1. HEPATITIS B AND LIVER CANCER: WHY SHOULD WE CARE? Amanda Wong Founder, Team HBV Collegiate Chapters 10/18/2010

2. What is hepatitis B? Hepatitis B: a virus that causes a serious inflammation of the liver and can lead to liver cancer or liver failure

3.  370-400 million people worldwide have chronic (life-long) hepatitis B (HBV) infection (compared with 40 million living with HIV) 1,2  Without appropriate treatment or monitoring, 1 in 4 people with chronic HBV will die of liver cancer, cirrhosis or liver failure 3  60-80% of primary liver cancer cases (Hepatocellular carcinoma) are caused by chronic hepatitis B infection 4  HBV takes 700,000 to 1 million lives a year 1,2 Hepatitis B: a neglected global epidemic 1. CDC. Available at: www.cdc.gov/ncidod/diseases/hepatitis/b/faqb.htm 2. WHO. Available at: www.who.int/csr/disease/hepatitis/en/ 3. WHO. Available at: http://www.who.int/mediacentre/factsheets/fs204/en/ 4. Lavanchy D. Hepatitis B virus epidemiology, disease burden, treatment, and current and emerging prevention and control measures. Journal of Viral Hepatitis. 2004, 11:97-107.

4. Global prevalence of hepatitis B Asia accounts for 76% of the burden of disease Asia accounts for 76% of the burden of disease CDC: Accessed at: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5708a1.htm http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5708a1.htm

5. Annual global incidence of liver cancer Liver cancer incidence 15 per 100,000 6 -<15 per 100,000 <6 per 100,000 Source: http://rafscience.com/liver_cancer.htm Globocan 2005.

6. HBV in the United States  800,000 - 1.4 million persons currently chronically infected (in US)  3,000 deaths associated with HBV due to chronic liver disease, per year  Costs > $700 million in medical and work loss costs CDC: 2010 http://www.cdc.gov/hepatitis/PDFs/disease_burden.pdfhttp://www.cdc.gov/hepatitis/PDFs/disease_burden.pdf

7. APIs affected disproportionately 1 in 10 foreign-born Asian and Pacific Islanders (APIs) are chronically infected with hepatitis B 1 Chronic hepatitis B infection is 100 times more common among APIs than the general US population 1 Each year between 1994-2003, about 40,000 HBsAg+ legal immigrants entered the US (over 50% Asian) 2 1.Lin SY, Chang ET, So S. Hepatology 46:1034-1040, 2007 2.CDC. Accessed at: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5416a1.htm General US population: 1 per1000 Asian/Pacific Islanders: 100 per1000

8. Greatest ethnic health disparity Disease stateRacial/ethnic groups comparedFold difference in prevalence 1. Chronic HBVForeign-born Asians & Whites68 2. GonorrheaBlacks & Whites28 3. Congenital syphilisBlacks & Whites22 4. TuberculosisAsians & Whites20 5. Fetal alcohol syndromeAI/AN & Whites15 6. AIDSBlacks & Whites15 7. Smoking during pregnancyAI/AN & Whites12 8. Congenital syphilisHispanics & Whites12 9. Chronic HBVUS-born Asians & Whites11 10. HIV-related deathsBlacks & Whites10 11. Smoking during pregnancyBlacks & Whites9 12. Non-fatal firearm injuriesBlacks & Whites9 Chao SD, Chang ET, So SK. Eliminating the Threat of Chronic Hepatitis B in the Asian and Pacific Islander Community: A Call to Action. Asian Pacific J Cancer Prev. 2009,10;507-512

9. Asian and Pacific Islander Population 3.7 million in 1980 -15.2 million* in 2006 1 About 62.5% were foreign born in 2006 2 *including part-APIs Fastest growing racial population in the US in terms of percentage growth US Census Bureau. Accessed at: http://www.census.gov/Press-Release/www/releases/archives/facts_for_features_special_editions/013385.html US Census Bureau. Accessed at: http://factfinder.census.gov/

10. Five most common cancers in Males by Race/Ethnicity, California, 2003-2007 California Cancer Facts & Figures 2010, American Cancer Society

11. Back to the disease…

12. Birth: Perinatal transmission from an infected mother to newborn at birth Accounts for about 50% of the cases in Asia 1 Blood: Direct contact with infected blood Unsafe injections and transfusions Sharing or reusing needles or syringes Open wound contact Sex: Unprotected sex How do you get HBV? WHO Western Pacific Region. Available at: http://www.wpro.who.int/internet/resources.ashx/EPI/docs/HepB/HepBBirthDoseFieldGuidelines.pdf CDC. Available at: www.cdc.gov/ncidod/diseases/hepatitis/b/faqb.htm

13. Common misconception The best way to prevent hepatitis B infection is through vaccination. 1 1.CDC. Accessed at: http://www.cdc.gov/HEPATITIS/B/bFAQ.htm

14. What can happen if a patient is infected? Win the battle – Develop life long immunity (anti- HBs positive) Lose the battle – Die of acute infection from liver failure (0.5%-1%) – Become chronically infected (HBsAg positive, also known as hepatitis B carrier) – Most of the morbidity/mortality is caused by chronic infection Premature death Liver cancer (~70% deaths) Scarring of the liver, cirrhosis, liver failure WHO Western Pacific Region. POA_hepb. 2003

15. Chronic hepatitis B is often asymptomatic Even if a patient feels healthy, they could still be chronically infected with hepatitis B Most people with chronic hepatitis B infection have no symptoms Blood tests for liver enzymes are often normal 2 out of 3 API tested positive are not aware they are infected Chronic HBV infection: A Silent Killer in API Lin SY, Chang ET, So S. Hepatology 46:1034-1040, 2007

16. HBV Testing  Hepatitis B surface antigen test (HBsAg)  Positive (+): have hepatitis B  Negative (-): do not have hepatitis B  Hepatitis B surface antibody test (HBsAb)  Positive (+): have immunity  Negative (-): do not have immunity

17. HBV Vaccination  Available for over 20 years  The first “anti-cancer” vaccine - CDC  Confers life-long protection “3 for life” 1 st shot 2 nd shot (1 month later) 3 rd shot (5 months later) 6-month, 3 shot series Video

18. We have failed …  …to mount a comprehensive global hepatitis B prevention and treatment initiative  In 1992, WHO set goal that by 1997, all countries integrate infant HBV vaccination into their infant immunization programs  By 2001, only 66% of member countries had infant HBV vaccination programs  Many are getting infected because they are not vaccinated  No global initiative to provide affordable hepatitis B antiviral treatment  No global fund, USAID, or major foundation interests (Gates/Clinton/Carter)  Many are dying because they are not treated

19. Average price/dose of HBV vaccine from UNICEF 1993-2005 1. World Health Organization. Western Pacific Regional Plan for hepatitis B control through immunization; January 2003. 2.WHO/WPR. http://www.wpro.who.int/health_topics/hepatitis_b/.

20. A single HBV shot…

21. Lack of Provider HBV Knowledge Providers n=117 78% 25% 24% Nurses n=493 22% 14% 26%  Chronic HBV infection has no symptoms  1 in 10 API have chronic HBV  1 in 4 people with chronic HBV will die of liver disease Percent surveyed answering correctly 1 1.Chao S, Cheung C, So S. Unpublished data. 2008 2.Lai CJ, Nguyen TT, Hwang J, et al. Provider knowledge and practice regarding hepatitis B screening in Chinese-speaking patients. J Cancer Educ. 2007 Spring;22(1):37-41. Physicians incorrectly identified HIV infected persons (16%), MSM (18%), and IVDU (23%) as having higher prevalence of chronic HBV than Chinese immigrants 2

22. Lack of Provider Action  Of obstetricians surveyed:  only 45% routinely provide education about HBV 1  only 44% inform pregnant women that their infants need to complete the HBV vaccine series 1  Only 18% of internists who care for high-risk API routinely screen for hepatitis B 2  21% of physicians knew what to do next if a patient was found to be HBsAg-positive 3 1.Chao S, Cheung C, So S. Unpublished data. 2008 2.Chu D. Hepatitis B screening practices of Asian-American primary care physicians who treat Asian adults living in the United States. Oral presentation at the 13 th International Symposium of Viral Hepatitis and Liver Disease. Washington, DC. March 20-24, 2009. 3.Ferrante JM, Winston DG, Chen PH, de la Torre AN. Family physicians’ knowledge and screening of chronic hepatitis and liver cancer. Fam Med 2008;40(5)345-51.

23.  Founded in 1996 by Dr. Samuel So  1 st non-profit organization that addresses the high incidence of HBV and liver cancer in API through:  Outreach and education  Advocacy  Research

24. Jade Ribbon Campaign To increase awareness about hepatitis b and provide ethnic-sensitive health information to API community

25. http://teamhbv.org

26. Current Chapters Brown Cornell Duke Emory Harvard Princeton Rice Stanford UC Berkeley UC Davis UC Irvine UC Riverside UC Santa Cruz UCLA UCSD UPenn USC Vassar Upcoming Chapters MIT Yale U of Maryland U of the Sciences Philadelphia

27. In the doctor’s chair… Mr. Chen is a 30-year-old male who was born in China. He is a new patient. He tells you that he feels great and just needs a physical for his new job. You decide that it would be best to screen Mr. Chen for hepatitis B. Mr. Chen protests, reassuring you that he’s fine and doesn’t need any tests. How would you counsel him?

28. A. Inform him that hepatitis is endemic in the US. B. APIs have high prevalence, and most are asymptomatic. Mr. Chen’s lack of symptoms does not mean he is not infected. C. Mr. Chen is correct. He does not have jaundice or other symptoms. Therefore, testing is not warranted. D. Mr. Chen should get tested only if he has traveled abroad in the past three months. E. All of the above How would you counsel Mr. Chen?

29. What can you do? Join the Jade Ribbon Campaign  Tell a friend about what you learned  Wear a jade bracelet  Pin a jade ribbon onto your backpack  @Cal: Join Team HBV, Hep B Project, SFHBC  Educate yourself

30. Resources http://www.iom.edu/Reports/2010/Hepatitis- and-Liver-Cancer-A-National-Strategy-for- Prevention-and-Control-of-Hepatitis-B-and-C.aspx http://liver.stanford.edu/Public/pguide.html http://liver.stanford.edu/Public/brochures.html http://liver.stanford.edu/Media/documentaries.html