Hepatitis B

Acute Infection

Health care professional with h/o HIV, IV drug use presents with acute onset jaundice. Reports recent needlestick at work and episode of sexual assault. ROS positive for fatigue, poor appetite, N/V, abdominal pain, and dark urine. Denies h/o hepatitis B vaccination. Low-grade fever, jaundice, RUQ tenderness, hepatosplenomegaly on exam.

  • Labs

    • Positive HBsAg, anti-HBc, IgM anti-HBc

    • Negative anti-HBs

    • Obtain CBC, CMP, PT/INR

    • Obtain HBeAg, anti-HBe

    • Obtain HAV Ab, HCV Ab, hepatitis D Ab, HIV (ELISA Ag/Ab)

  • Imaging: Obtain RUQ U/S

  • Treatment: Refer to GI

    • Healthcare worker with needlestick exposure to HBV positive blood: Administer hepatitis B immunoglobulin and start hepatitis B vaccine series if not vaccinated

    • Newly diagnosed disease in HBeAg negative pt: Retest HBeAg in 6 months to determine if seroconversion to HbeAg positive state has occurred (see below for treatment of chronic hepatitis B)

    • Negative HAV Ab: Administer hepatitis A vaccine now and again in 6 months

    • Administer hepatitis B vaccine to other household members and any sexual contacts

  • Counseling

    • Transmission

      • Pt informed that HBV can be spread via intercourse, exposure to blood of an infected individual, and sharing personal items such as a toothbrush or razor

      • Pt reassured that HBV is not spread by casual contact (e.g. sharing food, kissing) or breastfeeding

    • Pt advised to stop drinking alcohol

    • Pt counseled that monitoring will include regular liver enzyme and HBV DNA level testing

Screening for Chronic Infection

Male pt born in a developing nation with h/o immunosuppression and ESRD requiring dialysis presents for routine health maintenance exam. Reports chronic injection drug use, regular sexual intercourse with men. Previous lab work shows elevated AST, ALT. No documented h/o hepatitis B vaccination. Household contacts include hepatitis B positive individuals. Plan: Obtain HBsAg and anti-HBc.

  • HBsAg negative, anti-HBc negative: Obtain anti-HBs to determine need for vaccination

  • HBsAg negative, anti-HBc positive: Obtain anti-HBs to verify immunity status

  • HBsAg positive, anti-HBc positive: Acute vs. chronic infection

    • Obtain IgM anti-HBc and anti-HBs to determine acute vs. chronic infection

    • Refer to sections on evaluation and treatment of acute (above) and chronic (below) hepatitis B infection

 

Chronic Hepatitis B Evaluation and Treatment

Evaluate for

  • History of co-infection with HCV, HIV

  • Personal/family h/o liver disease

  • History of alcohol use

  • Signs/symptoms active cirrhosis


Labs

  • Obtain HbsAg, anti-HBc, IgM anti-HBc, anti-HBs

  • Obtain HBeAg, anti-HBe, HBV DNA, and HBV genotype

  • Obtain HAV IgG, HCV Ab, hepatitis D Ab, HIV (ELISA Ag/Ab)

  • Evaluate liver function: Obtain CBC with diff, CMP, PT/INR

Referrals and Monitoring

  • Refer to GI for further evaluation

    • Pt informed that further workup/treatment may include liver biopsy, anti-viral therapy, and/or liver transplant

    • Counseling: See acute hepatitis B infection (above)

  • Yearly monitoring for cirrhosis: Obtain alpha-fetoprotein levels and RUQ ultrasound with liver elastography

  • Refer pt to surveillance program for hepatocellular carcinoma

Treatment

  • Treatment for patients without cirrhosis

    • HBeAg positive six months after initial diagnosis

      • ALT <2x ULN: Continue to monitor

      • ALT >2x ULN: Start tenofovir 300 mg qd and obtain HBeAg, anti-HBe monthly; continue for 4 months s/p conversion to anti-HBe positive state

    • HbeAg negative, HBV DNA >2,000 IU, and ALT > 2x ULN: Start tenofovir 300 mg qd and consider continuing treatment indefinitely

  • Treatment for patients with cirrhosis and HBV DNA >2,000 IU: Start tenofovir 300 mg qd and continue indefinitely

  • All other patients: Continue to monitor and/or defer to GI recommendations

 

Notes

  • Acronyms: HAV, (hepatitis A virus), HBV (hepatitis B virus), HCV (hepatitis C virus), Ag (antigen), Ab (antibody)

  • Screening

    • In general, all patients born in Africa and mainland Asia should be screened; see the CDC Yellow Book for all nations with a >2% infection list that qualify for screening

    • Common risk factors: Dialysis, immunosuppression, increased exposure (e.g. men who have sex with men, IV drug users)

    • Standard screening tests: HBsAg and anti-HBc

  • Acute hepatitis B

    • Liver failure occurs in 1% of patients

    • Risk for progression chronic disease is greatest in infants (90%) and decreases with age; only 5% of adults progress to chronic disease

  • Chronic hepatitis B

    • Considered chronic when infection persists >6 months

    • Each year, 1 in 400 HBV carriers die due to liver complications

    • Ultimate goal of treatment is to prevent initiation/progression of cirrhosis

      • Patients without cirrhosis: Initiation primarily determined by seroconversion to anti-HBe and evidence of liver damage

      • In cirrhosis patients: Initiation determined by evidence of active disease

  • CDC overview of hepatitis B for health professionals