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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