B INFORMED NOW! PATIENT WORKSHOP
Holiday Inn Express Midtown, Philadelphia, PA
Saturday April 24, 2010
HEPATITIS B AND CHILDREN
Barbara Haber, M.D.
Pediatric Liver Specialist, Children’s Hospital of Philadelphia
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The pediatrician has a very different view of how to approach hepatitis B patients.
Hepatitis B is really a pediatric problem, and we need to care for children with HBV to help
prevent future complications (i.e. fulminant hepatitis, cirrhosis, HCC, death, hospitalization).
Close to 80% of the world’s population lives in an area where HBV is common.
The largest contributors to the incidence of chronic HBV in the U.S. include:
o Immigrants from areas of the world where HBV is common.
o Adoptees from areas of the world where HBV is common.
o Children born to infected moms.
Vertical transmission (from infected mom to newborn, also known as “perinatal transmission”)
o If a mom is HBsAg+ and eAg+, 70-90% of infants will be infected and if they do not
receive HBIG and the first of the HBV vaccine, 90% will develop chronic infections.
o If a mom is HBsAg+ and eAg-, 25% of infants will become infected.
Horizontal transmission (from person to person)
o Different body fluids have different amounts of virus.
 Highest is in blood, serum, wound fluid (important for kids in school with
scraped knees, etc).
 Semen, vaginal fluid are moderate (important for kids when dating).
Who should be screened?
o People from most of the world!
o Children either born in areas of the world where HBV is common or born to parents
from high-risk areas of the world.
Prevention
o Vaccination has been the major strategy in the U.S. to prevent HBV.
o The vaccine cannot give you the virus, and it is 95% effective.
o Boosters are not recommended at this time, as it is known that the vaccine is effective
for at least 20 years or more.
o It is important, for full and long-lasting coverage, to complete the 3 doses of vaccine.
Am I protected?
o If an antibody titer test is ordered (i.e. a simple blood test), and then years later test
results are negative, you are still protected through “immunologic memory”.
o If you are intimate with someone who has HBV or live in close contact with someone
who is infected, you should have a blood test to check your antibody titers after vaccine
to make sure you have an immune response (1-2 months after last dose) and protected.
o If you do not have a response, get tested to see if you have been infected with HBV. If
this is negative, then start a second HBV vaccine series (most people will respond after
the repeated series).
B INFORMED NOW! PATIENT WORKSHOP
Holiday Inn Express Midtown, Philadelphia, PA
Saturday April 24, 2010
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If you still don’t respond, you are a non-responder and you need to know that if you are
exposed to HBV, then you will need to get two doses of HBV immuneglobulin (HBIG).
Perinatal prevention (protecting the baby born to an infected mom)
o Within 12 hours of birth, the baby should receive one dose HBIG and the first dose of
the HBV vaccine (and complete all three vaccine doses by 6 months of age).
o If this is done correctly, then a baby has a > 95% chance of not becoming infected.
o However, if HBIG and the vaccine are not given in time, then a baby has a > 90% chance
of becoming chronically infected. There is no second chance!
o Additionally, the 3 vaccine doses must be completed because 2 vaccine doses only
prevent 70% of infections.
o The baby should be tested for HBsAb two months after the 3rd (last) vaccine dose.
o At 9 – 18 months the baby should be tested for HBsAg.
o There is a 1-2% failure rate despite doing everything correctly, which could be the result
of the infected woman having very high viral DNA at the time of delivery.
Phases of chronic HBV infection. These need to be understood so parents know when their child
should be referred to a liver specialist and considered for treatment.
o Immune tolerant – high DNA, normal ALT, minimal inflammation or fibrosis – antiviral
therapies are ineffective at this phase, and treatment is not generally recommended
(the risk/benefit ratio is not favorable because a child is more likely to develop drug
resistance than achieve eAg or sAg clearance).
o Immune active – best time to intervene – declining DNA, rising ALT (body starts to fight
virus), liver inflammation and fibrosis can develop – usually no signs or symptoms.
o Inactive carrier – can move into this phase without treatment – DNA undetectable,
normal ALT – body puts itself into remission – more durable if you lose eAg and develop
eAb – no reason to treat at this point.
o Reactivation – occurs in 20-30% of patients, possibly treat.
 You do not necessarily move linearly through these phases.
Hep B Foundation’s Pediatric Algorithm
 Test ALT, DNA, eAg, AFP, ultrasound, family history are collected at baseline to
get a sense of what phase the child is in.
 Increased ALT, AFP, family history or eAg- disease with DNA >2000IU/mL, you
should be referred to liver specialist to consider treatment.
o When is a liver biopsy performed in children? Or, what do you get from a liver biopsy?
 Can help guide therapy or indicate presence of liver damage or inflammation
(especially in reactivation phase).
 Not necessary to make diagnosis of HBV – most children have little liver
damage.
 It is not an automatic that a biopsy is needed if there is liver damage.
Decision to treat
 Decide the pros and cons and decide if it’s worth it.
 Considerations include: chronic, elevated ALT, inflammation on biopsy.
B INFORMED NOW! PATIENT WORKSHOP
Holiday Inn Express Midtown, Philadelphia, PA
Saturday April 24, 2010
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 Viral suppression to prevent drug resistance is important.
Predictors of response to therapy – who will be a good candidate for treatment?
 High ALT, low DNA, compensated liver disease, genotype A/B, eAg+, low sAg
levels, prefer to use drugs that have low resistance rates.
 If someone has liver failure, genotypes C and D, and co-infection with HDV then
they are less likely to respond to treatment.
o What will happen if there is no treatment?
 Do infants, children, adolescents, or young adults clear the virus spontaneously?
 McMahon paper – followed over 1500 people and 72.5% converted to
eAb+ within 5 years without treatment. So, if you wait to treat, you
might naturally seroconvert without treatment.
o HBV Genotypes
 Genotype can dictate response to therapy and rate of spontaneous
seroconversion (and explain why some populations have more HCC than
others).
 People from different areas of the world have different genotypes.
 Genotype C – seroconvert later in life, not likely in adolescence.
 Genotype B - more likely to seroconvert earlier.
 Genotype A – Pegylated interferon works best in this group.
o Other considerations
 Social implications can be another reason to treat.
 Who to tell? How to tell?
 You do not have to disclose to school, school nurse, etc., in general.
 Guilt/fear of passing it on to future generations can be another reason to treat.
Treatment guidelines
o What do we use as criteria to decide when treatment should happen in children (from
age 1-17 years)?
 High DNA levels as cancer prediction do not apply to young children – do not
treat if ALT is normal, even with very high DNA – there is no benefit of
treatment and high risk of resistance.
 eAg- and <2000 IU/mL DNA, don’t treat.
 ALT >60, you would consider treatment if eAg+ and DNA >2000 IU/mL
(considered immune active).
 eAg- and DNA high (re-activation), treat.
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Goal of treatment
 Suppression of viral replication, improve liver health (no scarring or
inflammation to decrease risk of cirrhosis and cancer).
Endpoint of treatment
 In kids, it is seroconversion with loss of eAg and development of eAb+.
B INFORMED NOW! PATIENT WORKSHOP
Holiday Inn Express Midtown, Philadelphia, PA
Saturday April 24, 2010
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Approved treatments – not many options for kids (adults have 7 approved therapies)
o interferon > 12 months old.
o lamivudine > 3 years (high resistance rate).
o adefovir starting at age 12 (high resistance rate).
o entecavir at age 16.
So what can be done?
o Sometimes use entecavir or tenofovir in younger children, but need to be very careful.
Special populations to treat
o Patients with rapid deterioration of liver function (decompensated).
o Patients with compensated cirrhosis (lots of liver damage).
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Immunosuppression (chemotherapy, longterm steroid use).
Pregnant women to prevent perinatal transmission who have high viral levels during the
third trimester (the idea is that by decreasing the viral load in the third trimester, this
will decrease the risk of vaccine failure in the newborn at birth).
Questions and Answers
o Have you used pegylated interferon in HBV?
o If treatment is indicated, then pegylated interferon is always a safe choice because
there is no risk of drug resistance; there are side effects, but these can usually be well
managed in children.
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Is MRI as good as a biopsy to detect liver damage?
o It is a great imaging modality – in pediatrics, we are asking different questions than in
adults (i.e. you are not really looking for cancer or staging liver disease because this is
rare).
o In kids, ultrasound is good at providing an overview and indicating whether more needs
to be done, like an MRI.
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Should children be tested for AFP, the blood test used in adults to screen for liver cancer?
o All kids should be tested for AFP – it is cheap, generally covered by insurance, and can
pick up the rare case of HCC in young children and teens.
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Do you recommend a special diet for kids with HBV?
o There is no magic diet – good nutrition is the best thing.
o It is usually not necessary to eliminate iron because it can be associated with many
other negative issues.
If a mother has HBV, is breastfeeding a problem for her baby?
o The CDC recommends breastfeeding because the small risk is outweighed by the
benefits of breastfeeding. In addition, the baby should have been vaccinated at birth
which reduces any risk even more.
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