Hepatitis B has been our longest running program since 2006, prior to the forming of Asian Center – SE MI. It has been a research and service project by our executive director Dr. Lee, who continued the quest from University of Michigan to Asian Center – SE MI. The report here mainly focuses on the findings of our community in Michigan about hepatitis B disease, and major tasks she has carried on over the past 15 years. More details of each HBV program mentioned here can be requested by contacting us.
Our first task was to find out what prevalence rate of HBV was in Michigan. After screening 500 people, we paused and took the first look of the result. And here it is:
|HBsAg (+)||Anti-HBs (+)||HBsAg (-)/anti-HBs (-)||Total|
|33 (5.9%)||307 (54.1%)||227 (40.0%)||567|
In 2017, we did another data analysis and found it pretty consistent with our initial report.
|HBsAg (+)||Anti-HBs (+)||HBsAg (-)/anti-HBs (-)||Total|
|96 (6.4%)||756 (50.1%)||657 (43.5%)||1,059|
Over the 15 years, we actually collected about 2,000 datasets. But there were 500 datasets we did on a special request by CDC and that data is not included in here. That program was under an agreement exclusively for CDC use. We concluded 1,500 sample size is acceptable to establish the prevalence in Michigan.
Our screening efforts have been reduced after we closed our IRB (Institutional Review Board), which governed this task to protect our participants under the HIPAA requirements. We now only offer screening test as a service when needed.
We can only offer vaccination when we get free vaccines from CDC through MDHHS. Since May of 2010 we had been receiving free Twinrix on and off till Dec of 2011. The HBV vaccines usually can last a year long, we planned well from our screening data to estimate the numbers of doses we needed to last for enough people from a few regularly scheduled health fairs. Later we received Engirix from Aug of 2013 to Jul of 2015. So for a period of time from 2010 to 2016, we were able to offer this service to community of underserved continuously.
The HBV vaccination usually includes 3 shots, at 0, 1 & 6 months. We always scheduled the 1st vaccine about a month after a health fair. When we process screening result papers, we would tell eligible people in their recommendation letters that we would offer them free vaccination and gave them the schedules. Then we would call each eligible person to invite him/her for the free vaccination. After their first shot, we would give them a recording sheet with the nurse’s/phlebotomist’s signature, and the dates of their 2nd and 3rd shots. Then a week before their 2nd and 3rd shots, we would call them again as a reminder.
After we put so much effort for vaccination planning, it is rather disappointed to see less than half of the eligible people actually took our offer. The following table showed the number of eligible people during our offering period actually took it.
|# of eligible people||# of people took the vaccines||# of people declined|
|252||116 (46.03 %)||136 (53.97 %)|
When we started calling eligible people for vaccination after the initial screening, we realized many people did not care for it. We had to do a lot of talking to persuade them. In general, most of the people still did not know this disease and how it affects Asian Americans. Our volunteers had difficult time to convince people. Data collected for not wanting to participating in this part was very limited, yet consistent. They are listed in this order: 1) lack of transportation; 2) out of town; 3) working; 4) allergy; and 5) sick. From this experience, we realized education is extremely important. It is something we need to focus on.
For the six years when we had a patient navigation program, we did not manage to enroll even half of all eligible patients from our screened population. Following is the high level summary of our patient navigation program. We separated the first 4 years being the “active” program versus the last 2 years being the “passive” program to show that more interactions make a difference.
Table V HBV Patients Navigation Program Summary
The difference between active and passive in this case is the amount of interactions we could offer to patients. During the active period, we had Asian American medical students from UM medical school helping us follow-up with patients in addition to our CHW involvement. But students changed every year, continuation was hard. There were not enough resources to keep up training students every year with a new group. So after 4 years there were no more medical students joining in, only our CHWs continue working with patients. We could only do the minimum follow-up, thus we referred that period of 2 years the passive program.
From the above table, we can see that in the 1st phase (more active program), 47% of patients participated and received better care; but only 30.7% in the 2nd phase did. The weighted average of take-rate is 43.7%. That is a good data-based fact showing intervention (more phone calls for patient interaction) does make a difference.
There was another fact around that time. We noticed that less participants came to our health fairs. Since immigrants could buy health insurance under the Obamacare around that time, immigrants could get their own health insurance, thus had their own regular check up. Health fairs were not popular or in-demand any more. After we stopped screening in large amount, there were no “patients” to need help any more. We stopped the program
Overall, we were very disappointed that patients would not even take a liver panel test. The one solid conclusion is education is strongly in need among Asian Americans to understand HBV. The top reasons that patients did not participate in our navigation program are: 1) too busy, 2) don’t feel sick (no symptoms), 3) have no time to worry about it now, 4) I will deal with it when I feel sick, and 5) no health insurance. We had a few Chinese patients who said they would go back to China to get medical attention since they had health coverage in China. We helped a few uninsured patients apply for Medicaid. Our team maintains a large number of CHWs who can speak Chinese, Korean, Vietnamese and other common Asian languages to help patients in need.
Ever since we started the HBV program, we have been offering education to the Asian American community. Following is a list of different methods we used for the HBV education:
- Publish health articles of HBV in local Asian newspaper in Michigan, e.g., Michigan Chinese Newspaper, Korean Newspaper, Filipino Newspaper etc.
- Make small pamphlets or brochures distributed during any large Asian American gatherings
- Talk on radio at some local community stations
- Offer seminars during health fairs or expos or special set-up health events
- Offer one-on-one discussion during HBV screening
- Created a skit and made a movie to show in any opportunity (can be found on our site)
- Invite a small group of people (10+2) to discuss the disease and review a few cases over a paid lunch or afternoon tea gathering
For more than 15 years education to our community, we believe majority of Asian Americans are still very ignorant about the disease. After reviewing the low take rate of our free vaccination and patient navigation programs, we concluded that we need more renovation ways to educate Asian Americans of this deadly disease. Currently, we are still searching more effective way of education our community. We welcome your ideas and out-of-box thinking how to educate the Asian American community.