IN THIS ISSUE
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
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:
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
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:
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.