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NIH Consensus Development Conference: Management of Hepatitis B
October 20-22, 2008

Monday Report, by Christine Kukka, HBV Project Manager

BETHESDA, MD—Hepatitis B experts from across the United States tackled some of the confusing and conflicting approaches to understanding and treating hepatitis B infection on Monday at the National Institutes of Health.

The NIH has convened a consensus conference, which will continue through Wednesday, so experts can develop common approaches to identifying the prevalence of hepatitis B in the United States, and defining which treatments are most effective.

The following issues were addressed during the Monday session:

Is the U.S. accurately estimating true prevalence of HBV infection?
While hepatitis B immunization has caused a large decline in new infections in the United States, currently the federal government’s surveillance programs fail to screen many legal and undocumented immigrants who are infected with the hepatitis B virus (HBV).

W. Ray Kim, MD, MSc, MBA, associate professor of medicine in the Division of Gastroenterology and Hepatology at the Mayo Clinic, told the conference that many immigrants are missed in government surveys of HBV-infected populations.

In Olmsted County, MN, Kim described that 53 percent of all residents identified with hepatitis B are Asian immigrants, and 29 percent are African immigrants.

In Minnesota, 5.1 percent of Asian immigrants are chronically infected as are 8.4 percent from Africa, and 3.1 percent from Europe. In the United States, between 1994 and 2003, 26 percent of legal immigrants were from high HBV prevalence countries and 33 percent were from intermediate endemic areas.

In a survey of 1,000 refugees in New York City’s Chinatown, immigrants in their 20s had a 25 percent positive rate for the hepatitis B surface antigen (HBsAg), which indicates a chronic infection.

“Despite decreases in new infections, the prevalence and burden of chronic HBV infection in the U.S. remain substantial and underestimated,” Kim said. He explained that hospitalizations of people with HBV has increased from about 15,000 to 65,000 nationwide in an average quarter, and the cost of HBV medications has doubled between 2006 and 2008. The number of patients with hepatitis B-related liver cancer on the liver transplant waiting list has increased 146 percent between 1985 and the present, which shows the rising burden of HBV infection in the country.

“We can’t make a scientific projection of what will happen, but looking at Chinatown data, we could experience a second wave of HBV infection and liver disease-related deaths in the future,” he added.

Substandard care common for immigrants and others with HBV:
Because many immigrants with HBV are undocumented and uninsured, they are fearful of the U.S. medical system. They and their family members are not getting screened or vaccinated. Experts called for more culturally-sensitive programs to provide proper screening and care to this population. Early screening and prevention will in the long run provide better quality care and save health care dollars.

Would the U.S. government ever bar immigrants who are infected with HBV from entry into the U.S.?
Currently, no immigrant is required to be tested for HBV on entry into the United States. Currently the U.S. restricts immigration of people with HIV and tuberculosis. A representative from the U.S. Centers for Disease Control and Prevention, which recently recommended that doctors screen patients from countries with moderate prevalence for HBV (instead of just patients from high prevalence), said, “we do not want HBV to be an excludable condition. While we recommend testing among immigrants from other countries, we do not recommend anything that would interfere with immigration.”

High HBV DNA levels lead to higher rates of liver cancer and cirrhosis. High viral load, defined as more than 100,000 copies/mL, especially sustained over many years in older people--especially men--results in increased rates of cirrhosis and liver cancer.

Even when genotype is taken into consideration, sustained high viral load, rather than infection with a specific genotype, is associated with more severe liver damage and liver cancer. Experts made an argument for use of antivirals to decrease viral, which leads to fewer liver disease symptoms.  More information will be posted tomorrow.

Combination therapy yields few benefits to date.
While hepatitis C has been successfully treated with a combination of antiviral and pegylated interferon, no such beneficial combinations have been found for hepatitis B treatment, according to reports. In general, a combination of interferon and antivirals has yielded no additional declines in viral load.

However, experts look forward to using newer antivirals, including tenofovir (Viread) which are stronger and cause less viral resistance, in new combinations in their search for an effective treatment.

 

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