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

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

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 failure3

60-80% of primary liver cancer cases (Hepatocellular carcinoma) are caused by chronic hepatitis B infection4

HBV takes 700,000 to 1 million lives a year1,2

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.

Global prevalence of hepatitis B

Asia accounts for 76% of the burden of disease

CDC: Accessed at: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5708a1.htm

Annual global incidence of liver cancer

Source: http://rafscience.com/liver_cancer.htm

Globocan 2005.

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.pdf

APIs affected disproportionately

• 1 in 10 foreign-born Asian and Pacific Islanders (APIs) are chronically infected with hepatitis B1

• Chronic hepatitis B infection is 100 times more common among APIs than the general US population1

• 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, 20072. CDC. Accessed at: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5416a1.htm

General US population:1 per1000

Asian/Pacific Islanders:

100 per1000

Greatest ethnic health disparity

Disease state Racial/ethnic groups compared Fold difference in prevalence

1. Chronic HBV Foreign-born Asians & Whites 68

2. Gonorrhea Blacks & Whites 28

3. Congenital syphilis Blacks & Whites 22

4. Tuberculosis Asians & Whites 20

5. Fetal alcohol syndrome AI/AN & Whites 15

6. AIDS Blacks & Whites 15

7. Smoking during pregnancy AI/AN & Whites 12

8. Congenital syphilis Hispanics & Whites 12

9. Chronic HBV US-born Asians & Whites 11

10. HIV-related deaths Blacks & Whites 10

11. Smoking during pregnancy Blacks & Whites 9

12. Non-fatal firearm injuries Blacks & Whites 9

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

Asian and Pacific Islander Asian and Pacific Islander PopulationPopulation

3.7 million in 1980 -15.2 million* in 20061

About 62.5% were foreign born in 20062

*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.htmlUS Census Bureau. Accessed at: http://factfinder.census.gov/

Five most common cancers in Males by Race/Ethnicity, California, 2003-2007

California Cancer Facts & Figures 2010, American Cancer Society

Back to the disease…

• Birth: Perinatal transmission from an infected mother to newborn at birth• Accounts for about 50% of the

cases in Asia1

• 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

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

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

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

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

HBV Vaccination

Available for over 20 years The first “anti-cancer” vaccine - CDC Confers life-long protection “3 for life”

6-month, 3 shot series

Video

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

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/.

A single HBV shot…

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 correctly1

1. Chao S, Cheung C, So S. Unpublished data. 20082. 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 immigrants2

Lack of Provider Action Of obstetricians surveyed:

only 45% routinely provide education about HBV1

only 44% inform pregnant women that their infants need to complete the HBV vaccine series1

Only 18% of internists who care for high-risk API routinely screen for hepatitis B2

21% of physicians knew what to do next if a patient was found to be HBsAg-positive3

1. Chao S, Cheung C, So S. Unpublished data. 20082. 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 13th 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.

Founded in 1996 by Dr. Samuel So 1st non-profit organization that addresses

the high incidence of HBV and liver cancer in API through: Outreach and education Advocacy Research

Jade Ribbon Campaign

To increase awareness about hepatitis b and provide ethnic-sensitive health information to API community

http://teamhbv.org

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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?

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?

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

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