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Joining East and West: Coordinating HBV Management Between Western and Traditional Asian Medicine Practices This program is supported by an educational.

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1 Joining East and West: Coordinating HBV Management Between Western and Traditional Asian Medicine Practices This program is supported by an educational grant from

2 clinicaloptions.com/hepatitis Joining East and West About These Slides  Users are encouraged to use these slides in their own noncommercial presentations, but we ask that content and attribution not be changed. Users are asked to honor this intent  These slides may not be published or posted online without permission from Clinical Care Options ( Disclaimer The materials published on the Clinical Care Options Web site reflect the views of the authors of the CCO material, not those of Clinical Care Options, LLC, the CME providers, or the companies providing educational grants. The materials may discuss uses and dosages for therapeutic products that have not been approved by the United States Food and Drug Administration. A qualified healthcare professional should be consulted before using any therapeutic product discussed. Readers should verify all information and data before treating patients or using any therapies described in these materials.

3 clinicaloptions.com/hepatitis Joining East and West Faculty David D. Liu, PhD, LAc, OMD Dean, Professor, Academic Advisor Departments of Acupuncture and Internal Medicine Academy of Chinese Culture and Health Sciences Oakland, California Director, Supervisor Departments of Acupuncture and Internal Medicine Chinese Medicine Clinic and Education Center San Francisco, California Tram T. Tran, MD Associate Professor of Medicine Geffen UCLA School of Medicine Division of Gastroenterology Medical Director of Liver Transplant Comprehensive Transplant Center Cedars Sinai Medical Center Los Angeles, California

4 clinicaloptions.com/hepatitis Joining East and West Faculty Disclosures David D. Liu, PhD, LAc, OMD, has no significant financial relationships to disclose. Tram T. Tran, MD, has disclosed that she has received consulting fees from Bristol-Myers Squibb, Gilead Sciences, and Vertex and contracted research support from Bristol- Myers Squibb.

5 Tram T. Tran, MD HBV Epidemiology, Natural History, and Screening Recommendations

6 clinicaloptions.com/hepatitis Joining East and West IOM Report: Burden of HBV Disease  15% to 25% risk of early death caused by liver cancer or end-stage liver disease among patients with chronic HBV infection [1-3]  WHO global HBV estimates [3] –~ 2 billion people infected with HBV –~ 350 million people living with chronic HBV infection –~ 600,000 deaths annually caused by HBV-related liver disease or HCC 1. IOM. Hepatitis and liver cancer: a national strategy for prevention and control of Hepatitis B and C. Washington, DC: The National Academies Press; p Beasley R, et al. In: Hollinger FB, et al, eds. Proceedings of the 1990 international symposium on Viral Hepatitis and Liver Disease: Contemporary Issues and Future Prospects. Williams & Wilkins; WHO. Hepatitis B fact sheet N˚204.

7 clinicaloptions.com/hepatitis Joining East and West Estimated Prevalence of HBsAg-Positive Persons in the US by Population Segment  Prevalence reflects patterns of HBV infection in regions of origin  Potential for immigration from highly endemic countries to ↑ US HBV prevalence despite ↓ incidence of new infections –Age-adjusted prevalence of anti-HBc and HBsAg in the US statistically similar during vs [2] –~ 40,000 persons with chronic HBV infection immigrate to US each yr [3] 1. Cohen C, et al. J Viral Hepat. 2008;15: Wasley A, et al. J Infect Dis. 2010;202: Mast EE, et al. MMWR Recomm Rep. 2006;55(RR-16):1-33. *Non-Asian Americans includes blacks, whites, and other ethnicities. Population GroupHBsAg Prevalence, % US-born API [1] 1.40 Foreign-born API [1] 8.90 Non-Asian Americans* [1] 0.42

8 clinicaloptions.com/hepatitis Joining East and West Impact of Immigration on HBV Prevalence in the US HBsAg Prevalence [2] ≥ 8% (high) 2% to 7% (intermediate) < 2% (low) Immigration Numbers by Continent: [1] ~ 3.9 million Asians ~ 924,000 South Americans ~ 907,000 Africans ~ 1.2 million Europeans 1. US Department of Homeland Security. Yearbook of immigration statistics: Weinbaum CM, et al. MMWR Recomm Rep. 2008;57(RR-8):1-20.

9 clinicaloptions.com/hepatitis Joining East and West Growth and Diversity of US Asian Population  Asian American population: 4.8% of the US population (14.7 million) [1] –1990 census: 2.9% total US population [2] –2000 census: 3.6% total US population [1,2] –43% growth since 2000 [1] –Projection for 2050: > 40 million (9.7% total population) [3]  Extremely diverse –52 different countries [3] –100 languages and dialects [3] –Religious, cultural, societal differences –Immigrated in different eras 1. US Census Bureau. The Asian population: Issued March US Census Bureau. The Asian population: Issued February President’s Advisory Commission on Asian Americans and Pacific Islanders. Facts and data: critical issues facing Asian Americans and Pacific Islanders.

10 clinicaloptions.com/hepatitis Joining East and West API Americans and Chronic Hepatitis B  Among API Americans, HBV transmission occurs most often at birth or in early childhood [1,2] –Each yr, ~ 20,000 HBV-infected women give birth in the US [2] –More than one half of these mothers are APIs Americans 1. Asian Liver Center, Stanford School of Medicine Physician’s guide to hepatitis B: a silent killer. 2. Asian Liver Center, Stanford School of Medicine. FAQ about hepatitis B.

11 clinicaloptions.com/hepatitis Joining East and West Burden of HBV Among API Americans  API Americans represent 4.8% of overall US population, but constitute > 50% of Americans with chronic HBV infection [1-3] –1 in 10 APIs Americans has chronic hepatitis B vs 1 in 1000 in the US general population [3]  Birth in highly HBV endemic country a strong risk factor for chronic HBV infection among US API population [4]  HCC is a leading cause of cancer mortality among API men in California [3] –Ranks second in Vietnamese Americans and Cambodian Americans –Ranks fourth in Chinese Americans and Korean Americans 1. US Census Bureau. The Asian population: Issued March CDC. MMWR Morb Mortal Wkly Rep. 2009;58: Asian Liver Center, Stanford University School of Medicine. FAQ about hepatitis B. 4. Lin SY, et al. Hepatology. 2007;46:

12 clinicaloptions.com/hepatitis Joining East and West Relationship Between HBV DNA and HCC Development  REVEAL: long-term (mean follow-up: 11.4 yrs) cohort study to determine risk of cirrhosis and HCC among untreated HBsAg+ individuals in Taiwan Yrs of Follow-up Cumulative Incidence of HCC (%) N = 3653 Taiwanese patients Chen CJ, et al. JAMA. 2006;295: Baseline HBV DNA Level, copies/mL ≥ 1 million 100, ,999 10,000-99, < 300

13 Screening and Diagnosis of HBV

14 clinicaloptions.com/hepatitis Joining East and West Candidates for HBV Screening  Persons born in high and intermediate endemic areas (≥ 2% prevalence)  US-born children of immigrants from high endemic areas (≥ 8%; only if not vaccinated as infants in the US)  Household and sexual contacts of HBV carriers  Persons who have injected drugs  Persons with multiple sexual partners or history of STDs  Men who have sex with men  Inmates of correctional facilities  Individuals with chronically elevated ALT/AST  Individuals infected with HIV or HCV  Patients undergoing dialysis  Patients undergoing immunosuppressive therapy  All pregnant women  Infants born to HBV carrier mothers Weinbaum CM, et al. MMWR Recomm Rep. 2008;57(RR-8):1-20. AASLD practice guidelines: chronic hepatitis B. September 2009.

15 clinicaloptions.com/hepatitis Joining East and West AASLD Guidelines: Interpreting HBV Serology CDC. Hepatitis B information for health professionals: FAQs. January HBsAgAnti-HBsTotal Anti-HBcIgM Anti-HBc  Indicates that the person is infected  Indicates recovery and immunity from HBV infection  Develops in a person who has been successfully vaccinated against hepatitis B  Indicates previous or ongoing infection with HBV in an undefined time frame  Appears at the onset of symptoms in acute hepatitis B and persists for life  Indicates recent infection with HBV (≤ 6 mos)  This test is used to distinguish acute from chronic HBV infection

16 David D. Liu, PhD, LAc, OMD Overcoming Challenges to HBV Screening in the Traditional Chinese Medicine Setting

17 clinicaloptions.com/hepatitis Joining East and West Potential Barriers to HBV Screening  Lack of healthcare coverage –Makes screening process too expensive for many people  For those who may not be staying in the US legally, fear of being caught by authorities  No time to get screened due to busy work schedules –Typically true for immigrants and their families  HBV is silently transmitted and has a silent progression –Many people with chronic HBV infection exhibit no symptoms and feel perfectly healthy

18 clinicaloptions.com/hepatitis Joining East and West Potential Barriers to HBV Screening  Lack of education regarding the high rate of HBV in Asian populations –Leads to lack of urgency to get screened  For older populations, it may be more difficult for them to use modern technology to its fullest extent to learn more about HBV (eg, Web sites, videos, etc)  Language and communication difficulties

19 How Can Traditional Chinese Medicine Specialists Encourage HBV Screening?

20 clinicaloptions.com/hepatitis Joining East and West Case Vignette  The patient is a 35-yr-old Chinese male; he has 2 jobs  Visited Chinese Medicine clinic for chief complaint of sciatic pain  During discussion of history and initial exam, the practitioner finds other symptoms of fatigue, bitter mouth, and flank distention pain  How do you manage the patient?

21 clinicaloptions.com/hepatitis Joining East and West Case Vignette: Management  Given his risk factors and mild symptoms, you suspect HBV infection –You counsel the patient that screening would be warranted even in the absence of symptoms  You suggest to the patient that he be given a blood test for HBV  The patient is HBsAg positive, has high HBV DNA level  Starts antiviral therapy and TCM practitioner manages sciatic pain

22 clinicaloptions.com/hepatitis Joining East and West Overcoming HBV Screening Barriers: Engaging At-Risk Patients  Ask at-risk patients if they are familiar with HBV  Educate patients about HBV disease and potential consequences if left undiagnosed  Explain the simple blood test needed to undergo screening  Provide screening opportunities in Traditional Chinese Medicine practice or referral to a trusted colleague

23 clinicaloptions.com/hepatitis Joining East and West Emphasize Key Points for Patients  Diagnosis is easily missed by both patients and their physicians due to asymptomatic nature of disease –Thus, the only way to diagnose HBV infection is through a simple and inexpensive blood test: HBsAg  Up to 1 out of every 4 chronic carriers will eventually die of liver failure or cancer caused by hepatitis B, if left untreated or unmonitored –Hepatitis B takes a life every secs Asian Liver Center, Stanford School of Medicine. FAQ about hepatitis B.

24 clinicaloptions.com/hepatitis Joining East and West Strategies to Increase HBV Screening in Traditional Chinese Medicine Practices  Lower cost of the screening process to make it more affordable  Help alleviate fears regarding immigration status  Make education on HBV more accessible in your practice –Emphasize the higher rate of HBV cases in Asian populations [1] –HBV can cause lifelong infection and can lead to cirrhosis of the liver, liver cancer, liver failure, and death [1] –HBV often spread from mother to child but can be spread through contact with contaminated blood and body fluids, such as unprotected sex, drug use, shared razors or toothbrushes [1] 1. Asian Liver Center, Stanford School of Medicine. Know HBV: what every Asian and Pacific Islander should know about hepatitis B and liver cancer

25 clinicaloptions.com/hepatitis Joining East and West Strategies to Increase HBV Screening in Traditional Chinese Medicine Practices  Provide readily accessible resources for getting screened  Provide translators for people who do not speak English (very well)  Traditional Chinese Medicine providers can have available (translated) educational resources that they can provide to patients who are interested (eg, pamphlets, handouts)

26 Tram T. Tran, MD Antiviral HBV Therapies and Treatment Recommendations

27 clinicaloptions.com/hepatitis Joining East and West Goals of HBV Therapy  Primary goal – Prevention of cirrhosis, HCC, and death –May be achievable by durable suppression of serum HBV DNA to low or undetectable levels  Secondary goals in clinical practice –Decrease serum HBV DNA –Decrease or normalize serum ALT –Induce HBeAg loss or seroconversion –Induce HBsAg loss or seroconversion

28 clinicaloptions.com/hepatitis Joining East and West Keeffe EB, et al. Clin Gastroenterol Hepatol. 2008;6: Chu CJ, et al. Gastroenterology. 2003;125: Lok AS, et al. Hepatology. 2001;34; Chronic Hepatitis B Disease States  HBeAg positive –Also known as “wild type” –Negative for antibody to HBeAg (anti-HBe) –HBV DNA generally > 20,000 IU/mL (> 10 5 copies/mL)  HBeAg negative –Also known as “precore mutant” –Positive for antibody to HBeAg (anti-HBe) –HBV DNA generally > 2000 IU/mL (> 10 4 copies/mL)

29 clinicaloptions.com/hepatitis Joining East and West PhaseImmune Tolerant Immune Clearance Inactive Carrier State Reactivation Liver Minimal inflammation and fibrosis Chronic active inflammation Mild hepatitis and minimal fibrosis Active inflammation Optimal treatment times Anti-HBe HBV DNA ALT activity Current Understanding of HBV Infection 4 Phases of Chronic HBV Infection HBeAg Yim HJ, et al. Hepatology. 2006;43:S173-S181. Copyright © John Wiley & Sons, Inc. All Rights Reserved.

30 Treatment Candidacy

31 clinicaloptions.com/hepatitis Joining East and West What Is an Elevated ALT Level?  Increased levels of the ALT enzyme can indicate liver damage [1,2]  Reference ranges for “normal” ALT vary between 2 most widely used commercial laboratories –Men: 4-60 IU/L; women: 6-40 IU/L –Men: 0-55 IU/L; women: 0-40 IU/L  Most HBV treatment algorithms recommend lower ULN levels for ALT when making treatment-initiation decisions [1-3] –30 IU/L for men –19 IU/L for women 1. Prati D, et al. Ann Intern Med. 2002;137: Keeffe EB, et al. Clin Gastroenterol Hepatol. 2008;6: AASLD practice guidelines: chronic hepatitis B. September 2009.

32 clinicaloptions.com/hepatitis Joining East and West HBV DNA Testing  Indicates chronic hepatitis B when HBV DNA is still positive 6 mos after acute HBV infection –Can differentiate among different states of infection  HBV DNA level correlates with disease progression  Change in HBV DNA level used to monitor response to therapy  Increasing HBV DNA level during antiviral therapy indicates emergence of drug resistance Adapted from Keeffe EB, et al. Clin Gastroenterol Hepatol. 2008;6:

33 clinicaloptions.com/hepatitis Joining East and West Histology  Liver biopsy –Establishes disease baseline before initiation of therapy –Helps to exclude other causes of liver disease –More sensitive and accurate than ALT –May be considered in patients who meet criteria for chronic hepatitis B infection –Limitations –Invasive procedure –Sampling error –Interobserver variability

34 clinicaloptions.com/hepatitis Joining East and West MONITOR Q3-6 mos ALT Q6-12 mos HBeAg MONITOR Q3 mos ALT Q6 mos HBeAg Consider biopsy if persistent or aged > 40 yrs and TREAT as needed MONITOR Q1-3 mos ALT and HBeAg and TREAT if elevations persist Liver biopsy optional TREAT immediately if jaundice or decompensated 1-2 x ULN AASLD practice guidelines: chronic hepatitis B. September AASLD Guidelines: Treatment Candidacy for HBeAg-Positive Patients < 1 x ULN> 2 x ULN ALT: > 20,000 IU/mL < 20,000 IU/mL > 20,000 IU/mL HBV DNA: and APPROACH:

35 clinicaloptions.com/hepatitis Joining East and West MONITOR Q3 mos ALT x 3, then Q6-12 mos if ALT still < 1 X ULN MONITOR Q3 mos ALT and HBV DNA Consider biopsy if persistent and TREAT as needed TREAT if elevations persist Liver biopsy optional 1-2 x ULN AASLD Guidelines: Treatment Candidacy for HBeAg-Negative Patients < 1 x ULN≥ 2 x ULN ,000 IU/mL < 2000 IU/mL ≥ 20,000 IU/mL and ALT: HBV DNA: APPROACH: AASLD practice guidelines: chronic hepatitis B. September 2009.

36 HBV Antiviral Therapies

37 clinicaloptions.com/hepatitis Joining East and West Interferon alfa-2b Lamivudine Adefovir Peginterferon alfa-2a Telbivudine Tenofovir FDA-Approved HBV Therapies Entecavir

38 clinicaloptions.com/hepatitis Joining East and West Current Guideline Recommendations for First-line HBV Antiviral Therapy  Use ONE of the following [1-3] : –Weekly injectable medication: pegIFN alfa-2a –Exceptions: pregnancy, chemotherapy prophylaxis, decompensated cirrhosis or autoimmune disease, acute infection, uncontrolled severe depression or psychosis –Daily oral nucleos(t)ide analogue; either –Entecavir or –Tenofovir  Older drugs no longer recommended for first-line therapy due to high rates of resistance (eg, lamivudine, adefovir) [1,3] 1. EASL. J Hepatol. 2012;57: Liaw YF, et al. Hepatol Int. 2012;6: AASLD practice guidelines: chronic hepatitis B. September 2009.

39 clinicaloptions.com/hepatitis Joining East and West Comparison of PegIFN vs Nucleos(t)ide Analogues PegIFNNucleos(t)ide Analogues ProsConsProsCons  Finite course of therapy  No resistance  Higher rate of HBeAg loss in 1 yr  Higher rate of HBsAg loss with short duration therapy*  SQ administration  Frequent AEs  Contraindicated in patients with cirrhosis, in pregnancy, with acute hepatitis B, and who are immunosuppressed  PO administration  Infrequent AEs  Safe at all stages of disease, including decompensated cirrhosis †  Safe in immuno- compromised populations  Selected drugs probably safe in pregnancy  Need for long-term or indefinite therapy  Potential for drug resistance  Unknown long- term safety *Particularly for HBeAg-positive patients with genotype A infection. † Recent case report of lactic acidosis in severe liver failure. EASL. J Hepatol. 2012;57: Lok AS, et al. Hepatology. 2009;50: Lok AS. Hepatology. 2010;52: Buster EH, et al. Gastroenterology. 2008;135: Lange CM, et al. Hepatology. 2009;50: AASLD practice guidelines: chronic hepatitis B. September 2009.

40 clinicaloptions.com/hepatitis Joining East and West Treating Asian Patients With HBV: Special Considerations  High rate of HBeAg-negative chronic hepatitis B –Long-term therapy often required –Increased risk for HCC  Treatment-induced drug resistance mutations –Loss of treatment efficacy –Possible flares resulting in serious complications, including HCC and death  Poor response to treatment –Poorer response to interferon in patients with genotype C –Poor response in patients with normal ALT levels

41 David D. Liu, PhD, LAc, OMD Overview of Traditional Chinese Medicine Beliefs

42 clinicaloptions.com/hepatitis Joining East and West Basic Concepts of TCM Theory  TCM syndrome: a profile of symptoms and signs as a series of clinical phenotypes –Guides understanding of the human homeostasis –Basis for the applications of Chinese herbs and acupuncture  Heat, cold, excess, and deficiency are the 4 basic syndromes of maladjustment nature in TCM  One study found 47 syndromes related to CHB [1] –Majority among individuals without cirrhosis: Liver Depression and Spleen Deficiency or Liver-Gallbladder Dampness Heat/Dampness-Heat Obstructing Middle Energizer –Common in those with severe CHB: Liver-Kidney Yin Deficiency and Spleen-Kidney Yang Deficiency Zeng XX, et al. Am J Chin Med. 2011;39:

43 clinicaloptions.com/hepatitis Joining East and West TCM Theories Regarding Etiology and Pathology  Toxin: pathogenic factors that cause acute contagious and infectious diseases and their complications –Special pathogenic factors in the theory of etiology of TCM, which is either included in the 6 exogenous causes of disease—wind, cold, summer heat, dampness, dryness, and fire—or dissociates itself from them  Accumulation of damp heat in the liver –External invasion of damp heat –Damp heat food over time Proceedings of TCM Conference at West China University of Medical Science

44 clinicaloptions.com/hepatitis Joining East and West TCM Theories Regarding Etiology and Pathology  “Qi is an infinitesimal substance by which the human body is nourished. It is the basic substance that sustains life and is vital to the function of the internal organs” -- cen yuefang  Qi and blood stagnation [1] –Theory that all diseases originate from an imbalance of qi and blood flow, leading to stagnation and blockage –Restoring balanced flow can restore health  Upright qi (body’s resistance to disease) and yin (that which maintains and endures) deficiency [1] 1. Xutian S, et al. Am J Chin Med. 2012;40:

45 clinicaloptions.com/hepatitis Joining East and West TCM Theories Considered During Management of HBV Patients  Eliminate pathogenic factors and toxin for acute stage  Drain dampness and clear heat for infection stage  Open and soothe liver to overcome qi stagnation for relief of symptoms  Invigorate the blood for late stage  Tonify (nourish and replenish) healthy qi and yin for chronic stage  TCM nutrition therapy for recover stage TCM Internal Medicine, by Dave Liu, 1992

46 Tram T. Tran, MD Overview of Barriers to Treatment and Engagement in Care

47 clinicaloptions.com/hepatitis Joining East and West Causes for Health Disparities  Chronic HBV infection and liver cancer is the greatest health disparity between APIs and white Americans [1,2]  Health disparities between APIs Americans and the US general population can be attributed to [1] –Communication challenges [1] –Cultural differences [1] –Socioeconomic factors [1] –Lack of awareness and misinformation [1] –Potential for more aggressive HBV progression among APIs Americans (higher rate of genotype C HBV infection) [3] 1. Bailey MB, et al. J Community Health. 2011;36: Asian Liver Center, Stanford University School of Medicine Colvin HM, et al, eds. Hepatitis and liver cancer: a national strategy for prevention and control of hepatitis B and C. Washington, DC: The National Academies Press; 2010.

48 clinicaloptions.com/hepatitis Joining East and West Asian Health Beliefs About Wellness and Disease Western CulturesAsian Cultures Separate mind and bodyEmbrace a holistic approach to health Strive toward movement and explorationCultivate “what is” Dissect and analyze the bodyRestore body functioning

49 clinicaloptions.com/hepatitis Joining East and West Healthcare Practices Among API Patients  Many API patients adhere to Eastern healthcare practices [1,2] –How many patients used herbal remedies? –38% of Vietnamese patients [2] –36% of Japanese patients [2] –1 in 4 Koreans used acupuncture [2] –14% of Chinese patients saw traditional Chinese healers [2] 1. Ahn AC, et al. Am J Public Health. 2006;96: The Commonwealth Fund 2001 health care quality survey: quality health care for Asian Americans.

50 clinicaloptions.com/hepatitis Joining East and West Healthcare Practices Among API Patients  Two thirds of Vietnamese and Chinese patients have used complementary or alternative medical therapies [1] –Only 7.6% had discussed these with their Western physicians [1]  Many APIs do not see a doctor unless they are sick –No screening during pregnancy –Insufficient screening for chronic HBV infection 1. Ahn AC, et al. Am J Public Health. 2006;96:

51 clinicaloptions.com/hepatitis Joining East and West Barriers to Treatment: Language  Ability to speak English tremendously affects healthcare access [1,2] –Communication with providers [1,2] –Accessing services (eg, Medicare/Medicaid) [1,2] –Impact of limited English –Less likely to have routine preventive care [1,2] –Their children also less likely to receive care [3] –Limits ability to understand and comply with medication use [1] 1. Ngo-Metzger Q, et al. J Gen Intern Med. 2007;22: Fiscella K, et al. Medical Care. 2002;40: Weinick RN, et al. Am J Pub Health. 2000;90:

52 clinicaloptions.com/hepatitis Joining East and West Barriers to Treatment: Language  Limited English proficiency definition: does not speak English “very well” –Legal implications  Linguistic isolation: no one in household aged 14 yrs or older speaks English at least “very well” –More than one third of Korean, Taiwanese, Chinese, Hmong, and Bangladeshi households [1] –45% Vietnamese households [1] 1. US Census Bureau. Census 2000 brief: language use and English speaking ability: Issued October 2003.

53 clinicaloptions.com/hepatitis Joining East and West Barriers to Treatment: Communication Challenges  Most API patients report lower satisfaction in communication with their physicians –< 50% of API patients said that their physician “listened to everything” [1] –Of Asian patients with limited language skills, large proportions report –Dissatisfaction with their involvement in healthcare decisions –That they did not spend enough time with their physician Ngo-Metzger Q, et al. J Gen Intern Med. 2004;19:

54 clinicaloptions.com/hepatitis Joining East and West Barriers to Treatment: Religious Perspectives on Health and Well-being  Buddhism –Suffering as an integral part of one’s life  Confucianism –Worship of ancestors –Family well-being more important than individuals  Taoism –Perfection is achieved when things are allowed to take the more natural course Tran TT. Cleve Clin J Med. 2009;76:S10-S13.

55 clinicaloptions.com/hepatitis Joining East and West Barriers to Treatment: Poverty  Perception of increasing per capita income [1]  Asians more likely to be living in poverty compared with whites (12% vs 10%) and lower per capita income [2]  Disaggregated data: Asian subpopulations particularly affected by poverty [3] –Hmong: 37.8% –Cambodian: 29.3% –Laotian: 18.5% –Vietnamese: 16.6% 1. Tran TT. Cleve Clin J Med. 2009;76:S10-S US Census. Income, poverty, and health insurance coverage in the United States: September President’s Advisory Commission on Asian Americans and Pacific Islanders. Facts and data: critical issues facing Asian Americans and Pacific Islanders.

56 clinicaloptions.com/hepatitis Joining East and West Barriers to Treatment: Health Insurance Coverage  Uninsured by subgroups –Korean: 25.5% –Vietnamese: 19.8% –Native Hawaiian and Pacific Islander: 16.7% –Chinese: 13.4% –Asian Indian: 11.8% –Filipino: 10.9% –Japanese Americans: 6.6% US DHHS. ASPE research brief: the Affordable Care Act and Asian Americans and Pacific Islanders. April 2012.

57 clinicaloptions.com/hepatitis Joining East and West Barriers to Treatment: Educational Attainment  Educational achievement is associated with attainment of financial security and health insurance [1] –86% of Asians complete high school (general US population 85%, white 90%) [2] –Southeast Asians much lower rates of HS completion (between 61% and 72%, depending on subgroup) [2] –Asians more likely to have bachelor degree (49% vs 28% overall) except certain subgroups (ie, Southeast Asians) [2]  Bimodal distribution is seen in some subgroups regarding educational attainment [1] 1. Tran TT. Cleve Clin J Med. 2009;76:S10-S US Census Bureau American community survey, 3-year estimates.

58 clinicaloptions.com/hepatitis Joining East and West Barriers to Treatment: Educational Attainment US Census Bureau, Less Than HS Education (%) Hmong Cambodian Laotian Vietnamese Tongan Fijian Bangladeshi Chinese Korean Filipino Japanese Taiwanese

59 clinicaloptions.com/hepatitis Joining East and West Barriers to Treatment: Health Workforce  IOM: “Racial concordance is associated with greater patient participation, higher patient satisfaction, and greater adherence” [1]  US physician diversity [2] –75% of physicians in the US are white whereas Asians are the largest minority group of physicians (12.8%) –Among Asian subgroups, Japanese, Filipino, Vietnamese, Korean are least represented  US nursing diversity [3] –11 of the 16 Asian subgroups underrepresented 1. IOM. Unequal treatment: confronting racial and ethnic disparities in healthcare. Washington, DC: National Academies Press; March AAMC. Diversity in the physician workforce: facts and figures Summer APIAHF. Diverse communities diverse experiences. The status of Asian Americans and Pacific Islanders in the US

60 David D. Liu, PhD, LAc, OMD Tram T. Tran, MD Building Partnerships and Overcoming Barriers: Integrating Western and Traditional Chinese Medicine

61 clinicaloptions.com/hepatitis Joining East and West Example Case Vignettes of HBV Patients Seeking TCM Therapy  Case 1: HBV patient with suppressed HBV DNA on antiviral therapy still experiencing symptoms of fatigue, loss of appetite, etc –Seeks TCM for symptom relief  Case 2: HBV patient seeking TCM for infertility issues –TCM provider asks her to initiate antiviral HBV medication treatment first –1 yr later, her HBV DNA levels are negative and after discussion with HBV doctor, she starts TCM treatments for infertility

62 clinicaloptions.com/hepatitis Joining East and West Role of TCM Provider as a Trusted Healthcare Provider: Encouragement  Screening for HBV  HBV vaccination  Antiviral therapy  Management of chronic HBV infection  Screening for liver cancer  Eliminating HBV myths

63 clinicaloptions.com/hepatitis Joining East and West TCM Approaches That May Be Used in Patients Receiving Antiviral Medication  Use of TCM in China is based on clinical observations and wisdom accumulated > 2000 yrs of use and practice [1]  Addressing symptoms in HBV in hopes of improving quality of life [1,2] –Fatigue and depression –Sleep difficulties –Promoting kidney health –Headaches and muscle pain  Strategies aimed at boosting immune function, promoting liver health, resisting liver fibrosis [1-3] 1. Zhang L, et al. Hepatology. 2010;51: Wang BE. J Gastroenterol Hepatol. 2000;15(suppl): E67-E Feng Y, et al. Chin Med. 2009;4:16.

64 clinicaloptions.com/hepatitis Joining East and West Role of Western Medicine Providers in Overcoming Barriers  Interactions with patients –Reassure –Educate on disease and transmission –Be sensitive to cultural attitudes –Refer for assistance to access programs –Have in-language materials and interpreter

65 clinicaloptions.com/hepatitis Joining East and West Role of Western Medicine Providers in Overcoming Barriers  Cultural training  Education programs specific to their needs for their particular community  Provide in-language materials to use/distribute

66 clinicaloptions.com/hepatitis Joining East and West Bridging the Gap With TCM and Western Medicine  Be open and nonjudgmental regarding concomitant TCM usage –Overall better reported quality-of-care ratings if discussions are initiated  Open dialogue and collegiality among Western clinical team and TCM practitioners, preferably in-language –Team approach to treatment rather than “us vs them” or “right vs wrong” Ahn AC, et al. Am J Pub Health. 2006;96: Ngo-Metzger Q, et al. J Gen Intern Med. 2003;18:44-52.

67 Go Online for More Information on Management of Hepatitis B clinicaloptions.com/HBVEastWest


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