Hep B Blog

How to Find a Liver Specialist Who Really Knows Hepatitis B

Image courtesy of stockimages at FreeDigitalPhotos.net
Image courtesy of stockimages at FreeDigitalPhotos.net

By Christine Kukka

If you have chronic hepatitis B or are newly-diagnosed, it’s important to see a liver specialist who has experience with hepatitis B.

Having a specialist with hepatitis B expertise on your team not only safeguards your health, it also lessens the stress of having a chronic liver disease. “My specialist gave me all the possible scenarios, but most importantly, he gave me my life back,” one hepatitis B patient recalled.

When first diagnosed, it’s often a primary health provider (PCP) or for children a pediatrician who gets the test results and calls to break the news. Doctors may run additional blood tests and/or immediately refer you to a liver specialist. They may recommend a specialist who accepts your insurance or practices in the same healthcare system, but you may have to do some research to find the best specialist to treat your hepatitis B.

There are two types of specialists who treat liver diseases:

  • A gastroenterologist is an internist who has trained in digestive disorders including the liver, but how much liver expertise a gastroenterologist (GI doctor) has varies based on their training. It’s important to find out if they specialize in liver diseases.
  • A hepatologist is a physician who specializes in the liver. This doctor has the most expertise and should be up-to-date about new treatments and clinical trials. But not all hepatologists have treated hepatitis B. Many will have treated hepatitis C, but not hepatitis B, so you need to ask.

Tips for finding a specialist:

  • Are they in the Hepatitis B Foundation directory? The foundation has a Physician Directory of liver specialists who treat hepatitis B around the world. These doctors have voluntarily signed up  for the database. It is not an exhaustive list, there may be hepatitis B specialists in your area who have not yet joined the directory.
  • Call the practice ahead of time and ask questions. How many hepatitis B patients have they treated? Do they participate in any clinical trials?  Are they aware of current monitoring and treatment guidelines for hepatitis B?
  • What’s the doctor’s reputation? Does anyone in your community see a liver specialist for viral hepatitis? Whom do they recommend?
  • Will you actually see the specialist or an assistant? Do you see a specialist only if there is a need for treatment? If you go to a teaching hospital, do you see the doctor or an intern, fellow or resident?

You are entering into a long-term relationship with someone who may care for you for many years. You need their expertise, but you also need to feel comfortable working with them. Do they listen when you speak and make eye contact? Trust and rapport are very critical.

“It’s really important that they don’t judge me,” one hepatitis B patient explained.  Another patient said that finding a doctor who spoke his language, or had an assistant who was fluent in his language, helped immensely.

Once you identify a specialist, here are some questions to ask:

  • Is the specialist accepting new patients? How long do you have to wait to get an appointment?
  • What hospital or lab do they use, and are they convenient for you? It’s important for you to always use the same lab so you have consistent results that allow apples-to-apples comparisons.
  • Will the doctor call you with the results or will a nurse or other assistant communicate with you?
  • What would you like your care plan to be? Will you go for blood tests and then see the specialist? Typically, hepatitis B patients get blood tests once or twice a year to monitor their liver, unless they are undergoing treatment.

How to design a long-distance care plan if the specialist is far away:  Sometimes, the best hepatitis B specialist is a few hours-drive from where you live, but distance doesn’t have to be a deal breaker. Many people see a specialist for a first visit, and afterwards simply have their PCPs or local labs email lab results to the specialist. For this remote healthcare relationship to work, your PCP needs to be willing to partner with the specialist. Also, your specialist needs to be open to telephone consultations with you as needed.

Technology matters. Sharing medical records and lab tests electronically make a remote relationship work smoothly. If there are firewalls between practices, find out how to ensure your PCP and specialist share your medical records. Be prepared, you may have to be the conduit if the two healthcare systems don’t talk to each other.

Insurance and cost: Ideally, the hepatitis B specialist closest to you accepts your insurance or is in your provider network. That doesn’t always happen so finding out the charges in advance is important.

  • Will the specialist bill your insurance or will you need to pay the fee upfront and manage the insurance reimbursement yourself?
  • How much do you have to pay out-of-pocket if the specialist is outside your network, or if you are not insured? Some specialists charge a lower fee to uninsured patients. You may be able to have an annual consultation with a specialist and bring your lab results.

One hepatitis B patient reported he was not entirely happy with the specialist his PCP referred him to. “At the time, I had great insurance so all the tests he ordered weren’t a lot of money out-of-pocket,” he said. “But then I changed jobs and I couldn’t afford all of his tests, and he wanted me to go on treatment though my lab reports didn’t justify it.

“I went looking for a new one and found one in the Hepatitis B Foundation’s website,” he said. “I had to drive farther to see him, but his knowledge and patience were very comforting and he spoke my primary language. He really helped me regain confidence in life. ”

Prepare for your visit: Before you see the specialist, put together a list of questions (see sample questions) and have your lab reports available — either bring hard copies or call ahead of time to make sure the doctor has access to your latest labs and medical records.

After you meet with your specialist, take some time to reflect. Are you happy with the doctor? Did he or she communicate well? Are you clear about what you need to do in the weeks and months ahead to take charge of your health? If the answer is yes, congratulations, you have assembled a good healthcare team.

Iron Overload Affects More Than the Irish, People with Hepatitis B-Related Liver Damage Need to Be Tested

Image courtesy of zole4 at FreeDigitalPhotos.net.
Image courtesy of zole4 at FreeDigitalPhotos.net.

By Christine Kukka

Iron is crucial to our health, but too much iron – called iron overload – can put us at risk of liver damage and other health problems, especially if we have hepatitis B-related liver disease and/or we’re Irish.

Irish and hepatitis B are not normally two words you hear in the same sentence, but both populations may need to be careful about how much iron they eat.

  • A liver inflamed or damaged by a chronic hepatitis B infection or other causes doesn’t process or store liver effectively and the excess iron accelerates liver damage and causes a host of other medical problems.
  • If you’re Irish or of northern European ancestry, one in eight of you have a genetic predisposition for hereditary hemochromatosis (HH) – commonly called the Celtic Curse — that occurs when the body doesn’t process or store iron properly, leading to a four-fold increase in iron absorption.
  • If you’re Irish and have chronic hepatitis B, you may want to celebrate St. Patrick’s Day with a trip to your doctor for a simple blood test for ferritin (iron) and transferrin saturation. If they’re elevated, your doctor may order a gene test to see if you have HH.

The relationship between iron overload and hepatitis B has been problematic, or as researchers like to say, “not well defined.”

Our liver is the body’s major storage organ for iron. About one-third of the iron we consume is stored in liver cells, which play a major role in recycling iron and synthesizing transferrin (the main transporting protein) and ferritin (the major storage protein) from iron.

Image courtesy of Stuart Miles at FreeDigitalPhotos.net.
Image courtesy of Stuart Miles at FreeDigitalPhotos.net.

When our livers are damaged or inflamed from hepatitis B, the Celtic Curse, fatty liver or alcohol, they don’t synthesize iron well, leading to excessive iron deposits in the liver which leads to more liver damage, including inflammation, fibrosis and even liver cancer.  In some hepatitis C patients, iron overload was found to reduce the effectiveness of antiviral treatment in some patients.

Researchers often found elevated iron levels in hepatitis B patients and suspected chronic hepatitis B could lead to iron overload. Recently, new research has discovered it’s the inflammation or liver damage from hepatitis B that causes iron problems. People with “inactive” hepatitis B with no signs of liver damage usually do not experience iron overload.

“Our data clearly indicate that hepatitis B-related liver injury, but not direct chronic hepatitis B infection, is likely responsible for the changes in the serum iron markers,” researchers concluded in a report on this topic published in the European Journal of Gastroenterology & Hepatology.

Hepatitis B Foundation Medical Director Robert Gish believes that iron overload is a “non-issue” for hepatitis B patients. However, he does have his patients get a transferrin saturation test. (A score of 20 percent indicates iron deficiency while a score exceeding 50 percent suggests iron overload.)

Many foods in our diet are rich in iron, including iron-fortified cereals, breads and pastas and meat including beef, pork, poultry and seafood.

According to experts, unless we have severe liver damage (often indicated by elevated liver enzymes (ALT/SGPT) or an ultrasound), we don’t need to restrict our consumption of foods rich in iron.

But if we do have liver damage and/or are Irish, it might be worth a conversation with our doctor. When we have excess iron, it is usually not detected by a complete blood count (CBC), hemoglobin, or hematocrit, test, it requires the transferrin saturation test.

Symptoms to watch for include fatigue, joint pain, abdominal pain, irregular heartbeat, skin color changes, irregular menstrual cycles, loss of libido and impotence, bone density changes, depression, anxiety, muscle pain, brain fog, chronic diarrhea, diabetes, liver damage and headaches.

For more information on HH, visit the website of the American Hemochromatosis Society.

Struggling with Depression and Hepatitis B? You’re Not Alone

Image courtesy of Tuomas_Lehtinen at FreeDigitalPhotos.net.
Image courtesy of Tuomas_Lehtinen at FreeDigitalPhotos.net.

By Christine Kukka

Studies show people with chronic hepatitis B have higher rates of depression and anxiety than the general population, which should surprise no one.

There’s no cure, people with hepatitis B face stigma and discrimination, and when we disclose, we risk rejection or friends think we’ve done drugs or slept around. And, if we are people of color, we’re already viewed as outsiders or different already; a medical diagnosis just adds to our feeling of alienation.

Sometimes, we need help. We need to be reminded once again that hepatitis B is nothing to be ashamed of, that millions of people around the world are infected not because they did anything wrong, but because it’s not a perfect world and not everyone had access to the hepatitis B vaccine at birth or sterile medical equipment or is able to practice safe sex 100 percent of the time.

Some symptoms of depression include feeling sad, down, or just emotionally flat or apathetic. We may feel tired, irritable, or experience mood swings and find we are unable to concentrate. If we’re taking antivirals, we may frequently forget to take our meds. We might also lose our appetite, sleep too much or too little, and fantasize about harming ourselves or even suicide.

Image courtesy of David Castillo Dominici at FreeDigitalPhotos.net
Image courtesy of David Castillo Dominici at FreeDigitalPhotos.net

It’s time to get some help. Medical guidelines usually recommend a combination of “talk” therapy and antidepressant medication. Talking to a therapist, especially if you’ve always kept your hepatitis B a secret, can help you get a better handle on your infection. It can be liberating to have another person challenge your cataclysmic view of life, especially if you’re you’ll never find love or happiness.

It’s also good to join a support group or an email list to confirm that you’re not the only one in the world with hepatitis B.

The other treatment for depression are antidepressant pills, taken daily. Antidepressants take a while to build up in your system so you usually have to take them for a few weeks before you feel better.

Are antidepressants safe if you have hepatitis B?

Antidepressants generally do not harm the liver, unless you have severe, pre-existing liver damage (such as cirrhosis), are older, or are taking several medications at once.

According to research, about 0.5 percent to 3 percent of those taking antidepressants may develop very mild elevation in their liver enzymes (called ALT or SGPT), which indicate mild liver damage. Unless you already have severe liver damage, experts see no threat from antidepressants, but if there is concern, your doctor should monitor your ALT/SGPT levels more frequently than usual during your first weeks of antidepressant treatment, especially if your ALT/SGPT level is already elevated.

“I would say antidepressant shouldn’t be used if there’s been liver failure,” said Hepatitis B Foundation Medical Director Robert Gish. “If there’s just cirrhosis and you have normal liver function (normal ALT/SGPT) antidepressant still should be fine. The only one not to use is Cymbalta (duloxetine). “

The antidepressants that may cause the highest risk of moderate liver damage,  include monoamine oxidase (MAO) inhibitors, tricyclic/tetracyclic antidepressants, nefazodone, bupropion (Wellbutrin, also used for ADD and smoking cessation), duloxetine and agomelatine.

Drugs with lower risk of causing liver damage include citalopram, escitalopram, paroxetine (Paxil) and fluvoxamine.

Among the most common antidepressants used today is fluoxetine (Prozac).  According to the National Institutes of Health LiverTox report,  in people with no pre-existing liver infections or damage, “Liver test abnormalities have been reported to occur rarely in patients on fluoxetine (less than 1 percent), and elevations (in ALT/SGPT) are usually modest and usually do not require dose modification or discontinuation.”

In addition to seeking treatment and therapy, below are some other ways to relieve stress and improve your sense of well-being.

  • Join a support group.
  • Ask friends of family for help.
  • Don’t isolate yourself.
  • Replace negative thoughts with positive ones, even if you don’t believe it at the beginning. Talk it until you can walk it.
  • Join a yoga, meditation or stress management class.
  • Get out in the sunlight and exercise more, even if it’s taking a short walk. Find something you find joy in.
  • Eat healthy foods, exercise regularly.
  • Get at least eight hours of sleep each night, and talk to your healthcare provider if you have problems sleeping.
  • Avoid alcohol (which is a depressant) and other self-medication.

 

March 1 Is Zero Discrimination Day: Ending Hepatitis B Stigma Starts with Us

2017-zero-discrimination-day_en.pdfBy Christine Kukka

Around the world, millions of people with chronic hepatitis B face wrenching discrimination that limits their dreams, education, careers, income and personal relationships. Here are examples:

  • A Vietnamese woman working in a hotel in Dubai is found to have hepatitis B and is fired, isolated, deported and given a life-time ban on re-entering the country.
  • A young person from the Philippines, aspiring to increase her income to support her impoverished family, is hired to work in Saipan, but her work visa is suddenly cancelled by the employment agency when it discovers she has hepatitis B.
  • A young man from the state of Washington, who worked hard in high school to get into the Naval Academy, is summarily dismissed within days of his arrival when it’s discovered he has hepatitis B. The U.S. military continues to bar people with hepatitis B from serving.

All of this discrimination is unethical, unnecessary and a violation of human rights. Hepatitis B is simply not transmitted through casual contact. The stigma that persists is based on ignorance and it impacts millions around the world daily. This is why we need to recognize Zero Discrimination Day on Wednesday, March 1.

Image courtesy of cooldesign at FreeDigitalPhotos.net.
Image courtesy of cooldesign at FreeDigitalPhotos.net.

This day, designated by the United Nations, highlights the negative impact of discrimination and promotes tolerance, compassion and peace. Many hepatitis activist organizations, including the Hepatitis B Foundation, is using this celebration to draw attention to global hepatitis B discrimination.

In the U.S., some progress has been made to eradicate the unequal treatment of people affected by chronic hepatitis B infection. In 2012, prompted in part by complaints filed by the foundation, CDC issued new regulations that clarified that hepatitis B should not, “disqualify infected persons from the practice or study of surgery, dentistry, medicine, or allied health fields.” These recommendations and a U.S. Department of Justice letter warned medical, nursing, dental schools that they could not exclude applicants and students with hepatitis B, concluding, “… for most chronically HBV-infected providers and students who conform to current standards for infection control, HBV infection status alone does not require any curtailing of their practices or supervised learning experiences.”

However, today people with hepatitis B can’t even get jobs as hotel maids in many countries in the Middle East and Asia. Fear and ignorance, and reluctance by government officials to outlaw these discriminatory practices, have allowed these rules that diminish basic human rights to continue. The young woman who was exiled from Dubai, wrote of her experience:

“When I was 21, I had my internship in Dubai and needed to undergo a blood test. I was not aware of the rules in that country so when I was tested positive, the hotel that I worked for isolated me. I was going through a very hard time because I was completely alone in a foreign country. My work visa was canceled, they brought me to a place that looked like a jail, they took my iris scan, and I was deported along with a lifetime ban, which means I can never come back to that country again. That was the most horrible memory in my life. I am still scared every time I think about it. Sometimes I cannot sleep at night, I keep blaming, cursing myself for having this kind of virus inside my body.”

Image courtesy of meepoohfoto at FreeDigitalPhotos.net,
Image courtesy of meepoohfoto at FreeDigitalPhotos.net,

No one is to blame for hepatitis B, including the millions who were infected at birth or from unsafe and contaminated syringes and medical devices. There is a safe and effective vaccine that prevents hepatitis B today. When people are protected, there is no reason to fear that healthcare workers or hotel maids will spread this infection.

It is morally reprehensible that given the tools and knowledge we have that this discrimination should continue today.

Every day is zero discrimination day, and ending discrimination starts with us working individually in any way we can in our communities to end this stigma.

Make the NOhep:NOexcuse pledge and take simple actions to help eliminate viral hepatitis. It only takes a minute to pledge your support! 

The United Nations first celebrated Zero Discrimination Day on March 1, 2014, after UNAIDS, a UN program on human immunodeficiency virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS), launched its Zero Discrimination Campaign on World AIDS Day.

Doctors Get a New Tool to Improve Hepatitis B Treatment and Monitoring

Photo courtesy of CDC.
Photo courtesy of CDC.

By Christine Kukka

A recently-approved test now allows doctors to measure exactly how much hepatitis B surface antigen (HBsAg) people with chronic hepatitis B have in their blood; so why should patients get this test and how will it help the millions of people around the world infected with hepatitis B?

According to experts, including the Hepatitis B Foundation’s Medical Director Robert Gish, knowing a patient’s HBsAg levels gives doctors:

  • A better understanding of what stage of hepatitis B a patient is in;
  • A more accurate assessment of a patient’s liver cancer risk; and
  • Essential information to judge if it’s time to start or stop treatment.

And in the future, this test may be critical to finding a cure.

Don’t labs already test for HBsAg? HBsAg, the protein that makes up the surface of the virus, is what labs look for in a blood sample to determine if a person is currently infected with hepatitis B.

Historically, labs determined only if HBsAg was present or not, which is why patients either tested positive or negative for HBsAg. Recently, countries outside the U.S. began measuring HBsAg quantities in blood samples and late last year became available in the U.S. as a federally-approved (CLIA) lab test from Quest Diagnostics.

Hepatitis B Foundation President Timothy Block
Hepatitis B Foundation President Timothy Block

“The strange thing about HBsAg, is that each hepatitis B virus requires only about 100 HBsAg molecules to provide its envelope protein, but the virus produces about 100- to 1 million-times more HBsAg than is needed, leaving millions of HBsAg circulating in the bloodstream,” explained Timothy Block, president of the Hepatitis B Foundation and the Baruch S. Blumberg Institute, the foundation’s research arm.

That over-abundance of HBsAg is why people continue to test positive for HBsAg even if they have an undetectable viral load (HBV DNA).

Why is there so much HBsAg? Researchers, including Block, suspect that in addition to covering the virus’ surface, HBsAg also serves as a decoy to “exhaust” or deflect our immune system’s:

  • T-cells, so they can’t attach to and attack the virus,
  • And B-cells, so they don’t generate the antibodies needed to destroy the viral antigens that make up the virus.

So when HBsAg levels decline–either due to treatment or a strong immune response to the infection–researchers know a patient is on the road to clearing the infection. Bottom line: A low or undetectable HBsAg level means patients are winning the war against hepatitis B and their risk of liver damage is greatly reduced. 

When should doctors measure HBsAg? According to Quest Diagnostics, which created the test, measuring HBsAg levels better identifies which patients are at risk of hepatitis B reactivation.

For example, a patient may be HBeAg-negative and have normal liver enzymes (ALT/SGPT) that indicate a liver is “healthy,” but if HBsAg remain high, doctors know a patient remains at risk of reactivation and hasn’t really entered the safer, “inactive” stage.

Quest maintains that measuring HBsAg and viral load (HBV DNA) together, “…improves the ability to differentiate the phases in HBeAg-negative patients and HBeAg-positive disease and results in a diagnostic accuracy of 70 to 94 percent.

According to Quest, patients with HBV genotype B or C who have low HBV DNA levels (less than 2,000 IU/mL) and HBsAg levels below 1,000 IU/mL have lower risk of liver damage and cancer. In fact, if HBsAg is under 100 IU/mL, patients may be on their way to clearing HBsAg from their blood.

Dr. Robert Gish
Dr. Robert Gish

Knowing for sure when treatment is working: HBsAg levels also reflect the amount of virus protein produced by infected liver cells and if treatment is effectively stopping the virus from producing these proteins. If a patient is treated with pegylated interferon, a decline in HBsAg during the first 12 weeks indicates a successful response to the drug. No change in HBsAg levels indicates interferon will not be effective.

HBsAg changes may also determine if antivirals are working. “In HBeAg-negative patients, low (HBsAg) levels at the end of treatment are associated with sustained virologic response,” Quest officials noted.

If patients have been treated with antivirals for many months or years and achieve undetectable viral load and low HBsAg levels, doctors may consider taking them off the drug.

Dr. Gish considers this new test an essential tool that providers should employ and patients should ask for to get an accurate picture of their infection state and liver cancer risk.

“I use it today to determine when to start treatment, assess a patient’s prognosis while on treatment, enhance patient compliance and determine when treatment can be stopped or should be continued,” he explained. “And this will also be an extremely helpful tool for drug developers in the future to identify promising treatments.”

Because lowering or eradicating HBsAg appears essential to stopping chronic infection and empowering the immune system to fight this complex infection, researchers around the world are working to develop treatments that inhibit HBsAg.

“I am a big believer in finding drugs that suppress HBsAg,” Dr. Block noted. Two of these surface antigen eradicator products are currently in Phase II trials.

Valentine’s Day Advice for Those Looking for Love While Living with Hepatitis B

Image courtesy of photostock at FreeDigitalPhotos.net.
Image courtesy of photostock at FreeDigitalPhotos.net.

By Christine Kukka

Valentine’s Day celebrates love and romance, but when you have hepatitis B, you may fear dating could lead to rejection and heartbreak.

Alright, so you had a few unhappy dating experiences because of hepatitis B … believe me, you’re better off without those people. If hepatitis B hadn’t ended the relationship, it would have been some other issue.

Here are two pieces of valuable advice for those looking for love while living with hepatitis B.

A leader of the Hepatitis B Information and Support email list recently offered this sage counsel to members who feared they would never date, marry or have children because of their hepatitis B.

“As the list mom and a divorced woman who has been dating for the last eight years, I have personal experience with this topic. I have to remind you, having chronic hepatitis B does NOT have to create a barrier to dating. If anything, it can help you determine who is a good partner and will possibly be there for you in the long-term.

Image courtesy of Graphics Mouse at FreeDigitalPhotos.net.
Image courtesy of Graphics Mouse at FreeDigitalPhotos.net.

“Also, and this is the biggie, there is a VACCINE for hepatitis B. If you meet someone you want to have an intimate relationship with, they can be vaccinated (some already are!)

“There is no reason to feel as if you are inferior or less deserving of love because of your hepatitis B.  We all want and need acceptance. The only barrier is what you have built in your mind.

“Personally, I have been in three long-term relationships since my divorce.  I am currently in a loving relationship with a man who cares about me deeply and has no issues with my hepatitis B.

“A word of wisdom from a friend has stuck with me. If someone loves you, they will care about YOUR heath, and make room for ways to keep you in their life.

“Don’t wall yourself off from the experiences of meeting new people and potential love and partnership with another soul.  Life is too short to be afraid of getting hurt.  You ‘will’ get hurt, and you WILL get back up to live another day and love again. The risk of rejection is worth the reward.

Disclose, before it’s too late.

When you disclose your hepatitis B status before sex – even if it’s safe sex with a condom – we don’t jeopardize our partner’s health or their trust in us. Talking about hepatitis B helps reduce the stigma surrounding this infection and may even prompt the person to get vaccinated.

So how do we tell a potential partner that we have hepatitis B? Calmly and carefully. Here is one way to initiate disclosure: “Before we become intimate, we need to talk about STIs and contraception. The reason I’m bringing this up is that I have hepatitis B. You need to know that, and we need to decide how to protect ourselves… ”

Do some research. Having a thorough understanding about hepatitis B can make it easier for you to explain it to a potential partner. The more you know, the less you fear, and the more comfortable you will be in dispelling their fears and conveying a sense of truth and integrity.

Image courtesy of radnatt at FreeDigitalPhotos.net.
Image courtesy of radnatt at FreeDigitalPhotos.net.

Here are some tips from the American Sexual Health Association for disclosing a sexually-transmitted infection.

  1.  Pick a time when both of you will be in reasonably good moods and relaxed for this conversation. Choose a place with few, if any, distractions.
  2.  Start out on a positive note (“I’m really happy with our relationship…”). This will put them in a positive mindset, and they may respond more agreeably than if you start out saying something like, “I have some really, really bad news… “
  3.  Your delivery can influence their reaction to what you say. If you talk calmly about hepatitis B, they may respond similarly. If you act like it’s the end of the world, they might agree that it is.
  4.  Allow a conversation to take place, rather than doing all of the talking yourself.

Disclosure is the right and ethical thing to do. How they respond is out of your control, but their response might just surprise you.

A Valuable Tool Against Chronic Hepatitis B Goes Unused in Many Developing Countries

Image courtesy of tuelekza at FreeDigitalPhotos.net.
Image courtesy of tuelekza at FreeDigitalPhotos.net.

By Christine Kukka

A critical tool that stops the spread of nearly half of all new chronic hepatitis B infections is still unavailable in many developing countries – the hepatitis B vaccine birth dose.

When the hepatitis B vaccine is immediately administered to a baby born to a hepatitis B-infected mother, it stops the terrible spread of hepatitis B to a new generation.

But this vaccine remains unavailable and financially out-of-reach for many parents in rural areas of Africa, Asia and other regions.

“In Ghana, even if parents know where to find the vaccine, the cost sometimes deters them from accessing it,” said Theobald Owusu-Ansah of the Hepatitis B Foundation of Ghana.   “And when midwives help mothers deliver their babies in their homes, they do not have the vaccine with them because it must be refrigerated.”

While a global childhood immunization program, sponsored by the global vaccine alliance GAVI, has saved millions of lives, the hepatitis B birth dose remains a critical, missing piece of its otherwise successful global immunization strategy.

Image courtesy of africa at FreeDigitalPhotos.net.
Image courtesy of africa at FreeDigitalPhotos.net.

To effectively prevent mother-to-child (perinatal) transmission of hepatitis B, the single-dose hepatitis B vaccine must be administered within 12 to 24* hours of birth. In about 90 percent of cases, this vaccine effectively prevents infection, unless the mother’s viral load is extremely high.**

Today, GAVI funds and promotes the pentavalent vaccine, which prevents five diseases including hepatitis B, for nearly all children in developing countries. But here’s the catch, the earliest the first dose of the pentavalent vaccine can be administered is six weeks of age because it contains the diphtheria vaccine. This is far too late to prevent perinatal hepatitis B infection.

GAVI’s pentavalent vaccine makes economic and medical sense. One vaccine that prevents several diseases lowers manufacturing and shipping costs and requires fewer injections. Indeed, widespread immunization with GAVI’s pentavalent vaccine in 73 developing countries has prevented 7 million deaths, but it doesn’t prevent chronic hepatitis B acquired at birth.

The World Health Organization (WHO) has made eradication of hepatitis B by 2030 a major goal, but it is unattainable unless perinatal infection is prevented.

Without GAVI’s financing or promotion of the hepatitis B birth dose, many developing countries have done little to promote the birth dose, despite their high rates of hepatitis B. According to the WHO, in 2015, 8.4 million babies were born in African countries that did not provide the birth dose of the hepatitis B vaccine.

In addition to a lack of political will on the part of GAVI and these countries, there are other barriers to distributing the hepatitis B birth vaccine. As Owusu-Ansah explained, about one-third of births in his native Ghana  and about 45 percent of all births in Africa take place without a healthcare worker or midwife present.

Volunteers from the Rann India Foundation teach villagers about hepatitis B testing and prevention in India.
Volunteers from the Rann India Foundation teach villagers about hepatitis B testing and prevention in India.

Suren Surender, founder and president of the Rann Bhoomi Foundation, which educates rural villagers in India about hepatitis B prevention, added that even when healthcare workers are present at childbirths, “there is a lack of knowledge about birth dose administration and there is also a lack of community awareness about the benefits of getting the birth dose.”

Having a global leader like GAVI lend financial and strategic support for the hepatitis B birth vaccine would go far to chip away at these high perinatal infection rates in rural regions. In 2013, GAVI and the global vaccine alliance explored funding the hepatitis B birth dose as part of its Vaccine Investment Strategy (VIS),  but officials decided not to fund it.

According to a GAVI spokeswoman, the key deterrent was implementation — getting the refrigerated vaccine birth dose to rural areas within hours of a child’s birth – rather than cost.

“Many births in GAVI-supported countries do occur outside health facilities,” she noted. “Indeed, coverage of hepatitis B birth dose in many countries delivering this intervention is low. Ultimately, the Vaccine Investment Strategy analysis and consultations recommended that (GAVI) should focus its limited resources on other high-impact vaccines at the time.”

However, research suggests the hepatitis B vaccine may be effective for several days or weeks in warm climates without refrigeration, which could increase their use in rural regions if there was more financial and political support.

In 2018, GAVI will reconsider potential support for the hepatitis B birth dose when it develops a new Vaccine Investment Strategy, with a decision expected in late 2018.

GAVI’s support for the birth vaccine is needed immediately. Only GAVI has the resources and political clout to help countries realign their immunization policies to allow the next generation of children born to hepatitis B-infected parents to live without liver disease.

*North American medical guidelines recommend the first hepatitis B vaccine dose be administered within 12 hours of birth, while WHO recommends the vaccine be given within 24 hours of birth.

**The addition of a dose of HBIG (hepatitis B antibodies) along with the vaccine raises the prevention rate a few percentage points. However, the vaccine alone is highly effective.

If Hepatitis B Is Sexually Transmitted, How Come My Partner Isn’t Infected?

Image courtesy of David Castillo Dominici at FreeDigitalPhotos.net.
Image courtesy of David Castillo Dominici at FreeDigitalPhotos.net.

By Christine Kukka

I thought hepatitis B was sexually transmitted? I just tested positive, but my partner tested negative, we’ve been together for years, what gives?

This question is a common one. Hepatitis B is indeed easily transmitted sexually, so why do some people — who were not vaccinated — never get hepatitis B from their sexual partners?

It comes down to variables, such as the type of sexual activity you engage in, the viral load (HBV DNA) of the infected partner, and who is on the receiving end of infectious body fluids, especially blood that contains the most virus and semen.

Having one partner infected, and other not, can add more stress to an already traumatic hepatitis B diagnosis. “It was very confusing and made me question how was it possible I was the only one infected,” said a woman who tested positive while her husband tested negative.  “I thought it was possibly a mistake, maybe I was a biological anomaly, which of course I was not.”

Let’s look at the factors that affect who gets infected and who doesn’t when two people have sex.

Viral load: Semen, vaginal fluids and blood all contain the hepatitis B virus (HBV), and the higher the viral load, the more infectious one’s blood and body fluids are. However, having an undetectable viral load doesn’t mean you won’t infected someone during unsafe sex. Even if a man has an undetectable viral load, studies show his semen still contains some HBV and can spread infection, though the risk is lower.

So the rule here is if a man tests positive for the hepatitis B surface antigen (HBsAg), he must consider himself infectious.

The role of gender: In heterosexual relationships, uninfected women are at higher risk of getting infected by a male partner infected with hepatitis B, than the reverse. Women are on the receiving end of semen, which greatly increases their risk of becoming infected unless a condom is used.

Image courtesy of renjith krishnan at FreeDigitalPhotos.net.
Image courtesy of renjith krishnan at FreeDigitalPhotos.net.

When a woman is infected with hepatitis B, an uninfected man is at risk through direct contact with her vaginal secretions, but that contact is lower-risk than a woman’s direct exposure to infectious semen during intercourse.

However, an infected woman who is menstruating is more likely to spread hepatitis B because blood can contain higher levels of HBV than vaginal secretions. That is why gloves and dental dams are recommended to provide a barrier against exposure.

The type of sexual activity: Certain sexual activities are far more efficient at spreading hepatitis B than others. Oral sex appears to have a lower rate of hepatitis B transmission than vaginal sex. Anal sex carries a very high risk of transmission because of tears in the skin that can occur during penetration improves transmission of HBV.

Fingering carries a lesser risk, unless the infected woman is menstruating or a person has bruises or cuts on their hands that allow entry to hepatitis B in semen or vaginal fluids, then gloves are recommended.

The “uninfected” partner could already have been infected and cleared hepatitis B: When a person is first diagnosed with hepatitis B, doctors often test his or her partner for only the hepatitis B surface antigen (HBsAg), which indicates a current hepatitis B infection. If they are negative for HBsAg, they are immediately vaccinated.

If the partner isn’t also tested for the hepatitis B surface antibody (anti-HBs or HBsAb), then no one knows if  the individual was infected years ago (or earlier in the relationship) with hepatitis B and cleared the acute infection.

Hepatitis B is not called the “silent” infection for nothing — many people who get hepatitis B never have any symptoms and never realize they were infected. As a result, a wife, husband, partner or lover who tested negative for HBsAg, may actually have been infected in the past and cleared the infection and now has protective hepatitis B surface antibodies to forever safeguard them from infection. If they’re immediately vaccinated and retested after the three-dose vaccination, they will test positive for surface antibodies, without ever knowing that their antibodies resulted from a past infection, not immunization.

Bottom line, if one of you have been diagnosed and the other is not infected, it is unusual but not uncommon. Get tested and immediately vaccinated if the uninfected partner tests negative for the hepatitis B surface antibody.

Take a quiz to find out how much you know about hepatitis B transmission: click here.

Facing the Threat of Hepatitis B Following Sexual Coercion or Assault

Image courtesy of tuelekza at FreeDigitalPhotos.net.
Image courtesy of tuelekza at FreeDigitalPhotos.net.

By Christine Kukka

Around the world, the most common way hepatitis B is spread is through sex — and sometimes it’s not consensual.

In the United States, sexual transmission of hepatitis B accounts for nearly two-thirds of acute or new cases in adults. According to a U.S. Centers for Disease Control and Prevention (CDC) report, about one in five women and one in 71 men reported experiencing rape at some point in their lives. And abusers rarely use condoms.

One of the hardest things to talk about is the relationship between how hepatitis B is spread and sexual assault or coercion – defined as anytime a woman, man or child is forced to submit to sex either through rape or assault, or with a partner who refuses to use a condom.

About one in 20 women and men (5.6% and 5.3% respectively) experienced sexual violence, such as sexual coercion or unwanted sexual contact in the 12 months prior to the CDC’s survey; and 13 percent of women and 6 percent of men reported they had experienced sexual coercion at some time in their lives. Among women, most abusers were intimate partners, family members or acquaintances. Among males, most perpetrators were acquaintances.

Research suggests these figures under-estimates the true prevalence of sexual violence around the world, which endangers public health on many levels. There is the mental trauma victims experience and there is the spread of sexually-transmitted infections, such as hepatitis B and HIV.

Hepatitis B is 50- to 100-times more infectious than HIV and can be passed through the exchange of body fluids, such as semen, vaginal fluids and blood. The CDC recommends the following steps to protect against hepatitis B following sexual assault.

When the perpetrator has hepatitis B (is positive for the hepatitis B surface antigen-HBsAg):

  • If the victim has never been vaccinated, he or she should receive the hepatitis B vaccine series and also receive a dose of HBIG (hepatitis B antibodies).
  • If the victim has been vaccinated in the past, he or she should immediately get a hepatitis B vaccine dose (called a booster dose.)

When the perpetrator’s hepatitis B status is not known:

  • If the victim has not been immunized against hepatitis B, he or she should received the hepatitis B vaccine series.
  • If the victim has already been vaccinated against hepatitis B, no treatment is needed.

In South Africa, for example, women’s inability to control their lives sexually is fueling the HIV epidemic. One study that followed 1,500 pregnant women who were in married or stable relationships found an astonishing HIV infection rate of 38 percent. Many reported having been abused physically and sexually in the recent past, which helps explain why AIDS is now the biggest killer of young women in southern Africa.

Image courtesy of Sira Anamwong at FreeDigitalPhotos.net
Image courtesy of Sira Anamwong at FreeDigitalPhotos.net

Sexual assault is not always accompanied by physical violence. A woman may not have the power to require her partner to use a condom without risking physical or verbal abuse, or a person may not tell his or her sexual partner that they have hepatitis B. Coercion can be silent, and fueled by ignorance and low self-esteem.

Here is an email that the Hepatitis B Foundation recently received that illustrates this: “My boyfriend is hepatitis B and C positive, as he was a drug addict. We had unprotected sex often over two to three months. I want to ask, is there any chance of myself being infected?”

Sadly, this woman is at very high risk of infection, especially from hepatitis B. What stopped her from insisting he wear a condom or walking away from a relationship with a man who had little concern for her health and welfare?

Poverty, a lack of choices, resources and education, and a host of other factors stop victims from walking away from their abusers every day around the world.

To protect the health of people around the world, we need to fight in any way we can to stop sexual violence, protect women’s reproductive health, and enable everyone to control their lives.

In southern Africa, researchers have come up with a vaginal ring that contains anti-HIV drugs and discreetly protects a woman from HIV infection, without requiring her to negotiate condom use with an abuser inside or outside her marriage.

But this treats a symptom, not the disease of sexual violence that spreads trauma, fear and diseases such as hepatitis B. However we can, whenever we can, we must work to make a difference.

The Hepatitis B Community Cringes As Vaccine Skeptics Take the Stage in Washington

Image courtesy of Tuomas_Lehtinen at FreeDigitalPhotos.net
Image courtesy of Tuomas_Lehtinen at FreeDigitalPhotos.net

By Christine Kukka

In a profound blow to science, public health and the hepatitis B community, President-elect Donald Trump is reportedly asking Robert F. Kennedy Jr. — who believes that vaccines cause autism — to chair a national commission on vaccines.

Countless studies show vaccines are safe and effective and do not cause autism. The hepatitis B vaccine alone has contributed to an 82 percent drop in this deadly liver disease in the U.S. since 1991. Before universal childhood immunizations became available, one in 20 Americans had been infected with hepatitis B. Sadly, that spectacular success has not quieted vaccine skeptics.

It is heart-breaking to hear that an anti-vaccine activist may gain a public forum to promote his scientifically-unfounded opinions. If the hepatitis B vaccine had been available to my daughter and millions of others around the world at birth, there would be fewer people with chronic hepatitis B, fewer deaths from liver disease and cancer and far less anguish, fear and stigma. Vaccines safely and effectively prevent disease, and all of us who have been touched by hepatitis B can attest to their life-saving value.

Let’s review the indisputable scientific facts about vaccines, and why this controversy has resurfaced.

In 1998, the well-respected medical journal Lancet published a paper by researcher Andrew Wakefield and 12 of his colleagues linking a standard measles, mumps and rubella (MMR) vaccine and its preservative  thimerosal to autism. Despite its tiny sample size (just 12 children) and its speculative conclusions, the study was publicized and bolstered the anti-vaccine movement.

The study proved to be a fraud. Editors of the Lancet later retracted the report, and additional investigations into the study found some of children in the study did even have autism. But the damage was done and hepatitis B vaccine makers and others scrambled to remove thimerasol from their vaccines to counter the undocumented claims that it posed a threat to children. A thimerasol-free, hepatitis B vaccine became available in  late 1999.

Image courtesy of meepoohfoto at FreeDigitalPhotos.net.
Image courtesy of meepoohfoto at FreeDigitalPhotos.net.

But parents in the U.S. increasingly chose not to vaccinate their children, even after the disappearance of thimerasol. They didn’t like all the shots their babies were given, and vaccines became victims of their own success. They were so effective that parents began to believe their children were no longer at risk of these vaccine-preventable diseases and did not need immunization.

Before the measles vaccine became available, there were 500,000 cases of measles annually in the U.S. and 500 deaths. By 2000, due to universal immunization, measles had been eradicated. Then the anti-vaccine movement took hold and more and more parents chose not to vaccinate their children. In 2014, the U.S. experienced 667 cases of measles in 27 states, including an outbreak at Disneyland. This is what happens when parents stop vaccinating their children.

What is so piercing and terrible is that millions of us would be free of hepatitis B if only we had been vaccinated at birth or during childhood.

To arouse suspicion about vaccines that save millions of people every day is unforgivable. My daughter has hepatitis B today because this vaccine was not available when she was born. To plant false seeds of doubt about a life-saving vaccine undermines all we have worked for in our effort to eradicate hepatitis B in the next 30 years.

“A conspiracy theory such as the one about the autism vaccine is like an untreated wound,” wrote Michael Specter recently in The New Yorker. “It has festered for years, and yesterday Trump and Kennedy guaranteed that it can only deepen—causing tremendous destruction and needless pain.”

For factual information about vaccine safety, schedules, and why babies are given so many vaccines, click here.