Hepatitis B – Q & A

1. Hepatitis B – Q & A Dr R V S N Sarma MD, FIMSA

2. Question 1 • Your clinic nurse had a needle stick injury while collecting blood. The patient is known HBsAg positive. What should you advise her?

3. Answer 1 • Your clinic nurse had a need stick injury while collecting blood. The patient is known HBsAg positive. What should you advise her? • Answer: She requires HBIG (Hepatitis B Immunoglobulin) and HBV vaccination full course, if she is HBsAg negative and is never vaccinated.

4. Question 2 • A software engineer reports for a routine check up. He doesn’t remember if he had HBV vaccine. Wants to have it now. What would you do?

5. Answer 2 • A software engineer reports a for routine check up. He doesn’t remember if he had HBV vaccine. Wants to have it now. What would you do? • Answer: Test for HBsAg. If negative – give him full course of HBV vaccine. If positive evaluate for activity of the HBV infection.

6. Question 3 • A commercial sex worker seeks your advise regarding HBV protection. She is HBsAg negative. She had a course of HBV vaccine. Will you assure her that she is protected? How will you ensure that?

7. Answer 3 • A commercial sex worker seeks your advise regarding HBV protection. She is HBsAg negative. She had a course of HBV vaccine. Will you assure her that she is protected? How will you ensure that? • Answer: As she is a high risk individual, test for HBsAb titer, if >10mIU/ml, she is protected. If not, give her HBV vaccine and advise her on safe sex practices and risks of other STD.

8. Question 4 • A new born baby is seen by you immediately after birth. Her mother is a known HBsAg positive. How will you ensure that the baby is protected fully ?

9. Answer 4 • A new born baby is seen by you immediately after birth. Her mother is a known HBsAg positive. How will you ensure that the baby is protected fully? • Answer: Child must receive HBIG on one arm and HBV first dose on the other within 12 hrs of birth. Second and third doses after 1 month and sixth months.

10. Question 5 • A patient is routinely tested for HBsAg and found to be positive. What will be your next step?

11. Answer 5 • A patient is routinely tested for HBsAg and found to be positive. What will be your next step? • Answer: Must ascertain the activity of the virus and must follow the patient for at least two years. HBeAg, Anti-HBeAb, Total Anti-HBcAb, IgM Anti HBcAb, Viral DNA copies, ALA and clinical profile will decide activity and treatment. Has potential danger for transmission. Advise safe sex practices, screen spouse and children.

12. Question 6 • A patient has tested for HBsAg and HBeAg. Would proceed to start on antiviral or what you will do to decide on antiviral Rx?

13. Answer 6 • A patient has tested for HBsAg and HBeAg. Would proceed to start on antiviral or what you will do to decide on antiviral Rx? • Answer: Get the viral load (copies of viral DNA per ml) and see the ALT levels. If the viral load is at least 105 copies/ml and if the ALT is 2 times the upper normal limit, anti viral Rx will be indicated.

14. Question 7 • A patient’s HBV serology is as follows • HBsAg negative, Tot Anti-HBc negative, Anti-HBsAb negative. How do you classify him? What do you do?

15. Answer 7 • A patient’s HBV serology is as follows • HBsAg negative, Tot Anti-HBc negative, Anti-HBsAb negative. How do you classify him? What do you do? • Answer: Such person is termed as susceptible He/she needs full 3 doses of HBV vaccine now.

16. Question 8 • A patient’s HBV serology is as follows • HBsAg negative, Tot Anti-HBc positive, Anti-HBsAb positive. How do you classify him? What do you do?

17. Answer 8 • A patient’s HBV serology is as follows • HBsAg negative, Tot Anti-HBc positive, Anti-HBsAb positive. How do you classify him? What do you do? • Answer: Such a person is Immune by natural infection and does not require any intervention. He has a totally resolved infection. A few of such patients may flare up later. So follow.

18. Question 9 • A patient’s HBV serology is as follows • HBsAg negative, Tot Anti-HBc negative, Anti-HBsAb positive. How would you classify him?

19. Answer 9 • A patient’s HBV serology is as follows • HBsAg negative, Tot Anti-HBc negative, Anti-HBsAb positive. How would you classify him? • Answer: This individual is properly immunized by HBV vaccine. He is protected. If the titer of Anti-HBsAb is >10 mIU/ml, it shows good immunity.

20. Question 10 • A patient’s HBV serology is as follows • HBsAg positive, IgM AntiHBc positive, AntiHBsAb negative. He has jaundice. What is his clinical status. What would you do?

21. Answer 10 • A patient’s HBV serology is as follows • HBsAg positive, IgM Anti-HBc positive, Anti-HBsAb negative. He has jaundice. What is his clinical status. What would you do? • Answer: This patient has Acute Hepatitis B disease. Usually it resolves and recovers. A few patient may become Immune Active or Immune Resolved and will be a case of Chronic active B hepatitis (CHBV)

22. Question 11 • A patient’s HBV serology is as follows • HBsAg positive, Total Ig Anti-HBc positive, Anti-HBsAb negative. What is his clinical status. What would you do?

23. Answer 11 • A patient’s HBV serology is as follows • HBsAg positive, Total Ig Anti-HBc positive, Anti-HBsAb negative. What is his clinical status. What would you do? • Answer: This patient suffered HBV infection in the past (Total Ig Anti HBc positive) and has not recovered fully (HBsAg positive). He is a chronic carrier. He may become Immune Active or Immune resolved. He needs follow up every 3 months.

24. Question 12 • A patient’s HBV serology is as follows • HBsAg negative, IgTotalAntiHBc positive, AntiHBsAb negative ? Why is it that IgG AntiHBc alone is positive?

25. Answer 12 • A patient’s HBV serology is as follows • HBsAg negative, IgTotalAntiHBcpositive, AntiHBsAb negative ? Why is it that IgG AntiHBc alone is positive? • Answer: There are three reasons for this scenario – namely 1. The patient is in window period and yet to develop HBsAg positivity. 2. Patient may have had very remote infection and dropped his HBsAg and his anti HBsAb waned off but the memory remains or 3. The isolated AntiHBc positivity is a false positive result.

26. Question 13 • You want to test a patient for HBV infection status. What test(s) do you order? And in what order?

27. Answer 13 • You want to test a patient for HBV infection status. What test(s) do you order? And in what order? • Answer: The first step is screening test – HBsAg test . If this is negative, do Anti HBsAb to confirm if he is already immune (immune patient will be positive for AntiHBsAb). If the patient is HBsAg positive, as a second step, we need to know the activity of the virus – order for HBeAg. If HBeAg is positive, the third step would be to order for HBV DNA quantitative assessment (copies/ml) to decide on the Antiviral Rx. We need serum ALT level to assess the liver injury.

28. Question 14 • What tests you order in a full panel of HBV serology?

29. Answer 14 • What tests you order in a full panel of HBV serology? • Answer: • 1. HBsAg • 2. HBsAb • 3. AntiHBcAb IgM • 4. AntiHBcAb Total • 5. HBeAg • 6. AntiHBeAb • Viral DNA count (copies/ml) if HBeAg is positive • If viral multiplication + ve, serum ALT; Only rarely liver biopsy. • Never test for HBcAg in serum. This never appears in blood

30. Question 15 • What are the three phases of chronic HBV infection?

31. Answer 15 • What are the three phases of chronic HBV infection? Answer A. Immune Tolerant B. Immune Active wild and Immune Active (mutant) C. Inactive Carrier

32. Question 16 • What do you understand by the term Immune Tolerant phase of chronic HBV disease.

33. Answer 16 • What do you understand by the term Immune Tolerant phase of chronic HBV disease. This patient is in harmony with the virus. He has active viral replication but no liver injury as yet. His/her 1. AntiHBcAb total will be negative 2. HBeAg will be positive 3. His viral DNA copies will be high 4. But his liver enzyme ALT will be normal

34. Question 17 • What do you understand by the term Immune Active phase of HBV disease.

35. Answer 17 • What do you understand by the term Immune Active phase of HBV disease. This patient the virus took the upper had and liver injury has stated. He has active viral replication too. His/her 1. AntiHBcAb total will be negative 2. HBeAg will be positive in wild and negative in mutant 3. His viral DNA copies will be high 4. But his liver enzyme ALT will be increased.