Suboptimal linkage to care after identification of serum hepatitis B surface antigen-positive individuals in territory-wide screening: a need for educational and public health policies

Abstract

Background and Aims: Ensuring linkage to care is a key element to achieve the World Health Organization’s goal of eliminating hepatitis B virus (HBV) as a public health threat by 2030. Data on linkage to care in chronic HBV patients under Asian health care systems remains lacking Method: Hepatitis B surface antigen (HBsAg)-positive individuals identified during a territory-wide hepatitis seroprevalence study in 2015–2016 in Hong Kong were referred to regional secondary care for further management. We assessed subsequent linkage to care using surveys conducted via telephone and text messaging. The first survey in 2018 focused on their follow-up status, reasons for refusing referral among those without follow-up, and suggestions on improving linkage to care. The second survey in 2019 assessed their latest follow-up status, any active anti-HBV treatment and the presence of liver-related complications including cirrhosis and hepatocellular carcinoma (HCC). Results: Among 10,256 Chinese participants from the initial seroprevalence study, we identified 803 HBsAg-positive individuals (7.8%), of which 382 (47.6%) had no prior knowledge of their HBV carrier status. 539 (67.1%) responded to the first survey, with 388 (72.0%) having active follow-up for their HBsAg-positive status. 279 (71.9%) were followed up at in the public sector, while 247 (63.4%) had received liver ultrasonography. Common reasons for patients refusing referral include: believing they were healthy and not requiring clinical care (38%), no available time (20.0%), lack of disease knowledge (12.6%) and long appointment waiting times (4.6%). Suggestions to improve linkage to care include text message reminders (43.0%), patient education programs (10.8%), availability of patient support groups (10.4%) and shortened appointment waiting times (1.7%). Among 402 individuals responding to our second survey, only 149 (37.1%) remained in active follow-up. 78 (19.4%) had commenced anti-HBV treatment, 10 (6.7%) had biochemical or radiological evidence of cirrhosis. Two patients had developed HCC, both detected during surveillance and were amenable to curative resection. Conclusion: Post-screening linkage to care for chronic HBV patients remained suboptimal in Hong Kong, with low rates of engagement to clinical care and high rates of dropout. Considerable proportion of patients required treatment or developed complications. Systematic reminders and patient education coupled with timely referrals may facilitate linkage to care and prevent defaulting of follow-up.