JAN. 11, 2010

Liver cancer expert discusses Institute of Medicine report on hepatitis treatment

BY BRUCE GOLDMAN

STANFORD, Calif. — The Institute of Medicine is releasing a report Jan. 11 that attempts to raise awareness of hepatitis B and hepatitis C in order to prevent the consequences, all too often fatal, of chronic infection. Samuel So, MD, the Lui Hac Minh Professor and director of Stanford’s Asian Liver Center, is a co-author of the report and discussed some of the issues surrounding hepatitis treatment.

Q. What motivated the institute to issue this report?

So: A lot of the patients who come to see me have chronic hepatitis B or C. But their doctors never screened them. Now they have advanced liver cancer. When I was invited to join the institute’s Board of Public Health and Population Health two years ago, I suggested that hepatitis B and C, together, constitute one of the most-neglected public-health problems in the country. We got funding and embarked on this project, whose goal is to identify public-health gaps in prevention of new hepatitis B and C infections and in reducing the complications of chronic infection by these two viral forms of hepatitis. The report, called “Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C,” makes a series of recommendations as to how to address those gaps.

Q. Why is it so pressing to address these problems?

So: These two viruses are the primary factors in liver cancer — they cause about 80 percent of all liver cancer in the world. Both cause acute infection, which in many cases are asymptomatic unlike, say, the flu. But if people with hepatitis progress to develop chronic infection, then they become at risk for developing liver cirrhosis, liver cancer, and liver failure, usually decades after the initial infection. According to figures from the Centers for Disease Control and Prevention, between 3.5 and 5.3 million Americans are chronically infected with hepatitis B or C. More people in this country die from the complications of chronic hepatitis B and C — about 15,000 annually — than from HIV, responsible for about 14,000 deaths per year.

What is truly alarming is that a lot of those who are infected don’t even know it. An estimated 65 percent of those with chronic hepatitis B and 75 percent of those with hepatitis C are not aware of their infections. This lack of awareness extends to health-care providers and policymakers. As a result, policymakers fail to allocate adequate resources to address it. The CDC’s division of HIV, STD, TB and viral hepatitis has an annual budget of about $1 billion. Only 2 percent is allocated to viral hepatitis.

Q. Who is at risk for hepatitis B and hepatitis C?

So: The majority of cases of hepatitis C in the United States are related to intravenous drug use. The major population at risk for hepatitis B, on the other hand, consists of foreign-born persons, especially from Asian and African countries where as many as 8 percent or more of the population are chronically infected. A lot of these folks got infected when they were babies or small children.

Without treatment or monitoring, as many as 25 percent of those with chronic hepatitis B will die of liver cancer or liver cirrhosis. For chronic hepatitis C, the figure is 1 percent to 5 percent. But if you diagnose these infections early, medications can help to control the infection. Long-term management involves screening for liver cancer, which might mean ultrasound once a year, and twice-yearly blood tests for levels of a liver-cancer marker called alpha-fetoprotein. For those with biochemical evidence of liver damage associated with elevated viral loads, there are now a number of effective antiviral drugs that can reduce the risk of further liver damage.

Q. What does the report recommend be done to raise awareness?

So: The CDC should evaluate the prospect of initiating a national hepatitis B and C public-surveillance system. This doesn’t exist at the moment, so even the true burden of the disease is not very clear. We also need to increase awareness among health-care providers, policymakers, and the public — especially at-risk populations — about who should be screened and how cases should be managed. Although the CDC estimates that one in every 12 Asian-Americans is chronically infected with hepatitis B, studies done here at Stanford and elsewhere show that this population is very poorly informed about their risk of getting hepatitis B and what it can lead to.

It is vital that we integrate viral-hepatitis services into Medicare, Medicaid and private health-care programs. We found out that most health-care providers don’t even collect data on whether their patients are foreign-born. But the foreign-born population is especially at risk. If you’re not even collecting that data, how are you going to make sure your patients are screened appropriately?

Q. Isn’t there an effective and inexpensive three-dose vaccine to prevent hepatitis B?

So: Yes, hepatitis B can be eliminated through universal vaccination, but it only works if you get it. The CDC estimates some 20,000 pregnant women with chronic hepatitis B give birth every year in the United States. Despite recommendations in place right now that their babies get immunized and receive hepatitis B immune globulin within 12 hours of birth, each year a thousand newborns still become chronically infected, putting them at risk for premature death from liver disease. Studies we’ve done at Stanford show that only 60 percent of these women who learned they have chronic hepatitis B when they became pregnant were referred for care by their obstetrician. The federally funded perinatal hepatitis B coordinators program tries to identify these women and make sure their babies are vaccinated promptly after birth to minimize the risk of perinatal transmission. But that program doesn’t have adequate resources to direct those women to care. So another report recommendation is to make sure these women receive long-term management.

To protect our future generation from hepatitis B, the CDC recommends that all newborns receive the hepatitis B vaccine, yet less than 50 percent of the newborns in the country are vaccinated within the first day of birth as recommended. Research shows that most of the nurses in the nursery — whom we’re relying on to convince parents it’s really important that their child should get this shot to prevent liver cancer in the future — often have a really poor understanding of why the shot is so important. In one study, almost half of primary-care doctors don’t even know what test to order to check for chronic hepatitis B. If we’re telling doctors to screen patients, and they don’t even know what test to order, we have a problem!

Stanford University Medical Center integrates research, medical education and patient care at its three institutions - Stanford University School of Medicine, Stanford Hospital & Clinics and Lucile Packard Children's Hospital. For more information, please visit the Office of Communication & Public Affairs site at http://mednews.stanford.edu/.