Hep B Blog

Tag Archives: Adults

Diagnosed With Chronic Hepatitis B? What Stage – HBeAg-Positive Chronic Infection / Immune Tolerant?

Do you know the stage or phase of your chronic hepatitis B infection? Quite often people may refer to themselves as “hepatitis B carriers”. This statement by itself does not really say anything about your chronic hepatitis B infection except that you are someone who tests positive for hepatitis B, and that you are HBsAg positive.  The names of the stages or phases of HBV have changed a bit over the years, but they reflect the natural history of the virus. It is important for your doctor to determine if you are in the immune tolerant, immune active or clearance phase, the inactive carrier phase, have developed HBe negative chronic hepatitis B, or if you are in an HBsAg negative phase. It may take a few months or even half a year to accurately determine the phase, and then your doctor can talk to you about possible treatment options and whether or not treatment would benefit you at this time.  Remember, hepatitis B is typically not an emergency, so try to relax with the process knowing you may not have immediate answers.

If you are acutely infected, you also follow the natural course of the virus in a matter of months (clearance of an acute HBV infection within 6 months is considered an acute hepatitis B  infection). However, at the end of 6 months, those acutely infected will have a resolved infection, and will no longer be HBsAg+. If you are chronically infected, you will pass through many of these phases too, but unfortunately you will likely never get to an HBsAg negative or resolved phase.  The journey from phase to phase is different for each person and the time it takes to move through these phases varies along with the amount of liver damage that occurs. The importance of a good liver specialist or knowledgeable doctor  cannot be over emphasized. These stages and phases may seem simple to understand, but not everything is black and white, and the gray between phases, time between phases, lab and other diagnostic data collected, varies with each patient. The importance of being actively involved in your hepatitis B care can also not be overstated. Tracking your lab data over time and putting it into an excel spreadsheet or graphing the data may help you understand what is happening with the virus and may even be helpful for your doctor, so don’t forget to request copies of all lab results. You are more in control than you think. Get involved with your care!

Once you have confirmed that you have chronic hep B, you need further testing to determine your HBeAg status. Those with chronic hepatitis B  are either HBeAg positive or negative. If you are HBeAg positive, you have a higher hepatitis B viral load/HBV DNA and are more infectious to others. People who are HBeAg positive are either in the immune tolerant stage or the immune clearance stage. Additional labs will clarify this for your doctor.

If you are in the immune tolerant stage, you are HBeAg positive and have a high viral load. You will have normal or very mildly elevated ALT (SGPT) levels and mild or no inflammation or damage to the liver. This is very common with chronically infected young children who may have viral loads in the millions or even billions. During this time the virus is actively replicating in the liver, but the immune system has not recognized the virus so it is not trying to kill the infected liver cells. It is not the replication of the virus that kills liver cells, causing liver damage, but it is the response of your immune system killing these infected liver cells.  So, during the immune tolerant phase the virus is happily replicating, completely unchecked by the immune system, which accounts for the high viral load and lack of liver damage during this time. People in the immune tolerant phase may remain in this phase for a couple of years, or it may be decades.  Treatment is not typically recommended during this phase.  Certainly for those that have been in this phase for decades, treatment is something that may be recommended by your liver specialist.

What happens when you move into the HBeAg-positive chronic hepatitis /Immune Reactive / Immune clearance  phase? Read more. 

China Approves Hepatitis E Vaccine – What that means if you have HBV

It was an interesting couple of weeks for viral hepatitis vaccines.  A potential vaccine for Hepatitis C appears to be on the horizon, and China announced it has approved a vaccine for use for hepatitis E virus (HEV).

What does this mean if you have hepatitis B?  I’m not sure. If you are living with HBV, it is clear that it is best to avoid coinfection with another hepatitis virus or infectious agent.  Coinfection will likely hasten liver disease progression and increase the risk for liver cancer.  At this time, the hepatitis A vaccine is recommended for those who are infected with HBV in order to avoid additional stress to the liver. Please keep in mind that the mode of transmission is the same for HBV and HCV, but is different for HAV and HEV.  It’s important to keep your viral hepatitis ABC’s straight!

Hepatitis E is a self-limiting disease, which is shed in the feces and transmitted via contaminated water and food – very much like HAV.  Although HEV is an acute infection like hepatitis A (HAV), it has about a 3% overall mortality rate and a much higher rate among pregnant women, and solid organ transplant recipients. It predominantly affects those between the ages of 15 and 40 years. HEV is endemic in Central and South-East Asia,  North and West Africa, Mexico and developing nations where there may not be access to clean water and proper sanitation and hygiene.  At this time, it is not prevalent in the U.S., but we are a traveling nation, and it’s something to think about when traveling abroad.

The HEV vaccine, developed by Xiamen University and Xiamen Innovax Biotech Co. Ltd. is a three-shot series : shot one followed one month later by shot 2, followed by shot 3 six-months after the third shot. The phase III trial results were found to be well tolerated and safe for the general adult population.  This would make the HEV vaccine a good choice for travelers in endemic areas who can receive adequate protection with a 2-shot series in one month.

However, these results for the phase III study were for the general population only and did not include children, adults over 65 years, pregnant women and those living with chronic liver diseases such as HBV or HCV.  If you are infected with HBV, it would make sense to be vaccinated against a virus that can cause additional harm to the liver, but at this time, additional research needs to be done ensuring the vaccine will benefit those living with hepatitis B or C.

Sheree Martin Retires from the Hepatitis B Information and Support List

After 13 Years, our Mammablondie has retired as a listowner of the Hepatitis B Information and Support List.  Sheree Martin has been List Mom to thousands of hepBers who have come to us from all over the world.  Like a true mother, she was quick to give hugs, the cyber kind, just when we needed them most.  And when we squabbled, she was there to call “time out”.

As for the “information” component of our list, Sheree has contributed more than anyone else.  She has spent countless hours scanning the Internet daily for HBV research and news.  The result of her efforts is our Hepatitis B Research List. For those wishing for information only, you can select send a blank email to HBV_Research-on@mail-list.com

For a number of years the PKIDS organization hired her to do the same thing for them, provide them with daily bulletins about kids’ infectious diseases. Sheree donated the money she earned to our listserv in order to cover miscellaneous  expenses.

In the beginning days of the List, John Kirk and I recognized immediately what a gem Sheree was, and we invited her to join us as a third listowner. She was smart, she was a nurse, she had IT skills, she was a good writer, and she knew how to referee when the two male egos would wrestle.

Sheree lives in the same small town where she grew up, on the edge of the Appalachian Mountains.  She’s proud of what she calls her hillbilly roots.

We all got to know and love Sheree’s mother, Yvonne, when she accompanied Sheree to the Hepatitis B Foundation’s patient conferences.  Not only did Yvonne have HBV, but in 1999, Sheree’s only sibling, Mike, died of liver cancer associated with HBV.  Fighting HBV was a very personal battle for Sheree.

We’ll need two people to fill Sheree’s shoes on the List.  Yvonne Drazic (Australia) will be our new listowner, and Christine Kukka (Maine) will take over the Research List.

At home in that picturesque country village, Sheree will have more time to do what she loves most–  being a mother to her 3 sons, 2 grandsons, 2 dachshunds, and 1 beagle.

We won’t lose our List Mom completely.  “I’ll still be around,” Sheree promises.  I’ll be lurking in the wings.”

A big hug to Sheree,

Steve Bingham, Retired List Dad

If you or someone you know is living with hepatitis B, we encourage you to join this HBV online forum filled with information, support and compassion!

Living with HBV and Dealing with “Itchy” Skin

The previous Hepbtalk blog discussed skin manifestations associated with hepatitis B and liver disease. This is a follow-up with some suggestions on dealing with rashes and pruritus (itchy) skin. Unfortunately, I have experience with this.

Most people living with HBV have episodes with rashes that itch, or with an itch without the rash. Rashes can be caused by all kinds of things, but the skin truly does let us know when there is something going on with our body. We may not be able to eliminate the itch, but we can work on providing the body with a little relief, and to be sure we do not do anything to make the persistent itching worse.

First, consider the root of the problem. It is possible that your rash and itching are unrelated to the current status of your HBV infection.  Unless you have serious liver disease, this might be difficult to pin down since many living with chronic HBV have compensated livers that perform all of the necessary liver functions required for life.  That does not mean you aren’t going crazy with itchy skin, but it is important to look at other factors that may be contributing to your pruritus.

  • Are you currently being treated with IFN or PEG for your HBV?
  • Have you recently started a new medication?
  • Do you have allergies, seasonal, food or otherwise?
  • Do you have other symptoms that might relate to another virus or infection?
  • Have you recently switched laundry detergents or rinses?
  • Have you recently switched any of your personal care items – shampoo, soap, creams, deodorant, etc.

Try to determine if there is a pattern associated with your skin problems.  Any of the above can cause rashes or pruritus without the added complication of HBV or advanced liver disease from HBV. I was convinced that HBV was the root of all skin problems, but I was wrong. That’s why it’s good to look at other possible sources so you can at least eliminate the things you have control over.

Here are some simple things you can do to help reduce the degree of pruritus:

  • Choose products that are unscented including laundry detergent and dryer sheets, along with shampoos, conditioners, creams and other personal care items. Unscented products are better for you liver, anyway. Everyone in my house is clean, but there is no fresh, clean smell.
  • Avoid soaps and use gentle skin cleansers like Cetaphil (another favorite in our house).
  • Use moisturizers that contain a minimum of alcohol, since alcohol is drying.  There is sometimes a balance with thick vs. thinner creams. We bounce back and forth between Cetphil and Eucerin, but you might have to test a few of them before you find the one that works best for you.
  • Take tepid rather than hot showers and baths, but be sure to bathe daily.
  • Wean your kids out of the tub ASAP.  This broke my heart, but the extra time in the bath is drying.  (However, oatmeal baths are recommended, even though this didn’t work for us). Don’t spend too long in the shower.  Learn to take a 5 minute shower.
  • When you come out of the shower, do not completely dry yourself, and immediately apply gentle cream or lotion from head to toe to lock in the moisture.
  • Use topical steroids in order to combat affected skin patches.  For kids we found the ointment, though a little messier, was more effective. Take care when topicals are used for extended periods of time.  It thins the skin, which can be especially problematic in the summer. Don’t forget sunscreen, too!
  • Keep nails cut short to avoid the temptation.  We even tried gloves and socks at night.  Try to avoid scratching with sharp objects, but be sure to properly sanitize them if they are used inappropriately. We often had concerns with “weepy” skin and needed to keep it covered in public.
  • If you choose to add humidity during the winter months be careful to balance that with possible dust mite allergies.  We initially used warm mist humidifiers and that was a big mistake, even though it feels great.  Unfortunately it took us a while to make that link.  As it turns out, a more moderate temperature is better – that and additional circulation with a ceiling fan.
  • Stay hydrated by drinking plenty of water
  • After swimming in a chlorinated pool, be sure to rinse immediately and apply moisturizer.
  • Pruritus is worse at night, so take an anti-histamine like Benedryl or prescription Atarax to help with the itching.  Atarax is effective for a longer period of time, so it’s a favorite in our house.

Although the “itching” in our house brought many tearful nights, and nasty looking skin patches that persisted for years, it did get better over time, with changes. It is important to note that is was much worse during treatment with interferon. Pruritus truly is a horrible, sometimes unrelenting symptom for those with more advanced liver disease.  Although the above ideas are worth investigating, it is important that you discuss severe pruritus with your doctor.  There are more potent prescriptions available that might help reduce the relentless itching.

Got any tips for reducing the itch? Feel free to comment and share your ideas with others living with HBV.

Got HBV? What is Your Skin Trying to Tell You?

The liver is the largest solid organ in the body, and your skin is the largest organ.  It only makes sense that the skin may be a window into what is going on inside your body and your liver.  The problem is trying to figure out what your skin is trying to tell you!

The most common skin manifestation associated with “hepatitis” is the yellowing of the skin (jaundice) and the sclera, or white part of the eye.  Jaundice  may be associated with a newly acquired or acute hepatitis B infection.  It certainly gets your attention and gets you to the door of your doctor, which is a good thing.  However, keep in mind that HBV is often asymptomatic, with few or no obvious symptoms, and jaundice is a more severe symptom of an acute HBV infection. Jaundice may also occur in those with advanced liver disease, and a decompensated liver. Jaundice is due to an accumulation of bilirubin, a yellow pigment, in the blood and tissues.  Your liver is responsible for controlling the levels of bilirubin.  If your liver is having problems performing basic, yet essential functions, yellow skin, eyes, dark urine, and itching (pruritus) may all be due to an inability to filter excess bilirubin.  Please see your doctor immediately if you experience jaundice of the skin or eyes.

It is also not uncommon for those with more advanced liver disease such as cirrhosis to have palmar erythema, which presents like red palms –especially around the base of the thumb and little finger.  Keep in mind that there may be other reasons for experiencing red palms, such as high blood pressure, pregnancy, or elevated estrogen levels. Talk to your doctor if you have concerns.

Spider nevi or spider angioma are another indicator of more serious liver disease. These are not to be confused with spider veins. It is also important to note that 10-15% of healthy adults and children have spider nevi, with no underlying disease. They range in size from 0.5 to 1 cm in diameter, with a dark center, radiating out to fine, red lines. When the center is depressed with the finger, the radiating lines disappear, and then re-appear, when the finger is lifted. Spider nevi may be caused by an increased level of estrogen in the body.  Naturally these may also appear during pregnancy, and in women using oral contraceptives. Following pregnancy and the discontinuation of contraceptives, the spider angiomas will disappear on their own. Like so many basic, but essential functions, the liver is responsible for breaking down and removing excess estrogen. Spider nevi associated with liver disease tend to be large in number and appear on the upper part of the body, face, and neck – especially on the backs of the hands and arms. Once again, it is a good idea to point out these out to your doctor.

Gianotti-Crosti Syndrome is a rash associated with HBV and EBV (Epstein Barr Virus). This rash almost always occurs in children, with 90% of kids under the age of four. The rash may last from two to eight weeks. Basically, it’s just a response to a virus, and nothing to worry about – just an indicator. Kids often have a rash for one reason or another.  If the rash is excessively itchy, talk to your pediatrician about using a topical steroid. Every parent of a child with HBV is convinced their child has some sort of HBV associated rash. (Speaking from experience…) Even the pediatric liver specialist was unsure, so she got a consult with a pediatric dermatologist.  The rash was unrelated to HBV.

Wondering about your finger nails?  There’s a condition called Terry’s Nails which is present in many of those with cirrhosis. The nail appears mostly white, similar to the appearance of “ground glass”, and possibly with a little pink strip at the top of the nail bed.  This is due to a decrease in blood flow to the nail bed and an increase in connective tissue.  Remember that your doctor will not be able to see any of this if you wear nail polish to your appointment.

How about your basic rash that is associated with hepatitis B?  Rashes are most often associated with acute hepatitis B infections, although a recurring rash may occur in those chronically infected.  Talk to people living with HBV and they’ll tell you they have occasional rashes and annoying itching, even if their doctor may tell them they do not.  Could be totally unrelated, or it could be erythematous papular lesions, or palpable purpura.  In other words, your basic red or purplish, raised, bumpy rash. It’s not easy to find specific information linking your basic rash to HBV, but when you consider how the skin is a window to your general health, it makes sense that you may see skin manifestations that reflect your immune system response to your HBV infection as it cycles through various stages, phases and flares.

If you are living with HBV, you know the importance of monitoring your HBV status and your liver health.  Annual, bi-annual, or the schedule recommended to you by your liver specialist, will keep you on top of what is going on with your HBV and any associated liver disease.  However, it is good to take notice of any changes in the skin and nails as the liver is a non-complaining organ.  Sometimes we have to look for evidence that something is going on. That being said, I feel the need to rush to a mirror and check myself out after having researched and written this blog.  The skin may be a window to our general health, but it is not always easy to figure out what it’s trying to tell us. If you have any questions, don’t try to self-diagnose. Talk to your doctor and bring any of your concerns to his attention.

To Disclose or Not to Disclose, That is the Question

Choosing to disclose, or not to disclose your hepatitis B status is a very personal decision.  The key thing to keep in mind is that once this private information is out, it cannot be reeled back in.  It’s best to stop, and give it serious thought before you move forward with your decision.

Being diagnosed with a chronic illness can be overwhelming.  Many are shocked by their HBV diagnosis. Some have been living with HBV since birth, but because it is often a silent infection, with few to no symptoms, they are surprised they are infected.  Others may have no idea how they were infected. A support network of friends, family and loved ones is important at this time.  Sadly, your news may elicit a variety of responses, from loving support to complete avoidance.  Unfortunately, there is often a stigma associated with HBV.  People are afraid of what they don’t understand, and most are ignorant about infectious diseases.  It’s something that happens to someone else.  Little do they know that HBV does not discriminate.

Here are some important points to consider:

  • Location – Where do you live?  If you live in a large city or community, you may be able to better pick and choose who learns of your HBV status. In a larger community you may have a little more flexibility to move around, or make changes if your HBV disclosure is a problem.  If you live in a small town, with few employment opportunities, and a hand-full of nosy neighbors, you might want to think long and hard about telling anyone in your community.
  • Family – Only you know your family.  Depending on your ethnic background, there may be a cultural stigma associated with having HBV. Break the news gently and be prepared to supply easy-to-understand information. Remember there is the possibility that you acquired your HBV infection at birth, and other family members may be at risk and need to be tested.
  • Work – Unless you are symptomatic and missing work due to your HBV, it might be a good idea to keep your hepatitis B status under wraps.  In many countries, an HBV infection destroys careers.  Even subtle discrimination can ruin your reputation at work.  If you require time off due to HBV, be sure to take it up with human resources.  Your information will be kept confidential.
  • Sexual partners – It is more important than ever to ensure you are having protected sex if you are not in a monogamous relationship. If you have HBV, you do not want a coinfection with another infectious disease like HCV or HIV.  Insist on protection, and use a condom.  You owe it to yourself and your partner(s).  Be sure any significant others are vaccinated.  If you believe they have been exposed, then they need to be tested. The flip-side is the concern with a relationship that turns serious, where you have not yet disclosed your HBV status. This is a difficult balance.  They may be hurt or angry that you did not disclose, earlier, and yet you don’t want to enter every new relationship spilling all of your private info.
  • Friends – Friends have been made and lost over personal information such as HBV disclosure. If they can’t accept you, living with HBV, who needs that kind of friend?  This is true, as long as they will respect your privacy and choose not to disclose your private information to others. Take a good look at your friends, and remember that many really are acquaintances.   Acquaintances do not need to know the details of your HBV status.  It’s your choice who you decide to tell.
  • Medical professionals – All health care providers must practice infectious disease protocols and standard precautions.   It keeps everyone safe.  That being said, it is important that your doctor is aware of your status.  He is making treatment decisions and prescribing medications that could effect your liver health. HIPAA regulations will keep your private information protected at medical offices.
  • Support groups – It might be difficult to find a traditional hepatitis B support group, but there are wonderful on-line HBV support groups out there.  This is a great environment to query others living with HBV about who they choose to tell and not tell.  It helps to hear it from others that truly understand what you are going through.  Friends and family may love you, but it’s very possible they won’t fully understand what you’re going through.   As the newness of your HBV diagnosis wears off, I can promise that things will get better.  Give yourself a little time….

Disclosure truly is a personal decision. There is no right or wrong answer.  Much depends on your personality and what you can live with. When you make the decision to disclose, you need to make the commitment to educate.  This is admirable because it takes courage to stand up, raise awareness, and be out there with your personal story.  The response from others may surprise you – for better or for worse!  Just remember that before you decide to disclose, you had best be informed.  Educate yourself, so you can educate others on the HBV basics and help raise awareness.  Let friends know  how HBV is transmitted.  Encourage hepatitis B vaccination. Arm yourself with simple explanations.  Your goal is not to scare your audience, but rather raise their awareness of those living with hepatitis B.  Remember it’s your decision, but take your time…

Having HBV and Using Immunosuppressants

Studies have shown a direct danger of HBV reactivation for those patients that were previously HBV infected, currently surface antigen-negative (HBsAg -), and using ‘biological response modifiers’ (ex. Rituximab, which has a black box warning).  These patients may be under-going treatment for lymphoma, rheumatoid arthritis, irritable bowl or other serious diseases.  Dangerous reactivation of hepatitis B can be prevented by the simultaneous, prophylactic  treatment with HBV antivirals.  Guidelines exist for screening patients, and the need for prophylaxis is understood, but unfortunately not known or followed by all treating physicians. This is a real danger to the patient, and can result in a fatal outcome.

The topic of general immunosuppressant use has come up repeatedly at previous HBF hepatitis B patient conferences among those currently living with hepatitis B. Patients took it upon themselves to ask the experts what they thought because they were constantly on alert for things that might impact their HBV status.  Immunosuppressants are drugs that are used to treat all kinds of acute and chronic conditions.  They tamp down the immune response by suppressing it.  This could be problematic for someone with HBV, because the virus  may replicate readily with the immune system suppressed. The evidence is out there for hard-core long-term immnosuppressants or targeted therapy as noted above,  but there’s not much out there about the general use of steroids for those with HBV.  It’s worth thinking about, and having the conversation with your liver specialist because we are always looking for ways to avoid further liver injury.  Here are a list of typical steroids that many of us use while living with HBV. They are listed top to bottom, from the least concern to greater concern.

  • Topical steroids – (least concern) creams or ointments applied to the skin for things like eczema and other dermatitis
  • Steroid inhalers – used for asthma and other respiratory related conditions
  • Oral steroids – numerous uses, varying doses, varying duration of use
  • IV steroids – May be given during surgical procedures as necessary or prophylactically, or in an emergency

There is little concern about steroids that are applied topically or delivered through an inhaler.  These may have other issues or potential side effects when used long term, but they should not affect your HBV status. We struggled with this one in our household, as potent prescriptions were prescribed and the topicals were applied daily for l-o-n-g periods of time. Discuss this with your doctor if you have concerns, but keep in mind that it should have no impact on your HBV.

The oral dosing of steroids will vary greatly by the condition, and then by the prescription, dosing and duration of use. If you are considering use of oral immunosuppressants, especially extended use, then don’t forget to remind your prescribing physician about your hepatitis B. They may not always recall that you have HBV.  Have the converstion with your liver specialist about your HBV status, whether or not you’re currently being treated, and the new immunosuppressive  drug you are to be prescribed.  Weighing the pros and cons will be dependent on an individuals’ HBV status. You want to be sure you’re safe!

Talk to your liver specialist about his thoughts on IV steroids and their use during surgical procedures.  Our liver specialist told us to avoid IV steroids if possible, although in the event of an emergency, the acute emergency trumped any HBV concerns. I also learned that steroids are sometimes given prophylactically for some types of surgical procedures. One surgeon, highly regarded in his field, was aware of the patient’s HBV status.  However, he was not an HBV expert and had never considered the prophylactic dose of steroids he typically used. We were in agreement, that if it did not appear to be needed, then it would not be used.  Once we had the discussion, I was content with his decision. If a situation arose requiring the use of IV steroids then I would know that the benefits of having the steroid outweighed any potential risk to the current HBV status.

Please don’t be afraid to be your own hepatitis B advocate.  Most doctors are not HBV experts. They’re experts in something else!  If you have concerns about immunosuppressants or other forms of treatment, then bring up the topic at your next visit with your liver specialist.  Then you’ll have the information you need so you can discuss these topics with other doctors, should the need arise. Keep a file of pertinent articles to reference, and the the contact information of your liver specialist in case your doctor would like additional input on a particular topic.

 

Got Hepatitis B? Keeping loved ones safe through HBV vaccination

If you just found out you have hepatitis B, or if you are adopting a child with HBV, you will want to ensure that all household and close contacts are properly vaccinated to prevent the transmission of hepatitis B.

Hepatitis B is not transmitted casually, so no need to worry about shaking hands, kissing, hugging, changing diapers and daily living.  HBV is transmitted through infected  blood and sexual fluids and requires direct contact of infected blood to an open sore (from microscopic to gaping), mucous membrane or orifice.  It is also transmitted sexually and via personal care items such as razors, toothbrushes, tweezers and clippers that may contain microscopic blood droplets.

Household contacts and loved ones are at greater risk of contracting HBV due to the daily logistics of life.  And of course accidents happen.  HBV may transmitted by borrowed razors, or accidentally touching infected blood. Getting vaccinated is the best way to keep everyone HBV free for life.

The hepatitis B vaccine is a safe, and effective, three-shot-series that protects you from HBV.  Typically when you get your HBV vaccine, you do not return to ensure that your vaccine was successful in generating an adequate immune response.  However, if you are living with a loved one with HBV, if would be good to ensure that you are protected.  All it takes is one follow-up blood test.  Ask your doctor to run a quantitative hepatitis B surface antibody test (HBsAb, anti-HBs).  Often HBV antigen/antibody tests are run qualitatively, which means you get a positive/negative or reactive/non-reactive response.  When you get a quantitative HBsAb test, it will tell you how much surface antibody you have.  An adequate titre is a value greater than 10 mIU/mL.  The key is to ensure that you have been tested at the right time.  Keep in mind that you could also have a standard, qualitative surface antigen test run because it will not be reactive unless it is greater than 10.  However, I have found that most people like to see the number if it’s an option.

This test needs to be run four to six weeks following your last shot of the three shot series.  If your titre is greater than ten, then you are protected for life.  If your titre is less than ten, negative or non-reactive, then you will need to repeat the series.  It is recommended that you try a vaccine made by a different pharmaceutical company for the second round.  For example, if your first vaccine series was completed using the Engergix B vaccine, then you would want the second series to be done with the Recombivax HB vaccine the second time. Following this second series, you will again need to be tested 4-6 weeks following the last shot of the series.

Approximately 5-10% of people are considered non-responders if they complete two series of the vaccine and do NOT produce an adequate immune response.  Sometimes age and weight can contribute to difficulty in building adequate immunity.  And of course each person’s immune system is unique, so there will always be some that do not generate adequate immunity for no known reason, while others with a suppressed immune system may also have difficulty.  The final thing to consider is whether the person considered a non-responder actually has HBV.  If you fall into this category, please be sure ask that your doctor test you for surface antigen (HBsAg), along with an HBV viral DNA test.

Vaccination is always preferable because it’s just easier and it works –  most of the time.  However, with simple changes a “non-responder” parent or loved one can dig right into life’s daily goings-on!  Follow simple precautions to keep you and your family safe.  There aren’t vaccines available for everything, so it never hurts to play it safe.

For those that had their HBV vaccines years ago, but were unable to test within the four to six week window, don’t be alarmed if your titres are below ten, or if you do not have a positive or reactive HBsAb value.  It is recommended that you repeat the series (you might see a little variation in viewpoints between booster vs. 3-shot-series) and then be tested within the four to six week window to ensure you have adequate titres.

At this time, HBV booster shots are not recommended, regardless of when you were vaccinated.  You may find years later that your surface antibody is no longer reactive, or is below ten, but you know that it was adequate after the 4-6 week period following your vaccination. Do not be alarmed.  Our amazing immune systems have something called immune memory, which continues long after detectable antibody in the blood.  Simply put, you may not have a lot of HBV antibodies circulating in your system, but if you happened to be exposed to HBV after your titres had waned, your immune system would go into over-drive in order to protect you from an exposure.  As long as you once built up an adequate response, you are free from HBV for life!

Got HBV? Adding Vitamin D to Your Diet

Do you have hepatitis B, and are you considering adding vitamin D to your diet?  Adding vitamin D seems to be a win-win for those with liver disease since it is a potent immune modulator, appears to aid in the prevention of cancer, and other potentially related disorders such as NAFLD, along with Type I and II Diabetes, glucose intolerance and metabolic syndrome.  Before you make any big additions, be sure to talk to your doctor or liver specialist to ensure it’s safe for you with your current health status.

Vitamin D is a fat soluble vitamin (needs a little fat to digest), versus a water soluble vitamin, that is ultimately stored in the liver.  There are pros and cons to this.  Fat soluble vitamins are not necessarily needed on a daily basis as they are stored in fatty tissues and in the liver making it available for longer periods of time.  Vitamin D is specifically stored in the liver. Unlike water soluble vitamins, excesses are not excreted through urine on a daily basis. That makes the balance a little trickier because you don’t want vitamin D accumulating in the liver and causing toxicity. Symptoms of vitamin D deficiency include osteomalacia, or softening of the bones, or perhaps less obvious bone pain and muscle weakness. Symptoms of vitamin D toxicity may include decreased appetite, nausea,vomiting, excess calcium blood levels or an accumulation of calcium in soft tissues. Too much of a good thing is NOT good for you!

Current guidelines for vitamin D intake are 600 IU or 15 mcg per day. (See table for age specific info). Natural sources of vitamin D in foods (vitamin D2, or ergocalciferol) are hard to come by, but they are out there.  Mega sources include fatty fish like salmon, mackerel, and tuna.  Cod liver oil is an excellent source, which is probably why we see old movies with mom spooning cod liver oil into the mouths of young children! In the U.S. many dairy products, and others such as cereals, or orange juice are fortified with vitamin D and other vitamins. (There’s a great reason for the fortification of dairy with vitamin D – absorption is enhanced in the presence of calcium.) It is also found in smaller amounts in egg yolks. Naturally all of this needs to be balanced with the concerns of farm raised fish and possible exposure to PCBs, or mercury levels found in tuna, pollution of our oceans, raising your cholesterol levels due to focusing on the yolks, possible toxic levels of vitamin A with cod liver oil  (in Western countries where foods are fortified with vitamin A), or simply the bad, fishy taste associated with cod-liver oil. It’s a tough balance, but it’s important to work through some of the risks versus benefits in your own mind.

Sunshine is another readily available source of vitamin D (vitamin D3, cholecalciferol), but you need to be sure to balance it with the risk of over-exposure to the sun’s rays. And of course in the north, during the winter months, it may be difficult to get adequate sunshine to boost your vitamin D levels. You can get adequate sun exposure with 10-15 minutes in the sun, 3-5 times per week, with the exposure of face and arms. Naturally this will vary based on the sun’s intensity, how much skin is exposed and each individual’s skin tone, since the amount of necessary sun increases with the amount of melanin (pigment) in the skin.  Just to confuse matters, a recent study shows a possible link of higher levels of vitamin D to non-melanoma skin cancer, even though higher levels are thought to reduce the risk of basal cell cancer. Clearly more studies need to be done, but until that time, just keep reminding yourself that balance is important.

Sometimes it’s tough to get adequate vitamin D levels from natural sources such as food and sunshine, so there is the option for vitamin D supplements. This is where my anxiety levels intensify. Bad enough I have to worry about my food sources – PCBs from farm raised fish and such things, but now I have to choose a supplement – perhaps cod liver oil in a liquid or capsule that I can take daily.  Will it be in a form that is able to be absorbed?  (There’s a debate on the true benefit of cod liver oil once it is processed.  The same argument might apply to many available supplements.) How will I know this?  Will I break the bank trying to purchase these supplements?  I started to do the research on vitamin D supplementation, but like so many supplements, it’s very complex.  I always feel like I’m being sold. Using supplements is a personal thing. My personal preference would be to get my vitamin D through the foods I eat, and a short duration of sunshine.  However, I currently have adequate levels of vitamin D, so whatever I’m doing seems to be adequate.  That’s the key: tailoring your decisions based on you, your family history, or ethnicity and things you might be prone to such as a vitamin D deficiency, or other issues.

Please don’t forget to talk to your PCP and your liver specialist before drastically changing your vitamin D intake.  This is especially important if you are currently undergoing treatment for HBV.  Your doctor may wish to get a general baseline of your vitamin D levels, and continue to monitor them if there are problems.  Your doctor may be uncomfortable recommending a specific supplement since there is little or no regulation. Heed her advice before moving forward, and if you choose the supplementation route, be sure to do your homework to get the best quality product that is readily absorbable, without causing toxicity.

Be sure to take a look at last week’s blog on Vitamin D here.

Hepatitis B and Vitamin D

Vitamin D is essential for everyone, but how might vitamin D help those living with HBV? Vitamin D is especially important for children and older adults, as it aids in the body’s absorption and regulation of calcium and phosphorus, which helps form and maintain healthy bones and teeth.  Vitamin D is also a potent immune modulator, and aids in the prevention of hypertension, and cancer. Vitamin D levels appear to play a critical role in type I and type II diabetes, glucose intolerance, and metabolic disorders.  Studies have also shown a link between low vitamin D levels and NAFLD (Non-alcoholic fatty liver disease), independent of metabolic syndrome, diabetes, or insulin-resistance profile (for those without HBV). The lower the vitamin D level, the higher the risk for NAFLD, or fatty liver disease.  The liver plays such an integral part in digestion, regulation, storage, and removal of toxins – the list goes on.  You can’t live without it!  As a result, it seems logical that healthy levels of vitamin D would benefit those living with HBV, if adequate vitamin D levels help reduce the risk of NAFLD, metabolic syndrome, etc.

Vitamin D is a potent immune modulator.  It has been on the radar for the prevention and treatment of infectious diseases for years. If you are being treated for HBV, you may want to discuss the potential benefits of adding vitamin D to your current therapy.  It has been shown to benefit hepatitis C patients undergoing treatment.  There is currently a clinical trial in Israel looking into the possible benefits of adding vitamin D supplementation to hepatitis B patients undergoing Peginterferon, or treatment with nucleotide analogs.

While researching this blog, I ran across a couple references that mention Fanconi’s Syndrome and vitamin D.  This is interesting since Fanconi’s Syndrome may be acquired as a result of HBV treatment with tenofovir.  Fanconi’s Syndrome and supplementation with vitamin D is also mentioned on the Mayo Clinic site.  The problem is there are no studies that definitively discuss the benefits of vitamin D supplementation for those living with HBV.  I am no doctor, but there seems to be a connection between vitamin D and good liver health.

Start by talking to your doctor or liver specialist about the pros and cons of considering additional vitamin D in your diet. Request that your vitamin D levels be tested so you get a snapshot of your current levels. I had my girls’ levels checked.  They were adequate, but I regretted having them tested during the summer break when they are outside more often. I wonder how this reflects on their levels in the winter when they are rarely outside?  Food for thought.

The 25-hydroxyvitamin D (25(OH) D) blood test is used to measure serum levels of vitamin D. Normal serum levels, indicated by the Institute of Medicine (NIH), are 50 nmol/L (20 ng/mL) or greater.  Low levels are under 30 nmol/L (12 ng/mL).  See detailed charts for age specific requirements. There are all kinds of reasons for inadequate levels of vitamin D, so it is important to follow up with your doctor if your results are out of the normal range.  You may require additional testing.

It is important to maintain a balance and use common sense when considering supplementing your diet with Vitamin D.  Vitamin D is essential, but too much of a good thing can be dangerous to your health. Be sure to keep your doctor in the loop – especially if you are currently undergoing HBV treatment.

Check out Thursday’s blog for those looking for vitamin D details and sources.