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Disclaimer: CME certification for these activities has expired. All information is pertinent to the timeframe in which it was released.


Delivering Optimal Care: Prevention, Detection, and Management of Hepatitis B in Asian and Pacific Islander Americans


GOAL
To provide primary care physicians, nurses, nurse practitioners, and physician assistants with up-to-date information about the detection, prevention, and management of patients with hepatitis B virus.

TARGET AUDIENCE
This activity is designed for primary care physicians, nurses, nurse practitioners, and physician assistants. No prerequisites required.

LEARNING OBJECTIVES
At the conclusion of this activity, the participant should be able to:

  • Recognize the high prevalence of chronic hepatitis B virus (HBV) infection in persons of Asian/Pacific Islander origin, and apply this knowledge to improve HBV screening within this population.
  • Diagnose patients with chronic HBV infection (for primary care physicians, nurse practitioners, and physician assistants). Nurses should be able to conduct prescribed treatment plans and properly screen and counsel patients.
  • Develop strategies for referral and counseling once a diagnosis is made.
  • Summarize available therapies for patients infected with HBV.
  • Perform effective patient counseling on the prevention, transmission, and treatment of HBV.

The Johns Hopkins University School of Medicine and The Institute for Johns Hopkins Nursing take responsibility for the content, quality, and scientific integrity of this CE activity.

ACCREDITATION STATEMENT
The Johns Hopkins University School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education
for physicians.

The Institute for Johns Hopkins Nursing is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.

CREDIT DESIGNATION STATEMENT
The Johns Hopkins University School of Medicine designates this educational activity for a maximum of 2 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

This 1.6 contact hour Educational Activity (Provider Directed/Learner Paced) is provided by The Institute for Johns Hopkins Nursing. Claim only those contact hours actually spent in the activity.

The estimated time to complete this educational activity: 2 hours.

After reading this monograph, participants may receive credit by completing the CE test, evaluation, and receiving a score of 70% or higher.

Release date: December 15, 2007. Expiration date: December 15, 2009.

DISCLAIMER STATEMENT
The opinions and recommendations expressed by faculty and other experts whose input is included in this program are their own. This enduring material is produced for educational purposes only. Use of The Johns Hopkins University School of Medicine and The Institute for Johns Hopkins Nursing name implies review of educational format, design, and approach. Please review the complete prescribing information of specific drugs or combinations of drugs, including indications, contraindications, warnings, and adverse effects, before administering pharmacologic therapy to patients.

This program is supported by an educational grant from Bristol-Myers Squibb.

Full Disclosure Policy Affecting CE Activities:
As a provider accredited by the Accreditation Council for Continuing Medical Education (ACCME), it is the policy of the Johns Hopkins University School of Medicine to require the disclosure of the existence of any significant financial interest or any other relationship a faculty member or a provider has with the manufacturer(s) of any commercial product(s) discussed in an educational presentation. The Program Director and Participating Faculty reported the following:

PROGRAM DIRECTOR

Paul J. Thuluvath, MD, FRCP
Director, Hepatology
Director, Liver Research
Medical Director, Liver Transplantation
The Johns Hopkins Hospital
Johns Hopkins University School of Medicine
Baltimore, Maryland
Dr Thuluvath reports receiving grants/research support from GlaxoSmithKline, Johnson & Johnson, Roche Laboratories, and SciClone; honoraria from Gilead Sciences, Inc, Idenix Pharmaceuticals, Novartis, and Roche Laboratories; and serving on the speakers' bureau for Gilead Sciences, Inc, Novartis, and Roche Laboratories.

PARTICIPATING FACULTY

Hie-Won L. Hann, MD
Professor of Medicine
Jefferson Medical College
Director, Liver Disease Prevention Center at the Division of Gastroenterology and Hepatology
Thomas Jefferson University Hospital
Philadelphia, Pennsylvania
Dr Hann reports receiving grants/research support from Bristol-Myers Squibb, Gilead Sciences, Inc, and Idenix Pharmaceuticals; and receiving honoraria from and serving on the speakers' bureau for Bristol-Myers Squibb,  Gilead Sciences, Inc, and Idenix-Novartis.

Ke-Qin Hu, MD
Director of Hepatology Services
Division of Gastroenterology and Hepatology
H.H. Chao Comprehensive Digestive Disease Center
University of California, Irvine
School of Medicine
Orange, California
Dr Hu reports receiving educational grants from Astella Pharma USA, Inc, Bristol-Myers Squibb Company, Gilead Scientific Inc, Novartis Pharmaceuticals, Roche Pharmaceuticals, Schering-Plough Corporation, and Valeant Pharmaceuticals; and serving on the speakers' bureau of Bristol-Myers Squibb Company, Gilead Scientific Inc, Novartis Pharmaceuticals, and Schering-Plough Corporation.

Tram T. Tran, MD
Medical Director, Liver Transplantation
Center for Liver Disease and Transplantation
Cedars-Sinai Medical Center
Assistant Professor
University of California School of Medicine
Los Angeles, California
Dr Tran reports receiving grants/research support from Bristol-Myers Squibb and Idenix/Novartis; and serving as a consultant for Bristol-Myers Squibb, Gilead Sciences, Inc, Idenix/Novartis, and Schering-Plough.

This monograph was reviewed by Daksha Brahmbhatt, RN, MPH, for the American Nurses Credentialing Center's accreditation purposes.

Notice: The audience is advised that articles in this CE activity may contain reference(s) to unlabeled or unapproved uses of drugs or devices.

Dr Thuluvath–tenofovir.
Dr Hann–tenofovir disoproxil fumarate.

All other faculty have indicated that they have not referenced unlabeled/unapproved uses of drugs or devices.

Johns Hopkins Advanced Studies in Medicine provides disclosure information from contributing authors, lead presenters, and participating faculty. Johns Hopkins Advanced Studies in Medicine does not provide disclosure information from authors of abstracts and poster presentations. The reader shall be advised that these contributors may or may not maintain financial relationships with pharmaceutical companies.

Delivering Optimal Care: Prevention, Detection, and Management of Hepatitis B in Asian and Pacific Islander Americans
Paul J. Thuluvath, MD, FRCP*

Despite availability of a safe and effective vaccine since 1982, hepatitis B  virus (HBV) continues to remain a major public health problem, killing as many as 1 million people worldwide every year. An estimated 350 million people are living with chronic HBV (CHB) infection, the majority of whom are from the Asian-Pacific region or Africa. In the Asian-Pacific region, HBV is endemic, affecting anywhere between 2.4% and 16% of the population. Because the majority of Asian/Pacific Islander (A/PI) individuals acquire HBV infection perinatally or in early childhood, the natural course of the disease in these individuals tends to be more malevolent. HBV infection acquired early in life is more likely to become chronic, progress despite normalizing laboratory markers (eg, hepatitis B e antigen [HBeAg] seroconversion, hepatitis B surface antigen [HBsAg] clearance, HBV DNA levels <20 000 IU/mL, and normal alanine aminotransferase [ALT] levels), and respond less to interferon (IFN) therapy. As a result of these complicating prognostic factors, 1 in 4 Asians with CHB will die from cirrhosis, liver failure, or liver cancer–unless they receive appropriate monitoring and treatment.

As a result of increasing immigration to the United States from areas of high HBV prevalence, such as the A/PI region, CHB infection has become a substantial public health concern in regard to management of widespread transmission and disease-related sequelae. The prevalence rates of HBV in some US areas can actually mirror those of highly endemic regions. One screening program conducted among a predominantly immigrant Asian population found that 15% of newly tested positive New York City residents had CHB, with the rate of hepatocellular carcinoma being 5- to 11-fold higher compared with other ethnic groups. Various liver organizations have sponsored large-scale awareness campaigns targeting A/PI communities with multilingual educational material and vaccination programs. Although these outreach programs have been very successful in encouraging at-risk persons to undergo screening, vaccination, and treatment, there is still much to be done in reaching more patients. At the forefront of patient care, primary care providers can have a major impact on improving screening/diagnosis and management of at-risk patients.

This issue of Johns Hopkins Advanced Studies in Medicine is dedicated to educating primary care providers, including physicians, physician assistants, nurses, and nurse practitioners, on detection, prevention, and management of HBV in A/PI Americans. Tram T. Tran, MD, offers an extensive discussion on the basics of HBV virology and transmission, focusing on the natural history of the disease in A/PI patients. Dr Tran, who is the Medical Director of Liver Transplantation at Cedars-Sinai Medical Center and Assistant Professor at the University of California School of Medicine in Los Angeles, reviews recent data regarding HBV prevalence and disease burden among the nation's general population versus the A/PI population. Most Asians acquire HBV via perinatal transmission and studies have shown HBsAg positivity in 8.3% of 38 000 tested pregnant Asian women. The highest and lowest rates of HBsAg positivity are found in women of Chinese origin (11.4%) and in those born in Japan (2%), respectively. Although perinatal transmission accounts for more than 50% of HBV cases in endemic Asian countries, horizontal transmission in early childhood is also an important mode of transmission. Dr Tran also discusses diagnostic techniques and vaccination efforts, disclosing that despite recommendations urging all countries to initiate routine HBV vaccination of infants, only 116 of 215 countries had developed an immunization policy by the year 2000.

Next, Hie-Won L. Hann, MD, explores recent prevalence studies and awareness surveys among various A/PI communities across the United States, offering screening recommendations and interpretation of tests and monitoring. Dr Hann, who is Professor of Medicine at Jefferson Medical College and Director of the Liver Disease Prevention Center at the Division of Gastroenterology and Hepatology at the Thomas Jefferson University Hospital in Philadelphia, Pennsylvania, offers numerous counseling suggestions specific to A/PI communities, addressing common myths and misconceptions regarding HBV transmission and prevention. She presents various surveys exploring Chinese health beliefs about the liver, vaccination, and preventive strategies, offering clinicians insight regarding educational gaps in A/PI patients.

Finally, Ke-Qin Hu, MD, reviews the major principles of treating patients with CHB infection, focusing on factors used to determine treatment response and therapeutic endpoints in A/PI patients. Some of these patients have disease progression despite HBeAg seroconversion, HBsAg clearance, HBV DNA levels lower than 20 000 IU/mL, and ALT levels between 2 and 5 times the upper limit of normal. Clinicians should take these factors into consideration when setting therapeutic goals in A/PI patients. In his discussion on treatment strategies, Dr Hu, who is the Director of Hepatology Services at the H.H. Chao Comprehensive Digestive Disease Center, University of California in Irvine, cautions that Asian patients tend to exhibit lower responses to IFN and lamivudine, because many of these individuals have normal ALT levels at presentation.  Dr Hu also offers a primer on HBV treatment strategies for special populations (ie, pregnancy, HIV coinfection, cirrhosis, and post- liver transplantation). In addition to this monograph, we are also offering a patient education handout pad, which can be ordered online in Mandarin, Korean, or Vietnamese. These pads, written in easy to understand language, contain concise information about transmission and prevention of HBV, as well as resources providing more extensive services related to HBV. By improving patients' understanding of this disease, we hope to increase the impact of this educational program in decreasing HBV in the A/PI community.

*Director, Hepatology, Director, Liver Research, Medical Director, Liver Transplantation, The Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Baltimore, Maryland.
Address correspondence to: Paul J. Thuluvath, MD, FRCP, Director, Hepatology, Director, Liver Research, Medical Director, Liver Transplantation, The Johns Hopkins Hospital, Johns Hopkins University School of Medicine, 1830 Building, Room 429, 600 North Wolfe Street, Baltimore, MD 21287. E-mail: pjthuluv@jhmi.edu.

The content in this monograph was developed with the assistance of a staff medical writer. Each author had final approval of his article and all its contents.





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