Viral hepatitis, or inflammation of the liver, is one of the most common infectious diseases in the world. Hundreds of millions of people live with chronic hepatitis and, because the infection often progresses to liver failure and liver cancer, millions die from it every year.

But it doesn't have to be that way.

"There are established treatments for hepatitis as well as vaccines for prevention. We can keep people from dying and from contracting these infections in the first place," says Lewis Roberts, M.B., Ch.B., Ph.D., a Mayo Clinic gastroenterologist and hepatologist. "Unfortunately, barriers are preventing the people who most need this care from receiving it."

In the U.S., the disease is most common among communities of people who recently immigrated from sub-Saharan Africa and parts of Asia and Eastern Europe. Dr. Roberts leads a research group trying to better understand, treat and prevent viral hepatitis in communities of people who most need this medical care.

The Advancing the Science Team recently sat down with Dr. Roberts and Essa Mohamed, Ph.D., a Mayo Clinic researcher who works with Dr. Roberts, to ask them about their research and what they hope to achieve through their work to close the gap in health disparities.

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ADVANCING THE SCIENCE: How do people catch viral hepatitis, and how does it lead to liver failure or cancer?

Dr. Roberts: There are three main types of viral hepatitis — types A, B and C — and one of the main differences is how they are transmitted. Type A is foodborne and causes temporary illness in most people but very rarely death or chronic illness. Types B and C are both acquired by exposure to blood or blood products, or unsafe injections. Type B in particular can be transmitted sexually. It can also be passed by blood or other bodily fluids from a mother to her baby during childbirth, or between people with close contact to young children.

Chronic viral hepatitis causes scarring or cirrhosis of the liver, which damages the liver and keeps it from functioning as it should. This scarring can progress to liver failure or cancer.



Dr. Mohamed: Historically, hepatitis infections have often been neglected. A lot of people who have hepatitis are not aware that they have it. Eventually, when these patients come into the clinic to find why they are having abdominal pain, the disease is often already at a late stage.

ADVANCING THE SCIENCE: How can viral hepatitis be treated or prevented?

Dr. Roberts: Both hepatitis A and B can be almost entirely prevented by vaccination. There is a recommended vaccination schedule starting at birth, followed by infant vaccination. In many low-resource countries, these vaccinations are often not done, or the series is not done completely.

There is no vaccination for hepatitis C, so the best way to avoid it is to avoid behaviors that can spread the disease, such as injecting drugs using shared needles or getting tattoos using unsterilized needles. In the U.S., the Centers for Disease Control and Prevention recommends screening all adults for hepatitis C and all people who were born or lived in a country with a high prevalence of hepatitis B. These recommendations help to identify people at higher risk for liver failure or cancer so they can be enrolled in surveillance and get regular testing. Early detection allows more effective treatment and improves long-term survival.

ADVANCING THE SCIENCE: What are the barriers to getting medical care for viral hepatitis? How do these contribute to health disparities?

Dr. Roberts: The barriers to overcoming hepatitis include low vaccination rates, lack of awareness of the hepatitis infection and decreased access to treatment. Lack of insurance and lack of access to care also prevent evaluation and effective treatment. In addition, a lack of trust in the health care system sometimes drives people to seek complementary or alternative care, delaying diagnosis and treatment.

Dr. Mohamed: Immigrant populations that move to the U.S. from areas endemic for hepatitis B and C, such as sub-Saharan Africa and parts of Asia and Eastern Europe, are at higher risk. Here in Minnesota, if you're from one of these immigrant communities, you're three or four times more likely to develop liver cancer than the rest of the population. It's quite alarming.

ADVANCING THE SCIENCE: What do you hope to achieve through your hepatitis research?

Dr. Roberts: The overall goal of our work is to achieve a world without viral hepatitis. Our research group is actively involved in studies to understand the prevalence and frequency of chronic viral hepatitis in immigrant communities in the U.S. We're conducting community-based studies to enhance awareness of viral hepatitis and its consequences. We want to better understand the effects of immigration on rates of viral hepatitis and liver cancer.



Dr. Mohamed: My entire Ph.D. work with Dr. Roberts has focused on community-based research with immigrant populations. Three of my four grandparents have succumbed to liver disease related to viral hepatitis. And my remaining grandpa has it, as well. This is something I'm willing to push for my entire career. Push and push to improve health equity for all people through hepatitis screening, prevention and treatment, even if they move from one place to another. There has to be a safety net.

ADVANCING THE SCIENCE: Is there stigma related to hepatitis diagnosis? How do you manage this issue when working with communities?

Dr. Roberts: There is a lot of stigma surrounding the diagnosis of viral hepatitis, usually from misunderstanding how it is transmitted. Many people try to keep their infection a secret, resulting in delays in treatment and worsening of their disease, as well as increased risk of transmitting the disease to other people.

Dr. Mohamed: The communities are very tight-knit, and word travels fast. The implications of a positive diagnosis for hepatitis could be quite daunting. Other people might see it as: "This person is being punished for their transgressions."

One of the barriers we need to address is to make sure there is the assurance of confidentiality. When we take blood samples, we assure people that when someone works with your sample, the only thing they see is a number associated with a vial.



We work with our community-engaged research advisory boards to make sure our message is clear before we go out to try to recruit participants for these studies.

ADVANCING THE SCIENCE: Why is it important for viral hepatitis research to be driven by communities?

Dr. Mohamed: Without the community's involvement or buy-in, we might as well not even begin. We're working with people who have not been historically part of clinical research, and they have a very leery perspective on it. There's lack of trust. To get community buy-in, we work with community leaders, and we try to be present in the community to help people understand what we want to study and how it will benefit them. And when we disseminate the results, we work with the community, and they help decide how they want that to happen.

On a larger scale, communities should be included in policy and advocacy work. The community needs to be the face of the work when communicating with public health organizations and policymakers.



Without them we would not be able to achieve our goal of reducing illness and death from hepatitis and ultimately have a world free of viral hepatitis.

Editor's note: This research is supported by the Mayo Clinic Center for Clinical and Translational Science. The researchers made use of Mayo's Clinical Research and Trials Unit to support their work. In addition, Dr. Mohamed is a recent graduate of the Mayo Clinic Graduate School of Biomedical Sciences Ph.D. program in Clinical and Translational Science.

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