Serologies, diagnosis and management of hepatitis B

1. Hajira Nisar Cheema
Resident Internal Medicine

3.  DNA virus
 Incubation period: 6 weeks to 6 months
 Highly resistant to heat
 Mode of spread: Blood products, needle stick injury, sexual contact, perinatal route

9. The patient was previously infected with HBV, but he has cleared the infection. He
should be reassured and counselled to avoid further exposure.

10.  To improve survival and quality of life
 To prevent mother to child transmission
 Regression of fibrosis and cirrhosis in patients with established advanced fibrosis

11.  HbeAg positive or negative chronic hepatitis B: when HBV DNA levels are greater
than 2000IU/mL and ALT >Upper limit off normal, moderate liver
necroinflammation/fibrosis
 With compensated or decompensated cirrhosis with any HBV DNA levels
 Patients with HBV DNA >20,000IU/mL and ALT greater than 2 times the upper
limit of normal regardless of fibrosis
 HbeAg positive chronic HBVinfection (persistently normal ALT and high HBV
DNA levels, may be treated if they are older than 40 years of age)
 HbeAg positive or HbeAg negative chronic HBV infection and family history of
HCC or cirrhosis and extrahepatic manifestations

12.  HbeAg positive chronic HBV infection >30 years of age: every 3-6 monthly
 HbeAg negative chronic HBV infection and HBV DNA <2,000 IU/mL: every 6-12
months
 HbeAg negative chronic HBV infection and HBV DNA >2,000IU/mL: 3 months for
1st year and 6 months thereafter

13.  The preferred regimens are nucleoside analogues with high barrier to resistance.
 1. Entecavir
 2. Tenofovir disoproxil fumarate
 3. Tenofovir alafenamide
Lamivudine, adefovir dipivoxil and telbvivudine are not recommended in treatment
of chronic hepatitis B.

14.  Long term suppression of HBV DNA levels
 HbeAg loss with or without anti Hbe seroconversion
 ALT normalization
 HbsAg loss with or without anti Hbs seroconversion

15.  HBV reactivation is the abrupt reappearance or rise in HBV DNA in a patient
with previously inactive chronic or resolved hepatitis B. It is often accompanied by
a flare in disease activity with elevation of liver enzymes with or without
symptoms. HBV reactivation can be severe, resulting in death.

16.  Patients who test positive for both anti-HBc and HBsAg are at substantially
higher risk of reactivation than are those who are positive for both anti-HBc and
anti-HBs. Others at risk include people:
 undergoing cancer chemotherapy
 taking immunosuppressive therapy, including:
 Rituximab and other drugs that target B lymphocytes (black box warning),
 high-dose steroids, and
 anti-TNF agents;
 with HIV infection who have discontinued therapy with antiretroviral drugs that
also have activity against HBV;
 undergoing solid organ or bone marrow transplantation; and
 being treated for HCV coinfection

17.  Entecavir, Tenofovir disoproxil fumarate and Tenofovir alafenamide are started
irrespective of HBV DNA level and patient is assessed for liver transplantation.
 Pegylated interferons are contraindicated.

18.  All patients on transplant waiting list with HBV related liver disease should be
treated with nucleoside analogue.
 Combination of HBIG and a potent nucleoside analogue is recommended after
transplantation for prevention of HBV recurrence.

19.  HIV positive patients with HBV coinfection should start tenofovir disoproxil
fumarate or Tenofovir alafenamide based ART irrespective of CD4 cell count.
 HDV-HBV coinfected patients should receive pegylated interferons for atleast 48
weeks in case of compensated liver disease.

20. ARE PATIENTS UNDERGOING
TREATMENT FOR HCV AT
RISK FOR HBV
REACTIVATION?
 Because of recent reports of HBV reactivation in HCV coinfected patients
receiving direct acting antiviral (DAA) therapy for HCV infection, all patients
initiating HCV DAA therapy should be tested for HBV infection with HBsAg, anti-
HBs, and anti-HBc. People testing positive for HBsAg and/or anti-HBc should be
monitored while receiving HCV treatment

21.  Screening for HbsAg: is must in first trimester.
 Pregnant women with chronic hepatitis B: Tenofovir disoproxil fumarate
 HBV DNA levels (>200,000 IU/ml) or HbsAg levels >4log10IU/ml, antiviral
prophylaxis with TDF should start at week 24-28 weeks of gestation and continue
for upto 12 weeks after delivery.
 Breastfeeding is NOT contraindicated in HbsAg positive untreated women or on
TDF.

22.  Vasculitis
 Purpura
 PAN
 Arthralgias
 Peripheral neuropathy
 Glomerulonephritis
Patients should receive treatment with nucleoside analogues.

23.  Vaccines currently available: Engerix-B, Recombivax HB, Heplisav-
B, preHevbrio
 Vaccination available in Pakistan: Engerix-B, Euvax-B, Gervax, Herbiova C
 Immunologic memory remains intact for atleast 30 years among healthy people
who initiated hepatitis B vaccination at >6 months of age.