2. Hepatitis B Virus and Cancer Everett Schlam, MD 9/22/2011

3. Pick any number between 2 and 10 Multiply that number x 9 Add the two digits of that number together Subtract 5 from that number Pick the letter which corresponds to that number in the alphabet Ie, A=1 B=2 C=3 D=4 Pick a country which begins with that letter. Now take the second letter of that country and choose a large animal which begins with that letter

5. Viral Hepatitis 5 types: A : fecal-oral transmission B : sexual fluids & blood to blood C : blood to blood D : travels with B E : fecal–oral transmission Vaccine Preventable Adapted from Corneil, 2003

6. Hepatitis B Epidemic jaundice described by Hippocrates in 5th century BC Jaundice reported among recipients of human serum and yellow fever vaccines in 1930s and 1940s Australia antigen described in 1965 Serologic tests developed in 1970s

7. Hepatitis B Complications Fulminant hepatitis Hospitalization Cirrhosis Hepatocellular carcinoma Death

8. Hepatitis B Virus Infection More than 350 million chronically infected worldwide Established cause of chronic hepatitis and cirrhosis Human carcinogen—cause of up to 80% of Hepatocellular carcinomas More than 600,000 deaths worldwide in 2002

10. Natural History of Hep C Adapted from Lauer and Walker, NEJM 2001 Healthy Liver Acute Infection Chronic Infection 20% Clear the Virus 80% Virus Continues to Damage Liver Only 20% will show symptoms Initially !

11. Natural History Con’t Chronic Hepatitis Cirrhosis 20-30% Liver Cancer 1-4%/year Most symptoms begin to show only when liver is more severely damaged

12. Factors Affecting Progression 30yrs or longer if: Young at time of infection Healthy liver at time of infection Female 20yrs or less if: Drinking alcohol Co-infection (HIV, Hep B) Damaged liver before infection Adapted from Bigham, BC Hepatitis Services 2002

13. Risk Factors HCV-infected household member/sexual partner (7%) Tattooing piercing (6%) Hospitalization dental work (6%) Transfusion/dialysis blood contact (4%) Incarceration (3%) No RF identified (23%) IDU/snorting (51%) Source: Health Canada Enhanced Surveillance, Oct 98-Oct 99, Calgary, Edmonton, Winnipeg, Ottawa

14. Hepatitis C Affects each person differently No vaccine available Many people have the virus and do not even know it *BC Hepatitis Service 2003 Overall cure rate with new treatment is 55% *

15. Hepatitis C Dispelling Myths Hepatitis C is not spread by: –Casual contact –Hugging/kissing –Sharing eating utensils and drinking glasses –Sneezing/coughing –Shaking hands –Sitting on a toilet seat

16. HBV Disease Burden in the United States Pre-vaccine era –estimated 300,000 persons infected annually, including 24,000 infants and children 2005 –estimated 51,000 infections –Overall cure rate about 55%

17. Hepatitis B Perinatal Transmission* If mother positive for HBsAg and HBeAg –70%-90% of infants infected –90% of infected infants become chronically infected If positive for HBsAg only –5%-20% of infants infected –90% of infected infants become chronically infected *in the absence of postexposure prophylaxis

18. Who should be vaccinated with Hepatitis B Vaccine ?

19. Strategy to Eliminate Hepatitis B Virus Transmission—United States Prevent perinatal HBV transmission Routine vaccination of all infants Vaccination of children in high-risk groups Vaccination of adolescents Vaccination of adults in high-risk groups

20. Risk Factors for Hepatitis B CDC Sentinel Sites. 2001 data.

21. Hepatitis B Vaccine Long-term Efficacy Immunologic memory established following vaccination Exposure to HBV results in anamnestic anti-HBs response Chronic infection rarely documented among vaccine responders

22. Adults at Risk for HBV Infection Sexual exposure –sex partners of HBsAg-positive persons –sexually active persons not in a long-term, mutually monogamous relationship* –persons seeking evaluation or treatment for a sexually transmitted disease –men who have sex with men *persons with more than one sex partner during the previous 6 months

23. Adults at Risk for HBV Infection Percutaneous or mucosal exposure to blood –current or recent IDU –household contacts of HBsAg-positive persons –residents and staff of facilities for developmentally disabled persons –healthcare and public safety workers with risk for exposure to blood or blood-contaminated body fluids –persons with end-stage renal disease

24. Who should have Hepatitis B screening Tests?

25. Prevaccination Serologic Testing Not indicated before routine vaccination of infants or children Recommended for –all persons born in Africa, Asia, the Pacific Islands, and other regions with HBsAg prevalence of 8% or higher –household, sex, and needle-sharing contacts of HBsAg-positive persons –HIV-infected persons Consider for –Groups with high risk of HBV infection (MSM, IDU, incarcerated persons)

26. What are the recommended serological screening tests for Hepatitis B?

27. Screening Tests for Hepatitis B HBsAg Anti-HBs Cost for both tests about (150-250 dollars) Further testing and treatment determined by results of HBsAG and Anti-HBs

28. Chronic Inactive Hepatitis B Infection Surveillance monitoring for reactivation

29. Chronic Active Hepatitis B Treatment Options Interferons –Interferon alfa-2b –Peginterferon alfa 2-b Nucleotids(t)ide analogs –Lamivudine –Adenovir –Entecavir –Telbivudine –Tenofovir

31. Who is post vaccination serological testing recommended for and when should the testing be performed?

32. Postvaccination Serologic Testing Not routinely recommended following vaccination of infants, children, adolescents, or most adults Recommended for: –Infants born to HBsAg+ women –Hemodialysis patients –Immunodeficient persons –Sex partners of persons with chronic HBV infection –Certain healthcare personnel

33. Postvaccination Serologic Testing Healthcare personnel who have contact with patients or blood should be tested for anti-HBs (antibody to hepatitis B surface antigen) 1 to 2 months after completion of the 3-dose series

34. Management of Nonresponse to Hepatitis B Vaccine Complete a second series of three doses Should be given on the usual schedule of 0, 1 and 6 months Retest 1-2 months after completing the second series

35. Persistent Nonresponse to Hepatitis B Vaccine Less than 5% of vaccinees do not develop anti-HBs after 6 valid doses May be nonresponder or "hyporesponder" Check HBsAg status If exposed, treat as nonresponder with postexposure prophylaxis

36. Needle Prick 1.Do not “milk” prick site 2.Wash the area with soap and water 3.Go to nearest emergency department for assessment and treatment

37. Chronic Hepatitis B and risk of Hepatocellular Cancer Hepatocellular Cancer occurs in up to 25% of men and 15% of women over their lifetimes

38. Hepatitis B and Cancer Hepatocellular Cancer is a devastating complication of Hepatitis B Prevention is the optimal strategy to prevent acquisition of Hepatitis B Immunization and avoidance of high risk activities are of upmost importance

39. Questions??