Race, Ethnicity


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  • However, with regards to the latter group, Mexican Americans comprise only 66.9 % of all American Hispanics The heterogeneity and rapid growth of the Hispanic population in the U.S., which is projected to more than double by 2050 (17), stresses the importance of understanding HCV epidemiology in this group.
  • Missing race data by clinic: FHC 11% MDLS 24% JIMA 26% JFMA 31%
  • Among Hispanics who were asked about IDU, 40% admitted to this, compared with 22% of blacks and 8% of whites who were asked. History of percutaneous exposure as a health care worker was rarely specified (n=4).
  • We still feel that races are handled differently. The fact that there were different risk factor history ascertainment rates for controversial risks, which was more frequent, may be the clue. The low rate of conventional risk factor ascertainment was too low for us to discredit this notion. What factors underlie low risk factor ascertainment rates? Providers Competing priorities Patients Knowledge Trust Why is testing for HCV in the presence of IDU not more common? Is testing being ordered but not pursued by patient? Despite findings in our retrospective study, could race-based differences in the approach to HCV management still exist? Demonstrated with respect to ascertainment of controversial risk factors The rate of conventional risk factor documentation was too low to exclude the possibility that race affected ascertainment rates
  • Although our retrospective study indicated that there were actually NO differences among races with regards to testing, risk factor ascertainment was low in this study. Moreover, we still had the clinical suspicion that races may be handled differently with regards to HCV. Therefore, we chose a conservative and measurable endpoint for our primary hypothesis.
  • All questionnaires were available in English or Spanish Composite- racial/demographic/knowledge information
  • Data collected included provider’s documentation of risk factor, HCV related discussion with the patient, recommendation/order for testing, and actual test result. Provider discussion of HCV risks with the patient and whether testing was suggested and performed.
  • Of those 24 with conventional risks only, 17 of them are US born hispanics. The remaining 7 are from the following locations: 1 is from Mexico, 2 are from DR, 1 is from Central America and 3 are from South America
  • Only U.S. born Hispanics reported a history of injection drug use. Tattoos were reported as the most common risk for HCV.
  • Both race and education were independently associated with HCV knowledge with lower levels of education being associated with a greater number of incorrect answers (p<.0001).
  • Misconceptions regarding HCV decrease with an increasing number of years Hispanic immigrants reported living in the United States.
  • Race, Ethnicity

    1. 1. Race, Ethnicity & HCV Management in Primary Care Practice Simona Rossi, MD Stacey B. Trooskin, PhD, MPH Maricruz Velez, MPH, CHES Thomas Jefferson University Division of Gastroenterology & Hepatology Philadelphia, Pennsylvania
    2. 2. Workshop Objectives <ul><li>To understand the epidemiology of hepatitis C and the risks for acquisition </li></ul><ul><li>To understand barriers to diagnosis and management of hepatitis C in primary care, as they relate to race of the patient </li></ul><ul><li>To understand the effect of race on hepatitis C treatment response </li></ul><ul><li>To propose strategies for improved identification of individuals at risk for HCV </li></ul>
    3. 3. Overview <ul><li>Published Guidelines for HCV Testing </li></ul><ul><li>HCV Management in Primary Care </li></ul><ul><li>Viral Hepatitis in Minority Populations </li></ul><ul><li>Questions & Answers </li></ul>
    4. 4. HCV Published Recommendations <ul><li>No published recommendations for HCV Risk Factor Assessment </li></ul><ul><li>Published guidelines for HCV Testing & Management </li></ul><ul><ul><li>NIH Consensus Statement on the Management of Hepatitis C (1997) </li></ul></ul><ul><ul><li>CDC Recommendations for Prevention & Control of Hepatitis C (1998) </li></ul></ul><ul><ul><li>U.S. Preventive Services Task Force (USPSTF) Screening for Hepatitis C Virus Infection in Adults: Recommendation Statement (2004) </li></ul></ul><ul><ul><li>AASLD Practice Guideline Diagnosis, Management & Treatment of Hepatitis C (2004) </li></ul></ul><ul><li>Testing practices are largely determined by the patient’s HCV risk factor status </li></ul><ul><ul><ul><li>Conventional vs. Controversial </li></ul></ul></ul>
    5. 5. -Tattooing or body piercing -IDU -HIV infection -Hemophilia, clotting factor prior to 1987 -Hemodialysis -Abnormal ALT -Transplant or transfusion (prior to 1992) -Children born to HCV infected mother -HC worker w/ needlestick -Sexual contact of HCV infected person AASLD -Tattooing or body piercing -HIV infection -Children born to HCV infected mother -IDU -Sexual contact of HCV infected person -Occupational infected blood exposure -Share personal care items w/ infected contact -Needlestick NIH Testing Not Recommended for: Testing of Uncertain Needs: Testing Routinely Recommended for: Testing Guideline
    6. 6. -IDU -Transplant or transfusion (prior to 1992) -Hemodialysis -Children born to HCV infected mother USPSTF -HC, emergency , medical and public safety workers -Pregnant women -Household (non-sexual) contact of HCV+ person -General population -Recipients of transplanted tissue -Intranasal cocaine & other non-injection drug use -Tattooing or body piercing -History of multiple sex partners or STDs -Long term steady sex partners of HCV+ persons -IDU -HIV infection -Hemophilia, clotting factor prior to 1987 -Hemodialysis -Abnormal ALT -Transplant or transfusion (prior to 1992) -Children born to HCV infected mother -HC worker w/ needlestick CDC Testing Not Recommended for: Testing of Uncertain Needs: Testing Routinely Recommended for: Testing Guideline
    7. 7. HCV Recommendation Summary <ul><li>IDU is the most common risk factor for which testing is consistently recommended </li></ul><ul><li>Transfusions and transplants before 1992 are becoming more rare </li></ul><ul><li>Uncertain need for sexual contacts of HCV infected persons </li></ul>
    8. 8. Hepatitis C In Minority Populations: The Identification Of Barriers To Screening And Testing In Urban Primary Health Care Settings Stacey B. Trooskin PhD, MPH Thomas Jefferson University Division of Gastroenterology & Hepatology Philadelphia, Pennsylvania
    9. 9. Background <ul><li>Hepatitis C virus (HCV) infection is the most common chronic bloodborne infection in the United States </li></ul><ul><li>Persons ever infected (1.6%) </li></ul><ul><ul><li>4.1 million (3.4-4.9)* </li></ul></ul><ul><li>Persons with chronic infection </li></ul><ul><ul><li>3.2 million (2.7-3.9)* </li></ul></ul><ul><ul><li>* 95% Confidence Interval </li></ul></ul>
    10. 10. HCV Risk Factors <ul><li>Conventional risk factors: </li></ul><ul><ul><li>injection drug use (IDU) </li></ul></ul><ul><ul><li>blood transfusion/ solid organ transplant before 1992 </li></ul></ul><ul><ul><li>unsafe medical practices </li></ul></ul><ul><ul><li>occupational exposure to infected blood </li></ul></ul><ul><ul><li>birth to an infected mother </li></ul></ul><ul><li>Controversial risk factors: </li></ul><ul><ul><li>sex with an infected person / high-risk sexual practices </li></ul></ul><ul><ul><li>intranasal cocaine use </li></ul></ul><ul><ul><li>tattoos and body piercing </li></ul></ul>
    11. 11. Prevalence of HCV Infection United States, 1999-2002 Anti-HCV Est. Infections Percent of Group Positive millions (95% CI) Infections Source: Annals of Internal Medicine 2006, 144 (10) 705-714.
    12. 12. HCV & Minority Populations <ul><li>Minorities are a heterogeneous group </li></ul><ul><ul><li>NHANES included black, white and Mexicans </li></ul></ul><ul><ul><li>Multitude of Hispanic subgroups </li></ul></ul><ul><ul><li>Epidemiology of HCV in minorities may be changing </li></ul></ul><ul><li>Blacks do not respond as well to therapy as white counterparts. </li></ul><ul><li>Minorities are underrepresented in clinical trials </li></ul><ul><li>Few studies have focused on differences in risk ascertainment, appropriate testing, and referral for treatment between minority and non-minority populations for HCV infection. </li></ul>
    13. 13. Primary Care Practices & HCV <ul><li>Only 59% of primary care physicians ask all patients about risk factors </li></ul><ul><li>Only 68% of primary care physicians routinely test patients with elevated liver enzyme levels </li></ul><ul><li>These findings indicate that despite accessing primary care, HCV infected individuals may remain undiagnosed </li></ul>Hepatology 1999; 30: 794-800; J Am Board Fam Prac 1999; 12:427-435; Hepatology 1999;30 209A
    14. 14. Benefits to Diagnosing HCV in Primary Care Settings <ul><li>Counseling regarding behaviors that may transmit infection </li></ul><ul><li>Education regarding behaviors that may hasten the progression of liver disease </li></ul><ul><li>Preventive services such as hepatitis A and B vaccines </li></ul><ul><li>Referral for hepatitis C therapy </li></ul>
    15. 15. General Hypothesis <ul><li>In urban primary care practices, HCV risk factor ascertainment, appropriate testing, and referral for treatment differ between minority and non-minority patients. </li></ul><ul><li>This general hypothesis was addressed in two studies </li></ul><ul><ul><li>Retrospective Chart Review </li></ul></ul><ul><ul><li>Prospective Cohort Study </li></ul></ul>
    16. 16. Retrospective Cohort Study <ul><li>Specific aims </li></ul><ul><ul><li>To assess the rates of HCV risk factor ascertainment, testing, and referral for treatment in urban primary care practices </li></ul></ul><ul><ul><li>To determine if these practices differ among racial and ethnic groups </li></ul></ul>
    17. 17. Retrospective Study: Methods <ul><li>4 urban primary care practices </li></ul><ul><li>Charts were systematically selected, at random </li></ul><ul><li>Retrospective data collected: </li></ul><ul><ul><li>Demographic and insurance information </li></ul></ul><ul><ul><li>Documentation of HCV risk factors </li></ul></ul><ul><ul><li>In the presence of a documented risk factor; </li></ul></ul><ul><ul><ul><li>HCV testing </li></ul></ul></ul><ul><ul><ul><li>Referral for treatment </li></ul></ul></ul>
    18. 18. Retrospective Study: Results <ul><li>Final cohort: N=4376 </li></ul><ul><ul><li>1333 (28%) Black </li></ul></ul><ul><ul><li>1103 (23%) Hispanic </li></ul></ul><ul><ul><li>846 (18%) White </li></ul></ul><ul><ul><li>1094 (23%) of charts reviewed did not document race </li></ul></ul><ul><li>Groups were similar with respect to the average age of patients at the time of review (mean age 43). </li></ul><ul><li>44% percent of black patients were male, as compared to 34% of Hispanics and 45% of whites. </li></ul>
    19. 19. Retrospective Study: Results <ul><li>Documentation of injection drug use (IDU), [+ or – history] </li></ul><ul><ul><li>12% overall </li></ul></ul><ul><ul><ul><li>18% black, 4.4% Hispanic, 16% white </li></ul></ul></ul><ul><li>Documentation of transfusion history </li></ul><ul><ul><li>1.8% overall </li></ul></ul><ul><ul><ul><li>1.7% black, 1.0% Hispanic, 3.4% white </li></ul></ul></ul><ul><li>No differences in rates of documentation, by site </li></ul>
    20. 20. Documented HCV Risks by Race ┼ Significantly different from whites p<0.05 ╪ Significantly different from Hispanics p<0.05 § Significantly different from whites p<0.001 § ┼ ┼ ┼ §╪ § § §┼ § § ┼
    21. 21. Testing for Those with Documented IDU History *Total number within each race group on which the testing rate (%) is based. ╫ significantly different from whites (p<.05) 50% admit to non-IDU 38% admit to non-IDU 10% admit to non-IDU Unknown No Yes 712 (9.1) 123 (13) 11 (55) White Rate of HCV testing 1055 (14) 29 (24) ╫ 19 (58) Hispanic Rate of HCV testing 1092 (8.3) 187 (20) ╫ 54 (56) Black Rate of HCV testing N* (% tested) N* (% tested) N* (% tested) History of IDU?
    22. 22. Rates of testing among individuals with a documented controversial HCV risk factor but no conventional risk factors *Numbers may not be mutually exclusive 24.1 903 History of HIV testing 19.4 706 History of STD 30 60 Incarceration 33.3 6 Prostitution 21.6 513 History of Non IDU 50 4 Piercing 36.4 33 Tattoos % Tested # with only controversial risk factors *
    23. 23. Retrospective Cohort Study: Testing Rates by Race/ Ethnicity ┼ Includes individuals for which no risk factor was documented and those who responded that they did not have a risk factor when questioned. * Significantly different from whites and blacks (p<.05) ╪ Significantly different from whites and Hispanics (p<.05) Seropositive: 77% Seropositive: 22% Seropositive: 6% 6.9 3212 19 1071 56 124 Overall* 6.4 733 30 92 57 21 White 9.9* 848 27 232 57 23 Hispanic 5.4 737 16 ╪ 535 57 61 Black % tested N % tested N % tested N No risk factor identified ┼ At least one controversial risk factor identified (with no conventional risk factor) At least one conventional risk factor identified
    24. 24. Referral for Subspecialty Care <ul><li>Of the 93 patients who were identified as being HCV positive (and for whom race/ethnicity was known) </li></ul><ul><ul><li>40% were referred to a specialist </li></ul></ul><ul><ul><li>29% were not referred </li></ul></ul><ul><ul><li>31% data not collected </li></ul></ul><ul><li>Referral rates by race/ethnicity </li></ul><ul><ul><li>71% of whites </li></ul></ul><ul><ul><li>40% of Hispanics </li></ul></ul><ul><ul><li>32% of blacks </li></ul></ul><ul><li>When referral rates were examined by clinic, blacks were found to have a lower rate of referral as compared to whites. </li></ul>
    25. 25. Retrospective Study: Conclusions <ul><li>Documentation of conventional HCV risk factors is uncommon in urban practices, irrespective of race or ethnicity. </li></ul><ul><li>Documentation of controversial risks is more common, particularly for minorities. </li></ul><ul><li>Physicians may be less likely to ascertain a history of conventional risk factors from Hispanics. </li></ul>
    26. 26. Retrospective Study: Conclusions <ul><li>Race/ethnicity does not influence testing practices in the presence of a conventional risk factor. </li></ul><ul><ul><li>When IDU was denied, blacks and Hispanics were significantly more likely to be tested for HCV. </li></ul></ul><ul><li>Blacks are least likely to be tested in the presence of a controversial risk factor. </li></ul><ul><li>Minorities are less likely to be referred to a specialist than whites. </li></ul>
    27. 27. Limitations: Retrospective Study <ul><li>There may have been a clinic effect/site bias </li></ul><ul><li>Clinical evidence of liver disease was not collected from the chart </li></ul><ul><ul><li>This could explain higher rates of testing among those who denied IDU </li></ul></ul><ul><li>Undocumented race/ ethnicity and referral information </li></ul>
    28. 28. Prospective Cohort Study
    29. 29. Prospective Cohort Study: Rationale <ul><li>Based on our retrospective study, several questions remain: </li></ul><ul><ul><li>What factors underlie low risk factor ascertainment rates? </li></ul></ul><ul><ul><li>Why is testing for HCV in the presence of IDU not more common? </li></ul></ul><ul><ul><li>Despite findings in our retrospective study, could race-based differences in the approach to HCV management still exist? </li></ul></ul>
    30. 30. Prospective Cohort Study <ul><li>Primary Objectives </li></ul><ul><ul><li>To assess self-reported HCV risk factors from participants </li></ul></ul><ul><ul><li>To determine the rates of physician initiated HCV risk factor ascertainment and testing among those with self reported HCV risks </li></ul></ul><ul><ul><li>To determine differences in these rates as influenced by race/ethnicity </li></ul></ul><ul><li>Secondary Objectives </li></ul><ul><ul><li>To assess knowledge about HCV </li></ul></ul>
    31. 31. Prospective Cohort Study: Methods <ul><li>Consecutive new, adult patients were enrolled over 6 months </li></ul><ul><li>4 urban primary care sites in Philadelphia </li></ul><ul><li>Prior to seeing a provider, patients completed: </li></ul><ul><ul><li>HCV risk factor assessment (in duplicate) </li></ul></ul><ul><ul><li>Questionnaire </li></ul></ul>
    32. 32. <ul><li>Providers </li></ul><ul><ul><li>Given guidelines and in-services about HCV management, prior to study initiation </li></ul></ul><ul><ul><li>Instructed to review each patient’s completed HCV risk factor assessment form </li></ul></ul><ul><ul><li>No recommendations were given to the provider with regards to specific management of the patient </li></ul></ul>Prospective Cohort Study: Methods
    33. 33. <ul><li>Additional Study procedures </li></ul><ul><ul><li>Chart review </li></ul></ul><ul><ul><li>Telephone Interviews </li></ul></ul><ul><ul><ul><li>Patient reporting of medical encounter </li></ul></ul></ul><ul><ul><ul><li>Specific risk factor (eg. IDU) and for those born outside of the U.S., the year of immigration </li></ul></ul></ul>Prospective Cohort Study: Methods
    34. 34. Methods: Assessment of Knowledge <ul><li>Natural History </li></ul><ul><ul><li>“ If someone is infected with hepatitis C virus, they will most likely carry the virus all their lives.” </li></ul></ul><ul><ul><li>“ Infection with the hepatitis C virus can cause the liver to stop working.” </li></ul></ul><ul><ul><li>“ Someone with hepatitis C can look and feel fine.” </li></ul></ul><ul><li>Availability of vaccine </li></ul><ul><li>Appropriateness of alcohol consumption in the presence of liver disease. </li></ul>
    35. 35. Methods: Assessment of Knowledge <ul><li>Transmission of HCV </li></ul><ul><ul><li>“ You can get hepatitis C by: </li></ul></ul><ul><ul><ul><li>shaking hands with someone who has hepatitis C.” </li></ul></ul></ul><ul><ul><ul><li>kissing someone who has hepatitis C.” </li></ul></ul></ul><ul><ul><ul><li>being born to a woman who had hepatitis C when she gave birth.” </li></ul></ul></ul><ul><ul><ul><li>being stuck with a needle or sharp instrument that has hepatitis C infected blood on it.” </li></ul></ul></ul><ul><ul><ul><li>by working with someone who has hepatitis C.” </li></ul></ul></ul><ul><ul><ul><li>by injecting illegal drugs, even if only a few times.” </li></ul></ul></ul>
    36. 36. Study Population Attributes of All Patients Comparisons made by multiple chi-squares: ┼ Significantly different from Hispanics (p<0.05); ♦ Significantly different from white (p<0.05); ╪ Significantly different from both Hispanics and whites(p<0.05) 3.8% ♦ 5.2% ♦ 8.9% 60 years or older 40.8% ♦ 17.3% ╪ 3.1% < High School Grad 23.9% ♦ 41.5% ╪ 11.1% HS Grad 41.7% 40.2% 46.3% Male Age 42.8% 34.4% ╪ 42.3% 18 to 29 years 25.9% 24.0% 22.3% 30 to 39 years old 17.4% 22.0% ♦ 14.9% 40 to 49 years old 10.1% 14.4% 12.5% 50 to 59 years old 11.0% ♦ 5.0% ╪ 36.0% > College Grad 7.5% ♦ 9.2% ♦ 30.2% College Grad 16.8% 27.1% ╪ 20.6% Some College Education Hispanic (N=507) Black (N=460) White (N=694)
    37. 37. Study Population Attributes of All Patients Comparisons made by multiple chi-squares: ┼ Significantly different from Hispanics (p<0.05); ♦ Significantly different from white (p<0.05); ╪ Significantly different from both Hispanics and whites (p<0.05) 41% ♦ 77% ╪ 96% Insured 1% ♦ 3% ♦ 23% >$100,000 3% ♦ 8% ╪ 28% $50,000-$99,000 8% ♦ 23% ┼ 20% $30,000-$49,000 17% ♦ 27% ♦ 12% $15,000-$29,000 70% ♦ 39% ╪ 17% <$15,000 Annual Household Income Hispanic (N=507) Black (N=460) White (N=694)
    38. 38. Risk factor status by race/ethnicity, conventional and controversial risk factors (n=1657) ╪ Significantly different from both white and black groups (p<0.05) ┬ Significantly different from white (p<0.05) 30% ╪ 47% ┬ 36% Risk Factor Present Hispanic (n=507) Black (n=459) White (n= 691)
    39. 39. Prevalence of Conventional Risk Factors (N=89) *Some patients had more than one risk factor. N* Specific Risk Factor 31 History of IDU 27 Needlestick Accident 2 Long-term Kidney Dialysis 0 Organ Transplant before 1992 35 Blood Transfusion before 1992
    40. 40. Provider Management of Patients with Conventional HCV Risk Factors (n=89) ♦ Significantly different from white (p<0.05) Test performed Test recommended (or ordered) Testing discussed with patient 5 (29.4) 11 (45.8) ♦ 9 (20) 25 (28.1) 5 (29.4) 10 (41.7) ♦ 3 (6.7) 18 (20.2) 5 (29.4) ♦ 10 (41.7) ♦ 2 (4.4) 17 (19.1) Black (N=17) # (%) Hispanic (N=24) # (%) White (N=45) # (%) Overall (N=89) # (%)
    41. 41. Risk Factor Status for All Hispanic Subgroups by Birth Country *Two non-US born Hispanics did not identify country of origin and 2 were born in Spain and Germany respectively 36 691 Whites 47 459 Blacks 30 507 Hispanic Americans 15 59 South America 17 46 Central America (excludes Mexico) 14 85 Dominican Republic 25 4 Cuba 9 54 Mexico 15 248* Non-US Born 45 255 US-Born (US & Puerto Rico) Percent with risk factor N Birth Country
    42. 42. Specific Rates of Risk Factors US Born vs. Non-US Born Hispanics * 68% of total number of Hispanic individuals with a self-reported risk factor, 32% of participants were lost to follow-up for phone interview ┼ p<.05 57.7% 73.1% Tattoos 3.9% 5.1% Significant other HCV+ 19.2% 28.2% Prison for >24hrs 0% 1.3% Kidney Dialysis 7.7% 2.6% HCW needlestick 0% 14.1% ┼ IDU Non-US born (n=26)* US born (n=78)*
    43. 43. Racial/Ethnic Differences in Risk Factor Status: Results <ul><li>Among Hispanic immigrants, year of immigration was associated with risk factor status </li></ul><ul><ul><li>With each year spent in the US, the odds of having a risk factor increased by approximately 7%, after controlling for age and sex. </li></ul></ul><ul><ul><li>(OR=1.07085 95% CI [1.014, 1.13]) (p=0.014) </li></ul></ul>
    44. 44. Racial/ethnic differences in knowledge Percent incorrect, overall mean score (n= 1657) ┼ Significantly different from US-born Hispanics (p<0.05) ♦ Significantly different from white (p<0.05) ╪ Significantly different from both Hispanics & whites Hispanic (n=507) Black (n=459) White (n=691) 60% ┼ 48% 53% ♦ 42% ╪ 29% Non-US born US born Overall
    45. 45. HCV Knowledge and Years Living in the US Among Hispanic Immigrants (N= 185*) *Of the 248 foreign born Hispanics, 63 were lost to follow-up and thus did not report year of immigration
    46. 46. HCV Knowledge and Years Living in the US Among Hispanic Immigrants <ul><li>After adjusting for age, education and sex Hispanic individuals who immigrated to the US > 5 yrs ago were less likely to have misconceptions regarding HCV than individuals who had been living in the US for 5 years or less </li></ul><ul><li>(OR 0.85 95% CI [0.73, 0.97]) </li></ul>
    47. 47. Conclusions <ul><li>Even with prompting that a risk factor exists and given the appropriate education, providers rarely test patients for HCV when indicated. </li></ul><ul><li>Race may impact testing for HCV in the presence of a known conventional risk factor: </li></ul><ul><ul><li>Blacks and Hispanics are more likely than whites to have testing discussed. </li></ul></ul><ul><ul><li>Hispanics are most likely to have testing ordered and performed. </li></ul></ul><ul><ul><li>Blacks are least likely to have testing performed. </li></ul></ul>
    48. 48. Conclusions <ul><li>Hispanics who are born in mainland United States or Puerto Rico have a higher prevalence of HCV risk factors than individuals born in other Hispanic countries. </li></ul><ul><li>Among Hispanics born outside of the U.S., the odds of having a risk factor increases with each year spent in the US. </li></ul>
    49. 49. Conclusions <ul><li>Blacks and Hispanics have greater knowledge deficits regarding HCV than whites. </li></ul><ul><li>Non-U.S. born Hispanics have greater knowledge deficits than US born Hispanics, with deficits greatest among recent immigrants. </li></ul>
    50. 50. Limitations: Prospective Study <ul><li>The inability to determine the significance of the site effect seen in our data. </li></ul><ul><ul><li>Rates of testing by race were stratified by site: </li></ul></ul><ul><ul><ul><li>Blacks were consistently tested less frequently in the presence of a risk factor than whites </li></ul></ul></ul><ul><ul><ul><li>Hispanics were tested more frequently than both whites and blacks. </li></ul></ul></ul>
    51. 51. Viral Hepatitis in Minority Populations Simona Rossi, MD Assistant Professor of Medicine Thomas Jefferson University Hospital October 26, 2006
    52. 52. 1.6% US population HCV Ab + 79.7% viremic (3.2 million Americans) Expected impact of HCV in the United States in upcoming decade 1. 61% increase in cirrhosis 2. 279% increase in OLT requirement 3. 166,000 deaths 4. 27,200 HCC related liver deaths Armstrong et al, Annals 2006 Davis et al. Hepatology 1998 Wong et al. Am J Pub Health 2000
    53. 53. HCV Prevalence by Demographics <ul><li>GENDER % </li></ul><ul><ul><li>Male……………………………2.1 (1.8-2.5) </li></ul></ul><ul><ul><li>Female………………………...1.1 (0.8-1.7)* </li></ul></ul><ul><li>AGE AT FIRST SEXUAL INTERCOURSE </li></ul><ul><ul><li>16-17………………………..2.3 (1.4-3.7) </li></ul></ul><ul><ul><li>12-15…………………….....4.5 (3.5-5.8)** </li></ul></ul><ul><ul><li><11………………………….10.1(5.8-17)* </li></ul></ul><ul><li>LIFETIME SEXUAL PARTNERS (Age 20-59) </li></ul><ul><ul><li>0-1……………………………0.5 (0.2-1.4) </li></ul></ul><ul><ul><li>10-19…………………………2.6 (1.5-4.6)* </li></ul></ul><ul><ul><li>>50…………………………..12.0 (8.5-16.7)** </li></ul></ul>*p<0.05 **p<0.005 Adapted from Armstrong et al, Annals 2006
    54. 54. HCV Prevalence by Demographics <ul><li>LIFETIME DRUG USE % </li></ul><ul><ul><li>None or only marijuana……………0.7 (0.4-1.1) </li></ul></ul><ul><ul><li>Other drug use……………………..3.5 (2.4-4.9)** </li></ul></ul><ul><ul><li>IVDA…………………………………57.5 (44.1-69.9)** </li></ul></ul><ul><li>POVERTY INDEX </li></ul><ul><ul><li>Below poverty……………………….3.2 (2.5-4.1)** </li></ul></ul><ul><ul><li>Greater than 2x poverty……...........1.0 (0.7-1.4) </li></ul></ul><ul><li>EDUCATION </li></ul><ul><ul><li><12 years………………………….….2.8 (2.3-3.6)** </li></ul></ul><ul><ul><li>>12 years……………………………..1.3 (0.9-1.8) </li></ul></ul>*p<0.05 **p<0.005 Adapted from Armstrong et al, Annals 2006
    55. 55. Prevalence (%) of HCV+ by Race/Ethnicity in the US Armstrong et al, Annals 2006 * * Mexican-Americans only
    56. 56. Prevalence of Chronic Infection by Race/Ethnicity Armstrong et al, Annals 2006
    57. 57. Prevalence (%) of HCV+ by Race/Ethnicity, Age & Sex Armstrong et al, Annals 2006
    58. 58. Prevalence (%) of HCV+ by Race/Ethnicity, Age & Sex Armstrong et al, Annals 2006
    59. 59. Biochemical Profiles by Race/Ethnicity <ul><li>Compared to Whites, Blacks, and Asians Hispanics have: </li></ul><ul><ul><li>Higher ALT (p<0.001) </li></ul></ul><ul><ul><li>Higher Bilirubin (p<0.001) </li></ul></ul><ul><ul><li>Lower Albumin (p<0.01) </li></ul></ul>Celona et al. Clin Gastro and Hep 2004
    60. 60. Progression of Fibrosis by Race/Ethnicity <ul><li>Los Angeles County U of Southern California Clinic </li></ul><ul><li>256 patients (52%) liver biopsy </li></ul><ul><li>Rate assessed in 103 </li></ul><ul><ul><li>Black: 0.077 fibrosis stage/year </li></ul></ul><ul><ul><li>White: 0.084 fibrosis stage/year </li></ul></ul><ul><ul><li>Hispanic: 0.215 fibrosis stage/year </li></ul></ul>Bonacini et al. AM J Gastro 2001
    61. 61. Progression of Fibrosis by Race % cirrhosis *Non-AA included 188 Whites, 47 Hispanics, 8 Asians Wiley et al. Am J Gasro. 2003
    62. 62. El-Serag, H. B. et. al. Ann Intern Med 2003;139:817-823 Age-adjusted Incidence Rates for Hepatocellular Carcinoma by Race Other: Predominately Asian
    63. 63. Liver Transplant Survival by Race/Ethnicity Rawls et al. J Clin Gastro, 2005
    64. 64. Treatment in Minorities <ul><li>Minority populations are under-represented in clinical trials </li></ul><ul><li>Historically Blacks do worse than Whites </li></ul><ul><li>Even less is known for Hispanic populations </li></ul><ul><li>Not all explained by greater prevalence of genotype 1 in Blacks </li></ul>
    65. 65. Historic Response by Race/Ethnicity * + *p=0.04 compared to white +p=0.07 compared to white Consensus interferon 3ug/9ug or SIFN 3 million U TIW Reddy et al. Hepatology 1999
    66. 66. Virologic Response by Genotype 1 Reddy et al. Hepatology 1999 * *p=0.038
    67. 67. Response by Race/Ethnicity in Genotype 1 Statistically significant only for AA versus white/Hispanic Gaglio et al. Liver,Panc, Biliary Tract 2004 Induction CIFN and variable dose CIFN
    68. 68. Racial Differences to Standard Therapy Multi-center trial………….180ug/wk Peg IFN-2a and wt based ribavirin Black= 196 White= 205 % HCV RNA- Adapted from Conjeevaram et al. Gastro 2006 ALL GENOTYPE 1
    69. 69. Racial Differences to Standard Therapy Multi-center trial………..1.5microgrm pegIFN -2b Black=100 + White=100 1000mg ribavirin 0-12 wks 800mg ribavirin 13-48wks Muir et al. NEJM 2004
    70. 70. Workshop Conclusions <ul><li>Hepatitis C is under-diagnosed in primary care practices, irrespective of patient race </li></ul><ul><li>Management of hepatitis C differs according to race; minorities are less likely to be referred for subspecialty care </li></ul><ul><li>African Americans respond less well to treatment for hepatitis C </li></ul>
    71. 71. Future Directions <ul><li>Strategies to improve the identification of patients at risk for hepatitis C, and appropriate testing, are needed. </li></ul><ul><li>Such strategies will entail addressing barriers identified in our research; </li></ul><ul><ul><li>The lack of primary care provider risk factor ascertainment </li></ul></ul><ul><ul><li>Patient knowledge deficits </li></ul></ul>
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