American Association For The Study Of Liver Diseases Recommendations
The 2016 AASLD guidelines for the treatment of chronic hepatitis B as well as select recommendations from the 2018 AASLD guidance update on the prevention, diagnosis, and treatment of chronic hepatitis B are outlined below and in the Guidelines section.
Adults with immune-active chronic hepatitis B infection
Administer antiviral therapy to lower the risk of morbidity and mortality associated with chronic hepatitis B infection.
The recommended initial agent for adults is PEG-IFN, entecavir, or tenofovir.
Adults with immune-tolerant chronic hepatitis B infection
Antiviral therapy is not recommended.
The AASLD suggests obtaining ALT levels at least every 6 months to monitor for potential transition to immune-active or -inactive chronic hepatitis B.
For select patients older than 40 years, the AASLD suggests antiviral therapy in the setting of normal ALT levels, elevated HBV DNA , and significant necroinflammation or fibrosis on liver biopsy specimens.
Adults with HBeAg-positive immune-active chronic hepatitis B who seroconvert to anti-HBe on nucleoside analog therapy
After a period of treatment consolidation , consider discontinuing NA therapy in noncirrhotic HBeAg-positive adults who seroconvert to anti-HBe while on NA treatment. If antiviral therapy is stopped, monitor the patient every 3 months for a minimum of 1 year for recurrent viremia, ALT flares, seroreversion, and clinical decompensation.
Adults with HBeAg-negative immune-active chronic HBV infection
Inpatient care
Treatment Of Children With Acute Hbv Infection
Children with acute HBV infection are usually asymptomatic. Those with fulminant hepatitis, severe acute hepatitis and protracted acute hepatitis might benefit from NA treatment. Lamivudine, adefovir, entecavir and tenofovir are considered acceptable options. IFN is contraindicated . Although an optimal duration of NA treatment has not been established, it is recommended that NA treatment be continued until HBsAg clearance, or at least 3 months after HBsAg seroconversion, or 1 year after HBeAg seroconversion without HBsAg loss .
Is Hepatitis B Preventable
Chronic hepatitis B infection affects at least 250 million people worldwide, causing over 880,000 deaths annually. It is also the major cause of liver cancer, the second leading cause of cancer-related deaths in the United States.
Unlike its cousin hepatitis C, hepatitis B can be prevented with vaccines. If you are accidentally exposed to the virus, there are also drug therapies you can takeâcalled postexposure prophylaxisâto avert the infection.
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Clinical Guidelines For Children With Chronic Hepatitis B
In general, the clinical guidelines for children are the same as for adults visits are usually scheduled every six months or once a year. Most children do not need drug treatment, but they still need to be monitored regularly to make sure they remain healthy and to detect any problems with their liver as soon as possible. Visits will include a physical exam, blood tests, and possibly an imaging study of the liver .
AASLD guidelines provide guidance for treating children under the Updated Recommendations on the Treatment of Patients With Chronic Hepatitis B, section 9A.
The Hepatitis B Foundation convened the first Pediatric HBV Workshop and invited the nations leading pediatric liver specialists to develop the first national recommendations for children living with hepatitis B to ensure that they receive the best care possible. These recommendations have been published in highly respected, peer-reviewed journals and provide expert guidance for the care of infected children.
Hepatitis B Foundations Clinical Guidelines for Pediatric HBV
HBFs Pediatric HBV Screening and Monitoring Recommendations Published in Pediatrics in November 2009Haber BA, Block JM, Jonas MM, Karpen SJ, London WT, McMahon BJ, Murray KF, Narkewicz MR, Rosenthal P, Schwarz KB. Recommendations for screening, monitoring, and referral of pediatric chronic hepatitis B. Pediatrics 124:e1007-13.
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National Institutes Of Health Recommendations
The National Institutes of Health recommends nucleoside therapy for the treatment of patients with acute liver failure, as well as cirrhotic patients who are HBV DNA positive and those with clinical complications, cirrhosis or advanced fibrosis with positive serum HBV DNA, or reactivation of chronic HBV during or after chemotherapy or immunosuppression. In addition, immunoglobulin and vaccination should be administered to newborns born to women positive for hepatitis B surface antigen .
In general, for hepatitis B e antigen -positive patients with evidence of chronic HBV disease, treatment is advised when the HBV DNA level is at or above 20,000 IU/mL and when serum ALT is elevated for 3-6 months.
For HBeAg-negative patients with chronic hepatitis B disease, treatment can be administered when the HBV DNA is at or above 2,000 IU/mL and the serum ALT is elevated for 3-6 months.
In patients coinfected with HBV and HIV, initiate therapy against HBV and administer antiretroviral therapy as well.
The NIH also indicates that immediate therapy is not routinely indicated for patients who have the following :
-
Chronic hepatitis B with high levels of serum HBV DNA but normal serum ALT levels or little activity on liver biopsy
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Low levels of or no detectable serum HBV DNA and normal serum ALT levels
-
Positive serum HBV DNA but not HBsAg , unless the patient is undergoing immunosuppression
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Virological Testing For Hbv
HBV DNA quantification
This is mainly used to assess the level of virus replication in HBV-infected patients. In addition, it can be used as a crucial component to select the indications and assess the efficacy of antiviral therapy. During antiviral therapy, obtaining a sustained virological response could significantly control the progression of cirrhosis and lower the risk of HCC.53,54 The quantitative detection of HBV DNA utilizes real-time quantitative polymerase chain reaction however, the detection limit varies between manufacturers reagents.
HBV genotyping
To date, at least nine HBV genotypes and one undefined genotype have been identified. Some genotypes are further divided into subtypes. The detection of HBV genotypes could help to predict the efficacy of IFN and determine the disease prognosis.5558
Detection of resistant mutants
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Phases Of Chronic Hbv Infection
The course of chronic HBV infection is characterized by fluctuations in HBV DNA and alanine aminotransferase levels, reflecting variations in the balance between HBV replication and host immune response. Traditionally, three clinical parameters are used to define the four phases of chronic HBV infection .
Phases of chronic HBV infection.3 Traditionally, phases of chronic HBV infection are defined by HBeAg status, serum HBV DNA, and ALT levels. Quantitative HBsAg levels are different in each phase and are generally highest in the immune tolerant phase and lowest in the inactive carrier phase. Although most patients progress from one phase to the next, not all patients go through each phase reversion to an earlier phase can occur. Immune tolerant: HBeAgpositive, high serum HBV DNA but normal ALT levels. Immune clearance/HBeAgpositive chronic hepatitis: HBeAgpositive, high serum HBV DNA, and elevated ALT levels HBeAg seroconversion to antiHBe occurs after varying durations. Inactive carrier: HBeAgnegative, serum HBV DNA low or undetectable. Reactivation/HBeAgnegative chronic hepatitis: HBeAgnegative, elevated levels of HBV DNA and ALT in serum, HBV precore and/or basal core promoter variant often present. Abbreviation: HBsAg, hepatitis B surface antigen.
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Approaches By Virus Life Cycle Stage
consist of a and sometimes a few stored in a capsule made of , and sometimes covered with a layer . Viruses cannot reproduce on their own and instead propagate by subjugating a host cell to produce copies of themselves, thus producing the next generation.
Researchers working on such “” strategies for developing antivirals have tried to attack viruses at every stage of their life cycles. Some species of mushrooms have been found to contain multiple antiviral chemicals with similar synergistic effects.Compounds isolated from fruiting bodies and filtrates of various mushrooms have broad-spectrum antiviral activities, but successful production and availability of such compounds as frontline antiviral is a long way away. Viral life cycles vary in their precise details depending on the type of virus, but they all share a general pattern:
Before cell entry
This stage of viral replication can be inhibited in two ways:
Uncoating inhibitor
Inhibitors of uncoating have also been investigated.
During viral synthesis
Reverse transcription
Integrase
Transcription
Vaccine Recommended For High
In Germany, the Standing Committee on Vaccination at the Robert Koch Institute is responsible for issuing recommendations about vaccines. They recommend that adults have the hepatitis B vaccine if they have certain risk factors for instance, if they
- are more likely to come into contact with the hepatitis B virus due to their job or voluntary work ,
- are in close contact with someone who has a chronic hepatitis B infection ,
- have an illness that means that a hepatitis B infection could have more serious consequences ,
- use syringes to inject drugs,
- have many different sexual partners and are a man who has sex with other men,
- travel to a country where hepatitis B is very common.
STIKO also recommends that all babies and toddlers be vaccinated against hepatitis B. For this purpose, there is a combination vaccine that also offers protection against other diseases such as diphtheria, tetanus, polio, whooping cough and haemophilus influenzae type b. Depending on the exact type of vaccine, 3 or 4 injections are needed to achieve enough protection. Teenagers who havent yet been vaccinated are advised to have the vaccine.
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Hepatitis B: Should I Have The Vaccine
In most adults, an acute hepatitis B infection will usually clear up on its own, without treatment. If it becomes chronic, though, it can have serious consequences. There is a vaccine to prevent hepatitis B. It is recommended for all babies and toddlers, as well as for adults who have a high risk of becoming infected.
The hepatitis B virus is mainly spread through blood, but also through other body fluids. This usually happens during unprotected sex most commonly between men who have sex with other men. Having several sexual partners and recurring sexual STIs can increase the risk of getting hepatitis B too. Other routes of infection include using non-sterile syringes when injecting drugs or having a tattoo done with non-sterile needles.
If a pregnant woman has hepatitis B, she might pass it on to her baby while giving birth. In Germany and other countries, pregnant women are offered a hepatitis B test to see whether they are infected.
The likelihood of becoming infected is generally quite low in countries like Germany, where less than 1 out of 100 people have hepatitis B.
Is There A Cure For Chronic Hepatitis B
Currently, there is no complete cure for hepatitis B. But when managed properly, those living with the virus can expect to live a normal life. Maintaining a healthy diet and avoiding alcoholic beverages and tobacco products are crucial components in managing the disease.
You should also visit a doctor familiar with hepatitis B at least annuallythough twice a year might be best to monitor your liver through blood tests and medical imaging. As with most diseases, detecting it early leads to a better outcome. If youre exposed to the virus, you should get an antibody injection within 12 hours of exposure.
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Who Are Hepatitis B Carriers
Hepatitis B carriers are people who have the hepatitis B virus in their blood, even though they dont feel sick. Between 6% and 10% of those people whove been infected with the virus will become carriers and can infect others without knowing it. There are over 250 million people in the world who are carriers of HBV, with about 10% to 15% of the total located in India. Children are at the highest risk of becoming carriers. About 9 in 10 babies infected at birth become HBV carriers, and about half of children who are infected between birth and age 5 carry the virus. A blood test can tell you if you are a hepatitis B carrier.
What Do I Need To Know About Having Hepatitis B
If you have chronic hepatitis B, getting the right medical care can help you stay healthy. Taking good care of your liver is important. Talk with your doctor before you take any prescription medication, over-the-counter drugs, vitamins, or nutritional supplements to make sure they wont hurt your liver. You should also stay away from alcohol, because drinking can damage your liver.
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Hepatitis B Treatment: Medication
There are five FDA-approved oral medications and one injection available to treat hepatitis B. The newer oral medications are stronger and less likely to develop viral resistance and have very few side effects.
The medication cannot cure the disease, but can help reduce the number of viruses in the body and the risk of complications. You may undergo periodic blood tests to monitor drug resistance and determine whether the medication is having an effect.
How Long Does It Last
According to the World Health Organization , the complete vaccine series induces protective antibody levels in of the infants, children, and adolescents who receive it.
Immune memory induced by the HBV vaccine can last for in healthy people. That said, studies into the duration of the protection that the vaccine offers are ongoing.
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How Is Chronic Hepatitis B Diagnosed
There are several blood tests available that can identify whether you are currently infected or have developed immunity to hepatitis B. Your sexual partners and people living in your household should also get tested. If you are diagnosed with chronic hepatitis B infection, you will require life-long blood and liver tests at least every 6 months to assess the condition of your liver. Learning that you have chronic hepatitis B infection can be very upsetting. Because most people do not have symptoms and can be diagnosed decades after their initial exposure to the hepatitis B virus, it can be a shock and a surprise to be diagnosed with chronic hepatitis B. The good news is that most people with this condition can expect to live a long and healthy life because there are medicines that can control and even stop the hepatitis B virus from further damaging your liver. If you have been diagnosed with chronic hepatitis B, contact The Hepatitis Foundation of New Zealand freephone 0800 332 010. They provide a free hepatitis B follow-up programme with information, support and regular blood tests.
How You Can Get Hepatitis B
You can get hepatitis B from:
- injecting drugs using shared needles
- being injured by a used needle
- having a tattoo or piercing with unsterilised equipment
- having a blood transfusion in a country that does not check blood for hepatitis B. Blood transfusions in the UK are checked for hepatitis B.
If you’re pregnant and have hepatitis B, you can also pass it onto your baby during pregnancy or birth.
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Who Should Get The Hepatitis B Vaccine
All newborn babies should get vaccinated. You should also get the shot if you:
- Come in contact with infected blood or body fluids of friends or family members
- Use needles to take recreational drugs
- Have sex with more than one person
- Are a health care worker
- Work in a day-care center, school, or jail
What Should You Know About Hepatitis B Before You Travel
Hepatitis B is quite common in China and other Asian countries, where as many as 1 in 12 people have the virus, though many dont know it. Before traveling to those places, you should make sure youve been vaccinated against the virus.
In addition to getting the vaccine, you can take these additional precautions to reduce your risk of contracting the virus:
- Refrain from taking illegal drugs.
- Always use latex or polyurethane condoms during sex.
- Make sure new, sterile needles are used during all piercings, tattoos and acupuncture sessions.
- Avoid direct contact with blood and bodily fluids.
- Know the HBV status of all your sexual partners.
- Ask your doctor about possible vaccination before you travel to a place where hepatitis B is common.
A note from Cleveland Clinic
Hepatitis B is a liver disease that can cause serious damage to your health. One reason that is dangerous is that it can easily go undetected for years while damaging your liver. Talk with your healthcare provider about being tested for hepatitis B if you have any reason to believe that you were not vaccinated or if you have engaged in risky behavior. If you do test positive, follow the directions from your healthcare provider so that you can live a longer, healthier and happier life.
Last reviewed by a Cleveland Clinic medical professional on 07/09/2020.
References
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Unlocking The Immune System To Control Hepatitis B
One sequence of the viral RNA code can contribute to several different hepatitis B virus proteins and also to viral replication. By targeting that sequence for clean out there is a potential broad impact on viral protein production, with the goal of eliminating the proteins effects on the immune system. This could set the stage for the immune system to take over and keep the virus suppressed for the long term without the need for ongoing medication.
Whilst the ultimate aspiration is to find a cure for hepatitis B, this approach could lead to what is called a functional cure, where the virus is undetectable in blood and at a low enough level in the liver that it can be controlled by the immune system without medication, meaning liver damage is less likely to progress and the burden of the disease on people will be reduced. Scientists hope this new approach will control the hepatitis B virus and lead to longer-lasting solutions for the 296 million people currently living with this disease.
Hepatitis B has been causing death and disability on a global scale for many years. We are committed to following the science to explore new approaches to address unmet needs and provide longer-lasting solutions for patients with this potentially life-threatening liver infection.