COMMENTARY

Eradication of Hepatitis B: A Nationwide Community CoalitionApproach to Improving Vaccination, Screening, and Linkageto Care

Chari Cohen • Jeffrey Caballero • Melinda Martin •

Isha Weerasinghe • Michelle Ninde •

Joan Block

� Springer Science+Business Media New York 2013

Abstract Infection with the hepatitis B virus (HBV) is a

significant public health concern in the US, disproportionately

affecting Americans of Asian, Native Hawaiian and Pacific

Islander descent, despite the availability of a simple blood test,

approved treatments, and an effective vaccine. Hep B United,

a national campaign to support and leverage the success of

community-based HBV coalitions, convened a partner sum-

mit in 2012 to develop a strategic response to the HHS Action

Plan for the Prevention, Care, and Treatment of Viral Hep-

atitis. The resulting community action plan focuses on

advancing three areas of the HHS plan: educating providers

and communities to reduce health disparities; improving

testing and linkage to care to prevent HBV-related liver dis-

ease and cancer; and eliminating perinatal HBV transmission.

Keywords Hepatitis B virus � Asian Americans �Healthcare disparities � Hepatitis B vaccine � Community

health

Introduction

Infection with the hepatitis B virus (HBV) can lead to life-

long, chronic infection and serious liver damage. Without

appropriate treatment and monitoring, 15–25 % people with

chronic HBV infection will die prematurely from cirrhosis,

liver failure, or primary liver cancer (hepatocellular

carcinoma, HCC) [1, 2]. In fact, chronic HBV infection is the

leading cause of HCC worldwide. Fortunately, a simple

blood test for HBV is readily available, there is an effective

vaccine to prevent infection, and seven medications are

currently approved in the US for the treatment of chronic

HBV infection [3–6]. And yet:

• An estimated two million Americans are chronically

infected with HBV, with up to 40,000 new infections

each year [7–9].

• Almost two-thirds of those chronically infected are

unaware they have the virus because the infection can

persist without symptoms for decades [10].

• 1 in 12 Americans of Asian, Native Hawaiian and

Pacific Islander descent are chronically infected with

HBV and are disproportionately impacted by higher

rates of related liver cancer [11, 12].

• Screening for HBV in high-risk communities is not

routine, and many health care providers have limited

understanding of HBV prevention, testing, and treat-

ment [10, 12].

• Less than 10 % of patients who need treatment are

estimated to receive medication [13].

• Every year, up to 1,000 newborns in the US acquire

chronic HBV infection from their mothers at birth [10].

• The economic burden of HBV in the US is estimated to be

as high as $1 billion (total direct and indirect annual cost)

[14].

Increasing National Focus on Hepatitis B Infection

and Health Disparities

A landmark report published by the Institute of Medicine

(IOM) in 2010, highlighted viral hepatitis as an urgent

C. Cohen (&) � J. Block

Hepatitis B Foundation, 3805 Old Easton Road, Doylestown,

PA 18902, USA

e-mail: chari.cohen@hepb.org

J. Caballero � M. Martin � I. Weerasinghe � M. Ninde

Association of Asian Pacific Community Health Organizations

(AAPCHO), Oakland, CA, USA

123

J Community Health

DOI 10.1007/s10900-013-9699-4

unmet medical need and recommended new policy, legis-

lative, community, and medical efforts to control HBV

infection [10]. In 2011, in response to the IOM report and

building upon the 2010 Patient Protection and Affordable

Care Act, the US Department of Health and Human Ser-

vices (HHS) released its Action Plan for the Prevention,

Care, and Treatment of Viral Hepatitis. As noted in the

plan, ‘‘HHS is committed to ensuring that new cases of

viral hepatitis are prevented and that persons who are

already infected are tested; informed about their infection;

and provided with counseling, care, and treatment.’’ [12

(p7)]. In addition, HHS Assistant Secretary for Health, Dr.

Howard Koh, has been working to raise awareness of the

disproportionate impact of HBV infection in Asian

American, and Native Hawaiian and Other Pacific Islander

(AA&NHOPI) communities [11]. Ongoing healthcare

system reforms (e.g., expanded insurance coverage) and

investments in health promotion, disease prevention, and

elimination of health disparities make this the ideal time to

focus on prevention and control of HBV infection, and to

work toward eradication.

The HHS Action Plan for the Prevention, Care,

and Treatment of Viral Hepatitis

The HHS National Viral Hepatitis Action Plan, or VHAP,

‘‘presents robust and dynamic steps for improving the

prevention of viral hepatitis and the care and treatment

provided to infected persons and for moving the nation

towards achieving Healthy People 2020 goals.’’ [12 (p57)].

The VHAP is organized into six topic areas:‘‘(1) educating

providers and communities to reduce health disparities; (2)

improving testing, care, and treatment to prevent liver

disease and cancer; (3) strengthening surveillance to detect

viral hepatitis transmission and disease; (4) eliminating

transmission of vaccine-preventable viral hepatitis; (5)

reducing viral hepatitis caused by drug-use behaviors; and

(6) protecting patients and workers from health-care asso-

ciated viral hepatitis.’’ [12 (p8)]. For hepatitis B specifi-

cally, HHS suggests that full implementation of the VHAP

could result in doubling the number of individuals who

know their HBV status (from 33 to 66 %, VHAP Goal 1.2),

and elimination of perinatal transmission of HBV (VHAP

Goal 4.1) [12].

Hep B United: Community Coalitions Working

Together for National Impact

In May of 2012, the Hepatitis B Foundation and the

Association of Asian Pacific Community Health Organi-

zations (AAPCHO), with the support of the HHS Office of

Minority Health (OMH), launched a new national cam-

paign, Hep B United. This campaign is comprised of a

national network of community-based coalitions across the

country that seek to raise awareness about hepatitis B,

promote screening, vaccination, and follow-up care, and

ultimately eliminate HBV, especially among high-risk

AA&NHOPI populations in the U.S.

The first Hep B United National Summit was held August

7–8, 2012 at the Hepatitis B Foundation’s headquarters in

Doylestown, PA. The goal of the summit was to develop a

national community-based response for addressing and

advancing the VHAP at the local level. Under the umbrella of

the Hep B United campaign, leaders from community-based

coalitions from across the country gathered to identify pri-

ority activities and share promising best practices for

addressing the public health challenge of HBV infection in

AA&NHOPI populations. To develop the national commu-

nity-based action plan, summit participants broke into

working groups to define objectives, activities, and progress

measures to help communities achieve goals in three of the

priority areas of the VHAP that are particularly relevant to

AA&NHOPI populations: educating providers and com-

munities to reduce health disparities (VHAP Goals 1.1 and

1.2); improving testing and linkage to care to prevent hepa-

titis-B-related liver disease and cancer (VHAP Goals 2.1 and

2.2); and eliminating perinatal transmission of hepatitis B

(VHAP Goal 4.1).

The following sections provide highlights of the Hep B

United Summit discussions on these three areas of the

VHAP, especially as they relate to AA&NHOPI popula-

tions, and the community action plan goals and objectives

developed by summit participants.

At Risk and Unaware: Educating Providers

and Communities

Very simply, the first step toward receiving care and treat-

ment is knowing that you have a condition that needs

attention [12]. Community-based coalitions and campaigns

can play an important role in educating people about the

vital importance of knowing their HBV status. Summit

participants discussed the challenges of reaching out to

AA&NHOPI communities, including the need for culturally

competent educational materials developed in the language

of the target audience. It was noted that many relevant

campaign materials and free viral hepatitis education

resources are already available through the CDC Division of

Viral Hepatitis and National Prevention Information Net-

work (NPIN, see http://www.cdcnpin.org/scripts/hepatitis/

index.asp); however, more evidence-based and community-

tested materials are needed, particularly in AA&NHOPI

primary languages.

Currently, routine screening at the primary care level

remains low, due to a number of provider-related barriers

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123

(e.g. knowledge, financial, language, cultural competency)

[15–18]. Providers need to be educated that failing to

routinely screen for HBV among high-risk populations is a

missed opportunity for prevention of serious liver disease

and cancer (i.e., diagnosis of HBV infection when the

patient presents with cirrhosis or liver cancer is often too

late) [14]. As many high-risk communities do not have

access to liver specialists, primary care providers need to

be able to address HBV prevention and screening, as well

as monitoring for disease progression, and management of

treatment if needed. Multiple studies indicate that active

screening and early treatment and management reduces

morbidity and mortality and is also cost-effective [19–21].

Summit participants developed the following national

community action plan goals and objectives to help com-

munity-based coalitions achieve VHAP Goals 1.1 and 1.2

on educating providers and communities to reduce health

disparities.

Community Education Goal Increase the number of

people in AA&NHOPI communities who know their HBV

status.

Community Objectives

• Increase community knowledge about HBV; the ben-

efits of testing and treatment; HBV and liver cancer;

and vaccination as a key prevention strategy.

• Increase consumer demand for HBV testing.

• Decrease community stigma and discrimination asso-

ciated with hepatitis B.

Provider Education Goal Increase the proportion of

providers who routinely screen their AA&NHOPI patients

for HBV.

Community Objectives

• Increase basic knowledge about HBV among providers;

enhance awareness of available HBV provider-focused

education materials.

• Develop and advocate for national quality measures;

advocate for the Bureau of Primary Health Care at the

Health Resources and Services Administration (HRSA)

to include screening requirements for providers.

• Identify and promote use of Electronic Medical Record

Tools and Meaningful Use requirements, and other

office-based strategies and systems (e.g., standing

orders for HBV screening, front desk inquiries about

screening status).

Knowing is Not Enough: Testing and Linkage to Care

Even when there is consumer demand for screening, and

providers who are willing to screen, barriers persist.

Summit participants identified transportation to and from

the screening site as a significant barrier for many people in

AA&NHOPI communities. Even if transportation is pro-

vided, it was noted that many people are hesitant to travel

beyond their community borders. Those who are screened

and test positive for HBV may not have insurance to cover

follow-up care. In some places, the issue is not lack of

insurance, but a lack of providers willing or able to manage

patients with hepatitis B infection. Summit participants

shared case examples where county health officials and

clinics had the resources available to conduct HBV

screening, but did not do so because they had no place to

refer people to if they tested positive. Community-based

coalitions can serve as a trusted coordinator of services and

resources to help people gain access to screening, vacci-

nation, and care (e.g., develop patient navigation tools or

transportation programs, catalog local resources and recruit

new partners).

Summit participants developed the following national

community action goals and objectives to help community-

based coalitions achieve VHAP Goals 2.1 and 2.2 on

improving testing and linkage to care to prevent HBV-

related liver disease and cancer.

HBV Screening Goal Increase the number of individ-

uals in high-risk AA&NHOPI communities who know

their HBV status.

Community Objectives

• Double the number of community-based screenings

and/or the number of sustainable screening sites (e.g.,

clinics, community based organizations, provider offi-

ces, health systems).

• Share promising best practices among local coalitions

across the U.S.

• Develop peer-to-peer technical assistance and mentor-

ing programs for local coalitions.

• Increase activities related to Hep B United’s national

priorities at the local level.

Linkage to Care Goal Provide opportunities for all

HBV-infected and susceptible individuals to access clinical

care, management, and vaccinations.

Community Objectives

• Increase by 20 % the number of HBV-infected indi-

viduals who are able to access sustainable and appro-

priate care.

• Decrease barriers to care.

• Educate people living with chronic HBV infection

about the importance of regular monitoring and care.

• Increase the number of HBV-susceptible individuals

who complete the HBV vaccine series.

• Advocate for broader allocation of funding for adult

HBV vaccination under Section 317 of the Public

Health Services Act.

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123

• Share promising best practices for improving vaccine

series completion rates.

At Risk from Day One: Eliminating Perinatal HBV

Transmission

Despite long-standing recommendations for HBV screen-

ing of pregnant women and HBV vaccination of infants at

birth, nearly 1,000 babies born in the U.S. every year

acquire HBV infection at birth from an infected mother

(perinatal transmission) [10, 22]. These infants are the

most vulnerable to developing chronic HBV infection,

and up to 25 % of those infected at birth will die pre-

maturely from HBV-related disease later in life [23].

There are many potential causes of perinatal transmission

of hepatitis B [24]. Not all pregnant women receive

prenatal care or deliver in a hospital, so they may not be

tested. Some women are screened, but are not appropri-

ately monitored or treated if positive for HBV, often due

to a breakdown in reporting procedures or lack of clinical

follow-up [25]. Infants born to HBV-positive mothers

may not have received the birth dose of vaccine and

hepatitis B immune globulin within 12–24 h of birth.

Education of all HBV-infected women (and their house-

hold contacts), and those providing care to pregnant

women, is paramount. Participants discussed the need for

standing orders for HBV testing and prophylaxis at all

birth hospital and clinics, and the need for outreach

through other community organizations that serve

AA&NHOPI communities, and women in particular.

Local perinatal coordinators are essential partners in

community-based efforts to reach out to HBV-infected

pregnant women and their households.

Summit participants developed the following commu-

nity action objectives to help community-based coalitions

achieve VHAP Goal 4.1 on eliminating perinatal trans-

mission of hepatitis B.

Prevention Goal Eliminate perinatal transmission of

HBV

Community Objectives

• Build partnerships with perinatal coordinators and

educate them about perinatal HBV transmission.

• Increase the education of all HBV-infected women

about the potential for perinatal HBV transmission.

• Provide appropriate case management for HBV-

infected pregnant women, including referring them

for care during and after delivery.

• Raise awareness of perinatal HBV transmission among

women’s AA&NHOPI health organizations and med-

ical societies.

Overarching Challenges

Over the course of the Hep B United summit, participants

identified a variety of challenges to be addressed in meet-

ing the goals of the VHAP. In particular, participants

emphasized the challenges of overcoming knowledge,

language, and cultural barriers, and ensuring funding and

sustainability of programs and effort.

Knowledge, Language, and Cultural Barriers

Simply translating existing English language HBV educa-

tional materials into other languages does not convey

knowledge effectively to other cultures. Misinformation,

stigma, and discrimination associated with HBV persist

[26, 27]. Participants stressed that materials need to be

developed by native speakers familiar with the nuances of

the culture and language. Someone who tests positive for

HBV infection needs to learn not only how to live with it,

but also how to talk to their family members about HBV

and how to encourage them to be screened, and vaccinated

if needed. Although the VHAP does not specifically

address stigma, participants felt that local community

education objectives should also target stigma and dis-

crimination experienced by HBV-infected individuals.

Participants discussed the potential role of community

health workers in helping to address cultural competency

and language barriers, particularly with the implementation

of the Affordable Care Act, and the importance of imple-

menting cultural competence curricula for providers.

Despite the risk of liver cancer from HBV, there is still

much more public concern about diabetes and heart dis-

ease, and summit participants suggested that offering HBV

screening along with heart disease or diabetes screening

may help facilitate testing of those who are hesitant to

bring themselves or family members to an HBV screening

event. It was also noted that many who test positive for

HBV do not go for follow-up care, even if it is free,

because they are not ‘‘sick.’’

Funding and Sustainability

In a difficult economy, resources for training and education

are often the first to be cut. This can further increase health

disparities because community-based organizations do not

have the staff for grant writing, fundraising, and evaluation.

Summit participants stressed the need to better utilize

federal programs and resources at the local level, and to

strengthen coalition partnerships with federal agencies.

One approach to stretch limited resources is by working

with other organizations serving the same populations (e.g.,

HBV information could be provided in immigration and

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123

naturalization classes). Another approach is cataloging

which coalition members can provide in-kind support (e.g.,

educational materials, technology) and engaging non-tra-

ditional partners that may have resources to share (e.g., a

venue for screening, distribution of materials). Sustain-

ability of effort is also an issue, and coalitions can play a

key role in building trust and maintaining momentum in

their local communities.

Concerns were also raised about the allocation of funds

for adult HBV vaccination under Section 317 of the Public

Health Services Act, and limited or unreliable funding for

vaccination was linked to the lack of educational cam-

paigns focused on vaccination.

Realizing a Future Without Hepatitis B

Hepatitis B is a disease that can be eradicated in the USA

vaccine for the prevention of HBV infection has been

available in the US since 1982, and CDC recommends

HBV vaccination of all newborns at birth, all children and

adolescents who were not vaccinated at birth, and all at-

risk adults (see CDC recommendations for further discus-

sion of at risk groups) [5, 6]. Despite the broad success of

immunization in decreasing the incidence of HBV infec-

tion, millions of Americans remain unprotected. Worse, up

to 2 million Americans are chronically infected, the

majority do not know it, and many of those that do know

their HBV-positive status are not receiving appropriate

care. Surveillance systems tracking viral hepatitis

throughout the US have not been adequate, and many

national surveys do not track the level of race/ethnicity

granularity needed to generate accurate prevalence esti-

mates. Many of those at risk or chronically infected are

first-generation Americans born outside the US in countries

where HBV is endemic. In the US, AA&NHOPI commu-

nities are disproportionately impacted by chronic HBV

infection and liver cancer.

Building upon the current national focus on prevention

and treatment of viral hepatitis, the Hep B United com-

munity action plan is designed to be a national resource for

local HBV coalitions across the country as they strive to

meet the health needs of their communities and eliminate

HBV-related health disparities. Together, Hep B United

and its local coalition partners across the US will continue

working to: raise the profile of hepatitis B and liver cancer

as an urgent public health priority; increase hepatitis B

testing and vaccination, particularly among AA&NOHPI

and other at-risk communities in the US; and improve

access to care and treatment for individuals living with

hepatitis B to prevent end-stage liver disease and liver

cancer.

There is much to be done, and Hep B United coalition

partners are continuing to discuss potential tactics strate-

gies for achieving their national goals and objectives at the

local level, and defining measures of progress. Educational

resources, links to local coalitions, and information on join-

ing the national campaign can be obtained at hepbunited.

org. Through a unified, strategic approach, local hepatitis B

coalitions across the country can work together to achieve a

measurable national impact on the eradication of hepatitis

B and liver cancer.

Acknowledgments The recommendations contained in this article

stem from the first Hep B United National Summit, hosted by the

Hepatitis B Foundation and AAPCHO, and funded in part by a grant

from the HHS Office of Minority Health. The authors thank the

community coalitions, non-profit organizations, and federal partners

who participated in the summit and contributed to the development of

the action plan: Carol Brosgart, MD, Viral Hepatitis Action Coalition,

CDC; Kuan-Lung Daniel Chen, MPH, CPH, Hepatitis B Foundation;

Moon Chen, PhD, MPH, Asian American Network for Cancer

Awareness Research and Training; Shane Chen, Asian American

Health Coalition/Hope Clinic; Ryan Clary, National Viral Hepatitis

Roundtable; Molli Conti, Hepatitis B Foundation; Corinna Dan, RN,

MPH, Office of HIV/AIDS, HHS; Doan Dao, MD, Dallas-Fort Worth

Hep B Free; Karen Jiobu, Ohio Asian American Health Coalition;

Cynthia Jorgensen, DrPH, National Center for HIV, Viral Hepatitis,

STD and TB Prevention, CDC; Sophie Kwon, HHS Office of

Minority Health; Hong Liu, PhD, Midwest Asian Health Association;

Heather Lusk, The CHOW Project and Hep Free Hawaii; Kate

Moraras, MPH, White House Initiative on Asian Americans and

Pacific Islanders; Kim Nguyen, MSW, Hepatitis B Coalition of WA/

Within Reach; Jane Pan, Hepatitis B Initiative-DC; Su Wang, MD,

MPH, Charles B. Wang Community Health Center; Aurora Wong,

Las Vegas Hep B Free. Assistance with preparation of the manuscript

was provided by Theresa Wizemann, PhD, of Wizemann Scientific

Communications, LLC, under contract with the Hepatitis B

Foundation.

References

1. Centers for Disease Control and Prevention. (2008). Hepatitis B

FAQs for Health Professionals. Retrieved February 21, 2013 from

http://www.cdc.gov/hepatitis/HBV/HBVfaq.htm.

2. McMahon, B. J. (2010). Natural history of chronic hepatitis B.

Clinics in Liver Disease, 14(3), 381–396.

3. Lok, A. S., & McMahon, B. J. (2009). Chronic hepatitis B:

Update 2009. AASLD Practice Guideline. Hepatology, 50(3),

661–662.

4. McHugh, J. A., Cullison, S., Apuzzio, J., et al. (2011). Chronic

hepatitis B infection: A workshop consensus statement and

algorithm. Journal of Family Practice, 60(9), E1–E8.

5. Mast, E.E., Margolis, H.S., Fiore, A.E., et al. (2005). A com-

prehensive immunization strategy to eliminate transmission of

hepatitis B virus infection in the United States: Recommenda-

tions of the Advisory Committee on Immunization Practices

(ACIP) part 1: Immunization of infants, children, and adoles-

cents. MMWR Recommendations and Reports, 54 (RR-16), 1–31.

6. Mast, E.E., Weinbaum, C.M., Fiore, A.E., et al. (2006). A com-

prehensive immunization strategy to eliminate transmission of

hepatitis B virus infection in the United States: recommendations

of the Advisory Committee on Immunization Practices (ACIP)

J Community Health

123

part II: Immunization of adults. MMWR Recommendations andReports, 55(RR-16), 1–33.

7. Cohen, C., Evans, A. A., London, W. T., Block, J., Conti, M., &

Block, T. (2008). Underestimation of chronic hepatitis B virus

infection in the United States of America. Journal of ViralHepatitis, 15(1), 12–13.

8. Centers for Disease Control and Prevention. (2011). Viral Hepatitis

Surveillance—United States, 2009. Retrieved February 19, 2013

from http://www.cdc.gov/hepatitis/Statistics/2009Surveillance/

index.htm.

9. Centers for Disease Control and Prevention. (2012). Viral Hepatitis

Surveillance—United States, 2010. Retrieved February 19, 2013

from http://www.cdc.gov/hepatitis/Statistics/2010Surveillance/

Commentary.htm.

10. Institute of Medicine. (2010). Hepatitis and Liver Cancer: ANational Strategy for Prevention and Control of Hepatitis B and C.Washington,: National Academies Press. Retrieved January 30,

2013 from http://books.nap.edu/openbook.php?record_id=12793.

11. Centers for Disease Control and Prevention. (2012). Viral Hep-

atitis Populations: Asian and Pacific Islanders. Retrieved Febru-

ary 21, 2013 from http://www.cdc.gov/hepatitis/Populations/

api.htm.

12. U.S. Department of Health and Human Services. (2011). Com-bating the Silent Epidemic of Viral Hepatitis: Action Plan for thePrevention, Care, and Treatment of Viral Hepatitis. Retrieved

January 30, 2013 from http://www.hhs.gov/ash/initiatives/

hepatitis/index.html.

13. Cohen, C., Holmberg, S. D., McMahon, B. J., et al. (2011). Is

chronic hepatitis B being undertreated in the United States?

Journal of Viral Hepatitis, 18(6), 377–383.

14. Weinbaum, C.M., Williams, I., Mast, E.E., et al. (2008). Rec-

ommendations for identification and public health management

of persons with chronic Hepatitis B virus infection.

MMWR,57(RR08), 1-20. Retrieved March 14, 2013 from http://

www.cdc.gov/mmwr/preview/mmwrhtml/rr5708a1.htm.

15. Lai, C. J., Nguyen, T. T., Hwang, J., Stewart, S. L., Kwan, A., &

McPhee, S. J. (2007). Provider knowledge and practice regarding

hepatitis B screening in Chinese-speaking patients. Journal ofCancer Education, 22(1), 37–41.

16. Upadhyaya, N., Chang, R., Davis, C., Conti, M. C., Salinas-

Garcia, D., & Tang, H. (2010). Chronic hepatitis B: perceptions

in Asian American communities and diagnosis and management

practices among primary care physicians. Postgraduate Medi-cine, 122(5), 165–175.

17. Khalili, M., Guy, J., Yu, A., et al. (2011). Hepatitis B and

hepatocellular carcinoma screening among Asian Americans:

Survey of safety net healthcare providers. Digestive Diseases andSciences, 56(5), 1516–1523.

18. Sam, J. J., Heathcote, E. J., Wong, D., Wooster, D. L., & Shah, H.

(2011). Hepatitis B learning needs assessment of family medicine

trainees in Canada: Results of a nationwide survey. CanadianJournal of Gastroenterology, 25(3), 127–134.

19. Hutton, D. W., Tan, D., So, S. K., & Brandeau, M. L. (2007).

Cost-effectiveness of screening and vaccinating Asian and Pacific

Islander adults for hepatitis B. Annals of Internal Medicine,147(7), 460–469.

20. Armbruster, B., & Brandeau, M. L. (2010). Cost-effective control

of chronic viral diseases: Finding the optimal level of screening

and contact tracing. Mathematical Biosciences, 224(1), 35–42.

21. Post, S.E., Sodhi, N.K., Peng, C.H., Wan, K., Pollack, H.J.

(2011). A simulation shows that early treatment of chronic hep-

atitis B infection can cut deaths and be cost-effective. HealthAffairs (Millwood), 30(2), 340–348.

22. Centers for Disease Control and Prevention. (2011). Hepatitis B

information for health professionals: Perinatal transmission.

Retrieved February 21, 2013 from http://www.cdc.gov/hepatitis/

HBV/PerinatalXmtn.htm.

23. Chang, M. H., You, S. L., Chen, C. J., et al. (2009). Decreased

incidence of hepatocellular carcinoma in hepatitis B vaccinees: A

20-year follow-up study. Journal of the National Cancer Insti-tute, 101(19), 1348–1355.

24. Apuzzio, J., Block, J. M., Cullison, S., et al. (2012). Chronic

hepatitis B in pregnancy: A workshop consensus statement on

screening, evaluation, and management, Part 2. The FemalePatient, 37(5), 30–34.

25. Smith, E. A., Jacques-Carroll, L., Walker, T. Y., Sirotkin, B., &

Murphy, T. V. (2012). The national Perinatal Hepatitis B Pre-

vention Program, 1994–2008. Pediatrics, 129(4), 609–616.

26. Hu, K. Q. (2008). Hepatitis B virus (HBV) infection in Asian and

Pacific Islander Americans (APIAs): How can we do better for

this special population? American Journal of Gastroenterology,103(7), 1824–1833.

27. Ma, G. X., Shive, S. E., Toubbeh, J. I., Tan, Y., & Wu, D. (2008).

Knowledge, attitudes, and behaviors of Chinese hepatitis B

screening and vaccination. American Journal of Health Behavior,32(2), 178–187.

J Community Health

123