Research Article Hepatitis Outreach Network: A practical strategy for hepatitis screening with linkage to care in foreign-born communities ⇑ Ponni V. Perumalswami , Stephanie H. Factor, Luciano Kapelusznik, Scott L. Friedman, Calvin Q. Pan, Charissa Chang, Frances Di Clemente, Douglas T. Dieterich Division of Liver Diseases, The Mount Sinai Medical Center, Mount Sinai School of Medicine, NY, United States Background & Aims: Many foreign-born persons in the US are at Ó 2013 European Association for the Study of the Liver. Published high risk of chronic hepatitis B (HBV) and C (HCV) infections, yet by Elsevier B.V. All rights reserved. are not aware of their infection, and lack healthcare coverage or linkage to care. Methods: A unique partnership, the Hepatitis Outreach Network, combines the expertise and resources of the Mount Sinai School Introduction of Medicine, the NYC Department of Health and Mental Hygiene, and community-based organizations, to provide education, Chronic infection with hepatitis B virus (HBV) and/or hepatitis C screening and link to care in communities with high prevalence virus (HCV) can lead to cirrhosis, liver cancer, and death. In the of chronic viral hepatitis. Comprehensive HBV and HCV screening US, HBV causes 3000–4000 deaths each year and HCV causes identifies infected patients, who then receive further evaluation 8000–13,000 deaths each year [1,2]. Many of these deaths are from either local or Mount Sinai physicians, combined with preventable with early diagnosis and appropriate treatment patient-navigators who organize follow-up visits. [3–5]. Results: Of 1603 persons screened, 76 had HBV and 75 had HCV. Early diagnosis of persons with HBV and/or HCV infection has Importantly, screening for HCV based on traditional risk factors been difficult. Because 70% of new HBV infections and 80% of new would have missed 67% of those who tested positive. Of the 76 HCV infections are asymptomatic [6,7], and more than 60% of persons with HCV infection, 49 (64%) received a medical evalua- persons with chronic HBV and/or HCV infection are asymptom- tion (26 with local providers and 23 at Mount Sinai). Of the 49 atic [8], early diagnosis has relied on screening for asymptomatic HCV-infected persons evaluated, treatment was recommended disease. Screening recommendations for HBV and HCV infection in 11 and begun in 8 (73%). Of the 76 persons with HBV infection, by the Centers for Disease Control and Prevention (CDC) and 43 (57%) received a medical evaluation (31 with local providers the American Association for the Study of Liver Diseases (AASLD) and 12 at Mount Sinai). Of the 43 HBV-infected persons evalu- target persons at high risk for these infections [2,8–12]. However, ated, treatment was recommended and begun in 5 (100%). many persons at high risk for HBV and/or HCV do not have regu- Conclusions: Hepatitis Outreach Network has successfully estab- lar access to healthcare and 75% of infected persons remain una- lished novel proof of concept for identifying HBV and HCV infec- ware of their infection [1]. tions in foreign-born persons through use of several unique Many foreign-born persons at high risk of HBV and HCV infec- elements that effectively link them to care. tion are not enrolled in healthcare [1,13] and therefore unlikely to be screened for these infections. Reasons include low socioeco- nomic status, undocumented status, limited English proficiency, and lack of familiarity with the US health care system [14]. Many Keywords: Epidemiology; Patient navigators; Viral hepatitis; Testing; Treatment. programs have offered screening outside the traditional medical Received 24 August 2012; received in revised form 26 December 2012; accepted 7 system to overcome some of these barriers [15–18]. January 2013; available online 15 January 2013 After diagnosis of HBV and/or HCV infection, infected persons ⇑ Corresponding author. Address: Mount Sinai School of Medicine, Division of Liver Diseases, One Gustave L. Levy Place, Box 1123, New York, NY 10029, United must be evaluated within the traditional medical system to States. Tel.: +1 212 659 8879; fax: +1 212 659 8377. determine if medical treatment is appropriate. While many E-mail address: [email protected] (P.V. Perumalswami). screening programs have diagnosed HBV and HCV infections in Abbreviations: HBV, hepatitis B virus; HCV, hepatitis C virus; CDC, Centers for foreign-born persons, many of the persons with newly-diagnosed Disease Control and Prevention; AASLD, American Association for the Study of Liver Diseases; HONE, Hepatitis Outreach Network; MSSM, Mount Sinai School of infection have not been linked to care or evaluated for treatment Medicine; NYC DOHMH, New York City Department of Health and Mental Hyg- [16,19–21]. iene; CBO, Community Based Organization; PN, Patient Navigator; FQHC, feder- Members of the Mount Sinai School of Medicine Division of ally qualified health center; PSA, public service announcement; HBsAg, hepatitis B Liver Diseases designed an education and screening program out- surface antigen; HBcAb, hepatitis B core antibody; HBsAb, hepatitis B surface side the traditional medical system targeting foreign-born per- antibody; HCV Ab, hepatitis C antibody; ALT, serum alanine transferase; DAA, direct acting antiviral; IDU, Injection Drug Use; HIV, Human Immunodeficiency sons at high risk of HBV and/or HCV infection to provide Virus; HEALS, Hepatitis C Education and Liver Screening; IOM, Institute of Med- services that simplify the process of linking to care. icine; SFHBF, San Francisco Hep B Free. Journal of Hepatology 2013 vol. 58 j 890–897 JOURNAL OF HEPATOLOGY Patients and methods Table 1. HONE overall demographics. Characteristic n (%) National average The Hepatitis Outreach Network (HONE) is a collaboration of the Mount Sinai School of Medicine (MSSM), the New York City Department of Health and Mental Age Hygiene (NYC DOHMH), and community-based organizations (CBOs), and was Median (IQR) 51 (38, 61) 37.2 designed in 2009 by members of the MSSM Division of Liver Diseases to link for- Sex, female 860 (54) 50.6% eign-born persons with HBV and/or HCV infection to care. The program provides education and screening events in communities with high prevalence of HBV and/ Insurance 699 (44) 83.3% or HCV infection in the New York Metropolitan Area, free HBV vaccine when Primary care physician 680 (43) n.a. appropriate, and facilitated linkage to care for persons with HBV and/or HCV Household income $49,777 median infection. The HONE collaboration was formed by first identifying communities of for- <15 K 393 (52) eign-born persons with a high prevalence of HBV and/or HCV infection in the 15-25 K 126 (17) metropolitan New York City area using 2006 and 2007 surveillance report data 25-50 K 123 (16) and guidance from NYC DOHMH [22]. CBOs in the identified communities were invited to join the HONE team and assisted in choosing the event venues, identi- 50-75 K 40 (5) fied and trained patient navigators (PNs) and collaborated with MSSM, NYCD- >75 K 66 (9) OHMH, and federally-qualified health centers (FQHC) in developing a HONE Education 87% high school graduate provider list of local healthcare workers with expertise in evaluation and treat- ment of HBV and HCV infection. Venues were chosen based on ‘‘pedestrian-traf- ≤8th grade 613 (39) fic’’ patterns and most were outside traditional health care settings (e.g., clinics 9-12 107 (7) and hospitals). Non-traditional venues included public schools, places of worship, Attended college 195 (12) YMCA’s, public parks, hotels, business centers, and train stations. Publicity for the education and screening events was targeted to foreign-born Associate/ 370 (24) persons in each community by messaging in both English and the language of the Bachelor’s degree country of origin. Printed advertisements were posted throughout the commu- Post-graduate 284 (18) nity. Radio stations, television stations, and newspapers presented public service n.a., not available. announcements (PSA) with the time, date, and location of the events. Bilingual health care providers gave the educational portion of each event, which was held either several weeks before, or on the day of the screening. Par- The full medical evaluation at the MSSM Liver Medicine Practice included a ticipants learned of the asymptomatic nature of HBV and HCV infection, the long- medical history and physical exam performed by a practicing hepatologist, a vari- term complications of chronic infection including cirrhosis, liver cancer, and ety of blood tests (complete blood count including platelets, comprehensive met- death, the benefits of early detection and treatment, and the opportunity for pre- abolic panel, and coagulation profile) including those to measure the synthetic vention with vaccination and condom use. function of the liver to determine the available treatment options (HBV and/or At the screening portion, bilingual volunteers navigated the informed consent HCV viral load, and HCV genotyping), and an abdominal ultrasound to screen process with each participant. All participants provided written informed consent for hepatocellular carcinoma. and the study protocol conformed to the ethical guidelines of the Declaration of Persons with HBV infection were recommended treatment based on the algo- Helsinki as reflected in a priori approval by the MSSM Institutional Review Board. rithm in the AASLD Treatment Guidelines [11]. Persons with HCV infection were After providing consent, participants completed a self-administered, printed sur- recommended treatment based on HCV viral load per the AASLD Treatment vey in English or in the language of their country of origin. The survey included Guidelines (i.e., patients with detectable virus were recommended for further questions on demographics, socioeconomic status, medical history, family his- evaluation and treatment) [9]. Given the timing of the HONE project and expected tory, and traditional risk factors for HBV and HCV infection. All surveys were writ- approval of the new direct acting antiviral (DAA) medication for treatment of HCV ten at a 6th grade reading level.