January is Cervical Health Awareness Month, and in celebration we are resharing an interview with Whitney Lieb, MD, MPH, in which she answers some frequently asked questions on cervical health.  

During the video Dr. Lieb provides useful gynecological information including what is the cervix, what is human papillomavirus (HPV) infection, and what are recommended screening guidelines for cervical cancer. The information provided is based upon The American College of Obstetricians Gynecologists Frequently Asked Questions.  

Although the number of cases and deaths from cervical cancer has decreased significantly over the past 40 years, it is still the fourth most frequent cancer in women around the world and significant racial health disparities persist.  Black, Latina, American Indian, and Alaskan Native women continue to be disproportionately affected by cervical cancer compared to white women. The mortality rate from cervical cancer in Black women is twice that in white women.

Dr. Lieb highlights that education, regular screening, the HPV vaccination, and follow-up after an abnormal Pap results are ways to help reduce these disparities.

Whitney Lieb, MD, MPH, is the Women’s Health Scholar with The Blavatnik Family Women’s Health Research Institute. She is also an Assistant Professor in the Department of Obstetrics, Gynecology, and Reproductive Science at the Icahn School of Medicine at Mount Sinai. Her interests include cervical cancer screening and prevention, maternal mortality, and reproductive health in the United States and globally.

Amy Balbierz, MPH, is a program manager in the Department of Population Health Science and Policy and for The Blavatnik Family Women’s Health Research Institute. She has worked alongside Elizabeth Howell, MD, MPP, founding Director of The Blavatnik Family Women’s Health Research Institute at the Icahn School of Medicine at Mount Sinai, on her NIH and RWJF funded research for the last 10 years.

Kimberly Glazer, PhD, MPH

The COVID-19 pandemic is a watershed global health crisis. It is heartrending, uncharted territory. Here in New York City, we have weathered a health emergency nearly inconceivable just a few months ago. With incredible fortitude, compassion, and grace, health care professionals and other essential workers carried us past the crest of this wave of infection. We have been forced to learn a set of arduous lessons: about the price of foregone planning and prevention; about limitations in our capacity to control hazards in an interconnected world; and about the imperative of working together to develop and share solutions to existential global issues.

In reflecting on the challenges of the past weeks, I cannot help but connect this crisis with my own research area of perinatal health. I have spent my postdoctoral training learning from expert clinicians, epidemiologists, and health service researchers studying maternal and infant health disparities in New York City. The themes coming to the surface in this pandemic, in particular its disproportionate toll on communities of color, are regrettably familiar.

COVID-19 mortality data indicate a clear differential impact by race. In a previous post, we showed how Black, poor neighborhoods suffer the highest burden of COVID-19 in New York City. According to the COVID Racial Data Tracker, a collaboration between The Atlantic’s COVID Tracking Project and the Antiracist Research and Policy Center, Black people are dying at a rate nearly two times higher than their share of the population. Some data suggest that Black people may be less likely to receive coronavirus testing when symptomatic, and delays in diagnosis and treatment are particularly consequential for people of color, who are more likely to suffer from risk factors for severe illness such as diabetes and hypertension. In another report, “The color of coronavirus: COVID-19 deaths by race and ethnicity in the U.S”, researchers at APM Research Labs conclude: “if they had died of COVID-19 at the same rate as White Americans, about 13,000 Black Americans, 1,300 Latino Americans and 300 Asian Americans would still be alive.”

We confront similarly appalling disparities for perinatal outcomes. The U.S. maternal mortality rate increased while other nations halted or reversed their trends. Black mothers die at alarmingly high and disproportionate rates, their infants are less than half as likely as their non-Hispanic White counterparts to survive the first month of life, and both Black and Latina mothers face increased risk of life-threatening pregnancy-related complications. A large proportion of these disparities are due to preventable complications and systematic deficiencies in obstetric and neonatal care quality.

Our research team at the Blavatnik Family Women’s Health Research Institute has developed a body of research examining these inequities. Critically, there is a growing recognition of disparities that persist even beyond differences in underlying health conditions, insurance coverage, and the hospitals where women receive care. Entrenched racial and ethnic biases manifest in power imbalances and communication gaps in maternal and neonatal care, contributing to the unnecessary escalation of avoidable morbidity.

I read an article about the impact of COVID-19 on global hunger, in which a volunteer in Kibera, the largest Nairobi slum, called the coronavirus “the great revealer, pulling the curtain back on the class divide and exposing how deeply unequal this country is.” His quote referred to Kenya but could have easily described the trajectory of the pandemic, or any number of health issues, here in the United States. In this moment, as we confront the legacy of deep-seated, structural racism and bias in our country, it is past time to challenge the systems that create the conditions for disparities.

This emergency provides a trying but important lesson in empathy–of shifting our paradigms to consider, and prioritize, equity and the common good. Looking out my window over the past few weeks–at largely empty streets, peppered with socially-distanced dog walkers and stir crazy runners–I have been heartened to see people heeding the warnings of public health and medical officials. Extreme social isolation has been necessary to slow the pace of infection and conserve health resources for those who need them most. We are living out the tension between individual liberty and public safety: taking stock of the implications that our choices have, day in and day out, for those around us, and considering the experiences of those whose circumstances differ from our own.

This is public health. And (though of course I am biased), I also think it is the best of humanity. When we force ourselves to ask difficult questions about what we can live without, what we need to mobilize now to mitigate future harm, and how to redress inequitable risk. These questions are applicable to a viral pandemic, a maternal mortality crisis, and each of the seemingly mounting threats facing humanity. Now what do we do with this wake-up call?

We can learn from this crisis. We can change how we think about health, and the capacity of our infrastructure, systems, and workforce to protect it. Listen to the data, engage the experts, and proceed as if lives depend on our actions. They always do.

Kimberly Glazer, PhD, MPH, is a perinatal epidemiologist with research interests in obstetric management and peripartum morbidity, with specific attention to maternal obesity. She is a postdoctoral fellow with the Blavatnik Family Women’s Health Research Institute. Her research evaluates social and quality of care determinants of severe maternal morbidity, adverse neonatal outcomes, and racial/ethnic perinatal disparities.

Those who identify as LGBTQ+ often have different health care and treatment needs. Clinicians must be trained to better understand and respond to those needs, according to Zoe Rodriguez, MD, a Blavatnik Family Women’s Health Research Institute faculty member and an Assistant Professor in the Department of Obstetrics, Gynecology, and Reproductive Science at the Icahn School of Medicine at Mount Sinai and Vice Chair of Operations at Mount Sinai’s Downtown campus.

Dr. Rodriguez discusses LGBTQ+ health in this Q&A made in recognition of LGBTQ+ Pride Month.

The Icahn School of Medicine at Mount Sinai has instituted curriculum changes to include diverse perspectives in health care for our medical students to build that knowledge base. Unfortunately, disparities exist in the LGBTQ+ community in health care due to years of discrimination and access to health, including sexual and mental health.  Dr. Rodriguez shares some of the resources that are available to patients who identify as LGBTQ+ in New York City.

Dr. Rodriguez is also part of the Center for Transgender Medicine and Surgery at Mount Sinai that provides gender-affirming surgeries, as well as comprehensive primary and mental health care for transgender people.

One of her patients wrote the following about their experience with her: “Dr. Rodriguez is THE OB-GYN for trans folk in NYC. Her and her staff are clearly in the loop and are consistently understanding and respectful. I would recommend every time for guys looking for that particular operation.”

Another wrote, “As a trans man I left so happy that I went. I was so nervous and kept canceling right before my appointment. Finally, I went and I was so relieved. They were EXTREMELY nice and respectful. Used all the correct pronouns and were helpful with any questions I had about my current transition. I would highly recommend Dr. Rodriguez and her amazing nurse to anyone.”

Tatyana Kushner

In recognition of Hepatitis Awareness Month, Tatyana Kushner, MD, MSCE, a member of the Blavatnik Family Women’s Health Research Institute, a hepatologist by training, an Assistant Professor in the Departments of Liver Diseases with a joint appointment in Obstetrics, Gynecology, and Reproductive Science at the Icahn School of Medicine answered questions on hepatitis and we decided to share them on our blog. Dr. Kushner, an expert in liver disease, is also the Associate Medical Director of the Hepatitis C and Drug User Health Center of Excellence for the Clinician Education Initiative, which is a program funded by New York State that provides education to providers about hepatitis C.

What is hepatitis?

Hepatitis broadly means inflammation of the liver. Hepatitis has several potential causes. Most commonly we think of viruses that cause hepatitis such as hepatitis A, hepatitis B, hepatitis C, hepatitis D, and even hepatitis E. In addition, there are other causes such as autoimmune conditions that can cause hepatitis, which is called autoimmune hepatitis, as well as nonalcoholic steatohepatitis, or NASH, which is also called “fatty liver disease” and reflects inflammation caused by fat accumulation in the liver.

 What are the different types of hepatitis? How do you distinguish them?

The different types of hepatitis include viral hepatitis, autoimmune hepatitis, alcohol hepatitis, and nonalcoholic steatohepatitis—all of which reflect inflammation in the liver caused by different entities. In viral hepatitis, there are five types, which includes hepatitis A, B, C, D, and E. We can distinguish between the types by assessing the patient with a careful history as well as blood tests. For example, blood tests are needed to diagnose hepatitis A, B, C, D, and E to detect virus replication, as well as the presence of some specific viral proteins in the blood. To help diagnosis alcohol hepatitis or NASH, a liver ultrasound may be done that would demonstrate signs of fat in the liver. Rarely, we may also perform a liver biopsy if the blood tests are not definitive—for example, with autoimmune hepatitis, blood tests are available but a biopsy would provide a more definitive diagnosis.

Which form of hepatitis is most severe?

Broadly speaking, hepatitis can be acute or chronic. Acute hepatitis can be very severe and lead to significant liver injury and even liver failure requiring liver transplantation. This can occur with viral hepatitis or autoimmune hepatitis, but fortunately is rare. Chronic hepatitis, which can be caused by hepatitis B and hepatitis C, autoimmune hepatitis, or NASH can lead to long-term liver damage which can lead to cirrhosis (or end stage liver disease) over time, which can also lead to liver failure requiring liver transplantation.

What are the symptoms of hepatitis?

Hepatitis is often completely asymptomatic. That is why it is important to have screening recommendations in place. For example, recently the  U.S. Centers for Disease Control and Prevention and the US Preventive Services Task Force (USPSTF) have recommended screening of all adults age 18 to 79 for hepatitis C. Similarly, patients with risk factors and/or pregnant patients are recommended to be screened for hepatitis B. Hepatitis can also present with symptoms, and the common ones are jaundice (yellowing of the skin and eyes) and generalized symptoms like fatigue/malaise or not feeling well in general. If hepatitis has progressed to liver failure or cirrhosis, you can see symptoms like confusion, swelling of the abdomen and legs, and/or bleeding, including blood in the stool and vomiting of blood.

How does one get hepatitis? What are some risk factors?

Different types of hepatitis have different risk factors. For example, hepatitis B and hepatitis C are bloodborne infections, and therefore one acquires them through contact with an infected person’s blood. This can occur with injection drug use, obtaining tattoos with contaminated needles, blood transfusion prior to 1992 (when blood started being screened for hepatitis C), dialysis, and health care exposure. There is also a risk of sexual transmission as well as mother-to-child transmission. In contrast, hepatitis A and hepatitis E are transmitted through contaminated food, water, or human waste. Thus, it can be acquired by consuming contaminated raw meat or water, particularly in developing countries. Other forms of hepatitis, such as alcohol hepatitis, are caused by excessive alcohol use. Autoimmune hepatitis occurs sporadically, especially in persons with a prior history of autoimmune disease in general.

Are there groups more at risk of developing hepatitis?

Yes. Hepatitis C, for example, is most common among persons who inject drugs, as well as people born from the years 1945-1965, the Baby Boomers. High rates of hepatitis C occurred during this time due to lifestyle choices and drug use, as well as health care practices during that time period such as reuse of glass and metal syringes in medical practice. Hepatitis B is much more common in people from regions in Asia and Africa, where it is endemic.

How is hepatitis and the specific form of it diagnosed?

Generally hepatitis can be diagnosed with blood tests, which can distinguish between the different types of viral hepatitis, as well as evaluate for autoimmune hepatitis. Rarely, a liver biopsy can be helpful in particular for diagnosing autoimmune hepatitis.

What are the treatments for hepatitis?

Different types of hepatitis have different types of treatments. For example, for hepatitis B, we have antiviral medications that suppress virus replication, and therefore improve disease outcomes, such as decreasing the risk of developing cirrhosis and liver cancer. Although, there is currently no cure for hepatitis B, there are multiple ongoing clinical trials, including at Mount Sinai, which are evaluating new medications that can cure hepatitis B in the future.  For hepatitis C, we have a number of medication regimens available, called directly acting antiviral agents, which cure hepatitis C. This is an exciting recent development in our field, as prior to 2013 these medications had not been available. Now, we can cure virtually everyone with hepatitis C, even with advanced liver disease. For autoimmune hepatitis, we treat with immunosuppressive therapy such as steroids and other steroid-sparing medications. For alcohol hepatitis, the main recommendation is alcohol cessation. In specific instances, we can also treat with steroids if the alcohol hepatitis is very severe. For NASH, or fatty liver disease, lifestyle modification with the goal of weight loss and improved diabetes control, is critical, and we also have multiple ongoing clinical trials for the treatment and prevention of progression of NASH.

How does hepatitis affect pregnancy and childbirth?

Hepatitis is very important to consider in pregnant women. For example, hepatitis B and hepatitis C can be transmitted from the mother to the baby in pregnancy and childbirth. Therefore, we need to screen women for these viruses at the beginning of pregnancy to make sure we take all measures to prevent transmission which can lead to liver problems, and other problems, in the baby. For hepatitis B, we make sure that the baby gets the hepatitis B vaccine, as well as hepatitis B immunoglobulin (another agent that decreases risk of transmission) within 12 hours of birth to decrease risk of transmission. In addition, we recommend treatment with antiviral medication of the mother if she meets criteria. For hepatitis C, we currently do not treat mothers during pregnancy, but this is currently under evaluation. There are obstetrics management measures during the pregnancy that are also important to take in order to decrease the risk of transmission to the baby, such as minimizing invasive fetal monitoring.

Hepatitis can also impact the pregnancy. For example, hepatitis C increases the risk of cholestasis of pregnancy, a pregnancy-specific condition that can have a negative impact on the baby. There have also been studies which suggest an increased risk of preterm birth and gestational diabetes in women who have hepatitis during pregnancy.

Finally, hepatitis can also become more active in the setting of pregnancy. Hepatitis B can “flare” or become more active during pregnancy and in the postpartum period. Hepatitis E, although rare, can be especially severe during pregnancy.

What disparities exist between groups in regard to hepatitis prevalence or treatment?

There are disparities that exist in terms of testing and access to treatment in certain patient groups. For example, due to provider beliefs and insurance restrictions, it has been difficult for people who use drugs, and who are most affected by hepatitis C, to access hepatitis C medications, and therefore obtain a cure for hepatitis C. For example, a recent publication demonstrated significant disparities in outcomes from liver cancer in patients with hepatitis C between African Americans (mostly men) and Caucasian individuals with hepatitis C since the introduction of hepatitis C medications, suggesting that access to medications was inferior in the African American community.

There have also been disparities in testing and monitoring of hepatitis B, which affects a predominantly immigrant patient population. For example, immigrant patient populations, especially those without health insurance, often do not get the appropriate follow up for liver cancer screening as well as access to antiviral therapy, which leads to progression of the disease in these patient groups.

How do we work on reducing these disparities?

Education of health care providers, as well as of patients, is critical in order to reduce these disparities. For example, over the past few years there has been a significant emphasis on educating providers, and creating care models, in order to be able to provide people who use drugs with hepatitis C treatment. Furthermore, over time there has been a gradual reduction in cost of hepatitis C medications, as well as legislation changes, in order to lift insurance coverage restrictions that were targeting people who use drugs.

Providing education to patients about the importance of hepatitis B follow up, and the development of programs through the New York State Department of Health and the New York City Department of Health, dedicated to make sure that patients with hepatitis B are able to access care, are appropriately linked to care, and are not lost to follow up.

What can we do every day to prevent the spread of hepatitis?

It is important to know the current testing recommendations for hepatitis so that everyone gets tested, even if asymptomatic. Measures to decrease transmission, such as practicing safe sex, taking measures to decrease risk associated with drug use, and minimizing health care exposure (i.e. using sterilized techniques, not re-using needles – which is still currently in issue in certain countries abroad) are critical. For patients diagnosed with hepatitis, it is important to engage in care and be treated, in order to decrease community transmission.

Is there anything else you would like to share about hepatitis?

Adults age 18-79 should be tested for hepatitis C. If you test positive, there are excellent treatments available that can cure you. May 19, 2020 is Hepatitis Testing Day. Use this opportunity to get tested or check on the status if you have been exposed or diagnosed with hepatitis. Hepatitis is a leading cause of death worldwide. It is important to seek care if concerned if you develop symptoms such as jaundice. There are treatments available to halt progression of hepatitis such as hepatitis B and autoimmune hepatitis. If you have hepatitis B, come see us in Mount Sinai Institute for Liver Medicine to participate in clinical trials for the cure of hepatitis B. If you are interested in inquiring about additional hepatitis C trainings, visit ceitraining.org.