The Bay Area has one of the largest Asian and Asian Pacific Islander (API) populations in the entire country; together the two groups make up almost 19 percent of Oakland’s population. This group is uniquely at risk for hepatitis B, a disease that is sometimes known as the “silent killer,” as an infected person can remain asymptomatic for long periods of time, leaving many unknowingly infected. Nationwide, nearly 1 in 12 people of Asian and API descent are infected. But here in Oakland, healthcare workers are drawing more attention to getting residents screened for the disease and vaccinated against it, specifically among the low-income and uninsured.
Hepatitis B, which is caused by the hepatitis B virus (HBV), is transmitted through blood and during childbirth. It ultimately leads to cirrhosis or liver cancer, and nearly 600,000 people worldwide die each year from the disease. In the United States, liver cancer resulting from chronic hep B is the second cause of cancer death among Asian men.
“When someone is chronically infected, they don’t have any symptoms until it’s done damage to their liver,” said Tracey Liu, director of the Hep B Project—which offers free screenings and vaccinations throughout Alameda County. The group has provided more than 1,200 free screenings and 400 vaccinations since UC Berkeley student Kevin Hur founded it in 2009.
Hep B can be acute or chronic, according the Institute of Medicine of the National Academies. If acute, illness occurs within six months of exposure to the virus. If the virus remains active for more than six months, it becomes chronic, or lifelong. When symptoms finally emerge, they produce jaundice, abdominal pain or swelling as the liver becomes increasingly damaged.
Hep B can be transmitted through unprotected sex or by blood contact through sharing needles, razors or toothbrushes, as well as through transfusions or open wounds. But within the Asian and API community, it’s primarily passed from mother to child during delivery. In Asia, about 40 percent of chronic hep B infections occur at birth, said Chrissy Cheung, perinatal research coordinator of the Asian Liver Center at the Stanford School of Medicine. “Generation to generation have been passing down the disease from mother to child,” Cheung said.
There is no cure for hep B, although anti-viral medications can keep the virus from replicating, slowing down liver damage. But there is a vaccine. In the United States, babies are vaccinated at birth, again at age 1 to 2 months, and finally at six months old, states the Hep B Moms website, run by a non-profit based in Palo Alto that tries to educate and prevent perinatal hep B transmission.
Because of the large Asian and API community in Oakland, several organizations here are also working to provide vaccinations to older children and adults. The Hep B Project provides two free weekly clinics in Oakland; one on Wednesdays at the Street Level Health Project on International Boulevard and another every Saturday at Asian Health Services on Webster Street in Chinatown. Patients at the clinic can get a free blood test at each screening. If they test negative, staffers start them on a round of vaccinations; if they test positive for the disease, they’re directed to Asian Health Services or other providers that can assist them with long-term care. Staffers also call each patient to help them to better understand their prognosis and give them information about treatment.
Most of the Hep B Project’s workforce is made up of student volunteers from UC Berkeley, many of whom are pursuing degrees in public health, public policy, medicine or pharmacology, said Kathy Ahoy, a public health nurse with the Alameda County Department of Public Health, and co-founder of the Street Level Health Project. “The beauty of the project is that the students have realized that these are all intertwined,” Ahoy said.
The project relies on the help of its bilingual volunteers; among the staff, they can speak to patients in about nine different languages, including Mongolian, Thai, Mandarin and Korean. Most patients are older, ranging between 40 and 60 years old, and are low-income immigrants who speak English as a second language. “I had to call one patient and tell him that he was positive and then I had to call another patient—his wife—and tell them that they were both positive,” said Jason Cham, 21, clinic coordinator for the project and a student at Cal. “I ended up meeting up with them and talking about their background. Neither of them had seen a doctor for 25 years.”
The Alameda Department of Public Health also operates a Perinatal Hepatitis B Prevention Program. Under state law, healthcare providers are required to report any positive hep B tests among pregnant women to the public health department. The women are monitored by their doctors and the health department throughout their pregnancy to decrease the risk of transmission during birth. About 80-90 percent of the patients coming into the perinatal hep B program are Asian American or Pacific Islander, said Deanna Karraa, perinatal hepatitis B coordinator for the department.
The Centers for Disease Control and Prevention recommend that all infants be vaccinated at birth against hep B. The organization also recommends the vaccine for anyone who is sexually active, is infected with HIV or chronic liver disease, who travels to regions with high rates of infection, or whose job might expose them to bodily fluids. Vaccinations are also mandatory for enrollment throughout the Oakland Unified School District system.
The vaccine—which is 95 percent effective at preventing infection—is administered three times; after the first shot, a second one is given one month later, and the third five months after that. Public health clinics typically offer the shot free of charge to infants and young children, and insurance companies also often cover charges for children as well, states the Hepatitis B Foundation’s website. But for someone without insurance who has to pay out of pocket, each shot can cost nearly $100 dollars, Liu said.
In some countries, Karraa said—like China—stigmas against the disease, possibly related to its sexual transmission, keep people from getting screened, vaccinated and treated. In these countries, she said, people infected with chronic hep B can be ostracized or lose their jobs.
In Oakland, healthcare providers also have to be sensitive to cultural norms, say staffers of the Hep B Project, by understanding why Asian and American Pacific Islander populations are more susceptible to the virus and by making referrals to subsequent specialists and healthcare providers who are sensitive to its stigmas and are prepared to work around language barriers.
“Many of the population that we’re currently targeting are immigrants, which is a barrier to health care, especially in America,” Liu said. “I think what’s lacking here in Alameda County is an organization that is also willing to talk the cultural barrier side of the issue.”
But perceptions about hep B within the Asian community are also changing, Ahoy said, because although the Hep B Project doesn’t have the funding for advertisements, word of mouth is bringing in more and more patients. “One is telling the other,” Ahoy said. “They come in and they aren’t shy in saying that they want a test. People’s attitudes have changed and that’s made a difference. It’s about heart and mind if you want to change this community.”