MANAGEMENT AND REFERRAL

Counsel all HBsAg-positive patients on preventing progression of chronic hepatitis B infection to liver damage and preventing transmission of HBV to others (see Box 2). Refer IDUs to harm reduction services such as needle exchange and drug use cessation programs (Resources--NYC DOHMH for Patients).

Acute Hepatitis B. Care is supportive and antiviral treatment is generally not necessary in patients with symptomatic acute HBV, as most immunocompetent patients recover spontaneously.8,18 Patients with protracted, severe acute HBV infection (increase in international normalized ratio and deep jaundice persisting for more than 4 weeks) may require antiviral therapy and should be referred to a specialist.8 Monitor patients with acute HBV for clearance of the virus in 6 months.3 A positive HBsAg at 6 months indicates chronic HBV infection. Encourage patients to inform their close contacts so that they can receive prophylaxis.3

BOX 2. WHAT TO TELL YOUR PATIENTS WHO HAVE HEPATITIS B INFECTION
To prevent progression of liver disease:
  • Avoid alcohol.
  • See your doctor regularly to monitor your liver health, even if you feel well.
  • Consult a provider before taking any medications, including over-the-counter (eg, acetaminophen, ibuprofen, naproxen) and herbal medicines, herbal teas, supplements, and home remedies.
To prevent transmission of HBV to other people:
  • Encourage all household members, sexual partners, or drug-using partners to get tested and vaccinated.
  • Use a condom during sex if your partner is not vaccinated or naturally immune.
  • Do not share toothbrushes, razors, glucometers, clippers, nail files, nail scissors, washcloths, syringes, sex toys, or anything that may have come in contact with infected blood or body fluids.
  • Cover open cuts and scratches.
  • Wash hands well after touching infected blood or body fluids.
  • Clean blood spills with detergent or bleach.
  • Do not donate blood, organs, tissue, or sperm.
For injection drug users (IDUs):
  • Never share drug use equipment, always use new sterile equipment, wash your hands and injection site before and after each injection, and plan ahead to avoid withdrawal.

 

Chronic Hepatitis B. Monitor patients for progression of liver disease and development of liver cancer,2,3 and vaccinate against hepatitis A virus (HAV) (2 doses 6-18 months apart),3 pneumococcal disease, and influenza, according to the ACIP-recommended schedule (Resources).16 Do a full evaluation, including family history of liver disease and hepatocellular carcinoma and a physical exam.14 Order laboratory tests to3,8:

  • detect liver disease (complete blood counts with platelets, hepatic panel, and prothrombin time);
  • detect HBV replication (HBeAg/anti-HBe, HBV DNA);
  • rule out viral coinfections:
    • HCV: EIA, ELISA, chemiluminescent immunoassay, or rapid antibody test; if positive, quantitative viral RNA test
      (Resources--City Health Information: Hepatitis C)
    • HIV in people at risk: Rapid antibody test or ELISA; if positive, Western blot or indirect immunofluorescence assay
      (Resources--City Health Information: HIV)
    • HDV (hepatitis D virus) in people from countries where infection is common (Mediterranean Basin, Middle East, Central Asia, West Africa, Amazon Basin) and people with a history of injection drug use: radioimmunoassay or EIA; if infection is ongoing, RT-PCR.26

Refer patients with chronic HBV infection for liver biopsy if initial laboratory testing suggests liver damage, according to current practice guidelines (Resources).3,8

Because of the complex natural history of chronic hepatitis B infection, patients can fluctuate between periods of active and inactive disease.27 Determine the phase of chronic hepatitis B infection (see Table 3) and manage appropriately. The immune tolerant phase is seen only in patients infected neonatally or in early childhood and can last for decades. In the active phase, the virus is replicating and the immune system attempts to remove HBV from infected hepatocytes. In the inactive or nonreplicative phase, liver enzymes and HBV DNA are low; liver inflammation and fibrosis usually improve if the infection remains in this phase.8,27 Rarely, chronic HBV infection resolves. Risks for liver disease decrease significantly in these patients, but hepatocellular carcinoma and cirrhosis can still develop, especially if liver damage was already present.27

TABLE 3. PHASES OF CHRONIC HEPATITIS B INFECTION

Phase

HBe Status

HBV DNA Level
(copies/mL) PCR

ALT Levels

Action

Immune tolerant



HBeAg+

High: >20,000
IU/mL (>105
copies/mL)

Normal

ALT every 3-6 months; refer to specialist if ALT > upper limit of normal.

Active (virus
replicating)

HBeAg+ or HBeAg-/anti-HBe+

Moderately high:
>2000 IU/mL
(>104copies/mL)

Abnormal

Refer to specialist for antiviral treatment.

Nonreplicative
(inactive HBsAg carrier)

HBeAg-/anti-HBe+

Low: <2000 IU/mL (<104 copies/mL) or undetectable

Normal

ALT every 6 months; if > upper limit of normal, do HBV DNA. Refer to specialist if both are elevated.

Resolveda

HBeAg-/anti-HBe+

Undetectable

Normal

Refer to specialist if baseline serum albumin/platelet counts are low.

HBeAg = hepatitis B extracellular antigen; HBV DNA = hepatitis B virus DNA; PCR = polymerase chain reaction; ALT = alanine aminotransferase; anti-HBe = antibody to HBeAg.
aRisk for cirrhosis and hepatocellular carcinoma is significantly decreased, but not absent.
Adapted from McMahon J. Am J Med. 2008;121(12A):S45-S52; McMahon J, Peters M. AASLD guide; 2010.

Antiviral therapy may be appropriate for patients with active chronic hepatitis B (persistent inflammation that tends to progress to cirrhosis or liver cancer). The goal of antiviral therapy is to prevent or delay progression of chronic hepatitis B to cirrhosis, end-stage liver disease, and hepatocellular carcinoma.28 The Food and Drug Administration has approved 7 medications to treat patients with chronic hepatitis B infection: lamivudine, adefovir, entecavir, telbivudine, tenofovir, interferon alpha, and pegylated interferon. Refer patients with active chronic hepatitis B to a specialist for possible treatment unless you are experienced in antiviral therapy.

Hepatocellular Carcinoma Surveillance. Hepatocellular carcinoma, the most common form of liver cancer, is closely associated with HBV infection and is frequently asymptomatic at an early stage.8,10,29 In 2011 in the US, about 26,000 new cases were diagnosed and 20,000 deaths were attributed to hepatocellular carcinoma.30 In New York City in 2010, there were 663 deaths from liver cancer.31 Patients with chronic hepatitis B who are at high risk for hepatocellular carcinoma should have liver ultrasound and alpha-fetoprotein (AFP) level screening every 6 to 12 months.8,27 Risk groups include:

  • Men older than 40 years and women older than 50 years;
  • Men and women of any age, especially Asian and Pacific Islanders, with severe liver fibrosis (cirrhosis or bridging fibrosis), an AFP level greater than 10 ng/mL, or a family history of hepatocellular carcinoma;
    • Up to 20% of cases of hepatocellular carcinoma occur in Asian American men younger than age 40 years and women younger than age 50 years with clinically active chronic hepatitis, cirrhosis, or other risk factors.28
  • Women aged 40 years and older with an HBV DNA level higher than 2000 IU/mL and/or elevated ALT and/or positive HBeAg;
  • People coinfected with HIV and/or HCV;
  • Africans older than 20 years.3,8,23,27

Postexposure Prophylaxis. The Centers for Disease Control and Prevention (CDC) recommends the HBV vaccine series and HBIG to prevent HBV infection in unvaccinated patients after potential exposure. After accidental exposure via percutaneous or mucous membranes, administer HBIG, preferably within 24 hours and no later than 7 days of exposure14,24; after sexual exposure to an HBsAg-positive person, administer HBIG within 14 days of exposure.14 Hepatitis B immune globulin should also be administered to infants after perinatal exposure (see Resources--NYC Perinatal Hepatitis B Program) and to unvaccinated infants younger than 12 months who have been exposed to a primary caregiver with acute HBV.5 These recommendations change if the patient has been vaccinated1,5,15,16,32 (see Resources--ACIP recommendations and AAP Red Book). Hepatitis B immune globulin should be given intramuscularly with the first dose of HBV vaccine at a separate site. 

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