Viral Hepatitis in Hawai‘i – Differing Perspectives
I. Introduction
Alan D. Tice MD
p. 4
Viral hepatitis infections, particularly hepatitis A (HAV), hepatitis B (HBV), and hepatitis C (HCV) are a significant problem worldwide. HAV has been nearly eliminated in Hawai‘i due to immunizations, food safety, and the fact that it has no chronic form. HBV and HCV, however, are transmitted primarily through activities that involve percutaneous or mucosal contact with infectious blood or body fluids. They are similar and unique because of their capacity to cause persistent and often life-long infections. Over long periods of time, chronic liver inflammation and damage can contribute to the development of cirrhosis with organ failure and hepatocellular carcinoma, which is usually fatal. In 2006, chronic liver disease and cirrhosis comprised the 12th most common cause of death for adults in the United States between the ages of 25 and 64.1 Hawai‘i has the highest rate of liver cancer per capita in the United States, largely due to the incidence of HBV and HCV and delayed diagnosis.2 Globally, chronic HBV affects approximately 350 million people, with an estimated 1.4 million cases occurring in the United States, although the rate of new cases has declined since routine vaccination of children was recommended in 1991.3 The situation in Hawai‘i is unusual because of its high immigrant population, with data that indicates that 5% to 10% of Asian/Pacific Islander Americans are chronically infected with HBV, compared with 0.2% to 0.5% of the overall US population.4
HCV is the most common bloodborne infection in the United States, representing approximately 4 million chronically infected persons. HCV lives in approximately one in 50 Americans, or about 2% of the total population.3 Hepatitis C becomes a chronic disease in 85% of patients, and surfaces with cirrhosis and/or liver cancer decades after infection. HCV differs from HBV in that it can be eradicated, but there is no effective vaccine to prevent it.
High risk factors for which hepatitis screening is recommended include: injection drug use, nasal inhalation of cocaine, chronic renal failure on dialysis, incarceration, multiple sexual partners, transplantation or transfusion of blood products, occupational exposure to blood products, body piercings, tattoos, and birth to mothers with the virus.3 Therapy is available to suppress HBV in most people and to eliminate HCV in more than half of people infected.
These viruses, which are fatal to a growing number of individuals, pose a challenge to healthcare systems, healthcare providers, and the communities in which the virus is prevalent. Termed a ‘Silent Epidemic’, many patients are asymptomatic for decades before developing end stage liver disease or cancer. New and effective medications have been developed to help slow this epidemic and treat those who are already infected. For end stage liver failure, the best option for most individuals is a liver transplant, but it is increasingly difficult to obtain due to lack of qualified donors. Recent numbers show that there are about 15,000 patients currently registered on the liver transplant waiting list of the United Network for Organ Sharing, while only 4,500 cadaver donor livers become available for transplantation each year.5 Cadaver donor organ availability seems to have reached a plateau despite initiatives to increase donation. The waiting time for liver transplantation has increased steadily each year, rising from approximately one month in 1988 to more than a year in 1999. Currently, more than one-third of patients in the United States wait longer than two years for a liver transplant, and more patients die each year while awaiting transplantation. There is a critical shortage of donor organs, and this problem will continue to worsen in the foreseeable future. With the increase in the incidence of diagnosed nonalcoholic fatty liver disease and the epidemics of viral hepatitis infections, the number of deaths due to liver disease is expected to escalate in the next decade. Alcoholic liver disease is a frequent co-morbid condition which contributes to a more rapid progression of liver disease with both HBV and HCV. Education and early clinical intervention can be extraordinarily effective in preventing or at least slowing the insidious progression of individuals who have chronic hepatitis.
The objectives of recent annual symposia sponsored by the Hepatitis Support Network of Hawai‘i were to educate healthcare providers and community members, provide differing yet complementary perspectives regarding hepatitis issues, and make plans for the future to address the hepatitis needs in Hawai‘i. We believe that the parable of the blind men and the elephant is applicable, wherein six learned men went to examine an elephant despite the fact that they could not see (Figure 1). They were asked to describe what the elephant looked like based on a sensory examination, and arguing, each man gave a very different response. A wise leader awakened by the commotion called out, “The elephant is a big animal. Each man touched only one part. You must put all the parts together to find out what an elephant is like.” The ‘elephant’ before us is hepatitis, and requires the attention and collective perspectives of the healthcare community to provide an appropriate response.
This supplement outlines the perspectives of selected patients, physicians, administrators, and healthcare providers in a collaborative effort to present the problems and impacts caused by the ‘silent’ hepatitis epidemic and to learn solutions to problems encountered in managing viral hepatitis in our community.
