Sara Stevenson Hepatitis B Nurse Specialist St James’s Hospital, Leeds

HEPATITIS B The hidden disease Blood borne virus can infect the liver cells Global burden –1/3 world population have been infected –350 million surface antigen positive Leading cause of cirrhosis and HCC worldwide (0.5-1million deaths per year) Silent disease-many unaware they have the disease Stigma attached to disease

HIV 40 million HBV 350 million HCV 170 million

HBV is second only to tobacco as a human carcinogen

Modes of Transmission Percutaneous –Open cuts and wounds –Sharing contaminated equipment for drug taking –Tattoos, acupuncture, body piercing where equipment has not been sterilized properly –Sharing contaminated razors, toothbrushes –Needle stick injuries Sexual –Unprotected sex with an infected person Risk groups –Men who have sex with men –Sex workers –Drug users –People in same household as infected person

Modes of transmission con’t Vertical transmission –90% of children born to eAg +ve mothers will develop chronic HBV without immunoprophylaxis –All pregnant women should be screened –Antiviral prophylaxis for those with high virus levels –All babies born to HBV carriers should have immunisation Risk groups –Persons born in areas of high prevalence

China, SE Asia – Thailand, Cambodia, Africa, Brazil/Chile, E Europe

~1300 new cases of acute hepatitis B each year ~8000 new cases of CHB occur in the UK each year Only 300 chronic infections are acquired in the UK The remainder are identified in people who entered the UK from areas of high prevalence 1:3 people at risk of infection are difficult to identify UK J Clin Virol 2004;29:211 Commun Dis Public Health 1998;1: Proc Biol Sci 1993;253: Immigration of individuals from intermediate and high prevalence countries is thought to account for >95% of the cases of cHBV infection in the UK

Screening for HBV WHO recommends screening populations with a prevalence of 2% or greater NICE Ways to promote and offer testing to people at increased risk Opportunistic screening Targeted screening of high risk groups Targeted screening in the Chinese community in Leeds using dried blood spot tests. 199 people tested, 14 surface antigen positive 23 core antibody positive Screening focus now moved to other minority groups

Aims of Treatment No current cure for HBV Not everyone requires treatment but should be monitored in a specialist clinic Prevent disease progression, cirrhosis, HCC & liver failure Prevent vertical transmission in pregnancy Reverse liver failure Prolong survival

59 year old female attended screening at Leeds Chinese Christian church Born in Hong Kong and regularly returns for visits No previous tests for hepatitis B Asymptomatic Dried blood spot test – surface antigen positive CASE STUDY 1

CASE STUDY 1 – cont’d Confirmatory bloods at SJUH confirmed diagnosis Husband tested – core antibody positive Referred to hepatology and GP informed Seen in Viral Hepatitis Clinic 10 weeks later –Fibroscan 6.7 Kpa –Elevated liver function and virus levels Following a liver biopsy commenced treatment requested

32 year old male screened at a local Chinese restaurant Born in China, lived in UK for 7 years No previous tests for hepatitis B Asymptomatic Dried blood spot test – surface antigen positive CASE STUDY 2

CASE STUDY 2 – cont’d Confirmatory bloods at SJUH confirmed diagnosis Presumed vertical transmission. Parents live in China and advised to get tested. Sister attended her own GP and also found to be surface antigen positive. Referred to hepatology and GP informed Seen in Viral Hepatitis Clinic 8 weeks later –Fibroscan 8.0 Kpa –Elevated liver tests and virus levels Following liver biopsy which showed some scarring of the liver commenced treatment.

There is no cure Treatment is available to suppress the virus and prevent disease progression. Effective Vaccines are available but are not given universally in UK Health care professionals and those working with high risk groups have a responsibility to improve awareness identify those that are high risk facilitate screening