Hep B Blog

Tag Archives: HDV

Hepatitis B Research, Hepatitis Delta (HDV)

Eiger BioPharmaceuticals: Developing Two New Hepatitis Delta Treatments

Eiger is currently working on two new drugs for hepatitis delta; Lonafarnib and Pegylated Interferon Lambda, which are both currently inphase 3 clinical trials. Lonafarnib is a new type of treatment that attempts to control hepatitis delta through a new method: through blocking a key enzyme that is needed for the hepatitis delta virus to replicate. Blocking this enzyme prevents a new virus from being created, which may control and even cure hepatitis delta.

Lambda is being developed as a better tolerated interferon compared to interferon alfa (IFN alfa). Interferons work by stimulating the body’s own immune system to fight the virus. Pegylated interferon alpha, which is the only current treatment for hepatitis delta, is a difficult treatment to tolerate, with many patients experiencing unpleasant side-effects. Lambda utilizes the same method of treatment as IFN alfa, in combination with a new strategy, which stimulates an immune response and targets receptors in the liver, which may reduce side effects and result in improved tolerability.

Below is Eiger Biopharmaceuticals’ response to a series of questions we posed to them. 

Image courtesy of Praisaeng, at FreeDigitalPhotos.net.

1. Lambda is an immunomodulator and Lonafarnib is a prenylation inhibitor. Can you explain in laymen’s terms the mechanism for these drugs and how they work?

Eiger’s wording: Lonafarnib is a well-characterized, first-in-class, orally active inhibitor of an enzyme that is key to a vital process in the life cycle of HDV. Inhibiting this enzyme blocks the ability of HDV to assemble and package viral particles. Currently approved nucleos(t)ide treatments for HBV only suppress HBV DNA, do not affect HBsAg, and have no impact on HDV infection.

Lambda is being developed as a better tolerated interferon compared to interferon alfa (IFN alfa). Lambda is a well-characterized, first-in-class, type III interferon (IFN) that stimulates immune responses that are critical for the development of host protection during viral infections. By targeting receptors that are localized in the liver, Lambda treatment may reduce side effects and result in improved tolerability .

Can you share, in simple terms, the basic results of Eiger phase 3 studies for hepatitis delta trials? Are these drugs equally effective in HBeAg positive and negative HBV patients?

The Eiger Phase 2 LOWR program with Lonafarnib has been completed. Over 120 patients were dosed in Phase 2 dose-finding studies to identify combination regimens of lonafarnib (LNF) and ritonavir (RTV) with and without pegylated interferon-alfa (PEG IFN α), with efficacy and tolerability to enable viral load suppression of HDV RNA and ALT normalization at Week 24.

  • Dosing regimens of LNF 50 mg twice daily + RTV 100 mg twice daily with and without PEG IFN-a-2a 180 mcg once weekly were identified with the following reported results:
    • All-oral: Lonafarnib boosted with ritonavir
    •  29% of patients achieved ≥ 2 log decline and ALT normalization
  •  Combination: Lonafarnib boosted with ritonavir + PEG IFN-a-2a
    •  63% of patients achieved ≥ 2 log decline and ALT normalization

These dosing arms are being further studied in the global Phase 3 D-LIVR study. Phase 2 studies have not been stratified by HBeAg status.

The D-LIVR Study, a Phase 3 pivotal trial, is on-going and evaluating the safety and efficacy of lonafarnib treatments in patients chronically infected with Hepatitis Delta Virus (HDV). Topline Week 48 data will be available in 2021.

2. How will Lambda and Lonafarnib be administered to patients?

Lonafarnib capsules are administered orally twice daily by mouth. Lonafarnib is taken in combination with ritonavir, a therapeutic booster that increases the bioavailability of lonafarnib. Ritonavir tablets are administered orally twice daily by mouth.

Pegylated interferon-lambda is administered as a self-administered subcutaneous injection once weekly.

3. Do you anticipate combination therapy will be needed and if so, which combinations do you anticipate?

No form of viral hepatitis has been cured with a single drug. Combinations of treatments with different mechanism of actions have always been required.

Lonafarnib and interferons have different mechanisms of action and have been studied as monotherapies and in combination together as treatments for HDV. While each treatment alone reduces the HDV viral load, combination studies have shown that using these treatments together leads to a synergistic effect and further reduces the HDV viral load.

Recently, the interim end of treatment results of peginterferon lambda (Lambda) and lonafarnib combination study in HDV-infected patients were presented at AASLD 2019. The LIFT study is being conducted within the National Institutes of Health (NIH) at the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). LIFT is a Phase 2a open-label study of 26 adult patients with chronic HDV treated with Lambda 180 mcg once weekly in combination with Lonafarnib 50 mg twice daily boosted with ritonavir 100 mg twice daily for 24 weeks. Primary efficacy endpoint is > 2 log HDV RNA decline at end of treatment. At the time of analysis, 19 of 26 patients had reached Week 24. Median HDV RNA decline was 3.4 log IU/mL (IQR: 2.9-4.5, p<0.0001) with 53% (10 of 19) patients achieving below the limit of quantification and 37% (7 of 19) patients achieving undetectable HDV RNA at Week 24. 18 of 19 patients (95%) achieved primary endpoint of > 2 log decline during 24 weeks of therapy. We believe these data are the most encouraging yet in pursuit of HDV cure.

4. What kind of side effects can patients expect with Lambda and Lonafarnib, with or without combination therapy?

The most common side effects of lonafarnib include diarrhea, nausea, fatigue, decreased appetite, vomiting, abdominal pain, and decreased weight. Antacid, antiemetic, and antidiarrheal medications may be used prophylactically to treat these gastrointestinal side effects.

The most common side effects of pegylated interferon-lambda (Lambda) are the expected side effects of interferons. However, these side effects have been demonstrated to be much milder and less severe than what has been previously been shown with pegylated interferon-alfa (alfa). These include musculoskeletal (myalgia, arthralgia, and back pain), flu-like symptoms (chills, pyrexia, and pain) and elevated alanine aminotransferase (ALT) levels.

A combination of these side effects is expected with combination therapy.

5. Are Lambda and Lonafarnib safe for use in people with cirrhosis?

Currently, the safety and efficacy of lonafarnib and pegylated interferon-lambda are being investigated in persons chronically infected with HDV. The clinical trials require study participants meet certain eligibility criteria to be included in these studies. These eligibility criteria may or may not reflect the type of patient who will use these therapies after they receive FDA approval.

Phase 2 and Phase 3 studies both include patients with well-compensated cirrhosis.

6. With a clearance of HDV, would you also anticipate a loss of surface antigen – functional cure for chronic HBV as well? If so, in what percentage of HBeAg and HBeAb patients?

HDV is always found as a co-infection with HBV because HDV requires just a small amount of HBV surface antigen (HBsAg) to complete HDV viron replication. However, an HDV / HBV coinfection leads to much more severe chronic viral hepatitis compared to HBV monoinfection alone. Therefore, it is important to treat HDV, even if HBV is not cured. It is possible to clear HDV RNA without loss of HBsAg.

7. Lambda and Lonafarnib are currently in phase 3 trials for delta. Are you able to provide an approximate timeline for when it will be approved for use in U.S. and Europe?

Eiger BioPharmaceuticals is committed to developing safe and effective therapies for HDV and providing patients with a pathway to gain access to approved therapies as quickly as possible.

The D-LIVR Study is a global study that is evaluating the safety and efficacy of lonafarnib treatment in patients chronically infected with HDV. The D-LIVR Study is recruiting subjects in up to 20 countries in over 100 study sites. The D-LIVR study includes 48 weeks of treatment with two different lonafarnib-based treatment regimens, followed by 24 weeks of follow-up. Primary endpoint is ≥ 2 log decline and ALT normalization at Week 48. Topline data from the Phase 3 D-LIVR study will be available in 2021. For more information about study locations and eligibility, please visit www.clinicaltrials.gov  (NCT03719313).

End of Phase 2 meeting with FDA to discuss Phase 3 development with Lambda monotherapy is planned for Q1 2020.

HDV, Hepatitis Delta (HDV), Living with Hepatitis B

My Hepatitis B Viral Load is Low (Or Undetectable), Am I Still Infected with Hepatitis Delta?

For people who have been diagnosed with chronic hepatitis B and delta coinfection, a low or undetectable hepatitis B viral load does not usually indicate that they’ve cleared both infections. This is because, in cases of coinfection, hepatitis delta usually becomes the dominant virus, and suppresses hepatitis B, slowing or even stopping its replication entirely. If someone is still positive for the hepatitis B surface antigen (HBsAg), the hepatitis delta virus can still replicate (often with copies in the millions) and cause potential liver damage  1. For this reason, the test to measure hepatitis delta activity, the HDV RNA test, is important in disease monitoring and management  2,3. Available since 2013, the HDV RNA test can be acquired internationally through the Centers for Disease Control and Prevention (CDC), and from several labs in the US. 

For those suspected of having acute hepatitis B and delta coinfection, HBsAg testing should follow 6 months after initial diagnosis. If HBsAg is negative (non-reactive), both infections are likely to have cleared. It’s important to remember that people who contract hepatitis B and delta during one exposure are likely to clear both viruses.  If HBsAg is positive (reactive) after 6 months, both infections are likely chronic (life-long). Those who are known to have a chronic hepatitis B infection and then become infected with hepatitis delta later on, they are likely to develop chronic coinfections.  

Following diagnosis with hepatitis B, with or without delta coinfection, it is important to have close, household contacts and sexual partners screened, and to follow simple prevention measures and practice safe sex using condoms.  

Both hepatitis B and delta are prevented with the safe and effective hepatitis B vaccine series.  

For more information on hepatitis B and delta coinfection, visit www.hepdconnect.org or contact us at connect@hepdconnect.org.  

References: 

  1. Huang, C. R., & Lo, S. J. (2014). Hepatitis D virus infection, replication and cross-talk with the hepatitisB virus. World journal of gastroenterology, 20(40), 14589–14597. 
  2. YurdaydınC, Tabak F, Idilman R; Viral Hepatitis Guidelines Study Group. Diagnosis, management and treatment of hepatitis delta virus infection: Turkey 2017 Clinical Practice Guidelines. Turk J Gastroenterol 2017; 28(Suppl 2); S84-S89. Available at: https://www.turkjgastroenterol.org/sayilar/304/buyuk/S84-S89.pdf 
  3. Tseng, C. H., & Lai, M. M. Hepatitis delta virus RNA replication.Viruses, 1(3), 818–831.  

Hepatitis Delta (HDV)

Hepatitis Delta: Flying Under the Radar in the U.S.

As of 2019, the Centers for Disease Control and Prevention (CDC) requires over 100 diseases, infections and conditions – including hepatitis A, B and C – to be reported by state and local health departments. Physicians who diagnose these conditions, and diagnostic laboratories, are required to report confirmed and/or suspected cases to health departments, who then notify the CDC. This requirement allows the government to monitor disease patterns and track outbreaks to contain the spread of disease and protect the public. While all other forms of viral hepatitis are federally ‘reportable’, hepatitis delta cases are not required to be reported. Hepatitis delta is the most severe form of viral hepatitis, and spreads similarly to hepatitis B; through blood and sexual fluids, making it a public health threat, particularly for the 2.2 million people who already have hepatitis B in the U.S.

Hepatitis delta can only be contracted along with hepatitis B or after someone is already infected with hepatitis B. Acute cases can cause liver damage and even liver failure, and in chronic cases, can accelerate the rate of liver disease progression, as there are no effective treatments available. Although estimated to affect 5-10% of hepatitis B patients, hepatitis delta is severely underdiagnosed, leaving the true disease burden largely unknown in the U.S. and worldwide.

In conjunction with awareness efforts, adding hepatitis delta as a reportable disease could reveal a more accurate prevalence landscape of hepatitis B and delta coinfection and allow for more effective prevention efforts. The CDC asserts that “reporting of cases of infectious diseases and related conditions has been and remains a vital step in controlling and preventing the spread of communicable diseases,1” yet hepatitis delta has still been left out of the list of nationally reportable diseases. While notifying CDC is only voluntary2, 23 states have designated hepatitis delta infections as reportable to local and state health departments, allowing for surveillance of outbreaks, particularly relevant to the current nationwide opioid crisis.

Worchester, Massachusetts, which is currently experiencing a hepatitis A outbreak, also saw one of the worst hepatitis delta outbreaks in the country in the mid 1980’s. The infection was seen among drug users and their sexual partners, sickened 135 people, and killed 15. In those infected with hepatitis B, delta coinfection was present in 54% of drug users and 33% of their sexual partners3
. Interestingly, in Massachusetts, only labs (and not clinicians) are required to report hepatitis delta cases. The reporting requirement allowed the state to be alerted of a spike in cases and respond accordingly – a luxury many other states may not have if neither labs nor clinicians are required to report in their state.

Some states are even scaling back their surveillance; in 2016, New York State removed hepatitis delta from their list of reportable diseases, citing just 21 cases in a two-year period and a health code that asserts a “providers obligation” to “report unusual manifestations of novel strains of hepatitis.”4. Although hepatitis delta is more common outside the U.S., there is evidence to suggest persistent and even growing prevalence. A 2016 prevalence map presented by Eiger BioPharmaceuticals revealed New York City as a “hot-spot” for hepatitis delta cases5. Although more recent prevalence studies are sparse, and often include only small sample sizes, several have noted increases in hepatitis delta coinfection among certain groups. One study in Baltimore, published in 2010, compared blood samples from drug users in the 1980’s to samples obtained from 2005-2006 – and found a 21% increase in hepatitis delta coinfection among people already chronically infected with hepatitis B6. A 2015 study analyzed the blood records of 2,100 hepatitis B positive veterans – nearly 4% were coinfected7. A larger study, analyzing chart records of 500 chronic hepatitis B patients in California found that 8% of patients had a delta coinfection8. Another 2018 publication utilized data from 2011-2016 from the National Health and Nutrition Examination Survey (NHANES) and estimated there to be over 350,000 Americans with past or current hepatitis delta9.

While the true burden of hepatitis delta in the U.S. is debated, one study that analyzed diagnosis codes for over 170 million people showed 10,000 coinfected patients newly diagnosed in 2016 alone4. The American Association for the Study of Liver Diseases (AASLD) recommends delta testing in high-risk groups, but countless journals and leading hepatologists have called for universal testing of hepatitis B patients for hepatitis delta9,10,11  which could reveal thousands of unknown infections. Low awareness, testing, and the lack of inclusion on the notifiable diseases list contribute to the unclear picture of prevalence in the U.S. Inconsistent reporting across states creates holes in data collection and opportunities for missed outbreaks and subsequent treatment and prevention efforts. Adding hepatitis delta to the list of reportable diseases nationally could be the key to understanding who this ‘hidden epidemic’ is affecting, and where, and allow for effective surveillance to prevent future infections.

For more information about Hepatitis Delta Connect or hepatitis delta, visit www.hepdconnect.org or email connect@hepdconnect.org.

References:

1. Centers for Disease Control and Prevention. (1990, June 22). Mandatory Reporting of Infectious Diseases by Clinicians. Morbidity and Mortality Weekly Reports. Retrieved from https://www.cdc.gov/mmwr/preview/mmwrhtml/00001665.htm.

2. Centers for Disease Control and Prevention. (2018). National notifiable diseases surveillance system (NNDS): Data collection and reporting. Retrieved from https://wwwn.cdc.gov/nndss/data-collection.html

3. Lettau, L. A., McCarthy, J. G., Smith, M. H., Hauler, S. C., Morse, L. J., Ukena, T., et al. (1987). Outbreak of severe hepatitis due to delta and hepatitis B viruses in parenteral drug abusers and their contacts. N Engl J Med, 317(20), 1256-1262.

4. The City of New York. (2016). Hepatitis D and E and other suspected infectious viral hepatitides reporting. Retrieved from http://rules.cityofnewyork.us/tags/reportable-diseases.

5. Martins, E and Glenn, J. Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States: Results from an ICD-10 Review. Poster Sa1486 DDW May 2017.

6. Lauren M. Kucirka, Homayoon Farzadegan, Jordan J. Feld, Shruti H. Mehta, Mark Winters, Jeffrey S. Glenn, Gregory D. Kirk, Dorry L. Segev, Kenrad E. Nelson, Morgan Marks, Theo Heller, Elizabeth T. Golub, Prevalence, Correlates, and Viral Dynamics of Hepatitis Delta among Injection Drug Users, The Journal of Infectious Diseases, Volume 202, Issue 6, 15 September 2010, Pages 845–852.

7. Kushner, T., Serper, M., & Kaplan, D. E. (2015). Delta hepatitis within the veterans affairs medical system in the United States: Prevalence, risk factors, and outcomes.

8. Gish, Robert & Yi, Debbie & Kane, Steve & Clark, Margaret & Mangahas, Michael & Baqai, Sumbella & A Winters, Mark & Proudfoot, James & Glenn, Jeffrey. (2013). Coinfection with Hepatitis B and D: Epidemiology, Prevalence and Disease in Patients in Northern California. Journal of gastroenterology and hepatology. 28. 10.1111/jgh.12217

About Hepatitis B, Living with Hepatitis B

What’s the Difference: Hepatitis B vs Hepatitis C?

With five different types of viral hepatitis, it can be difficult to understand the differences between them. Some forms of hepatitis get more attention than others, but it is still important to know how they are transmitted, what they do, and the steps that you can take to protect yourself and your liver!

This is part one in a three-part series.

What is Hepatitis?

Hepatitis means “inflammation of the liver”. A liver can become inflamed for many reasons, such as too much alcohol, physical injury, autoimmune response, or a reaction to bacteria or a virus. The five most common hepatitis viruses are A, B, C, D, and E. Some hepatitis viruses can lead to fibrosis, cirrhosis, liver failure, or even liver cancer. Damage to the liver reduces its ability to function and makes it harder for your body to filter out toxins.

Both hepatitis B and C are blood-borne pathogens, which means that their primary mode of transmission is through direct blood-to-blood contact with an infected person. Also, both hepatitis B and C can cause chronic, lifelong infections that can lead to serious liver disease. Hepatitis B is most commonly spread from mother-to-child during birth while hepatitis C is more commonly spread through the use of unclean needles used to inject drugs.

 

Hepatitis B vs. Hepatitis C

Despite having an effective vaccine, hepatitis B is the world’s most common liver infection; over 292 million people around the world are estimated to be living with chronic hepatitis B. While hepatitis C tends to get more attention and research funding, hepatitis B is considerably more common and causes more liver-related cancer and death worldwide than hepatitis C. Combined, chronic hepatitis B and C account for approximately 80% of the world’s liver cancer cases. However, studies show that those with chronic hepatitis B are more likely to die from liver-related complications than those who are infected with hepatitis C. With hepatitis C, most people develop cirrhosis, or scarring of the liver, before liver cancer. In certain cases of hepatitis B, liver cancer can develop without any signs of cirrhosis, which makes it extremely difficult to predict the virus’ impacts on the body, and makes screening for liver cancer more complicated.

The hepatitis B virus is also approximately 5-10 times more infectious than hepatitis C, and far more stable. It can survive – and remain highly contagious – on surfaces outside of the body for at least seven days if it is not properly cleaned with a disinfectant or a simple bleach solution. A new study suggests that the hepatitis B virus has the ability to survive in extreme temperatures, whereas the hepatitis C virus has been known to survive outside of the body for a short period of time on room-temperature surfaces. However, more research will need to be done on the topic.

Another major difference between the two forms of hepatitis is how the virus attacks a cell. The hepatitis C virus operates like other viruses; it enters a healthy cell and produces copies of itself that

Hepatitis C Virus
Courtesy of Google Images

go on to infect other healthy cells. The hepatitis B virus reproduces in a similar fashion, but with one large difference – covalently closed circular DNA. Covalently closed circular DNA (cccDNA) is a structure that is unique to only a few viruses. Unlike a typical virus, hepatitis B’s cccDNA permanently integrates itself into a healthy cell’s DNA – a component of the cell that allows it to function properly and produce more healthy cells. The cccDNA resides within an essential area of the cell called the nucleus and can remain there even if an infected person’s hepatitis B surface antigen (HBsAg) levels are undetectable. Its presence means that a person with chronic hepatitis B may have a risk of reactivation even if the HBsAg levels have been undetectable for a long period of time. The complex nature and integration process of cccDNA contributes to the difficulties of finding a cure for hepatitis B. The cccDNA’s location inside of the nucleus is especially troublesome because it makes it difficult to isolate and destroy the cccDNA without harming the rest of the cell.

Hepatitis C, on the other hand, has a cure! Approved by the FDA in 2013, the cure is in the form of an antiviral pill that is taken once a day over the course of 8-12 weeks. For hepatitis C, a cure is defined as a sustained virologic response (SVR), which means that the virus is not detected in a person’s blood 3 months after treatment has been completed. In the United States, an affordable, generic version of the hepatitis C cure is set to be released by Gilead Sciences, Inc. in January 2019.

People living with chronic hepatitis B are susceptible to hepatitis Delta. Only people with hepatitis B can contract hepatitis D as well. Hepatitis Delta is considered to be the most severe form of hepatitis because of its potential to quickly lead to more serious liver disease than hepatitis B alone. Of the 292 million people living with chronic hepatitis B, approximately 15-20 million are also living with hepatitis D. Unlike HIV and hepatitis C coinfections, there are currently no FDA approved treatments for hepatitis Delta. However, there are ongoing clinical trials that are researching potential treatments!

Hepatitis B/C Coinfection

It is possible to have both hepatitis B and C at the same time. The hepatitis C virus may appear more dominant and reduce hepatitis B to low or undetectable levels in the bloodstream. Prior to curative treatment for hepatitis C, it is important for people to get tested for hepatitis B using the three-part blood test (HBsAg, anti-HBc total and anti-HBs). People currently infected with hepatitis B (HBsAg positive) or those who have recovered from past infection (HBsAg negative and anti-HBc positive) should be carefully managed according to the American Association for the Study of Liver Diseases (AASLD) treatment guidelines in order to avoid dangerous elevation of liver enzymes resulting in liver damage.

How to Protect Yourself   

The hepatitis B vaccine is the best way to protect yourself and your family against hepatitis B. Although there is no vaccine for hepatitis C, you can protect yourself from both liver infections by following simple precautions! Simple steps such as not sharing personal items such as razors or toothbrushes, thoroughly washing your hands, and disinfecting surfaces that have been in contact with blood, can keep your liver healthy!

 

Hepatitis Delta (HDV), Living with Hepatitis B

Ask An Expert: Managing Hepatitis Delta During Pregnancy

 

  What is the standard treatment for hepatitis delta and how long is it taken?

 

Although there are no standard guidelines for the treatment of hepatitis delta, pegylated interferon has been shown to be effective for some patients. It is usually administered via weekly injections for 1 year or more and is able to cure roughly 15-40% depending on the length of time that treatment is administered. Although many patients see declines in their hepatitis delta virus levels, most do not maintain long-term control following the conclusion of treatment.

Can pregnant hepatitis delta patients be treated with interferon?

 

Interferon has not been proven to be safe for administration during pregnancy and should not be administered. It may be harmful to the baby.

 

What is the best way to manage a hepatitis delta infection during pregnancy, if interferon cannot be used?

 

A liver specialist may continue to manage the hepatitis B infection during pregnancy through antiviral treatment. The American Association for the Study of Liver Diseases (AASLD) recommends antiviral treatment during the third trimester of pregnancy for women with high hepatitis B viral loads.

How can hepatitis B and delta transmission be prevented to the baby?

 

Because a hepatitis B infection is required for someone to become infected with hepatitis delta, transmission from mother to child can be prevented with the hepatitis B vaccine. Centers for Disease Control and Prevention (CDC) guidelines recommend the first dose within 12 hours of birth, along with and a dose of HBIG (hepatitis B immunoglobulin), followed by the additional 2 vaccine shots; one at 1 month and the final one at 6 months old. The vaccine, along with HBIG and hepatitis B antiviral treatment (if necessary) greatly reduce the risk of transmission to the baby. In resource-limited countries, the World Health Organization (WHO) recommends the first dose of the hepatitis B vaccine within 24 hours of birth, followed by the additional shots on the recommended schedule. Once the vaccination series is completed, the baby should be protected for life against hepatitis B and delta.

If hepatitis delta cannot be treated during pregnancy, do most women have progression of their liver disease during pregnancy?

 

 While some women may see progression of their liver disease, due to the relative short length of pregnancy, most women do not show clinical signs of advancing liver disease.

 

What treatment should follow delivery? 

 

 

Following delivery, the mother may resume interferon treatment as long as she is not breastfeeding. Interferon treatment while breastfeeding could be harmful to the baby. As for all patients, keeping up-to-date on the latest hepatitis delta clinical trials could provide access to new, experimental treatments that may be more effective. For a global list of clinical trials for hepatitis delta, visit the clinicaltrials.gov web page.

It is very important for all pregnant women who are hepatitis B and delta positive to be managed by a liver specialist who is familiar with managing coinfected patients. For assistance in locating a specialist near you, please visit our Physician Directory page. For additional questions, please visit www.hepdconnect.org or email connect@hepdconnect.org.

Hepatitis Delta (HDV)

Nearly 1 in 4 Romanians with Hepatitis B also Infected with Hepatitis D

 

By Sierra Pellechio, Hepatitis Delta Connect Coordinator

Since the 1990’s most of Eastern Europe has seen a decline in the prevalence of hepatitis D, a dangerous coinfection of hepatitis B, attributed to successful vaccination programs and government prioritization. Romania, which has the highest hepatitis B prevalence in the EU, has not seen such declines of hepatitis D, which affects 23% of its hepatitis B patients. Hepatitis D coinfection is considered hyperendemic to the country, and has some of the highest rates of coinfection globally1. Seventy percent of these 200,000 patients will progress to cirrhosis, often within only 10  years2, and face barriers to receiving effective treatment and management. Although the country enacted a national hepatitis B vaccination program for all newborns in 1995 and a catch-up program for school-age children in 1999, older populations already infected with hepatitis B and inadequately immunized young people represent susceptible groups for coinfection with hepatitis B and disease.1,3. Additionally; lack of hepatitis B vaccination recommendations for high risk groups, low implementation of hepatitis B screening during pregnancy, supply shortages and vaccine hesitancy, have created opportunities for hepatitis B and D transmission. Exposure to infected blood or sexual fluids through blood transfusions or surgeries (before the 1990’s), tattoos, piercings, injection drug use, or sexual contact with an infected person, can expose people already living with hepatitis B to hepatitis D, or expose those who have not received the full hepatitis B vaccine series to both viruses. Control of hepatitis B and D coinfection has also been hindered by the lack of a national registry and surveillance system thus preventing an understanding of the accurate prevalence and public health burden1.

With health expenditure and life expectancy the lowest in the EU, Romania is battling large system-wide failures that have fostered the persistence of hepatitis B and D in its population5.

Dr. Florin Caruntu, of the National Institute of Infectious Diseases in Bucharest, has suggested that there is a general low level of awareness and screening among health care providers in Romania, which has led to late diagnoses and cost many patient lives. For patients who are diagnosed, investigational testing is not covered by the national insurance house, placing a financial burden on patients to pay out of pocket for the additional testing necessary to manage their coinfection. With pegylated interferon injections as the only semi-effective treatment option, even diagnosed patients struggle to effectively control their coinfection and even less are connected to clinical trials. Although there are 7 new drugs in clinical trials, progress has lagged behind patient need for new therapies, many of whom are living with cirrhosis.

Increased government investment in the healthcare system, including medical training and education programs for provider awareness, updated protocols and coverage of investigational testing, would pave the way for increased patient identification and navigation to successful care. As clinical trials continue to progress, it is critical that Romania be a top consideration for clinical trial sites, as patients anxiously await more effective treatment options.

For more information on HDV in Romania, please watch our webinar featuring expert speaker, Dr. Florin Caruntu, of the National Institute of Infectious Diseases in Bucharest, Romania.

For more information about hepatitis B/D coinfection and the Hepatitis Delta Connect program, please visit www.hepdconnect.org or email us at connect@hepdconnect.org. If you are a hepatitis delta patient, and wish to receive information about upcoming clinical trials, please enter your information here. Hepatitis Delta Connect seeks to provide information, resources and support for hepatitis B/D patients and their families through its website, social media, fact sheets, webinars  and hepatitis D liver specialist directory.

1. Hepatitis delta virus infection in Romania: Prevalence and risk factors. (2015). Journal of Gastrointestinal and Liver Diseases, 24(4) doi:10.15403/jgld.2014.1121.244.dtv

2. Noureddin, M., & Gish, R. (2014). Hepatitis delta: Epidemiology, diagnosis and management 36 Years after discovery. Current Gastroenterology Reports, 16(1), 1-8. doi:10.1007/s11894-013-0365-x

3. Ruta, S. M., Matusa, R. F., Sultana, C., Manolescu, L., Kozinetz, C. A., Kline, M. W., & Cernescu, C. (2005). High prevalence of hepatitis B virus markers in Romanian adolescents with human immunodeficiency virus infection. Journal of the International AIDS Society, 7(1), 68-68. doi:10.1186/1758-2652-7-1-68

4. Gheorghe, L., Csiki, I. E., Iacob, S., & Gheorghe, C. (2013). The prevalence and risk factors of hepatitis B virus infection in an adult population in Romania: A nationwide survey. European Journal of Gastroenterology & Hepatology, 25(1), 56.

5. OECD/European Observatory on Health Systems and Policies (2017), Romania: Country Health Profile 2017, State of Health in the EU,OECD Publishing, Paris/European Observatory on Health Systems and Policies, Brussels. http://dx.doi.org/10.1787/9789264283534-en

 

Hepatitis Delta (HDV), Living with Hepatitis B

Karen and Dave’s Story

One Couple’s Journey through Hepatitis B, Hepatitis D and Liver Cancer

“Dave knew he had hepatitis B for decades, but honestly, no one ever seemed concerned. His liver
enzymes were slightly elevated, so the doctor told him to just watch what he ate and drank. He didn’t
even insist on bi-yearly blood tests!

In 2016, Dave was scheduled for a routine colonoscopy. Because he’d been looking pale and sickly
around that time, I suggested they do a blood test first at his family doctor. His numbers were off the
chart. They sent us back for the colonoscopy and added an endoscopy too. They found four varices
(enlarged veins in the esophagus that can indicate serious liver disease). How did this happen?

This was when I started to get angry. The gastroenterologist called us in to discuss the results. He asked
if Dave knew he had hepatitis B. Dave said yes, knowing his drug use in his teens and early twenties was
likely the source. Dave never felt shame about it at all, and just accepted it as a path he took, and
thankfully came out of. After that conversation, the doctor slammed his chart shut and pushed it across
the desk. He said that Dave’s liver was so badly damaged that there was nothing he could do and to
‘come back in a year’. When we asked about his options for treatment for the varices and his hepatitis B,
he actually told me that no one would treat the varices unless they were bleeding! He also told us that
hepatitis B antivirals would “make things worse”. That didn’t make sense. We asked about a transplant.
He said there was ‘no way’ anyone would give him a new liver. He didn’t even let us know that there
were actual liver clinics for this very purpose. He sent Dave away to die, really.

Many months later, with much perseverance, we made it to Stanford, where he was immediately put on
entecavir to treat his hepatitis B and to hopefully relieve some of his liver damage. That doctor alerted
us that he should also be tested for hepatitis D, a coinfection of hepatitis B. “It won’t be good if you have
it.” He did.

Due to changes in our health insurance, we were sent to continue at the University of California San
Francisco Liver Center…they were our saving grace. They treated the varices right away and put him on
other medications to help his failing systems. His hepatitis B viral load was now undetectable, with
hepatitis D being the biggest concern. Dave tried interferon to treat the hepatitis D, but with no luck. His
only chance was a transplant, but even though he was doing poorly, his test results didn’t qualify him to
get on the transplant list right away. He had lots of ER visits – 210 office visits in 2017 alone. It was a
whirlwind. Dave hadn’t even driven in 2 ½ years. It was an enormous stress on me, too.

Dave developed liver cancer but wasn’t in good enough shape to go through treatment. As he got sicker,
he eventually qualified for two different                  
liver transplant waiting lists. Finally, on
Thanksgiving night 2017, we got the call
that a healthy liver was available, and we
took it.
Caregiving is a very tough road. Especially
when your person also has encephalopathy,
caused by years of liver damage – and Dave
had it really bad. The encephalopathy
caused mood swings, short-term memory
loss, hand tremors, low appetite. He could
be down-right nasty. At that time, we were
doing the 4 ½ hour drive to San Francisco
once or twice a week. It was stressful for
both of us – and he was really unaware of
the stress that was put on me. Between
driving, taking out the garbage, bills, our
construction business…you name it, I did it
all.

The first 3-4 months out of the transplant, people were telling him all that had gone on. Much to my
frustration, he didn’t believe any of it! Now, over 6 months post-transplant, little things are coming back
to him. I showed him about 2 dozen pictures of him during his journey, and he was shocked! He said he
thought he was fooling everyone into thinking he was well.

The hardest part of this journey was seeing Dave so sick at times. I spent a lot of time in my closet
crying. It was hard on our adult girls too, to see their dad so weak and disoriented. I had a lot of support
through our girls though, and my family, which made a world of a difference. My sister is also a retired
nurse, and she accompanied us to most of our visits. She was a helpful adviser, since his medications
always needed tweaking, and we were often on long calls with our care team, health insurance
company, and pharmacies.

The good we took away is his health! He still doesn’t feel it’s real. We went through so much, and are so
grateful to be on the other side.

Things I’ve learned:
• Get on a Facebook forum for liver transplant patients…they are a great resource and a wealth of
information from other patients.
• Take a third person with you to doctor visits and procedures. At times, I was so consumed with
my concern for Dave, it was easy for me to forget some of the things we discussed. My sister
would take notes, and we would review them after.
• Always get a second opinion if you don’t have a good feeling about your doctor. You will all
become a team, and it’s important to have a team you can trust.
• Get on the transplant list at multiple hospitals, their criteria for transplant varies!
• Have willing family members and friends get tested to see if they are donor matches. Usually the
recipient’s insurance will pay for the testing and survey if they are a match. My sister-in-law and
I were both tested but were not a match.
• Ask about organ swap programs. Apparently, my kidneys were in perfect health. My
hepatologist had me apply to the kidney donor program, in hopes that I may be able to donate
my kidney in exchange for a piece of someone’s liver for Dave.
• Dave was put on depression and anxiety medication early in the process. He was initially very
resistant, mostly because of the stigma. His doctors finally convinced him it would be very
helpful for his general mood…it was!
• I had to make several phone calls to his team without his knowing. Encephalopathy really makes
you confused, and in Dave’s case, grumpy. I asked the doctor to push for the depression and
anxiety medications, which she did. Also, he wouldn’t exercise or take short walks before
surgery, which she had asked him to, to better prepare for surgery. I made the phone call, and
at the next visit, she set him up with a Fitbit! It helped that the ‘suggestions’ came from his
doctor and not me!
• After the transplant, I was so surprised he wasn’t more ‘thankful’ …that he wasn’t in awe of
what we had all gone through for HIM! I got angry with him. I made a private call to our new
post-transplant team. She said depression right after is very common. The patient feels
overwhelmed, and sometimes not very thankful. It’s kind of a way to deny they were in trouble,
to deny that they needed help. That fits my man to a tee!
• I would strongly suggest lots of patience after the transplant. I wish our team would have told
me the possible mental-state Dave might be in. Don’t force them to be thankful. Don’t play the
‘remember when’ game, “remember when I drove you to the ER in the middle of the night?
Remember when they told us you had cancer? Remember when I tried to be your donor?”
Because a lot of it he doesn’t remember.
• Take pictures along the way, but don’t show them until at least 6 months out. I showed Dave
pictures right away, and they didn’t resonate. I just showed him them the other night…and he
was floored! He really ‘got it’. He’s been looking at things differently lately: he’s calmer and
more loving.
• I wish I had kept a journal. The ups and downs of this journey were sometimes excruciating, and
Dave wasn’t ‘present’ to understand it. Hire cleaning help if needed. Get family and friends to
take the patient to lesser important appointments. Don’t let household things pile up on you. Fix
the gutter. Repair the screen. Hire a gardener for a few hours. Ask family to set things up for
you. It’s amazing how in two years without Dave to physically help around the house, things
started to go south pretty quickly! Luckily, I dug in and kept up.

Quite the journey for sure. I feel blessed to be on this side of health!”

– Karen

Hepatitis Delta (HDV)

Hepatitis Delta: Coinfection vs. Superinfection

By Sierra Pellechio, Hepatitis Delta Connect Coordinator

Hepatitis delta is an aggressive form of hepatitis that can only exist alongside hepatitis B. This means that all hepatitis B patients are at risk for hepatitis delta, but so are people who have not received the hepatitis B vaccination series.

If contracted, 70-90% of people with chronic hepatitis B will go on to also develop a chronic hepatitis delta infection – called a “superinfection”. Approximately 70% of these cases will progress to cirrhosis (liver scarring), compared to 15-30% of those infected only with the hepatitis B virus.

Due to the likelihood of liver complications, hepatitis B patients should be aware of potential exposures to hepatitis delta. The virus is spread the same way as hepatitis B, through direct blood-to-blood contact and unprotected sex with an infected person. It is important to be aware that blood contact could also occur by exposure to unsafe blood transfusions, unsterile medical or dental equipment, and the sharing of razors or toothbrushes with an infected person due to the possibility of infected blood entering the body.

People who are not infected with hepatitis B may be at risk for “coinfection”, when someone contracts hepatitis B and delta simultaneously during one exposure. In these cases, greater than 90% of adults will clear both infections and develop protective antibodies. While a co-infection generally resolves spontaneously after about 6 months, it can sometimes result in a life-threatening or fatal liver failure.

The good news is that the hepatitis B vaccine series can prevent both viruses in people who are not already infected. Once completed, the vaccine can provide a lifetime of protection!

For more information about hepatitis B/delta coinfection, please visit www.hepdconnect.org or email us at connect@hepdconnect.org.

Hepatitis B Prevention

Who’s at Risk for Hepatitis B? Learning the Hep B Basics

 

Are you or someone you know at risk for hepatitis B? You might be more at risk than you think, and since hepatitis B is vaccine preventable, it makes sense to get tested and vaccinated for HBV.  Hepatitis B is the number one cause of liver cancer worldwide. The survival statistics for liver cancer are particularly grim, with a relative 16,6% 5-year survival rate.  The hepatitis B vaccine also protects against hepatitis delta, the most severe form of viral hepatitis.

It is important to note that everyone is susceptible to hepatitis B. It does not discriminate.  It infects, babies, children, teens, adults and seniors. It has no racial or religious bias, though it is certainly more prevalent among certain ethnic groups –mainly because it is endemic to the homelands of these communities. For example, if you look at the prevalence map for hepatitis B, you will see that in most of the world, hepatitis B is at an intermediate, (2-7%) or high HBsAg prevalence (>8%) level.  Looking at the numbers, 2 billion people in the world, that’s 1 out of 3 people, have been infected with HBV and 257 million are chronically infected. That represents three-quarters of our world. Even if you aren’t living in these parts of the world, you may be traveling to some of these areas for work or pleasure, or perhaps your parents and other family members were born in HBV endemic areas.  Since there are often no symptoms for HBV, and screening and vaccination may be lacking in some populations, HBV is transmitted from one generation to the next, with many completely unaware of their HBV status – until it’s too late.

People at risk for hepatitis B include the following: (not noted in a particular order)

  • Health care providers and emergency responders due to the nature of their work and potential for exposure.
  • Sexually active heterosexuals (more than 1 partner in the past six months)
  • Men who have sex with men (MSM)
  • Individuals diagnosed with a sexually transmitted disease (STD)
  • Illicit drug users (injecting, inhaling, snorting, pill popping)
  • Sex contacts or close household members of an infected person (remember, you may not know who is or is not infected)
  • Children adopted from countries where hepatitis B is common (Asia, Africa, South America, Pacific Islands, Eastern Europe, and the Middle East) and their adopted families
  • Individuals emigrating from countries where hepatitis B is common (see above)
  • Individuals born to parents who have emigrated from countries where hepatitis B is common (see above)
  • ALL pregnant women – because infants are so vulnerable to HBV (90% of infected infants will remain chronically infected, and HBV is very effectively transmitted from infected mother to baby.)
  • Recipients of a blood transfusion before 1992
  • Recipients of unscreened blood and blood products – sadly an issue in many parts of the world.
  • Recipients of medical or dental services where strict infection control practices are not followed – sadly another issue in parts of the world.
  • Kidney dialysis patients and those in early renal failure
  • Inmates of a correctional facility
  • Staff and clients of institutions for the developmentally disabled
  • Individuals with tattoos and body piercings performed in a parlor that does not strictly adhere to infection control practices – it may be up to you to ensure proper infection control practices are followed.
  • People living with diabetes are at risk if diabetes-care equipment such as syringes or insulin pens are inadvertently shared.

The good news is that hepatitis B is a vaccine preventable disease. There is a safe and effective, 3-shot HBV vaccine series that can protect you and your loved ones from possible infection with HBV.  The earlier you are vaccinated, the better. In the US, a birth dose of the vaccine is recommended for all infants, since these little ones are most vulnerable to hepatitis. (90% of infected infants will live with HBV for life). HBV vaccination doesn’t give you a free-pass from other infectious diseases such as HCV or HIV, both without vaccines, so strict infection control practices should still be followed. However, HBV is a tenacious virus that survives outside the body for a week and is 50-100 times more infectious than HIV  3-5 times more infectious than HCV.  Plus the HBV vaccine is actually an anti-cancer vaccine, so why not get vaccinated?

Hepatitis B isn’t casually transmitted, but in the right scenario, it is effectively transmitted. You may think that situation may never come about for you, or for your loved ones –especially your little ones who are so vulnerable to HBV. Some people travel to exotic lands with unsafe blood supplies and poor infection control practices, and sometimes they get sick, or require emergency dental or medical services, so they may be put at risk. Most people have had a lapse in judgment – sometimes it’s a one-time thing, sometimes it lasts for years, but the net-net is that it’s unusual to find someone who has not engaged in some sort of high-risk activity, whether intentionally or unintentionally. If you are properly vaccinated to protect against hepatitis B, you can cross that concern off your list.

B sure. Get screened. if you do not have HBV, get vaccinated and be hepatitis B free. If you discover you have HBV, talk to your doctor and have him refer you to a liver specialist who can better evaluate your hepatitis B status and your liver health.

Hepatitis B Diagnosis & Monitoring, Hepatitis B Prevention, Hepatitis Delta (HDV)

Hepatitis D Coinfection with Hepatitis B

Hepatitis D virus (HDV) – the “D” is for delta – is a viral enigma that doesn’t act like a normal virus. It is helpless – that is, it can’t infect a cell – without its viral accomplice, the hepatitis B virus (HBV), and makes infection with HBV worse.

Delta virus can only cause illness in those already infected with HBV, said Timothy Block, Ph.D., President and Co-Founder of the Hepatitis B Foundation, Professor and Director, Drexel University Institute for Biotechnology and Virology Research.

“It can take quiescent HBV and turn it into an acute, lethal viral infection,” Block said. “Liver disease – cirrhosis, liver failure – that might take decades to develop or could only take a year or two. Delta virus converts HBV infection into an emergency situation.”

“It’s one of the most severe forms of human viral hepatitis,” said Jeffrey Glenn, MD, Ph.D., Associate Professor of Medicine at Stanford Cancer Institute.

“Delta virus is a parasite of HBV because it encodes its own genome and coat-like protein but it doesn’t make its own envelope protein,” Glenn explained. “It steals that from HBV. It needs the B envelope protein to make its own, and this provides a means to infect new cells and subsequently make a fully formed viral particle to get out of those cells to infect others.”

Individuals can acquire delta virus two ways: Either after infection with HBV, which is called a “superinfection” and more likely to stay chronic, or a “co-infection”, which entails becoming infected with both viruses at the same time. In the latter, acute infections are more severe and increase the likelihood of developing liver disease much more quickly.

Worldwide, more than 15 million are infected, though fewer than 100,000 in the U.S. have the virus. It is concentrated in particular regions worldwide. Mediterranean areas such as southern Italy and southern Greece, for example, have larger than usual numbers of affected individuals, and in Turkey it is endemic. There are eight reported genotypes of HDV, which vary by geographical distribution and pathogenicity. Some believe that HDV’s incidence is declining. This is likely due to the hepatitis B vaccined and the resulting decrease in HBV carriers.

Because HDV is not a huge problem in the U.S., it flies under the radar screen of public awareness. Screening for HDV is not routinely ordered; however, infection with delta virus should always be considered when a patient with chronic liver disease suddenly gets worse.

Researchers have been frustrated in their attempts to develop effective treatments against HDV. Newer antiviral drugs that keep down levels of HBV DNA don’t do much against delta virus because they don’t affect the HBV envelope protein. The response rate to pegylated interferon alpha is typically poor.

With research there is always hope. Currently, there is a clinical trial of lonafarnib for the treatment of those coinfected with hepatitis B and D in the United States. It was originally developed for the treatment of different types of cancers. Perhaps additional information will come out of this year’s International Meeting on Molecular Biology of Hepatitis B Viruses. We shall soon hear.

Hepatitis D Fast facts:

—   Delta hepatitis is one of the most severe forms of viral hepatitis.

—   It is an incomplete viral particle that was discovered in 1977.

—   Approximately 15 million people are infected with HDV worldwide.

—   In the U.S., an estimated 6,000-13,000 people suffer acute HDV infection 
each year; 30,000 suffer from chronic HDV; and 1,000 Americans die 
from HDV-related diseases annually.

—   It is transmitted by blood from people already infected with hepatitis B.

—   Preventing hepatitis B, especially vaccination, will prevent HDV.

—   There is currently no effective treatment for HDV

Baruch S. Blumberg Institute