October 2008

Early Detection Crucial to Hepatitis B Treatment

Marion Peters, M.D.
Chief of Hepatology Research
UCSF Medical Center

Due to the long asymptomatic nature of chronic hepatitis B (HBV) contracted early in life, many patients may not know they have the virus. Chronic carriers of "inactive" HBV often have no symptoms and normal laboratory tests, but can transmit the virus to others. Without treatment, patients infected with the virus can develop severe, long-term liver damage and have a one in four chance of dying prematurely of cirrhosis or liver cancer. HBV can lead to liver failure, which may necessitate a liver transplant.

The virus is responsible for an estimated 5,000 to 6,000 deaths each year. The Center for Disease Control and Prevention (CDC) estimates that 150,000 to 300,000 people in the United States are newly infected with HBV each year and that more than 1 million people currently carry the virus, many of whom are undiagnosed.

Hepatitis B Vaccination

The Advisory Committee on Immunization Practices recommends that the following persons be vaccinated against hepatitis B:

  • Infants at birth
  • Children up to age 19, who have not yet been been vaccinated
  • Sex partners of those who test positive for hepatitis B surface antigen (HBsAg)
  • Those who are sexually active and not in a long-term, mutually monogamous relationship or who have more than one sex partner during the previous six months
  • Patients seeking evaluation or treatment for a sexually transmitted disease
  • Men who have sex with men
  • Injection-drug users
  • Susceptible household contacts of HBsAg-positive persons
  • Health care and public safety workers at risk for exposure to blood or blood-contaminated body fluids
  • Those with end-stage renal disease, including predialysis, hemodialysis, peritoneal dialysis and home dialysis patients
  • Residents and staff of facilities for developmentally disabled persons
  • Travelers to regions with intermediate or high rates of endemic HBV infection
  • Patients with chronic liver disease
  • Patients with HIV infection
  • Others seeking protection from HBV infection (Acknowledgment of a risk factor is not a requirement for vaccination.)

Who Should You Test?

Certain ethnic populations have a higher rate of HBV, particularly Asian and Pacific Islanders (API) who come from areas of high endemicity. APIs have the highest risk of HBV of any ethnic group in the country. San Francisco's API residents comprise 34 percent of the city's population. It's estimated that APIs are up to 100 times more likely to suffer from chronic HBV infection and four times more likely to die from liver cancer compared to the general population. The virus is responsible for 80 percent of all liver cancers among APIs. San Francisco has the highest rate of liver cancer in the country.

Patients born in countries with high rates or chronic HBV (China, South East Asia, Sub-Saharan Africa) should be screened as early as possible. Many have had the virus in their liver and blood since birth or early childhood and could develop active liver disease at any age.

Even if patients don't experience symptoms, the following patients should be tested for HBV:

  • Patients from Asia, Pacific Islands, Middle East, Eastern Europe and Russia, Sub-Sahara Africa, Amazon Basin, Caribbean and indigenous populations of Alaska and Canada
  • Household, sexual and needle-sharing contacts of known HBV-infected patients
  • Patients who are HCV positive or HIV positive
  • Current or former injection-drug users
  • Pregnant women
  • Men who have sex with men
  • All children and adolescents who have not yet been vaccinated

For testing, the HBsAg and anti-HBs blood tests should be ordered.

Anyone who wishes to be protected against HBV regardless of his or her ethnic background should have the HBV vaccination.

What Do Test Results Mean?

Patients with a negative HBsAg and negative anti-HBs test results aren't immune to HBV. They should be vaccinated. The HBV vaccine is one of the safest and most effective vaccines available. It prevents HBV infection and therefore liver cancer. A patient already infected with HBV or immune to HBV due to disease exposure won't benefit from vaccine.

Patients with a negative HBsAg and positive anti-HBs test results are immune to HBV. Discuss possible risk factors and behaviors for contracting HBV with these patients.

Patients with a positive HBsAg and negative anti-HBs tests are infected with chronic HBV. For these patients, you should:

  • Evaluate their HBV status following standard medical guidelines
  • Vaccinate them against hepatitis A
  • Monitor them for hepatocellular carcinoma (HCC) at six to 12 month intervals after age 40 or if they have a family history of HCC
  • Counsel them to have household members and sex partners tested for HBV, seek medical follow-up, refer to appropriate specialists, use condoms, avoid sharing razors and toothbrushes, and minimize the use of alcohol

HBV Treatment

Chronic HBV is a dynamic disease that doesn't always need treatment but requires monitoring. When necessary, it can be effectively managed and treated with medications that suppress, slow or reverse associated liver disease. All chronically infected patients require life-long monitoring, although many patients will never need treatment.

Currently, there are a number of Food and Drug Administration (FDA)-approved treatments for chronic HBV — interferon alpha-2B (Intron A), peglyated interferon lamivudine (Epivir-HBV; 3TC), adefovir, entecavir, telbivudine and tenofovir. In some cases, treatment isn't recommended for people with chronic HBV, based on whether their liver disease is active with elevated liver enzyme levels, high HBV viral load and extent of liver damage. Patients with altered immune system status (HIV), those undergoing immune based therapies (e.g. prednisone, biologic response modifiers) or transplantation should be treated because they're at high risk of reactivation of hepatitis B infection during or after therapies.

Patients being treated for HBV should be monitored regularly. Liver function tests, HBV viral load assays, HBeAg antigen status and measures of liver damage should be performed to help determine treatment efficacy.

End-Stage Liver Disease

Each year, about 4 percent of the 6,000 liver transplant recipients in the United States have HBV. Liver transplant may be an option for people whose HBV progresses to liver failure and who fail to respond to treatment or can't tolerate treatment. The evaluation for a transplant is complex and generally requires several months. Even if a patient is feeling well, they should be referred for a transplant at the first sign of liver failure or if they have advanced liver disease or HCC diagnosed by X-ray studies or liver biopsy.

The UCSF Liver Transplant Program, which integrates the efforts of gastroenterologists and surgeons, performs over 100 transplants each year, making it one of the leading programs in the U.S. Survival statistics are among the very best in the country.

For more information, contact the Physician Referral Service at UCSF Medical Center:
Phone (888) 689-UCSF or (888) 689-8273
Email referral.center@ucsfmedctr.org

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