Children and HBV

Hepatitis B does not usually affect a child’s normal growth and development. Most children with chronic hepatitis B infections will enjoy long and healthy lives. Unlike other chronic medical conditions, there are generally no physical disabilities associated with hepatitis B, nor are there usually any physical restrictions for these children.

As a parent, you can take comfort from the fact that every child presents unique challenges. Therefore, your child with hepatitis B is just like any other child. The challenges of raising a child with hepatitis B are manageable if you are well informed and use common sense.

Adoption

The key to successful adoption of a child with hepatitis B is to be prepared with accurate information about the disease, and to protect yourself and other members of your household with the hepatitis B vaccine prior to the child's arrival.

International and Domestic Adoption           

Many people wish to adopt children from countries where hepatitis B infections are common: Asia, South America, Eastern Europe, and some parts of Africa. Children from these regions are often infected with the virus from their birth mothers who have hepatitis B and unknowingly pass the disease on to their children during delivery. In addition, many of these countries re-use needles for medications or blood tests, a practice that places children at risk if they have not already been infected at birth.

Domestic adoptions also present some risk to potential adoptive families. Children born to women in high-risk groups (e.g. illicit drug users, multiple sexual partners, etc.) could have been infected with hepatitis B at birth. In addition, children from group homes are at increased risk for hepatitis B infection.

Hepatitis B Testing

Your agency should be able to tell you if a child has been tested for hepatitis B. With an international adoption, it is advised that you do not request that your child be tested since the blood test itself could be a source of infection.

Reassurance for Adoptive Parents

Finding out that the child you wish to adopt has chronic hepatitis B can be upsetting, but should not be cause for alarm or stopping an adoption. We hope that a hepatitis B diagnosis will not change your decision to adopt a child. You can be reassured that most children will enjoy a long and healthy life. Hepatitis B does not usually affect a child's normal growth and development, and there are generally no physical disabilities or restrictions associated with this diagnosis.

Advice for Parents

Parents face a whole host of issues when making the decision to raise children. A child with hepatitis B presents new challenges, but they are manageable if you are well informed and use common sense.

The Hepatitis B Foundation has compiled a list of useful guidelines that may be helpful. Since each family is unique, and each community is different, please adjust your decisions accordingly.

Avoid the Spread of Hepatitis B

All parents, siblings, and other household members should be vaccinated. Extended family members, childcare providers, family, friends, and others should consider vaccination if they have, frequent and close contact with your child.

Know the Facts

If people are unfamiliar with hepatitis B, there is a possibility they will become alarmed when told your child has chronic hepatitis B. The key to reducing people's anxiety is to give them clear, simple facts.

§  Hepatitis B is not transmitted casually. It cannot be spread through the sharing of toys, sneezing, coughing, spitting, or hugging.

§  Hepatitis B is spread through blood and infected bodily fluids. Therefore, it could be spread through bites and scratches that result in broken skin.

§  Inform people that there is a safe hepatitis B vaccine and that the American Academy of Pediatrics recommends that all infants and children up to age 18 years be vaccinated. 

Know the Risk

In making the decision about telling others, be sure to consider whether your child is at high or low risk for exposing others to his or her blood (e.g. consider age, frequency of accidents, nosebleeds, biting, etc.). Consider the degree of risk a person has for exposure (frequent vs. occasional contact), and whether a person or child may have already been vaccinated.

Although there is no specific law that addresses hepatitis B, the Americans with Disabilities Act (1991) is a federal law that may protect children and adults with hepatitis B from discrimination.

Telling Others

Use common sense in deciding who you should tell about your child's hepatitis B. Once you tell, you can't take it back. So take your time and choose wisely as you decide who can be trusted with this information.

Fortunately, most children are now vaccinated against hepatitis B, so the risk of your child infecting others is reduced. Most states also require the hepatitis B vaccine for school entry. Although you do not necessarily have a "duty" to inform people of your child's hepatitis B, there may be situations where it is wise to disclose your child's diagnosis.

If possible, give literature to reinforce your facts. The Hepatitis B Foundation publishes free educational literature that you can request to give other parents, teachers, or school nurses.

What Should You Say?

Know your facts, use simple explanations, and remain calm. Emphasize that your child is healthy and poses no risk if blood accidents are handled carefully. Remind people (and health care providers) that blood is a two-way street. Other children may have unknown infections that can be spread to your child, therefore, the blood of all children should be handled carefully.

In addition, the hepatitis B vaccine is recommended for all infants and children up to 18 years. Therefore, most children should already be vaccinated and protected against hepatitis B.

Universal Precautions

The Centers for Disease Control (CDC) recommends that everyone use "universal precautions" for any accident. This means that the blood and bodily fluids of all adults and children should be treated as if it is potentially infectious.

Universal precautions (or "standard precautions") should be followed for ALL accidents, not just the blood of those with known chronic hepatitis B infection.

Cleaning Up Blood Spills

Avoid direct contact with blood, vomit, diarrhea and other bodily secretions, and ensure that others will not come into contact with them either.

§Clean all spills with a diluted solution of bleach (mix one part fresh household bleach with nine parts water).

§Discard cleaning materials into a plastic bag and tie securely. Dispose of properly in the garbage can.

§Wash your hands thoroughly with soap and warm water.

PKIDs Pediatric Hepatitis Report

Additional information for parents can be found in the Pediatric Hepatitis Report, which is the first-ever, comprehensive resource about children living with hepatitis B and C. Information about hepatitis B, from transmission to diagnosis, to treatment and civil rights protections is included in this excellent publication. It is published by the national non-profit PKIDs (Parents of Kids with Infectious Diseases).

Approved Drugs for Children

Chronic hepatitis B is normally a mild disease in children and teens. Most children can expect to live full, healthy lives unmarked by visible symptoms. In some children, however, the virus can cause serious liver damage. These children will need medical intervention and treatment.

ALL children with chronic hepatitis B should be seen regularly by a pediatric liver specialist or knowledgeable doctor whether they are on treatment or not. Visits may be every six months or once a year, depending on your child's situation. A physical exam, blood tests, and possible ultrasounds of the liver are part of the usual visit.

Approved Treatments

There are currently two approved treatment options available in the United States for children with chronic hepatitis B.

Interferon alpha (Intron A) is an injection usually given three times a week for 6 months to a year. Children generally experience fewer side effects than adults, but they can include flu-like symptoms.

Lamivudine (Epivir-HBV, Zeffix, Heptodin) is a pill that is taken once a day for at least one year or more. There are almost no side effects.

Not every child (or adult) with chronic hepatitis B needs to be treated. A pediatric liver specialist should evaluate your child to see if she or he is a candidate for treatment based on a physical exam, blood tests, and other test results. Treatment appears to be of greatest benefit to those who show signs of active liver disease.

Disclosing Your Child's Diagnosis

If you decide to disclose your child's hepatitis B, remain calm, provide literature to reinforce the facts, and give the school a letter from your child's doctor stating that s/he is healthy and poses no risk to the other children if appropriate precautions are maintained. Most states require hepatitis B vaccination prior to school entry, so this reduces any potential risk to other students.

We recommend the following when disclosing your child's hepatitis B to school officials:

§ Stress the importance of confidentiality and universal precautions to protect your child from social discrimination.

§ Remind school officials that hepatitis B is transmitted through exposure to blood; it is not transmitted casually.

§ Explain that hepatitis B is not the only blood-borne disease that puts children at risk.

§ Consider saying "Treat my child as you should treat every child — with care. You know what risk my child poses, but you don't know the risk that other children might present." 

Living with Hepatitis B

Adults and HBV

Will I recover?
The first question most people ask is whether or not they will recover from a hepatitis B infection.  The answer is directly related to that age at which a person is infected.  Most infected adults will recover without any problems, but unfortunately, most infected babies and children will develop chronic hepatitis B infections.

Acute Vs. Chronic

A hepatitis B infection is considered to be “acute” during the first 6 months after being exposed. This is the average period of time it takes to recover from a hepatitis B infection. If you still test positive for the hepatitis B virus (HBsAg+) after 6 months, you are considered to have a "chronic" hepatitis B infection, which can last a lifetime.

What should I do if I am diagnosed with chronic hepatitis B?
Make an appointment with a hepatologist (liver specialist) or gastroenterologist familiar with hepatitis B. This specialist will order blood tests and possibly a liver ultrasound to evaluate your hepatitis B status and the health of your liver. Your doctor will probably want to see you at least once or twice a year to monitor you and determine if you would benefit from treatment.

Most people with chronic hepatitis B can expect to live long, healthy lives. It is important to know that you can pass the virus along to others, even if you don’t feel sick. This is why it’s so important that you make sure that all close household contacts and sex partners are vaccinated against hepatitis B.

Consider following these helpful tips:

§ Avoid alcohol and smoking, as they can be extremely harmful to a liver already infected with the hepatitis B virus.

§ Talk to your doctor before taking any prescription, over the counter medication, or herbal remedies.

§ Although there is no special diet for people who have chronic hepatitis B, a healthy, well-balanced diet that is low-fat and includes plenty of vegetables is recommended.

§ Avoid eating raw shellfish, since they can contain bacteria that are harmful to your liver.

Is there a cure for chronic hepatitis B?
Right now, there is no cure for chronic hepatitis B, but the good news is there are  treatments that can help slow the progression of liver disease by slowing down the virus. If there is less hepatitis B virus being produced, then there is less damage being done to the liver. Sometimes these drugs can even get rid of the virus, although this is not common.

With all of the new exciting research, there is great hope that a complete cure will be found for chronic hepatitis B in the near future. 

Should I be on medication?
It is important to understand that not every person with chronic hepatitis B needs to be on medication. You should talk to your doctor about whether you are a good candidate for drug therapy or a clinical trial. Be sure that you understand the pros and cons of each treatment option. Whether you decide to start treatment or not, you should be seen regularly by a liver specialist or a doctor knowledgeable about hepatitis B.

Treatment of Liver Cancer

Early diagnosis and aggressive intervention are key to improving the prognosis of those diagnosed with liver cancer. Promising advances in the treatment of liver cancer are also giving patients new hope. Treatment of liver cancer is particularly challenging when compared with other types of cancer because in addition to the cancer itself, many patients have livers that have sustained damaged by chronic hepatitis B resulting in cirrhosis and various degrees of liver failure.

For each individual patient, the potential benefits of the various treatment options must be balanced with the risk of liver failure and how it affects the patient's quality of life.

Surgical Treatment

When the tumor is small or deemed surgically resectable, and the patient's liver condition is deemed fit for the planned resection, surgical removal offers the best chance for long-term survival. Despite complete removal of the tumor, patients are still at risk for recurrent disease, and they need to be followed closely long-term, especially during the first year when the risk of recurrence is greatest.

Nonsurgical Treatment

For patients who are not suitable resection candidates for anatomic or medical reasons, a number of treatment options, though limited in effectiveness, are available or being investigated in an attempt to control the disease long-term and with the aim of maintaining normal quality of life.

§  Traditional chemotherapy is generally ineffective, causes many side effects that may severely impair the patient's quality of life, and often does not prolong survival.

§  Intrahepatic arterial chemoembolization or chemoinfusion (TACE or TAC) has been adopted in the treatment of selected patients with unresectable lesions by the Stanford Multi-disciplinary Liver Tumor Clinic for the last four years. This treatment is not suitable for patients who already have signs of moderate liver failure and in patients with blockage of the portal vein. Long-term treatments with TACE or TAC have been associated with prolonged patient survival, and those who have good control or shrinkage of the tumor may even become suitable candidates for surgical resection or transplantation.

Liver Transplantation

Liver transplant is a treatment option for HCC that are surgically or medically unresectable, provided that the tumor is small (less than 5 cm or fewer than 4 lesions), confined to the liver, and without invasion into the blood vessels. More extensive tumors have a high risk for early recurrence and death after liver transplantation. After transplantation, the patient must receive either hepatitis B immunoglobulin (HBIG) or lamivudine, or both, to prevent HBV reinfection of the new liver.

Early diagnosis of small tumors is the only effective way of improving the outcome of liver cancer treatment, and that is only possible through screening of the high-risk population.

Liver Biopsy

A liver biopsy is a procedure that involves taking a small piece of tissue from the liver to examine under the microscope. A liver biopsy is ordered to detect potential liver damage caused by chronic hepatitis B infections. The results of a biopsy can be used to help in making treatment decisions or evaluating current treatment.

A liver biopsy is considered a minor surgical procedure that is done in the hospital, but does not usually require admission (it's done as an "out-patient procedure"). From check-in to check-out, patients should expect to be in the hospital for approximately  6 - 8 hours. Although the procedure itself is relatively short, there is a longer recovery period where they will be asked to lie on their right side for several hours to prevent any bleeding. Be sure to tell patients to arrange for someone to drive them home upon discharge.

Methods of Liver Biopsy

Needle Biopsy
Most patients undergo this type of liver biopsy. This procedure involves numbing an area on the right ribcage, making a tiny incision, and then inserting a thin needle between the ribs to obtain a small tissue sample from the liver (a ½ inch sample is removed).

Laparoscopic Biopsy
This procedure is ordered when tissue samples from specific parts of the liver are required. A special tube called a "laparoscope" is inserted through a small incision in the abdomen. The laparoscope sends images of the liver to a monitor that a doctor watches to guide him or her in obtaining tissue samples from one or more parts of the liver.

Tran venous Biopsy
This procedure is used when patients have blood-clotting problems or fluid in the abdomen. It involves placing a biopsy needle inside a tube called a catheter, which is inserted into a vein in the neck and then guided into the liver to obtain a tissue sample

Evaluation of Liver Cancer

Ultrasound of the liver and conventional CT scan are regularly obtained in the diagnostic evaluation of HCC (hepatocellular cancer or primary liver cancer), but they are often too insensitive to detect multi-focal small lesions and for treatment planning.

Thorough assessment with a biphasic spiral CT scan of the abdomen is essential. The fast spiral scanner allows scanning of the liver at the arterial phase shortly after the patient is given an intravenous bolus of contrast.

Percutaneous fine needle biopsy may be indicated in cases when the diagnosis of primary versus metastatic liver tumor is uncertain, providing that it can be safely performed. Post biopsy bleeding can be life threatening in cirrhotic patients with low platelet count, prolonged clotting time, and enlarged blood vessels that are under high pressure (portal hypertension). In general, metastatic liver lesions are rare in patients with cirrhosis. Screening for liver cancer is the only effective way of improving the outcome of treatment.

Liver Cancer Screening

Symptoms

Liver cancer is a silent killer because the majority of the patients appear to be perfectly healthy and have no early signs or symptoms. Pain is uncommon until the tumor is quite large, and some large tumors don't even cause pain or other symptoms.

Later stages of liver cancer, when the cancer is very large or when it impairs the functions of the liver, can produce more obvious symptoms such as pain over the right upper abdomen, weight loss, lack of appetite, and finally the development of yellow discoloration of the eyes and skin (jaundice) and abdominal swelling.

Screening Frequency

Hepatitis B carriers who become infected early in childhood have a high risk of developing liver cancer whether they have cirrhosis or not. The risk is greater in men and those with a positive family history for liver cancer.

A reasonable approach to liver cancer screening includes:

§Alpha-fetoprotein (AFP) blood test every 6 months

§Liver Ultrasound at least once or twice a year

Either test alone, however, can miss the diagnosis. Once the patient develops cirrhosis, more frequent screening is generally recommended. 

Hepatitis B and Primary Liver Cancer

Chronic hepatitis B infections cause 80% of all primary liver cancer worldwide.

Patients with chronic hepatitis B infections are at increased risk for progressing to liver cancer or hepato cellular carcinoma (HCC), whether they develop cirrhosis or not.

In the U.S. the overall incidence of cancer is decreasing, except for primary liver cancer (as reported by the National Cancer Institute in 2005). This is due in large part to the increased number of Americans who are chronically infected with hepatitis B and hepatitis C. Although survival rates for most types of common cancers have improved over the years, the 5-year survival rate for liver cancer is still below 10%.

In the world, primary liver cancer is the 3^rd leading cause of death. According to the World Health Organization, at least 550,000 people die each year from primary liver cancer.

The hepatitis B vaccine was named the first "Anti-Cancer Vaccine" vaccine by the U.S. Food and Dug Administration since it prevents hepatitis B infections, the leading cause of primary liver cancer.

Who should be screened for liver cancer?

Early detection improves the chances of survival after treatment. Since liver cancer develops quietly, usually without symptoms, patients with chronic hepatitis B should undergo regular liver cancer screening. A reasonable approach is to begin regular liver cancer screening at 30 years of age (although experts are recommending starting an even earlier age since liver cancer can strike children, though rare).

It is important to stress that Asians and Asian Americans, who generally develop chronic hepatitis B infections soon at birth, have a high risk of developing liver cancer at an early age whether they have cirrhosis or not. The risk is greater in men and those with a positive family history for liver cancer.

What is liver cancer screening?

This generally consists of a simple blood test for alpha-fetoprotein (AFP) levels every 6 months and an ultrasound of the liver at least once a year. Either test alone can miss the diagnosis. Some doctors prefer CT scans to ultrasounds. Once the patient develops cirrhosis, or has a family history of liver cancer, more frequent screening is generally recommended.

What are the symptoms of liver cancer?

Liver cancer is a silent killer because the majority of patients appear to be perfectly healthy and have no early signs or symptoms. Both small and large tumors may be undetected due to the shielded location of the liver underneath the ribs.

Pain is uncommon until the tumor is quite large, and some large tumors don't even cause pain or any symptoms. Later stages of liver cancer, when the cancer is very large or when it impairs the functions of the liver, can produce more obvious symptoms such as abdominal pain, weight loss, lack of appetite, and finally the development of jaundice and abdominal swelling.

How is liver cancer treated?

Treatment of HCC is particularly challenging when compared with other types of cancer because in addition to the cancer itself, many patients have livers that have been damaged by chronic hepatitis B infections. For each individual patient, the potential benefits of the various treatment options must be balanced with the risk of liver failure and how it affects the patient's quality of life.

Surgical Treatment - When the tumor is small and the patient's liver condition is stable, surgical removal offers the best chance for long-term survival. Despite complete removal of the tumor, however, patients are still at risk for recurrent disease. They will need to be followed closely long-term, especially during the first year when the risk of recurrence is greatest.

Nonsurgical Treatment - For patients who cannot undergo surgery, a number of treatment options, though limited in effectiveness, are available or being investigated in an attempt to control the disease long-term and with the aim of maintaining normal quality of life. Traditional chemotherapy is generally ineffective, causes many side effects that may severely impair the patient's quality of life, and often does not prolong survival.

TACE (or TAC) - Since HCC are hypervascular tumors often fed by one or more blood vessels from the hepatic arteries, they present the unique opportunity to target the therapy directly into the tumor. Intrahepatic arterial chemoembolization or chemoinfusion (TACE or TAC) is used in the treatment of selected patients with tumors that cannot be surgically removed.

Long-term treatments with TACE or TAC have been associated with prolonged patient survival, and those who have good control or shrinkage of the tumor may even become suitable candidates for surgical resection or transplantation.

What about a liver transplant?

Liver transplant is the only treatment option for patients with liver cancer tumors that cannot be surgically or medically removed. The tumor must be small (less than 5 cm or fewer than 4 lesions), confined to the liver, and without invasion into the blood vessels. Larger or more extensive tumors have a high risk for early recurrence after liver transplantation.

What does the future hold?

Early diagnosis of small tumors is the only effective way of improving the outcome of liver cancer treatment, and that is only possible through screening of the high-risk population. Universal hepatitis B vaccination is ultimately the only hope for reducing the incidence of this frequently fatal cancer worldwide.