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Pre-Test
Managing Chronic Hepatitis B: Integrating Eastern Philosophies with Western
Approaches
Your participation matters to us! To help us provide the best possible
educational programming, please complete the pre-test, post-test and evaluation
for this activity.
* 1. Which ethnic groups have been determined to have higher prevalence of
chronic hepatitis B (CHB) than the general population?
Please select your best answer.
Sorry, you must provide an answer to this question.
Hispanic and non-Hispanic Whites
Hispanic and non-Hispanic Blacks
Non-Hispanic Blacks and Asians
Non-Hispanic Whites and Asians
* 2. The Traditional Chinese Medicine (TCM) approach to defining CHB and liver
disease can be characterized by which of the following characteristics?
Please select your best answer.
Sorry, you must provide an answer to this question.
Weakening of the Qi (biological substances and activities that preserve life)
Blockage of meridians (circulation channels of Qi) by blood stasis
Generation of dampness and heat (inflammatory pathogens)
All of the above
* 3. M, a 30-year-old woman with CHB, would like to start a family. She has
inactive disease, with low ALT and low viral load, and cirrhosis is not
suspected. She is not being treated with antiviral therapy. Which of the
following considerations or steps are relevant to this case?
Please select as many answers as you wish.
Sorry, you must provide an answer to this question.
Since M does not have active hepatitis B, disease surveillance may be deferred
until after she gives birth.
M should be asked about her current and planned use of TCM.
M should be vaccinated against hepatitis B before becoming pregnant in order to
prevent mother-to-child transmission.
M’s hepatitis B status should be closely monitored throughout her pregnancy in
case she experiences a change and needs to consider therapy.
* 4. All of the following statements are correct EXCEPT:
Please select your best answer.
Sorry, you must provide an answer to this question.
The rate of diagnosing HBV in the U.S is 18.6%.
In the U.S., the pharmacological treatment rate among all HBV patients is
estimated to be about 20%.
Both “western” antiviral medications and traditional Chinese medicine are
utilized in treatment of HBV in the U.S.
Herbal medicine accounted for 30-50% of total medicine consumption for treatment
of CHB patients in the U.S.
* 5. Goals of pharmacotherapy in CHB include:
Please select your best answer.
Sorry, you must provide an answer to this question.
Sustained suppression of viral replication
Normalization of ALT
Loss of HBsAg
Prevent or delay progression to cirrhosis and HCC
All of the above
* 6. Which of the following therapy has been shown to decrease the rates of both
decompensated liver disease and death in CHB patients?
Please select your best answer.
Sorry, you must provide an answer to this question.
Herbal therapy
Acupuncture
Antiviral therapy (Pharmacotherapy)
All of the above
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MANAGING CHRONIC HEPATITIS B: INTEGRATING EASTERN PHILOSOPHIES WITH WESTERN
APPROACHES

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MANAGING CHRONIC HEPATITIS B: INTEGRATING EASTERN PHILOSOPHIES WITH WESTERN
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MANAGING CHRONIC HEPATITIS B: INTEGRATING EASTERN PHILOSOPHIES WITH WESTERN
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Slide 1 Hello. Today, I would like to welcome everyone, and thank you for
participating in this educational program by Asian Health Foundation. We are
excited to present and discuss this topic, West Meets East for hepatitis B,
because a vast majority of hepatitis B patients in the world, as well as in the
US, are from East Asia. We would like to focus on the Eastern and Western
approaches to the management of hepatitis B. Slide 2 I would like to introduce
our distinguished faculty, Dr. Joseph Lim, Director and Professor of Medicine
from Yale University, Dr. Jian Zhang, a long-time hepatitis B care provider and
CEO of Chinese Hospital in San Francisco, and Dr. Danny Chu, a long-time
hepatitis B and leader in the Chinese community in New York area.  We will have
three topics today.  One is understanding hepatitis B from Eastern and Western
perspectives by Dr. Joseph Lim, herbal therapy and acupuncture vs
pharmacotherapy for hep B with Dr. Jian Zhang, and the impediments to hep B
care, discussion by Dr. Danny Chu.  Slide 3 So, I would like to first ask Dr.
Joseph Lim if you could give us an overview of the epidemiology of hepatitis B,
and what are some of the Eastern and Western perspectives with patients with
hepatitis B?

Dr. Lim: 
Absolutely. Thanks very much for the opportunity to share some thoughts about
this very important topic.  Slide 4 I think we all recognize that we need to be
very mindful of the cultural differences and perspectives in how we approach
human health, and specifically to chronic hepatitis B infection. As noted, the
hepatitis B epidemiology is notable for global burden of approximately 290
million persons.  Of this group, we believe that there are about 2 million
persons infected here within the United States, and within this group in the US,
a significant proportion of these individuals are believed to be foreign-born. 
Recent estimates by NHANES epidemiologic survey suggest an overall
seroprevalence of approximately 0.35 percent, which constitutes approximately
1.15 million persons.  Now, we recognize that NHANES is not optimal for
estimation of chronic infections because it excludes some of the highest risk
populations, and in this context, a number of studies suggested that when you
take into consideration foreign-born persons, the true burden of chronic
hepatitis B may be as high as 2.2 million persons.  A recent consensus
conference estimate suggests an overall burden of approximately 1.6 million
persons, with an upper interval up to about 2.5 million persons.

Now, we recognize that the reason why we care about hepatitis B and the ultimate
implication is that a significant proportion, up to one in four, may die of
liver disease and/or liver cancer.  Because of the unique relationship between
chronic hepatitis B and carcinogenesis with hepatocellular carcinoma, hepatitis
B is the number two carcinogen in the world after tobacco.  And, approximately
70 percent of all hepatitis B related deaths are attributable to liver cancer.

Slide 5 Now, if you take a deeper look into the epidemiology among US
individuals with chronic HBV, we see a disproportionate burden to ethnic groups,
specifically, among Asian-Americans and non-Hispanic Blacks.  We estimate that
about 70 percent are foreign-born, and are predominantly Asian, about 60 percent
of that group.  Now, if you look at a comparison to the general population,
again, two groups are higher than the general population, including Asians
(about eightfold the general prevalence) and non-Hispanic blacks (about twofold
general prevalence).  And, as expected, there are some differences between
US-born and foreign-born persons.

Slide 6 Now, as we think about this burden of disease that is concentrated in
foreign-born persons, predominantly from the Asian continent, we must take into
consideration differences in perspectives in our care of these patients. 
Eastern medicine approaches, such as Chinese Medicine and Complementary and
Alternative Medicine, have been used for centuries.  And, the theoretical
foundations really stem from ancient philosophies that rely on two therapeutic
approaches of holism and syndrome differentiation.  And, it's important to note
that the human body is not viewed as an entity in which there are organs that
are working interdependently, but really all part of a global universe
interaction between human and the surrounding environment.  And, in this
context, human illness is actually viewed not in terms of dysfunction of organ
systems, but an imbalance of Yin and Yang.  Slide 7 Now, chronic hepatitis B and
liver disease broadly do not easily fit within the definitions of traditional
Chinese medicine.  However, the components that are linked to chronic hepatitis
B include the following concepts:  Number one, weakening of Qi, which are
biological substances and activities that preserve life; number two, blockage of
meridians, which represent circulation channels of Qi by blood stasis; and
number three, generation of dampness and heat, which suggests inflammatory
pathogens. 

Slide 8 Now, in this context, we need to highlight that this directly influences
many of our patients in terms of how they view their health specific to
hepatitis B and liver disease.  Whereas in the West, we view the body as a
machine, in the East, it's viewed as a garden.  In the West, we view hepatitis B
and liver disease as a diseased organ rather than a weakening of the Qi. In the
East, we look at hepatitis B as a blockage of meridians. Liver inflammation in
the West, generation of heat in the East.  And, this directly influences
therapeutic approaches.  So, in the West, we focus on pharmacologic therapy with
antivirals, with oral, nucleoside or nucleotide analogues, whereas in the East,
the focus on restoration of balance, of pathogenic and Qi, including a focus on
nutrition, herbal therapies and acupuncture. 

Slide 9 Now, we do need to keep in mind that a lot of these traditional Chinese
medical approaches have not until recently been validated using traditional
Western scientific approaches but, there is an abundance of growing literature,
particularly within the last ten years, to support the physiologic basis of
traditional Chinese medicine and therefore, this has renewed interest in drug
developments of herbal entities, and we are very excited.  There have been
important advances in the validation of inflammatory, antioxidant and
antifibrotic properties of some of these key herbal components of traditional
Chinese medicine and herbal therapies.  There remain important challenges in
drug development, predominantly due to the isolation and purification of the
individual components of herbal therapies.  But we know that with increasing
attention, support by the NIH and rigorous methodology and clinical trial
developments, we do anticipate that some of these traditional approaches may be
validated using Western scientific methodology.

Slide 10 Now, if you think about modern medicine in the West, we think about the
slide here towards the left bar, we think about treatments like pegylated
interferon, oral nucleoside/nucleotide analogues such as entecavir and
tenofovir.  And on the right, we look at the approach in Eastern medicine, which
focuses on manipulative body-based therapies, diet, herbal medicines and
vitamins, and think about homeopathy, naturopathy and acupuncture.  These are
fundamental differences in perspectives and approaches to therapy between the
East and West.  Slide 11 Now, I want to highlight that this is not something
that is concentrated in a very small proportion of patients with hepatitis B. 
We believe that up to 70 percent, based on current studies, of patients with
chronic hepatitis B use complementary and alternative medicines.  Therefore, it
is important that we, as clinicians, routinely query our patients about the use
of complementary or alternative medicines, or traditional Chinese medicine in
our evaluation of patients.  We need to have careful, mindful discussions with
patients about what we know about the safety and efficacy of these approaches. 
And, I believe that we must think about these as complementary approaches
between East and West so we can augment our understanding of these different
perspectives to improve the quality of care of patients with chronic hepatitis
B.

Slide 12 So, in conclusion, I hope I've been able to articulate that hepatitis B
remains a very common global and local public burden with substantial morbidity
and mortality due to its link to liver cirrhosis and liver cancer.  Although
current Western therapies are highly effective in suppression of HBV DNA with
improvement in clinical outcomes, we must recognize that Eastern medicine
approaches remain commonly used in our patients with chronic HBV, particularly
in those from Asian communities. Therefore, clinicians should routinely query
their patients regarding their use of these therapies and counsel them regarding
known safety and efficacy.  It is quite clear that additional investigation is
needed to further define the potential utility of traditional Chinese medicine
and complementary alternative medicines in future treatments of chronic
hepatitis B.  Thank you very much, Mindie, for this opportunity.

Dr. Nguyen: 
Thank you so much, Dr. Lim.  That was a very clear and helpful review and
discussion of the foundational differences in the Eastern and Western approaches
to hepatitis B management and perspective.  That is very helpful for care. 
Slide 13   Now, I would like to turn to Dr. Jian Zhang in regards to the
complementary care approach to hepatitis B.  As Dr. Lim already alluded to, this
would be herbal medication, acupuncture. Could you give us more information on
some examples of herbal medicine, acupuncture versus the Western traditional
pharmacotherapy for hepatitis B?

Thank you very much, Dr. Nguyen. Slide 14 I will talk a little bit about herbal
therapy and acupuncture versus pharmacotherapy in treatment of chronic hepatitis
B.  in the United States. Sadly, only 18.6 percent of chronic hepatitis B is
diagnosed with very low treatment rate of only 5.7 percent here.  I want to
point that out.  And in the United States, there is a lot of herbal medicine
that's used, about 30 to 50 percent, and more so in China and in Taiwan, with 80
percent.  So, a lot of our patients are using herbal medications, even those not
approved, butcalled supplements.

Slide 15 The goals of pharmacotherapy in chronic hepatitis B. The primary goal
is to sustain suppression of viral replication.  And, the secondary goals:to
achieve clinical remission, which includes ALT normalization, loss of hepatitis
B e-antigen and surface antigen, and stabilize liver function, and also to
prevent or delay progression to cirrhosis and liver cancer.

Slide 16 Herbal therapy in chronic hepatitis B. There are no herbal treatments
proven to improve outcomes in patients with chronic hepatitis B.  I know that
there are a lot of studies, but a lot of them are poor quality and no control
and protocol. That's why some of the medicines can cause serious liver toxicity,
because it's not really going through clinical trials.  A lot of them, it's
considered a supplement. I had a patient who took the supplements and it caused
elevation of liver enzymes--and ended up in the hospital.  Herbal treatments are
not recommended for patients with chronic hepatitis B. A lot of patients can buy
it in a market, so, that's why it's really widely used by our patients.

Slide 17 Acupuncture in treatment of chronic hepatitis B is very common, too. 
It was first documented a long, long time ago, a hundred years B.C., in The
Yellow Emperor's Classic of Internal Medicine.  And so, widely used in clinical
practice in a lot of the Asian countries to decrease discomfort, relieve
symptoms like loss of appetite and nausea, right upper quadrant discomfort,
typical chronic hepatitis B symptoms. Acupuncture can increase leukocyte counts,
increase blood natural killer cell count and activity, and improve erythrocyte
immune function, and reduce TNF-alpha and interleukin 1 beta in the serum.
Acupuncture is very commonly used in China, as I have visited many clinics
there, and here in United States, too.

Slide 18 So, if you would like to look into this Cochrane study by Kong and
colleagues, they talk about eight randomized clinical trials with 555 patients,
all in China, and compared acupuncture therapy versus no intervention.  And
again, a lot of the studies they used said that there's some improvement in
patients' symptoms, and then some increase the conversion of hepatitis
Be-antigen. But, a lot of the studies are not well controlled, so that's why
some of them were saying that they have some reduction in detectable hepatitis B
DNA levels.  And, because there are no strict controls, we really don't know
whether it's acupuncture or it's other treatments there.

Slide 19: Antiviral Therapies] The antiviral therapies, we know, are proven to
decrease  

Slide 20 In summary, I would like to point out that the effects of acupuncture
for chronic hepatitis B, it's not clear and more controlled studiesshould be
done to prove that.  And, benefits of herbal treatments of chronic hepatitis B
are really not proven.  And so, I think again, more controlled studies should be
done, and not just that it's not helpful; some of them are really harmful,
because can cause liver toxicity. Certain herbal treatments can cause
life-threatening liver failure, and so really not recommended at this point.  I
know a lot of patients say I want to try, but really should talk to their
doctors and make sure that severe liver failure is not going to happen.  Thank
you very much.

Dr. Nguyen: 
Thanks so much, Dr. Zhang, for giving us a very comprehensive and detailed
review of this very important topic. Many of our patients use it, and many
believe in it even more than the Western medicine that we are familiar with. 

Slide 21 Next, I want to ask Dr. Chu if you could help review for us the current
barriers for hepatitis B care, because the barrier is not just financial, as
many people may think. Data from even patients with private insurance in the US
show that only about 20 percent of US hepatitis B patients have been diagnosed,
and even patients with very severe complications like cirrhosis and liver
cancer, only about one-third or one-half have received treatment.  So, Dr. Chu,
could you help us understand more of the barriers and how we could help overcome
some of these?

Dr. Chu: 
Great, thank you very much.  I've been practicing in New York City Chinatown for
about 25 years. so A lot of the subject matter is something I've experienced, so
maybe I can share some of that thought on the impediments to hepatitis B care.

Slide 22 Well, first, there's a lot of misconception and there's reality.  So,
whenever I see a patient, I try to gauge their understanding. The first thing I
ask, how do you get hepatitis?  And sure enough, a lot of people say well, you
get it through sharing food and utensils, and in fact, some family member will
say I have bowls in the house.  Well, the reality is that it is transmitted
through blood and body fluid and sex. I tell them that you can share the forks
and knives, but don't share the razors and the toothbrushes. And have your
family members tested, because obviously, they should be immunized or make sure
they're not a carrier. 

The second thing they always talk about is that well, my mother has it, I have
it, so it must be inherited.  The reality is that it is not a genetic disease,
but it is something that can be given through vertical transmission, so that's
something I go through with them, again, just to educate them.  The third thing
is they feel well, I have no symptoms, so do I really have hepatitis B?  And, I
think that they associate jaundice with liver diseases but the reality is that
that only occurs with acute symptoms.  But, when, I try to explain to them, you
have chronic hepatitis B, you'll be asymptomatic and for that reason, you should
be followed with a doctor to make sure that your liver enzymes and your virus
level is okay. 

The last thing that they don't understand is that they don't think there's a
treatment available.  What I tell them is that the reality is that there is
treatment.  But I go further and say that there is no cure, especially if you're
on any type of antiviral; there is no cure, and the fact that some doctor may
give you medicine for three months, well, you can't stop it after three months. 
You have to continue taking it.  So, these are a couple of points that I try to
explain to the patient so that we can at least get to where they can understand
it. 

One of the biggest things is education; try to educate the patient from day one,
when you start seeing the patient, to gauge what they know, and try to
supplement what they know with some information so they can at least go home
understanding a little bit about hepatitis B.

Now, after talking about, really, the misconception, there's a lot of also bad
perceptions about hepatitis B.  Slide 23 Here we have a survey that was done in
rural China, about 6,000 people who were found and were looked at. And this is a
study from 2016, so this is not from the 1980s, right?  You find that there's a
lot of people who are unwilling to accept gifts from hepatitis B carriers, which
is about 67 percent.  About 78 percent of their family will not permit their
children to play with hepatitis B carriers.  72 percent will not have dinner
with hepatitis B carriers at this point.  And, about 61 percent of the people
will not even touch the patient with hepatitis B, whether it be a hug or a
handshake.

Slide 24 Now, how about self-perceptions?  What do patients themselves think
about hepatitis B?  A lot of them, more than 58 percent, think that hepatitis B
brings trouble to the family.  36 percent think they should avoid close contact
with other family, and 33 percent think they're not a desirable spouse. I just
had this last week, where a man and a woman were going to get married.  The man
was here to see me for hepatitis B and I said, “Have your family members
tested?” And the woman goes, “Well, I can't tell my family members because if
they know he has hepatitis B, they won't let me marry him.”  Well, that's a real
thing that's happening these days, so these are some of the perceptions.
 Obviously, people have experienced discrimination from employers from having
hepatitis B, so they don't want to reveal that because that'll be something that
employers can use against them.

Slide 25 Now, again, in Asian countries, a lot of hepatitis B institutional
stigma.  In China, admission has been denied to school/university because you
have hepatitis B.  There has been unfair treatment from employers.  In fact,
it's only in the 2000s, 2007, there was anti-discrimination legislation to end
termination of a worker with hepatitis B.  In 2010, they banned testing for
hepatitis B before starting school or work.  So, this is actually some of the
stuff that people have experienced as they're living in this Asian country.  I
have a patient who comes to see me from Minnesota every six months. And he
speaks perfect English, so he doesn't have to come to see me for hepatitis B,
but he does it because he owns two restaurants and he doesn't want the health
department to know he has hepatitis B, because he's fearful that they're going
to shut his restaurant down.  So, there's a lot of stigma that's attached to
that.

Slide 26 Now, in the community setting, maybe the socioeconomic status and
language barrier, would hinder them from understanding hepatitis B.  But, if you
look at even American college students who are Asian, here's a study with 258
students and you ask them questions and only 22 percent of them knows that it is
not hereditary, so 78 percent doesn't know.  61 percent believe that you can get
it from a shared utensil.  And, only 50 percent knew that you can get it from
sex and blood.  So, the last two slides are trying to raise is the point that we
do need to do a lot of education in the community setting with our Asian
patients.

Slide 27 Now, what does that mean?  Well, this means is you get some clinical
consequences, right?  So, if there's a negative perception, you don’t understand
what's going on, then you don't want to be tested.  And, if you don't want to be
tested, there's obviously going to be a delay in hepatitis B diagnosis, which
leads to continued transmission of hepatitis B from person-to-person.  And, if
you don't know you have the disease, then you can't really monitor and manage
your disease well.  And, there's a delay in treatment.  And, as Joe said the
first time you may even find out you have hepatitis B is when you have right
upper quadrant pain. You do a sonogram, you may find out you have liver cancer.
which obviously is what people usually die from, progression of the disease from
liver cirrhosis to cancer.  So, as a whole, we want to catch the disease early.
We don't want to have these problems with mortality and cancer and cirrhosis.

Slide 28 Now, we can go back and say well, these are the patients.  How about
the people who provide the care?  Are they up to par?  This is a study done
where surveys were mailed to Asian primary care doctors or healthcare providers
who take care of more than 25 percent Asian patients.  And, about 95 percent of
the healthcare providers said they screen the patients for hepatitis B.  But if
you ask them if they're routinely screening all of their patients, only 20
percent does.  And, if you ask them do you routinely screen all of the Asian
patients, only 50 percent of the primary care doctors or healthcare providers
say yes.  And, you know, if you follow the CDC guideline, anything with a
prevalence of greater than 2 percent needs to be screened.  So, I'm going to
guess that 50 percent is a little bit too low; it should be closer probably to
90 to even 99 percent.  And, if you ask the question what's the reason for
hepatitis B screening test in Asian patients, 26 percent said it was from
elevated liver tests, and 21 percent said elevated liver tests plus a family
history of hepatitis B or liver disease.  Again, when you have elevated LFTs and
you're doing further testing, it's not screening anymore, really; you're trying
to make a diagnosis. Screening means you're just testing all the at-risk
population.18 percent of the doctors screen patients born outside of the United
States, right?  That should be maybe higher, as I said; if you have Asian
patients who were born outside the United States, a lot more should be tested.

Slide 29 In terms of the most important reason for not ordering a screening test
of Asian patients: Well, 23 percent said they're not considered to be an at-risk
group for hepatitis B.  16 percent said they have no symptoms of hepatitis B… of
liver disease.  Again, they have their own misconception. Why would you not
screen somebody, when they're an at-risk group, and only test people who have
symptoms? The third thing is 15 percent said well, they've had their vaccination
series.  Well, in my practice, I always test the people with the vaccination
series anyway because you want to know if they're immune.  But, in certain
countries, they just give vaccine without testing if you're a carrier or not, so
sometimes people who are hepatitis B carriers are getting a vaccine, which
aren't going to work anyway, so they should be tested.  And, only 13 percent of
the people said well, I'm not testing the Asian patients because they have no
insurance.  Well, as you know, these tests are pretty cheap.  You can probably
do a surface antigen antibody test for less than $30 with some of the commercial
labs that you can make a deal with, so that shouldn't be an excuse.  We really
also need to educate our primary care doctors who care for our Asian patients so
that a lot more patients are being tested. As my previous colleagues mentioned,
a lot more people are left undiagnosed.

Slide 30 Now, if you happen to get the patients diagnosed and get them to the
point where they're going to get treated, one of the biggest problems is
non-adherence. I don't think non-adherence is really unique to just hepatitis B;
I think it applies to diabetes, high blood pressure. People take their medicine,
they stop the medicine, they skip a few days.  Well, the problem with hepatitis
B, is that if you do that, then there's always a risk of resistance.   There's a
survey of chronic hepatitis B on what is a barrier to treatment, about 300
patients, and they found out that medication is expensive in about close to 50
percent. 45 percent said forgetfulness. I always tell my patients to tie that
hepatitis B medicine to the toothpaste, so when they brush their teeth, they can
take one.  There's a lot of concern of side effects, they're concerned about
certain medication with kidneys and with bones and whatnot.  But I think that
goes along also with education.  And, some people are nonadherent because they
don't want other people to know. Slide 31 So, there's a lot of misconception, a
lot of negative perceptions, and I think that comes from the fact because
there's a gap in hepatitis B knowledge.  Hepatitis B is not a national health
priority issue like HIV.  Because of that, there's a lack of education and
funding, a lack of media coverage.  You know, in certain Asian countries, a
certain star has hepatitis B, they'll do a lot of public service announcements
but we don't have that.  A lot of the hepatitis B formal education is not
integrated at school.  I asked my daughter about hepatitis B and they don't have
that in school.  Only 14 states require hepatitis B vaccine before start of
school, and only eight states mandate hepatitis B education.  So, I think one of
the biggest things we can do is that once a person is in front of you as a
captive audience, I think the most important thing is not just give the
medication and say take it, but I think you have to sit there and really try to
understand what their understanding of hepatitis B is and try to help them
understand a little bit better, and I think that goes a long way in helping them
be more compliant with medication, and hopefully as this topic says, bring the
Eastern philosophy closer to the Western perspectives in treatment.  So, thank
you very much.

Dr. Nguyen: 
Thank you, Dr. Chu.  And, I would like to thank again our faculty, Dr. Joseph
Lim, Dr. Jian Zhang and Dr. Danny Chu for reviewing with us very important
foundational differences in the Eastern and Western approaches.  I also would
like to thank our viewers, and we hope that the information we presented today
will be helpful to you and your patients in your practice.  As Dr. Chu pointed
out, there is much to be done, both at the health policy level, as well as at
the individual doctors and patient.  So, we all can do more, one at a time. 
And, thank you again so much for joining us.

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 * OVERVIEW
   
   Experts in chronic hepatitis B within Asian communities discuss prevention,
   screening and management options to reduce the number of new cases and the
   risk of progression to cirrhosis, hepatic failure, and hepatocellular
   carcinoma. Experts also will consider the integration of Western and Eastern
   Medicine approaches to treatment and how cultural perceptions and community
   stigmatization of persons of Asian descent with chronic HBV infection can
   create barriers to diagnosis and care.


 * DISCLOSURE OF CONFLICTS OF INTEREST
   
   Asian Health Foundation, Chinese Hospital and Global Education Group (Global)
   require instructors, planners, managers and other individuals and their
   spouse/life partner who are in a position to control the content of this
   activity to disclose any real or apparent conflict of interest they may have
   as related to the content of this activity. All identified conflicts of
   interest are thoroughly vetted by Global for fair balance, scientific
   objectivity of studies mentioned in the materials or used as the basis for
   content, and appropriateness of patient care recommendations.
   
   The faculty reported the following financial relationships or relationships
   to products or devices they or their spouse/life partner have with commercial
   interests related to the content of this CME activity:
   
   Name of Faculty or Presenter
   
   Reported Financial Relationship
   
    Mindie Nguyen
   
   Consultant/Advisory Board: Eli Lilly, Exact Sciences,  Janssen, Novartis,
   Spring Bank, VIR
   
   Research Grant: Gilead Sciences, VIR
   
   Danny Chu
   
   Speaker: Gilead Sciences
   
   Joseph Lim
   
   Research Grant to Yale: Allergan, Celgene, Genfit, Gilead, Intercept
   
   Jian Q. Zhang
   
   Nothing to disclose
   
   The planners and managers reported the following financial relationships or
   relationships to products or devices they or their spouse/life partner have
   with commercial interests related to the content of this CME activity:
   
   Name of Planner or Manager
   
   Reported Financial Relationship
   
   Patricia Chung
   
   Nothing to disclose
   
   Jennifer Kuang
   
   Nothing to disclose
   
   Liddy Knight
   
   Nothing to disclose
   
   Ashley Marostica
   
   Nothing to disclose
   
   Ashley Cann
   
   Nothing to disclose
   
   Andrea Funk
   
   Nothing to disclose
   
   Jocelyn Woog
   
   Nothing to disclose
   
   Raquel Da Rosa
   
   Nothing to disclose
   
   Joanne Jablonski
   
   Nothing to disclose
   
   Scott Huang, DO
   
   Individual Stock Holder: Gilead Sciences, Inc.
   
   


 * TARGET AUDIENCE
   
   HCPs practicing in Asian American communities, including MDs, DOs, NPs, PAs,
   and RNs


 * LEARNING OBJECTIVES
   
   After completing this activity, participants will be better able to:
   
    1. Apply knowledge of the high prevalence of HBV in Asian communities to
       deploy best practices for prevention, screening, and treatment to reduce
       new cases of hepatitis B, rates of CHB, and progression to HCC.
    2. Describe the differences between Western and Eastern medicine including
       traditional Chinese medicine with respect to the definition, causes,
       clinical features, treatment and prevention of CHB.
    3. Discuss how differences between Western and Eastern medicine can
       influence screening, diagnosis and management of patients with CHB.
    4. Recommend the rational combined use of Western HBV pharmacotherapy such
       as nucleos(t)ide analogs and Eastern treatment such as Traditional
       Chinese Medicine including herbs and acupuncture.
    5. Integrate into practice how cultural perceptions of HBV infection and
       community stigmatization of persons of Asian descent with CHB can create
       barriers to screening and management.


 * ACCREDITATION AND CREDIT DESIGNATION STATEMENTS
   
   Physician Accreditation Statement
   This activity has been planned and implemented in accordance with the
   accreditation requirements and policies of the California Medical Association
   (CMA) through the  joint providership of Chinese Hospital and Asian Health
   Foundation.  The Chinese Hospital is accredited by the CMA to provide
   continuing medical education for physicians.
   
   Physician Credit Designation
   The Chinese Hospital designates this educational activity for a maximum of
   .50 AMA PRA Category 1 Credits™.  Physicians should claim only the credit
   commensurate with the extent of their participation in the activity. This
   credit may also be applied to the CMA certification in Continuing Medical
   Education.
   
   Nursing Accreditation
   Global Education Group is accredited with distinction as a provider of
   nursing continuing professional development by the American Nurses
   Credentialing Center's Commission on Accreditation.
   
   This educational activity for 0.50 contact hours is provided by Global
   Education Group. Nurses should claim only the credit commensurate with the
   extent of their participation in the activity.


 * PROVIDERS
   
   


 * COMMERCIAL SUPPORT
   
   This continuing medical education activity is supported by an independent
   educational grant from Gilead Sciences, Inc.
   
   
   
   This activity is jointly provided by the Asian Health Foundation and Chinese
   Hospital.
   
   
   
   This activity is jointly provided for nursing credit by the Asian Health
   Foundation and Global Education Group.
   
   


 * CONTACT INFORMATION
   
   Chinese Hospital Information
   For information about the physician accreditation of this program, please
   contact Chinese Hospital at jenniferk@chasf.org
   
   Global Contact Information
   For information about the nursing accreditation of this program, please
   contact Global at 303-395-1782 or cme@globaleducationgroup.com
   
   Asian Health Foundation Information
   For more information about the Asian Health Foundation, please contact
   Jocelyn Woog at asianhealthfoundation@charter.net


 * TERM OF OFFERING
   
   This activity was released on May 1, 2021 and is valid for one year. Requests
   for credit must be made no later than May 1, 2022.


 * FEE INFORMATION& REFUND/CANCELLATION POLICY
   
   There is no fee for this educational activity.


 * DISCLAIMER
   
   Disclosure of Unlabeled Use
   This educational activity may contain discussion of published and/or
   investigational uses of agents that are not indicated by the FDA. Chinese
   Hospital, Global Education Group (Global) and the Asian Health Foundation do
   not recommend the use of any agent outside of the labeled indications. 
   
   The opinions expressed in the educational activity are those of the faculty
   and do not necessarily represent the views of any organization associated
   with this activity. Please refer to the official prescribing information for
   each product for discussion of approved indications, contraindications, and
   warnings.
   
   Disclaimer
   Participants have an implied responsibility to use the newly acquired
   information to enhance patient outcomes and their own professional
   development. The information presented in this activity is not meant to serve
   as a guideline for patient management. Any procedures, medications, or other
   courses of diagnosis or treatment discussed in this activity should not be
   used by clinicians without evaluation of patient conditions and possible
   contraindications on dangers in use, review of any applicable manufacturer’s
   product information, and comparison with recommendations of other
   authorities.


 * PUBLICATION DATES
   
   Release Date: 05/01/2021
   
   Expiration Date: 05/01/2022

Presenters
Mindie H. Nguyen, MD, MAS, AGAF, FAASLD
Joseph Lim, MD
Danny Chu, MD
Jian Q. Zhang, DNP, MS, FNP-BC, NEA-BC, FAAN


RELATED


 * HEPATITIS B AND YOU: GETTING THE FACTS
   
   Show more


FACEBOOK COMMENTS


Recommended
Details
Presenters
Related
Comments

RECOMMENDED







 * OVERVIEW
   
   Experts in chronic hepatitis B within Asian communities discuss prevention,
   screening and management options to reduce the number of new cases and the
   risk of progression to cirrhosis, hepatic failure, and hepatocellular
   carcinoma. Experts also will consider the integration of Western and Eastern
   Medicine approaches to treatment and how cultural perceptions and community
   stigmatization of persons of Asian descent with chronic HBV infection can
   create barriers to diagnosis and care.


 * DISCLOSURE OF CONFLICTS OF INTEREST
   
   Asian Health Foundation, Chinese Hospital and Global Education Group (Global)
   require instructors, planners, managers and other individuals and their
   spouse/life partner who are in a position to control the content of this
   activity to disclose any real or apparent conflict of interest they may have
   as related to the content of this activity. All identified conflicts of
   interest are thoroughly vetted by Global for fair balance, scientific
   objectivity of studies mentioned in the materials or used as the basis for
   content, and appropriateness of patient care recommendations.
   
   The faculty reported the following financial relationships or relationships
   to products or devices they or their spouse/life partner have with commercial
   interests related to the content of this CME activity:
   
   Name of Faculty or Presenter
   
   Reported Financial Relationship
   
    Mindie Nguyen
   
   Consultant/Advisory Board: Eli Lilly, Exact Sciences,  Janssen, Novartis,
   Spring Bank, VIR
   
   Research Grant: Gilead Sciences, VIR
   
   Danny Chu
   
   Speaker: Gilead Sciences
   
   Joseph Lim
   
   Research Grant to Yale: Allergan, Celgene, Genfit, Gilead, Intercept
   
   Jian Q. Zhang
   
   Nothing to disclose
   
   The planners and managers reported the following financial relationships or
   relationships to products or devices they or their spouse/life partner have
   with commercial interests related to the content of this CME activity:
   
   Name of Planner or Manager
   
   Reported Financial Relationship
   
   Patricia Chung
   
   Nothing to disclose
   
   Jennifer Kuang
   
   Nothing to disclose
   
   Liddy Knight
   
   Nothing to disclose
   
   Ashley Marostica
   
   Nothing to disclose
   
   Ashley Cann
   
   Nothing to disclose
   
   Andrea Funk
   
   Nothing to disclose
   
   Jocelyn Woog
   
   Nothing to disclose
   
   Raquel Da Rosa
   
   Nothing to disclose
   
   Joanne Jablonski
   
   Nothing to disclose
   
   Scott Huang, DO
   
   Individual Stock Holder: Gilead Sciences, Inc.
   
   


 * TARGET AUDIENCE
   
   HCPs practicing in Asian American communities, including MDs, DOs, NPs, PAs,
   and RNs


 * LEARNING OBJECTIVES
   
   After completing this activity, participants will be better able to:
   
    1. Apply knowledge of the high prevalence of HBV in Asian communities to
       deploy best practices for prevention, screening, and treatment to reduce
       new cases of hepatitis B, rates of CHB, and progression to HCC.
    2. Describe the differences between Western and Eastern medicine including
       traditional Chinese medicine with respect to the definition, causes,
       clinical features, treatment and prevention of CHB.
    3. Discuss how differences between Western and Eastern medicine can
       influence screening, diagnosis and management of patients with CHB.
    4. Recommend the rational combined use of Western HBV pharmacotherapy such
       as nucleos(t)ide analogs and Eastern treatment such as Traditional
       Chinese Medicine including herbs and acupuncture.
    5. Integrate into practice how cultural perceptions of HBV infection and
       community stigmatization of persons of Asian descent with CHB can create
       barriers to screening and management.


 * ACCREDITATION AND CREDIT DESIGNATION STATEMENTS
   
   Physician Accreditation Statement
   This activity has been planned and implemented in accordance with the
   accreditation requirements and policies of the California Medical Association
   (CMA) through the  joint providership of Chinese Hospital and Asian Health
   Foundation.  The Chinese Hospital is accredited by the CMA to provide
   continuing medical education for physicians.
   
   Physician Credit Designation
   The Chinese Hospital designates this educational activity for a maximum of
   .50 AMA PRA Category 1 Credits™.  Physicians should claim only the credit
   commensurate with the extent of their participation in the activity. This
   credit may also be applied to the CMA certification in Continuing Medical
   Education.
   
   Nursing Accreditation
   Global Education Group is accredited with distinction as a provider of
   nursing continuing professional development by the American Nurses
   Credentialing Center's Commission on Accreditation.
   
   This educational activity for 0.50 contact hours is provided by Global
   Education Group. Nurses should claim only the credit commensurate with the
   extent of their participation in the activity.


 * PROVIDERS
   
   


 * COMMERCIAL SUPPORT
   
   This continuing medical education activity is supported by an independent
   educational grant from Gilead Sciences, Inc.
   
   
   
   This activity is jointly provided by the Asian Health Foundation and Chinese
   Hospital.
   
   
   
   This activity is jointly provided for nursing credit by the Asian Health
   Foundation and Global Education Group.
   
   


 * CONTACT INFORMATION
   
   Chinese Hospital Information
   For information about the physician accreditation of this program, please
   contact Chinese Hospital at jenniferk@chasf.org
   
   Global Contact Information
   For information about the nursing accreditation of this program, please
   contact Global at 303-395-1782 or cme@globaleducationgroup.com
   
   Asian Health Foundation Information
   For more information about the Asian Health Foundation, please contact
   Jocelyn Woog at asianhealthfoundation@charter.net


 * TERM OF OFFERING
   
   This activity was released on May 1, 2021 and is valid for one year. Requests
   for credit must be made no later than May 1, 2022.


 * FEE INFORMATION& REFUND/CANCELLATION POLICY
   
   There is no fee for this educational activity.


 * DISCLAIMER
   
   Disclosure of Unlabeled Use
   This educational activity may contain discussion of published and/or
   investigational uses of agents that are not indicated by the FDA. Chinese
   Hospital, Global Education Group (Global) and the Asian Health Foundation do
   not recommend the use of any agent outside of the labeled indications. 
   
   The opinions expressed in the educational activity are those of the faculty
   and do not necessarily represent the views of any organization associated
   with this activity. Please refer to the official prescribing information for
   each product for discussion of approved indications, contraindications, and
   warnings.
   
   Disclaimer
   Participants have an implied responsibility to use the newly acquired
   information to enhance patient outcomes and their own professional
   development. The information presented in this activity is not meant to serve
   as a guideline for patient management. Any procedures, medications, or other
   courses of diagnosis or treatment discussed in this activity should not be
   used by clinicians without evaluation of patient conditions and possible
   contraindications on dangers in use, review of any applicable manufacturer’s
   product information, and comparison with recommendations of other
   authorities.


 * PUBLICATION DATES
   
   Release Date: 05/01/2021
   
   Expiration Date: 05/01/2022

Presenters
Mindie H. Nguyen, MD, MAS, AGAF, FAASLD
Joseph Lim, MD
Danny Chu, MD
Jian Q. Zhang, DNP, MS, FNP-BC, NEA-BC, FAAN


RELATED


 * HEPATITIS B AND YOU: GETTING THE FACTS
   
   Show more


FACEBOOK COMMENTS



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Key Considerations for Coadministration: Fighting Against COVID-19 & Other
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Key Considerations for Coadministration: Fighting Against COVID-19 & Other
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Key Considerations for Coadministration: Fighting Against COVID-19 & Other
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Key Considerations for Coadministration: Fighting Against COVID-19 & Other
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Key Considerations for Coadministration: Fighting Against COVID-19 & Other
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Key Considerations for Coadministration: Fighting Against COVID-19 & Other
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Key Considerations for Coadministration: Fighting Against COVID-19 & Other
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legitimate interest. You may exercise your right to consent or object to a
legitimate interest, based on a specific purpose below or at a partner level in
the link under each purpose. These choices will be signaled to our vendors
participating in the Transparency and Consent Framework.
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Strictly Necessary Cookies

These cookies are necessary for the website to function and cannot be switched
off in our systems. They are usually only set in response to actions made by you
which amount to a request for services, such as setting your privacy
preferences, logging in or filling in forms. You can set your browser to block
or alert you about these cookies, but some parts of the site will not then work.
These cookies do not store any personally identifiable information.

PERFORMANCE COOKIES

Performance Cookies

These cookies allow us to count visits and traffic sources so we can measure and
improve the performance of our site. They help us to know which pages are the
most and least popular and see how visitors move around the site. All
information these cookies collect is aggregated and therefore anonymous. If you
do not allow these cookies we will not know when you have visited our site, and
will not be able to monitor its performance.

FUNCTIONAL COOKIES

Functional Cookies

These cookies enable the website to provide enhanced functionality and
personalisation. They may be set by us or by third party providers whose
services we have added to our pages. If you do not allow these cookies then some
or all of these services may not function properly.

TARGETING COOKIES

Targeting Cookies

These cookies may be set through our site by our advertising partners. They may
be used by those companies to build a profile of your interests and show you
relevant adverts on other sites. They do not store directly personal
information, but are based on uniquely identifying your browser and internet
device. If you do not allow these cookies, you will experience less targeted
advertising.

STORE AND/OR ACCESS INFORMATION ON A DEVICE

Store and/or access information on a device

Cookies, device identifiers, or other information can be stored or accessed on
your device for the purposes presented to you.

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PERSONALISED ADS AND CONTENT, AD AND CONTENT MEASUREMENT, AUDIENCE INSIGHTS AND
PRODUCT DEVELOPMENT

Personalised ads and content, ad and content measurement, audience insights and
product development

 * SELECT BASIC ADS
   
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   Ads can be shown to you based on the content you’re viewing, the app you’re
   using, your approximate location, or your device type.
   
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 * CREATE A PERSONALISED ADS PROFILE
   
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   A profile can be built about you and your interests to show you personalised
   ads that are relevant to you.
   
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 * SELECT PERSONALISED ADS
   
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   Personalised ads can be shown to you based on a profile about you.
   
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 * CREATE A PERSONALISED CONTENT PROFILE
   
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   A profile can be built about you and your interests to show you personalised
   content that is relevant to you.
   
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 * SELECT PERSONALISED CONTENT
   
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   Personalised content can be shown to you based on a profile about you.
   
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 * MEASURE AD PERFORMANCE
   
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   The performance and effectiveness of ads that you see or interact with can be
   measured.
   
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 * MEASURE CONTENT PERFORMANCE
   
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   The performance and effectiveness of content that you see or interact with
   can be measured.
   
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 * APPLY MARKET RESEARCH TO GENERATE AUDIENCE INSIGHTS
   
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   Market research can be used to learn more about the audiences who visit
   sites/apps and view ads.
   
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 * DEVELOP AND IMPROVE PRODUCTS
   
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   Your data can be used to improve existing systems and software, and to
   develop new products
   
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USE PRECISE GEOLOCATION DATA

Use precise geolocation data

Your precise geolocation data can be used in support of one or more purposes.
This means your location can be accurate to within several meters.

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ACTIVELY SCAN DEVICE CHARACTERISTICS FOR IDENTIFICATION

Actively scan device characteristics for identification

Your device can be identified based on a scan of your device's unique
combination of characteristics.

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ENSURE SECURITY, PREVENT FRAUD, AND DEBUG

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Ensure security, prevent fraud, and debug

Your data can be used to monitor for and prevent fraudulent activity, and ensure
systems and processes work properly and securely.

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TECHNICALLY DELIVER ADS OR CONTENT

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Technically deliver ads or content

Your device can receive and send information that allows you to see and interact
with ads and content.

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MATCH AND COMBINE OFFLINE DATA SOURCES

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Match and combine offline data sources

Data from offline data sources can be combined with your online activity in
support of one or more purposes

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LINK DIFFERENT DEVICES

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Link different devices

Different devices can be determined as belonging to you or your household in
support of one or more of purposes.

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RECEIVE AND USE AUTOMATICALLY-SENT DEVICE CHARACTERISTICS FOR IDENTIFICATION

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Receive and use automatically-sent device characteristics for identification

Your device might be distinguished from other devices based on information it
automatically sends, such as IP address or browser type.

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WE CARE ABOUT YOUR PRIVACY

We and our partners store and/or access information on a device, such as unique
IDs in cookies to process personal data. You may accept or manage your choices
by clicking below, including your right to object where legitimate interest is
used, or at any time in the privacy policy page. These choices will be signaled
to our partners and will not affect browsing data.


WE AND OUR PARTNERS PROCESS DATA TO PROVIDE:

Use precise geolocation data. Actively scan device characteristics for
identification. Store and/or access information on a device. Personalised ads
and content, ad and content measurement, audience insights and product
development. List of Partners (vendors)

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