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Hepatitis B virus (HBV) infection is widely prevalent among racial and ethnic minorities in the United States; however, few data have been available regarding HBV testing and referral to care for these populations. Using survey data collected in 2009-2010 from the Racial and Ethnic Approaches to Community Health (REACH) across the U.S., we assessed rates and determinants of hepatitis B testing and access to care in 28 minority communities in the U.S. Of 53,896 respondents, 21,129 (39.2%) reported having been tested for hepatitis B. Of the 1,235 who reported testing positive, 411 (33.3%) reported currently receiving specialty care. After controlling for demographic and socioeconomic characteristics, the likelihood of having been tested for hepatitis B and receiving care if infected was higher among males, non-English speaking persons, and those having health insurance compared to their counterparts. Compared to college graduates, respondents without a college education were less likely to get tested for hepatitis B. Conclusion: These data indicate that more than half of racial/ethnic minority persons in these communities had not been tested for hepatitis B, and only about one-half of those who tested positive had ever received treatment. More state and federal efforts are needed to screen racial/ethnic minorities, especially foreign-born persons, for HBV and link those with infection to care. (Hepatology 2013;53:856–862)
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racial and ethnic approaches to community health across the United States
Hepatitis B virus (HBV) infection is a major public problem in the United States and around the world, with significant morbidity and mortality.[1, 2] It is estimated that 350-400 million persons worldwide have chronic HBV infection, with 620,000 annual deaths due to HBV-related liver disease.[3, 4] Although the incidence of HBV infection has declined in the U.S., the prevalence of chronic HBV infection remains relatively high, with at least 550,000-940,000 persons living with chronic infection. Furthermore, the incidence and prevalence of hepatitis B infection is greater among persons of minority race/ethnicity, especially among immigrants from countries of higher HBV prevalence. Nevertheless, data are relatively limited about HBV testing and referral to care in minority communities across the U.S.
The principal modes of HBV transmission are: (1) percutaneous (injection drug use, blood or body fluid exposures associated with healthcare, and blood transfusions), (2) sexual, and (3) perinatal (from infected mothers to infants).[5, 6] Early testing and detection of chronic HBV infection provides the greatest opportunity for prevention and therapy. In 2008, the Centers for Disease Control and Prevention (CDC) issued recommendations to screen for HBV infection among persons coming from geographic regions with 2% or higher prevalence of hepatitis B surface antigen (HBsAg). More recent findings indicate that screening is not only cost-effective for populations with an HBsAg prevalence of 2% but is also cost-effective at a prevalence as low as 0.3%. With recent advances in hepatitis B treatment, the CDC recommends hepatitis B screening not only to prevent new infections but also to refer HBV-infected persons for appropriate care and treatment. However, HBV testing among populations at risk are less than optimal. Previous studies have reported that minority race/ethnicity has been strongly associated with lower socioeconomic status, greater disease risk and burden, as well as significant barriers to healthcare access.[10, 11] Examination of the sociodemographic variables associated with hepatitis B testing and referral to care is useful in targeting prevention and treatment services for communities most affected by hepatitis B. In this study, we sought to characterize hepatitis B testing and access to care rates among racial and ethnic minorities in 28 communities across the U.S.
Materials and Methods
The CDC launched the Racial and Ethnic Approaches to Community Health across the U.S. (REACH U.S.) in 2007 to address the CDC's efforts to close health gaps among racial and ethnic minority groups in the U.S. A total of 40 communities were selected competitively and funded. The REACH U.S. Risk Factor Survey collected health-related information annually from 28 minority communities that targeted cardiovascular disease, diabetes mellitus, breast and cervical cancer, adult immunization, and hepatitis. These communities are located in 17 states (Arizona, California, Georgia, Hawaii, Illinois, Massachusetts, Michigan, New Mexico, New York, North Carolina, Ohio, Oklahoma, Pennsylvania, South Carolina, Virginia, West Virginia, and Washington). The following racial/ethnic minority populations were targeted: African American, Hispanic, Asian / Pacific Islander (APIs), and American Indian / Alaska Native (AI/AN). To be eligible for participation, a person had to be 18 years of age or older, live or stay in a household within the targeted geographic area, and be in the targeted racial/ethnic group(s) for that community. Up to two eligible persons within the household were selected for interview about him or herself and other household members.
An address-based sampling method was used in the survey to reduce the potential coverage bias of traditional random-digit-dialing. The survey was conducted through multi-modes including telephone interviews, self-administrative questionnaire mailing, and in-person interviews (see Supporting Table). In telephone interviews, the median response rate for household screening was 46% for sampled households that were contacted and 49% for family member interviews among all the eligible members. The median household level response rate was 23% in the mailing survey. For the in-person interview, the median response rate was 75% for household screening and 72% for family member interviews. The respondents were weighted to reflect the adult population for the community.
The questionnaire collected information on demographics (age, sex, race/ethnicity, place of birth, language), socioeconomic status (education, annual household income), healthcare access, and insurance coverage. From 2009 onwards, several specific questions devoted to hepatitis B testing, infection, and treatment were included. Questions were worded as follows: “Have you ever had a blood test for hepatitis B?,” “Have you ever been told by a medical doctor, nurse, or other health professional that you have hepatitis B?,” “Are you currently seeing a doctor for your hepatitis B?,” “Have you ever taken medications such as pills or shots prescribed by a doctor for hepatitis B?” The REACH survey instrument was administered by mail or telephone and was conducted in English, Chinese (Mandarin and Cantonese), Haitian Creole, Khmer, Spanish, Vietnamese, and Korean (Phase 2 only). Potential participants who could not communicate in any of the aforementioned languages were not included in the study.
Both REACH Phase 1 (May 1, 2009 to November 19, 2009) and Phase 2 (December 10, 2009 to August 2, 2010) were used in the current study. Rates of hepatitis B testing and treatment were calculated and stratified by demographics, socioeconomic factors, and survey modes. The SUDAAN (RTI International, Research Triangle Park, NC) callable function CROSSTAB was applied with the consideration of sampling level by year, community, and primary sampling unit. Each sample was weighted to reflect the probability of selection, the number of eligible members, and the number of selected members at the sampled address, and was adjusted by age-gender population sizes of members of the surveyed minority population. Multivariate logistic regression models using the RLOGIST function were used to estimate adjusted odds ratio (ORadj) with 95% confidence interval (95% CI) and associated P value. Age was classified into two categories for the multivariate analysis (18-64 and ≥65 years). The interaction terms between race and age and between race and birth outside the U.S. were statistically significant and were included in the final multivariate model (Table 2). P < 0.05 was considered statistically significant.
A total of 53,896 minority persons were interviewed (24,169 [44.8%] in 2009 and 29,727 [55.2%] in 2010). The sociodemographic characteristics of respondents are shown in Table 1. Overall, 39.2% of respondents reported having been tested for hepatitis B with the percentages varying from 42.5% (95% CI: 41.4-43.6) among APIs to 35.6% (95% CI: 34.7-36.5) among Hispanics. Among APIs, the percentage of testing was much higher in foreign-born persons than those U.S.-born (48% versus 31%). The most common setting of testing was the doctor's office or laboratory (51% overall, ranged from 37% in AI/AN to 66% in APIs). The next two common settings were clinics other than doctor's offices (20% overall, ranged from 16% in APIs to 26% in Hispanics) and hospitals (16% overall, ranged from 10% in APIs to 20% in AI/AN).
Table 1. Hepatitis B Virus Testing, Infection, and Referral to Care Among Racial/Ethnic Minorities: REACH U.S., 2009-2010
Currently Seeing a Physician for HBV Infectionb No. (%)
Numbers might not add up to total due to missing responses. All responses are self-reported. HBV, hepatitis B virus.
aOf those reporting having been tested for hepatitis B.
bOf those reporting HBV infection.
Asian/ Pacific Islander
American Indian/Alaska Native
Age group, year
Language of interview
Annual household income
Less than high school
High school graduate
Data collection mode
Of those reporting having been tested for hepatitis B, 5.8% (95% CI: 5.5-6.2) were told that they had HBV infection, with the highest prevalence among APIs at 12.7% (95% CI: 11.6-13.8) and lowest prevalence rates among AI/AN at 3.4% (95% CI: 2.8-4.3) (Fig. 1). While reports of hepatitis B testing decreased from 40% among younger age groups to 27% among those aged 65 or older, self-reports of HBV infection increased with age, reaching 10% among those aged 55-64 years (Table 1). Foreign-born persons reported higher rates of infection compared to those who were U.S.-born (9.3% versus 4.2%). Of the 1,235 persons reporting ever being told to have HBV infection, 411 (33.3%) reported currently seeing a physician for hepatitis B, ranging from 19.0% in AI/AN to 41.3% in APIs. Among those seeing a physician, the percentage of persons who had ever taken medications for HBV was 51.3% in African Americans, 66.7% in Hispanics, 48.0% in APIs, and 68.3% in AI/AN.
Table 2 displays adjusted odds ratios of the associations of selected factors with HBV testing and access to care. Compared to African Americans aged 18-64 years, other racial/ethnic groups had a significantly lower likelihood of HBV testing. No significantly racial/ethnic difference was found among persons aged 65 years or older, except that AI/AN were more likely to report getting tested for hepatitis B compared to African Americans in the same age category. Persons aged 65 years or older in all racial/ethnic populations were less likely to get tested for hepatitis B than those aged 18-64 years. Foreign-born individuals and non-English speakers had higher odds of reporting HBV testing compared to their counterparts (Table 2). The likelihood of testing was lower among persons without a college education compared to college graduates. Compared to uninsured persons, those having health insurance were more likely to report hepatitis B testing (ORadj = 1.32, 95% CI: 1.24-1.40). Those who completed the survey by mail were less likely to report having the tests than those completed through telephone (Table 2). As with testing, the likelihood of seeing a physician for HBV infection was strongly associated with health insurance coverage (ORadj = 2.41, 95% CI: 1.61-3.60). Males were more likely (ORadj = 1.64, 95% CI: 1.25-2.15) than females and foreign-born African Americans were more likely than U.S.-born persons to be currently seeing a physician for their hepatitis B infection.
Table 2. Factors Associated With Hepatitis B Testing and Linkage to Care Among Racial/Ethnic Minorities: REACH U.S., 2009-2010
dORadj: adjusted odds ratio, 95%CI: 95% confidence interval; the model is adjusted for all of the variables listed in this table and the interaction terms between race and age and between race and having been born in U.S.
This study of racial/ethnic minorities in 28 communities across the U.S. shows that less than one-half have reported testing for hepatitis B and among those who reported having HBV infection only about one-third reported currently seeing a physician for their hepatitis B infection. Previous studies including Asian Americans reported similar low rates of hepatitis B testing in this population,[12-14] where rates of chronic HBV infection are significantly higher than the general population.[2, 15] The recent Institute of Medicine report stressed the importance of screening for, vaccinating against, and linkage to care for persons with HBV infection, given that they estimated that up to 65% are unaware of their infection.
While this study and analysis focused on four racial and ethnic minorities in the U.S., of any origin, there were important findings relevant to about one-third of minorities who had been born outside the U.S. Although some foreign-born persons, such as Asians, were more likely to report having been tested for hepatitis B compared to U.S.-born participants, many of them have never been tested for hepatitis B. The CDC recommends screening all persons born in regions where the prevalence of hepatitis B surface antigen is ≥2%, which represents the vast majority of foreign-born persons in the U.S. Therefore, our findings suggest that implementation of recommendations could be significantly improved. Language barriers have been previously reported to affect access to care among Asians[17, 18]; however, in our population of non-English speakers, most of them were foreign-born, and more likely to have been tested for hepatitis B. Awareness campaigns in the Asian American communities in San Francisco and New York City such as San Francisco's “Hep B Free” model and the “Bfree NYC” model have been effective in promoting awareness, testing, and referral to care for Asian Americans.[19, 20] Expanding programs like these to other cities and to other racial/ethnic minorities with high rates of infection are needed.
More than 53,000 persons with chronic hepatitis B per year are estimated to immigrate to the U.S. from countries of intermediate to high endemicity for chronic hepatitis B. In addition, the rate of chronic hepatitis B is 10-fold higher among foreign-born persons in the U.S. compared to the national prevalence rate. For these reasons, international support for programs to prevent hepatitis B infection are important not only from an international perspective but for the public health of the U.S. The Global and U.S. vaccination programs for newborn and infant hepatitis B immunization have resulted in increased hepatitis B vaccination coverage globally and large declines in hepatitis B prevalence among vaccinated cohorts.[16, 23] However, hepatitis B immunization only has been implemented recently in many countries; hence, many foreign-born persons, who did not benefit from childhood vaccination programs at home, will be infected prior to arrival in the U.S. Interventions are needed to identify and reach these populations.
Socioeconomic factors, notably availability of health insurance and higher education status, were important determinants of hepatitis B testing and access to care in our population, which agrees with findings from other studies.[17, 18, 24] Furthermore, compared to younger persons, persons aged 65 years or older were less likely to be tested for hepatitis B in all racial/ethnic groups and were less likely to be currently seeing a physician among APIs. The experience of healthcare providers in the diagnosis and treatment of HBV infection may affect testing and referral to care rates. Lack of awareness about HBV risk factors among some providers despite the high prevalence of hepatitis B among racial/ethnic minorities might hinder testing of populations at risk for infection. For example, a survey among family physicians showed that less than 70% would screen immigrants from HBV-endemic regions and less than one-half would test household contacts of HBV-infected persons.
While primary prevention of HBV infection is critical, it is equally important to strengthen secondary prevention goals of determining who is infected and referring them to appropriate care. Persons who are chronically infected with HBV can remain asymptomatic and unaware of their infection status for years. With recent advances in hepatitis B treatment, one of the cornerstones of the CDC's prevention and care strategies is to recommend hepatitis B screening to not only prevent new infections but to refer HBV-infected persons for care and possible therapy. After the initial diagnosis and evaluation, all chronically infected persons should receive long-term monitoring to assess disease progression and related complications, as well as the need for and response to treatment, as high viral load is associated with increased risk of cirrhosis, hepatocellular carcinoma (HCC), and liver-related death.[26, 27, 29-31] Recommendations for monitoring and treatment are constantly being updated and physicians should consult the most recent recommendations made by various authorities in the field.[26-28]
A major limitation of this study is the use of self-reported data, which may have potential recall or social desirability bias. In addition, it is difficult to ascertain what proportion of hepatitis B testing occurred in the context of health screening versus diagnostic testing performed due to complications of chronic hepatitis B infection such as cirrhosis or HCC. Furthermore, the lack of laboratory test results hinders the ability to distinguish chronic from resolved hepatitis B infection, leading to our failure to identify persons who do not need care and treatment. Finally, the cross-sectional design of this study limits the ability to determine causal effects.
Despite these limitations, this study is the first to assess hepatitis B testing and linkage to care in a large sample of racial/ethnic minorities in the U.S. The inclusion of such a large sample size would have been difficult to achieve in a serosurvey. While most of the literature on screening and treatment of hepatitis B in the U.S. has focused on Asian American communities, our study also examined these practices among Hispanics and African Americans. Hepatitis B testing was less than optimal, especially among foreign-born persons who in the majority come from countries of intermediate endemicity. Socioeconomic factors, particularly availability of health insurance, played an important role in screening and access to care. Awareness and screening campaigns for physicians and the public should be implemented widely to promote hepatitis B testing and facilitate access to care, as have been conducted among some Asian American communities.[19, 20]
Disclaimer: The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention.