1.  Hepatitis B: Decreasing the Burden and Increasing Compliance Abby Wurzel, BSN, RNC Augustina Manuzak, MD, PhD, MPH

2. 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

3. 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

4. Hepatitis B Virus  Hepadnaviridae family – Primarily infect liver cells  Human are the only known host  Double strain circular DNA vi  100 x more infective than HIV  Retain 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)

5. 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 1 st year of life become chronic  15-20% of adults chronically affected die from Hepatitis B related cancer

6. Epidemiology Triangle of Hepatitis B Host Humans Environment Sexual Transmission Intravenous Drug Use Endemic Areas Blood Transfusions Transmission Blood Body Fluid

7. 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

8. 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 www.cdc.gov/hepatitis/HBV/PDFx/Chronic

9. Pacific Islanders & Asians Centers for Disease Control and Prevention. (2013). Know Hepatitis B. Retrieved from www.cdc.gov/knowhepatitis B/www.cdc.gov/knowhepatitis

10. 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  10 th 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)

11. 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)

12. 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 1 st 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%

13. 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

14. Prevention  Primary prevention  Vaccinate and educate  Secondary prevention  Screen the patient  Tertiary prevention  Treatment and prevent complications

15. Vaccinate!!!!

16. 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

17. Serology

18. CDC Recommendations for Routine Testing and Follow-up for Chronic Hepatitis B Virus Infection Population Recommendation TestingVaccination/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).

19. Treatment  Acute  Supportive  Chronic  Regular monitoring of liver disease progression  May use antiviral drugs

20. Conclusion  Immunization averts 2-3 million deaths per year  Hepatitis B is preventable  Hepatitis B can affect anyone  Need to screen high-risk individuals

21. 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

22. References  Centers for Disease Control and Prevention. (2014). Adult vaccination. Retrieved from http://www.cdc.gov/vaccines/adults/find-pay-vaccines.html 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 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 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.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. 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.pdfhttp://www.cdc.gov/hepatitis/HBV/PDFs/HepB-API.pdf

23. 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.pdfhttp://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/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 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