Chronic Hepatitis B infection

exp date isn't null, but text field is

Clinical features

  • Can be symptomatic or asymptomatic:
    • Weakness and malaise, low grade fever
    • Nausea, loss of appetite and vomiting
    • Pain or tenderness over the right upper abdomen
    • Jaundice, dark urine, severe pruritus
    • Enlarged liver
    • Complications: liver cirrhosis, hepatocarcinoma

Investigations

  • Hepatitis B surface antigen positive for >6 months
  • Hepatitis B core antibody: Negative IgM and Positive IgG to exclude acute hepatitis B infection
  • Liver tests, repeated at 6 months
  • HBeAg (can be positive or negative)
  • HBV DNA if available
  • HIV serology
  • APRI (AST to Platelets Ratio Index): a marker for fibrosis

  • Alpha fetoprotein at 6 months
  • Abdominal ultrasound at 4-6 months

ManagementTreatment

General principles

  • Screen for HIV: if positive, refer to HIV clinic for ART: coninfection is a risk factor for disease progression and some ARVs are active against Hepatitis B virus
  • If HIV negative: refer to a regional hospital for specialist management
  • Antiviral treatment is given to prevent complications and it is usually given for life
  • Patients with chronic hepatitis B need periodic monitoring and follow up for life
  • Periodic screening for hepatocarcinoma with alfa fetoprotein and abdominal ultrasound once a year

Treat with antivirals if the patient has any one of these:

  • All persons with chronic HBV infections who have cirrhosis (whether compensated or not) based on clinical findings and/or APRI score >2, irrespective of liver enzyme levels, HbeAg status or hepatitis B viral load)
  • HIV co-infection (use a tenofovir based combination)
  • Patients with no cirrhosis (APRI score <2) but persistently elevated ALT on 3 occasion within 6-12 months and viral load >20,000 IU/L (if available) regardless of HbeAg status

First line antivirals:

  • Adults and children >12 years or >35 kg: tenofovir 300 mg once a day
  • Child 2-11 years (>10 kg): Entecavir 0.02 mg/kg

The following patients should NOT be treated

  • Patients without evidence of cirrhosis (APRI ≤2) and with persistently normal ALT level and HBV viral load < 2000 IU/ml (if available)

Health education

  • Management is lifelong because of the need to monitor hepatitis
  • Bed rest
  • Urge patient to avoid alcohol as it worsens disease
  • Immunisation of household contacts
  • Do not share items that the patient puts in mouth (e.g. toothbrushes, cutlery) and razor blades

Inactive Hepatitis B Carriers

Carriers are patients with chronic but inactive infection:

  • HBsAg positive for more than 6 months plus
  • Persistently normal liver function (at least 3 times in 12 months) and
  • No evidence of viral replication (negative HBeAg and/or HBV DNA < 2000 IU/ml)

Patients classified as inactive carriers need to be monitored once a year with CBC, renal and liver tests, HBsAg, abdominal ultrasound. If possible, do HBV-DNA every 3 years.

They are not highly infectious but close contacts should be immunized and appropriate precautions should be followed.

Pregnant Mother HbsAg Positive

If a pregnant mother is found HBsAg positive:

  • If also HIV positive,
    • Start ARVs
    • Child should receive HepB vaccine at birth
  • If she is HIV negative,
    • She should be referred for further testing (HBeAg, HBV DNA) to assess the risk of transmission to the baby and eventual need of antiretrovirals
    • Child should be immunized at birth
  • Breastfeeding is safe