Hepatitis B Virus Infection: Fatigue-Associated Illness Experiences Among Koreans

The unvirtuous cycle of discrimination affecting people with hepatitis B: a multi-country qualitative assessment of key-informant perspectives

Background

An estimated 296 million individuals live with chronic hepatitis B worldwide, most have not been diagnosed and remain at risk of liver disease and cancer. People with hepatitis B often face discrimination that denies them employment or education opportunities, results in unfair treatment at work or in school, limits their ability to emigrate to certain countries, and in some cases prohibits them from serving in the military. Discrimination specific to hepatitis B has not been widely documented within the literature. This study aims to investigate and describe hepatitis B related discrimination, document discrimination occurring around the globe, and provide initial recommendations for addressing discrimination using key informant interviews.

Methods

Purposive and snowball sampling were used to identify potential key informants for qualitative interview. Key informants identified as community health leaders, public health scientists, doctors, and researchers, many of whom were also living with hepatitis B. Using a semi-structured guide, participants were asked to describe their experience and any challenges for people living with hepatitis B including marginalization and its’ consequences. A codebook was used to guide the organization of data for analysis, and all transcripts N = 17 were double coded.

Results

The overarching themes identified from interviews demonstrate explicit experiences with discrimination of those directly affected, the psychological responses, and the negative health outcomes associated with the unvirtuous cycle of discrimination. All key informants reported on the substantial quality of life implications and often poorer health outcomes resulting from hepatitis B discrimination. Participants also identified the significant impact of hepatitis B discrimination occurring within a range of education-based services across several countries as well as military exclusion or removal if individuals are found to have hepatitis B.

Conclusion

Our data demonstrate that hepatitis B discrimination has a significant impact. Discrimination can occur at various points in life from education, to seeking employment, to marriage, to restrictions on entry, travel and stay in other countries. This study demonstrates the impact of discrimination and the need for future research that can lead to policy change and protections for people living with and impacted by hepatitis B.

Hepatitis B-related acute-on-chronic liver failure induced by hepatotropic viral insult is associated with worse prognosis than that induced by non-virus insult

BACKGROUND

The manifestations and prognoses of acute-on-chronic liver failure (ACLF) with different precipitating events remain heterogeneous. We aimed to investigate the characteristics and prognosis of patients with hepatotropic viral insult (HVI)-induced hepatitis B-related ACLF (HBV-ACLF).

METHODS

452 patients with confirmed diagnosis of ACLF were screened in three medical centers in China, and 203 HBV-ACLF patients with definite acute precipitating events were retrospectively analyzed. According to the precipitating events, HBV-ACLF patients induced by HBV reactivation and super-infection with HAV were classified as the hepatotropic viral insult group and those induced by other factors, as the non-virus insult (NVI) group. The clinical characteristics, predictive scoring model, and prognosis of the two groups were compared.

RESULTS

Hepatitis B virus reactivation accounted for the largest proportion (39.9%) among all precipitating events. Exacerbation time frame of the HVI group was significantly longer than that of the NVI group (20 days vs. 10 days, P < 0.001). Comparison of intergroup prognosis showed that there was no significant difference in the 28 day mortality (20.9 vs. 13.7%, P = 0.125), while the 90 day and 1 year mortality in the HVI group were higher than those in the NVI group (36.3 vs. 24.4%, P = 0.014; 39.5% vs. 27.5%, P = 0.020, respectively). In the HVI group, the lactic acid-free APASL-ACLF Research Consortium (AARC) had better predictive value for 90 day mortality (0.741).

CONCLUSIONS

The 90 day and 1 year survival rate was lower in HBV-ACLF patients induced by HVI than by NVI. The lactate-free AARC score was a better predictor of short- and long-term prognosis in patients with HVI-induced HBV-ACLF.

Liver disease symptoms are associated with higher risk of adverse clinical outcomes: A longitudinal study of North American adults with chronic Hepatitis B

Background

Symptoms of chronic hepatitis B (CHB) are not well characterized.

Aims

To evaluate CHB symptoms and associations with disease activity and clinical outcomes.

Methods

Longitudinal data from 1,576 participants in the Hepatitis B Research Network Cohort Study who completed symptom assessments were analyzed. A composite symptom score was calculated using a Symptom Checklist (0=none to 40=extreme). Multivariable mixed models assessed variables associated with symptom change over time. Latent class symptom trajectories were evaluated. The cumulative probability of long-term clinical outcomes (new onset cirrhosis, hepatic decompensation, hepatocellular carcinoma, liver transplantation, death) was examined by baseline symptom groups.

Results

Participants median age was 42 (range:18-80), 51% were male, 75% Asian, (68% of whom were born outside North America) with a median follow-up of 4.2 years. On average, symptoms did not significantly change over time. The multivariable model identified several variables associated with higher symptoms during follow-up: being female, non-Asian, born in the US/Canada, lower education, higher AST, lower platelets, and more comorbidities. Two patient subgroups were identified based on longitudinal symptom trajectories: a low symptom group (92%, n=1,451) with symptom scores averaging 2.4 over time and a moderate symptom group (8%, n=125) with symptom scores averaging 11.5. During follow-up, 7.3% in the moderate symptom group, but only 3.2% of the low symptom group, developed adverse outcomes (p=0.02).

Conclusions

In this large cohort of CHB patients, symptoms were generally mild and stable over time. However, in some patients with moderate symptoms at baseline, deleterious clinical outcomes were more frequent in follow-up.

Work-health-personal life conflicts in naive patients with chronic hepatitis B receiving initial treatment in China: a qualitative study

OBJECTIVES

People with chronic hepatitis B (CHB) perform sick roles, work roles and personal roles simultaneously. At times, role conflicts arise because of failure to meet the expectations of different roles. Role conflicts may increase dissatisfaction in work and family and impair their physical and mental health. This study aimed to explore the perceptions of role conflicts of treatment-naive patients with CHB in work, personal and sick roles, together with ameliorating factors in the Chinese cultural context.

DESIGN

A qualitative descriptive study. Semistructured interviews were used to collect the experience of work-health-personal life conflicts (WHPLCs), and a brief questionnaire was used to collect demographic and clinical information. SPSS V.21.0 was used for descriptive analysis and Dedoose (V.7.5.9) was used to code and analyse interview transcripts. This study selected six cities with different socioeconomic levels in Zhejiang Province, China. Then, researchers chose one tertiary hospital from each city as the study site, so a total of six tertiary hospitals were involved.

PARTICIPANTS

We recruited 32 patients with CHB (59.38% male) who had just started antiviral therapy for no more than three months. Participants were within the age range of 19-57 years, and the average age was 36.03 (SD=9.56) years.

RESULTS

Participants noted that having CHB influenced their daily life and intersected with work and personal roles, therefore causing role conflicts. Role conflicts focused on three types: time-based conflicts, strain-based conflicts and behaviour-based conflicts. The contextual factors contributing to role conflicts were identified, including personal characteristics, financial strain, traditional social roles and work environment.

CONCLUSIONS

These findings enhance our understanding of the WHPLCs experience of treatment-naive patients with CHB in China. Our findings suggest that multidimensional role conflicts should be taken into account in the intervention design and psychological counselling to improve role balance and well-being among patients with CHB.

Patient-reported outcomes in a large North American cohort living with chronic hepatitis B virus: a cross-sectional analysis

BACKGROUND

Patient-reported outcomes (PROs) such as health-related quality of life (HRQoL) and symptoms associated with chronic hepatitis B viral (HBV) infection have not been well-described in North American cohorts.

AIMS

To evaluate several PROs and associations with HBV disease activity markers.

METHODS

Cross-sectional analysis including 876 adults who completed PRO measures during the Hepatitis B Research Network Adult Cohort Study. Participants on HBV treatment were excluded. Outcomes included: HRQoL using the SF-36 mental component summary and physical component summary scores; symptom burden using a 10-item Total Symptom Checklist and fatigue using an instrument from the Patient-Reported Outcomes Measurement Information System®. Covariates included laboratory markers of disease severity, virological status, comorbidities and medications.

RESULTS

Median age was 42 (range: 19-79), 51% were female, 73% Asian, 19% HBeAg (+), 2% had AST-platelet ratio index (APRI) ≥1.5 and 74% without comorbidities. Mean mental component summary T-score = 52, physical component summary T-score = 54 and PROMIS Fatigue T-score = 47. On a scale from 0 (none) to 40 (extreme), the mean Symptom Checklist score = 3 and 25% reported no symptoms. The most frequent symptoms were fatigue (60%), irritability (32%) and itching (32%). Most symptoms were 'a little bit' bothersome. In multivariable regressions, APRI ≥1.50 and more comorbidities were associated with worse patient-reported outcomes; virological markers were not. Adding the Total Symptom Checklist score to original regression models increased explanation of variation in the mental component summary score from 4% to 44% and the Physical Component Summary Score from 17% to 34%.

CONCLUSIONS

Untreated North American HBV patients with mild liver disease report favourable health-related quality of life and minimal symptoms. HBV does not impact health-related quality of life unless advanced liver disease or comorbidities are present. High symptom burden explains substantial variation in health-related quality of life. (CT.gov identifier: NCT01263587).

A quantile regression approach to explain the relationship of Fatigue and Cortisol, Cytokine among Koreans with Hepatitis B

Fatigue is a major symptom among patients with Hepatitis B virus (HBV). However, the physiological mechanisms regarding mediate fatigue and the relationships between fatigue, cortisol and cytokines are unclear in patients with HBV. The purpose of this study was to examine the relationships between perceived fatigue, cortisol, and cytokines in Korean patients with HBV. The mean score for overall fatigue was moderate. In linear regression analyses, TNF-α was only significant as a predictor of fatigue. In quantile regression analyses, the cortisol level was significant in the 70^th, 80^th, 90^th quantiles in the cognitive/mood fatigue subdimension, which correspond to severe levels of fatigue. IL-6 levels were significant in 90^th quantile in overall fatigue and in the cognitive/mood fatigue subdimension. Cortisol, IL-6, and TNF- α were related to perceived fatigue in patients with HBV, particularly in the cognitive/mood dimension. This suggests that the fatigue patterns of patients with HBV are related to their mental and mood states and physical responses, such as cortisol and cytokine levels, are correlated with the nature of the fatigue. In the clinic, interventions to manage fatigue in patients with HBV should be developed based on the characteristics of the fatigue.