S

Hepatitis B: Decreasing the Burden and Increasing Compliance

Abby Wurzel, BSN, RNCAugustina Manuzak, MD, PhD, MPH

Objectives

Recognize the disease burden

Identify the risk factors for the transmission of Hepatitis B Virus (HBV)

Identify the coverage and compliance rates of Hepatitis B vaccination

Recognize the guidelines on the prevention and intervention of HBV infection

Hepatitis B

What is Hepatitis B?• Liver disease caused by the Hepatitis B Virus (HBV)

Acute vs. Chronic• Acute short-term illness occurs within 6 months of

exposure• Signs and symptoms include: fever, fatigue, loss of appetite,

nausea, vomiting, abdominal pain, dark urine, clay-colored stool, joint pain and jaundice

• Chronic is long term and remains in the person’s body• Cirrhosis and liver cancer

Hepatitis B Virus

Hepadnaviridae family – Primarily infect liver cellsHuman are the only known hostDouble strain circular DNA vi100 x more infective than HIVRetain infectivity 7 days (room T)Numerous antigenic components

- surface antigen: HBsAg- core antigens: HBcAg,

HBeAg- DNA polymerase

Clinically may cause- Acute hepatitis- Chronic hepatitis- Chronic carrier state- Hepatocellular carcinoma

(HCC)

Disease Burden

2 billion people infected worldwide

350 million suffer from chronic HBV infection

600,000 to 1.2 million deaths per year from complications of chronic hepatitis B

24,000 infants are born to HBV infected mothers annually

80-90% of infants infected during 1st year of life become chronic

15-20% of adults chronically affected die from Hepatitis B related cancer

Epidemiology Triangle of Hepatitis B

HostHumans

Environment

Sexual TransmissionIntravenous Drug

UseEndemic Areas

Blood Transfusions

Transmission

BloodBody Fluid

Epidemiology of HBV Infection

HBV infection is a global public health problem

- High Morbidity and Mortality

- Asia & Western Pacific are highly endemic countries

In US: High prevalence of HBV infection in Asian &Pacific Islander

- Immigration pattern affects prevalence

Endemic Areas

<1% in Western Europe and North America

2-5% in the Middle East & Indian Subcontinent

5-10% in Sub-Saharan Africa and East Asia

CDC. (2008). Traveler’s Health. www.cdc.gov/hepatitis/HBV/PDFx/Chronic hepBtestingflwup.pdf

Pacific Islanders & Asians

Centers for Disease Control and Prevention. (2013). Know Hepatitis B. Retrieved from www.cdc.gov/knowhepatitis B/

Disease Burden of Chronic HBV Infection

World Wide 2 out of 6 billion world pop. have

been infected with HBV 350-400 million Chronic carriers WW

15-40% develop cirrhosis, HCC, or end stage liver failure

HBV is Human carcinogen 80% of HCC caused by HBV

Chronic HBV cause 1 .2 million death each year 10th leading cause of death

United States 1.25 million carriers 2 million carrier if counted w/

immigrants endemic areas immigrants, including API, impact the US pattern of dis.

(Source: AASLD 2008 conference presentation, with references: WHO Fact Sheets; Conjeevaram, et al. (2003), JHepatology, 38:S90-S103; Lee (1997), N Engl J Med., 337, 1733-1745; Lok (2002), N Engl J Med., 346, 1682-1683)

Global Impact of Hepatitis BGlobal Impact of Hepatitis B

WHO Fact Sheets, available at www.who.int. Accessed: September 24, 2004.Conjeevaram, et al. J Hepatology. 2003;38:S90-S103.Lee. N Engl J Med. 1997;337:1733-1745.Lok. N Engl J Med. 2002;346:1682-1683.

World population 6 billion

2 billion with past/presentHBV infection

350–400 million withchronic hepatitis B

15-40% develop cirrhosis, liver failure or

HCC

1 million/year die from HBV-associated liver disease

Global Burden of Chronic HBV carriers

• 350 millions people infected WW

• 250 millions are in Asia Pacific

• South Pacific highest carrier (prevalence in Kiribati = 31%)

• Developed countries HBsAg prevalence is high among immigrants from high endemicity regions

(Source: WHO, 2000; Goldstein et al., 2005)

Healthy People 2020

Goal

Decrease rate of new hepatitis B cases among 2 to 18 year olds to 0%

Maintain vaccination coverage of 19 to 35 month olds- 90%

Achieve and maintain 1st dose of Hepatitis B between 1-3 days- 85%

Increase Hepatitis B vaccination in healthcare providers-90%

Current

0.1

93.5%

50.9%

64.3%

Healthy People 2020

Goal Increase percentage of providers

who have vaccination coverage- 50% (provided immunizations up to 6 y/o)

Reduce chronic infections in infants and young children- 400

Reduce Hepatitis B in adults 19 and older- 1.5 cases

Reduce cases in high-risk populations• Injection drug users –215• Men who have sex with men- 45

Current

40%

799 cases

2.0 cases per 100,000 persons

285

62 new cases

Prevention

Primary prevention Vaccinate and educate

Secondary prevention Screen the patient

Tertiary prevention Treatment and prevent complications

Vaccinate!!!!

Screening

Testing is recommended for: All pregnant women Persons born in regions with intermediate or high rates of Hepatitis B (HBsAg

prevalence of ≥2%) U.S.–born persons not vaccinated as infants whose parents were born in regions

with high rates of Hepatitis B (HBsAg prevalence of ≥8%) Infants born to HBsAg-positive mothers Household, needle-sharing, or sex

contacts of HBsAg-positive persons Men who have sex with men Injection drug users Patients with elevated liver enzymes (ALT/AST) of unknown etiology Hemodialysis patients Persons needing immunosuppressive or cytotoxic therapy HIV-infected persons Donors of blood, plasma, organs, tissues, or semen

Serology

CDC Recommendations for Routine Testing and Follow-up for Chronic Hepatitis B Virus Infection

Population

Recommendation

Testing Vaccination/Follow up

Person born in regions of high and intermediate HBV endemicity (HBsAg prev 2%)

Test for HBsAg, regardless of vaccination status in their country of origin, including – immigrants – refugees – asylum seekers – internationally adopted children

If HBsAg-positive, refer for medical management. If negative, assess for on-going risk for hepatitis B and vaccinate if indicated.

US born persons not vaccinated as infants whose parents were born in regions with high HBV endemicity ( 8%)

Test for HBsAg regardless of maternal HBsAg status if not vaccinated as infants in the United States.

If HBsAg-positive, refer for medical management. If negative, assess for on-going risk for hepatitis B and vaccinate if indicated

Adapted from: CDC. Recommendations for Identification and Public Health Management of Persons with Chronic HBV Infection.

MMWR 2008; 57 (No. RR-8).

Treatment

Acute Supportive

Chronic Regular monitoring of liver disease progression May use antiviral drugs

Conclusion

Immunization averts 2-3 million deaths per year

Hepatitis B is preventable

Hepatitis B can affect anyone

Need to screen high-risk individuals

Recommendations Recommendations for action

- Promote increased awareness for hepatitis B in at-risk populations

and health providers

- Collaborating of key stakeholders with state and federal agencies for

PH intervention program for hepatitis B screening and vaccination

- Finding resource to fund the continuation of the program

Recommendations for future study

- Expand screening and vaccination program to increase coverage in

ethnic subgroups with low numbers of participants

References

Centers for Disease Control and Prevention. (2014). Adult vaccination. Retrieved from http://www.cdc.gov/vaccines/adults/find-pay-vaccines.html

Centers for Disease Control and Prevention. (2010a). Global routine vaccination coverage, 2009. Morbidity and Mortality Weekly Report, 59(42). 1367-1371. Retrieved from http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5942a3.htm

Centers for Disease Control and Prevention. (2010b). Hepatitis B. Retrieved from http://www.cdc.gov/hepatitis/HBV/PDFs/HepBGeneralFactSheet.pdf

 Centers for Disease Control and Prevention. (2013a). For Parents: Vaccinations for your children. Retrieved from http://www.cdc.gov/vaccines/parents/index.html

Centers for Disease Control and Prevention. (2013b). Hepatitis B information for healthcare professionals. Retrieved from http://www.cdc.gov/hepatitis/HBV/VaccAdults.htm.

Centers for Disease Control and Prevention. (2012). Vaccination of infants, children, and adolescents. Retrieved from http://www.cdc.gov/hepatitis/HBV/VaccChildren.htm. 

Centers for Disease Control and Prevention. (2013c). Testing Asian Americans and Pacific Islanders for Hepatitis B. Retrieved from http://www.cdc.gov/hepatitis/HBV/PDFs/HepB-API.pdf

References (cont)

Centers for Disease Control and Prevention. (2013c). Testing Asian Americans and Pacific Islanders for Hepatitis B. Retrieved from http://www.cdc.gov/hepatitis/HBV/PDFs/HepB-API.pdf

Centers for Disease Control and Prevention. (2013d). Viral hepatitis. Retrieved from http://www.cdc.gov/hepatitis/b/

Centers for Disease Control and Prevention. (2014). Global vaccination and immunization. Retrieved from http://www.cdc.gov/globalhealth/immunization

Guirgis, M. M., Yan, K. K., Bu, Y. M., & Zekry, A. A. (2012). General practitioners' knowledge and management of viral hepatitis in the migrant population. Internal Medicine Journal,42(5), 497-504. doi:10.1111/j.1445-5994.2011.02440

Iloeje, U., Yang, H., & Chen, C. (2012). Natural history of chronic hepatitis B: What exactly has REVEAL revealed?. Liver International, 32(9), 1333-1341. doi 10.1111/j.1478-3231.2012.02805