Community-based hepatitis B screening: what works?
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- Robotin, M.C. & George, J. Hepatol Int (2014) 8: 478. doi:10.1007/s12072-014-9562-4
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Chronic hepatitis B (CHB) affects over 350 million people worldwide and can lead to life-threatening complications, including liver failure and hepatocellular cancer (HCC). Modern antiviral therapies could stem the rising tide of hepatitis B-related HCC, provided that individuals and populations at risk can be reliably identified through hepatitis B screening and appropriately linked to care. Opportunistic disease screening cannot deliver population-level outcomes, given the large number of undiagnosed people, but they may be achievable through well-organized and targeted community-based screening interventions.
Material and methods
This review summarizes the experience with community-based CHB screening programs published in the English-language literature over the last 30 years.
They include experiences from Taiwan, the USA, The Netherlands, New Zealand, and Australia. Despite great variability in program setting and design, successful programs shared common features, including effective community engagement incorporating the target population’s cultural values and the ability to provide low-cost or free access to care, including antiviral treatment.
While many questions still remain about the best funding mechanisms to ensure program sustainability and what the most effective strategies are to ensure program reach, linkage to care, and access to treatment, the evidence suggests scope for cautious optimism. A number of successful, large-scale initiatives in the USA, Asia–Pacific, and Europe demonstrated the feasibility of community-based interventions in effectively screening large numbers of people with CHB. By providing an effective mechanism for community outreach, scaling up these interventions could deliver population-level outcomes in liver cancer prevention relevant for many countries with a large burden of disease.
KeywordsChronic hepatitis BHepatocellular cancerCancer screening and preventionCommunity-based screening
Chronic infection with hepatitis B virus represents a global public health challenge, given that approximately 350 million people are infected worldwide . Approximately 95 % of infected adults and older children can successfully clear the infection and become immune, but 90 % of infected neonates and 25–50 % of children infected in infancy become chronically infected . Chronic hepatitis B (CHB) can remain asymptomatic for decades, but can lead to cirrhosis or hepatitis B-related liver cancer (hepatocellular cancer, or HCC) in approximately 25 % of cases, explaining the 800,000 deaths/year attributable to the infection and its complications [3, 4]. The Global Burden of Disease study estimated that, of the 8.0 million lives lost to cancer in 2010, HCC was second only to lung cancer in terms of cancer deaths; half of these cases were hepatitis B related .
Over 80 % of liver cancers occur in East Asia and Sub-Saharan Africa ; with increasing international migration, increasingly they are also HCC disease determinants in North America, Western Europe, and Australia, particularly among immigrant populations [6–9]. US Vietnamese males are 11 times more likely to develop HCC than non-Hispanic Whites , and Australian males born in Vietnam are 13 times more likely to develop HCC than other Australians .
Currently available antiviral therapies have the potential to change the natural history of CHB, [11–14] given that screening and treating high-risk populations appear cost effective in studies from the USA , Canada , Australia , and The Netherlands . This is predicated upon people being aware of their status and willing and able to access regular monitoring and treatment , not readily provided through opportunistic CHB screening. Current estimates suggest that two-thirds of Americans  and 40 % of Australians living with CHB  are unaware they are infected; in the European Union this figure may be as high as 90 % , with people undiagnosed (many of them migrants and underserved populations) destined to replicate the natural history of the disease .
Community-based screening could provide CHB screening in populations where limited English proficiency, lower socioeconomic and educational levels, lack of health insurance, and disease stigma preclude their ability to effectively navigate the health care system , with health care provider- and health system-related barriers posing additional challenges . Hepatitis B vaccination is the mainstay of modern hepatitis B prevention. The implementation of universal vaccination has led to dramatic reductions in the overall hepatitis B disease burden, and as of July 2011, 179 countries reported inclusion of the hepatitis B vaccine in their national immunization schedules (up from 31 countries in 1992) . However, vaccination is of no benefit to those already infected, who need to access medical care to mitigate disease outcomes . Disease screening offers people already infected a gateway into care, which needs to remain open until the pool of existing infections is exhausted. While the approach to screening may vary, identifying those infected remains a priority in all countries which have sizable at-risk populations.
This systematic review examines the evidence around community-based hepatitis B screening, seeking to better understand the common factors of success and challenges.
We used Rein’s definition of community-based hepatitis B screening programs, as those that “systematically offer HBsAg testing to all members of a population group based on country of birth or participation in high-risk behaviour.” This definition excludes “screening conducted by state and local public health departments, including screening performed by refugee health programs” .
Whitehead views community-based interventions (CBIs) as alternatives to “top-down” interventions designed to improve the health and/or socioeconomic status of the world’s poor . Based upon who initiates, drives, and carries out the intervention, he proposes seven types of community-based interventions, ranging from completely self-sufficient programs, driven and funded exclusively by the community (type 1) to those planned and implemented as equitable partnerships by the community in collaboration with an external change agent (type 7). The continuum includes interventions involving the recipient community to different degrees, from merely program recipients to active partners in program implementation, with the “ideal” CBI being a true partnership between technical experts and the communities they serve. The former contributes conceptual strength, comprehensive design, and rigorous implementation, while community endorsement and support increase the likelihood of program incorporation into its sociocultural context, strengthening sustainability and diffusion .
We graded the effectiveness of community engagement as “high” or “low” according to the programs’ self-reported capacity to establish meaningful community partnerships.
Community clinic model (CCM), with screening integrated into routine primary care services; the screening decision is informed by risk factor review, with doctors providing counseling and testing referrals.
Community outreach model (COM), which involves screening in community settings (i.e., health fairs and community centers), with testing provided by phlebotomists and with volunteers providing logistical support at screening events.
Partnership and contract model (PCM), in which screening is contracted to general health screening companies (such as wellness campaigns targeting Asian employees).
Outreach and partnership model (OPM), which combines elements of COM and PCM; screening takes place in COM-type settings, with planning activities coordinated by a community organization with direct links to the target community.
Screening model employed and extent of community engagement
Program’s target population
Program components and services provided
Hepatitis B screening programs identified by the literature search and their key features, components, and outcomes
Project name/target population/aim/duration
Agent delivering intervention/mode of service delivery
Program components and services provided
Outcomes and recommendations
Community engagement extent (L/?/H) and model used
Milne et al. 
Population of Kawerau, North Island, New Zealand
Hepatitis Foundation (NGO) in Bay of Plenty, North Island, NZ
Hepatitis B screening
Vaccination for those susceptible
7,901 people screened (93 % of the population of Kawerau)
Hsu et al. 
Hepatitis B initiative: targeting AAPI in Boston
Goals: educate, empower, and eradicate HBV in affected communities
Reported activity from 1997 to 2002
Student volunteers from Harvard University’s Public Health and Medical Schools (and other local universities)
Awareness campaign using posters, info kits for local media and schools, talks, health fairs, radio, and “guerrilla media” events
Free testing at community health center
997 free screenings; 39 % of susceptible offered free vaccination; 59 % completed 3 shots
Strong and committed student leadership, annual recruitment and training of student volunteers
Now also targeting African Americans
Lee et al. 
Collected data on HBV status of AAPI migrants in Colorado in 2002
Aim: address high HCC rates in Korean and Vietnamese communities
Community partnerships with Korean and Vietnamese communities, the Asian Pacific Development Center, and Colorado Dept. of Health
Hepatitis B testing at community health fair (9Health Fair)
Educational brochures distributed in churches, temples, and Korean stores
Advertising: local media, posters
Convenient testing sites and bilingual volunteers used
Of 1,117 AAPI fair participants, 161 were screened; 7 (4.3 %) HBsAg +ve
Identified a need for effective HBV prevention programs to reduce HCC incidence and health disparities
Robinson et al. 
HepBFree: NZ Hep B screening and follow-up program, ongoing
Targeted 15–40-year-old Maori, Asians, and Pacific Islanders in Auckland and Northland regions of New Zealand
Hepatitis Foundation (community screening) and Northern Region Hepatitis Consortium (opportunistic GP screening)
Screening in local facilities (marae), mobile caravans, and local GP offices
Ethnic specific outreach in community settings
Hep B screening
Follow-up and care
177,000 tested, 5.7 % HBsAg +ve; highest prevalence (13 %) in Tongans, 6.2 % in Asians, 5.6 % in Maori
Low uptake (10 %) for GP model invitation letters
Multiagency collaborations and culturally appropriate services needed to establish community trust
Chen et al. 
Measured HBV and HCV seroprevalence in Taiwanese aged ≥18 years
Screening results 1996–2005
Liver Disease Prevention and Treatment Research Foundation, Taiwan
Screening at “screening stations”
Limited details re community engagement: invites to attend screening stations by mail and via local media
Tested liver function, anti-HCV, α-fetoprotein
164,302 screenings, 17.3 % HBsAg +ve; 4.4 % anti-HCV +ve
Intercounty differences in prevalence rates observed
Hsu et al. 
Aim: educate, test, and vaccinate local Asian population in Montgomery County, Maryland
Oct 2005–July 2006
Partnership of 9 faith/community organizations, AAPI community, care providers, academic institutions, and local Dept. of Health and Human Services
Educational activities for care providers and local community reached via language schools, community centers, and health fairs
Free community screening
807 subjects from eight AAPI groups tested
Highest infection rates in Cambodian (7 %) and Thai (7 %)
% susceptibles highest in Asian Indians (70 %) and Thai (56 %)
Infection rates and knowledge scores negatively correlated; targeted HBV education needed
Marineau et al. 
Filipino community, Hawaii 2005–2006
One-off health fair
Key stakeholders from Filipino health care and church communities
Outreach via community media, churches, and grassroots effort
Free blood tests for hepatitis B and C
Abnormal results sent to individual’s health care provider
500 attended, 167 tested, 5 HBsAg +ve
Knowledge gap re HBV transmission, risk factors, immunization
Culturally sensitive interventions need to factor in language, cultural, and economic barriers to care
Hepatitis B initiative-DC
Targeting Asian American adults in Baltimore–Washington DC to prevent HCC
Piloted a faith-based HBV program with Korean church
Culturally and linguistically appropriate outreach materials
Developed social support networks
Provided HBV education
Screening and vaccination events
Offered technical assistance for other campaigns
1,775 people tested, 61 % susceptible (79 % completed 3-shot vaccine series), 2 % HBsAg +ve
Culturally tailored booklets on HBV
Integrating traditional beliefs in educational programs key factor for success
Program extended to nine Korean and Chinese churches and via pastors’ conference
Tipper and Penman 
Robotin et al. 
Targeting Chinese- and Vietnamese-born Australians in SW Sydney
Cancer Council NSW
Partnership with local Division of General Practice, specialists, RACGP, community leaders, and associations
CHB screening and F/U at GP surgeries
CHB screening and F/U protocol
Community awareness and education via ethnic media and events
CHB screening and treatment found to be cost effective
Poor initial results prompted extensive community and provider consultation
1,200 people enrolled in registry; community engagement key factor
Chang et al. 
Three for Life
Targeted foreign-born Chinese Americans in the Richmond District of San Francisco
Asian Liver Center and SF Department of Public Health
Testing and vaccination at SF Richmond District YMCA
Free HBV testing
Screening and subsidized vaccination
Education using bilingual brochures
1,106 people tested; 9 % were HBsAg +ve, 53 % susceptible (85 % completed vaccination)
Program replicated in LA, San Diego, Arizona, Hawaii
Rein et al. 
Audit of US community-based programs offering systematic CHB screening based upon COB or high-risk behavior
Collected information on service delivery of CHB community screening
Collected information on location, services provided, groups targeted/HBsAg prevalence among those screened
55 possible programs identified, 31 reached; 21,817 screened in 1 year, 8.1 % HBsAg +ve
Seroprevalence highest in Vietnamese (9.7 %), Chinese (8.0 %)
90 % of programs offered HBV screening and vaccination, 74 % HBV education, 71 % referrals, 29 % treatment
Bailey et al. 
Overall strategy and evaluation by Gish and Cooper 
San Francisco Hep B Free (SFHBF)
Targeting API community in SF
Aim: to make SF the first hepatitis B-free city in the USA
Results detailed for 2007–2009
Grassroots, community-based health initiative
Key players: Asian Liver Centre, SF Dept. of Public Health, API community, ethnic media, California Pacific Medical Center, and Sutter Pacific Medical Foundation
Culturally targeted awareness-raising promoting testing and vaccination
Used ethnic media, brochures, Internet resources
Offered free testing and low-cost vaccination
Used bilingual hospital/clinic staff and volunteers
>400 community partners
Engaged >150 organizations; reached 1,100 care providers and >200,000 people
Providing care for uninsured challenging
Comprehensive program evaluation included community impact
Hwang et al. 
Aim: identify HBV and HCV prevalence among AAPIs and facilitate specialist referral rates in Houston, TX
One-off testing at community health fair
Coalition of community and academic organizations
Testing advertised via newspapers, TV, community networks
Hep B +ve people phoned and sent customized in-language letters and provided referrals
202 people screened, 118 AAPIs; 13.6 % had CHB; 92 % unaware of infection
Successful referrals: 83 % for CHB, 100 % for HCV
Recommended a population-based viral hepatitis registry
Lee et al. 
Part of Healthy Asian Americans Projects
Aim: study HBV prevalence as baseline to devise education and interventions for AA in Michigan
Screened Chinese, Korean, Vietnamese AAPI at community fairs
Program delivered by University of Michigan in collaboration with local community and health service organizations
Advertised via flyers, health fairs, community media
Free HBV screening for HBV surface Ag and Ab
Provided community education through 30 articles in ethnic media and brochures translated into six languages
567 participants tested at 8 health fairs; screening rates 36–94 %
~6 % had CHB, 40 % susceptible
>95 % migrants, 45 % without health insurance
Recommended language-specific, culturally sensitive educational interventions
Sheu et al. 
San Francisco Hepatitis B Collaborative (SFHBC)
Targeting APIs in San Francisco
Focused health disparity curriculum developed by students at UCSF and aligned with SFHBF and Department of Public Health efforts
Recruitment via language-concordant media, email, provider referrals, community presentations
Student clinics offered free screening and low-cost vaccinations/referrals
477 students educated and screened; 804 participants from 14 countries
63 % participants had limited English proficiency, 55 % had annual household income <25,000 USD; 46 % were uninsured
10 % HBsAg +ve, 44 % susceptible
Chao and So 
Early results described by Lin 
Jade Ribbon Campaign (JRC)
Targeting AAPI in San Francisco
Aim: raise disease awareness and promote screening
Asian Liver Center working with >400 community partners
Together with SF Department of Public Health and Chinese media, formed the basis for the SFHBF campaign
Raised awareness among AAPI and health professionals
Provided access to vaccination and incorporated API values in program
Outreach: ethnic media, educational brochures, and web-based resources
Screened 12,308 people; 85 % vaccine completion rate
Recommended screening second-generation AAPIs
Program: national hepatitis B model, precursor of San Francisco Hep B Free campaign
Kallman et al. 
Aim: HBV, HCV prevalence in a Vietnamese community in Virginia
Testing at a local doctor’s office and annual Vietnamese health fair
Demographic and clinical data collected
No educational component described
322 Vietnamese tested: 2.2 % anti-HCV +ve, 9.3 % HBsAg +ve
Overall low HBV vaccination rates
Suggested HBV testing by risk factor profile, not abnormal LFTs
Aim: to promote screening and access to Rx in Chinese and Korean Americans; BfreeNYK targeted also other nationalities at higher risk
The New York City pilot program:
Coalition-driven initiative (five key partners) driving comprehensive effort to decrease HBV disparities in Asian American (AA) community
Engaged health provider organizations, Department of Health, NY University
Community outreach and education
Multimedia campaign in ethnic media
Free screening and vaccination
Screening and F/U using standardized protocols
Screened 9,000 people; 18 % tested +ve, 57 % linked to care
Findings informed CDC HBV screening guidelines
Costs per participant: screen and vaccinate, 273 USD; education outreach, 139 USD; 1,344 USD/year/infected case
Now funded as a National Center of Excellence
Rein et al. 
Describes outcomes of a specific pilot program funding community-based hepatitis B screening programs
July 2008–Jan 2009
Screening and program data collected from five funded programs to identify different models of service delivery, demographic data on those screened, and cost/screen
community clinic (CCM):
community outreach (COM)
partnership and contract (PCM)
outreach and partnership (OPM); community screening supported by community organization
Programs screened 1,623 participants; 54.2 % without insurance/regular Dr
CCM program screened fewest participants with cost/screen 40 USD; PCM screened most with cost 280 USD
Best to identify populations amenable to clinical versus community outreach
Richter et al. 
Testing of Turkish residents of Arnhem, The Netherlands for hepatitis B and C
Local hospital’s infectious disease unit, migrant resource center, Turkish GPs, and Municipal Public Health Service
Customized resources: poster, brochure, video, website, and hotline
Advertising via ethnic media, mosques, Turkish businesses
F/U: own GP and hospital clinics
Counseling and contact tracing
15 educational meetings, 450 participants
709 people screened, 18 with CHB, 2 with active HCV infection
Screening process cumbersome; suggested integrating screening into routine clinical care
Ma et al. 
Church-based HBV screening and vaccination program for Korean communities in Philadelphia and New Jersey
Center for Asian Health (CAH) at Temple University and the Asian Community Health Coalition (ACHC): academic–community partnerships
Goals: increase HBV knowledge and awareness, screening and vaccination, and health care utilization in CHB
Community-based participatory research, and delayed HBV intervention in controls
Pilot: 2 churches in intervention, 2 as controls
Low-cost HBV test, vaccination, and consultation
Health care providers offered patient navigation
330 participants; flexible clinic hours
Significant increase in HBV screening in intervention group
Challenges: financial constraints, access for under/uninsured, limited English proficiency
Subsequently awarded 5-year grant to implement a full-scale program in 30 Korean churches in PA and NJ
Veldhuijzen et al. 
Campaign targeting Chinese community in Rotterdam
Rotterdam Municipal Public Health Service, Erasmus Medical Center, and National Hepatitis Center
Disease awareness activities through outreach
Free HBV testing at outreach locations
Guideline-based specialist referral
1,090 Chinese migrants tested; 8.5 % (92) HBsAg +ve, 38 % referred to specialists; 15 started antivirals
A convenience sample answered before–after knowledge questions; found improved knowledge score postintervention
Perumalswami et al. 
Hepatitis Outreach Network (HONE)
Targeting foreign-born individuals at risk of hepatitis B or C in NYC
Collaboration between Mt. Sinai Med School, NYC DoH, and CBOs
Publicity (radio, TV, PSA, papers)
Screening at community events
Linkage to care using patient navigators
1,603 people educated and screened at 25 events involving participants born in 68 countries
76 diagnosed with CHB, 75 with HCV
Success factors: engaging CBOs, publicize events, relevant languages, and patient navigators
Van der Veen et al. 
RCT in Turkish migrants aged 16–65 in The Netherlands
Rotterdam Municipal Public Health Service, Erasmus Medical Center, University Medical Center
Culturally tailored intervention via the Internet
Participants assigned to: BCT (behaviorally and culturally tailored)/BT (behaviorally targeted) or GI (generic info) arms
Free HBV screening offered in each arm
10,069 persons invited, 1,512 (15 %) logged onto the website, 623 tested
Screening uptake was 44, 46, and 44 % per arm
BCT had favorable intervention effects, but no added value on screening uptake compared with BT
Woo et al. 
Testing for hepatitis B (year 1) and B and C (year 2) by a single center at a community fair over 2 years
Schiff Center for Liver Diseases, Miami University, FL
Free screening offered to all Asian Culture Festival participants aged 18–65
Free screening for hep B and C provided by multilingual Schiff Center staff
+ve tests mailed results and F/U phone calls made
Year 1: 1.6 % (173) attendees tested (31 % Asian descent), 1 HBsAg +ve; year 2: 2.6 % (231) tested (22 % of Asian descent); 3 HBsAg +ve
50 % HBsAg +ve contactable for F/U
Screening incentives ineffective
Xu et al. 
Targeting Korean and Chinese American communities in LA County
Asian Pacific Liver Center (APLC) in LA: not-for-profit organization providing community outreach
Free screening events advertised in ethnic media and places of worship
Lectures on CHB; test results mailed
HBsAg +ve were encouraged to get medical F/U
Comprehensive work-up if seeing specialists
7,387 people screened (93 % Korean/Chinese) at 63 events
CHB prevalence 5.2 %; 99 % of 387 +ve born overseas, 22 % spoke no English; 26 % were insured
Most F/U if insured (57 %) and having active disease
Zuure et al. 
Aim: to investigate prevalence and determinants of HCV and HBV infection in Egyptian FGM in Amsterdam
All Egyptian organizations in the Amsterdam area contacted and KOL enlisted
Public Health Service of Amsterdam (PHSA)
Viral hepatitis educational sessions delivered by Arabic educators
Free screening sessions at Egyptian meeting places and PHSA
Infected participants referred for F/U
11 educational and screening sessions; 465 people tested
HBsAg +ve 1.1 %, all genotype D
2.4 % HCV Ab +ve
Risk factors: older age + parenteral antischistosomal therapy
Two US papers reported aggregate results of US-based community screening programs: one reported outcomes of a nationwide audit of community-based hepatitis B screening programs ; the other described four models of community-based screening , which we also used for consistency.
Screening model employed and estimated degree of community engagement
An OPM was employed by 13 programs. Some were large one-off initiatives (e.g., screening the entire population of Kawerau, New Zealand , the adult population of Taiwan , the Asian American and Pacific Islander migrants in Colorado, USA ), while others operated for a longer duration, such as programs in California (Hep B Free  and the Jade Ribbon Campaign in San Francisco  and a program run by the Asian Liver Center in Los Angeles ) and the BFreeNYC program in New York [34, 35]. Medium-sized OPM programs screened 1,000–2,000 participants: the Hepatitis B Initiative in Washington, DC , the Hepatitis Outreach Network (HONE) program in New York , and the Three for Life initiative in San Francisco . Smaller OPM programs (screening <1,000 people) were run in conjunction with faith-based community organizations (i.e., Korean churches in New Jersey  and Montgomery County in Maryland ) and through health fairs in Michigan . In addition to hepatitis B screening, OPM programs included specific outreach and educational activities, including hepatitis talks, distribution of printed materials, and web-based resources and effectively used ethnic media for publicity.
COMs provided screening through one-off events at community health fairs and/or community centers. All were US based and targeted Asian Americans and Pacific Islanders in Boston , Houston , Miami , and Hawaii . No ongoing community engagement was documented, and they reached between 100  and 1,000 people .
The HepBFree program in New Zealand used community screening with outreach in rural areas and screening in general practices (GPs) in Auckland [46, 47]; the latter was also employed by a program in Virginia, which combined testing at a local doctor’s surgery with testing at an annual fair .
Multiple methods were employed by the Dutch initiatives: testing was offered in community centers, schools, churches, and the Municipal Public Health Service in Rotterdam and Arnhem [49, 50]; an Internet intervention was trialled in Rotterdam , and screening at Egyptian meeting places and the Public Health Service was offered in Amsterdam .
In San Francisco, clinic-based screening was offered by the Three for Life program  and through clinics run by medical students. The Australian program offers primary care-based screening by GPs in Sydney [53, 54].
Sufficient information allowed us to ascertain a high degree of community involvement in eight programs; the Australian B Positive program commenced as a clinical intervention delivered by general practitioners and was repositioned as a community–agency collaboration to increase program visibility and participation rates .
Program target population
The target populations ranged from country-wide hepatitis B and C screening in Taiwan  to city-wide screening in New York (BFreeNYC ) and San Francisco (Hep B Free) programs . Screening targeted people of Asian and/or Pacific Islander heritage in Boston  and Maryland [39, 40] and the HONE program in New York . The HepBFree program in New Zealand targeted the local Maori population, as well as Asian and Pacific Islander residents [46, 47]. Korean and Vietnamese Americans were the target population in Colorado , Korean and Chinese Americans in the Baltimore–Washington area, LA County, and San Francisco [31, 33], Chinese, Korean, and Vietnamese Americans in Michigan , the Filipino community in Hawaii , and Chinese–Korean communities in Philadelphia and New Jersey . In Australia, the B Positive program targets Chinese and Vietnamese residents in Sydney , while Dutch programs targeted Chinese and Turkish migrant communities of Rotterdam and Arnhem [49–51], and Egyptian migrants in Amsterdam .
Some US-based programs were promoted and supported by faith-based organizations [36, 39, 40], and some were offered by clinical groups offering education and testing at community events [30, 43, 45]; while some screened all participants (in Miami, FL and Houston, TX) [43, 44], others based testing decision on risk factors (Colorado) .
In New Zealand, testing was offered at Maori meeting places (marae), mobile caravans, and through GP offices . In Australia, it is offered through GP offices , and in The Netherlands at community sites and Municipal Public Health Services [49–52]. The Taiwanese program invited participants to attend clinics at designated screening stations .
Most programs were the result of collaborations between academic institutions or clinics and community-based organizations; some also had support from local public health units. The number of community partners ranged from >400 in the case of San Francisco Hep B Free  to just the agency delivering the intervention [41, 44].
Two reports described controlled intervention studies: one was a church-based HBV screening and vaccination pilot program in Philadelphia , the other a randomized controlled trial (RCT) conducted in The Netherlands .
The US pilot study recruited 330 Korean Americans through churches in the intervention area, and randomized them to either HBV education and HBV testing at enrollment (the intervention group), or to a delayed intervention, where these services could be accessed at a later stage (the control group). A statistically significant increase in HBV screening was observed in the early intervention group compared with controls .
The Dutch study recruited first-generation Turkish residents of Rotterdam to a culturally tailored Internet-based intervention aiming to promote HBV screening . Through a clustered randomized design, participants were computer-randomized to receive either a behavioral tailoring intervention (BT), one combining behavioral and cultural tailoring, or just generic online information. An invitation letter explained the intervention and directed recipients to the project’s website, which “streamed” participants into one of the three intervention groups. Approximately 15 % of those sent letters logged onto the website, and overall screening uptake was similar (~45 %) across all three intervention groups . This was the first documented intervention using the Internet to increase hepatitis B testing rates in a migrant community; given the low participation rate, these findings need further validation .
The remaining 25 papers describe nonrandomized screening interventions which incorporated some form of community outreach and education in addition to screening.
Program components and services provided
Programs publicized hepatitis B screening using ethnic media and flyers/posters; all but 3 (88 %) offered community education using lectures and workshops, educational brochures, articles published in ethnic newspapers, and web-based resources. City-wide programs in San Francisco and New York had sophisticated multimedia campaigns and marketing strategies and developed program-specific websites with tailored educational information.
Vaccination (either free of charge or subsidized) was offered by 12 programs (48 %); most US programs and the New Zealand programs offered it. Vaccination was not included in the Dutch, Taiwanese, and Australian programs, which may be due to the ability to access vaccination through other means.
One-year follow-up was provided by the two controlled intervention studies, with the San Francisco Hep B Free  and the BFreeNYC  programs also providing follow-up, constrained by limited resources. Long-term follow-up is offered by the New Zealand  and Australian programs .
The Dutch [49–52], Australian , and New Zealand programs  as well as some US programs offered linkage to care [35, 43, 56] or employed a patient navigator to negotiate the medical system on the patients’ behalf [41, 57]. Programs in Michigan , Texas , Virginia , Florida , and Southern California offered referrals to insured participants ; 71 % of the US programs identified by Rein et al.  provided treatment referrals, with 29 % providing antiviral treatment.
A complete CHB care package encompassing hepatitis B screening, HCC surveillance, ongoing disease monitoring, and treatment was offered by BFreeNYC  and San Francisco Hepatitis B Free  and programs in New Zealand [46, 47], Australia , and The Netherlands .
Some programs provided hepatitis C testing [29, 37, 43, 45, 50, 52], contact tracing (the New Zealand program)  or physician education about HBV (some US and the Australian program) [32, 34, 54] or disease advocacy.
San Francisco seeks to become the first HBV-free city, with the Hep B Free Campaign offering screening, vaccination, and treatment to all Asian and Pacific Islander residents (representing 30 % of its population) . To improve disease surveillance, the city established a population-based chronic hepatitis B registry, with enhanced disease surveillance ascertaining transmission patterns and participants’ ability to access hepatitis care . The Australian program includes a CHB disease registry to optimize patient follow-up and collect population-level data on CHB disease characteristics [53, 54].
Most interventions reported results in terms of the number of people reached, number of screenings performed, and estimated HBsAg prevalence overall and by ethnic groups.
The most comprehensive outcome measures were documented by the BFreeNYC program, which also conducted a random survey of Asian Americans 2 years after the program ended . They documented a 34 % increase in new CHB cases reported from areas with a high Asian population during its 4 years of activity, with 57 % of people with CHB remaining in care until the end of the program . BFreeNYC reached over 1 million people, provided education for 11,000, screened approximately 9,000 people, and diagnosed and managed 6 cases of HCC and 22 of end-stage liver failure .
During its first 2 years, the San Francisco Hep B Free program reached over 200,000 people and tested 3,315 Asian–Pacific Islanders at standalone screening sites  and 12,000 people through the Jade Ribbon Campaign ; 6.5 % were chronically infected and referred for follow-up care . The largest “yield” of screening occurred in higher education establishments with a large proportion of Asian students, Asian street festivals and fairs .
The HepBFree New Zealand program tested 177,000 people, 5.7 % being HBsAg-positive; significant regional and ethnic differences in HBsAg-positive rates were observed among Maori (5.6 %), Pacific islander (7.3 %), and Asian people (6.2 %) . Successful outreach raised CHB community awareness and led to effective partnerships with local health care providers [47, 59].
With few exceptions, programs did not report the size of their target population, but the Kawerau study in New Zealand was able to test 93 % of the town population, finding HBsAg prevalence rates of 4.2 % among European residents and 18.2 % amongst the Maori population .
Rein et al.  reported results for five US screening programs screening over 1,600 participants over 7 months; 95 % of those screened were foreign-born, and most (56 %) did not have a regular medical practitioner or health insurance (54 %).
Screening uptake was highest for programs using an outreach and partnership model (OPM) [31, 33, 37, 59]; the COM at community fairs yielded fewer screenings [30, 34, 45]; screening offered by clinical experts had low uptake. The Healthy Asian American Projects initiative in Michigan targeted Chinese, Korean, and Vietnamese Asian Americans at eight health fairs over 2 years; despite wide advertising, education, and distribution of brochures in six languages, screening rates remained low, attributed to “resistance by Asian Americans to participate in clinical studies” . Similar outcomes were documented by a program in Florida, where free access to specialists and a screening incentive led to 1.6 and 2.6 % of participants taking up screening in the first and second year, respectively .
Successful completion of hepatitis B vaccination was monitored by the Hepatitis B initiative in Boston (59 %)  and Washington (79 %) , as well as the Three for Life (85 %)  and Jade Ribbon campaigns in San Francisco .
Linkage to care (beyond vaccination) was offered by 11 programs, mostly in countries with socialized medicine: in Europe 2 (or 66 %) out of 3 (or 66 %) and in Australia–New Zealand 2 (or 66 %) out of 3 (or 66 %) programs offered linkage to care, compared with the USA, where 6 (30 %) out of 20 did so. In five US screening programs, 54 % of participants had no insurance cover and/or no regular health care provider ; in Michigan 45 % , in San Francisco 46 % , and in Los Angeles 74 %  of people accessing the programs were uninsured.
BFreeNYK was able to maintain 57 % of its 1,100 CHB patients in care until the end of the 4-year program , but high rates of loss to follow-up occurred in other programs: just 77 % of the 7,000 people screened by the Asian Pacific Liver Center in Los Angeles could be traced 6 months later .
Cost of care estimates were provided by the BFreeNYC program, with annual cost per infected patient estimated at 1,598 USD . Rein et al.  compared the costs of four types of community screening in the USA and found that CCM was the least costly per screened participant, albeit screening fewer participants, while the partnership and contract model (PCM) screened most participants, at the highest cost per screening.
Over the last 30 years, many initiatives have sought to increase hepatitis B screening rates in high-risk communities, by targeting migrant populations in the USA, Australia, and The Netherlands, as well as indigent populations in New Zealand and Taiwan. A few programs successfully reached large numbers of people, but the majority screened modest numbers: the 31 programs active across the USA in 2008 screened a total of 21,817 people, or approximately 700 people per program. Even assuming seroprevalence rates of 10 % in the target populations, this translates into just 2,000 new CHB diagnoses. Given that the USA has approximately 2 million infected people , of whom 60 % (i.e., 1.2 million) are unaware of their infection , opportunistic screening cannot make a significant impact in populations with low access to medical care , making community-based screening a more attractive option. Successful programs achieved significant buy-in from target communities, delivering culturally appropriate educational initiatives and offering comprehensive care packages, as exemplified by the BFreeNYC , San Francisco Hep B Free , and the New Zealand [46, 47] and Australian programs [53, 54].
Large US programs grappled with the challenge of offering ongoing care to uninsured participants, as two-thirds of people not attending follow-up arrangements had no financial means or medical insurance . The BFreeNYC program was the only US program able to provide free treatment over its 4-year existence ; the San Francisco programs faced great logistical challenges to provide access to care to uninsured . Availability of free medical care did not ensure successful referral to care: one-third of patients eligible for treatment in a Dutch study did not see a specialist , and the uptake of the Sydney-based program was low initially, despite providing free screening and treatment .
Successful programs found innovative ways to leverage organizational and individual resources, including garnering political and practical support [34, 62]. To ensure program sustainability, costs and outcomes require close scrutiny; while CHB screening integrated with primary care services is less labor intensive and less costly, evidence from the USA  and New Zealand  suggests it delivers lower screening rates. Conversely, outreach models deliver greater community involvement, but at higher costs. The New York program suggested main-streaming these activities into primary care and educating primary care providers .
Key program challenges included the high cost of screening and limited ability to offer affordable long-term care, so new approaches and financing arrangements are critical to make access to care a reality for many. Most US programs relied upon volunteer support and commitment from communsity-based organizations, and reliance on their continued support may be unsustainable in the long run [34, 55]. Given that low community awareness, widespread misinformation, and persisting cultural stigma remain significant barriers, sustained community awareness-raising campaigns, complemented by culturally appropriate care delivery models, are acutely needed .
The noted “resistance by Asian Americans to participate in clinical studies”  prompted recommendations for educational interventions to be developed in native Asian languages, rather than using translated English resources . Although previous research suggested that Asian Americans prefer to access health information from health care providers speaking their language , programs providing access to health specialists speaking Asian languages and offering screening incentives did not achieve a great deal of success .
The linkage to care and treatment is critical to ensure program buy-in and effectiveness, and this poses serious challenges in many countries with high CHB disease prevalence, but with costs of antiviral therapies likely to fall in the future, a community-based model of CHB diagnosis could still provide the impetus for offering a large-scale treatment program for a larger population.
Factors ensuring effective program delivery
Community awareness and education
Using community networks and grassroots work to promote programs
Ethnic and language-specific program promotion
Maintaining an ongoing awareness campaign
Culturally and linguistically tailored outreach materials
Making effective use of ethnic media to publicize events and resources
Screening models incorporating community outreach
Bilingual or culturally aware staff delivering intervention
Offering flexible and varied screening options at suitable times and places
Developing and implementing standardized screening and follow-up procedures
CHB monitoring and treatment protocols integrated with medical records
Integrating CHB screening into routine care
Health provider education, training, and support
Access to patient navigators to provide linkages and patient assistance
Political endorsement and support
Advocacy at local and national level
On the “wish list”
Ability to provide affordable linkage to care, including ongoing disease monitoring and treatment
Large and renewable volunteer pool (or ideally funding for staff)
Disease register to facilitate follow-up and epidemiological data collection
This review suggests that community-based hepatitis B screening is an active area of research and experimentation in countries with large migrant populations, such as the USA, The Netherlands, New Zealand, and Australia. Successful programs used a range of strategies to increase community awareness and knowledge and leveraged community partnerships to achieve significant community engagement and penetration. They combined HBV education, community empowerment, and collaborative partnerships, and they incorporated the target population’s values in program design and implementation. In addition to screening and vaccination, “ideal” programs must offer access to ongoing care and support, inclusive of antiviral therapy and HCC screening.
Many unanswered questions still remain regarding optimal funding mechanisms, program sustainability, the best way of ensuring linkage to care, and how to develop, select, and implement the most effective strategies of screening, disease surveillance, and community engagement and education.
J.G. is funded by the Sydney Medical Foundation of the University of Sydney and by grants from the National Health and Medical Research Council of Australia (project grant 1047417 and programme grant 1053206), the Cancer Council New South Wales (Strategic Research Partnership grant SRP 08-03), and the New South Wales Cancer Institute (grant 11/TRC/1-6).
Compliance with ethical requirements statement
Ethics approval for the B Positive program has been granted by the South West Sydney Area Health Service. This paper is the result of desktop research, as we conducted a review of the published evidence of existing programs.
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