A public service announcement (PSA) campaign designed to increase awareness of hepatitis A, B, and C among the public has been launched by the American Digestive Health Foundation (ADHF) and the American Liver Foundation (ALF). The campaign incorporates a culturally diverse outreach initiative designed to target African Americans, Hispanics, gay men, and others at increased risk of the diseases.

The campaign was announced in February at the National Hepatitis Summit, a one-day event held as part of the Digestive Health Initiative (DHI). The DHI is an education and outreach program developed by the ADHF and ALF to increase awareness among healthcare consumers about the prevention, early detection, and treatment of various digestive health disorders. Organizations participating in the DHI's hepatitis awareness project include the National Minority AIDS Council, the National Coalition of Hispanic Health and Human Services Organizations, the National Council on Aging, and the Association of Asian-Pacific Community Health Organizations.

The indications for the campaign are undeniable. Each year, more than 350,000 new cases of acute viral hepatitis occur in the US. Nearly 5 million Americans have chronic viral hepatitis, and many of these individuals are unaware of their infection and unknowingly transmit the infection to others. More than 15,000 people in the US die each year as a result of viral hepatitis. The PSAs, both broadcast and in print, provide critical information in English and Spanish on the risk factors, diagnosis, treatment, and prevention of viral hepatitis. The broadcast PSAs feature the animated "Dr. Dan", who also starred in DHI-sponsored national campaigns to treat ulcer disease and promote colorectal cancer screening.

Cultures at Risk -- African Americans

The DHI hepatitis awareness campaign was developed in recognition of the unique cultural characteristics of groups at high risk of viral hepatitis. According to the Centers for Disease Control and Prevention (CDC), African Americans comprise 12.7 percent of the US population and account for 7 percent of reported cases of hepatitis A, 21 percent of hepatitis B, and 4 percent of hepatitis C. About 3.2 percent of African Americans are infected with hepatitis C virus (HCV), as compared with 2.1 percent of Hispanics and 1.5 percent of whites.

A variety of factors combine to place African Americans at increased risk of viral hepatitis. More than three million African-American men and women work in occupations that may increase their exposure to blood-borne pathogens. African-American high school students have a high incidence of sexual intercourse, and 40 percent of African-American children today live in poverty. The increased risk of exposure to viral hepatitis among African Americans is compounded by a lack of access to affordable medical care and a distrust of the US healthcare system based on notorious incidents of past discrimination.

There is evidence that previous public hepatitis awareness campaigns have not reached the majority of African Americans. The results of a public awareness poll conducted by the ALF found that, compared to the general public, African Americans are less aware of the risk factors and symptoms associated with viral hepatitis. While 51 percent of African Americans reported reading mainstream newspapers on an average weekday, there has been little, if any, information about the impact of viral hepatitis on African Americans in the mainstream press. Similarly, a recent media analysis revealed that there has been little coverage of hepatitis in the African-American press.

The communication strategy developed by the DHI to increased hepatitis awareness among African Americans includes a combination of media tactics and consumer and professional education programs. The ALF has determined that radio and television are exceptionally efficient media for reaching African Americans. Compared to the general population, African Americans were found to spend almost four hours more listening to the radio and view 50 percent more television daily. In response to these trends, the DHI program will form alliances with radio and television broadcasters and develop PSAs specifically targeted to African-American audiences. The DHI will also encourage radio and television producers to incorporate hepatitis story lines into programs identified as popular among African American viewers.

Other strategies included in the DHI plan to effectively reach African Americans include targeting general consumer magazines and other publications with significant numbers of African-American readers, placing billboards and announcements in public transportation centers, and creating alliances with church leaders and others recognized by African Americans as trusted and reliable sources of information. The DHI will also develop consumer education kits to be distributed by healthcare providers that provide information on hepatitis awareness specifically relevant to African Americans.

Hispanics

Hispanics currently comprise 10 percent of the US population and account for 16 percent of reported cases of hepatitis A virus (HAV) infection, 10 percent of hepatitis B virus (HBV) infection, and 6 percent of HCV infection. The Hispanic population is growing at two to three times the rate of the general US population, and within 50 years, Hispanics will account for one-fourth of the US population.

According to the National Coalition of Hispanic Health and Human Services Organizations, Hispanics live in polluted areas and in substandard living conditions in which HAV is likely to be transmitted. Most of the US Hispanic population is Spanish-speaking, and most Hispanics prefer to use their native language and obtain information through native language media. Nearly one- third of US Hispanics lack health insurance, and Hispanics generally place greater emphasis on healthcare issues affecting their families as opposed to themselves.

Radio and television are prime targets of the DHI strategy to increase hepatitis awareness among Hispanics. A survey sponsored by the DHI found that Spanish language television reaches 92 percent of all Hispanic homes, and that three of four Hispanics listen to Spanish language radio. Spanish language newspapers, read by 41 percent of Hispanics, are another venue for reaching Hispanics with hepatitis information.

The target markets for the DHI communication program include Hispanic mothers with children aged 5 to 14 years; children in this age group currently comprise 30 percent of reported cases of HAV infection. Another target market is young urban Hispanics aged 14 to 24 years, who are at particularly increased risk of HBV and HCV infection. The DHI media messages will be delivered in Spanish language by Hispanic spokespersons including celebrities, sports figures, actors, and other recognized personalities. The effort will include the development of strategic alliances with influential Hispanic leaders and the creation of community outreach projects designed to produce and disseminate culturally and linguistically appropriate hepatitis educational materials.

Gay Men

Gay men represent 3-5 percent of the US population with clustering in urban areas. Gay men are as diverse as the general population. Men who have sex with men (MSM), even if not gay-identified, are at increased risk of HAV and HBV infection. The spread of HCV through sexual contact is not well defined and appears to be rare. About 7 percent of cases of HBV infection and 3.5 percent of HCV infection are transmitted through sexual contact among MSM.

According to a survey sponsored by the ALF, gay men interacting with the gay community are likely to be aware of safe sex guidelines through AIDS prevention and education programs, whereas closeted gay men, bisexual men, and gay men who do not identify with the gay community are less likely to be familiar with risk reduction messages and are at high risk for exposure and transmission of HAV, HBV, and other sexually transmitted pathogens.

After 15 years of AIDS prevention messages, targeting gay men directly may have limited effectiveness. Gay consumers are effectively reached by the mainstream media, and gays have the highest internet usage of any population subgroup. The communication strategy developed by the DHI to increase hepatitis awareness among gay men and MSM includes the development of mainstream media messages referencing MSM, the creation of hepatitis information websites for MSM, and community outreach programs targeting MSM at community centers, bars, health clubs, and gay pride festivals.

Table 1. Diagnosis of Viral Hepatitis
Acute Viral Hepatitis in the US
HAV	~32%
HBV	~42%
HCV	~20%
HDV	~2%
HEV	~1%
Serologic Diagnosis of Acute Viral Hepatitis
Disease	Serology		Comments
Hepatitis A	igM anti-HAV		Specific
Hepatitis B	HBsAg		May be negative late
	IgM anti-HBc		Usually indicates acute hepatitis B
Hepatitis C	Anti-HCV		Often appears late: 4-8 weeks
Hepatitis D	HBsAg and anti-HDV		Anti-HDV may appear late
	(+)IgM anti-HBc		Coinfection
	(-)IgM anti-HBc		Superinfection
Hepatitis E	All negative		Travel history
Hepatitis Non-A-E	All negative		History of risk factors
Chronic Viral Hepatitis in the US
Type	Cases/year	%Chronic	Prevalence
HBV	128,000	~5%	0.3%
HCV	28,000	>8.5%	1.8%
Serologic Diagnosis of Acute Viral Hepatitis
Disease	Serology		Comments
Hepatitis B	HBsAg		(-)IgM anti-HBc
	-Active viral replication (HBeAg, HBV DNA)
	-Low/absent viral replication (anti-HBe,(-) HBV RNA)
Hepatitis C	Anti-HCV (EIA)		Anti-HCV (± RIBA) HCV RNA
Hepatitis D	HBsAg and anti-HDV (>1:100)		HDV antigen
Hepatitis Non-B-D	All negative		History of risk factors, exclusion of other diagnoses
Role of Liver Biopsy in Chronic Hepatitis
-Establishment of diagnosis		-Staging of progression
-Detection and exclusion of other lesions		-Evaluation of effects of therapy
-Grading of inflammatory activity
Components of the HAI (Knodell Score)
Component			Score
Grading of inflammatory activity: Periportal necrosis ± bridging Lobular degeneration and focal necrosis Portal inflammation			0-10 0-4 0-4
Staging of progression: Fibrosis			0-4
HAI=histology activity index (Knodell et al., Hepatology 1981; 1:431) Data courtesy of American Digestive Health Association and the American Liver Foundation

Table 2. Recommended Prophylaxis and Vaccine Guidelines for Hepatitis A and Hepatitis B
Immune Globulin Prophylaxis of Hepatitis A
Pre-exposure (travelers to endemic areas)	Short-term (< 3 mo) Long-term (> 3 mo)		0.02mL/kg 0.06 mL/kg q 4-6 mo
Post-exposure	Household/intimate contacts Institutions (day care,custodial-care centers) Common-source outbreaks		0.02 mL/kg 0.02mL/kg 0.02 mL/kg
Hepatitis A Vaccines
-Vaccines licensed in US: Havrix® and VAQTA®		-Can administer vaccine and immune globulin together
-More than 95% anti-HAV within 1 mo of intitial injection		-Patients with compensated liver disease respond well
Recommended Scheduling and Dosing
Patients	Schedule (mo)*	Havrix	VAQTA
Children (2-18 yr)	0, 6-12	720 ELU‡/0.5mL	—
Adolescents and adults (>18 yr)	0, 6-12	1,440 ELU‡/1.0mL	—
Children (2-17 yr)	0, 6-18	—	25 U/0.5mL
Adolescents and adults (>17 yr)	0, 6	—	50 U/1.0mL
‡Elisa Units *0 means time of initial dose
Recommendations for Hepatitis A Vaccination
-Persons traveling to or working in countries with high or intermediate rates of disease -Children living in communities with high rates of disease and periodic outbreaks -Children and young adults living in communities with intermediate rates of disease -Individuals who engage in high-risk behaviors, such as homosexual activities or injection drug use -Patients with chronic liver disease -Individuals with occupational risk of disease (e.g., primate handlers) -Immunocompromised individuals†
Recommendations for Hepatitis B Vaccination
Routine immunization: -All infants and previously unvaccinated children (by age 11) Increased risk: -People with multiple sex partners -Household contacts and sexual partners of HBV carriers -People who engage in high-risk behaviors, such as homosexual acitvities or injection drug use -Persons traveling to or working in countries with high or intermediate rates of disease -Individuals with occupational risk of disease (e.g., healthcare workers) -Client/Staff of institutions for developmentally disabled -Patients with chronic renal failure -Hematologic conditions requiring multiple transfusions and recipients of clotting factor concentrates -Immunocompromised individuals†
Administration Schedules and Dosing of Hepatitis B Vaccine
	Schedule(mo)*	Recombivax HB	Engerix-B
Newborn child of HBsAg- mother	0-2, 1-4, 6-18	2.5µg/0.5 ml 1	0µg/0.5ml
Newborn child of HBsAg+ mother	At birth (<12 hr) with HBlg, 1-2 and 6	5.0µg/0.5 ml	10µg/0.5 ml
Children (1-10 yr)	0, 1-2, 4-6	2.5µg/0.5 ml	10µg/0.5 ml
Adolescents (11-19 yr)	0, 1-2, 4-6	5.0µg/0.5 ml	10µg/0.5 ml
Adults	0, 1-2, 4-6	10µg/1.0 ml	20µg/1.0 ml
Immunocompromised	0, 1, and 6	40µg/1.0 ml	40µg/2.0 ml
*0 means time of intital dose † This recommendation added by the journal Data adapted from the American Digestive Health Association and the American Liver Foundation

David S. MacDougall is a medical writer in New Jersey. E-mail: dsmac@earthlink.net

©1998, Medical Publications Corporation