations in NYC AAHBP Screening Site Source: US Census 2000

18. Program Accomplishments • Educational workshops for almost 4500 individuals • Screened more than 4000 individuals • Vaccinated more than 1000 individuals (more than 1800 vaccine doses) • Identified over 900 HBV-infected patients and provided about 700 initial evals and >1000 follow up visits

19. Program Challenges Developing an effective coalition involves trust and overcoming many potential obstacles, including: • Coordination between different institutions • Communication between institutions • Reaching new immigrants This required a collaborative effort involving health specialists, community-based organizations, local governments and health departments

20. Program Innovations • Identified new funding source • Developed new comprehensive model • Invested heavily in collection of data that permitted sophisticated analysis and new observations • High-impact by publication of results and media exposure

21. Addendum • Project funded for Program Year 3 • Expand target populations to include South Asians and Southeast Asians • Focus on young adult high-risk populations

22. Asian American Hepatitis B Program funded by the City Council of New York. The following is a partial list of partners and contributors to the AAHBP program: American Cancer Society: Ming-Der Chang, PhD, Li Ma Bellevue Hospital: William Bateman, MD, Chris Cho, Edith Davis, Judy Aberg, MD, Scott Fuller, Janice Charles, Thomas Jasper, Robert Boyd Charles B. Wang Community Health Center: Thomas Tsang, MD, Alan Tso, MD, Christina Lee, Regina Lee, Esq, Phyllis Kwok, MD Community Healthcare Network: Kameron Wells, RN, Catherine Abate, ED, Gloria Leacock, MD Korean Community Services: Jinny Park, Shin Son, PhD Gouverneur Healthcare Services: Pearl Korenblit, MD, Lily Yiu, L Chiang, PA, S Shi, MD NY Downtown Hospital: William Wang, Waiwah Chung, RN, Charles Ho, Eric Poon, MD NYU School of Medicine: Kejia Wan, MPH, John Nolan, Paige Baker, Rona Luo, Jenny Bute, Gemma Rochford, Ming Xia Zhan, Ruchel Ramos, MPA, Alex Sherman, MD, Hillel Tobias, MD, Helene Lupatkin, MD, Chau Trinh,DrPH, Henrietta Ho-Asjoe, Gerald Villaneuva, MD, Mariano Rey, MD, Henry Pollack, MD.

23. Charles B. WangCommunity Health Center Mission To be a leader in providing quality, culturally relevant, and affordable health care and education, and advocate on behalf of the social needs of underserved Asian Americans. History and Description • Established in 1971 • Federally Qualified Health Center • 2 locations in Manhattan, 1 in Flushing • Total of ~140,000 patient visits annually • 70% of patients insured though federal programs (Medicaid, Medicare, CHP), 28% are uninsured, 2% have private insurance • Bilingual and bicultural services • Comprehensive Primary and Specialty Care

24. Community-Based Hepatitis BScreening Program (2000) • Public – Private collaboration with Oxford Health Plans, CAIPA / CAMS and Glaxo SmithKline • Program Goals • To raise awareness of hepatitis B infection • To screen for patients with CHB (HBsAg +)

25. Lessons Learned • From a community perspective Public–Private collaboration provided efficiency and necessary resources • From a provider perspective How can we better ensure that carriers return for follow-up care? How can we provide hepatitis B vaccinations for patients at risk for infection?

26. Community-Based Hepatitis BScreening Program (2001) • Same public – private collaboration (Oxford Health Plans, CAIPA / CAMS and Glaxo SmithKline) • Program Goals • To follow-up on CHB patients identified in year 2000 screenings • To conduct individual screenings in provider offices to ensure better follow-up

27. Lessons Learned • From a community perspectiveNeed for increased community support and involvement in the screenings • From a provider perspective 13% of uninsured patients specifically indicated that lack of insurance was a barrier to seeking F/U care at MD office Need to vaccinate at risk patients

28. DOH Program: ScreeningHousehold Contacts (2002–Current) • New collaboration with NYC Dept of Health and Mental Hygiene • Program GoalTo provide education, screening and vaccination to household members of pregnant women who tested positive for HBsAg • Targeted group of high-risk individuals that is often hard to reach • Over last 4 years: • Among pregnant women at CBWCHCHBsAg positive rate consistent at about 16% • Total of 1,823 household contacts screenedHBsAg positive rate consistent at about 20%

29. Lessons Learned • From a community perspective How can we maintain resources (e.g., vaccines) and support for the program? Need to increase marketing and outreach • From a provider perspectiveHow can we improve F/U for CHB patients? Lack of insurance continues to be a barrier to seeking F/U care

30. “B” Healthy Model Care Program(2006) • Partnership with the Association of Asian Pacific Community Health Organizations (AAPCHO) • Chronic Care Model* applied as conceptual framework to a largely immigrant community that faces social, cultural, linguistically, and financial barriers to quality care • Designed to serve as a model for a multifaceted approach to hepatitis B intervention • 3Areas of Focus, 4 Primary Objectives • Comprehensive care management for CHB patients • Outreach and education to a community with limited English proficiency • Increasing awareness of the impact of hepatitis B in the AAPI community through local, regional, and national advocacy efforts (AAPCHO) • Supported by BMS * Wagner EH. Chronic disease management: What will it take to improve care for chronic illness?Effective Clinical Practice. 1998;1:2-4.

31. “B” Healthy Model Care Program5 Primary Objectives • Comprehensive care management for CHB patients • Objective #1: To train primary care physicians on new management issues related to hepatitis B infection • On-site provider training seminars conducted by various leaders in hepatitis B management • Objective #2: To encourage high-quality CHB care at CBWCHC • Hepatitis B flow sheets

32. “B” Healthy Model Care Program5 Primary Objectives • Comprehensive care management for CHB patients • Objective #3: To develop an enabling service to improve access to hepatitis B treatment and management services for AAPIs with CHB • Bilingual case managers • Availability of social workers • Availability of mental health services • Referrals to diagnostic tests and specialists

33. “B” Healthy Model Care Program5 Primary Objectives • Comprehensive care management for CHB patients • Objective #4: To provide education and support for hepatitis B carriers and their families and the community • Developed culturally and linguistically appropriate educational materials • Brochure focusing on importance of screening, vaccination, and risk of perinatal transmission • Two 10-minute videos: perspective of a patient with CHB, perspective of a family member of a patient with CHB • Monthly radio programs were aired on popular Chinese stations

34. “B” Healthy Model Care Program5 Primary Objectives • Comprehensive care management for CHB patients • Objective #4 (cont’d) Support groups • Three sessions (90 minutes each) • #1, patients only (5): Overview of Hepatitis B • #2, patients only (5): Living with Chronic Hepatitis B • #3, patients and family (8): Family Life & Coping with Hepatitis B • Patients encouraged to gain knowledge from speakers, facilitators and other patients • Assist in developing and improving coping skills • Increase confidence and acceptance of patients’ liver disease through the knowledge that they are not alone

35. Perceptions of Hepatitis B in the Chinese Community* • Awareness of hepatitis B but many underestimate the severity • Link between hepatitis B infection and liver cancer & liver damage is not clear • Many myths regarding transmission • Spread by sharing food or chopsticks • Vaccine can transmit hepatitis B infection • Cure for hepatitis B exists *Observations by CBWCHC staff from past hepatitis B programs

36. Educating & Empowering Patients • Importance of education • Many misperceptions about hepatitis B • Many unaware of the seriousness of a chronic infection • Importance of empowerment • Self-management greatly affects disease control and outcomes • Empower the patient through information, emotional support and strategies for living with chronic illness

37. Conclusions • An unmet need in large-scale hepatitis B screenings remains within the Asian community • Community-based, collaborative prevention strategies allow for increased outreach into the community, access to resources and public support • Targeted clinical and educational interventions should be created for high risk populations that face barriers to access • Education module must be developed to accommodate low literacy patients • Care and support for chronic hepatitis B patients involves the collaboration of multiple disciplines