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“The only thing necessary for these diseases to the triumph is for good people and governments to do nothing.”

                    

Information on Hepatitis B

http://hivinsite.ucsf.edu/InSite.jsp?doc=2098.3e4b

   
 

 

by Robert G. Gish, MD, Pacific Hepatology, California Pacific Medical Center

Hepatitis B is a virus that infects the liver and usually causes progressive damage by bringing the immune cells into the liver and invoking an inflammatory response. The general word "hepatitis" indicates the presence of this inflammatory response. Once the inflammation (presence of pus cells) begins, fibrosis (scar tissue) may form and eventually a patient may develop cirrhosis liver failure and liver cancer. Liver transplantation is a possible treatment for hepatitis B induced liver failure but recurrence of the infection in new the new liver is still a problem in some patients.

Hepatitis B infected patients are contagious:

  • Hepatitis B can be sexually transmitted either through heterosexual or homosexual relations.
  • Hepatitis B can be acquired just by living in the same household as a person who has hepatitis B.
  • Hepatitis B can be acquired through needle stick exposure, blood transfusion or sharing needles by IV drug abusers.

Laboratory Terms:

surface antigen (HBsAg):

This means a patient has the virus and is infected with hepatitis B and is infectious to others.

surface antibody (sAby or anti-HBs):

If this test is positive it means that a person is immune to the hepatitis B virus and does not carry infection.

core antibody (cAby or anti-HBc):

This test if positive means the patient has be exposed to the hepatitis B virus but does not mean immunity or active infection, please refer the two tests above.

e antigen (HBeAg):

This is a crude marker of active reproduction (and infectivity) of the virus.

e antibody (HBeAby or anti-HBe):

This test is used to show low reproduction of virus a patient is positive if the e antigen test is negative.

    

Hepatitis B DNA:

This is the genetic code for the virus and is also a blood test If this test is positive, shows that the patient has a very actively reproducing the virus in the body. The presence of HBV DNA in the blood is also a marker of infectivity.

Types of hepatitis B infection:

Active infection with inflammation (immune active):

patients with active infection have elevated liver enzymes and inflammation on liver biopsy. These patients are the most likely to respond to interferon and may spontaneously convert from a state of high viral replication to low or even spontaneous clear the virus from the body and liver.

Silent carrier (immunotolerant phase):

patient with normal liver enzymes and a normal liver biopsy do not recognize the presence of the hepatitis B infection. These patients have a low likelihood of spontaneous conversion (1% per year) or respond to therapy such as interferon. The best management for such patients is to observe for liver enzyme abnormality and then consider a liver biopsy and therapy. This type of patients is the most common worldwide. Such patients usually acquired the hepatitis B infection at birth or in childhood. These patients have a high risk of liver cancer starting at age 30-50. If there is a family history of liver cancer and/or other causes of liver found (such as hepatitis C or alcohol) blood test for alpha-fetoprotein and ultrasound should start at age 40. If there is no family history of liver cancer and no other cause of liver disease, I recommend ultrasound and AFP annually starting at age 50.

Cirrhosis:

This is the scarring process for ongoing inflammation and is found in l0-30% of patients with active hepatitis but can also occur, rarely, in silent carriers. This diagnosis is difficult to determine by physical exam and laboratory testing early. All patients with hepatitis B, as with other causes of liver disease should have a liver biopsy if the liver enzymes are elevated. If cirrhosis is present the risk of liver cancer (the most common cancer in the world) is 200 times as common as in normal people.

The immune system attempts to rid the body of the Hepatitis B virus using lymph cells and proteins (cytokines) such as interferon. The effect of interferon, according to the published studies, on patients with hepatitis B infection is to decrease or halt the replication (the virus reproducing itself) of the hepatitis B virus. 40% of patients have a fall in liver enzymes, and a fall or disappearance of the DNA of the virus. The inflammatory changes seen on liver biopsy improve in most of the patients who improve their liver enzymes. 10% of patients clear the virus (convert from surface antigen positive to surface antigen negative) and can be stated to be cured. A long-term follow-up study showed that patients treated with interferon will eventually lose HBsAg and be cured of hepatitis B.

Treatment:

  • Interferon:

Patients likely to respond to interferon:

    • Hepatitis B duration less than 4 years
    • HBeAg positive
    • Hepatitis B DNA positive
    • Elevated liver enzymes

Patients not likely to respond to interferon:

    • Long duration of disease
    • Hepatitis B acquired at childbirth
    • Hepatitis B DNA negative (the virus is not reproducing)
    • Presence of HIV (AIDS) virus
    • Older age
    • Normal liver enzymes

Interferon is given by subcutaneous injection and is usually given at higher dose (5 million units per day or 10 million units three times a week) for 16 weeks. The side effects of interferon include soreness at the injection site, slight fever, muscle aches, elevated blood sugar, mood swings, hair loss, nausea, joint aches, head ache, decreased blood cell counts, including white blood cells (those used to fight infection), platelet count (used for blood clotting), and anemia (a decrease in red blood cells which~are used for carrying oxygen). There is no known risk of HIV or AIDS (immunodeficiency disease) from the use of these treatments.

Newer forms of interferon will also act against HBV infection:

    • Wellferon
    • Consensus interferon (Infergen) (alfacon-1)
    • Roferon (alfa-2a)
          
  • Oral medications that can be prescribed at a pharmacy that suppress KB infection but do not cure disease are:
    • lamivudine
    • famciclovir
    • ganciclovir

These medications could be used with interferon, complete information on the utility of combination therapy has not been published. Combination therapy could increase the chance of cure and decrease the chance of mutations that lead resistance.

  • Medications in trial in the United States:
    • lobucavir
    • FTC
    • Adefovir

These oral medications have few side effects and are not give by injection.

  • Newer experimental medications that may be used to treat chronic hepatitis infection include:
    • Cyl899 - a therapeutic vaccine
    • monoclonal antibodies (experimental)
    • tucaresol (experimental)

Hepatitis B vaccination:

The hepatitis B vaccine is produce my recombinant technology (genetic engineering) and has no risk of transmission of the AIDS virus. Minor local reactions or fever are the side effects most noted. There is no increased risk ot severe reactions or side effects such as Guillan-Barre.

There is a vaccine available for hepatitis B and all household contacts and sexual contacts of a person infected with the Hepatitis B virus should be vaccinated. All homosexuals should be vaccinated. All patients of Asian origin should be vaccinated. All health care workers should be vaccinated.

The hepatitis B vaccine should be administered to high risk individuals. There currently no reason not to take the vaccine.

HIGH RISK INDIVIDUALS:

  • All health care workers
  • Emergency workers
  • Pregnant women
  • International travelers
  • Military personnel
  • Morticians and embalmers
  • Patients and personnel at institutions of mentally handicapped and incarceration
  • High risk ethnic groups
  • Male homosexuals
  • Intravenous drug users
  • Infants born to HBsAg positive mothers

The vaccination process involves 3 injections at 0, 1 month and 6 months. No booster is required.

Evaluation of patients who are at high risk for HBV infections:

  • Best screening test: HBcAby
  • Hepatitis B core antibody >>>> negative >>>> vaccinate
    • if positive order HBsAg
    • positive HBsAg = infectious
  • Order liver enzymes >>>> abnormal >>>> liver biopsy
  • If cirrhosis: start bi-annual liver cancer screening with U.S. and AFP
  • If no cirrhosis by liver biopsy or if liver enzymes are normal:
    • Ask if family history of liver cancer
    • if yes, start liver cancer screening at age 40 by AFP and US yearly
    • if no, start liver cancer screening at age 50 by AFP and US yearly
  • Liver enzymes should be measured bi-annually in all patients

 

 

ROBERT G. GISH, MD
STEPHEN L. STEADY, MD
ADIL "ED" WAKEL, MD
FRANCIS YAO, MD
FRED POORDAD, MD

 

Pacific Hepatology
2340 Clay St.
California Pacific Medical Center
Department of Transplantation
San Francisco, California 94115
Fax: 415-474-8543
Tel: 415-202-1530 or 923-3450