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Hepatitis B Prevention

Options for HBV Vaccine Non-Responders

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Are you a hepatitis B vaccine non-responder? Approximately 5-15% of people who receive the vaccine are considered non-responders. This is especially important for health care workers, families living in households with people that have HBV, and others who may be at increased risk of exposure to HBV.  A vaccine non-responder is someone that does not build up an adequate immune response after receiving two, 3-shot series of the HBV vaccine.  In other words, they complete one series of the HBV vaccine, and follow it with a surface antibody test (HBsAb or Anti-HBs) 4-6 weeks following the last injection of the series.  If the anti-HBs titre is not greater than 10IU/l, than the series is repeated, preferably with an HBV vaccine from a different manufacturer, and the person is once again tested for immunity by testing for adequate anti-HBs. (See previous blog, “Got Hepatitis B? Keeping loved ones safe though HBV vaccination” for details)

Fortunately there are other options for those concerned with being an HBV vaccine non-responder. There is a higher concentration of the HBV vaccine recommended by the CDC that is used for patients undergoing dialysis, and for those that are immune suppressed.  It is a 40µg/ml concentration. If it has been one year or less since you completed the three-shot series of the regular concentration of the vaccine, you can try one intramuscular dose of 1.0 ml of the 40µg HBV vaccine.  If it has been more than one year since your last three shot series of the vaccine, you can repeat the entire three-shot series with the 40µg concentration of the vaccine.  Follow up with an anti-HBs titre test 4 to 6 weeks following the last injection to ensure it is greater than 10 IU/l, and that you have adequate immunity.

If you continue to remain a non-responder, you can try a series of as many as five intra-dermal injections, given every two weeks, using the 40µg concentration of the HBV vaccine.  Dose one consists of 0.10 ml of the 40µg/ml vaccine, followed by the same dose two 2-weeks later.  At that time an anti-HBs titre test would be drawn to check for immunity.  If there was not adequate immunity, a third-intra-dermal dose of the vaccine would be given two weeks later.  Anti-HBs titres would be checked every two weeks and the patient would be given another intra-dermal injection up to a total of 5 intradermal injections of the 40µg concentration of the HBV vaccine. Don’t forget to ensure that your anti-HBs titre is greater than 10IU/l.

Please note that the schedule for the series might vary depending on the study your doctor chooses to follow.  However, it is recommended that the higher concentration (40µg) of the hepatitis B vaccine be used for best results.

Hepatitis B Diagnosis & Monitoring, Living with Hepatitis B

To Disclose or Not to Disclose, That is the Question

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

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

Here are some important points to consider:

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

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

Hepatitis B Diagnosis & Monitoring, Living with Hepatitis B

Living With HBV and Drinking Coffee

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The pros and cons of drinking coffee have been wildly debated for years.  However, for those with Hepatitis B and other liver diseases, the addition of a couple of cups of coffee per day to slow down the progression of liver disease, along with decreasing the risk of diabetes and heart disease just makes sense.

Dr. Melissa Palmer was a guest speaker at a previous Hepatitis B Foundation patient conference. The information from her presentation had all sorts of nutritional nuggets for those with HBV (Check out Dr. Palmer on podcast if you would like to have a listen!) She stated, based on studies, that coffee and caffeine intake has been associated with improvements in liver ALT and AST levels.  There also seems to be a correlation between increased coffee consumption and warding off cirrhosis and HCC.

Just recently there are was an article that discussed the benefits of coffee for those patients with HCV, undergoing treatment with pegylated interferon (PEG) and ribavirin therapy.  It claimed that drinking three or more cups of coffee a day not only reduced some of the difficult side-effects associated with treatment of PEG, but it also increased the treatment success.  However, like so many of these coffee studies, it was a small study and had to be adjusted for other factors.

We all know that HBV and HCV are very different viral infections, but you have to wonder if any of the benefits of coffee that is seen in those being treated for HCV can be extrapolated to include those with HBV being treated with Pegylated interferon or antivirals.  Dr. Palmer did mention that coffee did seem to have a greater impact on those with hepatitis C, although I have no idea why.

Regardless, if you’re living with HBV, you have to think about the pros and cons of adding coffee to your daily list.  Since all studies seem to show an increased number of cups of coffee having a more positive impact on preventing liver disease progression, or warding off cirrhosis or potentially reducing PEG side effects or benefiting treatment, you have to consider just how much caffeine you can take.  It does not appear that caffeine is the only factor involved, but rather the coffee bean itself and associated antioxidant features.  This seems to be the case because tea, despite all of its benefits, does not appear to have the same protective effect on the liver.

What about decaffeinated coffee?  I kept looking to see if it was specifically referenced, but I haven’t seen it. However, during the decaffeinating process, much of the bean is lost, and it may be treated with a chemical solvent, both which might nix the positive benefits.  If you’re going to give decaffeinated coffee a try, consider a coffee with a more natural decaffeinating process. Personally, I’d have a tough time balancing the jitters and racing heart rate associated with drinking more than a cup or two of high-test coffee a day, but we’re all individuals.  If you can drink coffee and sleep well at night, it seems like it can’t hurt your liver health to add a few cups to your daily regimen.

Hepatitis B Diagnosis & Monitoring, Living with Hepatitis B

Having HBV and Using Immunosuppressants

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

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

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

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

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

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

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

 

Hepatitis B Diagnosis & Monitoring, Hepatitis B Prevention, Living with Hepatitis B

Got Hepatitis B? Keeping loved ones safe through HBV vaccination

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

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

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

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

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

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

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

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

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

Hepatitis B Prevention

Infection Prevention is Everyone’s Business…That means YOU!

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In the U.S. we have wonderful infection prevention procedures, clinical practices and standards of care in place.  There’s a documented protocol for everything from giving a simple injection, to surgical procedures, to the disposal of biomedical waste.  HCW and other appropriate personnel are trained and practices are implemented. They are constantly evolving. Despite all of these safeguards, the CDC is worried.  A couple of weeks ago it was a nurse doing diabetes training using the same diabetes testing device on multiple people, (one person one device) with not even a disinfecting process in between patients.  Unfortunately, this is not a unique event.  I scrolled through the last seven months of HBF Top Stories and noted the following events in the news:

You don’t have to root around too hard to find these incidences. Despite best practices and protocols, training procedures and safeguards, the people that perform these duties are not without error. Intentional negligence is rare, but unknowing negligence would not be surprising. Budgets are tight, staffing is reduced, and work loads are increased.  Personnel are tired and stressed, and they make occasional errors. It may not be right, but mistakes do happen.

This is where the above sign comes into play.  Infection protection is everyone’s business.  That includes YOU!  Speak up.  Let your voice be heard.  You see the signs in your doctor’s office “Ask me if I’ve washed my hands”.  Why not start there, and ask? Had I read the article, or thought about my endoscopy/colonoscopy, I would have asked about the equipment used for my procedure.  Shame on ME.

I’m not going to get a bloodborne pathogen like hepatitis B from shaking my doctor’s hand, as HBV is not transmitted casually, but procedures where trace amounts of blood may not be properly disinfected or devices disposed is a different story.  HBV is transmitted by direct contact from an infected person’s blood or body fluid to an open cut, mucous membrane or portal of entry of another person. A health care setting with blood, sharps, tubes and medical devices is an effective transmission route if there are infected body fluids.  Fortunately practices firmly put into place prevent nearly all such possible exposures. Regardless, these uncommon errors, could affect parents in nursing home environments, veterans in VA hospitals, patients getting colonoscopies, and all kinds of patients in various health care clinics and settings. Infection control practices are written, taught and implemented, but every once in a while, you’re going to get someone that neglects to follow the rules or makes a simple mistake.  This should not cause a panic among patients, but it is a reminder that mistakes happen, and sometimes it’s necessary for us to speak up and ask questions. Remember, infection prevention is everyone’s business.

Note: Please keep in mind that HBV is 100 times more infectious than HIV.  It is also more infectious than HCV.  There are no vaccines for HIV and HCV, but there is a safe, effective vaccine for HBV. Get vaccinated and be HBV free for life.

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Donate Your Car to Support the Hepatitis B Foundation

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Are you thinking of selling or trading in a vehicle?  Donate it to the Hepatitis B Foundation instead. Turn your car, running or not, into a tax-deductible contribution and help find a cure and improve the quality of life for those affected by hepatitis B worldwide.

The Hepatitis B Foundation works with a full-service partner that will make all the arrangements to conveniently and quickly pick-up your vehicle donation at no cost to you. They handle the pick-up, the title transfer requirements, and sale of the vehicle.

To complete your vehicle donation, follow the instructions on the Donation Line website, or call 877-227-7487.  Need more information? View our most frequently asked questions below or contact us at info@hepb.org.

 

FAQs

What can I donate?
We accept most cars, vans, trucks, trailers, motorcycles, boats, jet skis, snowmobiles, RVs and even airplanes!

Is my donation tax deductible?
The Hepatitis B Foundation is recognized by the IRS as a not-for-profit 501(c)(3) charitable organization and your donation is tax-deductible to the full extent of the law.  To benefit from this tax-deduction, you must itemize your taxes.

What do I need to provide?
Besides the car, we would like the title to the vehicle. If you do not have it, call us anyway. It is possible that other arrangements may be made.

My car hasn’t run in years. Can I still donate it?
Yes, most vehicles are accepted, running or not (exceptions include older vehicles whose value would not offset the cost of towing).

Can you pick up vehicles in all 50 states?
It is possible to pick up most vehicles in the continental U.S. and Hawaii.

How will the car be picked up?
Arrangements will be made to have your vehicle towed away at a scheduled time.

How long will it take to pick up my car?
Someone will contact you to schedule an appointment within three or four business days at the most.

To donate your car, click here, and follow the instructions.

Thank you!

Hepatitis B Diagnosis & Monitoring, Hepatitis B Prevention

Hepatitis B, Hurricane Irene and Other Natural Disasters

Hurricane Irene is currently slamming the eastern seaboard.  I wrote this blog in anticipation of losing power.  It was a tough week. First, the east coast “earthquake of the century”, and now Hurricane Irene and related flooding.

Last spring, during an incredible deluge of flooding, a tweep (an HBF friend on twitter) was concerned about the increased risk of HBV infection due to flooding.  She asked that I warn flood victims about this potential hepatitis risk.

The risk of hepatitis B is unlikely even with the threat of hurricanes and heavy flooding.  Once again the confusion between hepatitis A and hepatitis B seems to be the issue.  It’s important to know the ABCs of viral hepatitis. Hepatitis A is spread as a result of contaminated food and water, which could readily occur during severe flooding or a natural disaster when clean sources of water may be  hard to come by.  Overcrowding, contaminated water, and compromised sanitation all increase the risk of hepatitis A transmission. This is unlikely with HBV since it is transmitted through blood or body fluid contact of an infected person to an open wound, mucous membrane or orifice of another person.  Perhaps over a long period of time with a catastrophe of historic proportions, the odds of transmission would be increased, but in most cases it is extremely unlikely.  Some of this would also be dependent on the conditions prior to the disaster, and the projected length of time in overcrowded conditions, without adequate sanitation and clean water sources.  The worse the conditions, perhaps a country already struggling, or lacking the infrastructure to provide clean water, or adequate sanitation,  the higher the likelihood. The emergency response time and actions might also contribute. Once again this would vary with the country or area, and the infrastructure in place prior to the disaster.

Getting vaccinated against hepatitis A and B is kind of like a mini insurance policy, or pulling together an emergency supply kit for your family. You never know when you’re going to need it, and it’s better to be safe than sorry.

Flashlights and replacement batteries are impossible to find hours before the storm. In the midst of a disaster, or in those precious hours before a disaster occurs, it is unlikely potential hurricane or flood victims are going to flock to their Primary Care Physician to ensure they are vaccinated against Hepatitis A and B.  However, it is yet another reminder that we are all vulnerable.  Should the opportunity exist to get the vaccine against HBV and HAV, whether separately or in combination, it is certainly worth pursuing during a time of calm rather than waiting for an emergency.  The vaccines are safe and effective.  Get vaccinated and be safe.

Hepatitis B Diagnosis & Monitoring, Living with Hepatitis B

Got HBV? Adding Vitamin D to Your Diet

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

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

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

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

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

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

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

Hepatitis B Diagnosis & Monitoring, Hepatitis B Treatment, Living with Hepatitis B

Hepatitis B and Vitamin D

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

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

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

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

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

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

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

Baruch S. Blumberg Institute