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Posts for: September, 2016

September 28, 2016
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I attended a wonderful talk today at Egleston's Pediatric Grand Rounds by Dr. Rene Romero, Director of the Liver Transplant Program. Today's topic was Hepatitis B & Hepatitis C.

Hepatitis is, of course, inflammation of the liver. It has many causes. Some are infectious, e.g. the B virus and the C virus; other causes are toxic injury, poisoning, alcohol, fatty infiltration of liver cells from obesity, and others.

Dr. Romero reviewed the development of liver injury from the B virus (HBV) and the C virus (HBC). What I found most interesting is that these viruses alone are not themselves the source of injury to the liver, but instead trigger the body's immune system to fight the infection in the liver cells. The body's immune system response is what can injure the liver. 

Some human immune systems tolerate infection by HBV and there is no liver injury. The individual feels well even though he or she is contagious to others from body fluids, especially blood. Sometimes, a persons immune system actually spontaneously cures the infection.

As years go by, however, in some persons, the immune system shifts from tolerating the presence of HBV in liver cells to recognizing the virus as foreign. The immune system then no longer tolerates HBV in the liver cells and causes an immune response to fight HBV. This immune response can injure liver cells in the fight to eradicate viral infection. Active inflammation and hepatits results. Liver cells die. Scarring or fibrosis results. Symptoms of yellow jaundice ensue and one feels badly requiring healthcare. Usually these individuals are older_even adult in age.

Risky adult behaviors can lead to spreading infection with HBV. If one shares body fluids (blood, sexual secretions, needles, etc), a "well" person with HBV, or a sick person with HBV hepatitis, can share the virus with other participants in such risky behaviors. Depending on one's immune system, one might tolerate the viral infection for a while and seem well, spontaneously cure it, or become actively sick with liver injury.

Now newborn babies are in a different situation. Their immune systems by definition are immature. A baby who comes into contact with HBV through pregnancy or delivery from the mother's infected blood or vaginal secretions, is very likely to become infected. Because of the baby's immature tolerant immune system, the baby may appear well yet has a greater than 90% chance of becoming a lifelong chronic carrier of HBV. At some future time this tolerant, yet infected baby, will likely develop active liver disease that progresses to chronic liver disease, eventual liver failure and sometimes liver cancer_both of which are incompatible with life without complex treatment, even including liver transplantation.

That is why today's mothers receiving ongoing prenatal care to prepare for healthy childbirth are routinely screened for HBV. If a mother is found to be positive for HBV, even if they are otherwise well (not yet having liver disease or liver injury), their babies are presumed exposed to the virus and are offered two important treatments at birth, even if they appear perfectly healthy: 1] Hepatitis B Immune Globulin HBIG) and 2] Hepatitis B vaccine immunization. Both these interventions are time sensiitive, safe and effective.

HBIG is antibody to HBV which when given to newborns of infected mothers, "fights" the mother's virus in the baby's body. HBV immunization is a killed purified vaccine which when given to newborns can trigger the baby's immature immune system to make baby's own antibodies to fight the mother's HBV in the baby's body hopefully preventing inection of the baby's own liver. This approach is highly effective. Babies exposed to maternal HBV at birth who would normally have over a 90% chance of becoming chronically infected with resultant serious liver disease including liver cancer, have a minimal chance of liver infection when treated in this manner.

So this makes sense for babies of mother's known to be positive for HBV. But what about newborns of mothers who are not HBV positive? Why are these healthy uninfected newborns supposed to get Hepatitis B vaccines before they leave their birthing facility, or as soon as possible after a home birth?

Since friends and family of these healthy newborns to HBV negative mothers also come into contact with these new babies in the first months of life, we still advise immunizing all babies at birth. The proud parents of these newborns just can't know who may or may not be a "healthy" carrier of HBV who might unknowingly handle the baby. Even if parents ask their friends and family if they have been tested for HBV, it is very likely said friends and family won't know, won't remember, or just won't get it right. 

HBV has been found in perspiration, tears, and saliva of well carriers of HBV who don't know they are infected and are contagious to others through these body fluids. There is NO DOWNSIDE to immunizing a newborn baby with HBV vaccine before returning home or shortly after home birth. The vaccine is non-infectious. It is not a living vaccine. It can not injure the baby's liver as can the actual live virus. 

So my thanks to Dr. Romero for reviewing a very complex field of liver virus disease. We didn't even talk about Hepatitis C.

I will say one thing about Hepatitis C. Dr. Romero informed us today that current medications by mouth have over a 90% cure rate for Hepatits C. Every adult Boomer should have at least once a screening blood test for Hepatitis C, even if well without jaundice or evidence of liver disease. Because if found to be HBC positive when well, the virus can be cured before disease presents itself and the adult can be made non-contagious to others, barring reinfection from repeated risky adult behaviors.

Maybe more later on this complex subject.

To simplify and summarize: Please consider the benefits to immunizing your healthy newborn babies with their first dose of HBV vaccine before leaving your birthing facility or shortly after your home birth. Don't bother to investigate the HBV status of your "well" friends and family. They won't know, and if they do, can you rely on their answers? Best not to ask, just protect your new baby with a safe and effective HBV as requested by your newborn's doctor.

And of course, protect your baby and all babies this winter by getting your influenza vaccine and at least one Tdap (Tetanus, Diphtheria, Pertussis/Whooping Cough) for persons 11 years of age and older who will be in contact with your baby the first year of life.

Staying in touch,

Dr. T