Reframing: Sociopolitical Conditions and Geographical Risk Factors for Hepatitis B Screening and Elimination

Abstract

In the January 2021 issue of Current Hepatology Reports, Wang et al. [1] advocate for policy and guideline changes to increase hepatitis B vaccination, screening, and treatment by addressing current barriers to its elimination in the USA. They describe a significant goal for eliminating hepatitis B as identifying people in the USA living with chronic hepatitis B (cHBV) through surveillance efforts. Ultimately, they recommend universal testing and vaccination for hepatitis B similar to current recommendations for HIV and hepatitis C screening in the USA—which we strongly agree with. However, in regards to approaching the ongoing care needs of those living with cHBV, Wang et al. state that “half of individuals living with chronic HBV infection in the U.S. identify as Asian” and “immigrants from Asia, the Pacific Islands, and Africa comprise a high proportion of people living with chronic HBV infection [1]”. The racial and ethnic categories described by Wang et al. are too broad and vague to be clinically useful in the discussion surrounding hepatitis B elimination. This approach implicates biological underpinnings of race [2] as a factor rather than supporting clinician understanding of geographical risk factors and sociopolitical conditions underlying immigration history [3]. For instance, aggregating Asian-Americans with recent Asian immigrants conflates ancestry with an imagined shared genome that confers HBV risk instead of shared risk attributable to geospatial epigenetic exposures. In fact, true risk factors include immigration from select Asian countries without universal hepatitis B vaccination and healthcare system barriers that may prevent adequate screening. Furthermore, using such broad socially constructed categories in generalization inadvertently furthers biological essentialist supposition that these categories of identities have a predilection for HBV thus perpetuating stigma. The authors astutely assert “failure of risk-based testing for HIV and HCV is that complicated and sometimes stigmatizing risk factors are inadequately assessed in practice [1].” Similarly, the country of origin and path of immigration of a patient are not accurately assessed in clinical settings [4]. Factors including “region of origin, refugee status and decade of study were independently associated with [HBV] infection [3]”and are more representative and arguably less harmful than reifying racial categorizations of risk. In addition to country of origin, route of immigration (refugee, asylum seeker, immigrant, etc.) is important to delineate because higher rates have been noted in those with a history of forced migration [3]. Documentation of this information in health records is admittedly poor: “viral hepatitis surveillance data from the Centers for Disease Control (CDC) indicated that, in 2016, the country of origin was unknown for most HBV-infected individuals living in the US (78%).” [5]. The assumption of homogeneity among those labelled as being of African origin opacifies important differences in HBV prevalence, virologic features, and genotypes. North Africa has intermediate HBV prevalence compared to SubSaharan Africa which also has significant intercountry variability (e.g., the prevalence in South Africa of 9% while prevalence in the Democratic Republic of the Congo of 20% [5]). Significant differences are found in HBV virologic features and genotypes among those variants tracked in West Africa (thought more likely acquired through vertical transmission and at a younger age), versus East Africa (thought This article is part of the Topical Collection on Hepatitis B