Reminiscing About the Coming Plague

I recently attended a meeting at the Maricopa County Department of Public Health – ostensibly to review health status data and offer my opinion about the most pressing health issues confronting Maricopa County residents. However, within the course of discussion, I was surprised to learn that dengue fever and malaria are moving northward through Mexico, and both diseases will eventually be taking a toll on Arizona residents. The mere mention of these diseases brought back fond memories and youthful dreams.

As a callow graduate student in public health at UCLA, I had yearned for a career overseas investigating vector-borne diseases like dengue fever and malaria. My professors peppered their epidemiology lectures with stories of their own exploits in exotic foreign lands (one professor, Dr. Telford Work, helped discover West Nile Virus back in the late 1950s), and I imagined myself following in their footsteps.

Indeed, while working in the CDC STD Program, I had the opportunity to interview for a dengue fever epidemiology position in Puerto Rico. I was just certain that this position would jumpstart my brilliant career in global health, and that I would spend a good bit of the rest of my life finding adventure in foreign lands. Unfortunately, I was not selected for the position. I therefore find it ironic that while I never did make it overseas, exotic infectious diseases like dengue fever and malaria are – after all these years – making their way to me.

However, from my perch at APCA, I don’t anticipate playing any role in the fight against either dengue fever or malaria. So, sadly, it would seem that I never will achieve my dream of global health work. Well, not so fast.

The vast majority of people that our agency serves are in fact foreign born and bring to this country a health profile with diverse, global risks. Infectious diseases like tuberculosis and chronic hepatitis B infection are relatively common among new immigrants. So, too, are nutritional deficiencies such as rickets. Immigrants also bring to this country their indigenous conceptions of health. Our understanding of their disease risks, beliefs and behaviors is critical towards effectively working with them on health improvement strategies. As such, our work is partially ethnographic in nature, and we are in a sense cultural brokers of good health. To this end, we often find ourselves thinking globally and acting locally.

So, I’ve come to realize that my dream of global health work is being fulfilled right here in the Phoenix area, and I’m grateful every day for the opportunity to perform this work. And who knows, some day I might just dust off my barely used passport and spend a few weeks volunteering with an international health organization in some far off country. You never know, they might just learn a thing or two from an old global health hand like me.

-Doug Hirano, MPH, APCA Executive Director

Of Viruses and Cancer

I came across an interesting story in New York Times yesterday. The story, “Human Papillomavirus, 1985,” describes Dr. Peyton Rous’ conjecture and eventual demonstration that viruses can cause cancer. He demonstrated this fact through his work with solid tumors in chickens back in 1914.

Seventy years later, scientists would still be trying to prove that viruses cause cancer in humans. In 1983, Dr. Harald zur Hausen, definitively connected infection with the human papillomavirus (HPV) with cervical cancer. Indeed, he discovered and made HPV16 and 18, the two strains most commonly associated with cervical cancer, available to the scientific community for vaccine development. More than two decades later (2006), a vaccine for HPV infection was approved for use in girls and young women ages 9 to 26 years of age. Given that 5% of all cancers worldwide are caused by HPV, the development and widespread use of the vaccine will eventually save tens of thousands of lives every year.

While most of us have never heard of Drs. Rous and zur Hausen, we clearly owe them a debt of gratitude. I’m happy to say that both received the Nobel Prize for their work.

Particularly among Vietnamese American women, cervical cancer rates are disproportionately high. In fact, rates of cervical cancer are several-fold higher among Vietnamese women, when compared to all other racial/ethnic groups. Efforts to educate and vaccinate the Vietnamese and other Asian American and Pacific Islander communities are warranted.

Interestingly, the article did not mention the other virus that causes cancer in humans: the hepatitis B virus (HBV). HBV infection is conclusively linked with liver cancer. Given the disproportionately high rates of HBV infection among Asian Americans, it is not surprising that liver cancer rates are much higher for Asian Americans, when compared to non-Hispanic whites. The 1982 development of a vaccine to prevent hepatitis B infection by Dr. Baruch Blumberg is another milestone in the history of cancer prevention, but perhaps that is a story for another time.

- Doug Hirano, MPH, APCA Executive Director

World Hepatitis Day Proclamation

WORLD HEPATITIS DAY, 2011

BY THE PRESIDENT OF THE UNITED STATES OF AMERICA

A PROCLAMATION

Across our Nation, millions of Americans are living with viral hepatitis. As many as three-fourths of Americans living with the disease are unaware of their status and are not receiving care and treatment for their condition. Raising awareness about hepatitis is crucial to effectively fight stigmas, stem the tide of new infections, and ensure treatment reaches those who need it.

On World Hepatitis Day, we join with people across our country and around the globe in promoting strategies that will help save lives and prevent the spread of viral hepatitis.

Viral hepatitis is inflammation of the liver, and can cause a lifetime of health issues for people who contract it. Hepatitis B and C viruses are the cause of a growing number of new liver cancer cases and liver transplants. In the United States, hepatitis is a leading infectious cause of death, claiming the lives of thousands of Americans each year. While we have come far, work still needs to be done to prevent and treat this disease.

Viral hepatitis touches Americans of all backgrounds, but certain groups are at greater risk than others. Past recipients of donated blood, infants born to mothers infected with viral hepatitis, and persons with sexually transmitted diseases or behaviors such as injection-drug use have risks for viral hepatitis. Baby boomers and African Americans have higher rates than others of contracting hepatitis C. Half of all Americans living with hepatitis B today are of Asian American and Pacific Islander descent, and one-third of people living with HIV also have either hepatitis B or hepatitis C. Worldwide, one in twelve people is living with viral hepatitis.

We must make sure that this "silent epidemic" does not go unnoticed by health professionals or by communities across our country. Under the Affordable Care Act, services including hepatitis immunizations for adults and hepatitis screenings for pregnant women are fully covered by all new insurance plans. My Administration has also released a comprehensive Action Plan for the Prevention, Care and Treatment of Viral Hepatitis. The plan brings together expertise and tools across government to coordinate our fight against this deadly disease. Our goal is to reduce the number of new infections, increase status awareness among people with hepatitis, and eliminate the transmission of hepatitis B from mothers to their children.

The first step toward achieving these goals is raising public awareness of this life-threatening disease. We must work to reduce the stigma surrounding hepatitis, and to ensure that testing, information, counseling, and treatment are available to all who need it. The hard work and dedication of health-care professionals, researchers, and advocates will help bring us closer to this goal. On this day, we renew our support for those living with hepatitis, and for their families, friends, and communities who are working to create a brighter, healthier future.

NOW, THEREFORE, I, BARACK OBAMA, President of the United States of America, by virtue of the authority vested in me by the Constitution and the laws of the United States, do hereby proclaim July 28, 2011, as World Hepatitis Day. I encourage citizens, Government agencies, nonprofit organizations, and communities across the Nation to join in activities that will increase awareness about hepatitis and what we can do to prevent it.

IN WITNESS WHEREOF, I have hereunto set my hand this twenty-seventh day of July, in the year of our Lord two thousand eleven, and of the Independence of the United States of America the two hundred and thirty-sixth.

BARACK OBAMA

- Doug Hirano, MPH, APCA Executive Director

World Hepatitis Day

The World Health Organization has designated July 28th as World Hepatitis Day. However, we don’t have to look globally to find a crisis related to hepatitis B infection.

Data from the Arizona Department of Health Services indicate that Asian Americans have constituted 40% of all reported cases of chronic hepatitis B in Maricopa County over the past five years. Considering that Asian Americans constitute only 3% of the population, this is alarming.

Nationally, it is estimated that 1 in 12 Asian Americans is permanently infected with hepatitis B, a virus that attacks the liver. For all other Americans, the rate of chronic hepatitis B infection is just 1 in 1,000. Without medical monitoring and treatment, 25% of individuals with chronic hepatitis B infection will suffer and possibly die due to severe liver cirrhosis and/or liver cancer. The Centers for Disease Control and Prevention (CDC) estimates that 65% of all individuals infected with hepatitis B are unaware of their infection.

These data suggest that nationally there are more Asian Americans undiagnosed with hepatitis B than all Americans undiagnosed with HIV/AIDS. Compared to HIV/AIDS, very little attention is paid to the problem of chronic hepatitis B – particularly among Asian Americans. This is a shame given that a simple blood test can detect the infection and a vaccine exists to prevent infection. We need to continue to spread the word that all Asian Americans get tested and vaccinated for hepatitis B.

In recognition of World Hepatitis Day, we are hosting a free hepatitis B testing and education event at the Vietnamese Community Center, 2051 W. Warner Road, Suite 22, Chandler, from 9 am to 1 pm on Saturday, July 30th. Information will also be provided to help individuals without health insurance coverage to enroll in publicly funded health insurance programs or otherwise find affordable medical care. Further information is available from the Asian Pacific Community in Action at (602) 265-4598 or www.apcaaz.org.

A warm reception from our President

With approximately 200 Asian American and Pacific Islander colleagues, I had the pleasure of visiting the White House today in acknowledgment of Asian American and Pacific Islander Heritage. Here’s what my “thank you” note to the President will read:

"Thank you, Mr. President, for the opportunity to visit your stately home. Your hospitality in the form of your kind words and the hors d’oeuvres and beverages was most generous – particularly since you already had a lot on your plate, including an imminent national TV appearance about the war in Afghanistan.

While I didn’t get a chance to speak to you directly, I did have the chance to speak to one of your key health officials, Dr. Howard Koh – your Assistant Secretary for Health and Human Services (pictured). He was kind enough to say that he would look into my suggestion that the federal government support a hepatitis B testing day for Asian Americans. Considering that there is already an HIV/AIDS awareness day for Asian Americans, it would seem reasonable that attention be paid to the preponderance of chronic hepatitis B infection among this group as well.

I will be following up with Dr. Koh about this matter. I believe hepatitis B among Asian Americans needs to stay on the radar screen until something more is done. There are far more Asian Americans unknowingly infected with chronic hepatitis B than all Americans unknowingly infected with HIV/AIDS. We on the front lines in various communities throughout the nation fight the good fight to increase hepatitis B awareness among the general public, among Asian Americans and Pacific Islanders, and the medical community, but sometimes one is not a prophet in his or her own land. Hearing more from our federal officials about this preventable epidemic of liver disease due to hepatitis B is critical and essential. Action can prevent more death and disability due to hepatitis B.

Again, thank you for your cordiality, and I hope that you and your family stay well. Please feel free to come visit us in Arizona, and we would be happy to share some of our Asian American and Pacific Islander hospitality in return."

- Doug Hirano, MPH, APCA Executive Director

Hello Mr. President . . .

I very recently received an invitation to a White House reception that will be recognizing Asian American and Pacific Islander heritage. It appears that President Obama and the First Lady will both be in attendance. Invitations were made to Asian American and Pacific Islander community leaders, and I’m proud to be considered in that grouping.

Will I be attending? Who could turn down an invitation that starts with “The President and Mrs. Obama request the pleasure of your company . . . ”?

In any case, if I have a chance to speak at any length with President Obama, I think I will remind him that five million Americans are currently infected with hepatitis B or hepatitis C, and that these individuals will need medical monitoring for the remainder of their lives because of their high risk for serious liver disease. I will let him know that many of these individuals are among the working poor or unemployed who do not have health insurance and cannot afford medical care. I will remind him that exemplary government programs like the Ryan White CARE Act support medical care and treatment for low-income individuals with HIV/AIDS, but no such program exists for individuals with hepatitis B or C. I will remind him that more than half of the 1.4 million individuals chronically infected with hepatitis B are Asian Americans and yet there is virtually no large-scale public health effort to encourage Asian Americans to get screened for hepatitis B or to educate physicians to offer screening to these individuals.

I think I will remind him that Title VI of the Civil Rights Act assures individuals of language access in health care facilities that receive federal dollars, yet thousands of individuals are denied these services on a daily basis in facilities throughout the nation. I will remind him that Asian Americans and Pacific Islanders are the fastest growing racial/ethnic groups in this country and that while health care facilities are doing better in offering culturally competent services to Hispanic Americans, Asian Americans and Pacific Islanders are a virtual afterthought when it comes to culturally competent care.

Lastly, I think I will thank him profusely (and offer a fist bump) for his leadership and vision on the Affordable Care Act and let him know that our agency is actively supporting its continuation. Having said that, I will let him know that the same political will exerted on the ACA will be more than sufficient to address the continuing health disparities related to hepatitis and language access. I will humbly offer my assistance, proffer my business card, and then wander off in search of hors d’oeuvres.

- Doug Hirano, MPH, APCA Executive Director

National Black HIV/AIDS Awareness Day – A Model for the Asian American Community?

February 7th was the 11th anniversary of National Black HIV/AIDS Awareness Day. HIV/AIDS has had a disproportionate impact on the Black community in this country.

Here’s quote from the CDC website:

“By race/ethnicity, African Americans face the most severe burden of HIV in the United States. At the end of 2007, blacks accounted for almost half (46%) of people living with a diagnosis of HIV infection in the 37 states and 5 US-dependent areas with long-term, confidential, name-based HIV reporting.”

State, local and national organizations have created and implemented activities focused on motivating African Americans to get tested and learn their HIV status, as well as educating communities about the importance of prevention. No doubt these efforts have saved lives.

It would seem high time that the Asian American communities across the nation organize a similar day related to hepatitis B. Asian Americans constitute more than 50% of all individuals chronically infected with hepatitis B, yet there is little national attention to this problem. I have contacted a colleague of mine with the CDC Viral Hepatitis Division about the possibility of replicating a national HBV recognition day in the Asian American community. I will keep you posted as to his response. However, it should be said that regardless of the CDC interest in this initiative, Asian American communities throughout the country should organize and act.

- Doug Hirano, MPH, APCA Executive Director

CDC Releases New Health Disparities Report: What’s Missing?

The Centers for Disease Control and Prevention has issued a landmark report on health disparities – the first produced by the CDC that covers a variety of health problems. Areas addressed include environmental health, health care access, infant deaths, motor vehicle deaths, suicides, HIV infection, obesity and diabetes, among other areas. It’s required reading for those of us working to end health disparities and is a nice companion piece to the recently released Healthy People 2020 document.

Having said that, there will probably be discussion about the health areas that were not included in this health disparities report. Here’s how the CDC folks explained what was and what wasn’t included in the report:

Topics included in CHDIR 2011 were selected on the basis of one or more of the following criteria: 1) leading causes of premature death among segments of the U.S. population as defined by sex, racial/ethnicity, income or education, geography, and disability status; 2) social, demographic, and other disparities in health outcomes; 3) health outcomes for which effective and feasible interventions exist; and 4) availability of high-quality national-level data.

It can be argued that areas such as breast cancer qualify to be addressed on the basis of the aforementioned criteria. Breast cancer is clearly a major cause of premature death; demographic disparities exist (African American women have disproportionately high mortality rates), effective interventions (early screening and detection) exist, and high-quality national-level data (vital statistics) are available. Why wasn’t breast cancer addressed in this report?

For those of us focused on issues that face Asian Americans and Pacific Islanders, there is the question as to why hepatitis B was not addressed in this report. Hepatitis B among AAPIs also meets at least three (and arguably four) of the four aforementioned criteria. In a prior blog entry, I had commented on the lack of attention to hepatitis B in the Healthy People 2020 document. There would seem to be a pattern here.

Clearly, more work remains for those of us advocating for more attention to the silent epidemic of hepatitis B – particularly among AAPIs. In a future entry, I will discuss a short term opportunity to provide important input to the federal government on this topic.

-Doug Hirano, MPH, APCA Executive Director

Battling for Attention

The National Viral Hepatitis Roundtable (NVHR) recently issued a press release decrying the fact that controlling hepatitis B and C is not among the “six winnable battles” identified by the Centers for Disease Control and Prevention (CDC).

Here are some excerpts from the release:

"The CDC's newly released 'six winnable battles' strategy makes a mockery of the broad-based, comprehensive, and integrated public-health strategy that our nation so desperately needs. In seeking to win six narrowly defined health care battles, the CDC may well lose the overall public-health war.

"The CDC's omission of viral hepatitis from its list of 'winnable battles' is not simply an oversight - it's an abdication of duty to many Americans who may well lose their battle with chronic viral hepatitis in the decades to come."

In a prior blog entry, I had commended the CDC for having the wisdom (and nerve) to identify just a few key health areas for strategic focus.

However, I fully expect that other passionate and well-intentioned public health agencies and advocates will join the NVHR in questioning the completeness of CDC’s winnable battle list. And, I think, most will have a good argument. There are many, many other areas of extreme public health urgency (e.g., diabetes, substance abuse, Novel H1N1 flu, and domestic violence, to name a few). However, it should be pointed out that the six winnable battle areas (HIV, motor vehicle injuries, obesity/nutrition/physical activity/food safety, healthcare associated infections, teen pregnancy and tobacco) cover a lot of ground in terms of health impact, and there is crosscutting value in effectively working on these health concerns (e.g., efforts to control HIV also benefits efforts to control the spread of other sexually-transmitted diseases, including hepatitis B and C).

Most importantly, though, the CDC is the leading public health institution in the world, and as a citizen and a public health professional, I expect the agency to exert leadership. The identification of “winnable battles” is a bold and controversial step. It provides strategic perspective to those of us battling in the trenches, but shouldn’t be perceived as a mandate.

As I stated in my prior blog entry, for those of us working on improving health among Asian Americans and Pacific Islanders, controlling hepatitis B is our “winnable battle”. In that regard, I will continue to support the efforts of the NVHR (APCA is a member) to put hepatitis B and C on the national radar screen and to advocate for additional resources.

-Doug Hirano, MPH, APCA Executive Director

An Epidemic Silence

The silence is deafening. Every day, 6,000 Asian Americans and Pacific Islanders residing in Maricopa County live another day with a disease they don’t even know they carry. It’s a disease that may have already taken the lives of family and friends. It’s a disease that is so widespread in their native countries that it’s present in big cities, the rural countryside, the mountains, the plains, inland, and on the coasts. In many areas, it’s been passed along for generations. Mostly, it’s a disease that no one is talking about. The silence is deadly.

Hepatitis B is a virus that attacks the liver and causes liver cancer and cirrhosis. For those with “chronic” infection, the virus is carried for life. In the United States, it is a disproportionately significant source of death and disability among Asian Americans and Pacific Islanders. More than 50% of the 1.25 million individuals with chronic hepatitis B in the United States are Asian Americans and Pacific Islanders. Tragically, less than half are aware that they are infected, even though a simple blood test can detect the presence of the virus.

Here are some simple, but possibly life-saving facts about hepatitis B:

• Among foreign-born Asian Americans and Pacific Islanders, many are infected as infants during childbirth or as young children through household exposure;

• One can carry the virus for decades without any symptoms – and still develop serious liver disease later in life;

• There is a vaccine that can prevent those who have not yet been exposed to the virus from becoming infected;

• Only a blood test can definitively diagnose hepatitis B;

• There is no cure for hepatitis B, but there are several FDA-approved treatments that can slow down the replication of the virus in the liver.

Every Asian American or Pacific Islander should get tested for hepatitis B. The only exceptions would be those who have already been tested and American born children less than 18 years of age. Ask your doctor for a hepatitis B test and vaccination.

Protect your family. Protect your community. Spread the word about hepatitis B. Break the silence!

-Doug Hirano, MPH, APCA Executive Director

No time for HIV/AIDS complacency

I have only had a chance to glance through the new National HIV/AIDS Strategy, but I can tell you it could not have come any sooner. Interest in HIV/AIDS, which has become a largely treatable disease, has waned in this country over the last decade. With 56,000 new infections annually, and 1.1 million individuals currently infected, now is not the time for declaring victory on this front.

The document was created with broad input and addresses four main areas for concerted action: reducing new infections, increasing access to care and improving health outcomes for people living with HIV, reducing HIV-related health disparities and health inequities, and achieving a more coordinated national response to the HIV epidemic.

For me, I like the vision for the plan: “The United States will become a place where new HIV infections are rare, and when they do occur, every person, regardless of age, gender, race/ethnicity, sexual orientation, gender identity, or socio-economic circumstance will have unfettered access to high-quality, life-extending care, free from stigma and discrimination."

I look forward to the day that a similar national plan is developed for the hepatitis epidemic in this country. But for now, we need to remain vigilant on multiple health fronts. HIV/AIDS is an infection with a profound impact on this country and the world. Effective action is absolutely critical.

- Doug Hirano, MPH, APCA Executive Director

Rapid Hepatitis C Testing Now Available

The Food and Drug Administration (FDA) has just approved a rapid test to detect hepatitis C infection. This test, called OraQuick HCV Rapid Antibody Test, utilizes whole blood from a venous blood draw to generate a test result within 20 minutes. It does not require an instrument for diagnosis.

Orasure Technologies, the manufacturer of the test, hopes to receive FDA approval of the test version that utilizes oral fluid or whole blood from a fingerstick. This will make the test more palatable for individuals put off by a venous blood draw. The test is already approved in Europe for use with oral fluid and whole blood from a fingerstick.

In any case, this is a marked step forward in the fight to identify the many individuals who are unknowingly infected with hepatitis C. According to the Centers for Disease Control and Prevention, there are approximately 3.2 million people in the United States chronically infected with HCV and each year, about 17,000 people are newly infected. It is speculated that the majority of the 3.2 million individuals are unaware of their infection status. Earlier detection can lead to better treatment outcomes. Hepatitis C is a major cause of liver disease, leading to 12,000 deaths annually in the United States.

With more than 350 million people chronically infected with hepatitis B, it is hoped that progress can be made in developing rapid testing for hepatitis B as well. In the United States, an estimated 1.25 million individuals are infected with hepatitis B. The majority of these individuals are Asian Americans and Pacific Islanders and, as with hepatitis C, most individuals are unaware of their infection status.

-Doug Hirano, MPH, APCA Executive Director