Hepatitis B Virus Patricia T' Poole, RN Hepatitis B Coordinator North Carolina Immunization Branch 9

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Hepatitis B VirusPatricia T. Poole,
RNHepatitis B CoordinatorNorth Carolina
Immunization Branch(919) 715-6777
patricia.poole_at_ncmail.net

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Hepatitis B Virus
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National Public Health Impact of Hepatitis B

• 80,000 new acute cases/year
• 5-8,000 chronic infections/year
• Many cases are asymptomatic
• Liver failure
• Liver cancer

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Geographic Distribution -Chronic HBV Infection
HBsAg Prevalence
?8 - High
2-7 - Intermediate
lt2 - Low
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Reported Acute Hepatitis B by Age United States,
1990-2002
0-11 years old
94 decline
20 years old
61 decline
12-19 years old
88 decline
Source National Notifiable Disease Surveillance
System (NNDSS), CDC
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HEPATITIS B, AcuteNC 1991-2003(N3,853)
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Modes Of Transmission

• HBV is a blood-borne pathogen.
• Percutaneous
• contaminated sharps
• non-intact skin entry
• Nonpercutaneous
• perinatal
• sexual
• other mucous membrane

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Clinical Features

• Incubation 6 WEEKS-6 MONTHS
• Symptoms
• Jaundice
• gt50 of infections asymptomatic
• HBsAg present several weeks before symptoms
  days-months after onset
• HBsAg persists in chronic infection

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Reported Risk Factors Among Adults With Acute
Hepatitis B, United States, 1991-2001
Heterosexual, 42
Other, 5
None identified, 16
MSM, 19
Injecting drug use, 18
Other Household contact, institutionalization,
hemodialysis, blood transfusion, occupational
exposure Source Sentinel Counties Study of
Viral Hepatitis, CDC
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Hepatitis B Virus
HBsAg
HBcAg
HBeAg
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HEPATITIS B NOMENCLATUREAND/OR LAB TESTS (1)

• HBV Hepatitis B virus.
• HBsAg Hepatitis B surface antigen. Marker of
  infectivity when found in serum.
• anti-HBs or HBsAb Antibody to HBsAg. Marker of
  immunity when found in serum.
• HBcAg Hepatitis B core antigen. No commercial
  test available for this.
• anti-HBc or HBcAb Antibody HBcAg. Marker of past
  or current infection.

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HEPATITIS B NOMENCLATUREAND/OR LAB TESTS (2)

• IgM anti-HBc IgM is an antibody subclass of
  anti-HBc. Indicates recent infection with HBV
  (usually lt4-6 mos. but can persist in some
  chronic cases).
• IgG anti-HBc IgG is a subclass of anti-HBc.
  Indicates older infection with HBV.
• HBeAg Hepatitis B e antigen. Can only be
  present if HBsAg is positive. Marker of high
  degree of infectivity and high viral replication.
• Anti-HBe Antibody to e antigen. May be present
  in infected or immune person.

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INTERPRETATION OF HEPATITIS B PANEL
HBsAg negative antiHBc negative susceptible
antiHBs negative
HBsAg negative antiHBc positive immune due
to natural infection antiHBs positive
HBsAg negative antiHBc negative immune due
to vaccine antiHBs positive
HBsAg positive antiHBc positive acutely
infected IgM antiHBc positive antiHBs negative
HBsAg positive antiHBc positive chronically
IgM antiHBc negative infected antiHBs negativ
e
HBsAg negative antiHBc positive four
possible interpretations antiHBs negative (see
next slide)
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FOUR POSSIBLE INTERPRETATIONS OF ISOLATED
ANTIHBC POSITIVE
1. May be recovering from acute HBV infection. 2.
May be distantly immune and test not sensitive
enough to detect very low level of anti-HBs in
serum. 3. May be susceptible with a false
positive anti-HBc. 4. May be undetectable level
of HBsAg present in the serum and the person is
actually a carrier.
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ACUTE HEPATITIS B

• Acute illness with
• a) discrete onset of symptoms and
• b) jaundice or elevated serum aminotransferase
  levels (ALT/AST)
• Laboratory criteria for diagnosis
• -- IgM anti-HBc positive or HBsAg positive
• -- IgM anti-HAV negative (if done)

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Acute Hepatitis B Virus Infection with
Recovery Typical Serologic Course
Symptoms
anti-HBe
HBeAg
Total anti-HBc
Titer
anti-HBs
IgM anti-HBc
HBsAg
0
4
8
12
16
20
24
28
32
36
52
100
Weeks After Exposure
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CHRONIC CARRIER

• Discrete symptom onset or no symptoms
• Probable carrier
• -- single positive HBsAg test result
• -- Total anti-HBc positive (if done)
• -- IgM anti-HBc negative
• Confirmed carrier
• -- HBsAg positive at least 6 months after acute
  infection, or
• -- HBsAg positive two times at least 6 months
  apart

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Progression to Chronic HBV Infection Typical
Serologic Course
Acute (6 months)
Chronic (Years)
HBeAg
anti-HBe
HBsAg
Total anti-HBc
Titer
IgM anti-HBc
Years
0
4
8
16
20
24
28
36
12
32
52
Weeks after Exposure
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Medical Management

• Acute infections
• (Supportive treatment)
• Chronic infections
• (Treatment may be effective in 25-50 of
  cases.)
• Chronically infected persons need ongoing medical
  evaluations

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SURVEILLANCE REPORTING10A NCAC 41A .0101

• Laboratory reporting
• Acute case reporting
• Chronic carrier case reporting

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Hepatitis B Control Measures (10A NCAC 41A .0203)

• Hepatitis B Immune Globulin (HBIG)
• Provides temporary passive protection
• Indicated in certain postexposure settings
• Hepatitis B Vaccine
• Provides active protection
• Active immune response occurs in approximately
  50 of vaccinated persons after one dose
• If an active immune response occurs after
  vaccination, antibodies develop in approximately
  2 weeks

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VACCINE NONRESPONSE

• Postvaccination testing is advised for
• Infants born to HBsAg-positive mothers
• Dialysis patients and staff
• Persons with HIV
• Persons at occupational risk
• Sexual or needle-sharing partners to HBV cases
• Revaccination is indicated for nonresponse
  (anti-HBs lt10 mIU/ml) in above categories.

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Advisory Committee on Immunization Practices
Strategy to Eliminate HBV Transmission

• Prevent perinatal transmission
• Universal infant vaccination
• Catch-up vaccination
• All children and adolescents focus on 11-12 y
• Adults in high risk groups

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Acute and Chronic HBV Infection Age at
Acquisition, 1989 Estimates
4 Perinatal 18 4 Children 18
(1-10 yrs) 8 Adolescent 6
Acute HBV Infections
Chronic HBV Infections
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Perinatal Reporting and Tracking10A NCAC
41A.0203(d)(1)10A NCAC 41A.0203(b)(5)-(6)

• Pregnant women tested for HBsAg
• Case tracking
• Infant prophylaxis
• Infant post-vaccination testing

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PRENATAL TESTING

• Test EVERY pregnant woman during every pregnancy
  for HBsAg.
• Report HBsAg positive pregnant women to LHD
• Send a copy of the ORIGINAL lab report to the
  anticipated birthing hospital.
• Track all HBsAg-positive pregnant women and their
  infants.
• Test and vaccinate susceptible contacts.
• Develop alliances among local health departments,
  physicians and hospitals.

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Universal Childhood Vaccine Distribution Program

• State and federal funding
• Provides hepatitis B vaccine free to all N.C.
  children (0-18 years of age)
• 91 out of 93 birthing centers in N.C. offer the
  birth dose
• NIS data

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Sixth-Grade School-Site Hepatitis B Immunization
Initiative

• Completion of 9 out of 10 cohort years
• Initiative ends after SY 2005-2006
• More than 521,800 adolescents vaccinated
• State and national data show promising trends

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Hepatitis B, Acute - Reported Cases, NC
1991-2003By Age Group(N3,853)
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Adults in High Risk Groups

• Difficult group to reach
• Data support the need to vaccinate
• Increased incidence among some adults
• Collaborative immunization projects

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Missed Opportunities for Adult Hepatitis B
Vaccination

• Of all persons with reported acute hepatitis B
• 37 reported prior treatment for an STD
• 29 reported prior incarceration
• 56 had been treated for an STD and/or
  incarcerated in a prison or jail prior to their
  illness
• Source Goldstein ST et.al., JID 2002185713-9

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Hepatitis B Vaccine Coverage in Adults (CDC Data)

• STD clinic clients 10
• IDUs 6
• MSM 16
• MSM 9
• HCWs 71
• Dialysis patients 60

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Hepatitis B Vaccination Acceptance Among
High-Risk Adults

• IDUs (San Diego, Denver) 70-86
• STD clinic clients (San Diego) 74
• HIV counseling and 71
• testing sites (Denver)
• Correctional facilities 72-85
• (Denver, Texas)
• Data from CDC.

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Elements of a Successful Vaccination Program

• Evidence-based recommendations
• Implementation strategy/partners
• Provider/patient education
• Vaccine purchase
• Infrastructure for vaccine delivery

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• QUESTIONS?

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Resources

• CDC Hepatitis B Website
• www.cdc.gov/ncidod/diseases/hepatitis/b/
• Immunization Action Coalition
• www.immunize.org
• NC Immunization Website
• www.immunizenc.org
• NC General Communicable Disease Control Branch
• www.epi.state.nc.us/epi/gcdc