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• W2065197367 abstract "The Dawn of a New Era: Transforming Our Domestic Response to Hepatitis B & C was held on September 10–11, 2009, in Washington, DC, with the goal of stimulating a fully coordinated national response to chronic viral hepatitis. It was inspired by the realization that progress in viral hepatitis research justifies a more robust public health response. Research findings have come from different scientific disciplines and there are many potential barriers to a comprehensive response; this meeting was convened to bring the multiple stakeholders together to discuss the way forward. Speakers from areas of government, academia, clinical medicine, patient advocacy, and health care organizations presented their perspectives, research, potential strategies, and solutions for addressing current and emerging issues in viral hepatitis in the United States. This report summarizes the most salient points from those forum presentations. A list of the topics and presenters included in this summary (Supplementary Table 1) can be accessed online at www.gastrojournal.org. The American Gastroenterological Association, the US Centers for Disease Control and Prevention (CDC), the US Department of Veterans Affairs, and the US National Institute of Allergy and Infectious Disease provided nonfinancial co-sponsorship of the 2-day meeting and the American Association for the Study of Liver Disease endorsed the meeting. The meeting was jointly sponsored by Postgraduate Institute for Medicine and HealthmattersCME. An estimated 2 million US residents have chronic hepatitis B virus (HBV) infection and 5 million have chronic hepatitis C virus (HCV) infection.1Armstrong G.L. Wasley A. Simard E.P. et al.The prevalence of hepatitis C virus infection in the United States, 1999 through 2002.Ann Intern Med. 2006; 144: 705-714Crossref PubMed Scopus (1755) Google Scholar, 2Centers for Disease Control and PreventionDivisions of Viral Hepatitis-Statistics and Surveillance Disease Burden from Viral Hepatitis A, B, and C in the United States.http://www.cdc.gov/hepatitis/PDFs/disease_burden.pdfGoogle Scholar, 3Cohen C. Evans A.A. London W.T. et al.Underestimation of chronic hepatitis B virus infection in the United States of America.J Viral Hepat. 2008; 15: 12-13PubMed Google Scholar, 4Edlin B.R. Shu M. Barron-Vaya Y. Five million Americans infected with the hepatitis C virus: a corrected estimate American Association for The Study of Liver Diseases. November 11–15, 2005 San Francisco.Hepatology. 2005; 42: 213AGoogle Scholar Although vaccination programs have reduced the incidence of acute HBV infections in the United States,2Centers for Disease Control and PreventionDivisions of Viral Hepatitis-Statistics and Surveillance Disease Burden from Viral Hepatitis A, B, and C in the United States.http://www.cdc.gov/hepatitis/PDFs/disease_burden.pdfGoogle Scholar, 5Wasley A. Grytdal S. Gallagher K. Surveillance for acute viral hepatitis—US, 2006.MMWR. 2008; 57 (No. SS–2)Google Scholar the prevalence of chronic HBV infection has not declined,6Sorrell M.F. Belongia E.A. Costa J. et al.National Institutes of Health Consensus Development Conference Statement: management of hepatitis B.Ann Intern Med. 2009; 150: 104-110Crossref PubMed Scopus (227) Google Scholar largely owing to immigration of individuals born in countries where HBV is endemic. Since the 1980s, the incidence of new HCV infections in the United States has decreased and the overall number of chronically infected individuals has stabilized.1Armstrong G.L. Wasley A. Simard E.P. et al.The prevalence of hepatitis C virus infection in the United States, 1999 through 2002.Ann Intern Med. 2006; 144: 705-714Crossref PubMed Scopus (1755) Google Scholar, 2Centers for Disease Control and PreventionDivisions of Viral Hepatitis-Statistics and Surveillance Disease Burden from Viral Hepatitis A, B, and C in the United States.http://www.cdc.gov/hepatitis/PDFs/disease_burden.pdfGoogle Scholar However, as individuals with chronic HCV infection (primarily those born between 1945 and 1964) grow older and the influx of those with chronic HBV infection continues, the associated burden of morbidity, mortality (Figure 1), and health care service utilization will only increase.1Armstrong G.L. Wasley A. Simard E.P. et al.The prevalence of hepatitis C virus infection in the United States, 1999 through 2002.Ann Intern Med. 2006; 144: 705-714Crossref PubMed Scopus (1755) Google Scholar, 3Cohen C. Evans A.A. London W.T. et al.Underestimation of chronic hepatitis B virus infection in the United States of America.J Viral Hepat. 2008; 15: 12-13PubMed Google Scholar,6Sorrell M.F. Belongia E.A. Costa J. et al.National Institutes of Health Consensus Development Conference Statement: management of hepatitis B.Ann Intern Med. 2009; 150: 104-110Crossref PubMed Scopus (227) Google Scholar, 7Klevens R.M. Miller J. Vonderwahl C. et al.Population-based surveillance for hepatitis C virus, United States, 2006–2007.Emerg Infect Dis. 2009; 15: 1499-1502Crossref PubMed Scopus (34) Google Scholar Although antiviral therapies are available for HBV and HCV infections, the translation of their benefits to patients varies. In viral hepatitis, as in most areas in medicine, therapeutic efficacies demonstrated in clinical trials do not necessarily equal their effectiveness in clinical practice.8Sung N.S. Crowley Jr., W.F. Genel M. et al.Central challenges facing the national clinical research enterprise.JAMA. 2003; 289: 1278-1287Crossref PubMed Scopus (980) Google Scholar Efficacy is the utility of a medical treatment evaluated under optimal conditions, whereas effectiveness is the usefulness of that same medical treatment in routine practice.9El-Serag H. When good treatments fail: The disconnect between efficacy and effectiveness.in: Presented at: The Dawn of a New Era: Transforming our Domestic Response to Hepatitis B&C, Washington, DCSeptember 10–11, 2009Google Scholar, 10Kramer T. Side effects and therapeutic effects: efficacy vs. effectiveness.http://www.medscape.com/viewarticle/448250_2Google Scholar Stated mathematically, effectiveness can be calculated as the product of multiplying efficacy by the probabilities of access to health care, making accurate diagnosis, giving appropriate recommendation, prescribing the treatment, and adhering to therapy by the patient. The effectiveness of therapies for chronic HBV and HCV infections are reduced by low rates of recognition of infected persons and treatment uptake among those identified, as well as reduced benefits of treatment, compared with patients in phase 3 trials. For example, in a study of 293 patients referred to Cleveland Metropolitan Hospital for evaluation of chronic HCV infection, 72% were not treated; of the 83 treated, only 13% achieved a sustained virologic response (SVR).11Falck-Ytter Y. Kale H. Mullen K.D. Sarbah S.A. Sorescu L. McCullough A.J. Surprisingly small effect of antiviral treatment in patients with hepatitis C.Ann Intern Med. 2002; 136: 288-292Crossref PubMed Scopus (287) Google Scholar Greater effectiveness of existing therapies for chronic HBV and HCV infections can be achieved only by improving recognition, diagnosis, and provider understanding of current testing and treatment approaches. Additional measures needed to improve effectiveness include expanding access to care, fostering patient acceptance of treatment, and providing support to help patients to adhere to treatment. Furthermore, deficits exist throughout the entire spectrum of care, particularly for HCV, and must be addressed.12Kanwal F. Asch S.M. Schnitzler M.S. et al.Predictors of quality care among patients with chronic hepatitis C virus infection.Hepatology. 2008; 48: 358ACrossref PubMed Scopus (23) Google Scholar HCV-specific quality indicators are now part of Medicare's Physician Quality Reporting Initiative. They include confirmation of HCV viremia, vaccination against hepatitis A and B, counseling about alcohol use, and testing for genotype and viral load before treatment; viral load testing and further antiviral therapy after 12 weeks of treatment; and counseling about contraception.12Kanwal F. Asch S.M. Schnitzler M.S. et al.Predictors of quality care among patients with chronic hepatitis C virus infection.Hepatology. 2008; 48: 358ACrossref PubMed Scopus (23) Google Scholar, 13Centers for Medicare and Medicaid Services. US Department of Health and Human ServicesOverview physician quality reporting initiative 2009 PQRI Quality Measures List.http://www.cms.hhs.gov/pqri/Google Scholar The suggested organizational-level strategies to enhance quality of care include use of patient registries, clinical reminders, and templates, as well as quality improvement collaboratives that involve multiple practices and hospitals. Government and nongovernment organizations must participate in making nationwide improvements in HBV and HCV screening, diagnosis, and treatment. The CDC released comprehensive HBV testing recommendations in 2008 to address the expanding need to identify and treat individuals with chronic HBV infection14Centers for Disease Control and PreventionRecommendations for Identification and public health management of persons with chronic hepatitis B virus infection.MMWR. 2008; 57: RR-8Google Scholar; the agency last released testing recommendations for chronic HCV infection in 1998, and these are being revised.15Centers for Disease Control and PreventionRecommendations for prevention and control of hepatitis C virus (HCV) infection and HCV-related chronic disease.MMWR Recomm Rep. 1998; 47: 1-39Google Scholar Compliance with HBV testing recommendations is high in certain patient populations, such as among patients who usually receive care in hospitals or other health care settings where tests are routinely performed for hepatitis B surface antigen (HBsAg).2Centers for Disease Control and PreventionDivisions of Viral Hepatitis-Statistics and Surveillance Disease Burden from Viral Hepatitis A, B, and C in the United States.http://www.cdc.gov/hepatitis/PDFs/disease_burden.pdfGoogle Scholar In the United States, virtually all pregnant women give birth in hospitals; screening rates for HBV among this population range from 89% to 96%.2Centers for Disease Control and PreventionDivisions of Viral Hepatitis-Statistics and Surveillance Disease Burden from Viral Hepatitis A, B, and C in the United States.http://www.cdc.gov/hepatitis/PDFs/disease_burden.pdfGoogle Scholar In addition, most patients undergoing renal dialysis at dialysis centers in the United States are tested monthly for HBsAg. However, in other settings, compliance with HBV testing recommendations is lower. Testing rates in public primary care centers of persons born in regions with high prevalence of HBsAg range from 30% to 50%.2Centers for Disease Control and PreventionDivisions of Viral Hepatitis-Statistics and Surveillance Disease Burden from Viral Hepatitis A, B, and C in the United States.http://www.cdc.gov/hepatitis/PDFs/disease_burden.pdfGoogle Scholar Most individuals with chronic HCV infection remain undiagnosed until they seek medical care for symptoms.16National Institutes of HealthManagement of hepatitis C: 2002.NIH Consens State Sci Statements. 2002; 19: 1-46Google Scholar A survey among primary care physicians found that only 59% ask their patients about HCV risk factors, 70% test those patients at risk, and <80% test patients who have increased levels of liver enzymes for HCV.17Shehab T.M. Sonnad S.S. Lok A.S. Management of hepatitis C patients by primary care physicians in the USA: results of a national survey.J Viral Hepat. 2001; 8: 377-383Crossref PubMed Scopus (102) Google Scholar A review of medical records from primary care clinics found that among individuals positive for HCV antibody, only 16% had been tested for HCV based on physician-identified risk factors.18Shehab T.M. Orrego M. Chunduri R. et al.Identification and management of hepatitis C patients in primary care clinics.Am J Gastroenterol. 2003; 98: 639-644Crossref PubMed Scopus (77) Google Scholar Screening rates for HCV have improved among patients with human immunodeficiency virus (HIV); in the HIV Outpatient Study, HCV testing rates among patients never tested or who previously tested negative increased, from 11% in 1996 to 22% in 2007.19Spradling P.R. Richardson J.T. Buchacz L. et al.Trends in Hepatitis C Virus Infection Among Patients in the HIV Outpatient Study, 1996–2007.J Acquir Immune Defic Syndr. 2009; Google Scholar Chronic HBV and HCV infection testing recommendations are not widely known among primary care physicians.20Kallman J.B. Arsalla A. Park V. et al.Screening for hepatitis B, C and non-alcoholic fatty liver disease: a survey of community-based physicians.Aliment Pharmacol Ther. 2009; 29: 1019-1024Crossref PubMed Scopus (42) Google Scholar In addition, there are multiple competing issues that need to be addressed during a routine visit and patients are reluctant to acknowledge behaviors, such as injection drug use. Medical societies need to develop resources that are specific to identification and management of chronic HBV or HCV infections, but new strategies for detection are also needed. System-wide process changes linked to quality assurance review are needed to supplement physician education. Strategies designed to prevent and control viral hepatitis and its complications must address significant disparities in morbidity and mortality associated with chronic HBV and HCV infections among different subpopulations. Although chronic liver disease mortality has decreased in the United States, the incidence of hepatocellular carcinoma (HCC) has doubled (Supplementary Figure 1) and is expected to continue to rise.21Kanwal F. El-Serag H.B. Hepatocellular cancer care: cost is important but only one factor of disease burden.J Hepatol. 2009; 50: 10-12Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar, 22McGlynn K.A. Racial, ethnic, and socioeconomic disparities in chronic liver disease and HCC in the US.in: Presented at: The Dawn of a New Era: Transforming our Domestic Response to Hepatitis B&C, Washington, DCSeptember 10–11, 2009Google Scholar Between 1992 and 2006, HCC increased 71% in blacks, 94% in whites, 73% in Hispanics, 5% in Asian/Pacific Islanders, and 103% in American Indians/Alaskan Natives.22McGlynn K.A. Racial, ethnic, and socioeconomic disparities in chronic liver disease and HCC in the US.in: Presented at: The Dawn of a New Era: Transforming our Domestic Response to Hepatitis B&C, Washington, DCSeptember 10–11, 2009Google Scholar, 23Altekruse S.F. McGlynn K.A. Reichman M.E. Hepatocellular carcinoma incidence, mortality, and survival trends in the United States from 1975 to 2005.J Clin Oncol. 2009; 27: 1485-1491Crossref PubMed Scopus (1427) Google Scholar In blacks, whites, and Hispanics, the increase in liver cancer rates is attributed to HCV, whereas in Asian and Pacific Islanders, chronic HBV infection is the primary contributing factor.24Chang E.T. Keegan T.H. Gomez S.L. et al.The burden of liver cancer in Asians and Pacific Islanders in the Greater San Francisco Bay Area, 1990 through 2004.Cancer. 2007; 109: 2100-2108Crossref PubMed Scopus (55) Google Scholar These trends might be attributed to variations in risk factors, particularly chronic HCV and HBV infections, among the groups. Although Asian and Pacific Islander Americans comprise approximately 5% of the general population, they account for half of those with chronic HBV infection in the United States.25Centers for Disease Control and PreventionNotice to readers: National Hepatitis B Initiative for Asian Americans/Native Hawaiian and Other Pacific Islanders.MMWR Weekly. 2009; 58: 503Google Scholar, 26Office of Minority Health. US Department of Health and Human ServicesAsian/Pacific Islander Profile.http://minorityhealth.hhs.gov/templates/browse.aspx?lvl=2&lvllD=53Google Scholar Within Asian/Pacific Islander communities in the United States, several initiatives have demonstrated some success in increasing chronic HBV infection awareness, screening, diagnosis, and treatment, in addition to effecting change at the legislative level (Table 1).Table 1Examples of Implemented Programs to Increase Awareness, Screening, Diagnosis, and Treatment of Chronic HBV InfectionProgram NameLocationDatesNo. of ParticipantsOutcomesJade Ribbon Campaign64Chao S.D. Chang E.T. Le P.V. et al.The Jade Ribbon Campaign: a model program for community outreach and education to prevent liver cancer in Asian Americans.J Immigr Minor Health. 2009; 11: 281-290Crossref PubMed Scopus (55) Google ScholarAsian Liver Center of Stanford University2001476 Chinese Americans■13% were found to be HBsAg+■Within 1 year, 67% of those who tested positive were tested for liver cancerAsian American Hepatitis B Program (AAHBP)65Centers for Disease Control and PreventionScreening for chronic hepatitis B among Asian/Pacific Islander populations—New York City, 2005.MMWR. 2006; 55: 505-509PubMed Google ScholarNew York City2005925 Asian Americans■14.8% had chronic HBV infection■31.6% of participants were found to be susceptible to HBV infection■1-, 2-, and 3-dose vaccination coverage rates were 89.3%, 78.8%, and 69.3%, respectivelyThe Hepatitis B Initiative-DC66Juon H.S. Strong C. Oh T.H. et al.Public health model for prevention of liver cancer among Asian Americans.J Community Health. 2008; 33: 199-205Crossref PubMed Scopus (29) Google ScholarBaltimore–Washington DC metropolitan area2003–20061775 Asian Americans■2% (n = 35) were found to be HBV HbsAg+■37% (n = 651) were HBV negative but protected (HbsAg−, HbsAb+),■61% (n = 1,089) were unprotected (HbsAg−, HbsAb−).■Most of these unprotected individuals (n = 924) received the first vaccination, 88.8% received the second and 79% completed the third vaccine in the series3 For LifeSan Francisco2004–20051206 Asian Americans■9% were chronically infected with HBV■53% were unprotected■85% of those found to be unprotected completed the HBV vaccine series Open table in a new tab The success of community-based programs for African Americans and Latinos has not been documented, yet public and private sector initiatives need to address significant disparities in access to care.27Kanwal F. Hoang T. Spiegel B.M. et al.Predictors of treatment in patients with chronic hepatitis C infection—role of patient versus nonpatient factors.Hepatology. 2007; 46: 1741-1749Crossref PubMed Scopus (104) Google Scholar, 28Smedley B.D. Stith A.Y. Nelson A.R. Committee of Understanding and Eliminating Racial and Ethnic Disparities in Health Care Unequal Treatment: confronting racial and ethnic disparities in health care. National Academy of Science, Washington, DC2003Google Scholar In combination, African Americans and Mexican Americans account for 30% of the national burden of HCV disease.1Armstrong G.L. Wasley A. Simard E.P. et al.The prevalence of hepatitis C virus infection in the United States, 1999 through 2002.Ann Intern Med. 2006; 144: 705-714Crossref PubMed Scopus (1755) Google Scholar As shown in Figure 1, mortality from HCV among African Americans and Hispanics increased more than in other racial or ethnic groups between 1995 and 2004.29Wise M. Bialek S. Finelli L. et al.Changing trends in hepatitis C-related mortality in the United States, 1995–2004.Hepatology. 2008; 47: 1128-1135Crossref PubMed Scopus (192) Google Scholar In addition, the incidence of HCC is 2-fold higher among African Americans than whites.30El-Serag H.B. Davila J.A. Petersen N.J. et al.The continuing increase in the incidence of hepatocellular carcinoma in the United States: an update.Ann Intern Med. 2003; 139: 817-823Crossref PubMed Scopus (848) Google Scholar African Americans with chronic HCV face significant barriers to appropriate antiviral treatment and timely liver transplantation.27Kanwal F. Hoang T. Spiegel B.M. et al.Predictors of treatment in patients with chronic hepatitis C infection—role of patient versus nonpatient factors.Hepatology. 2007; 46: 1741-1749Crossref PubMed Scopus (104) Google Scholar, 31Butt A.A. Justice A.C. Skanderson M. et al.Rate and predictors of treatment prescription for hepatitis C.Gut. 2007; 56: 385-389Crossref PubMed Scopus (128) Google Scholar, 32Nguyen G.C. Thuluvath P.J. Racial disparity in liver disease: Biological, cultural, or socioeconomic factors.Hepatology. 2008; 47: 1058-1066Crossref PubMed Scopus (124) Google Scholar, 33Reid A.E. Resnick M. Chang Y. et al.Disparity in use of orthotopic liver transplantation among blacks and whites.Liver Transpl. 2004; 10: 834-841Crossref PubMed Scopus (93) Google Scholar African Americans are more likely to develop chronic HCV infection than Caucasians and are less likely to respond to interferon-based treatment.34Jeffers L.J. Cassidy W. Howell C.D. et al.Peginterferon alfa-2a (40 kd) and ribavirin for black American patients with chronic HCV genotype 1.Hepatology. 2004; 39: 1702-1708Crossref PubMed Scopus (238) Google Scholar, 35Thomas D.L. Astemborski J. Rai R.M. et al.The natural history of hepatitis C virus infection: host, viral, and environmental factors.JAMA. 2000; 284: 450-456Crossref PubMed Google Scholar The disproportionate burden of HCV among racial and ethnic minority groups indicates the need to address disparities in health care access and delivery. The rates of chronic HBV and chronic HCV infection screening, diagnosis, and treatment vary not only by geographical region but also within the same health care system. The prevalence of HCV is >2-fold higher in the Veterans Health Administration (VHA) patient population than the US general population36Dominitz J.A. Boyko E.J. Koepsell T.D. et al.Elevated prevalence of hepatitis C infection in users of United States veterans medical centers.Hepatology. 2005; 41: 88-96Crossref PubMed Scopus (182) Google Scholar; examination of trends in diagnosis and treatment within the system reveal important information about HCV care in the United States. As of December 2008, approximately 194,000 veterans in VHA care had evidence of HCV infection; >147,000 of those had documented HCV viremia.37Valdiserri R. HCV testing, prevention counseling, and treatment guidelines in the Veterans Health Administration.in: Presented at: The Dawn of a New Era: Transforming our Domestic Response to Hepatitis B&C, Washington, DCSeptember 10–11, 2009Google Scholar The decision to treat was based on current treatment guidelines and research protocols.37Valdiserri R. HCV testing, prevention counseling, and treatment guidelines in the Veterans Health Administration.in: Presented at: The Dawn of a New Era: Transforming our Domestic Response to Hepatitis B&C, Washington, DCSeptember 10–11, 2009Google Scholar Between 2006 and 2007, among patients with HCV genotype 1, approximately 18,700 received treatment with pegylated interferon and ribavirin; 24% achieved a SVR.37Valdiserri R. HCV testing, prevention counseling, and treatment guidelines in the Veterans Health Administration.in: Presented at: The Dawn of a New Era: Transforming our Domestic Response to Hepatitis B&C, Washington, DCSeptember 10–11, 2009Google Scholar SVR rates were higher in patients with genotypes 2 (∼3,900 treated; 59% had SVR) or 3 (∼2,500 treated; 48% had SVR); however, the SVR rates for all genotypes were substantially lower than those reported in clinical trials.37Valdiserri R. HCV testing, prevention counseling, and treatment guidelines in the Veterans Health Administration.in: Presented at: The Dawn of a New Era: Transforming our Domestic Response to Hepatitis B&C, Washington, DCSeptember 10–11, 2009Google Scholar A 2007 survey of VHA providers reported that the most frequent means of educating newly diagnosed patients included one-on-one counseling and referral to a formal HCV group education clinic.37Valdiserri R. HCV testing, prevention counseling, and treatment guidelines in the Veterans Health Administration.in: Presented at: The Dawn of a New Era: Transforming our Domestic Response to Hepatitis B&C, Washington, DCSeptember 10–11, 2009Google Scholar This approach is not feasible in most clinical settings, where resources for HCV care are limited. The US correctional system is another important setting to assess HCV prevention and control. More than 7 million Americans are currently in prison, jail, or on parole or probation.38Bureau of Justice, Department of Justice. Bureau of Justice StatisticsKey Facts at a Glance.http://www.ojp.usdoj.gov/bjs/glance/corr2.htmGoogle Scholar Most inmates eventually return to the community. This is an issue in prevention of viral hepatitis, because the CDC estimates that 2% of inmates have chronic HBV infection and 15% have chronic HCV infection.39Centers for Disease Control and PreventionPrevention and control of infections with hepatitis viruses in correctional settings.MMWR. 2003; 52: RR1Google Scholar Approximately 12%–15% of chronic HBV infection cases and 39% of chronic HCV infection cases occur in individuals who have previously been incarcerated.39Centers for Disease Control and PreventionPrevention and control of infections with hepatitis viruses in correctional settings.MMWR. 2003; 52: RR1Google Scholar In addition, 30% of all acute HBV infection cases occur in individuals with a history of incarceration, so immunization programs are needed in correctional facilities.40Goldstein S.T. Alter M.J. Williams I.T. et al.Incidence and risk factors for acute hepatitis B in the United States, 1982–1998: implications for vaccination programs.J Infect Dis. 2002; 185: 713-719Crossref PubMed Scopus (237) Google Scholar Collaboration between departments of corrections and public health can facilitate prevention education, immunization, treatment, and continuity of care after discharge. Evaluation of large managed care populations also provides vital information about screening and management of patients with HBV or HCV. The Kaiser Permanente Northern California (KPNC) Viral Hepatitis Registry includes data from >24,000 health plan members with chronic HBV and 40,000 with HCV infections.41Manos M. The practical realities of chronic viral hepatitis: what we can learn from managed care populations.in: Presented at: The Dawn of a New Era: Transforming our Domestic Response to Hepatitis B&C, Washington, DCSeptember 10–11, 2009Google Scholar Among KPNC patients with chronic HCV, the treatment rate was 21% (ranging from 13% to 35% among medical service areas). Preliminary data from a study of 2,500 patients treated for chronic HCV infection indicate that patients who achieved SVR had significant reductions in incidences of HCC, decompensated cirrhosis, liver transplantation, hospitalization for liver disease, diabetes, and death from liver disease; there are substantial long-term benefits of successfully treating hepatitis C. Comparison of HCV prevalence in the KPNC population (risk-based screening) with that projected by the NHANES study (comprehensive screening) suggests that 50% of chronic hepatitis C infections are undetected in the KPNC population. Feasibility studies will evaluate the potential impact of broader screens. Significant gaps exist in HBV recognition and diagnosis, particularly in patient populations with an high prevalence of HBV.32Nguyen G.C. Thuluvath P.J. Racial disparity in liver disease: Biological, cultural, or socioeconomic factors.Hepatology. 2008; 47: 1058-1066Crossref PubMed Scopus (124) Google Scholar, 42Lai C.J. Nguyen T.T. Hwang J. et al.Provider knowledge and practice regarding hepatitis B screening in Chinese-speaking patients.J Cancer Educ. 2007; 22: 37-41Crossref PubMed Scopus (52) Google Scholar Of the estimated 2 million individuals with chronic HBV infection, only 300,000 have been screened and 50,000 receive treatment.43Do S. Implementing HBV screening/treatment in the real world.in: Presented at: The Dawn of a New Era: Transforming our Domestic Response to Hepatitis B & C, Washington, DCSeptember 10–11, 2009Google Scholar A retrospective cohort study at a general medical practice center in San Francisco found that HBV screening was conducted in 72% of Asian/Pacific Islander patients (65% Chinese-speaking patients, 47% Korean patients, 36% Filipino patients), and 21% of white patients.32Nguyen G.C. Thuluvath P.J. Racial disparity in liver disease: Biological, cultural, or socioeconomic factors.Hepatology. 2008; 47: 1058-1066Crossref PubMed Scopus (124) Google Scholar, 42Lai C.J. Nguyen T.T. Hwang J. et al.Provider knowledge and practice regarding hepatitis B screening in Chinese-speaking patients.J Cancer Educ. 2007; 22: 37-41Crossref PubMed Scopus (52) Google Scholar, 43Do S. Implementing HBV screening/treatment in the real world.in: Presented at: The Dawn of a New Era: Transforming our Domestic Response to Hepatitis B & C, Washington, DCSeptember 10–11, 2009Google Scholar Suggested strategies to promote compliance with HBV screening guidelines in primary care include increased physician education, using insurance mandates or pay-for-performance screening targets, providing clear and strong governmental and medical society recommendations, instituting electronic health records, and offering education and support to patients. Lessons learned from the public health response to the HIV crisis might apply to viral hepatitis, because it is similar to HIV infection in that both are transmissible, preventable, and treatable. Key components for the national response to viral hepatitis include recognition of the role of comorbidities in success of treatment, participation of government agencies such as the National Institutes of Health (NIH) and the US Food and Drug Administration (FDA) in research and drug development, and demonstration of the cost-effectiveness of treatments. Another potential parallel is the capacity to reduce infection-associated mortality. The convergence of effective treatments for HIV and" @default.
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