Sample Hepatitis Screening Protocol

Checklist

At least 4 months before: Identify physician mentors! Note that this is absolutely imperative for the success of your program. Lab tests have to be ordered by a physician, and reports given to screened subjects must be signed by a physician. Don’t need to limit yourself to physicians only at your school. Much hepatitis is treated by community physicians as well, so consider reaching out to community physicians in your area.

At least 3-4 months before: Research follow-up care options, screening locale, laboratory testing logistics, obtain funding, gather educational materials, and necessary forms.

1 month before: Advertise your screening in local Asian newspapers, grocery stores, churches, and other areas in your community. Recruit and train volunteers.

2 weeks before: Determine volunteer schedule. Go over protocol with them.

Day of screening: Volunteers hand out educational materials, volunteers register clients (consent forms, health info, self addressed envelopes), phlebotomists draw blood, samples processed (with appropriate labeling), and taken to lab.

1-2 weeks later: Lab results are sent to the physician who signed the order. Physician review lab results.

2-3 weeks later: Contact everyone who participated in the screening via letters, phone calls, or educational sessions.

Screening Protocol

Preparation

Please contact hepatitis@apamsa.org if you will be organizing a screening program and would like to participate in the national APAMSA effort to collect hepatitis B data.

  1. Identify a local hepatologist or other physician who will serve as your mentor and oversee the screening. Important point: It is absolutely imperative you work with a physician for your program. Lab tests have to be ordered by a physician, and reports given to screened subjects must be signed by a physician. Determine what hepatitis B outreach needs are needed in your area. Ask how to get connected to resources for a screening program (i.e. labs, phlebotomist, etc…). Discuss with your mentor the need for obtaining IRB approval/waivers as needed. IRB approval will be needed if there are plans to analyze and report the data.

  2. Secure funding (see section on funding resources)

  3. Research the following questions. Send completed research to National APAMSA for databasing.
    HINTS: Here are some websites to find information about your local areas:
    http://www.hepb.org/resources/liver_specialist_directory.htm
    http://findahealthcenter.hrsa.gov/Search_HCC.aspx

    • Where can insured hepatitis B positive people obtain care? Provide referral information for physicians who see hepatitis B clients (you should follow up with the clients to make sure they contact a physician).

    • Where can uninsured hepatitis B positive people obtain care? Provide information regarding clinics for the uninsured. (sometimes you need a peer educator or community health advocate to function as a patient navigator, since many indigent clinics do not have resources for interpreters for many Asian languages.)

    • Where can hepatitis B antibody negative people obtain the vaccine?
      Provide information about where they can go to get the hepatitis B vaccine, either through their primary care physician or through a free/discounted vaccination program.

    • Where can other family members be screened? Provide information regarding places to be screened for hepatitis B.

  4. Develop a client follow up plan (i.e. How are you going to notify people of their results? Phone calls, letters, both, educational session, or something else.)

  5. Identify an appropriate screening location. This can be at a clinic that sees Asian patients, a church, community center, a hepatitis B screening in the Asian community, a hepatitis B screening that’s part of a more comprehensive health screening for the community, or many other options.

  6. Secure a phlebotomist + appropriate supplies to draw blood.

  7. Find a laboratory that will process your samples. Ask your physician mentors for suggestions. Also consider Quest Diagnostics. Most commercial labs will provide phlebotomist, and blood drawing kits and also dispose of sharps and biohazard materials. Quest gives a good rate but will not provide phlebotomists on Sundays. Some cities such as Chicago provide free hepatitis B screening through their health departments as well.

  8. Obtain educational materials in Asian and English languages regarding hepatitis B to distribute to the people who come to your screening. Use existing materials from ALF, Hep B Foundation, or Asian Liver Center. Contact information is provided in the resources section.

  9. Have available a waiver/consent form for clients to sign. This should also include a description about what will happen to their samples. This needs to be in English and also Asian Languages.

On the Day of Screening

  1. Have student volunteers ready at different stations.

    • Educational station—provide educational materials to people at screening about hepatitis B. Encourage people to get screened. HINT: Having clients sit through an educational presentation as a ticket into the free screening is an effective method of educating people during your screening.

    • Screening/paper work—Have people fill out health info form and consent form. Also during registration, assign a unique ID number to each person for your records. This ID number will be used to label their samples and also for subsequent data analysis. Keep these records that link client names with ID numbers in a secure location. Review with your clients what will happen to their samples and when they will be contacted.
      HINT: Have each person write their own address on an envelope or address label during registration. This significantly improves your chances of sending the letters to the right place.

    • Blood drawing station—manned by a licensed phlebotomist, and better to have a physician present too.

  2. All this seems like a daunting task for medical students, but there is help for you! The best and most effective way to conduct a screening is to connect yourself with other organizations that already have many of these resources already developed. We have compiled a list of many organizations who are eager to work with APAMSA to conduct screening/vaccination programs.

  3. We also recommend you contact your local American Liver Foundation chapter in your area which will likely be able to provide you with more information and direct you to physicians and local contacts who would be willing to help you. Also, please contact president@apamsa.org or hepatitis@apamsa.org to get connected to your local ALF, for more resources, and to discuss financing ideas.

After the Screening

Lab results will be returned to the physician who ordered them for you 2-3 weeks following the screening. Find out from the lab when you sign the contract how long it takes to get the results back. Also, you can request to have the lab also send you all of the data on a spread sheet.

GENERAL OVERVIEW OF SCREENING POSSIBILITIES:

Hepatitis B Surface Antigen Positive

Recommendation: Further testing, refer to primary care physician, or follow up at uninsured clinic.

For Insured clients:

  • Identify a physician/physicians who specialize in hepatitis B to refer people to. And also recommend people to go see a community or their own physicians.

Uninsured clients:

  • Best option would be to refer to community health center dedicated to the Asian population.

  • If that’s not available, refer to community health center, uninsured clinic which provides Asian language services, or an established navigator system.

  • Refer to community health center or clinic for the uninsured that’s affiliated with your school, such as a student run free health clinic. Be aware of what referral systems and services are offered at your student run clinic.

Hepatitis B Surface Antigen Negative, Hepatitis B Surface Antibody Negative

Recommendation: Get immunized with the hepatitis B vaccine.

Hepatitis B Surface Antigen Negative, Hepatitis B Surface Antibody Positive

Person has antibodies to hepatitis B and is immune. Encourage him/her to have family tested.

CLIENT FOLLOW UP PROTOCOL:

You will need some sort of follow up system. Simply sending persons a letter notifying them that they are hepatitis B positive is not effective. This is one of the best areas for students to get involved because you can help develop tracking programs and follow-up with both your hepatitis B surface antigen positive and negative persons. Hepatitis B surface antigen positive persons need to see a physician even if they have no symptoms. It is ideal to follow up with everyone who participates in your screening to educate them about hepatitis B and also direct them to appropriate avenues for treatment.

Hepatitis B negative persons who also are hepatitis B surface antibody negative, need to get the hepatitis B vaccine. You need to refer them to appropriate places to get the vaccine, and also provide recommendations for where they might go to get free vaccinations if they are uninsured.

Important point: Simply telling someone to go see their doctor or handing them a voucher to get a vaccine is not as effective as calling and writing to persons directly to 1) make sure they understand what they need to do, and 2) make sure they understand why. Vaccine voucher programs in the past have been unsuccessful because many people will not go get the vaccines. If the students however, participate in making phone calls and writing letters to people, they are much more likely to seek follow up care and/or get the appropriate vaccines.

Some examples of client follow up systems:

  1. Letters—If you send out letters to your clients, make sure they are in English and also appropriate Asian languages. Make sure your letters are customized with information regarding clinics, referrals, vaccine, and other hepatitis B services.
    HINT: When you register people for the hepatitis B screening, have them self-address an envelope to themselves that you will use to send them their results. This will minimize mistakes in mailing addresses.

  2. Letters and Phone calls—Sending letters and following up with phone calls is a better way of making sure the people understand the test results. Make sure if you make phone calls you have people who can speak the language of the person you’re calling. If you mail a letter, try to follow up with a phone call 2 weeks later to make sure they understand the letter and encourage follow up. Then follow up call 3 months later to see if action was taken. The down side about making phone calls is that you can’t give medical information to someone except for the person you screened, so you may have to call back several times.

  3. Educational Session, Letters, and Phone Calls—Perhaps the most time consuming method of notifying the screening participants, but has proven effective for some screening programs and more importantly this method allows for face-to-face communications. Basically you will tell everyone to come back a week or two later to receive their results. You can call them and leave messages too reminding them of this educational session, thereby, avoiding giving out medical information over the phone. During the educational session, explain to everyone the various possibilities of their screening results. Before or after the educational session, give people the letters with their results. It’s also good to provide food. Make sure your speaker is able to communicate in the language of the community.

WHAT ABOUT MALPRACTICE INSURANCE?

It is recommended before you proceed with anything to talk to your schools regarding the best way to handle this. While there is very little risk involved with drawing blood, every institution has different policies which you must check before proceeding with anything. This is another reason why one of the first steps is to secure a faculty/community physician advisor.