Outline: Introduction Epidemiologic Determinants Mode of transmission Burden of Hepatitis-B Prevention and treatment Challenges Recent Advances in Hepatitis B research Strategies References

1. Hepatitis-B
The Silent Killer
Bikram Adhikari
Adrian Elkins
Mark Lim, MD
World Hepatitis Day: 28th July

2. Outline
• Introduction
• Epidemiologic Determinants
• Mode of transmission
• Burden of Hepatitis-B
• Prevention and treatment
• Challenges
• Recent Advances in Hepatitis B research
• Strategies
• References
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3. Introduction
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4. Introduction
• Hepatitis B is a viral infection that attacks the liver and can cause
both acute and chronic disease.
• Acute HBV infection:
• Usual……..Symptomatic or subclinical……
• Chronic Hepatitis B infection (CHB):
• Cirrhosis, Liver failure, Hepatocellular carcinoma, and eventually death.
• Incubation period: 30-180days (mean: 75-days)
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5. Epidemiological Determinants
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6. Epidemiological Determinants
Agent Factors:
• Reservoir of Infection:
• One and Only: Human
• Cases and sub-clinical Cases
• Persistent carrier state  presence of HBsAg for more than 6 months
• Infective material:
• Contaminated Blood | Body secretion: Saliva, Vaginal secretions and Semen
• Resistance: stable |7days in env. | Sodium Hypochlorite | autoclave 30-60min
• Period of communicability
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In apparentSymptomatic

7. Epidemiological Determinants
Host Factors:
• Age
• High risk groups
• Surgeons(50X more)
• Prostitutes
• Drug abusers
• Immune compromised
• AIDS10% of total HIV infected
• Humoral and cellular responses
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Adapted from K Park, Preventive and social Medicine
Age wise Distribution of Hepatitis B (in %)

8. Modes of transmission of Hepatitis B
• Parenteral route Blood transfusion | Blood handling | accidental inoculation |
immunization |tattooing |circumcision
• Sexual transmission (50-100 times easier to transmitted than HIV)
• Perinatal transmission
• Occupational exposure (needle stick injuries) transmission rate 30-
60%)
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9. Clinical course of
Hepatitis B in adults
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In apparentSymptomatic

10. Shrestha SM. Seroepidemiology of hepatitis B in Nepal. J Commun Dis. 1990 Mar;22(1):27–32.
Burden of Hepatitis-B
• In 2015, Hepatitis B resulted in 887 000 deaths, mostly from
complications (Cirrhosis and Hepatocellular carcinoma).
• In 2015, of the 257 million people living with HBV infection, 9% (22
million) knew their diagnosis. Global treatment coverage was only 8%
(1.7 million)
• The prevalence of hepatitis B in Nepal: 0.9% on an average (m=1.1%
and f=0.5% )
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WHO Area Prevalence (%)
Western Pacific Region 6.2
African Region 6.1
South-East Asia Region 2
Eastern Mediterranean Region 3.3
European Region 1.6
America 0.7

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12. Treatment and Prevention
• Prevention
• A vaccine against hepatitis B has been
available since 1982
• Vaccine is 95% effective in preventing
infection and the development of
chronic disease and HBV related liver
cancer.
• In Nepal, HBV vaccination: 2002 AD.
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Adult: 10-20 micrograms initially, deltoid
muscles(preferred) vs. gluteal region, ID
Children (2-10yrs) : Half dose
Children less than 2 yrs: Antero Lateral aspect
of thigh, Intra muscular, ID is less reliable

13. Vaccination coverage in Nepal
• Overall 86% based on
annual Report 2016/17
• Highest in province 2
(99%) and lowest in
province 6 and 7 (76%)
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14. Treatment and Prevention
• Several treatments available:
• Interferon (IFN) based therapies— both standard IFN α and pegylated
(PEG)-IFN α
• Oral nucleos(t)ide analogues— adefovir, dipivoxil (ADV), entecavir (ETV),
lamivudine (LAM), telbivudine (LdT), and
tenofovir disoproxil fumarate(TDF)
• Tenofovir or Entecavir (recommended by WHO)
• Most potent drugs to suppress hepatitis B virus.
• Rarely lead to drug resistance as compared with other drugs
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15. Treatment and Prevention
• For immediate protection: HBIG
• For those who are exposed to HBsAg +ve blood samples
• Within 6 hours (not late than 48hrs)
• The simultaneous administration of HBIG and hepatitis B vaccine is more efficacious
than HBIG alone.
• Prevention:
• Carrier should not share razors, brush and they should use barrier method of
contraception
• Promote full aseptic techniques in lab-settings
• Promote self donated blood rather than purchased blood
• Blood should be screened before transfusion
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16. Challenges
• Despite immunization programs and patient education, Hepatitis B
virus (HBV) infection remains a serious health risk in the world
• Silent Killer
• Nepal
• Currently the country has a successfully running Anti-Retroviral Treatment
(ART) program in Nepal. However, a viral hepatitis program has not been
prioritized and is still a far outcry.
• There is no national public health research agenda for viral hepatitis. Viral
hepatitis sero-surveys are not conducted regularly.
• There is no routine surveillance for viral hepatitis.
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17. Recent Advances
• Studies suggest that long-term treatment with TDF or ETV can stop or
even reverse fibrosis and may also reverse cirrhosis.
• Based on 4 years follow up data
• Tenofovir and Entecavir have not shown significant virologic breakthrough.
• When breakthrough occurs, it is usually related to patient noncompliance and
not to resistance
• During this 4 years, rates of resistance were reported to be 0% for Tenofovir
and 1.2% for Entecavir.
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18. Strategies
• GLOBAL HEPATITIS PROGRAMME OF WHO, 2012
• Raising awareness, promoting partnerships and mobilizing resources;
• Formulating evidence-based policy and data for action;
• Preventing transmission;
• Scaling up screening, care and treatment services
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.

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20. Strategies
• Hepatitis mentioned in SDGs: Target 3.3 includes “Combating Hepatitis”
• WHO,2016
• For 2016–2021, the total cost of implementing the five key interventions would
be US$ 11.9 billion, with a peak at US$4.1 billion for the year 2021.
• The principal drivers of cost are testing and treatment for hepatitis B and C.
Implementation of the Global Health Sector Strategy would prevent 7.1 million
deaths between 2015 and 2030.
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21. Strategies
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22. Status of Nepal Regarding strategies
• There is a national policy that specifically targets mother-to-child
transmission of hepatitis B
• There is no specific national strategy and/or policy for preventing hepatitis
B
• There are no national clinical guidelines for the management of viral
hepatitis.
• Screening, care and treatment The government does not have national
policies relating to screening and referral to care for hepatitis B
• There is health policy to screen HBV and HCV in blood banks but no policy
for those who used injected drugs
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23. Status of Nepal Regarding strategies
• National coordination  no written national strategy or
plan that focuses exclusively or primarily on the prevention and
control of viral hepatitis.
• Awareness-raising and partnerships The government does not
collaborate with in-country civil society groups to develop and
implement its viral hepatitis prevention and control program.
• However, Above listed drugs are listed as essential drugs by GoN.
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24. References
• http://apps.who.int/iris/bitstream/handle/10665/85397/9789241564
632_eng.pdf;jsessionid=98D1AAECE55D81B08416FBAB4078E33F?seq
uence=1
• Global policy report on the prevention and control of viral hepatitis,
WHO press, 2013
• K-Park Preventive and Social Medicine, 23rd edition
• Several Other references…
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25. Thank you !
Any Queries???4/26/2019 25