Hepatitis and Liver Cancer A National Strategy for Prevention and Control of Hepatitis B and C (2010) / Chapter Skim
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1 Introduction
1 Introduction
Pages 19-40
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Chronic hepatitis B and chronic hepatitis C are serious and can result in liver cirrhosis and a type of liver cancer, hepatocellular carcinoma (HCC)
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0 HEPATITIS AND LIVER CANCER Caused by viruses Other causes 7 Tobacco HIV Malaria HBV + HCV Road accidents 6 Non-HIV TB Measles RSV, Rota Flu 5 Dengue Log10 global death rate Hospital infection HPV 4 Suicide West Nile 3 SARS Ebola Polio 2 Hanta vCJD 1 FIGuRE 1-1 Approximate global preventable death rate from selected infectious diseases and other causes, 2003. Abbreviations: HIV, human immunodeficiency virus; HBV, hepatitis B virus; HCV, hepatitis C virus; RSV, respiratory syncytial Hepatitis human papilloma vi Figure 1-1 virus; HPV, R01623 rus; SARS, severe acute respiratory syndrome; TB, tuberculosis; vCJD, variant Creutzfeldt-Jakob disease.
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INTRODUCTION TABLE 1-1 Key Characteristics of Hepatitis B and Hepatitis C Hepatitis B Hepatitis C Causative agent Partially double-stranded DNA Enveloped, positive-strand RNA virus virus Hepadnaviridae family Hepacavirus genus, Flaviviridae family Statistics In the United States, 0.8–1.4 In the United States, 2.7–3.9 million people are chronically million people are chronically infected with HBV infected with HCV Routes of Contact with infectious blood, Contact with blood of an infected transmission semen, and other body fluids, person, primarily through: • Sharing of contaminated primarily through: • Birth to an infected mother needles, syringes, or other • Sexual contact with an injection-drug equipment infected person • Sharing of contaminated Less commonly through: • Sexual contact with an infected needles, syringes, or other injection-drug equipment person • Birth to an infected mother • Contact with infectious blood Less commonly through: • Contact with infectious through medical procedures blood through medical procedures • Persons born in geographic • Persons who have ever injected Persons at risk regions that have HBsAg illegal drugs, including those prevalence of at least 2% who injected only once many • Infants born to infected years ago • Recipients of clotting-factor mothers • Household contacts of concentrates made before 1987 • Recipients of blood transfusions persons who have chronic HBV infection or solid-organ transplants • Sex partners of infected before July 1992 • Patients who have ever received persons • Injection-drug users long-term hemodialysis • Sexually active persons treatment • Persons who have known who are not in long-term, mutually monogamous exposures to HCV, such as relationships (for example, health-care workers after more than one sex partner needlesticks involving HCV during previous 6 months) positive blood and recipients of • Men who have sex with men blood or organs from donors who later tested HCV-positive • All persons who have HIV infection continued
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liver disease • Hemodialysis patients • Travelers to countries that have intermediate or high prevalence of HBV infection Potential for Among newly infected, 75–85% of newly infected persons chronic infection unimmunized persons, chronic develop chronic infection infection occurs in: • >90% of infants • 25–50% of children aged 1–5 years • 6–10% of older children and adults • 15–25% of chronically • 60–70% of chronically infected Clinical outcomes infected persons will die from persons develop chronic liver cirrhosis, liver failure, or disease • 5–20% develop cirrhosis over a hepatocellular carcinoma • 3,000 deaths each year are period of 20–30 years • 1–5% will die from cirrhosis or due to hepatitis B-related liver disease in the United hepatocellular carcinoma • 12,000 deaths each year are States due to hepatitis C-related liver disease in the United States Abbreviations: HBV, hepatitis B virus; HCV, hepatitis C virus; HBsAg, hepatitis B surface antigen. SOURCE: Adapted from CDC, 2009a.
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Without testing for infection, many chronically infected persons are not aware that they have been infected until symptoms of advanced liver disease appear. Advanced liver cancer has a 5-year survival rate of below 5% (American Cancer Society, 2009)
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Antiviral treatments for chronic HBV and HCV infections can effectively reduce the associated morbidity and mortality from liver disease. However, access to treatment is often limited by high costs of care and by the asymptomatic nature of chronic HBV and HCV infections.
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estimates that 3.5–5.3 million people in the United States -- 1–2% of the population -- are living with chronic HBV or HCV infection -- about 800,000 to 1.4 million people with chronic hepatitis B and an additional 2.7–3.9 million people with chronic hepatitis C (CDC, 2009d)
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TABLE 1-2 Burden of Selected Serious Chronic Viral Infections in the United States Percentage of Population unaware Deaths in 2006 Percentage of CDC of Infection Related to vaccine- Transmission NCHHSTP FY 2008 virus Prevalencea,b Statusc,d,e Infectiona,b Preventable Routes Budgetf HBV 0.8–1.4 million About 65% 3,000 Yes Birth, blood, sex 2% combined HCV 2.7–3.9 million About 75% 12,000 No Birth, blood, sex HIV/AIDS 1.1 million About 21% 14,016 No Birth, blood, sex 69% (domestic activities) Abbreviations: CDC NCHHSTP, Centers for Disease Control and Prevention National Center for HIV/AIDS, Viral Hepatitis, Sexually Transmitted Disease, and Tuberculosis Prevention; HBV, hepatitis B virus; HCV, hepatitis C virus; HIV/AIDS, human immunodeficiency virus/acquired immunodeficiency syndrome.
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. Although the incidence of acute HBV infection is declining in the United States, the number of people who are living with chronic HBV infection may be increasing as a result of immigration from highly endemic countries (that is, the hepatitis B surface antigen prevalence is ≥ 2%)
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. Although reporting of acute HCV infection does not accurately reflect the underlying incidence in the United States, the number of acute HCV infections peaked in the late 1980s and declined throughout the 1990s (Armstrong et al., 2006; Shepard et al., 2005)
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LIvER CANCER AND LIvER DISEASE FROM CHRONIC HEPATITIS B vIRuS AND HEPATITIS C vIRuS INFECTIONS Both chronic HBV and HCV infections can lead to HCC, a type of liver cancer, and liver disease (But et al., 2008; McMahon, 2004, 2008; Tan et al., 2008)
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Although government and nongovernment efforts have led to a decline in the number of cases, chronic hepatitis B and hepatitis C continue to be serious public-health problems in the United States. For that reason, CDC in conjunction with the National Viral Hepatitis Roundtable, a not-for-profit coalition of public, private, and voluntary organizations; the Department of Health and Human Services Office of Minority Health; and VA sought guidance from the Institute of Medicine (IOM)
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• Development of an effective HCV vaccine. Strategies for reducing morbidity and mortality from chronic HBV and HCV infections: • Providing appropriate medical referral, evaluation, and management of chronically infected persons.
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is beyond the scope of this report. However, treatment information can be found in guidelines published by the American Association for the Study of Liver Diseases (Ghany et al., 2009; Lok and McMahon, 2009)
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. The committee developed evidence-based recommendations to address the problems with the current systems to reduce the numbers of new HBV and HCV infections, to manage the care of chronically infected people more effectively by reducing morbidity and mortality, and to improve surveillance of chronic hepatitis B and hepatitis C cases.
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in United States e The Problem -- 12,000 deaths each year are due to hepatitis C-related liver disease • Over 150,000 deaths due to hepatitis B and hepatitis C are projected to occur in next 10 years Lack of Public Awareness Lack of Provider Awareness Underlying issues Lack of Public Resource Allocation • At-risk people do not know that they are at risk or how to prevent becoming infected • At-risk people may not have access to preventive services • Chronically infected people do not know that they are infected Consequences • Many medical providers do not screen people or know how to manage those infected • Infected people often have inadequate access to testing and medical management • Inadequate disease-sur veillance systems underrepor t both acute and chronic infections Improved Disease Improved Provider and Integration and Enhancement Recommendations Surveillance Community Education of Viral Hepatitis Services • Screening is widely used as a par t of good primary care • At-risk people and communities actively seek testing, preventive services, and appropriate medical management • Better information leads to -- Improved understanding of hepatitis B and hepatitis C Outcomes -- More effective and targeted prevention programs -- More research on effective vaccination and treatment options • Infected people have better health outcomes • Decreased transmission leads to fewer carriers of HBV and HCV and fewer cases of hepatitis B and hepatitis C FIGuRE 1-2 The committee's approach to its task.
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In Viral hepatitis and liver disease. Proceedings of the 0 international symposium on viral hepatitis and liver disease, edited by F
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2006. Past HBV viral load as predictor of mortality and morbidity from HCC and chronic liver disease in a prospective study.
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2009. Trends in waitlist registration for liver transplantation for viral hepatitis in the US.
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2004. The natural history of chronic hepatitis B virus infection.
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2002. Risk of hepatitis C virus infection among young adult injection drug users who share injection equipment.
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2008. Recommendations for identification and public health manage ment of persons with chronic hepatitis B virus infection.
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