October is Liver Cancer Awareness Month! This blog will discuss the importance of liver surveillance if you are living with hepatitis B.
Hepatitis B as a Major Risk Factor for Liver Cancer
Although liver cancer is the sixth most common cancer in the world, it is the second most common cause of cancer deaths. Many people do not realize that chronic hepatitis B is the primary global risk factor for developing liver cancer. Certain viruses, including hepatitis B, can cause hepatitis, which translates to “inflammation of liver.” The virus attacks the liver and weakens its ability to perform important tasks like filtering toxins from your blood and maintaining the level of sugar in your blood. Chronic (long-term) infection with hepatitis B or hepatitis C viruses can lead to liver cancer. Worldwide, hepatitis B is very widespread, making it a priority when it comes to the prevention of liver cancer. Approximately 292 million people around the world are living with hepatitis B.
Why Should I be Screened?
Early detection of liver cancer can save lives! Regular screening for liver cancer and early detection are the most effective ways to improve treatment success and survival rates. Early detection of liver cancer results in more treatment options, which greatly improves the chances of survival after initial diagnosis. For patients in whom liver cancer is detected at an early stage and before symptoms occur – while the tumor is small and can be surgically removed – the 5-year survival rate can sometimes be more than 50%. This is why regular liver cancer screening is so important.
If you have cirrhosis or other known risk factors for liver cancer, make sure your health care provider screens you for liver cancer during your medical visits. Finding the cancer early may increase the chance of successful treatment. Your health care provider may refer you to a hepatologist, a doctor who specializes in liver diseases. Hepatologists have the most experience in managing chronic hepatitis B and C infections, including regular screening for liver cancer.
How Often Should I be Screened?
Liver cancer screening can be done as part of your regular visit to the health care provider who manages your hepatitis B. The American Association for the Study of Liver Diseases (AASLD) recommends that liver cancer screening include ultrasound of the liver every 6 months. If you are living with hepatitis B and are not getting screened every 6 months for liver cancer, you should ask your healthcare provider to start!
Listen and Learn!
The Hepatitis B Foundation’s podcast B Heppy has an episode out: Liver Cancer and Hepatitis B. In this episode, they chat with Dr. Kenneth Rothstein of University of Pennsylvania about the relationship between liver cancer and hepatitis B. He gives insight into herbal medicines, treatment options, liver surveillance, and important questions patients should ask their healthcare provider. Listen for more: https://bheppy.buzzsprout.com
October marks the start of Liver Cancer Awareness Month! This month let’s celebrate your liver for all it does for your body!
Action Alert: Urge ACIP to Recommend Universal Hepatitis B Vaccination for Adults in the US
A universal hepatitis B recommendation for adults is critical in addressing the consistently low adult hepatitis B vaccination rates and eliminating viral hepatitis in the United States. Tell the CDC’s Advisory Committee on Immunization Practices (ACIP) that universal adult hepatitis is essential to preventing liver cancer. Take action here.
What Does Your Liver Do?
The liver is such an important organ – it’s like the engine of your body. It does hundreds of vital things to make sure everything runs smoothly:
Stores vitamins, sugar, and iron to help give your body energy
Controls the production and removal of cholesterol
Clears your blood of waste products, drugs, and other poisonous substances
Makes clotting factors to stop excessive bleeding after cuts or injuries
Produces immune factors and removes bacteria from the bloodstream to combat infection
Releases a substance called “bile” to help digest food and absorb important nutrients
The Link Between Liver Cancer and Hepatitis B
The most common type of liver cancer is “primary liver cancer” or hepatocellular carcinoma (HCC). Worldwide, the most common risk factor for primary liver cancer is chronic infection with the hepatitis B virus. Chronic viral hepatitis infections (hepatitis B and hepatitis C) cause about 80% of all liver cancers. Obesity, heavy alcohol use, fatty liver disease (NAFLD or NASH), and some metabolic disorders also increase the risk for primary liver cancer. People chronically infected with hepatitis B are more likely to develop liver cancer than uninfected people because the virus directly and repeatedly attacks the liver. These attacks over time can lead to increased liver damage, cirrhosis (scarring of the liver), and ultimately, liver cancer. People who have chronic hepatitis B can reduce their risk of liver cancer through regular medical monitoring, taking antiviral treatment if necessary, and making healthy lifestyle changes.
The best way to prevent liver cancer is to prevent hepatitis B infection! This is why hepatitis B vaccination is so important. When someone gets vaccinated to protect them from getting hepatitis B, they are also preventing liver cancer!
How Would I Know if I Have Liver Cancer?
If you have chronic hepatitis B, make sure you are getting routine surveillance for liver cancer every 6 months with your healthcare provider. This surveillance, which includes a combination of blood tests and liver imaging (ultrasound) is so important because early detection of liver cancer greatly improves the chances of survival with treatment. For patients in whom liver cancer is detected at an early stage and before symptoms occur – while the tumor is small and can be removed – the 5-year survival is greatly improved. Learn more about who should be screened for liver cancer here.
Unfortunately, liver cancer is on the rise in the United States. The 2020 Annual Report to the Nation on the Status of Cancer found that the incidence of primary liver cancer in the United States increased by 2.5% overall and by 3.7% amongst women – the largest increase in incidence of any cancer between 2012-2016. Liver cancer was also stated as the second most common cause of death for Asian American and Pacific Islander males, who are disproportionately impacted by HBV, and the fifth most common cause of cancer deaths for men overall.
Making sure that people are protected from getting hepatitis B is so important in the U.S. – and establishing universal vaccination recommendations is essential to reducing liver cancer incidence and mortality.
The Role of Universal Screening Guidelines for Hepatitis B
In the U.S., current childhood immunization recommendations by the Advisory Committee on Immunization Practices (ACIP) were established in the 1990s, and have significantly helped reduce rates of hepatitis B transmission over the past two decades, as more and more children have been vaccinated against hepatitis B. Individuals born prior to these recommendations, however, may be vulnerable to HBV, and span three generations: Baby Boomers, Generation X, and Millennials. Together, these groups account for approximately 63% of the U.S. population. Within this vulnerable population, the recent rise in incidence of hepatitis B cases has increased the most within 30- 49 year olds, attributed to the opioid epidemic. Of the 2.4 million Americans estimated to be living with hepatitis B, approximately 75% remain undiagnosed and may display no symptoms. This increases the risk of transmission to unvaccinated household members or sexual partners who are unaware that precautions should be taken to prevent transmission. Lack of awareness and low vaccination rates in this community leave millions of Baby Boomers, Generation X, and Millenials vulnerable to HBV.
Take Action: Sign the Petition to Support a Recommendation for Hepatitis B Vaccination for All Adults!
The CDC’s Advisory Committee on Immunization Practices (ACIP) is currently reviewing evidence to determine if they should recommend universal adult hepatitis B vaccination. If the committee votes in favor of the proposal, this would mean that all adults in the United States would officially be recommended to receive the hepatitis B vaccine by the federal government.
Listen and Learn – Listen to B Heppy’s newest podcast episode “Liver Cancer and Hepatitis B”! We chat with Dr. Rothstein from the University of Pennsylvania about the relationship between hepatitis B and liver cancer. He offers provider insight and recommendations to individuals listening.
Check Out Liver Cancer Connect – This program was created to provide individuals and families with the information and support they need when facing the challenge of primary liver cancer.
Seek Community Support – Hep B Community a global peer-led, volunteer-driven forum to support those living with and affected by hep B. They are dedicated to connecting people affected by hepatitis B with each other and verified experts in the field, who provide trustworthy and accurate advice.
Learn More From Experts – Dr. Robert Gish talks about treatment options for liver cancer. How does the stage of cancer affect treatment? Why are screening and surveillance so important? What are the available treatments and what are the therapies in development? Find out by listening to the webinar.
June is Men’s Health Month. This month we bring awareness to preventable health problems and encourage early detection and treatment of disease among men and boys. In 2020, The World Health Organization found that liver cancer is the third leading cause of cancer deaths with 830,000 deaths.1 Liver cancer occurs more often in men than in women with it being the 5th most commonly occurring cancer in men and the 9th most commonly occurring cancer in women.2
There are two main types of liver cancers, hepatocellular carcinoma (HCC) which accounts for about 75% of liver cancer cases, and intrahepatic cholangiocarcinoma which accounts for 12-15% of cases. Liver cancer especially impacts Asian countries like Mongolia, Vietnam, Laos, Cambodia, Thailand, and China. Hepatitis B is the leading cause of HCC globally. Of the 300 million individuals living with a chronic hepatitis B diagnosis, about 25% will develop HCC.3
HCC affects men with an incidence 2x-4x higher than women due to differences in behavioral risk factors and biological factors.3 Research has found men were less likely to undergo HCC screening and more likely to smoke. Additionally, studies have shown alcohol is a major risk factor for HCC. In the United States, HCC associated with alcohol is higher among men than in women at 27.8% and 15.4% respectively.3
Biologically, there is evidence estrogen (a female hormone) decreases IL-6 mediated hepatic inflammation and viral production.3 Studies have demonstrated IL-6 may promote virus survival and/or exacerbation of the disease.4 In the context of hepatitis B, men are at an increased risk for HCC as they do not produce estrogen which would help decrease the risk of IL-6, in turn, promoting viral survival.
The great news is that HCC can be prevented by preventing hepatitis B. There is a safe and effective vaccine that can be completed in either 2 or 3 doses over a span of 3 months. Ask your healthcare provider for the hepatitis B vaccine series.
If you are unsure of your hepatitis B status, you can get tested! Ask your healthcare provider for the “Hepatitis B Panel” – it should include 3 parts. The panel is super simple and only requires one sample of blood. If you are of Asian descent and male, it is especially important for you to get tested as liver cancer disproportionately impacts individuals from Asian countries and men.
If you have chronic hepatitis B, make sure your doctor screens you regularly for liver cancer. Typically done with a combination of blood tests and imaging, liver cancer screening can help detect HCC early when it is still curable.
As we wrap up June and Men’s Health Month, you are encouraged to get vaccinated and tested for hepatitis B. Take control of your health, and don’t wait!
Tomorrow, February 4th, marks World Cancer Day! This day harnesses the international community to “raise awareness, improving education and catalysing personal, collective and government action, we’re working together to reimagine a world where millions of preventable cancer deaths are saved and access to life-saving cancer treatment and care is equal for all – no matter who you are or where you live.”
Hepatitis B and Liver Cancer
Cancer is a disease in which normal cells change and grow uncontrollably, that can form a lump called a tumor or mass. A tumor can be benign (not cancerous) or malignant (cancerous). The name of the cancer depends on the part of the body where the cancer first started. The term “primary liver cancer” refers to hepatocellular carcinoma (HCC), the most common type of liver cancer, which starts in liver cells called “hepatocytes.”
In the United States, primary liver cancer has become the fastest growing cancer in terms of incidence (new cases), in both men and women. From 2012-2016, the incidence of liver cancer increased by 2.5%, the largest increase of any cancer during the time period. In 2018, an estimated 42,220 new cases of liver cancer were diagnosed and an estimated 30,200 people died.
Liver cancer mortality also continues to increase, especially among Caucasian, Alaskan Native, American Indian and Hispanic males. Liver cancer disproportionately impacts certain communities more than others: in the U.S., it is now the 5th most common cause of cancer death for men overall, but the 2nd most common cause of cancer death among Asian American and Pacific Islander men, and the 4th most common cause of cancer death among Alaskan Native, American Indian and Hispanic males. The five-year survival rate is about 18%.
Worldwide, the most common risk factor for liver cancer is chronic infection with the hepatitis B virus. Chronic viral hepatitis infections (hepatitis B and hepatitis C) cause at least 80% of all liver cancers. In the United States, the leading cause is chronic hepatitis C virus infections because of the greater number of Americans infected with this virus. Chronic infections with hepatitis B or C are responsible for making liver cancer the most common cancer in many parts of the world. Take a look at other factors which might put you at a higher risk for developing liver cancer.
The hepatitis B vaccine was named the first “anti-cancer” vaccine by the U.S. Food and Drug Administration because it prevents chronic hepatitis B infections, thereby preventing liver cancer caused by the hepatitis B virus. In the United States, the hepatitis B vaccine is recommended for all infants and children, and adults at high risk for infection. In many countries, including the United States, vaccinating newborns with the hepatitis B vaccine at birth has resulted in a dramatic reduction in the number of new cases of liver cancer caused by hepatitis B. For more information about the vaccine, visit here.
The holiday season is here! November and December are full with holidays like Diwali, Canadian Thanksgiving, American Thanksgiving, Hanukkah, Kwanzaa, Christmas, and the New Year just to name a few. This time is often filled with love, happiness, and delicious food. If you or a family member is living with hepatitis B, it is important to eat mindfully during this festive time. Eating healthy is not always a possible option – not with delicious smells filling your kitchen, but you can make healthier choices! Here is a list of action items you can do to help maintain a healthy liver during the holidays:
You can contribute a healthy dish – something filled with lean meats, hearty vegetables, and is low in sodium.
Try your best to avoid alcohol and go for drinks with lower amounts of added sugar.
Coffee has been associated with improvement in liver enzymes!
You can bring your own non-alcoholic beverage like a sparkling flavored drink.
Click on the veggies for some delicious and healthy recipes!
Stay active – take a walk with your family/someone in your COVID social circle or do a free online exercise video.
Most importantly, do not feel guilty. Try your best to make healthy choices and not over-indulge, but do not beat yourself up if you do – your next meal can be healthier!
Remember that everything you consume is filtered through your liver; your liver never gets a break! The lifestyle tips listed above may seem simple, but they can have a large, positive impact on your health. Sticking to a regular healthy routine even during the holiday season will make it easier to continue those habits all year long! You can also check out our healthy liver tips to see what other actions can be taken to protect your liver.
A new page has been created on the Hepatitis B Foundation’s website that contains a compilation of various opportunities available for people living with hepatitis B. These opportunities can be for clinical trials, other types of research, or toolkits with information and resources for those living with hepatitis B and their loved ones and community members. All of these postings are produced or organized by entities external to HBF, but all are related to improved quality of life and liver health. The first two of these opportunities are listed below.
New Tool from CME Outfitters
A new HBV Patient Education Hub has been compiled by continuing medical education company CME Outfitters. The hub includes a great deal of valuable information, such as an overview of hepatitis B, a list of questions to ask your healthcare provider, a patient guide, information about hepatitis B co-infection, doctors’ advice on what to expect from treatment, and many other resources. All information is in an engaging and accessible format. Check it out today!
New Study Opportunity Available for People Living with Itching (Cholestatic Pruritus) Due to Liver Disease or Injury
A new paid opportunity has become available for those experiencing itching caused by hepatitis B, hepatitis C, drug-induced liver injury, auto-immune hepatitis, or primary sclerosing cholangitis (PSC). If you live in Canada or the US and have this condition, you may be eligible to participate in an interview to help researchers better understand your lived experience. The new research study is seeking participants ages 12-80 living in the US and Canada who are living with this itch. This is an opportunity to be involved in research and help advance scientific understanding! Contact the research coordinator for more information and to check if you are eligible.
Please note that this study does not include treatment and pruritus must be at an intensity level of 4 on a scale of 1-10 for at least the past 8 weeks in order to participate. Patients cannot be pregnant or breastfeeding or have a diagnosis of primary biliary cholangitis.
We are very excited to unveil this new section of our website and hope it will be a useful resource for many going forward! Please check back often, as more opportunities will be posted as they arise.
SHEA Updated Guidelines on Health Care Workers Living With Hepatitis B, Hepatitis C, and Human Immunodeficiency Virus
Many health care students and professionals in the U.S. are living with hepatitis B, hepatitis C or HIV. Living with these conditions should not interfere with a person’s health care education or professional career. It is important that health care students and professionals are aware of their rights and responsibilities – and equally important that health care schools and institutions are aware of their responsibilities, as well. There are now new guidelines to help institutions understand how to manage health care professionals living with hepatitis B, hepatitis C or HIV.
Health care workers should have a complete vaccination series for hepatitis B. Learn more about the vaccination series
Health care professionals living with HBV who do not perform exposure-prone procedures should not be prohibited from participating in patient-care activities solely on the basis of their HBV infection
Health care personnel living with HBV should seek optimal medical management, including, when appropriate, treatment with effective antiviral agents
Consistent with CDC guidelines, there is no justification for, nor benefit gained from, notifying patients with regard to health care professionals living with HBV who are being managed through an institution’s oversight panel
Some of the important updated recommendations for health care workers living with hepatitis C includes:
Because of the opioid epidemic in the United States, consideration should always be given to the possibility of substance use disorder when health care professional-to-patient transmission of a bloodborne pathogen is detected
Health care professionals living with HCV should seek optimal medical management, including treatment with effective antiviral agents to achieve cure of the infection
Health care professionals living with HCV who received treatment resulting in ‘undetectable’ circulating HCV-RNA levels can perform exposure-prone procedures with some stipulations:
Has not been previously identified as having transmitted infection to patients following definitive therapy resulting in a sustained virologic response (SVR)
Provides the oversight panel with records and laboratory results (or permits the HCP’s personal physician to provide records and laboratory results) confirming receipt of treatment and SVR
Has achieved SVR by remaining HCV RNA negative for 12 weeks following the completion of therapy
Some of the important updated recommendations for health care workers living with HIV:
Health care professionals living with HIV and who, despite appropriate antiretroviral treatment, have a confirmed viral load >200 copies/mL should not perform exposure-prone procedures until they have achieved virologic suppression
Scientists acknowledge that when the viral load is undetectable = untransmittable
Health care professionals living with HIV whose confirmed viral load is below 200 copies/mL can perform exposure-prone procedures with some stipulations:
Has not been previously identified as having transmitted infection to patients while receiving appropriate suppressive therapy
Obtains advice from an oversight panel about recommended practices to minimize the risk of exposure events
Is followed by a physician who has expertise in the management of HIV infection and who is allowed by the individual to participate in or communicate with the oversight panel about the individual’s clinical status
Is monitored on a periodic basis (eg, every 6 months) to assure that the HIV RNA remains below the level of detection, with results provided to the oversight panel.
Is followed closely by their physician and the oversight panel instances in which fluctuations in HIV viremia occur, including appropriate retesting as discussed above to reevaluate the HCP’s viral load
Agrees, in writing, to follow the recommendations of the oversight panel
Henderson, D., Dembry, L., Sifri, C., Palmore, T., Dellinger, E., Yokoe, D., . . . Babcock, H. (2020). Management of healthcare personnel living with hepatitis B, hepatitis C, or human immunodeficiency virus in US healthcare institutions. Infection Control & Hospital Epidemiology, 1-9. doi:10.1017/ice.2020.458
Author: Evangeline Wang, Program Coordinator, Hepatitis B Foundation
Happy Liver Cancer Awareness Month! Your liver is an important organ for digesting food and breaking down toxins. Its main functions include: filtering blood from the digestive tract and transporting it back to the rest of the body, removing toxins from the blood, and storing important nutrients that keep the body healthy.
Hepatitis B is a viral infection of your liver that can cause serious damage over time. Chronic infection with the hepatitis B virus (HBV) can ultimately lead to scarring, cirrhosis, liver cancer, and liver failure. Liver cancer is the 3rd deadliest cancer worldwide, with 5-year survival rates of only 19%. There are few effective treatments for liver cancer, and we, therefore, must rely on prevention and early detection in order to save lives. Chronic hepatitis B infection causes approximately 78% of hepatocellular carcinoma (HCC), or primary liver cancer. The key to saving lives is ensuring that individuals infected with HBV are diagnosed and linked with appropriate care, including regular screening for liver cancer.
In the U.S., liver cancer incidence and death rates are increasing at a faster rate than any other cancer and are projected to continue to rise through at least 2030. Up to 2.2 million people are chronically infected by HBV in the U.S. and the majority is unaware of their infection. Identifying, managing and treating those with HBV infection can help prevent liver cancer in many people. Additionally, regularly screening people with chronic hepatitis B for liver cancer can aid with early detection and treatment of liver cancer. If diagnosed early, liver cancer can be treated and even cured.
Below are some practices you can easily incorporate into your daily life and routine to keep your liver healthy while living with hepatitis B.
Healthy Liver Tips
Reduce alcohol intake: Alcoholic beverages can damage or destroy liver cells and create additional health problems.
Eat a healthy diet: Increase the amount of whole foods in your diet like fruits and vegetables while decreasing the amount of refined carbohydrates (pastas, white rice, white bread), processed sugar, and saturated fats which can create a healthy environment for your liver.
Daily exercise: It is recommended for adults to exercise at least 60 minutes per day. Not only does this have many other health benefits, but it can reduce the fat surrounding your liver which can decrease your risk of liver cancer.
Avoid the use of illicit drugs: Drugs like marijuana, cocaine, heroin, inhalants, or hallucinogens put stress on your liver and reduce its functioning capability.
Wash produce and read labels on household chemicals: Pesticides and other chemicals can contain toxins which are harmful to your liver.
Incorporating these healthy practices does not have to be difficult. Choose one of the five tips that is most convenient with your current lifestyle and use it as a starting point for a healthier routine. By gradually incorporating each healthy liver tip into your lifestyle, you can reduce your risk of a negative liver outcome creating a healthier you!
Resources for Liver Cancer and Hepatitis B
Please join Hepatitis B Foundation, Hep B United and Hep B United Philadelphia’s webinar on October 20th at 3PM ET to learn more about hepatitis B and liver cancer. Dr. Kenneth Rothestein, Director of Regional Outreach and Regional Hepatology from Penn Medicine will be highlighting the importance of liver cancer screening for prevention. Register here!
The CDC’s Know Hepatitis B Campaign’s infographic, “Get Tested for Hepatitis B” encourages Asian Americans and Pacific Islanders to get tested for hepatitis B. This 2-page downloadable document is available in English, Traditional Chinese, Vietnamese and Korean languages and answers commonly asked questions about hepatitis B.
For more information about the Know Hepatitis B Campaign, visit the campaign website.
Author: Evangeline Wang, Program Coordinator, Hepatitis B Foundation
Hepatitis B is the most common serious liver infection in the world. Your liver is a vital organ which functions as your body’s engine. It processes toxins, stores vitamins, controls production and removal of cholesterol, produces immune factors, and releases bile to assist proper digestion. Hepatitis B may greatly inflame and damage the liver so it cannot perform these important processes efficiently. If left untreated, hepatitis B can cause severe damage such as fibrosis, cirrhosis, and liver cancer and lead to liver failure.
Smoking and Your Liver
Smoking itself may not directly cause liver cancer, though it can dramatically increase the risk for cancer in individuals who have other risk factors, such as a chronic hepatitis B infection (1). Carcinogenic chemicals in cigarettes can cause further damage to liver cells that are already at risk for cancer due to hepatitis infection. Research has found a strong association between chronic hepatitis B and C infections and smoking cigarettes as established risk factors for liver cancer (2). For example, research has found that smoking contains chemicals with cytotoxic potential which increasesnecroinflammation and fibrosis. Additionally, smoking increases the production of proinflammatory cytokines that are involved in liver cell injury (2).
Smoking and Hepatitis B
A 2010 study from the International Prevention Research Institute found anadditive interactionbetween hepatitis B infections and cigarette smoking. Smoking seemed to interact with both hepatitis B and C infections, and the results of the study suggest asynergistic effect between smoking and hepatitis infections on the risk of liver cancer (1). For example, a study conducted in China found that individuals who smoke and live with hepatitis B have a higher risk for liver cancer because the liver’s processes are impaired from the toxic chemicals from long-term cigarette use (3).
There is no “right” way to quit smoking; it can be cold turkey or gradual – it is your personal decision. If you are interested or considering quitting smoking or looking for alternatives to cigarettes, visitthis website for some great tips and recommendations to help you quit.
Chuang, S. C., Lee, Y. C., Hashibe, M., Dai, M., Zheng, T., & Boffetta, P. (2010). Interaction between cigarette smoking and hepatitis B and C virus infection on the risk of liver cancer: a meta-analysis. Cancer epidemiology, biomarkers & prevention : a publication of the American Association for Cancer Research, cosponsored by the American Society of Preventive Oncology, 19(5), 1261–1268.https://doi.org/10.1158/1055-9965.EPI-09-1297
Liu, X., Baecker, A., Wu, M., Zhou, J. Y., Yang, J., Han, R. Q., Wang, P. H., Jin, Z. Y., Liu, A. M., Gu, X., Zhang, X. F., Wang, X. S., Su, M., Hu, X., Sun, Z., Li, G., Mu, L., He, N., Li, L., Zhao, J. K., … Zhang, Z. F. (2018). Interaction between tobacco smoking and hepatitis B virus infection on the risk of liver cancer in a Chinese population. International journal of cancer, 142(8), 1560–1567.https://doi.org/10.1002/ijc.31181
Shrey Patel, University of Pennsylvania School of Dental Medicine
Kelli Sloan, University of Pennsylvania School of Social Policy and Practice
Evangeline Wang, Public Health Program and Outreach Coordinator, Hepatitis B Foundation
To discuss the latest advances in addressing viral hepatitis and other liver diseases in Africa, there will be a virtual Conference on Liver Disease in Africa (COLDA) from September 10th to 12th, 2020. COLDA is organized by Virology Education on behalf of the organizing committee led by Drs. Manal Al-Sayed, Mark Nelson, and Papa Saliou Mbaye. This virtual conference will gather clinicians, patients, other healthcare professionals, and policymakers from African regions, with international experts to support and exchange innovative ideas and knowledge about liver disease. The conference will consist of lectures discussing viral hepatitis infections, hepatitis co-infections, non-viral hepatitis-related infections, non-infectious induced liver disease, hepatocellular carcinoma, and end-stage liver disease. This virtual conference is important for addressing viral hepatitis since fewer than 1 in 10 people in Africa has access to testing and treatment for viral hepatitis. The World Health Organization (WHO) states that viral hepatitis is a bigger threat to Africa than HIV/AIDS, malaria, or tuberculosis with over 1.34 million deaths a year attributed to it.1 Over 60 million people in Africa have hepatitis B which annually accounts for an estimated 68,870 deaths.1 These statistics demonstrate the need for conferences like COLDA to discuss best practices and reduce viral hepatitis in Africa.
Mother-to-Child and Early Childhood Transmission
Hepatitis B is commonly transmitted from mother-to-child and close contact with infected individuals during the first 5 years of life. These modes of infection transmission are preventable with proper birth prophylaxis. There are two types of mother-to-child and early childhood transmission of hepatitis B resulting in chronic infection: vertical and horizontal. Vertical transmission refers to the transmission of hepatitis B from an infected mother to her baby during delivery. Horizontal transmission refers to infection with hepatitis B from direct blood-to-blood contact with an infected individual. Most early childhood transmission cases in sub-Saharan Africa are from horizontal transmission especially during the first 5 years of life from contact with family members or close friends infected with hepatitis B2, though vertical transmission from a hepatitis B infected mother to her baby is also common and completely preventable with birth prophylaxis.
The best way to prevent the transmission of hepatitis B (HBV) from mother to child is through a “birth-dose”, meaning infants are vaccinated against hepatitis B within 24 hours of birth. However, in the WHO Africa region, only 6% of infants are administered the birth-dose.1 Only three countries in Africa: Cameroon, Rwanda, and Mauritania, have national guidelines addressing mother-to-child transmission of hepatitis B.2 Additionally, healthcare providers do not routinely screen future mothers for hepatitis B which contributes to a higher burden.2 This lack of screening demonstrates the need for universal guidelines to provide information to future mothers about hepatitis B. The World Health Organization recently released updated guidelines for hepatitis B which recommends a universal birth dose for all infants, as soon as possible, preferably within 24 hours followed by an additional 2-3 doses (often fulfilled with the pentavalent vaccine). Additionally, the WHO newly recommends that pregnant women testing positive for a hepatitis B infection (HBsAg positive) with an HBV DNA ≥ 5.3 log10 IU/mL (≥ 200,000 IU/mL) receive tenofovir from the 28th week of pregnancy until at least birth, to prevent mother-to-child transmission of HBV.4 This is in addition to the three-dose hepatitis B vaccination in all infants, including the timely birth dose. The WHO also strongly recommends that in settings in which antenatal (pre-birth) HBV DNA testing is not available, HBeAg testing can be used as an alternative to HBV DNA testing to determine eligibility for tenofovir prophylaxis to prevent mother-to-child transmission of HBV.4 Testing for hepatitis B in early pregnancy, a timely birth-dose, pentavalent vaccination, and administration of antivirals in the last trimester if needed would prevent vertical transmission and in turn, prevent horizontal transmission.
There is a high burden of HIV/HBV co-infection in African countries because both diseases share similar transmission routes such as mother-to-child, unsafe medical and injection practices, and unscreened blood transfusions.2 Chronic HIV/HBV infection is reported in up to 36% of people who are HIV positive, with the highest prevalence reported in west Africa and southern Africa. The co-infection of HIV and HBV is especially dangerous because it accelerates liver disease such as fibrosis and cirrhosis. In fact, liver-related mortality is twice as high among people with an HIV/ HBV co-infection.2
Another common way hepatitis B is transmitted in Africa is through nosocomial transmission or transmission from a hospital setting.3 The World Health Organization estimates 24% of blood donations in lower-income countries are not systematically screened for hepatitis B or hepatitis C. Additionally, countries have inconsistent screening procedures and use non-WHO prequalified test kits. Implementation of screening guidelines would significantly assist in reducing the risk of transmitting hepatitis B.
There are numerous barriers to eliminating hepatitis B in African countries. Screening is costly and often inaccessible, especially in rural areas. Moreover, there is an irregular supply of test kits for screening for healthcare providers.2,3 Lack of public awareness and often provider knowledge also contributes to the higher hepatitis B burden. Research has found that less than 1% of Gambian adults previously knew their status when tested positive for HBsAg.3 Additionally, there are financial constraints when it comes to hepatitis B treatment and care. The World Hepatitis Alliance and the WHO found that 41% of the world’s population live in countries where there is no public funding for hepatitis B treatments.3 This financial barrier prevents people from accessing important screening and vaccination prevention services. A collaborative effort among governments, local health officials, and community members is needed to manage hepatitis B in African countries.
Importance of Conference
Hepatitis B disproportionately affects the WHO Africa Region where 6.1% of the adult population is infected.1The Conference on Liver Disease in Africa will address problems and discuss potential solutions for this neglected preventable disease. COLDA will help to make eliminating hepatitis B in Africa a reality by engaging the global community to collaborate on public health efforts, develop innovative ideas, and discuss best practices to reduce barriers. We hope to see you there!
Spearman, C. W., Afihene, M., Ally, R., Apica, B., Awuku, Y., Cunha, L., Dusheiko, G., Gogela, N., Kassianides, C., Kew, M., Lam, P., Lesi, O., Lohouès-Kouacou, M. J., Mbaye, P. S., Musabeyezu, E., Musau, B., Ojo, O., Rwegasha, J., Scholz, B., Shewaye, A. B., … Gastroenterology and Hepatology Association of sub-Saharan Africa (GHASSA) (2017). Hepatitis B in sub-Saharan Africa: strategies to achieve the 2030 elimination targets. The lancet. Gastroenterology & hepatology, 2(12), 900–909. https://doi.org/10.1016/S2468-1253(17)30295-9
Maud Lemoine, Serge Eholié, Karine Lacombe, Reducing the neglected burden of viral hepatitis in Africa: Strategies for a global approach, Journal of Hepatology, Volume 62, Issue 2, 2015, Pages 469-476, ISSN 0168-8278, https://doi.org/10.1016/j.jhep.2014.10.008
Prevention of mother-to-child transmission of hepatitis B virus: guidelines on antiviral prophylaxis in pregnancy. Geneva: World Health Organization; 2020. Licence: CC BY-NC-SA 3.0 IGO.