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Samuel So, MD, FACS: "How Serious is Hepatitis B?"

Samuel So, M.D., FACS, the featured Keynote Speaker at the B Informed Patient Conference (2006), presents "How Serious is Hepatitis B". This presentation provides useful, easy-to-understand answers to common questions surrounding hepatitis B management and treatment.

The annual B Informed Patient Conference,sponsored by the Hepatitis B Foundation and the Hepatitis B Information and Support List, draws attendees from around the world and is the only conference geared specifically toward hepatitis B patients and families.

Dr. So is the Director of the Asian Liver Center and Liver Cancer Program at Stanford University, Stanford California, and is also the leader of the well-known Jade Ribbon Campaign, a national hepatitis B awareness effort. Additionally, Dr. So is a professor in the Department of Surgery at the Stanford University School of Medicine.

1. How serious is HBV?

Now Hepatitis B as most of you know is the most common serious liver infection in the world. There are about 350 to 400 million people worldwide chronically infected compared with 40 million people living with HIV. So eight to ten times more people than HIV. So eight to ten times more people than HIV. And the danger of chronic hepatitis B is without appropriate treatment or monitoring one in four will eventually die from liver cancer, cirrhosis or liver failure. In fact, hepatitis B many people forget, takes anywhere between 700,000 to one million lives a year. And what is so appalling is we have had a vaccine for over twenty-five years to prevent it and in most parts of the world we are still not implementing an effective vaccination program to eliminate this disease. So I mean there is all this talk about an HIV vaccine. If you look at the hep B vaccine as the President, you know you may have a HIV vaccine people twenty years later will probably be bickering as to who should be getting it and people continue to get infected and people continue to die.

2. What is the geographic distribution of chronic HBV?

When you look at the geographic distribution of chronic Hepatitis B, you can see that that the incidence is high in Asia, parts of Africa, the natives in South America and also Alaska and just because of the pure density of the population in Asia, about seventy to seventy-five percent of the people with chronic hepatitis B live in Asia.

3. Is HBV transmitted the same as AIDS?

Now hepatitis B a lot of people often forget is transmitted the same way as HIV. It is not BS, but BBS. Okay. Birth from an infected mother to the newborn which accounts for forty to fifty percent of the cases in Asia, blood-direct contact with infected blood such as unsafe injections, sharing and reusing needles and syringes which is still a problem in a lot of the developing countries, open wound contact as well as unprotected sex. And because of the ability of the virus to exist outside in the external environment for up to seven days and it could exist in such high concentration, it is often referred to as an infection which is up to a hundred times more infectious than HIV.

4. Is HBV transmitted by casual contact?

Now I want to show you this slide because there is a lot of misconception about hepatitis B. So one example, please just remember that it is not just transmitted by sharing food or drinks. So you don’t have to bring your favorite chopsticks to China. Unless you are dripping blood on your plate, it is not transmitted by casual contact like shaking hands, sneezing and also not by kissing unless you bite people every time you really kiss someone. I always want to show you this picture because I asked some of my interns can you find me a picture of two Asian kids kissing? They went back to the dorm and the next day they gave me this picture they took in the dorm. So I always say Stanford students are very resourceful.

5. Why do Asians have high rates of HBV?

Now Asians have very high rates of chronic hepatitis B because many became infected at birth or early childhood. So this is the infection. The earlier you get infected the more likely you lose the battle and become chronically infected. So for a newborn, you know the risk is as high as ninety percent if the mother has the infection and passes it on to the baby during the birthing process. It is not a hereditary disease. It is a disease which is passed to the newborn most of the time at the time of birth. And then the risk is still high in young children and drops to about ten percent in children over the age of six. But this could all be prevented with three shots and it will protect you and you are okay for life. So even if the newborn is born to a mother who has chronic hepatitis B, as long as the newborn gets the first dose of the hep B vaccine at birth (you usually give it into the muscle) then there is protection. It is likely that it will protect the newborn ninety-five percent of the time. Now don’t give the vaccine in the fat, in the buttocks. It doesn’t work. The vaccine only works if you give it intra-muscular.

6. What is the connection between HBV and liver cancer?

Now basically I think when Molli asked me to talk about this and gave me the title “Making the Link” I thought well this is actually the person who should be giving the talk, because it was Dr. Beasley and his team of investigators in Taiwan who really made the connection between hepatitis B and liver cancer. I had the pleasure of actually giving a talk with him recently at Harvard in a Jade forum organized by the Hepatitis B Initiative in Boston. I also had the pleasure of meeting Dr. Tom London who did a lot of work to find an association and genetic factors associated with chronic hepatitis B and liver cancer. So it was Dr. Beasley that at a time, back in the 70’s when a lot of people thought Aflatoxin was the substance which caused liver cancer. Aflatoxin is a substance that could be produced in moldy peanuts so all of the sudden in China, everybody said don’t use peanut oil to cook because of this concern, right? But actually it was him in the study and his colleagues in Taiwan who conducted a study of 22,000 government workers in Taipei and found that the risk of liver cancer is sixty times higher in chronic hep B infected patients, which a lot of people don’t realize. This association is much higher than the association between lung cancer and smoking. And what he calculated is if you have chronic hepatitis B, especially those who acquire it during birth or early childhood, the lifetime risk of dying from liver cancer is forty percent in men and fifteen percent in women. So that is why when we say you have chronic hepatitis B, you have a twenty-five percent chance of dying from hepatitis, you know liver cancer or liver cirrhosis, because if you average it out, it is about twenty-five percent. So actually the risk is even higher in men.

7. Is there evidence that chronic HBV causes liver cancer?

But now there is irrefutable evidence that chronic hepatitis B causes liver cancer. More recently in 1997 the group in Taiwan published the adoption of a universal newborn vaccination program. After fifteen or sixteen years, they already saw a significant drop in the incidence of liver cancer in children under fifteen years of age. And last year HBV, Hepatitis B was officially inducted in the human carcinogen hall of fame. It is listed as one of fifty-eight known agents that cause human cancer.

8. What is the most common cause of liver cancer?

So in fact hepatitis, chronic hepatitis B causes about eighty percent of the liver cancer world- wide and many people don’t realize that it is second only to smoking tobacco in causing the most cancer world-wide. So the WHO (World Health Organization) calls the hepatitis B vaccine the first anti-cancer vaccine.

9. What is the burden of HBV and liver cancer in China?

Now it is not surprising that China has the greatest burden of liver cancer in the world because one-third of the population with chronic hepatitis B lives in China. One in ten Chinese have chronic hepatitis B. China, one country alone, accounts for fifty-five percent of the liver cancer deaths every year from liver cancer. In other words, every year about half-a-million people in China die from chronic hepatitis B and many die at the prime of life. This is not a cancer which often you know, like prostate cancer, affects people when they are very old. It tends to affect people actually between the age of thirty-five to sixty-five years of age. So in other words in China, every sixty seconds hepatitis B takes a life.

10. Where is chronic HBV most prevelant in China?

Just for some of you who might have originated from or whose family came from China, I want to show you this map of the prevalence rate of chronic hepatitis B in China. You can see no single province has an incidence of less than four percent whereas in this country in the U.S., the national prevalence of chronic hepatitis B is 0.2 to 0.3 percent. You can see a lot of the immigrants who come to this country from China are from Guangdong and Fujian where the incidence is over fifteen percent. In fact a recent survey from Guangdong Province shows that the incidence of chronic hepatitis B a few years ago was 17.2 percent. So in other words, if you go to Guangdong, the chances are one in six to one in seven persons you see in the street have chronic hepatitis B.

11. How do the rates of HBV compare to HIV in China?

Now if you look at what you know, turn on your television, read the newspaper, you will think the major health risk facing countries like China is HIV or the Avian flu. So let’s look at the facts. HIV in China - there were approximately 650,000 people living with HIV in China in 2005, representing 0.055 percent of the population. But look at hepatitis B. There are 130 million living with chronic hepatitis B representing ten percent of the population, but yet even China is not doing too much about it. It seems like they don’t have the political stomach to really mount a major effort to deal with this problem and so if you go to China, you will probably see posters about HIV and billboards and recently, because of the Olympics they want to make it a smoke-free Olympics. They have posters about anti-smoking but nowhere if you walk around in China do you see a single poster about hepatitis B.

12. How do the rates of Avian Flu compare to HBV in China?

Now there is a lot of talk about Avian flu. Now Avian flu has killed millions of birds in China but up to last week, this week actually, there have been only twelve reported deaths from Avian flu in China. And what is China planning to do? China is planning to vaccinate every bird against Avian flu. So when I did these talks in China, I said isn’t more important to vaccinate every person against hepatitis B because China only started vaccinating newborns three years ago and if you are not a newborn, it is not free. So with our advocacy this year, China decided to vaccinate up to three years of age. But there are 380 million Chinese children who are eighteen and under. So if you just vaccinate up to three years, it would take forever to eradicate this disease in China which kills half-a-million people every year.

13. What is the greatest health disparity between API and Caucasians?

Now even if you look at this country, chronic hepatitis B and liver cancer is the greatest health disparity between Asian Americans and Caucasian Americans. Although the incidence of chronic hepatitis B in this country is 0.3 percent, the incidence in Asian Americans is as high as ten percent and in the recent article you probably read in the New York Times, they did a survey of several thousand people in New York City, they found an incidence of fifteen percent. Up to 1.4 million people are estimated to have chronic hepatitis B in this country – over sixty percent are Asian Americans. Liver cancer incidence is four to thirteen times higher in Asians compared with white Americans and depending on the ethnic group of the Asians, liver cancer is the second leading cause of cancer death in Asian men living in the U.S. as listed by the recent data released by the CDC and National Cancer Institute.

14. How does chronic hepatitis B affect different ethnicities in the U.S.?

Now basically all this data has been staring at us for many years. If you actually look at data back in the 1980s, there are a number of investigators who have found that the incidence of chronic hepatitis B in the Asian community is as high as ten or even fifteen percent in various cities in the U.S. This is the data coming from CDC where they analyzed the incidence of chronic hepatitis B in all the pregnant women who gave birth in 2002. You can see that if you were white or Hispanic, the incidence of chronic hepatitis B in these pregnant woman was about 0.1 percent. If you were African American, it was 0.5 percent. If you were foreign born, Asian Pacific Islander, it was almost nine percent; U.S. born dropped to about 1.4 percent. So of the 23,000 women who gave birth in the U.S. in 2002 with chronic hepatitis B, seventy percent of them were Asian Pacific Islander Americans.

15. What are the 5 most common causes of cancer in CA?

If you look at the incidence of the five most common cancers in California, this data has been available for a number of years and it hasn’t resurfaced. You will find that liver cancer is not a very common cause of cancer if you are white, Hispanic or black living in California. But it is one of the most common cancers for Asian Americans living in California, number one for Laotian, number two for Vietnamese and Cambodian, number four for Chinese, number five for Korean and Filipino.

16. What is the 5 year cancer survival rate by year of dignosis?

Liver cancer is one of the deadliest cancers. It remains one of the deadliest cancers. This slide shows a five year survival rate for some of the more common cancers in this country, including breast cancer, colon cancer and prostate cancer. You can see in the last twenty years because of efforts in research, advocacy, prevention and screening, you see a significant improvement in survival. Liver cancer remains one of the cancers with the worst survival. And in this slide which also came out from NCI CDC, you can see liver cancer rates in this country have continued to increase. Isn’t it time we do something about this?

17. Why is chronic HBV called a silent killer?

So in the Asian Liver Center, we call chronic hepatitis B a silent killer because many people who have chronic infection have no symptoms. They don’t even know they have been infected. Sometimes routine liver function blood tests when you go for your annual physical are normal. So if your doctor doesn’t order a special blood test, they don’t even know you have chronic hepatitis B. So the patient and the doctors have a false sense of security and if you wait until you have symptoms, it is usually very late from advanced liver cancer or liver failure.

18. Are doctors aware of the risks of HBV?

Now what is discomforting is the doctors we are training now in our medical schools, many of them are not aware of the prevalence of hepatitis B and liver cancer in our community. This is a survey of the incoming house staff to Stanford Medical Center in 2003 and these are people who graduated from some of the best medical schools in the country and we found that only half of them knew Asian Americans had the highest incidence of hepatitis B. Only a quarter of them knew that there is a one-in-four risk of dying from liver cancer or cirrhosis. Only forty percent recognized that mother to child transmission is the most common transmission in Asians and this is a problem – only a quarter of them said they routinely do a screening, a hepatitis B test for Asians. And this is replicated in all the surveys we conducted. We did a survey when we had this program with the San Francisco health department. Of the 1,000 people who came for screening, only seventeen percent of them said that their doctors told them to get a hepatitis B test and many of these doctors are Asian physicians. It is not just Caucasian physicians.

19. Do API need testing before vaccination?

Many doctors don’t know that API, foreign born Asian Americans should be tested for hepatitis B surface antigen before hep B vaccinations. This is a study of Adrian Elkins who was adopted as an infant from India. When he came to this country they just gave him the vaccine and didn’t test him. He died of liver cancer caused by chronic hepatitis B at the age of 20 because they didn’t test him. A lot of you know any child adopted overseas when they come to this country even though they said from the country of origin they were negative, you need to retest them.

20. Why is regular screening for liver cancer important?

Many doctors themselves do not know about the importance of regular screening for liver cancer if they have hepatitis B. This is a sad story about Dr. Mark Lim, an internist in South San Francisco. He was told by his professor doctor that he was a “healthy carrier.” He never was advised about the importance of screening and they told him that oh maybe when you get to the age of 60 you may need to screen for liver cancer. But that is the perspective of a Caucasian chronically infected person who most likely got infected while they were in their 20’s and 30’s. But for Asian Americans who got infected at birth or early childhood, they run the risk of developing cancer much earlier in life. So he actually one day in the park developed acute belly pain. He went back to his own emergency room and found that he had diffused cancer in both lobes of the liver. And even though he wasn’t my patient, he saw one of our bus ads in the city. He came down and talked to me and said well if I had saw you about a few years ago, I might still be alive. And he actually wanted to tell his story to educate his fellow colleagues because he knew none of his colleagues at the same institution in South San Francisco were routinely screening the patients for hep B or routinely screening the hep B carriers for liver cancer. So he told his story which was published in the San Francisco Chronicle and he actually really wanted to continue to help, even when he was dying from liver cancer. Unfortunately, he died just before his 32nd birthday.

21. Can you develop liver cancer without any symptoms?

Many hepatitis B carriers don’t know that you can actually develop a very large liver cancer inside you without any symptoms. This happened to one of my patients who was a 35-year-old Asian American engineer. He knew he had chronic hepatitis B. He saw one of our public service announcements. So he went to his doctor and said, “I want to get an AFP level and ultrasound” and his doctor said, “no, your liver functions are normal. Why do you need to be screened?” His doctor never took an AFP blood test. So when he took the AFP blood test his was over 10,000. The usual AFP blood test is less than 10. So this is what he had inside him, a large 14 centimeter cancer and this was the cancer I took out from him.

22. How does early detection play a role in liver cancer survival?

Once again, you can have huge cancers in a patient in the liver with few symptoms because most patients with liver cancer have no symptoms until the cancer is really huge. And this is a patient, and actually he told his story in that video, the DVD I gave you. And he actually told his brother, his brother is a professor in Taiwan, also a hep B carrier. So he told his brother you better get screened for liver cancer and get an ultrasound. So his brother went to get an ultrasound. At the same time his brother had a 3 centimeter cancer in him. So he actually saved his brother’s life. But unfortunately for him, his cancer recurred after a year, he subsequently got transplanted, he went back to Taiwan but died two years after his transplant from recurring cancer. So the key is early detection because if you find the cancer early, if you have it removed, the chances of it coming back would be very low. But if you find it when it is so large, the risk of recurrence is very high.

23. Do HBV carriers need monitoring?

So what should every hepatitis B carrier need to do for monitoring? What I recommend is you screen for liver damage every six months with a simple ALT or SGPT. You need to screen for liver cancer. If your doctor won’t ask for it, you ask him for it. And if he doesn’t do it, switch, go and see another doctor. You need an AFP blood test every six months, an ultrasound of the liver once a year. And if you have family history, we recommend twice a year screening with ultrasound, for those who have family history of liver cancer and if you have cirrhosis. Because once you have a family history of liver cancer and cirrhosis, your risk of developing cancer is much higher than if you don’t have a positive family history of cirrhosis. If the ultrasound is not satisfactory, (some people when you do an ultrasound it is difficult to interpret because you might have a fatty liver or a very fibrotic liver), the ultrasound will look like a piece of swiss cheese. You don’t know which hole has cancer. Then in those cases you need to do a triphasic CT scan of the abdomen. You cannot just do one test alone because you can miss the cancer. AFP will only pick up about forty to fifty percent of the liver cancers.

24. Can regular screening lead to early detection?

Why is it important to undergo regular screening? Although not every person with chronic hepatitis B infection needs treatment, for those with elevated ALT appropriate anti-viral therapy can reduce the risk of liver cancer and cirrhosis and you are going to hear more about this later on by Dr. Mindy Newman. Regular screening for liver cancer can also lead to early detection just like mammograms that try and detect early breast cancer and hence the successful removal of the cancer and lower the risk of the cancer recurring after removal. At the moment, there is no effective systemic chemotherapy to treat unresectable liver cancer. So the best way to improve your chances of surviving liver cancer is early detection. This is a case of a 53 year old Asian gentleman who came to me for the first time for consultation and I asked him has anybody screened you for liver cancer? I mean this is a very wealthy person. And he said no. His doctors never screened him. So I did a screening. His AFP was negative but he had a very suspicious lesion in the liver and we did a triphasic CT scan which also showed the characteristics of liver cancer. The characteristics of liver cancer on the triphasic CT scan are if the anterior phase of the scan lights up and the venous phase actually gets less dense than the rest of the liver. So we took him to surgery and took out this little piece of liver and he had a 1.2 centimeter liver cancer in him. So if he waited, if no one screened him, he would have been dead. Now he is three years after his liver resection with no evidence of recurrence.

25. What is the California Liver Cancer Prevention Plan?

So this is the reason we helped to develop a liver cancer prevention plan for the first time in California because the incidence of liver cancer in California has increased by almost one- hundred percent in the last fifteen years. In partnership with the American Cancer Society and the Department of Health in California and with a large number of non-profit partners, we actually developed this consensus plan that by 2010 all Asian Americans living in California should be tested for hepatitis B. For those who are not protected, we want to get them vaccinated and we hope by raising awareness and testing we would be able to improve the liver cancer survival by a modest twenty percent.

26. Do you have any advice for HBV carriers?

So my advice to all of you who have chronic hepatitis B is just like the name of this conference “B-Informed.” Right? Learn the principles of HBV treatment and control. It is very simple. I always say hepatitis B is very simple. It is the doctors who make it difficult because those doctors who have made it difficult don’t really understand hepatitis B. I can say that because I am actually an FDA consultant for hepatitis B anti-viral drugs for the last eight years. So most of the drugs which are on the market came through our committee and whether you like it or not, we were responsible for approving them. So you need to find out what you test, what tests you need to monitor regularly, what treatment and when treatment is appropriate. Okay. Get your family tested for hepatitis B and vaccinated if they are not protected. Don’t assume all doctors are knowledgeable about hepatitis B and the risks of liver cancer. And don’t let your doctors scare you. You know people, my patients come to see me and then they say, “Oh my doctor told me I am going to die or I need a transplant.” You know? I look at their numbers and I say what the heck are you talking about? You know you just need to be monitored and if you need treatment, undergo appropriate treatment and go and have fun and enjoy life. So really with a few simple tests twice a year, you can enjoy a normal family life.