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A Quick Introduction to Public Health Funding in the United States

Written by Frank Hood- Associate Director of Policy and Partnerships at Hepatitis B Foundation!

 

The COVID-19 pandemic put a spotlight on why countries need a robustly funded public health system that can respond to the needs of its citizens quickly. In the United States, that public health system is a patchwork of federal, state, and local departments, agencies, and programs. Each has their own rules and regulations, which can be challenging to navigate. You might have a hard time seeing how it all works together without falling apart. And you might struggle to understand how resources can find their way to the local health centers and community-based organizations doing much of the important health work on the ground. This blog post provides a basic overview of how public health funding works within the United States. 

Hundreds of federal departments, agencies, and programs funnel money into the public health system of the United States. One of the more familiar organizations is the Department of Health and Human Services (HHS). Among its many health-related functions, HHS handles disease prevention and outbreak response through the Centers for Disease Control and Prevention (CDC) and provides health coverage for underserved and older Americans through the Centers for Medicare and Medicaid Services (CMS). Other departments like the Department of Agriculture (USDA) may not seem like a key source of health funding, and yet support dietary health initiatives and help states build rural medical facilities through infrastructure investment programs.

The amount of funding these departments, agencies, and programs receive varies yearly. Some funding, like for Medicare and Medicaid, doesn’t require an annual vote from Congress (known as “mandatory spending” in policy-speak) and is just paid for as expenses are incurred. Other funding, like for the Health Resources and Services Administration (HRSA), requires a yearly vote of Congress as well as sign-off by the President. This is known as discretionary spending. Most US public health programs fall in the discretionary spending category. That vote happens each year after the House and the Senate go through a formal process to determine how much money every department, agency, and program in the entire federal government receives. This process also includes specifying any special instructions or conditions associated with the funding like restrictions on how the money can be spent or requesting a status report on the impact of a specific program

If Congress can’t agree on funding levels by the start of the new fiscal year, then a government shutdown occurs. In those instances, any non-essential federal program funded by discretionary spending would be forced to suspend operations, while state and local programs would still be able to function but would not receive federal funds during that time.

Once Congress approves funding levels, federal funds and agencies begin the process of distributing money to their various internal programs and to states and other localities. In the simplest terms, many agencies will send money to states in the form of grants that the states apply for by listing how they would use the money and what positive impact it will have on the state. The amount of funding that passes down to states depends on the function of the agency. State health departments receive the largest percentage of their funding from federal sources, so the grant-making process can lead to states competing for limited federal funds. Federal funds make up anywhere between half and two-thirds of states’ total health funding.

Much of the remaining funding for state health departments comes from their state legislatures. Each state has their own specific process, but most states mirror the federal approach of having their legislatures determine how much state funding should be given to various departments, agencies, and programs in the state and any restrictions on the use of that funding. Other sources of public health dollars include fines, fees, charitable donations, and public-private partnerships.

 

 

 

 

 

 

 

 

 

 

 

Generally, state health departments send their dollars to local health departments, which deliver direct care or education on the ground. The funding the state keeps  is often used to pay for state-wide health systems like health surveillance, emergency response, and prevention education. How states determine where money goes varies, but there are usually similarities to how federal departments and agencies determine which states should receive what funding with grant applications.  

Once local health departments and community-based organizations have funding in-hand, they then must spend it according to the rules and regulations set by the source (Congressional instructions, federal agency requirements, state requirements, etc.).  

At this point, you see the complex tapestry of public health funding in action in your community: the health screenings at the local fair, the vaccine drives at your local place of worship, and even when your child brings home a pamphlet from a health educational program held at school. It’s all public health funding in action. 

In addition to public funds, some programs are funded in part directly through donations from people like you. If a public health program means a lot to you, see if you can help the organization who put it together by volunteering, spreading the word or donating. 

 

References:

https://www.cdc.gov/about/organization/mission.htm 

https://www.cms.gov/ 

https://www.usda.gov/our-agency/about-usda/mission-areas 

https://crsreports.congress.gov/product/pdf/R/R47106 

https://www.crfb.org/papers/qa-everything-you-should-know-about-government-shutdowns 

https://www.astho.org/topic/public-health-infrastructure/profile/#activities 

https://www.norc.org/PDFs/PH%20Financing%20Report%20-%20Final.pdf 

https://www.norc.org/PDFs/PH%20Financing%20Report%20-%20Final.pdf 

https://www.publichealthlawcenter.org/resources/state-local-public-health-overview-regulatory-authority 

Team Helpatitis: Students and Teachers Come Together to Raise Awareness of Hepatitis B in India! 

 

Hepatitis B is a critical public health crisis in India.  With over 40 million HBV carriers, it is estimated that over 115,000 people die each year from hepatitis B related causes and one million newborn babies are at risk of developing hepatitis B in India. 1 

In an effort to raise awareness for hepatitis B and contribute to the World Health Organization’s (WHO) viral hepatitis elimination plan, teachers and students at Amity International School in New Delhi, India launched Team Helpatitis to promote hepatitis B education.. Science teachers have integrated hepatitis B education in their extra-curricular activities to teach students about chronic hepatitis and liver health. School events and festivals have provided unique opportunities for students, teachers, and parents to come together and learn about the importance of prevention strategies like hepatitis B screenings in making India hepatitis free!  

Diwali Lamps Bring Hope and Awareness to the hepatitis B Cause in India 

During the month of Diwali, a religious festival of lights, Team Helpatitis students designed liver shaped oil lamps to promote awareness. These lamps are made from clay pots and are lit every year on Diwali to represent the transition from darkness into light in the coming new year. Students and teachers hope to combat the stigma and misconceptions associated with hepatitis B though these lamps. The lamps were distributed to school students and teachers to bring home and share the important message of hope and resilience with their friends and families. 

 

 

 

 

 

The liver shaped lamps were sculpted, packaged, and distributed by the students and teachers to raise awareness of hepatitis B during the Diwali festivities at their school.

Pin-O-Liv: Dart Throwing Competition to Understand the Difference between Good and Bad Liver Habits! 

The Winter Carnival at Amity International provided a platform for students to showcase their learning outside of the classroom and educate attendees about healthy and unhealthy habits for their liver. The students chose an interactive sport to keep the players informed and entertained. They created a dartboard with pictures representing good and bad lifestyle habits and their impact on the liver. Before the game, players were briefed on liver health and ways to keep the liver healthy and safe. Players were given five darts and challenged to hit the images with unhealthy habits.

 

 

 

 

 

 

 

 

 

Students participate in the dart-throwing competition to “kill” the bad habits that destroy our liver

Livbola: Students reinvent tambola to promote hepatitis B education among children and adults 

Tambola is a slightly different version of Bingo and is a beloved pastime of south Asian communities. The students were given a short presentation on hepatitis B and liver cancer. They were then introduced to the rules of the game and were quizzed on questions related to hepatitis and liver health. Prizes were distributed to players to encourage participation. The players included students, school staff, and community members.

 

 

 

 

 

 

School staff, students, and parents play the Livbola game during their annual winter carnival

The Hepatitis B Foundation was recently approached by the teachers at Team Helpatitis for a live session on hepatitis B. The Foundation met with the students and teachers via zoom a few weeks ago and discussed the physical, social, and financial impact of hepatitis B.  We also discussed the importance of preventative strategies like vaccines in promoting positive health outcomes for all communities.  

 

 

 

 

 

The students and teachers of Amity International School met with the Foundation for an introductory session on hepatitis B on zoom.

 

By participating in these activities, projects, and festivities with the help of their school’s leadership and administration, Team Helpatitis has expanded their reach beyond the classroom and amplified the voices of public health workers, advocates, and people living with hepatitis B! Check out Team Helpatitis’ social media channels to stay updated! 

Team Helpatitis’ Instagram:  https://www.instagram.com/helpatitis_aisv1_yppteam/ 

 

References: 

chrome extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.who.int/docs/default-source/searo/india/health-topic-pdf/factsheet-b-hepatitisday2016.pdf?sfvrsn=da61ef0_2#:~:text=In%20India%2C%20the%20prevalence%20of,D%2C%20followed%20by%20Aand%20C. 

Premkumar, M., & Kumar Chawla, Y. (2021). Chronic Hepatitis B: Challenges and Successes in India. Clinical liver disease, 18(3), 111–116. https://doi.org/10.1002/cld.1125 

 

2022 Advocacy Year in Review

As we wrap up 2022, we hope you’ll take some time to look back and celebrate the exciting and important hepatitis B policy and advocacy achievements of the past year! Community partners and grassroots advocates around the world came together to advance our shared advocacy goals and working toward the elimination of hepatitis B.  

  

 

 

 

 

 

 

 

 

 

 

 

This year we celebrated big wins in the U.S. including:  

Congressional Funding for Pennsylvania Center of Public Health Excellence  

With the passage of the Fiscal Year (FY) 2022 Omnibus Appropriations Act in March, the Hepatitis B Foundation received $475,000 to create a Center of Public Health Excellence focused on hepatitis B elimination by providing expert resources, advice, training, capacity building and technical assistance for state and local partners on how to best prevent, treat and control hepatitis B, and to increase the rate of adult vaccination and testing for hepatitis B. The Center of Public Health Excellence was one of nine community projects that Congressman Brian Fitzpatrick secured funding for in the FY 2022 Omnibus. 

 

Implementing Universal Hepatitis B Recommendations   

In April, universal hepatitis B vaccination for adults aged 19-59 became official recommendation. HBF immediately embarked on a dissemination campaign to raise awareness of the new guidelines amongst various stakeholder groups. HBF also launched the Hepatitis B Vaccination and Screening Advisory Council, which is comprised of key stakeholders from the provider and patient advocate communities and hepatitis B experts. The Council held a two-day meeting in June to develop implementation strategies for universal hepatitis B vaccination and screening (expected in 2023) and will publish its findings in a white paper. 

 As our network of grassroots advocates and storytellers continues to grow, we have also expanded our involvement in state/local advocacy and global advocacy. Our ongoing advocacy efforts in the U. S. include calling on Optum to restore the hepatitis B treatment Vemlidy back to their health insurance formulary. Globally we continue to put pressure on Gavi to move forward with implementation of hepatitis B birth dose in member countries, urging members of Congress and President Biden to help end hepatitis B discrimination in the U.S. military, recognizing National African Immigrant and Refugee HIV and Hepatitis Awareness (NAIRHHA) Day in the U.S., advocating for universal adult hepatitis B screening, and increasing funding for hepatitis B and liver cancer. 

 

Updated U.S. Public Health Service Corps Medical Standards  

The U.S. Public Health Service (USPHS) Commissioned Corps announced in December that it is updating its medical standards to accept future applicants living with chronic hepatitis B and HIV. Previously, HIV and hepatitis B infection were both considered disqualifying medical conditions. The Hepatitis B Foundation became aware of this issue in late 2020, when an individual with hepatitis B applied to serve but was denied due to their hepatitis B infection. Working alongside partners, we successfully advocated for a change in this policy by meeting with senior administration official and Congressional champions, and getting language included in the FY 2022 House Labor-HHS Appropriations report urging the USPHS to allow officers with hepatitis B to serve in the Commissioned Corps.  

  

Check out the report to learn more!  

https://www.hepbunited.org/assets/Advocacy/5d40b3bcc9/2022-HBU-Year-in-Review-Final.pdf 

  

From all of us at the Hepatitis B Foundation and Hep B United, THANK YOU for your continued support and dedication to advocating for hepatitis B awareness, prevention, treatment, and research and combatting stigma and discrimination. We are so proud of what the hepatitis B advocacy community achieved this year, and we look forward to continuing to work together to build on the momentum of these accomplishments in 2023! 

What You Need to Know About the 2022 Liver Meeting and How It Relates to Hepatitis Delta

 

 

 

 

This year, the annual Liver Meeting, hosted by the American Association for the Study of Liver Diseases (AASLD), was held in Washington, D.C. The featured presentations included new innovations in liver transplant surgery, disease modeling (which is a process that uses cells to show how a disease develops and to test possible treatment approaches), and drug development. While an effective, functional cure for hepatitis B virus (HBV) is still 5-10 years away, researchers, scientists, healthcare providers, and people with lived experience all came together and agreed that more needs to be done to reduce the burden of liver diseases and improve health outcomes now. One highlight of the meeting was Dr. Francis Collins, former director of the U.S. National Institutes of Health and special advisor to President Biden, hosting a special session to introduce a national hepatitis C elimination plan for the U.S. Unfortunately, this plan is focused on hepatitis C. As a response, the Hepatitis B Foundation will soon send an advocacy letter pushing for the inclusion of hepatitis B and hepatitis delta in this plan. Make sure you are signed up for our Action Center alerts to stay engaged with hepatitis B advocacy efforts.

Of particular note at this year’s meeting were the presence of many patient advocates and people with lived experience, and an increased focus on hepatitis delta. One important hepatitis delta poster presentation was delivered by Dr. Tatyana Kushner of Mount Sinai Hospital in New York City, entitled “HDV Patient Perspective: The Impact of Disease and Current Unmet Needs.” By including the perspectives of people living with hepatitis delta virus (HDV), this study aimed to empower the patient community. Dr. Kushner and her colleagues collected data on people’s quality of life to identify unmet needs, barriers and gaps in HDV care (including disease management and access-to-care inequities).

The researchers found that a person’s care is affected in two ways: In the care they receive for their clinical diagnosis and their emotional journey after diagnosis. The participants’ experience of care was often negatively impacted by having a delayed HDV diagnosis, and limited access to specialized care and tolerable treatment options. Findings describe that the lack of specific and acceptable treatment options for hepatitis delta left people with little hope, which put an emotional burden on their life post-diagnosis. Due to the gaps in providers’ knowledge of HDV, participants held little trust in their healthcare providers. The study participants also shared that they suffered emotionally due to the stigma attached to their diagnosis.

Dr. Kushner and her colleagues call for an increased effort to educate healthcare providers on hepatitis delta, as their lack of HDV-specific knowledge drives health disparities or differences between groups, where one group is more burdened by a disease than the other. These are driven by unequal opportunities to achieve good health (CDC, 2020). Health disparities are preventable, and educating providers is the first step to overcoming these inequalities. Educating providers on HDV will lead to more rapid identification of the disease, as they will have a better understanding of the signs, symptoms and risk factors for hepatitis delta. Increasing advocacy efforts for point-of-care testing for both HBV and HDV in the U.S. will increase levels of testing and earlier identification of people at risk for the diseases. Timely diagnosis allows for people to be linked to specialty care earlier, ultimately improving health outcomes. Improving community awareness of HDV will combat stigma and likely reduce testing hesitancy, which can improve health outcomes. The researchers call for drug developers to meet the needs of the patient community by developing tolerable and hepatitis delta-specific treatments.

In terms of drug development, researchers presented on antiviral treatments for people living with HDV and discussed preferred outcomes of treatment, based on what they believed to be most helpful to each individual’s physical health. To understand these treatment considerations, it is important to review how HDV functions. Hepatitis delta virus (HDV) uses a person’s RNA (ribonucleic acid) to produce and replicate the virus, so high HDV RNA levels in the blood indicate severe infection, and low or undetectable HDV RNA levels indicate that the virus is not rapidly reproducing (Stephenson-Tsoris & Casey, 2022). A virological response is defined as a long-term period of low-level replication that leads to undetectable HDV RNA levels in the blood six months after stopping treatment, and this indicates viral suppression (Yamashiro et al., 2004). A biochemical response is defined as normalization of alanine aminotransferase (ALT) levels after antiviral treatment (Kim et al., 2022). When liver cells are damaged, they release ALT into the bloodstream, so high levels of ALT indicate that one’s liver is diseased or damaged (MedlinePlus, n.d.). ALT normalization is considered a good indicator that antiviral therapy is working because it means that there is less liver damage, liver disease is less severe, and people living with HBV/HDV are at less risk of harm (Kim et al., 2022).

One study of interest from the meeting was the D-LIVR study by Eiger BioPharmaceuticals, Inc.: Lonafarnib Global Study in Chronic Hepatitis Delta. This study consisted of 400 participants, who were all on treatment for 48 weeks, then followed up with researchers 24 weeks after treatment. In total, 50 participants received pegylated interferon (Peg IFN) treatment for 48 weeks; 125 participants received a combination of Lonafarnib, Ritonavir and Peg IFN; and 175 participants received the oral antiviral therapy Lonafarnib and Ritonavir. There were also 50 people on a placebo treatment. A placebo is a harmless pill that has no effect on a person, and is often used in clinical trials to test the effectiveness of a specific treatment being studied, in this case, Peg IFN, Lonafarnib and Ritonavir (Harvard Health Publishing, 2021). The researchers decided that they wanted to see a decline in HDV RNA (virologic response) and normalization of ALT (biochemical response) at week 48 as their study’s main outcome or proof that the treatment could work. In this study, an acceptable virologic response was defined as a “2log decline of HDV RNA levels,” which means they wanted to see HDV RNA levels decrease by 99% from the original levels that were measured before starting treatment (Wikipedia, n.d.).

Pegylated interferon (Peg IFN) is a protein-based medication that prompts the body to activate its natural immune system (induce innate antiviral response) (Zhang & Urban, 2021; Drugbank, n.d.). For Peg IFN-based treatments, researchers determine that undetectable HDV RNA six months after stopping treatment is desirable. However, researchers emphasize the importance of yearly HDV RNA post-treatment screening to monitor for viral relapses after treatment. For long-term treatment (over 48 weeks), a 99% reduction of HDV RNA concentration levels is an appropriate virologic response for non-interferon-based treatments, but more studies must be done to establish whether a person living with hepatitis delta is actually benefiting from the treatment (this is called clinical benefit). When establishing the clinical benefits for non-interferon-based treatments (or any new treatment), researchers can measure delays in disease progression or improvement of signs and symptoms of the disease, which includes symptom relief, improved functioning and improved survival rates (Lee, n.d).

Based on a variety of extensive studies (not just D-LIVR), the researchers decided to combine virologic and biochemical responses to try to demonstrate the clinical benefit of using ongoing antiviral treatment as a functional cure for hepatitis delta. They concluded that acceptable endpoints for HDV treatment studies include undetectable HDV RNA six months after stopping treatment, the loss of the hepatitis B surface antigen (HBsAg), and ALT normalization in people living with chronic hepatitis delta. This can also be considered a functional cure since there are undetectable levels of HBsAg and HDV RNA in the blood for a sustained period of time, even after finishing treatment (Wong et al., 2022).

While there is still time before we overcome the burden of hepatitis delta, the presentations from The Liver Meeting show us that researchers and scientists are constantly working to improve the lives of people living with hepatitis delta. Development toward a functional cure is progressing, and advocates are incorporating peoples’ lived experiences and perspectives into drug development and education. Collaboration between all these groups is the best way to move forward in the fight against hepatitis delta.

For more information on hepatitis delta, you can visit the Hepatitis Delta Connect website or review this hepatitis delta fact sheet.

References

Centers for Disease Control and Prevention. (2020). Health disparities. Centers for Disease Control and Prevention, Division of Adolescent and School Health, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention. https://www.cdc.gov/healthyyouth/disparities/index.htm 

Drugbank. (n.d.). Peginterferon alfa-2a. Drugbank. https://go.drugbank.com/drugs/DB00008

Harvard Health Publishing. (2021, December 13). The power of the placebo effect. Harvard Health Publishing, Harvard Medical School. https://www.health.harvard.edu/mental-health/the-power-of-the-placebo-effect 

Kau, A., Vermehren, J., & Sarrazin, C. (2008). Treatment predictors of a sustained virologic response in hepatitis B and C. Journal of Hepatology, 49(4), 634-651. https://doi.org/10.1016/j.jhep.2008.07.013

Kim, S. H., Cho, E. J., Jang, B. O., Lee, K., Choi, J. K., Choi, G. H., Lee, J. H., Yu, S. J., Kim, Y. J., Lee, Y. B., Yoon, J. H., Kim, J. W., Jeong, S. H., & Jang, E. S. (2022). Comparison of biochemical response during antiviral treatment in patients with chronic hepatitis B infection. Liver International: Official Journal of the International Association for the Study of the Liver, 42(2), 320–329. https://doi.org/10.1111/liv.15086 

Lee, J. (n.d.). Defining Clinical Benefit in Clinical Trials: FDA Perspective [Presentation]. U.S. Food and Drug Administration, Center for Drug Evaluation and Research. https://celiac.org/main/wp-content/uploads/2015/04/great3-07.pdf 

MedlinePlus. (n.d.). ALT blood test. National Library of Medicine (U.S.). [updated August 3, 2022]. https://medlineplus.gov/lab-tests/alt-blood-test/ 

Raman, S. (2022 October 25). Administration eyes national hepatitis C treatment plan. Roll Call: Policy. https://rollcall.com/2022/10/25/administration-eyes-national-hepatitis-c-treatment-plan/ 

Stephenson-Tsoris, S., & Casey, J. L. (2022). Hepatitis delta virus genome RNA synthesis initiates at position 1646 with a nontemplated guanosine. Journal of Virology, 96(4), e0201721. https://doi.org/10.1128/JVI.02017-21 

Wikipedia. (n.d). Log reduction. https://en.wikipedia.org/wiki/Log_reduction

Wong, G. L. H., Gane, E., & Lok, A. S. F. (2022). How to achieve functional cure of HBV: Stopping NUCs, adding interferon or new drug development?. Journal of Hepatology, 76(6), 1249–1262. https://doi.org/10.1016/j.jhep.2021.11.024

Yamashiro, T., Nagayama, K., Enomoto, N., Watanabe, H., Miyagi, T., Nakasone, H., Sakugawa, H., & Watanabe, M. (2004). Quantitation of the level of hepatitis Delta virus RNA in serum, by real-time polymerase chain reaction—and its possible correlation with the clinical stage of liver disease. The Journal of Infectious Diseases, 189(7), 1151–1157. https://doi.org/10.1086/382133

Zhang, Z., & Urban, S. (2021). New insights into HDV persistence: The role of interferon response and implications for upcoming novel therapies. Journal of Hepatology, 74(3), P686-699. https://doi.org/10.1016/j.jhep.2020.11.032

Living with hepatitis B and Diabetes

 

 

 

 

 

 

 

 

 

Happy Diabetes Awareness Month 

November is American Diabetes Awareness Month! The Hepatitis B Foundation invited Dr. Tatyana Kushner, Theresa Worthington, and Marcia Mukanga Lange from Icahn School of Medicine at Mount Sinai to explain more about the relationship between hepatitis B and Diabetes. 

Diabetes and hepatitis B are linked in ways that are important for patients and healthcare professionals to be aware of in order to improve outcomes in patients with chronic hepatitis B. The great news is that through healthy lifestyle changes, patients with chronic hepatitis B and diabetes can take ownership of their health and manage their diabetes.  

Hepatitis B May Increase One’s Risk for Diabetes 

While still controversial, some studies indicate that patients with chronic hepatitis B, and particularly cirrhotic (liver scarring) hepatitis B, are at a greater risk for developing type II diabetes. Type II diabetes is a medical condition in which the body is unable to use glucose (blood sugar) for energy. The liver is a key metabolic organ with a host of necessary functions, one of which is blood sugar regulation. The liver helps keep glucose levels normal in the bloodstream to prevent serious health issues. It is not clearly understood how hepatitis B increases one’s risk for diabetes, but research has shown that damaged liver cells could lead to abnormalities in blood sugar regulation.  Liver damage as a result of hepatitis B can promote the development of diabetes without effective management to prevent further complications. 

It is also important to know that having diabetes can put a person at risk for hepatitis B due to frequent use of glucose monitoring devices. People with diabetes must regularly monitor and track their blood sugar or glucose levels by pricking their finger using a glucose meter/monitoring machine. Failure to clean the equipment properly or sharing the glucose monitor with others can result in the spread of hepatitis B. Therefore, people with diabetes should make sure they are vaccinated against hepatitis B to reduce the risk of transmission.  

Hepatitis B Increases Risk of Gestational Diabetes (being diagnosed with diabetes for the duration of the pregnancy)  

Research has also pointed to an increased risk of developing gestational diabetes in pregnant patients with chronic hepatitis B, likely also due to damaged liver cells. Gestational diabetes is distinct from type I or type II diabetes in that it is diagnosed specifically during pregnancy. The cause of gestational diabetes is unknown but likely related to the hormonal changes that occur during pregnancy. Being overweight or having pre-diabetes are two well known risk factors, aside from chronic hepatitis B, that increase a patient’s risk for developing gestational diabetes. Gestational diabetes is associated with harmful outcomes for the mother and baby, especially if not well controlled during pregnancy. These may include: 

  1. High blood pressure during pregnancy 
  2. Premature birth associated with breathing problems 
  3. Complications during delivery (giving birth to a child weighing nine pounds or more) 
  4. Developing type II diabetes later in life 

Hepatitis B and Diabetes Comorbidity (being diagnosed with multiple conditions at the same time) Increases Risk for Cirrhosis and Liver Cancer  

Chronic hepatitis B patients with diabetes are also at a greater risk for a more rapid progression of liver disease, including progression to cirrhosis, a condition where the liver is scarred and becomes permanently damaged.  

Moreover, chronic hepatitis B and diabetes are known risk factors for hepatocellular carcinoma, a type of liver cancer. When a patient has both hepatitis B and diabetes, the risk of hepatocellular carcinoma is even greater, likely due to liver inflammation as a result of insulin resistance (a condition in which the body cannot break down sugar for energy). However, this risk can be reduced with proper blood sugar control. Interestingly, treating patients who have both diabetes and chronic hepatitis B with metformin, a diabetes medication that improves blood sugar levels, decreased the incidence of liver cancer to a greater degree than treating patients with insulin directly. Thus, both cautious and appropriate management of diabetes in HBV patients is critical.   

Other Metabolic Risk Factors 

Other metabolic-related risk factors for liver disease and liver cancer exist including nonalcoholic fatty liver disease (NAFLD). NAFLD is a liver condition associated with an accumulation of excess fat on the liver that is not caused by alcohol consumption. Common risk factors for NAFLD include type II diabetes and obesity. As vaccination rates and treatments for hepatitis B continue to improve, NAFLD is quickly becoming the leading cause of liver disease, liver cancer, and liver transplantation in the United States. Patients living with both NAFLD and HBV are more likely to have their liver disease rapidly progress. Thus, providers should counsel patients with chronic hepatitis B, with or without diabetes, to manage their weight through healthy eating and physical activity. For those with diabetes, optimizing control of blood sugar levels in order to improve both overall and liver-specific health is also key.  

References  

Cheuk-Fung Yip T, Wai-Sun Wong V, Lik-Yuen Chan H, Tse YK, Pik-Shan Kong A, Long-Yan Lam K, Chung-Yan Lui G, Lai-Hung Wong G. Effects of Diabetes and Glycemic Control on Risk of Hepatocellular Carcinoma After Seroclearance of Hepatitis B Surface Antigen. Clin Gastroenterol Hepatol. 2018 May;16(5):765-773.e2. doi: 10.1016/j.cgh.2017.12.009. Epub 2017 Dec 12. PMID: 29246694.  

Lei S, Chen S, Zhao X, Zhang Y, Cheng K, Zhang X, Wang Z, Sun Y, Wu S, Wang L. Hepatitis B virus infection and diabetes mellitus: the Kailuan prospective cohort study in China. Hepatol Int. 2020 Sep;14(5):743-753. doi: 10.1007/s12072-020-10086-2. Epub 2020 Sep 3. PMID: 32885367.  

Liu Y, Ye S, Xiao X, Zhou T, Yang S, Wang G, Sun C, Zhang B, Wang G. Association of diabetes mellitus with hepatitis B and hepatitis C virus infection: evidence from an epidemiological study. Infect Drug Resist. 2019 Sep 12;12:2875-2883. doi: 10.2147/IDR.S218536. PMID: 31686868; PMCID: PMC6751765.  

Tacke F, Weiskirchen R. Non-alcoholic fatty liver disease (NAFLD)/non-alcoholic steatohepatitis (NASH)-related liver fibrosis: mechanisms, treatment and prevention. Ann Transl Med. 2021 Apr;9(8):729. doi: 10.21037/atm-20-4354. PMID: 33987427; PMCID: PMC8106094.  

Tan Y, Wei S, Zhang W, Yang J, Yang J, Yan L. Type 2 diabetes mellitus increases the risk of hepatocellular carcinoma in subjects with chronic hepatitis B virus infection: a meta-analysis and systematic review. Cancer Manag Res. 2019 Jan 14;11:705-713. doi: 10.2147/CMAR.S188238. PMID: 30679924; PMCID: PMC6338123.  

Xu C, Chen J, Zhang PA. Relationship Between Diabetes Mellitus and Cirrhosis Risk in Chronic Hepatitis B Patients in Wuhan, China. Med Sci Monit. 2019 Oct 29;25:8112-8119. doi: 10.12659/MSM.917000. PMID: 31661471; PMCID: PMC6839395.  

Zhang, J., Shen, Y., Cai, H., Liu, Y.-M., and Qin, G. (2015) Hepatitis B virus infection status and risk of type 2 diabetes mellitus: A meta-analysis. Hepatol Res, 45: 1100– 1109. doi: 10.1111/hepr.12481.  

https://www.cdc.gov/diabetes/basics/gestational.html 

https://www.cdc.gov/hepatitis/populations/diabetes.htm 

 

Why is it important to support the Hepatitis B Foundation?

This is a guest blog by Jean Holmes, Vice President of Institutional Advancement at the Hepatitis B Foundation and Baruch S. Blumberg Institute.  

Jean Holmes VP of Institutional Advancement

Why is it important to support the Hepatitis B Foundation? 

Gosh, where should I start? First off, support this cause if you care about people living with hepatitis B. Because honestly, many people don’t. Most people don’t know much about hepatitis B, and people don’t support things they don’t know much about or care about. So, if you are one of the few that do, please consider it, because there aren’t enough of us. We NEED you. 

Second, if you do care about people living with hepatitis B, the Hepatitis B Foundation should be on your giving radar. Your support would mean so much, because we have so much to do together.  

If you’ve made it this far on our website, you probably already know that 300 million people in the world have hepatitis B. Every 40 seconds, someone dies of liver cancer as a result of hepatitis B. Maybe you know someone who has hepatitis B, died of liver cancer, or maybe you have hepatitis B yourself. YOU. MATTER.  

This website is full of information about what the team is doing across the globe to eliminate hepatitis B. They’ve accomplished so much this past year that will help us gain more momentum in 2023 and beyond. We have to leverage those gains! 

This team is a group of WARRIORS. They are so smart and so dedicated, it blows my mind.  

But they need you. 

Thanks again just for being here to care enough to read this post. You obviously care enough to make a difference, so let’s start there.  

We can’t do this alone. It takes a lot of people to raise their voices in order to bring about change. When you give to the Hepatitis B Foundation, you’re telling the world, telling elected officials, telling the people with power, that hepatitis B has a VOICE.  

Your voice.  

What can you do? 

Give. Even if it’s just $5, it helps. Give just once, or become a member of the Champions Club and give $5 a month. That helps the team keep the work going, and ensures that there’s always resources to help people living with hepatitis B. 

Share. Did you know that most people are more likely to support causes that are recommended by family, friends or coworkers? Use your voice! 

Engage. I’ll be holding a volunteer panel in early spring to talk with supporters about how we can generate more support and momentum. I need you. Email me at jean.holmes@hepb.org, or call 215-489-4946 if you want to be a part of it. There will be something for everyone to do. 

Listen, there is so much to do. This is going to be a big year, but we need your help. Put your running shoes on, we’ve got to get going! 

If You Have Hepatitis B, Donating Your Blood May Change the Face of Hepatitis B Testing.

The Hepatitis B Foundation has partnered with Plasma Services Group to educate people living with Hepatitis B about the critical need for blood donation. This is not like the local blood drives you always hear about. Instead, Plasma Services Group focuses on specialty plasma collection which supports the making of diagnostic tests used in labs around the world. The demand for HBV testing grows every year, but access to those tests is not assured. As you know, only 25% of people in the U.S. and 10% of people worldwide with Hepatitis B have been diagnosed. With your help, we can reduce those real-life barriers to Hepatitis B testing and improve lives. Follow the link.

How do I donate?

Donating your blood to Plasma Services Group is easy. After you complete this form, they will reach out to you if you are a good candidate for blood donation. If chosen, they will send a phlebotomist to your home to complete the blood-draw.  PSG compensates participants financially as a thank you for the trust, time and efforts associated with donation. This program is only available to U.S. residents who are preferably in the Northeast. You must be 18 years of age or older and weight 110 pounds or more. You must be living with chronic Hepatitis B, which means you have had Hepatitis B for over 6 months.

Why this is important to the future of Hepatitis B?

As you may know, access to good healthcare isn’t always easy. By creating new blood tests, we can help diagnose Hepatitis B more reliably which helps more people get into care and manage their hepatitis B. Your blood donation could directly impact the detection, care and quality of life for millions of people living with hepatitis B who have not been diagnosed yet, as well as those who are managing their care on a daily basis.

Despite the large population of people living with hepatitis B, it is hard for companies that source biological raw materials to recruit donors. Most people are unaware of the large amount of blood plasmas that are essential to manufacture test kits. Rarer subtypes that are prevalent in Africa and Asia, where the need for detection is the highest and growing the fastest, are even harder to find in N. America. By becoming a regular donor to Plasma Services Group, you are filling a vital role for the medical diagnostic industry and helping to close the gap between patient and care.

Get started today!

Fill out this form and Plasma Services Group will fill you in on next steps.

Liver Cancer Screening Q&A with Dr. Amit Singal

Did you know that chronic infection with hepatitis B is the leading cause of liver cancer? 

For this month’s blog we talk to an expert in liver cancer, Dr. Amit Singal. Dr. Singal is a medical researcher and professor at the UT Southwestern Medical Center with extensive experience in digestive and liver diseases. Join us as we interview Dr. Singal about the importance of liver cancer screening as a preventive tool to improve health for people who may be at risk for hepatitis B or liver cancer.  

Question: What puts someone at risk for liver cancer or hepatocellular carcinoma (HCC)? 

There are several risk factors for liver cancer including obesity, being male, and older age; however, the biggest risk factor is the presence of advanced chronic liver disease (having cirrhosis for example). Most people who develop hepatocellular carcinoma (the most common type of liver cancer) do so after having cirrhosis (scarring of the liver). However, it is important to know that there is a small number of people with hepatitis B (about 10%) that can develop liver cancer or hepatocellular carcinoma without having cirrhosis.  

Question: Should a person with hepatitis B get screened for liver cancer? 

Chronic hepatitis B is a risk factor for HCC; but we do know that some patients are at higher risk than others for liver cancer. Most screening recommendations are based on demographics (like age and sex) and clinical characteristics (like how a person got hepatitis B and presence of other risk factors). We now have started to move to using a clinical risk calculator that incorporates these factors, such as the PAGE-B score (which is based on platelet count, age, and gender). A platelet count refers to the number of platelets or cells that help your blood clot. It is used in blood tests to detect any problems with your blood flow or diagnose any serious illnesses like cancer. You can learn more about the clinical risk calculators for liver cancer here.  

Question: Can liver cancer be detected at an early stage? 

Yes, liver cancer can be found at an early stage if patients undergo regular liver cancer screening. Liver cancer screening should be performed using abdominal ultrasound and a blood test, alpha fetoprotein (AFP), every 6 months. AFP is a protein found in the liver. Very high levels of AFP may indicate cancer. These tools are available, non-invasive (does not require the use of any tools to cut through the skin or enter the body) and can detect most liver cancers at an early stage. This is very important since we have cures available if liver cancer is found at an early stage, with average survival over 10 years in the United States for example. Unfortunately, patients where liver cancer is found at later stages do not typically have curative therapies available and have an average survival of only 2-3 years. Therefore, regular liver cancer screening, especially with hepatitis B, is so important.  

Question: Does an individual need to display symptoms before getting screened for liver cancer?  

We do not want to wait until patients have symptoms. Liver cancer can be silent and asymptomatic (without symptoms) for several months and is almost always silent at an early stage. Once people do have symptoms, patients typically have large tumors, and it is too late for curative liver cancer treatments.    

Question: What is the process of liver cancer screening like? What tests are used to screen for liver cancer? 

Screening should be performed using abdominal ultrasound and a blood test, alpha fetoprotein, every 6 months. These tools are available, non-invasive, and can detect most liver cancers at an early stage. If either test is positive or abnormal, then patients typically undergo confirmatory diagnostic testing with multi-phasic computerized tomography (CT) scan (a combination of x-ray scans that looks at changes insides your body) or contrast-enhanced MRI (a machine that produces pictures of organs in the body). 

Question: Are there any risks involved in liver cancer screening?  

Abdominal ultrasound and AFP are safe and non-invasive, so the risks of liver cancer screening are relatively low. However, there is a risk of false positive results, which means that someone tests positive when they are not positive for liver cancer. This can result in additional diagnostic testing and patient anxiety. Current research shows that these risks are uncommon, and the benefits of HCC screening far outweigh the associated risks.    

 

Our thanks to Dr. Singal for providing this life-saving information. Liver cancer may be silent, but people living with hepatitis B must be loud when telling their doctors that they need to be screened! 

If you have recently been diagnosed with hepatitis B or want to learn more about liver health, check out the Hepatitis B Foundation’s Information Guide here.  

“Photo from UT Southwestern.”

If it’s not broken, don’t fix it! A hepatitis B vignette.

The Scenario

Yufei Zhao is 45 years old and lives with his family in Philadelphia,   Pa. Yufei discovered that he had hepatitis B when he attended a community health fair with his family. Even though he was instructed to talk about his diagnosis with a doctor and learn more about possible treatment options, Yufei decided to do nothing as he did not feel sick. While he has health insurance through his employer, he never utilizes any health care services. He often skips annual wellness visits as he says he “never gets sick.”  

A few weeks ago, Yufei’s family noticed that he has been skipping meals frequently saying he’s full or not hungry. At his daughter’s urging, he decided to go for a visit. After conducting some more tests, his doctor explained that the chronic infection with the hepatitis B virus had progressed substantially, and he had developed cirrhosis. After an MRI diagnosis, it was revealed that Yufei had liver cancer.

The Hepatologist (liver doctor) explained to Yufei that the liver is an important organ and acts as a cleaning system for the body. It removes toxic waste, purifies blood, and helps to digest food properly. When the virus entered the liver, it made many copies of itself and started attacking healthy liver cells. This led to inflammation and weakened the ability of the liver to carry out its most essential tasks. Because he was never monitored for hepatitis B, the virus allowed tumors to grow in the liver which caused the cancer. When the tumors grow in size or number, it eventually spreads to other parts of the body and disrupts other vital processes as well. 

The doctor mentioned that liver cancer is often called the silent disease because symptoms may not always be present. Even with a hepatitis B, a person could look or feel okay but that does not mean the virus isn’t active and causing damage. When the symptoms do show up, it might be too late to prevent liver cancer. After discussing his options with the doctor, Yufei learned that the best treatment for him was to get a liver transplant.  

He weighed the pros and cons of getting a transplant and consulted with his family. Now, Yufei is placed on a waiting list for a liver transplant to become available. In the meantime, his doctor has suggested other methods to destroy the smaller tumors without surgery through radiation (ablation). Yufei continues to spend more time with his family as he hopes to respond well to treatment until a new or partial liver is available.  

The Challenge

Cultural Perceptions on Health & Well-being 

  • Yufei is an older male in the household and the backbone of the family. For this reason, he considers it an obligation to prioritize his family over his personal health. It is important to understand these cultural and social beliefs prevalent in many different cultures and households. 
  • Family members should be advised to encourage their loved ones (especially older family members) to take charge of their health. It is important to check-in with your loved ones and assure them that sickness does not necessarily mean weakness. Taking care of one’s health can mean taking charge of one’s future.  

Hep B and Liver Cancer

  • Hepatitis B is a virus that causes inflammation of the liver. Without proper diagnosis and treatment, the virus can continue to multiply and damage healthy liver cells. This can lead to inflammation and scarring of the liver. This prevents the liver from doing its most important functions to maintain overall health which may result in the development of harmful tumors.  

Liver Cancer is a Silent Disease 

  • Many people with hepatitis B or liver cancer do not show symptoms of sickness but that does not mean the virus isn’t present or not actively working to harm the liver. Eventually, the physical symptoms will become noticeable as the virus/cancer advances to a more dangerous stage. 
What can you do?

Get tested! 

  • The most important thing you can do to prevent liver cancer is to get tested for hepatitis B. Most liver cancers develop from undiagnosed hepatitis B infections. There are a lot of people who have hepatitis B and do not know about it because they have never been tested. Even if you feel healthy and okay, it does not hurt to get tested!
  • If you don’t have hepatitis B, the test can tell you if you are vaccinated or if you need vaccination (which can provide lifelong protection from ever getting hepatitis B and help prevent liver cancer). 

Get screened! 

  • If you have hepatitis B, it is critical to manage the progression of the virus in your liver. For this reason, it is important to go through monitoring of your hepatitis B infection, liver health, and screen regularly for liver cancer.
  • Discuss with your doctor if you are at high-risk and how often you should get screened. It is recommended to get an ultrasound every 6 months to check how the virus is impacting the liver. AFP testing may also be done with regular monitoring of the liver to check for the possibility of liver cancer. 

Get educated! 

  • Stay up to date with the latest research and information on liver cancer! If you have hepatitis B, you should know that there is no cure for the virus but there is a lot of research that shows what you can do to ensure you live a healthy and long life.
  • Take an active role in learning about the disease and how it can affect your health over time. Learn about fibrosis, cirrhosis, liver cancer staging, and available treatments for hep B infection.  

References
  1. https://www.hepb.org/research-and-programs/liver/screening-for-liver-cancer/ 
  2. https://www.cancer.org/cancer/liver-cancer/treating/by-stage.html#:~:text=Treatment%20options%20might%20include%20ablation,%2C%20and%2For%20radiation%20therapy. 
  3. https://www.cancer.org/cancer/liver-cancer/detection-diagnosis-staging/staging.html 
  4. https://www.hepb.org/research-and-programs/liver/risk-factors-for-liver-cancer/