ABSTRACT world, in United States, New York as well



    July 28th of every year, the WHO organizes World Hepatitis Day to increase awareness in the hope of completely eradicating Hepatitis thereby saving more infant and adult lives. The paper effectively summarizes the infectious Hepatitis B disease which is a threat to health-care professionals around the globe. The paper also summarizes the incidence and prevalence rates of the disease in different parts of the world, in United States, New York as well as Nassau County in Long Island. The risk factors as well as prevention strategies for the primary, secondary, and tertiary intervention of the disease have been described. Additionally, the paper supports the latest advancements made to combat the disease as well as future perspectives. A critical summary of a peer-reviewed article describes chronic Hepatitis B condition through mother to child transmission, its risk factors, treatment as well as challenges. The sources used for the paper are credible sources which have been referenced electronically.

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                                                                HEPATITIS B

   Hepatitis B is classified as a viral infection which is caused by the Hepatitis B virus (HBV). The virus primarily affects the liver and is capable of causing both acute and chronic infections. The virus can be transmitted upon contact with various bodily fluids such as blood, semen etc. from an infected person. The various modes of transmission include sexual contact, the sharing of infected needles, or any drug-injection machines. The virus can also be transmitted from mother to the child during birth. There are estimated 257 million individuals who have been diagnosed with Hepatitis B surface antigen positive and are currently living with HBV infection. HBV is an occupational hazard for the individuals working in the healthcare industry. It has become a global health problem by putting people at high risk of death by liver cirrhosis and liver cancer.

   The survival rate of a Hepatitis B virus (HBV) outside the body is about 7 days. The virus can still infect the person who has not been previously vaccinated when it enters at this stage. The incubation period for the virus is between 30-180 days with an average being 75 days. The detection of the virus can be done between 30-60 days after the infection which can progress to become chronic if not addressed. Perinatal transmission of the infection from mother to the child and horizontal transmission from an infected child to an unaffected child is seen commonly in endemic areas (WHO, 2017).

   The prevalence of Hepatitis B is highest in the Western Pacific Region with about 6.2% prevalence rate. The next in line is the Western African Region which has a prevalence rate of 6.1% respectively. This is followed by the East Mediterranean Region, South-East Asia Region and European region with a prevalence rate being estimated at about 3.3%, 2.0% and 1.6% respectively. About 0.7% prevalence is seen in the United States (WHO, 2017). The number of individuals estimated to be affected by Chronic Hepatitis B infection in the United States is around 850,000-2.2 million. In 2013, the number of acute incidences of HBV infection was reported to be around 19,800. The number showed a 5% increase in comparison to the cases which were reported in 2012. The increased numbers were seen after 20 years and have been a matter of concern. The CDC is suggesting that it could be linked to the opioid abuse epidemic which is currently prevalent in the United States (HHS.gov, 2017). In the Nassau County, the Hepatitis B incidence per 100,000 was reported to be 0.3. A three-year average incidence rate was reported to be 0.4 per 100,000 individuals. The New York City average incidence rate was reported to be 0.3 per 100,000 individuals. (New York State Department of Health, 2017).

   Age can be a factor which can be contributed to the severity of the disease in an individual. Children under 6 years have the highest chances of developing chronic infection. About 80-90% of children infected in their first year of life have the chances of developing chronic infections. About 30-50% children who are under 6 years of age can develop chronic infections. The most common age group among adults to develop chronic HBV is between 30-49 years with the most common reason for developing the disease being, injection of drugs related to the opioid abuse epidemic. The highest incidences of the infection in the United States are seen in individuals who have been born abroad (i.e outside of the US). In adults, the chances of developing chronic infection are about 5%. About 20-30% of chronically affected individuals will have the chance of developing liver cirrhosis and or liver cancer. Unvaccinated men having sex with men or having multiple sexual partners have chances of getting infected with HBV. (WHO, 2017).

   A strong relation of developing co-infection by HIV is seen in the individuals which have HBV. The estimation is that about 1% of individuals (2.7 million) which have been affected with HBV are also infected with HIV. Many of them reported sharing the same modes of transmission. The global prevalence for such co-infection is about 7.4%. All the individuals infected with HIV are advised to also get tested for HIV. Tenofovir which is one of the medications used in the treatment of HIV is also been used against HBV (WHO, 2017).

   It is difficult to isolate the cause of Hepatitis B infection from other forms of Hepatitis on a clinical basis. Hence, it is essential to get a laboratory testing done. Numerous blood tests done on the infected individuals would determine the progress of the disease and get distinguished between the acute and chronic conditions. The laboratory testing for the diagnosis includes the detection of the surface antigen HBsAg. Detection of this antigen is mandatory for testing for blood donations. In acute conditions, HBsAg and Immunoglobulin M (IgM) antibody is seen on the core antigen HBcAg. The high levels of replication of the virus can be seen with the presence of HBeAg. This suggests that body fluids and blood in of the individual is highly infectious. In chronic conditions, the antigen HBsAg has been in the blood system for a minimum of 6 months. The persistence of this antigen constitutes a principal marker for the development of risk for hepatocellular carcinoma (WHO, 2017).

   Mother to child transmission of the Hepatitis B infection is concerning mainly because it can be prevented. There are about 1000 cases of the virus being transmitted to infants every year in the United States. The condition could also cause an early death by HBV related causes. Hence, expectant mothers are tested at each pregnancy for the possibility of transmission and adequate precautions are taken accordingly. The Hepatitis B vaccine is completely safe and effective. About 3-4 shots are given in a 6-month time-frame after birth as part of the primary prevention regime. The Hepatitis B vaccine has been available since 1982. The World Health Organization has recommended giving the first shot of the Hepatitis B vaccine at the earliest possibility after the birth of a child. As many parents agree to get their child vaccinated as soon as the birth of their child, the incidence rate of chronic HBV in children under 6 years is slowing decreasing. The efficacy rate of the vaccine is about 95%. The vaccine has been covered under many health plans as a preventative service (HHS.gov, 2017). Protection with the vaccine lasts for about 20 years. People who have already taken the three doses of the vaccines do not need any booster vaccinations as per the WHO.

   As part of the secondary prevention, some oral treatments such as tenofovir or entecavir has been recommended by the WHO as they can suppress the HBV. These drugs tend to have no drug resistance in comparison to the other drugs and are simple to take. They also don’t have many side effects and there is only limited monitoring required. Oral anti-viral agents can treat chronic Hepatitis B infection. Early diagnosis and early start of the treatment would help to slow cirrhosis as well as reduce the chances of liver cancer thereby enabling long-term survival. Sometimes even treatment cannot fully cure the Hepatitis B infection completely and just functions to suppress the replication rate of the virus. The individuals who are currently undergoing treatment have to continue it throughout their lives. Individuals who tend to suffer from liver cancer due to the infection have very limited treatment options and even then, the treatment outcomes are generally poor. In countries and areas where people cannot afford the treatment for cancer have a survival rate of only a couple of months. In other places where the individuals can afford, their lives can be prolonged for only a couple of years. Liver transplantation has proven to show some success. However, it varies on a case by case basis (WHO, 2017).

   Drug pricing and pharmaceutical industry have monopolized the market by increasing their prices with patent protection. As a result only high income or upper-middle income families could afford treatment. Entecavir has become off-patent but still the prices and the availability of the drug varies greatly. According to the WHO report, the price of the drug Tenofovir which is patent- protected can vary anywhere from the US $400 to the US $1500 for a year’s worth of treatment in February 2017. Some generic versions of drug Tenofovir have been available in some countries at lower prices. The generic price of the drug according to the Global Price Reporting Mechanism (GPRM) could be anywhere from the US $48- US $50 in February 2017 (WHO, 2017).

   A recent study has shown that the chronicity of the disease could be attributed to the high viral load. The viral protein production is depending upon the transcription of a viral covalently closed circular DNA (cccDNA). The recent trials which have been conducted on humans show an RNA interference (RNAi) based treatment which primarily targets the HBV transcripts ARC-50. The HBS antigen showed high rates of reduction in the individuals who were tested positive for the HBeAg but the efficacy was not that much in the individuals who were HBeAg negative or who had nucleotide viral replications inhibitors treatment on a long-term basis. However, the exact source of the origination of the HBsAg is still unknown and could alter the result of the possible treatment (Wooddell, Yuen, Lik-Yuen Chan, Gish, Locarnini, Chav, Ferrari, Given, Hamilton, Kanner, Lai, Lau, Schluep, Xu, Lanford, Lewis,2017).

   Hepatitis B infection has become a worldwide problem. Hence, to address this issue in the future, the World Health Assembly came up with the first “Global Health Sector Strategy on Viral Hepatitis, 2016-2020.” The strategy would highlight the impact that Universal Health Coverage would help with the strategies that are aligned with the Sustainable Development Goals. The vision of the strategy is to completely eliminate viral hepatitis by reducing the cases of new viral infections globally by 90% as well as the deaths caused due to viral hepatitis by 65% by 2030 (WHO, 2017).

   The transmission from mother to child transmission of the virus poses a very serious problem globally. The perinatal mother to infant transmission (MTIT) is still prevalent despite active prophylaxis. The three modes of transmission of the diseases care intrauterine transmissions which include the leakage of the maternal blood trans-placentally, transmission during the time of delivery also called as intrapartum as well as a postnatal transmission which is mainly through breast milk. The virus could also be transmitted from other family members through close contact with the infant. However, a possible cause of MTIT predominantly is during delivery. The positivity of HBeAg as well as the high viral load are the significant causes attributing to the disease. As a result, some females electively choose to undergo a cesarean section to reduce the risk of transmission. Failure of the medication which would lead to hepatitis B surface gene mutation as well as undergoing invasive OB procedures have also shown to increase the chances of transmission (Shih, Liu, 2017).

   In the past before the era of vaccination predominated, only 40% of the cases would be detected for the virus. Since the HBeAg from the maternal side is responsible for the MTIT, about 90% of the infants born during that era had chronic infections. Despite the availability of the vaccine, there are still many challenges are being faced. The fact that many countries do not insist on getting the child immunized with Hepatitis B shot after birth poses a serious problem. Even the stoppage of the NUC postpartum is controversial. There have been cases where despite medication, the infants still suffered from the infection. Hence new studies and AASLD (American Association for the Study of the Liver) have shown that pregnant women with a high viral load (HBV DNA level > 200,000 IU/ml) should be administered oral NUC in their third trimester to significantly reduce transmission risk. Hence there is a need for optimal screening techniques for early detection and effective preventive strategies globally (Shih, Liu, 2017)