In 2008, I replaced another family physician as the sole physician at HOPE Clinic, a federally qualified health center in southwest Houston. The clinic was founded by members of the local Asian community to ensure that Asians would have a place to receive linguistically and culturally-appropriate medical care. From the outset, we treated anyone who came in the door, including many non-Asian patients. Due to our core mission, we cared for a large proportion of foreign-born patients from all over the world, speaking more than eighty different languages.
Many of our patients' countries of origin, including China, Vietnam, Myanmar, Iraq, and Nigeria, have a high (>= 8%) or intermediate (2-7%) prevalence of chronic hepatitis B (CHB), leading to a high prevalence in our patients. Initially, they were reflexively referred to hepatologists, but due to access and cost barriers, the community asked us to start treating hepatitis B right at HOPE.
I was an experienced, board-certified family physician, but I had never done any hepatitis B management. I sought training with local hepatologists, mostly through lectures and question-and-answer sessions, and gradually became comfortable with the vocabulary, epidemiology, concepts, and pharmacology of care for patients with hepatitis B.
Because of the HOPE Clinic's origins, most of our hepatitis B patients are of Asian ancestry. In the United States as a whole, roughly half of patients with CHB are of Asian descent, but in your community you might find a different ethnic/language mix. We are seeing an increasing number of non-Asian patients with CHB, including younger native-born Anglo patients with a history of unsafe drug use. Significantly, many American adults have not received hepatitis B vaccinations, leaving them susceptible to infection from sex, injection drug use, or snorting cocaine.
Different social approaches to drug use and addiction in some European countries (such as Portugal) have coincided with marked reductions in the number of new cases of viral hepatitis and HIV. Conversely, infection rates in Americans appear to be increasing. Now that a two-dose hepatitis B vaccine is available, family doctors have a valuable role to play in screening and immunizing susceptible patients, and in managing their patients with CHB.
Factors that make uncomplicated
CHB care easy to learn for family physicians
Factor
|
Remarks
|
Many patients don’t need
antiviral medications
|
These
visits are particularly simple
|
Very few medications are
used, usually just one at a time
|
1.
Entecavir
2.
Two forms of tenofovir: TAF or TDF
3.
Interferon use is rare at primary care level
4.
Older medications not used in USA due to
resistance
|
Medications are well
tolerated
|
One
pill per day, side effects are uncommon
|
Medications are effective
|
Most
patients achieve viral levels below the limits of detection, viral resistance
is uncommon.
|
Straightforward liver
cancer surveillance
|
RUQ
abdomen ultrasound and serum AFP every six months in cirrhotics.
Other
patients: RUQ u/s + AFP q 6-12 mos.
based on guidelines.
Consider
CT/MRI as appropriate
|
Infrequent visits needed
|
Once patient is established, 2-3 visits per year is a typical pattern
|
Telehealth/telemedicine
|
The
availability of free online-video specialist consultation is increasing.
Example: check for availability in your region, at https://echo.unm.edu/locations-2/echo-hubs-superhubs-united-states/
Though
there are only two listed ECHO hepatitis B-specific programs in the USA, there are 64
infectious disease programs, many of which include viral hepatitis
|
Knowing when to refer
|
Decompensated
cirrhosis: ascites, esophageal
variceal bleed, hepatic encephalopathy, bacterial peritonitis, hepatorenal
syndrome, liver cancer.
|