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Monitoring Chronic Hepatitis B in the Primary Care Office

Monitoring Chronic Hepatitis B in the Primary Care Office. Aimee J. Lee, R3 Infectious Disease CME. After this presentation:  The learner will be able to determine appropriate candidates for hepatitis B screening 

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Monitoring Chronic Hepatitis B in the Primary Care Office

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  1. Monitoring Chronic Hepatitis B in the Primary Care Office Aimee J. Lee, R3 Infectious Disease CME

  2. After this presentation:  • The learner will be able to determine appropriate candidates for hepatitis B screening  • The learner demonstrate an understanding of the natural history of hepatitis B • The learner will be able to monitor chronic hepatitis B from the primary care office  Objectives

  3. None Disclosures

  4. Hepatitis B: • 350 million persons worldwide • Annual mortality rate: 620,000 people • Chronic infection with hepatitis B virus (HBV) is a common cause of death associated with liver failure, cirrhosis, and liver cancer. Transmission: Contact with infectious blood, semen, and other body fluids Hepatitis B

  5. USPSTF Grade A for screening all pregnant women. • USPSTF Grade D for screening the general population • CDC recommendation: Screen for Hepatitis B in high risk populations (based on consensus/expert guidelines) • High risk individuals: • Behavioral exposures • Intimate contacts • Immunosuppressed • Liver disease of unknown etiology • Hx of HCV/HIV Hepatitis B Screening

  6. After a susceptible person is exposed, the virus is transported by the bloodstream to the liver • Can cause asymptomatic or symptomatic infection. When clinical manifestations of acute disease occur, illness typically begins 2 - 3 months after HBV exposure. • In immunocompetent adults, most HBV infections spontaneously resolve, whereas in most neonates and infants they become chronic.  Natural history of Hep B

  7. Viral Markers Hepatitis B Surface Antigen (HBsAg): Marker of current infection Hepatitis B e Antigen (HBeAg): Marker of active infection HBV DNA: Measures viral activity Hepatitis B Viral Model

  8. Hepatitis B Surface Antibody (HBsAb): Marker of recovery or immunity • Hepatitis B e Antibody (HBeAb): Marker of inactive virus (generally). • Hepatitis B Core Antibody (HBcAb): Marker of present or past infection. Present for life • IgMto hepatitis B core antibody (IgMHBcAb): Positivity indicates recent infection with HBV (≤6 months) • Complete screening using HBsAg and HBsAb Hepatitis B Markers

  9. Phase of Chronic Hepatitis B

  10. Perinatally acquired. High levels of HBV replication: • HBeAg(hepatitis B e antigen) and high HBV DNA in serum • No active liver disease • Poor responders to therapy Replicative Phase: Immune tolerance

  11. Phase of Chronic Hepatitis B

  12. Most immune competent adults begin in this phase • Occurs in perinatally acquired Hepatitis B when host immune system matures • Seroconversion: HBeAg HBeAb • HBeAgseroconversion is frequentlyaccompanied by biochemical exacerbations • Serious liver injury can occur HBeAg-positive chronic hepatitis: Immune clearance

  13. Phase of Chronic Hepatitis B

  14. Seroconversion is usually accompanied by stabilization of hepatitisknown as an “inactive carrier state” • Normalization of ALT levels • Decreases in HBV DNA • Histologically, minimal to mild hepatitis may be observed Low or nonreplication phase/inactive carrier state 

  15. Phase of Chronic Hepatitis B

  16. Chronic hepatitis may recur in up to one third of inactive HBV carriers without reversion of HBeAg in their serum • Likely due to infection with mutated HBV variants that cannot express HBeAg • Moderate levels of HBV replication and active liver disease • HBeAg negative. • elevated serum ALT and • chronic inflammation on liver biopsies HBeAg-negative chronic hepatitis 

  17. Phase of Chronic Hepatitis B

  18. Serologic Markers

  19. HBsAg negative phase: • Low levels of Hepatitis B replication and HBV DNA in the liver • Generally serum levels are undetectable • HBcAb (+), +/- HBsAb • Occurrence before onset of cirrhosis = favorable outcome • Occurrence after onset of cirrhosis = still risk for HCC • Immunosuppression can reactivate Occult Hepatitis B(Latent Phase)

  20. Immune-active phase • Predictors of worse outcomes: • Prolonged HBV DNA elevation • High level of alanine transaminase (ALT), • Presence of HBeAg. • Risk factors for HCC Predictors for Complications

  21. In younger patients in the immune-tolerant phase, those in the inactive-carrier phase, and those who have latent HBV infection. • In patient with concurrent serious conditions • In patients who are nonadherent Therapy Not Recommended:

  22. Patients beginning immunosuppressants • Infants of women who are HBsAgpositive. • Hepatitis B immunoglobulin and hepatitis B vaccination within 12 hours of birth to reduce the risk of perinatal transmission. Therapy Recommended:

  23. In patients with chronic HBV who have active liver inflammation may receive treatment depending on the progression of the disease • Other factors that may influence the decision to treat: • Male sex • Genotype C • Family history of hepatocellular carcinoma • Ongoing alcohol abuse. • Co-infection with human immunodeficiency virus (HIV), HCV, or HDV Therapy May Be Recommended:

  24. Confirm chronic HBV infection: • HBsAg+ for at least 6 months • Initial evaluation includes history, physical, LFTs + platelet count, HBeAg and HBeAb, HBV DNA • Determine phase of infection Initial Evaluation in HBsAg + Patient

  25. Phase of Chronic Hepatitis B

  26. Check ALT q3-6 m Refer Refer Phase of Chronic Hepatitis B Check ALT q6 m

  27. ALT q 3-6 months • If ALT levels are between 1-2 ULN, recheck ALT q1-3 months; consider liver biopsy if age 40, ALT borderline or mildly elevated on serial tests. • If ALT 2x ULN for 3-6 months and HBeAg, HBV DNA 20,000 IU/mL, consider liver biopsy and treatment Immune Tolerant

  28. ALT q 3 months for 1 year, if persistently normal, ALT q 6-12 months • If ALT 1-2 x ULN, check serum HBV DNA level and exclude other causes of liver disease. Inactive Carrier

  29. Screen for hepatocellular carcinoma with hepatic ultrasound of every 6 months for all individuals at high risk: • Asian men over the age of 40 years • Asian women over the age of 50 years • Patients with HBV and cirrhosis • African Americans/Africans • Patients with a family history of HCC HCC Surveillance for Patients with Chronic Hepatitis B

  30. Screen at risk patients. • Complete initial evaluation • Assess stage • Monitor immune tolerance and inactive stages • Refer to specialist for immune active phase • Vaccinate! Hepatitis B vaccination is recommended for all infants, older children and adolescents who were not vaccinated previously, and adults at risk for HBV infection. • Education patient and test family/sexual contacts • Notify Public Health Department Primary Care

  31. All new or previously unreported cases of chronic hepatitis B should be reported to the King County Public Health Department • Automated 24-hour reporting line: 206-296-4782 • Should notify within 1 month • Perinatal Hepatitis B Prevention Program: All pregnant women who are HBsAg-positive should be reported to the health department as early in pregnancy as possible. • Notify within 3 days • Notify with each pregnancy Notifiable Disease

  32. Thank you!

  33. AASLD Practice Guideline, Management of Hepatocellular Carcinoma: An Update. Bruix, J, Sherman, M. http://www.aasld.org/practiceguidelines/Documents/Bookmarked%20Practice%20Guidelines/HCCUpdate2010.pdf (Accessed on August 02, 2010). • Department of Health and Human Services: CDC. Interpretation of Hepatitis Serological Markers. http://www.cdc.gov/hepatitis/hbv/pdfs/serologicchartv8.pdf • Lok, Anna, et al. Chronic Hepatitis B. AASLD Practice Guidelines. Hepatology February 2009. 508-539. • McHugh, James, et al. Chronic Hepatitis B Infection: A workshop consensus statement and algorithm. The Journal of Family Practice. (2011) Vol 50, No 3. • McMahon, B. J. (2009), The natural history of chronic hepatitis B virus infection. Hepatology, 49: S45–S55. doi: 10.1002/hep.22898 • McMahon, Brian. Internist Diagnosis and Management of Chronic Hepatitis B. The American Journal of Medicine. (2012) 125, 1063-1067 • Public Health Department, King County. Perinatal Hepatitis B Prevention Program. http://www.kingcounty.gov/healthservices/health/communicable/providers/phbpp.aspx • Weinbaum CM, Williams I, Mast EE, et al., for the Centers for Disease Control and Prevention (CDC). Recommendations for identification and public health management of persons with chronic hepatitis B virus infection. MMWR Recomm Rep. 2008;57(RR-8):1–20. References

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