Download Chronic Hepatitis B

hepatitis
Chronic Hepatitis B Virus Infection:
What You Need to Know
Chester Grabowski
Senior Medical Scientist
Gilead Sciences
Agenda
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Understanding your liver
What is hepatitis?
Why should Asian Americans be concerned about hepatitis B?
How is hepatitis B diagnosed?
How can hepatitis B be managed?
Can hepatitis B be prevented?
What are common myths about hepatitis B?
Frequently asked questions
2
Understanding Your Liver
3
Understanding Your Liver
• The liver is like a factory that is essential
to life
– It builds proteins and sugars for other
parts of the body to use
• It is like a warehouse
– It stores vitamins, sugars, fats and nutrients and
releases them when the body needs them
• It is like a recycling center
– It filters the blood and breaks down chemicals that
the body cannot use
If your liver does
not work well,
you may get sick
Barrett KE. Gastrointestinal Physiology. http://www.accessmedicine.com/content.aspx?aID=2306090. Accessed April 19, 2009.
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Liver Disease Has Numerous Causes:
Many Are Preventable, and Many Are Treatable
Potential Causes
Examples
Viruses1,2
Hepatitis A , B, C
Alcohol1
Alcoholic liver disease
Drugs1
Certain medications can damage liver
(e.g., OTC pain medications)
Hereditary3
Iron overload (Hemochromatosis)
5
1. American Liver Foundation. Liver Wellness. http://www.liverfoundation.org/downloads/alf_download_29.pdf. Accessed April 1, 2009.
2. Keeffe EB, et al. Clin Gastroenterol Hepatol. 2008;6:1315-1341.
3. American Liver Foundation. Hemochromatosis. http://www.liverfoundation.org/education/info/hemochromatosis/. Accessed April 1, 2009.
Liver Disease Is Often Silent Until Too Late
The liver has few nerves, so lack of pain
does not always mean you have a healthy liver
Spinal cord
Thus, screening may be the only method
for early diagnosis
Maddrey C. Conquering Hepatitis C. Shelton, CT: PMPH-USA; 2000.
Asian Liver Center. 2007 Physician’s Guide to Hepatitis B: A Silent Killer.
http://liver.stanford.edu/Education/2007Handbook.pdf. Accessed April 1, 2009.
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What Is Hepatitis?
7
What Is Hepatitis?
• Hepatitis means “inflammation of the liver”1
• Viral hepatitis is the most common cause of
liver disease2
• The most common types of viral hepatitis in
the US are1:
–Hepatitis A
–Hepatitis B
–Hepatitis C
Hepatitis B Virus
Image from ICTVdB - The Universal Virus Database, version 4.
http://www.ncbi.nlm.nih.gov/ICTVdb/ICTVdB/
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1. Centers for Disease Control and Prevention. Hepatitis B FAQs.
http://www.cdc.gov/print.do?url=http%3A//www.cdc.gov/hepatitis/B/bFAQ.htm%23overview. Accessed April 1, 2009.
2. American Liver Foundation. Liver Wellness. http://www.liverfoundation.org/downloads/alf_download_29.pdf. Accessed March 11, 2009.
Overview of Hepatitis A, B, and C
Hepatitis A
Hepatitis B
Hepatitis C
Fecal oral route, usually
via contaminated food or
objects
Body fluids of an infected
person
Body fluids of an infected
person
Long-term Effects
No chronic
infection
May be chronic and
progress to liver disease
and death
May be chronic and
progress to liver damage
and death
Vaccine Available?
Yes
Yes
No
Transmission
9
Centers for Disease Control and Prevention. FAQs for Hepatitis A, B, and C. http://www.cdc.gov/hepatitis/.
Accessed April 1, 2009.
Chronic Hepatitis B Is an Infectious Viral Illness
• HBV is up to 100 times more infectious than HIV
• HBV can live outside the body for 7 days
• Many people who are chronically infected with HBV do not have
any symptoms
• Early detection is the key to preventing hepatitis B-associated
disease and death
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Asian Liver Center. 2007 Physician’s Guide to Hepatitis B: A Silent Killer.
http://liver.stanford.edu/Education/2007Handbook.pdf. Accessed April 1, 2009.
Potential Clinical Outcomes of
Chronic Hepatitis B
Chronic Hepatitis B
~70%1
HBsAg Carrier
State
~30%1
Chronic Infection
(Active Viral Replication)
Up to 40%2
Liver Failure
Cirrhosis
Hepatocellular
Carcinoma
1. Hsu YS, et al. Hepatology. 2002;35:1522-1527.
2. Lok AS. N Engl J Med. 2002;346:1682-1683.
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Chronic Hepatitis B (CHB)
• Is a long-term disease that occurs
when your immune system does not
get rid of the virus1
–May have no obvious symptoms1,2
–Patients often find out they are ill when
they develop serious liver damage2
–Is a serious disease; it can lead to
cirrhosis, liver cancer, and death2
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1. Mayo Clinic. Hepatitis B. http://www.mayoclinic.com/health/hepatitis-b/DS00398. Accessed April 1, 2009.
2. Asian Liver Center. 2007 Physician’s Guide to Hepatitis B: A Silent Killer.
http://liver.stanford.edu/Education/2007Handbook.pdf. Accessed April 1, 2009.
Types of Liver Disease That Can Be Caused by
Chronic Hepatitis B
The healthy liver
The fibrotic liver1
The cirrhotic liver2
Liver cancer3
This is a
healthy liver
The continuous
inflammation of the
liver caused by
hepatitis B can lead
to fibrosis—a formation
of scar tissue within the
liver
In cirrhosis of the liver,
scar tissue replaces
normal, healthy tissue,
blocking the flow of
blood through the liver
and preventing it from
working as it should
Liver cancer is the
formation of a
malignant tumor in
the liver
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1. Merck Online Medical Library. http://www.merck.com/mmpe/sec03/ch026/ch026b.html. Accessed April 16, 2009.
2. Lim YS, Kim WR. Clin Liver Dis. 2008;12:733-746.
3. Stedman’s Medical Dictionary Online. http://www.stedmans.com. Accessed April 1, 2009.
Why Should Asian Americans Be
Concerned About Hepatitis B?
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Hepatitis B Is a Global Problem
Prevalence of HBV Infection*
8% = High*
2-7% = Intermediate*
<2% = Low
*Individuals born in locations with intermediate or high prevalence should be routinely screened for HBV infection
Adapted from: Centers for Disease Control and Prevention. Morb Mortal Wkly Rep. 2008;57:1-16.
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HBV Infection Represents a Vital Public
Health Problem
• The Asian American community is projected to grow to 33.4 million people (or 8% of the total US
population) by 20501
– 68.9% of Asian Americans living in US are foreign-born2
– Asian Americans are 2.7 times more likely to develop liver cancer and 2.4 times more likely to die from it
than their white counterparts3
Asian Population in the United States, 2000 = ~12 million4,5
Korean
1,228,427
Chinese
2,734,841
Taiwanese
Asian Indian
1,899,599
Hmong
144,795
186,310
Laotian
198,203
Vietnamese
Filipino
1,223,736
2,364,815
Samoan5
133,281
1.
2.
3.
4.
5.
U.S. Census Bureau. http://www.census.gov/Press-Release/www/releases/archives/population/001720.html. Accessed February 10, 2009.
U.S. Census Bureau. http://www.census.gov/prod/2003pubs/c2kbr-34.pdf. Accessed February 10, 2009.
Lin SY, et al. Hepatology. 2007;46:1034-1040.
U.S. Census Bureau. http://www.census.gov/prod/2002pubs/c2kbr01-16.pdf. Accessed February 10, 2009.
U.S. Census Bureau. http://www.census.gov/prod/2001pubs/c2kbr01-14.pdf. Accessed February 10, 2009.
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Chronic Hepatitis B Is Common in Asians
• About 1 in 20 people in the world (400 million)
are living with chronic hepatitis B1,2
• Approximately 2/3 of people living with chronic
hepatitis B live in Asia2
• Although preventable by a vaccine, HBV kills
700,000-1 million people every year2
• Every 30-45 seconds, one person
dies from this disease2
• Although Asian Americans comprise only 4% of
the U.S. population, they account for over half of
the cases of chronic hepatitis B in the country2
1. Gish RG, Gadano AC. J Viral Hepat. 2006;13:787-798.
2. Asian Liver Center. 2007 Physician’s Guide to Hepatitis B: A Silent Killer. http://liver.stanford.edu/Education/2007Handbook.pdf.
Accessed April 1, 2009.
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Most Asians with Chronic Hepatitis B Were
Infected at Birth or Early Childhood1
Vertical Transmission
(Mother to Child)
Other Routes of
Transmission Include2
Razors/
Needles
Unprotected
Sexual Contact
with HBV+
Contact with
Infected Fluids
Transfusion/
Organ Transplant
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1. Lin SY, et al. Hepatology. 2007;46:1034-1040.
2. Centers for Disease Control and Prevention. Hepatitis B FAQs.
http://www.cdc.gov/print.do?url=http%3A//www.cdc.gov/hepatitis/B/bFAQ.htm%23overview. Accessed April 1, 2009.
More than Half of Americans Infected with
Chronic Hepatitis B Are Asian
• An estimated 2 million people
in the US have chronic hepatitis B1—
many are of Asian descent2
• Prevalence of chronic hepatitis B is
higher in Asian-born populations than
in North American-born counterparts3
– China: 13.6%
– Vietnam: 13%
– Korea: 8%
– Japan: 0.8%
– North America: 0.3%
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1. Gish RG, Gadano AC. J Viral Hepat. 2006;13:787-798.
2. Asian Liver Center. 2007 Physician’s Guide to Hepatitis B: A Silent Killer.
http://liver.stanford.edu/Education/2007Handbook.pdf. Accessed April 1, 2009.
3. Welch S, et al. Poster 853 presented at: 59th Annual Meeting of AASLD. October 31, November 4, 2008; San Francisco, CA.
Hepatitis B Status Was Unknown by Many
Asian Americans in San Francisco
 A study of 3,163 Asian American volunteers
were screened for HBV
– 45% needed vaccination
– 9% had chronic hepatitis
• 65% with CHB were unaware they had
the disease
Distribution of CHB Risk:
Asian Americans
(2001-2006, San Francisco)
Chronic
Hepatitis B
Immune
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Lin SY, et al. Hepatology. 2007;46:1034-1040.
Untreated Hepatitis B Can Cause Liver Cancer
• Hepatitis B virus is second only to tobacco
smoke in causing cancer deaths globally
• Liver cancer caused by chronic hepatitis B is
the 2nd leading cause of cancer death for
Asian men in the US
• The incidence of liver cancer is 9 times
higher in Asian American men than their
white counterparts
Hepatitis B-Associated Liver Cancer
Destroying Normal Liver
Image from netterimages.com
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Asian Liver Center. 2007 Physician’s Guide to Hepatitis B: A Silent Killer.
http://liver.stanford.edu/Education/2007Handbook.pdf. Accessed April 1, 2009.
How Is Hepatitis B Diagnosed?
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CDC Populations Recommended for
Routine HBV Testing
 Persons born in regions with HBV
prevalence ≥2%
 Source of blood/body fluid exposures
(e.g., needle sticks, sexual assault)
 Persons whose parents were born in
regions with HBV prevalence ≥8%
 Injection drug users
 Donors of blood, plasma, organs,
tissue, or semen
 All pregnant women
 Men who have sex with men
 HIV-positive persons
 Infants born to HBsAg-positive women
 Persons needing immunosuppressive
therapy
 Contacts (household, needle-sharing,
or sexual) of HBsAg-positive persons
 Persons with elevated ALT/AST
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Centers for Disease Control and Prevention. Morb Mortal Wkly Rep. 2008;57(RR-8):1-28.
Chronic Hepatitis B Screening:
It Is Important and Easy to Test
• Screening for hepatitis B is necessary to:
– Identify people who have chronic hepatitis B so
they can receive appropriate medical care
– Identify those who are unprotected so they can
be vaccinated
• It is important that you be screened for HBV
if you are at risk
– HBV screening is quick and easy
– All you need is a simple blood test to
detect infection
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Centers for Disease Control and Prevention. Morb Mortal Wkly Rep. 2008;57(RR-8):1-28.
HBV Routine Screening:
Your First Physician Office Visit
• Your physician will order a blood test for1
– Hepatitis B Surface Antigen (HBsAg)
• Negative: Normal
• Positive >6 months*: Patient has chronic hepatitis B
– Hepatitis B antibody (Anti-HBs)
• Negative: Not immune
• Positive: Immunity to hepatitis B from either previous
infection or vaccination
• HBV screening is available for free at many public
health clinics, and health insurance may cover the
cost of screening2
*If HBsAg is not positive for >6 months, patient has acute hepatitis B
1. Asian Liver Center. 2007 Physician’s Guide to Hepatitis B: A Silent Killer.
http://liver.stanford.edu/Education/2007Handbook.pdf. Accessed April 1, 2009.
2. Mayo Clinic. Hepatitis B. http://www.mayoclinic.com/health/hepatitis-b/DS00398. Accessed April 1, 2009.
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Can Hepatitis B Be Managed?
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What Should I Do If I Am Diagnosed with
Chronic Hepatitis B?
• Although there is no cure, chronic hepatitis B
can be a manageable disease1
– Early detection and proper management can
help save lives1
– Many patients with active disease, once treated,
can live normal and healthy lives1
• Regular visits with your physician are important1
– Schedule regular physician appointments every
3-6 months to monitor your CHB2
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1. Asian Liver Center. 2007 Physician’s Guide to Hepatitis B: A Silent Killer.
http://liver.stanford.edu/Education/2007Handbook.pdf. Accessed April 1, 2009.
2. Lok AS and McMahon BJ. Hepatology. 2007;45:507-539.
CHB Routine Follow-Up:
Screening for Liver Cancer
• The initial evaluation may include a physical examination, family history, tests for
HBV replication, tests to rule out other infections, and screening tests for liver cancer
• Liver cancer can be a serious complication of chronic hepatitis B
• Patients at high risk of liver cancer include:
–
–
–
–
–
–
Asian men >40 years old
Asian women >50 years old
Patients with cirrhosis
Individuals with a family history of HCC
Africans >20 years old
Patients >40 years old with persistent or intermittent ALT elevation and/or high HBV DNA levels
• Screening with ultrasound should occur every 6-12 months in these patients
– A blood test (alpha-fetoprotein, or AFP) may be used when ultrasound is not available or cost
is an issue
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Lok AS and McMahon BJ. Hepatology. 2007;45:507-539.
Oral Medications for the Treatment of
Chronic Hepatitis B
• Five oral medications are FDA approved:
– Adefovir dipivoxil
– Entecavir
– Lamivudine
– Telbivudine
– Tenofovir disoproxil fumarate
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Keeffe EB, et al. Clin Gastroenterol Hepatol. 2008;6:1315-1341.
Injectable Medications for the Treatment of
Chronic Hepatitis B
• Two injectable medications are FDA approved:
–Interferon alfa-2b
–Peginterferon alfa-2a
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Keeffe EB, et al. Clin Gastroenterol Hepatol. 2008;6:1315-1341.
Treatment for Hepatitis B May Reduce the Risk
of Cirrhosis and Liver Cancer
Treatment
High Hepatitis B
Virus Level
Cirrhosis
Higher
Lower Risk
Risk
Liver Cancer
31
Iloeje UH, et al. Gastroenterol. 2006;130:678-686.
Chen CJ, et al. JAMA. 2006;295:65-73.
Liaw Y. Semin Liver Dis. 2005; 25:40-47.
Can Hepatitis B Be Prevented?
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Vaccination Is Essential to Prevent
HBV Infection
• Vaccination is the best way to protect yourself and others without hepatitis B
from the disease1
• Who should be vaccinated?2
–All children at birth
• Vaccine series should be completed by 6-18 months
–Children and adolescents through 18 years of age
who were not previously vaccinated
–All unvaccinated adults at risk for HBV infection
–Health care workers
–Household members with an HBV-infected individual
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1. Mayo Clinic. Hepatitis B. http://www.mayoclinic.com/health/hepatitis-b/DS00398. Accessed April 1, 2009.
2. Centers for Disease Control and Prevention. Hepatitis B Vaccine: What You Need to Know.
http://www.cdc.gov/vaccines/pubs/vis/downloads/vis-hep-b.pdf. Accessed April 1, 2009.
What Are Other Ways to Reduce the Risk of
Hepatitis B Infection?
• Other ways to guard against infection include:
– Learn more about hepatitis, its prevention and treatment
– Use condoms for safer sex
– Don’t share needles, including those used for tattoos
– Don’t share razors or toothbrushes with an infected person
– Vaccinate newborn infants in a timely manner
– Do not donate blood or semen if you have hepatitis B
Refer to reference for complete list of ways to prevent hepatitis B
Mayo Clinic. Hepatitis B. http://www.mayoclinic.com/health/hepatitis-b/DS00398. Accessed April 1, 2009.
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Pregnancy Is a Time for Hepatitis B Screening
and Prevention
• Federal guidelines recommend that all
pregnant women be tested for chronic
hepatitis B at an early prenatal visit
• Infants born to women with chronic
hepatitis B should receive hepatitis B
immune globulin (HBIG)
• All newborns should be vaccinated
against hepatitis B at birth
• After giving birth, women with chronic
hepatitis B should talk to their doctors
about managing their chronic hepatitis B
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Asian Liver Center. 2007 Physician’s Guide to Hepatitis B: A Silent Killer.
http://liver.stanford.edu/Education/2007Handbook.pdf. Accessed April 1, 2009.
What Are Common Myths About
Hepatitis B?
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Clarifying Myths About Transmission of
Hepatitis B
Hepatitis B is Not Transmitted by
Sharing
Food, Water, Utensils,
Glasses
Mosquitoes
Tears, Sweat,
Urine, or Stool
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Asian Liver Center. 2007 Physician’s Guide to Hepatitis B: A Silent Killer.
http://liver.stanford.edu/Education/2007Handbook.pdf. Accessed April 1, 2009.
Clarifying Myths About Transmission of
Hepatitis B
Hepatitis B is Not Transmitted by
Hugging/
Kissing
Coughing, Sneezing
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Asian Liver Center. 2007 Physician’s Guide to Hepatitis B: A Silent Killer.
http://liver.stanford.edu/Education/2007Handbook.pdf. Accessed April 1, 2009.
Clarifying Myths About Transmission of
Hepatitis B
If I Have it, I’d
Have Symptoms
WRONG!
I Was Diagnosed
Years Ago so I
Shouldn’t Worry
WRONG!
Asian Liver Center. 2007 Physician’s Guide to Hepatitis B: A Silent Killer.
http://liver.stanford.edu/Education/2007Handbook.pdf. Accessed April 1, 2009.
Hepatitis B Can’t
Be Prevented
WRONG, HBV
can be prevented
with vaccination!
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Clarifying Myths About Transmission of
Hepatitis B
I’m Too Young to
Be Tested
WRONG!
I’m Too Old to
Be Tested
WRONG!
Hepatitis B Can’t Be
Treated
WRONG!
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Asian Liver Center. 2007 Physician’s Guide to Hepatitis B: A Silent Killer.
http://liver.stanford.edu/Education/2007Handbook.pdf. Accessed April 1, 2009.
Conclusions
• Globally, about 1 in 20 people (400 million) are
living with chronic hepatitis B1,2
• In the US, Asian-Pacific Americans account
for many of the estimated 2 million people with
chronic hepatitis B2
• Hepatitis B is a silent disease; many people
with chronic hepatitis B feel perfectly healthy and
do not have symptoms2
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1. Gish RG, Gadano AC. J Viral Hepat. 2006;13:787-798.
2. Asian Liver Center. 2007 Physician’s Guide to Hepatitis B: A Silent Killer.
http://liver.stanford.edu/Education/2007Handbook.pdf. Accessed April 1, 2009.
Conclusions
• HBV is common in our community
• HBV infection is quick and easy to detect; all
you need is a simple blood test for HBsAg
• If you do not have hepatitis B, you should get
vaccinated
• If you have hepatitis B, make sure you have
routine follow-up appointments to manage
your disease
• It's everyone's responsibility to spread the word
about HBV
– Make sure you and your loved ones are tested
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Asian Liver Center. 2007 Physician’s Guide to Hepatitis B: A Silent Killer.
http://liver.stanford.edu/Education/2007Handbook.pdf. Accessed April 1, 2009.
Frequently Asked Questions About Hepatitis B
• Q: What is the principal mode of transmission of hepatitis B in the Asian community?
– A: Most Asians with chronic hepatitis B were infected at birth or in early childhood1
• Q: Can hepatitis B be transmitted by sharing food?
– A: No2
• Q: Is poor hygiene the major cause for chronic hepatitis B?
– A: No3
• Q: What is the process of hepatitis B immunization?
– A: You receive 3 shots over a period of 6 months2
• Q: Will vaccination protect me against complications if I already have
chronic hepatitis B?
– A: No, vaccination is a prevention for HBV. There are medications available to treat chronic
hepatitis B; please see your doctor2
• Q: How much alcohol can I drink if I have chronic hepatitis B?
– A: You should avoid alcohol if you have been diagnosed with chronic hepatitis B3
1. Lin SY, et al. Hepatology. 2007;46:1034-1040.
2. Asian Liver Center. 2007 Physician’s Guide to Hepatitis B: A Silent Killer. http://liver.stanford.edu/Education/2007Handbook.pdf.
Accessed April 1, 2009.
3. Centers for Disease Control and Prevention. Hepatitis B FAQs.
http://www.cdc.gov/print.do?url=http%3A//www.cdc.gov/hepatitis/B/bFAQ.htm%23overview. Accessed April 1, 2009.
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Frequently Asked Questions About Hepatitis B
• Q: How effective is vaccination for hepatitis B?
– A: The vaccine is more than 95% effective in preventing hepatitis B
• Q: Will hepatitis B immunization protect me against other types of hepatitis?
– A: No; however, vaccination is available for people at risk of hepatitis A
• Q: What precautions should I take if I am pregnant?
– A: All pregnant women should be screened for chronic hepatitis B, and all newborns should
be vaccinated at birth
• Q: Should I avoid people with hepatitis B at work or school?
– A: No, there is no reason to avoid people who have hepatitis B
• Q: What are some recommended lifestyle changes for people with chronic hepatitis B?
– A: You should avoid alcohol, consult with your doctor before taking any medication, eat a healthy diet, and
practice measures to avoid transmission of hepatitis B
• Q: How long is treatment for chronic hepatitis B?
– A: The optimum duration of treatment has not been established
• Q: If I have chronic hepatitis B, how often should I be screened for liver cancer?
– A: Every 6-12 months, using ultrasound and/or AFP tests
1. Centers for Disease Control and Prevention. Morb Mortal Wkly Rep. 2008;57(RR-8):1-28.
2. Asian Liver Center. 2007 Physician’s Guide to Hepatitis B: A Silent Killer.
http://liver.stanford.edu/Education/2007Handbook.pdf. Accessed April 1, 2009.
3. Centers for Disease Control and Prevention. Hepatitis B FAQs.
http://www.cdc.gov/print.do?url=http%3A//www.cdc.gov/hepatitis/B/bFAQ.htm%23overview.
Accessed April 1, 2009.
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