A new page has been created on the Hepatitis B Foundation’s website that contains a compilation of various opportunities available for people living with hepatitis B. These opportunities can be for clinical trials, other types of research, or toolkits with information and resources for those living with hepatitis B and their loved ones and community members. All of these postings are produced or organized by entities external to HBF, but all are related to improved quality of life and liver health. The first two of these opportunities are listed below.
New Tool from CME Outfitters
A new HBV Patient Education Hub has been compiled by continuing medical education company CME Outfitters. The hub includes a great deal of valuable information, such as an overview of hepatitis B, a list of questions to ask your healthcare provider, a patient guide, information about hepatitis B co-infection, doctors’ advice on what to expect from treatment, and many other resources. All information is in an engaging and accessible format. Check it out today!
New Study Opportunity Available for People Living with Itching (Cholestatic Pruritus) Due to Liver Disease or Injury
A new paid opportunity has become available for those experiencing itching caused by hepatitis B, hepatitis C, drug-induced liver injury, auto-immune hepatitis, or primary sclerosing cholangitis (PSC). If you live in Canada or the US and have this condition, you may be eligible to participate in an interview to help researchers better understand your lived experience. The new research study is seeking participants ages 12-80 living in the US and Canada who are living with this itch. This is an opportunity to be involved in research and help advance scientific understanding! Contact the research coordinator for more information and to check if you are eligible.
Please note that this study does not include treatment and pruritus must be at an intensity level of 4 on a scale of 1-10 for at least the past 8 weeks in order to participate. Patients cannot be pregnant or breastfeeding or have a diagnosis of primary biliary cholangitis.
We are very excited to unveil this new section of our website and hope it will be a useful resource for many going forward! Please check back often, as more opportunities will be posted as they arise.
SHEA Updated Guidelines on Health Care Workers Living With Hepatitis B, Hepatitis C, and Human Immunodeficiency Virus
Many health care students and professionals in the U.S. are living with hepatitis B, hepatitis C or HIV. Living with these conditions should not interfere with a person’s health care education or professional career. It is important that health care students and professionals are aware of their rights and responsibilities – and equally important that health care schools and institutions are aware of their responsibilities, as well. There are now new guidelines to help institutions understand how to manage health care professionals living with hepatitis B, hepatitis C or HIV.
Health care workers should have a complete vaccination series for hepatitis B. Learn more about the vaccination series
Health care professionals living with HBV who do not perform exposure-prone procedures should not be prohibited from participating in patient-care activities solely on the basis of their HBV infection
Health care personnel living with HBV should seek optimal medical management, including, when appropriate, treatment with effective antiviral agents
Consistent with CDC guidelines, there is no justification for, nor benefit gained from, notifying patients with regard to health care professionals living with HBV who are being managed through an institution’s oversight panel
Some of the important updated recommendations for health care workers living with hepatitis C includes:
Because of the opioid epidemic in the United States, consideration should always be given to the possibility of substance use disorder when health care professional-to-patient transmission of a bloodborne pathogen is detected
Health care professionals living with HCV should seek optimal medical management, including treatment with effective antiviral agents to achieve cure of the infection
Health care professionals living with HCV who received treatment resulting in ‘undetectable’ circulating HCV-RNA levels can perform exposure-prone procedures with some stipulations:
Has not been previously identified as having transmitted infection to patients following definitive therapy resulting in a sustained virologic response (SVR)
Provides the oversight panel with records and laboratory results (or permits the HCP’s personal physician to provide records and laboratory results) confirming receipt of treatment and SVR
Has achieved SVR by remaining HCV RNA negative for 12 weeks following the completion of therapy
Some of the important updated recommendations for health care workers living with HIV:
Health care professionals living with HIV and who, despite appropriate antiretroviral treatment, have a confirmed viral load >200 copies/mL should not perform exposure-prone procedures until they have achieved virologic suppression
Scientists acknowledge that when the viral load is undetectable = untransmittable
Health care professionals living with HIV whose confirmed viral load is below 200 copies/mL can perform exposure-prone procedures with some stipulations:
Has not been previously identified as having transmitted infection to patients while receiving appropriate suppressive therapy
Obtains advice from an oversight panel about recommended practices to minimize the risk of exposure events
Is followed by a physician who has expertise in the management of HIV infection and who is allowed by the individual to participate in or communicate with the oversight panel about the individual’s clinical status
Is monitored on a periodic basis (eg, every 6 months) to assure that the HIV RNA remains below the level of detection, with results provided to the oversight panel.
Is followed closely by their physician and the oversight panel instances in which fluctuations in HIV viremia occur, including appropriate retesting as discussed above to reevaluate the HCP’s viral load
Agrees, in writing, to follow the recommendations of the oversight panel
Henderson, D., Dembry, L., Sifri, C., Palmore, T., Dellinger, E., Yokoe, D., . . . Babcock, H. (2020). Management of healthcare personnel living with hepatitis B, hepatitis C, or human immunodeficiency virus in US healthcare institutions. Infection Control & Hospital Epidemiology, 1-9. doi:10.1017/ice.2020.458
Author: Evangeline Wang, Program Coordinator, Hepatitis B Foundation
Hepatitis B and Discrimination of Health Care Students
Hepatitis B virus (HBV) infection affects more than 290 million persons globally and up to 2.2 million persons in the United States. Living with hepatitis B can mean living with stigma and facing discrimination. Stigma related to hepatitis B is often caused by low awareness from the general public and health care providers. Low awareness can lead to fear and misconceptions about the disease. Discriminatory practices that affect health care students with hepatitis B infection may include unjustified denial of school admission or enrollment, restriction of clinical training, or dismissal from an academic program. Given substantial progress in hepatitis B research and treatment in recent decades, it is important to address discriminatory policies that affect health care students.
Kate Moraras, Deputy Director of Public Health at the Hepatitis B Foundation led a research project which found that 36 accredited health care programs in Pennsylvania (43%) had policies which appear to be discriminatory against students living with hepatitis B. These policies included requiring proof of hepatitis B immunity for enrollment or program completion. Failure to produce proof could result in revocation of program admission or not being allowed to enter clinical rotations. This is problematic because the Americans with Disabilities Act (ADA) protects individuals living with hepatitis B. The Department of Justice (DOJ) states that there is no lawful basis for excluding persons living with hepatitis B from health profession schools. Not only does the DOJ protect individuals living with hepatitis B, but the Centers for Disease Control and Prevention (CDC) states that health care students with hepatitis B pose no risk to patients and should not be limited in their health care education. The CDC recommends that health care students should not be arbitrarily excluded or restricted from activities that could impede practice or studies. They additionally recommend hepatitis B testing only for healthcare providers at increased risk of infection or conducting invasive, exposure-prone procedures and most health care students are not participating in these invasive procedures. If you want to know what to do if you are facing discrimination visit the Know Your Rights section of our website.
Resources
Please join Hep Free Hawai’i, ACLU Hawai’i, the National Task Force on Hepatitis B: Focus on AAPIs, Hep B United, and Hepatitis B Foundation on October 15th at 6PM ET to address hepatitis B discrimination among health care students. Dr. Chari Cohen, Senior Vice President of the Hepatitis B Foundation and Taylor Mangan, University of California President’s Public Service Law Fellow at ACLU Hawai’i will discuss hepatitis B related institutional discrimination against health care students, current protections and recommendations in place to protect health care students from discrimination. Register here.
The Hepatitis B Foundation’s website has an entire page focused on the rights of individuals living with hepatitis B. Check it out each section:
Moraras, K., Block, J., Shiroma, N., Cannizzo, A., & Cohen, C. (2020). Protecting the Rights of Health Care Students Living With Hepatitis B Under the Americans With Disabilities Act. Public Health Reports, 135(1_suppl), 13S-18S. https://doi.org/10.1177/0033354920921252
Author: Evangeline Wang, Program Coordinator, Hepatitis B Foundation
Happy Liver Cancer Awareness Month! Your liver is an important organ for digesting food and breaking down toxins. Its main functions include: filtering blood from the digestive tract and transporting it back to the rest of the body, removing toxins from the blood, and storing important nutrients that keep the body healthy.
Hepatitis B is a viral infection of your liver that can cause serious damage over time. Chronic infection with the hepatitis B virus (HBV) can ultimately lead to scarring, cirrhosis, liver cancer, and liver failure. Liver cancer is the 3rd deadliest cancer worldwide, with 5-year survival rates of only 19%. There are few effective treatments for liver cancer, and we, therefore, must rely on prevention and early detection in order to save lives. Chronic hepatitis B infection causes approximately 78% of hepatocellular carcinoma (HCC), or primary liver cancer. The key to saving lives is ensuring that individuals infected with HBV are diagnosed and linked with appropriate care, including regular screening for liver cancer.
In the U.S., liver cancer incidence and death rates are increasing at a faster rate than any other cancer and are projected to continue to rise through at least 2030. Up to 2.2 million people are chronically infected by HBV in the U.S. and the majority is unaware of their infection. Identifying, managing and treating those with HBV infection can help prevent liver cancer in many people. Additionally, regularly screening people with chronic hepatitis B for liver cancer can aid with early detection and treatment of liver cancer. If diagnosed early, liver cancer can be treated and even cured.
Below are some practices you can easily incorporate into your daily life and routine to keep your liver healthy while living with hepatitis B.
Healthy Liver Tips
Reduce alcohol intake: Alcoholic beverages can damage or destroy liver cells and create additional health problems.
Eat a healthy diet: Increase the amount of whole foods in your diet like fruits and vegetables while decreasing the amount of refined carbohydrates (pastas, white rice, white bread), processed sugar, and saturated fats which can create a healthy environment for your liver.
Daily exercise: It is recommended for adults to exercise at least 60 minutes per day. Not only does this have many other health benefits, but it can reduce the fat surrounding your liver which can decrease your risk of liver cancer.
Avoid the use of illicit drugs: Drugs like marijuana, cocaine, heroin, inhalants, or hallucinogens put stress on your liver and reduce its functioning capability.
Wash produce and read labels on household chemicals: Pesticides and other chemicals can contain toxins which are harmful to your liver.
Incorporating these healthy practices does not have to be difficult. Choose one of the five tips that is most convenient with your current lifestyle and use it as a starting point for a healthier routine. By gradually incorporating each healthy liver tip into your lifestyle, you can reduce your risk of a negative liver outcome creating a healthier you!
Resources for Liver Cancer and Hepatitis B
Please join Hepatitis B Foundation, Hep B United and Hep B United Philadelphia’s webinar on October 20th at 3PM ET to learn more about hepatitis B and liver cancer. Dr. Kenneth Rothestein, Director of Regional Outreach and Regional Hepatology from Penn Medicine will be highlighting the importance of liver cancer screening for prevention. Register here!
The CDC’s Know Hepatitis B Campaign’s infographic, “Get Tested for Hepatitis B” encourages Asian Americans and Pacific Islanders to get tested for hepatitis B. This 2-page downloadable document is available in English, Traditional Chinese, Vietnamese and Korean languages and answers commonly asked questions about hepatitis B.
For more information about the Know Hepatitis B Campaign, visit the campaign website.
Author: Evangeline Wang, Program Coordinator, Hepatitis B Foundation
On Monday September 21st, a virtual celebration was held in honor of the sixth anniversary of National African Immigrant and Refugee HIV and Hepatitis Awareness (NAIRHHA) Day. This day, which itself is commemorated on September 9th, was created to build awareness and dismantle stigma around HIV and viral hepatitis in African immigrant and refugee communities. It takes place in September because this is the month that has been designated as National African Immigrant Month (NAIM) in the United States to celebrate the diverse and remarkable contributions African immigrants have made to enrich the United States, in spheres ranging from sports to writing to politics.
The virtual celebration that occurred last Monday included a discussion of the history of NAIRHHA Day and how it came to exist in its present form, a conversation with a hepatitis B advocate who is living with the disease, discourse about the importance of NAIRHHA Day on the national level and implications for making it a federally recognized day, and trivia questions about HIV and hepatitis B.
History of NAIRHHA Day: The Journey from 2014 to Present
Moderator: Chioma Nnaji, MPH, MEd, Program Director, Multicultural AIDS Coalition
Panelists: Augustus Woyah, Program Officer for Minority AIDS Initiative, Maryland Department of Health
Amanda Lugg, Director of Advocacy and LGBTQ Programming, African Services Committee
The idea for NAIRHHA Day was first conceived in 2006 at a convening of the Ethiopian Community Development Corporation in Washington, DC, at a session sponsored by Office of Minority Health about HIV in African immigrant communities. Conferences started to occur, primarily in the Northeast, although there was also interest in Atlanta and Seattle. It seemed that an opportunity had finally become available for advocates, researchers, and providers to all come together and focus on data collection, community mobilization, and policy work around HIV and viral hepatitis in African immigrant communities. The African National HIV/AIDS Alliance was established in 2010 and awareness days started in 2012 (Augustus played a large role in this). In 2014, Chioma Nnaji became connected to Sylvie Bello, the Executive Director of the Cameroonian Association in Washington, DC, and they, along with Amanda and Augustus, worked to get NAIRHHA Day off the ground. Chioma has largely spearheaded efforts to have NAIRHHA Day recognized nationally.
In terms of some of the challenges that have and continue to exist around NAIRHHA Day, obtaining community leadership and organizational buy-in, as well as national attention, are at the forefront. Social media and other digital platforms have been widely used in order to amplify the cause and try to obtain federal recognition. Additionally, maintaining relationships with government agencies has been quite difficult and has become a clash of visions of sorts. There is a strong belief that NAIRHHA Day should be a community-driven effort, but government agencies often have their own priorities, which can be distinct from those of the community and grassroots organizers. This is not to discount the government and organizational partners that are still involved, however, including NASTAD, the Hepatitis B Foundation, CHIPO, CHIPO-NYC, and Africans for Improved Access at the Multicultural AIDS Coalition. Another challenge has been reinforcing the distinction between African immigrant and African American communities and not treating the Black community as a monolith. Drawing this distinction in both data and policy remains difficult, thus often rendering African immigrant communities invisible.
When pondering what areas could use improvement going forward, a number of different items were considered. These included incorporating COVID-19 into the conversation, along with viral hepatitis and HIV; addressing social and environmental determinants of health that lead to the over-prevalence of both infectious and non-communicable diseases in minority, and particularly African immigrant communities; adhering to the primary goal of community mobilization and including advocates and researchers to influence policy that provides linguistically and culturally appropriate services that address the most pressing issue of stigma; securing national attention; and obtaining resources. It is critical to remember that advocacy never ends, the need to magnify work and amplify voices is always present, there is no room for complacency, and there exists intersectionality in all issues (social and health justice are all-encompassing).
#justB Storyteller Interactive Discussion
Moderator: Farma Pene, Community Projects Coordinator in Viral Hepatitis Program, New York City Department of Health & Mental Hygiene
#justB Storyteller: Bright Ansah
In this session, Bright spoke about his experience with living with hepatitis B, including his diagnosis, treatment, and communication with his family. He spoke about being able to put a face to hepatitis B, which has helped many people and also allowed him to build strong relationships with a broader community. Bright found out about his status in 2014 and initially felt very lost. The first couple of years were a big struggle, as he did not want to worry his family and it took a while for him to come to peace with his diagnosis. This peace eventually came from a lot of extensive research, after which he found out that hepatitis B is not a death sentence and can be managed very well. He then started to think about what he could do to prevent someone else from becoming “a statistic.”
When asked what message he would share with newly diagnosed people, Bright stated that stress and anxiety are normal, but you are not alone. Every day, people find out they are infected. Bright has given his contact information to many different people and he emphasized the incredible importance of having a support system in place. When asked about how he overcame stigma and barriers, Bright replied that the biggest barrier is the mental hurdle. It took him about two years to not feel overwhelmed. Bright does still struggle with feeling rejected from clinical trials and finds this very frustrating – he still feels like he is being punished for having chronic hepatitis B.
The best advice that Bright can offer is to always be your own advocate and do your own research. If the first doctor or liver specialist that you find does not take you seriously or you feel that they are not doing enough for you, you do not need to stay with them and you can absolutely find another doctor. Bright went through this process himself and eventually found a doctor he likes at Johns Hopkins, through a friend of his. This can be a challenge with language barriers, but there are organizations that can help and there is a Specialist Directory tool on the Hepatitis B Foundation website, a resource that Bright stated he found very helpful, along with the website of the National Institutes of Health (NIH). Farma reiterated that the HBF website is a great place to visit to understand lab results in plain language, and offers a good collection of resources for family and community members of people living with hepatitis B. Bright finds that the most important questions to ask are: What exactly is your status and viral load? What should reasonable expectations for your life and health be? Is treatment appropriate and if so, which one? It is crucial to establish mutual respect with your doctor, and to iterate what expectations you have for your doctor as well. The most important messages are: Reach out. Ask questions. Stand up for yourself. You are not alone.
The Important Role that NAIRHHA Day Plays from a National and Policy Prospective
Moderator: Chioma Nnaji, MPH, MEd, Program Director, Multicultural AIDS Coalition
Panelists: Boatemaa Ntiri-Reid, JD, MPH, Hepatitis Director, NASTAD
Jennease Hyatt, Community Liaison for Boston/New England, GILEAD
The final conversation focused on why NAIRHHA Day should become a nationally recognized holiday. VIral hepatitis is the seventh leading cause of death globally. Nineteen million African adults are living with hep C, and 5-8% are living with hep B. Hep B and HIV need to be considered part of the health portfolio of African immigrants, with care taken that this does not compound stigma. NAIRHHA Day is really an opportunity to focus on this community specifically. You get things done by doing them yourselves and we are who we’ve been waiting for.
There is a strong need for a multi-faceted approach to this work and for local, state, and national partnerships. African immigrants need to be at the forefront of the HIV/AIDS conversation. In Massachusetts specifically, over half of new HIV infections are in immigrant communities: These communities need to be leading the conversation. In terms of the role that government agencies play in NAIRHHA day, this needs to be more than a supportive role. We need to talk about novel approaches. We know that there are healthcare disparities. We need to consider how to use funding to build capacity and engagement, and make sure this work moves forward. This should include counting in community members and small businesses and bringing people to the table who are not usually there. The community really wants to be engaged. Promoting testing and awareness at soccer games, for example, is a great idea. We need strong partnerships and leadership from the beginning and to determine different approaches and thus different outcomes. Community members are the experts and we need to treat them as such.
Across the country, there are jurisdictions that have a prevalence of 40,000 people living with hepatitis in a state and viral hepatitis staff have teams of 1-7. Local and state health departments have more of a role to play. CDC publishes a list of viral hepatitis coordinators by state. It would be great to close the gap with them and discuss more about what they are doing generally and how to get them more involved in NAIRHHA Day specifically. In thinking about a vision for NAIRHHA Day next year, thoughts included that everyone who serves African immigrant communities (including health centers and multi-service organizations) needs to see themselves as part of the solution. Additionally, federal representation should be part of NAIRHHA Day next year.
Trivia and Conclusion
The event concluded with trivia questions about HIV and hepatitis B prevention, testing, and treatment. Amazing music was provided by DJ WhySham and Laura O (@LauraO_TV) served as an excellent moderator. Thanks to everyone who participated and we look forward to another wonderful event next year!
Hepatitis B is the most common serious liver infection in the world. Your liver is a vital organ which functions as your body’s engine. It processes toxins, stores vitamins, controls production and removal of cholesterol, produces immune factors, and releases bile to assist proper digestion. Hepatitis B may greatly inflame and damage the liver so it cannot perform these important processes efficiently. If left untreated, hepatitis B can cause severe damage such as fibrosis, cirrhosis, and liver cancer and lead to liver failure.
Smoking and Your Liver
Smoking itself may not directly cause liver cancer, though it can dramatically increase the risk for cancer in individuals who have other risk factors, such as a chronic hepatitis B infection (1). Carcinogenic chemicals in cigarettes can cause further damage to liver cells that are already at risk for cancer due to hepatitis infection. Research has found a strong association between chronic hepatitis B and C infections and smoking cigarettes as established risk factors for liver cancer (2). For example, research has found that smoking contains chemicals with cytotoxic potential which increasesnecroinflammation and fibrosis. Additionally, smoking increases the production of proinflammatory cytokines that are involved in liver cell injury (2).
Smoking and Hepatitis B
A 2010 study from the International Prevention Research Institute found anadditive interactionbetween hepatitis B infections and cigarette smoking. Smoking seemed to interact with both hepatitis B and C infections, and the results of the study suggest asynergistic effect between smoking and hepatitis infections on the risk of liver cancer (1). For example, a study conducted in China found that individuals who smoke and live with hepatitis B have a higher risk for liver cancer because the liver’s processes are impaired from the toxic chemicals from long-term cigarette use (3).
There is no “right” way to quit smoking; it can be cold turkey or gradual – it is your personal decision. If you are interested or considering quitting smoking or looking for alternatives to cigarettes, visitthis website for some great tips and recommendations to help you quit.
References
Chuang, S. C., Lee, Y. C., Hashibe, M., Dai, M., Zheng, T., & Boffetta, P. (2010). Interaction between cigarette smoking and hepatitis B and C virus infection on the risk of liver cancer: a meta-analysis. Cancer epidemiology, biomarkers & prevention : a publication of the American Association for Cancer Research, cosponsored by the American Society of Preventive Oncology, 19(5), 1261–1268.https://doi.org/10.1158/1055-9965.EPI-09-1297
Liu, X., Baecker, A., Wu, M., Zhou, J. Y., Yang, J., Han, R. Q., Wang, P. H., Jin, Z. Y., Liu, A. M., Gu, X., Zhang, X. F., Wang, X. S., Su, M., Hu, X., Sun, Z., Li, G., Mu, L., He, N., Li, L., Zhao, J. K., … Zhang, Z. F. (2018). Interaction between tobacco smoking and hepatitis B virus infection on the risk of liver cancer in a Chinese population. International journal of cancer, 142(8), 1560–1567.https://doi.org/10.1002/ijc.31181
Authors:
Shrey Patel, University of Pennsylvania School of Dental Medicine
Kelli Sloan, University of Pennsylvania School of Social Policy and Practice
Evangeline Wang, Public Health Program and Outreach Coordinator, Hepatitis B Foundation
ASCO: Updated Guidelines for Hepatitis B Screening
The American Society of Clinical Oncology (ASCO), recently updated their hepatitis B screening guidelines. The Provisional Clinical Opinion on hepatitis B is based on a rigorous, evidence-based approach and is periodically updated to reflect recently published data.
Recommendations
The American Society of Clinical Oncology updated their 2020 guidelines on hepatitis B and cancer screening. Most importantly, ASCO recommends universal screening for hepatitis B for patients undergoing cancer therapy. ASCO states that all cancer patients anticipating systemic anticancer therapy should be screened for hepatitis B through three tests. People living with chronic hepatitis B (HBV) receiving any systemic anticancer therapy should receive antiviral prophylaxis for the duration of anticancer therapy, as well as for at least 12 months after receipt of the last anticancer therapy. Antiviral therapy and management for cancer patients should follow national HBV guidelines, independent of cancer therapy, including management by a clinician experienced in HBV management for prevention of liver diseases such as cirrhosis or liver cancer. Patients with past HBV receiving anticancer therapies associated with an established high risk of HBV reactivation should be started on antiviral prophylaxis at the beginning of anticancer therapy and continued on antiviral therapy for at least 12 months after anticancer therapy ends. Patients with past HBV infection undergoing anticancer therapies that are not clearly associated with a high risk of HBV reactivation should be followed carefully during cancer treatment, with HBsAg and ALT testing every 3 months.
Risk Factors for HBV Reactivation
The article states a few risk factors for hepatitis B reactivation. These risk factors include types of cancers, various anticancer therapies, immunotherapy, radiation therapy and transarterial chemoembolization, other B-cell agents, and special situations. Because of these risk factors for hepatitis B reactivation, it is important for health care professionals to screen for hepatitis B prior to cancer treatment.
What Does This Mean for Providers
Oncologists and healthcare providers have a responsibility to screen their cancer patients for hepatitis B prior to treatment. Screening is especially important among vulnerable populations such as persons of Asian, Pacific Islander and African descent who are disproportionately affected by hepatitis B.
What Does This Mean for Patients
Patients with cancer should also advocate for themselves in healthcare settings to ask for a hepatitis B panel screening before treatment. Your provider will be able to interpret your test results, but here is a simple table to help you understand your hepatitis B panel screening results.
Hwang, J. P., Feld, J. J., Hammond, S. P., Wang, S. H., Alston-Johnson, D. E., Cryer, D. R., Hershman, D. L., Loehrer, A. P., Sabichi, A. L., Symington, B. E., Terrault, N., Wong, M. L., Somerfield, M. R., & Artz, A. S. (2020). Hepatitis B Virus Screening and Management for Patients With Cancer Prior to Therapy: ASCO Provisional Clinical Opinion Update. Journal of clinical oncology: official journal of the American Society of Clinical Oncology, JCO2001757. Advance online publication. https://doi.org/10.1200/JCO.20.01757
Author
Evangeline Wang, Public Health Program and Outreach Coordinator at the Hepatitis B Foundation
Commemorating National African Immigrant and Refugee HIV & Hepatitis Awareness (NAIRHHA) Day 2020
Each year in September, the Hepatitis B Foundation, along with partners around the U.S., recognizes National African Immigrant and Refugee HIV and Hepatitis Awareness (NAIRHHA) Day. Founded by advocates in Massachusetts, Washington D.C., and New York, NAIRHHA Day has been observed annually on September 9th by healthcare professionals, awareness campaigns, and other organizations since 2014. Although not yet nationally recognized, the Multicultural AIDS Coalition (MAC) and the Coalition Against Hepatitis for People of African Origin (CHIPO) are working to establish NAIRHHA day as its own federally designated awareness day. As explained by Chioma Nnaji, Director at the Multicultural AIDS Coalition’s Africans For Improved Access (AFIA) program, there is a great need to establish NAIRHHA day as its own day. “Several of the current awareness days are inclusive of African immigrant communities, but do not comprehensively address their unique social factors and cultural diversity, as well as divergent histories and experiences in the US.”
Why NAIRHHA Day?
People born outside of the U.S. often face different health challenges than those born in the country and face various barriers to accessing important healthcare services. African immigrants (AI) are disproportionately burdened by HIV and hepatitis B. Advocates for NAIRHHA Day recognized the need to address these health issues in the community and thought that a combined awareness day would be the most effective way to reach the largest number of people impacted.
Hepatitis B presents a significant public health burden for many African countries, and subsequent immigrant populations living in the United States. Although data is limited on hepatitis B infection among African immigrant (AI) and refugee communities in the U.S., studies have shown infection rates are high – between 5 and 18%1,2,3,4,5. One community study in Minnesota even found AIs accounting for 30% of chronic hepatitis B infections 6. AI communities are also known to be disproportionately affected by HIV/AIDS, with diagnosis rates six times higher than the general U.S. population7. Despite this alarming disparity, HIV and hepatitis B awareness, prioritization, and funding has remained limited for this population.
Two of the largest barriers to testing for HIV and hepatitis B among African immigrants are lack of awareness and stigma. Cultural and religious values shape the way people view illness, and there can be fears around testing and diagnosis of illness, and moral implications for why someone may feel they are at risk. While stigma about HIV/AIDS and hepatitis B often come from within one’s own community and culture, it is primarily driven by lack of awareness. Oftentimes, awareness is low in an individual’s home country because of limited hepatitis and HIV/AIDS education, resources, and healthcare infrastructure. When they arrive in the U.S., awareness remains low for similar reasons. Community health workers and physicians are vital stakeholders to raise community awareness in a culturally sensitive way to help identify current infections and prevent future ones through vaccination.
Commemorating NAIRHHA Day in 2020
Recognizing NAIRHHA Day is important to address the numerous barriers to prevention and treatment that African immigrants face. It was also founded to acknowledge the cultural and ethnic differences that influence how African-born individuals interact with their medical community and the concept of illness. The specific goals of this day of recognition include:
Raising awareness about HIV/AIDS and viral hepatitis to eliminate stigma;
Learning about ways to protect against HIV, viral hepatitis and other related diseases;
Taking control by encouraging screenings and treatment, including viral hepatitis vaccination;
Advocating for policies and practices that promote healthy African immigrant communities, families, and individuals.
This year, CHIPO, Multicultural AIDS Coalition, Hepatitis B Foundation and CHIPO-NYC, developed a suite of social media materials to improve awareness and create action around hepatitis B. This year’s campaign is focused on the incorporation of African proverbs into health messaging around ending stigma and increasing hepatitis B and HIV awareness, screening, prevention, and treatment. All graphics and an accompanying list of posts and tweets to go with each one can be found in a Google Drive folder here. We will be promoting the materials throughout the month of September, and we invite you to share them widely. Together, we can make a difference to address HIV and viral hepatitis among African immigrant communities!
References:
Kowdley KV, Wang CC, Welch S, Roberts H, Brosgart CL. (2012). Prevalence of chronic hepatitis B among foreign-born persons living in the United States by country of origin. Hepatology, 56(2), 422-433. And Painter. 2011. The increasing burden of imported chronic hepatitis B—United States, 1974-2008. PLoS ONE 6(12): e27717.
Chandrasekar, E., Song, S., Johnson, M., Harris, A. M., Kaufman, G. I., Freedman, D., et al. (2016). A novel strategy to increase identification of African-born people with chronic hepatitis B virus infection in the Chicago metropolitan area, 2012-2014. Preventing Chronic Disease, 13, E118.
Edberg, M., Cleary, S., & Vyas, A. (2011). A trajectory model for understanding and assessing health disparities in Immigrant/Refugee communities. Journal of Immigrant and Minority Health, 13(3), 576-584.
Kowdley, K. V., Wang, C. C., Welch, S., Roberts, H., & Brosgart, C. L. (2012). Prevalence of chronic hepatitis B among foreign‐born persons living in the united states by country of origin. Hepatology, 56(2), 422-433.
Ugwu, C., Varkey, P., Bagniewski, S., & Lesnick, T. (2008). Sero-epidemiology of hepatitis B among new refugees to Minnesota. Journal of Immigrant and Minority Health, 10(5), 469-474.
Kim WR, Benson JT, Therneau TM, Torgerson HA, Yawn BP, Melton LJ 3d. Changing epidemiology of hepatitis B in a U.S. community. Hepatology 2004;39(3):811–6.
Blanas, D. A., Nichols, K., Bekele, M., Lugg, A., Kerani, R. P., & Horowitz, C. R. (2013). HIV/AIDS among African-born residents in the United States. Journal of immigrant and minority health, 15(4), 718–724.
New Drug Approved for Treatment of Hepatitis Delta in Europe
A new drug to treat hepatitis delta has now been approved by the European Commission! The drug is called bulevirtide and will be marketed under the brand name Hepcludex. It was previously known at Myrcludex B. This approval follows a quarter century of research and development and is the first drug specifically for hepatitis delta approved in Europe. Due to the high prevalence of the hepatitis delta virus in Russia and the former Soviet Union, it has been approved for use there since the end of 2019, under the name Myrcludex. The European Medicines Agency recommended the drug for approval by the Commission at the end of May 2020 (German Center for Infection Research, 2020).
How Does It Work?
Hepcludex, developed by university researchers in Heidelberg, Germany, works as an entry inhibitor – that is, it prevents hepatitis delta virus (HDV) cells, and the hepatitis B virus (HBV) cells upon which HDV depends, from entering healthy liver cells. Both HDV and HBV cells are able to replicate and thrive exclusively in the liver because they need the bile acid transporter NTCP in order to do so. This transporter is the avenue through which HDV is received into the liver cell. Hepcludex works by blocking this reception process, so that the virus does not continue to infect healthy liver cells (German Center for Infection Research, 2020). The currently infected cells either die or are destroyed by the immune system.
How Have People Responded?
Hepcludex is an injectable medication given daily for 48 weeks. In phase I and II clinical trials, people seemed to respond well to this treatment. It seems that just a small amount of Hepcludex is needed, which is good news because it means that the normal processes of the bile salt transporter (NTCP – the receptor of the hepatitis delta virus) will not be widely disrupted (German Center for Infection Research, 2020). MYR Pharmaceuticals GmbH, which now has the license for Hepcludex, is currently in the process of running further phase II and larger phase III trials, in order to continue to determine long-term effects. Hepcludex has also been tested in combination therapy with PEG Interferon, which is administered weekly also via injection (Highleyman, 2019).
Does it also work for Hep B?
Right now, Hepcludex has been tested and works to treat people with hepatitis delta. Since hepatitis delta becomes the dominant virus in those co-infected with hepatitis B and hepatitis delta, clearing hep delta will not necessarily clear hep B as well. However, the curative properties of this drug for those only affected with hep B are being investigated, both alone and in combination with PEG interferon, and there was a loss of surface antigen (HbsAg) noted in 20% of clinical trial participants who were given this combination (Highleyman, 2019).
What does this mean for patients?
Research thus far indicates that Hepcludex can be more effective than interferon alone, the existing hepatitis delta treatment, which is usually not curative and has challenging side effects (Smith, 2020). Hepcludex is now available for prescription in Europe, although pricing schemes remain unclear. For updated information on pricing and availability, check with your doctor or visit the MYR Pharmaceuticals website here.
Clinical trials will continue to take place for this and other drugs. Researchers and pharmaceutical companies might experience difficulty in recruiting patients for hepatitis delta clinical trials because of a lack of awareness and testing – many people living with hepatitis delta worldwide remain undiagnosed. It is important for people at risk for hepatitis delta to be tested and linked to care if found to be infected. If you have hepatitis delta and are interested in participating in a clinical trial, you can search for one near you. To find a doctor to talk to about getting tested for hepatitis delta if you are living with hep B, click here. Hepatitis delta can often be managed and treated, and you are not alone! The most important first step is to know your status.
What does this mean for providers?
The exact number of people living with hepatitis delta around the world is unknown and estimates range anywhere from 20-70 million. Most of these individuals remain undiagnosed due in large part to a lack of testing and diagnostics. Stephan Urban, one of the researchers leading the effort in the development of Hepcludex has said that, in the United States, fewer than 5% of those tested for hepatitis B are also tested for hepatitis delta (Smith, 2020). It is true that in much of the world diagnostic tools remain unaffordable and so Dr. Urban and his team are developing a much less expensive and rapid test. If the capacity exists, however, testing is crucial for the management of this most severe form of viral hepatitis and all of the subsequent liver conditions that can develop from it. Additionally, as with all infectious diseases, vaccination of ALL people to prevent hepatitis B is critical. Click here for more information on hepatitis delta in general and here for questions and concerns.
Highleyman, L. (2019, December 16). Combination therapies show promise against hepatitis D. Retrieved August 31, 2020, from https://www.worldhepatitisalliance.org/latest-news/infohep/3548132/combination-therapies-show-promise-against-hepatitis-d
Infection Control in Dentistry and its Connection to Hepatitis B
Hepatitis B, a major cause of liver damage and liver cancer, is a silent epidemic worldwide. It is a bloodborne infection that is commonly transmitted through blood and sexual fluids. In the dental office, it is mostly transmitted via blood. It is vital to ensure infection control practices are being followed during dental procedures such as cleanings, extractions, injections, root canals, and surgical procedures to reduce the incidence of hepatitis B.
According to a study from the Department of Periodontology and Endodontics at the State University of New York at Buffalo, unvaccinated dental health care workers have a 10 times greater risk of becoming infected with hepatitis B compared to the average citizen because of possible occupational exposure.[1] The CDC recommends that all health care providers, including those working in dentistry, be vaccinated to protect them. Patients can also play a role by ensuring that they are vaccinated as well. The hepatitis B vaccine is safe and effective and protects for a lifetime!
The transmission of hepatitis B in dental surgery can also be prevented by the routine exercise of good clinical hygiene. The dental clinic must properly and routinely dispose of needles, sterilize instruments, and comply with all standard precautions (e.g., wearing appropriate personal protective equipment and disinfecting all equipment and surfaces after each patient) for all patients. In the 2016 update of Transmission of blood-borne pathogens in US dental health care settings, the authors identified lapses in infection prevention practices and failure to adhere to Centers for Disease Control and Prevention (CDC) recommendations as the major causes behind breakouts of hepatitis B in dental settings (see CDC guidelines for the United States here).[2] Examples of lapses included the failure to heat-sterilize handpieces between patients, a lack of training for interns/personnel, and the use of a combination of unsafe injection practices. [2] These reports emphasize the need to improve dental health care personnel’s understanding of the basic principles of infection control.
While at your dentist’s office, you can play a role in ensuring the staff implements proper infection control practices. Before being seated, make sure the chair and all surfaces have been properly wiped down after the previous patient completed treatment. Ensure there is no visible blood or saliva on any surfaces. Before any work is done, ask your dentist if the instruments have been properly disinfected or sterilized. Then, your dentist should take a thorough medical history, asking specific questions about medications, current illnesses, recurrent illnesses, or other infections. Your dentist should also use new protective attire and barrier techniques such as gloves, surgical masks, protective eyewear, and a gown or laboratory coat. In addition, do not be afraid to seek affirmation that the dentist has washed their hands prior to your treatment. When using sharp instruments or needles your dentist should use extraordinary care to prevent unintentional injuries. The needle should be properly disposed of or recapped to decrease the risk of needlestick injury.
The lack of awareness about the importance and dangers of hepatitis B often stems from dental schools. The Himachal Institute of Dental Sciences in Paonta Sahib, India conducted a study which revealed that while dentists are among the high-risk transmission groups for hepatitis, they have little knowledge or information on hepatitis B and/or the vaccine.[3] The study also concluded that proper infection control, sterilization, and prophylactic vaccination protocols should be followed in order to reduce the risk of hepatitis in India.[3] Another study, performed by Saveetha Dental College & Hospital in Chennai, India, evaluated the awareness of the hepatitis B virus among dental graduate students at the University Dental College.[4] A questionnaire regarding the awareness of hepatitis infections and various infection control measures was distributed among all the students in the dental graduate program.4 The data extracted showed that final year students had an increased awareness when compared to third-year students.[4] The overall awareness among the students was unsatisfactory and further signifies the need for continued infection control education.
Similarly, a study performed at Obafemi Awolowo University in Nigeria evaluated the attitude of 120 students towards the hepatitis B vaccine through an anonymous questionnaire.[5] The results showed that of the 94.7% of the students who did not receive the vaccine cited their busy schedule as the reason for their failure to be vaccinated.5 Furthermore, the University of Pretoria in South Africa conducted a study aimed to determine the knowledge among 292 dental students on the transmission and prevention of the hepatitis B virus.[6] It was found that more than 50% of the students did not know that the hepatitis B infection can be transmitted through piercings and more than 50% of the nonclinical students wrongly reported that antibiotics can be used to prevent infection after exposure.6 These studies demonstrate that there is a lack of knowledge surrounding hepatitis B in some dental school settings which contributes to insufficient knowledge about hepatitis B in professional dental settings.
Although awareness about hepatitis B is improving worldwide, dental schools must begin to stress its prominence and importance of infection control in dental settings. It is a good idea for patients to ask about the infection control practices implemented at their dental offices. Emphasis should always be placed on consistent adherence to recommended infection control strategies, and each dental clinic should have a written protocol for instrument reprocessing, operatory cleanup, and management of injuries. Such efforts will lead to the development of safer and more effective medical devices, work practices, and personal protective equipment; all in conjunction decreasing the incidence of hepatitis B.
Guest Author:
Shrey Patel
Bridging the Gaps Intern
Second Year Dental Student at the University of Pennsylvania School of Dental Medicine
References:
[1] Araujo MW, Andreana S. Risk and prevention of transmission of infectious diseases in dentistry. Quintessence Int. 2002;33(5):376-382.
[2] Cleveland JL, Gray SK, Harte JA, Robison VA, Moorman AC, Gooch BF. Transmission of blood-borne pathogens in US dental health care settings: 2016 update. J Am Dent Assoc. 2016;147(9):729-738. doi:10.1016/j.adaj.2016.03.020
[3] Dahiya P, Kamal R, Sharma V, Kaur S. “Hepatitis” – Prevention and management in dental practice. J Educ Health Promot. 2015;4:33. doi: 10.4103/2277-9531.157188. [PubMed: 26097847]. [PubMed Central: PMC4456879].
[4] Mahesh R, Arthi C, Victor S, Ashokkumar S. Hepatitis B infection awareness among dental graduate students: A cross sectional study. Int Sch Res Notices 2014. 2014:1–6.
[5] Adenlewo OJ, Adeosun PO, Fatusi OA. Medical and dental students’ attitude and practice of prevention strategies against hepatitis B virus infection in a Nigerian university. Pan Afr Med J. 2017;28:33. Published 2017 Sep 14. doi:10.11604/pamj.2017.28.33.11662
[6] Madiba T.K., Nkambule N.R., Kungoane T., Bhayat A. Knowledge and Practices Related to Hepatitis B Infection among Dental and Oral Hygiene Students at a University in Pretoria. J. Int. Soc. Prev. Community Dent. 2018;8:200–204. doi: 10.4103/jispcd.JISPCD_31_18.
