Eliminating the Public Health Problem of Hepatitis B and C in the United States Phase One Report (2016) / Chapter Skim
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2 The Elimination of Hepatitis B
2 The Elimination of Hepatitis B
Pages 33-82
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From page 33... ...
Recent estimates suggest about 250 million people have chronic HBV infection, causing about 780,000 deaths per year (Schweitzer et al., 2015; WHO, 2015b)
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The CDC estimates that immigration from HBV endemic countries accounts for most new chronic infections (see Figure 2-1)
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. HBV DNA can integrate into the host hepatocyte genome, promoting development of hepatocellular carcinoma even without cirrhosis (Lok and McMahon, 2007; Simonetti et al., 2010; Trépo et al., 2014)
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. The Natural History of Hepatitis B Virus Infection HBV infection is highly variable in both presentation and severity.
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Without intervention, up to 90 percent of infants born to HBV-infected, HBeAg+ mothers become chronically infected at birth; but chronic infection develops in 5 to 20 percent of infants born to HBV-infected, HBeAg– mothers (Ko et al., 2014; Mast et al., 2006)
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A recent meta-analysis found that significant liver disease was rare in those who had HBV DNA levels ≤20,000 IU/mL and persistently normal liver aminotransferase levels (Papatheodoridis et al., 2012)
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. Occult HBV infection, defined as the presence of HBV DNA in the serum or liver tissue of individuals with anti-HBc in the absence of HBsAg (Lo Re et al., 2007; Torbenson and Thomas, 2002)
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Early Acute + – + + + – + Infection Chronic Infection + – – +/– +/– +/– + Presence for ≥6 months Resolved or – + + – – – – Resolving Infection Occult Infection – – + – +/– SOURCE: Evans et al., 2014.
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From page 41... ...
is the most common cause of chronic hepatitis and hepatocellular carcinoma in the world. The United States has made encourag ing progress against the infection, but between 700,000 and 1.4 million people have chronic hepatitis B; almost 20,000 new acute infections occur every year.
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. Similarly, though antiviral treatment can reduce viral load and therefore lower the likelihood of transmission, antiviral treatment almost never cures HBV infection (Dienstag, 2008)
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. The last case of acute hepatitis B among Alaskan Natives was 1992, their last case of pediatric hepatocellular carcinoma was in 1999 (McMahon et al., 2011)
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• Undiagnosed, asymptomatic • Much of the burden for chronic infections a reservoir managing chronic hepatitis B for infection falls on overworked primary Reducing morbidity and Slowing progression to Feasible • Need for physicians trained care providers. mortality attributable to cirrhosis in the management of • There is a need to better ongoing infection chronic HBV infection understand the virus and • The threat of reactivation in the management of chronic Reducing deaths chronic or resolved infection hepatitis B
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From page 45... ...
. On the other hand, chronic infection develops in less than 5 to FIGURE 2-3 Outcome of hepatitis B virus infection by age at infection.
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From page 46... ...
Countries that have adopted universal infant and newborn hepatitis B immunization have seen marked reduction in the prevalence of hepatitis B infection and the incidence of acute hepatitis B infection in children. In China prevalence of chronic hepatitis B dropped from almost 10 percent in 1992 to 1 percent in 2006 after the vaccination campaign described in Box 2-3.
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Paying village health workers to provide vaccines. China has now met its 2010 goal of reducing chronic HBV infections in children under 5 years to below 1 percent; by 2005 93.4 percent of children completed the full vaccine series (Cui et al., 2010)
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. Without immunoprophylaxis, chronic infection develops in about 40 percent of babies born to HBsAg+ women (CDC, 2015d)
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In 2015 the American Association for the Study of Liver Disease (AASLD) made the conditional suggestion that pregnant women with a HBV viral load greater than or equal 200,000 IU receive prophylactic tenofovir in late gestation (Terrault et al., 2016)
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. In accordance with ACIP recommendation, 47 states now require hepatitis B immunization of children; 41 states mandate vaccination for children entering daycare, 46 states for school entry, and 39 states for middle school (Immunization Action Coalition, 2015)
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. Sustaining immunity to HBV in all age groups is crucial to eliminating hepatitis B, but, as Figure 2-6 shows, the prevalence of HBV infection increases sharply after adolescence.
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• thers, including international travelers to regions with high or intermediate O levels of endemic HBV infection, such as East Asia and sub-Saharan Africa, persons with chronic liver diseaase, persons with HIV infection, and all other persons seeking protection from HBV infection.
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From page 53... ...
Research at community health centers in Boston found 31.5 percent of patients seeking testing for HIV or sexually transmitted infection returned to the same center three times, enough to complete the HBV vaccine series (Sharfstein and Wise, 1997)
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. Eliminating transmission could also be aided by treating those with known HBV infection, a concept known as treatment as prevention.
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This is partly because HBV treatment is not recommended for all carriers. AASLD treatment guidelines recommend against antiviral therapy for adults with immune-tolerant chronic infection, despite some evidence of improved intermediate outcomes with antiviral therapy in this population (Lok et al., 2016; Terrault et al., 2016)
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From page 56... ...
vaccine, but only 38 percent receive the birth dose key to pre venting mother-to-child transmission. • S upport for birth dose coverage in the HBV endemic countries of Asia and Africa could help reduce the future domestic burden of HBV, as most chronic infections in the United States are imported.
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From page 57... ...
The AASLD guidelines suggest surveillance for hepatocellular carcinoma among certain chronic hepatitis B patients. These are Asian men over 40, Asian women over 50, African or African-Americans of any age, anyone with cirrhosis, and anyone with a family history of liver cancer (Bruix and Sherman,
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From page 58... ...
. Durable suppression of HBV replication has been shown to reverse liver fibrosis in chronic HBV infection (Calvaruso and Craxi, 2014)
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. Many patients living with chronic or resolved HBV infection may at some point require immunosuppressive drug therapy for cancer, autoimmune disease, or organ transplantation, putting them at risk for reactivation.
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. The benefits of prophylaxis for patients with resolved HBV infection who require immunosuppressive drug therapy remain less clear.
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. Prevalence of chronic HBV infection varies widely among different state and local health departments, following the different distribution of foreign-born people and other high-risk groups.
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A probable case has a single HBsAG+ or HBV DNA positive test (including qualititative, quantitative, and genotype testing) , or HBeAg positive lab result and does not meet the case definition for acute hepatitis B
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From page 63... ...
Immunization registries are secure, population databases that collect and consolidate vaccination records from various health providers in a given area (Community Preventive Services Task Force, 2015)
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. Even before patients can be brought to treatment, fear of a positive test result decreases likelihood of taking part in HBV screening (Li et al., 2012)
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recommended the screening of high-risk adolescents and adults, and pregnant women at first prenatal visit for HBV infection, thereby removing co-pays and co-insurance charges to people seeking this test (USPSTF, 2016)
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From page 66... ...
, such as sub Saharan Africa and southeast and central Asia • IV-positive persons H • njection drug users I • en who have sex with men M • ousehold contacts or sexual partners of persons with HBV infection H SOURCE: LeFevre, 2014. for screening and the onus it puts on the screener could be an obstacle to eliminating hepatitis B
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From page 67... ...
. HBV infection requires ongoing, usually lifelong care.
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From page 68... ...
A pilot study at federally qualified health centers used electronic records to identify patients at high risk for HBV. The electronic system linked with the patients' previous test results, and generated tools before each visit with information on managing chronic hepatitis B and counseling, prevention, and immunization for the patient's susceptible contacts (Toyoji et al., 2015)
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From page 69... ...
. The Charles B Wang Community Health Center in New York City has similar programs; provider teams at Charles B Wang created a hepatitis B registry to link their patients' electronic records with their records at other doctors (Dan, 2012)
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From page 70... ...
2012. Innate and adaptive immune responses in chronic hepa titis B virus infections: Towards restoration of immune control of viral infection.
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2012. Hepatitis B prevention and care for Asian Americans, Native Hawaiians and Pacific Islanders at community health centers.
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Wang Community Health Center.
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2012. Addressing hepatitis B: Community health centers, partnerships and the afford able care act.
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2002. Risk factors for hepatocellular carcinoma: Synergism of alcohol with viral hepatitis and diabetes mellitus.
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2014. Estimated annual perinatal hepatitis B virus infections in the United States, 2000-2009.
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2007. Prevalence, risk factors, and outcomes for occult hepatitis B virus infection among HIV-infected patients.
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2009. The natural history of chronic hepatitis B virus infection.
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2012. Tenofovir disoproxil fumarate for prevention of vertical trans mission of hepatitis B virus infection by highly viremic pregnant women: A case series.
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2001. Acute flares in chronic hepatitis B: The natural and unnatural history of an immunologically mediated liver disease.
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Paper presented at National Association of Community Health Centers Community Health Institute Annual Conference, Orlando, FL, August 22-25, 2015.
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2003. Lamivudine treatment during pregnancy to prevent perinatal transmission of hepatitis B virus infection.
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2009. Lamivudine in late pregnancy to prevent perinatal transmission of hepatitis B virus infection: A multicentre, random ized, double-blind, placebo-controlled study.
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