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.
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.
The AASLD does not recommend antiviral therapy in individuals with all of the following, regardless of HBeAg status or age :
- No clinical evidence of cirrhosis
- Persistently normal ALT levels
- Low levels of HBV DNA replication . ]
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
Adults with HBeAg-negative immune-active chronic HBV infection
Children with chronic hepatitis B infection
Individuals with HBV and HCV coinfection
Individuals with HBV and HIV coinfection
Persons New To Canada
Health care providers who see persons newly arrived in Canada should review the immunization status and update immunization for these individuals, as necessary. In many countries outside of Canada, HB vaccine is in limited use.
All persons from a country that is endemic for HB should be assessed and vaccinated against HB if not immune and not infected. Individuals born in developing countries are more likely to be carriers of HB, necessitating vaccination of their sexual and household contacts based on review of their serologic test results. HB vaccine is recommended for all household contacts whose families have immigrated to Canada from areas in which there is a high prevalence of HB and who may be exposed to HB carriers through their extended families or when visiting their country of origin.
Children adopted from countries in which there is a high prevalence of HB infection should be screened for HBsAg and, if positive, household or close contacts in the adopting family should be immunized before adoption or as soon as possible thereafter. Adults going to pick-up children from these countries should be vaccinated before departure. Refer to Immunization of Persons New to Canada in Part 3 for additional information.
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Patients With A Normal Level Of Alanine Aminotransferase
Hepatitis B virus infection is a dynamic process characterized by fluctuations in alanine ALT, which might hint toward immune-mediated virus clearance . Since the ALT level is not always indicative of inflammation in the liver, patients with normal ALT levels can present inflammation and fibrosis on liver biopsy. Thus, ALT is used as a substitute for liver inflammation when liver histology is a failure . But the challenge in defining the ULN of ALT is the difficulty of including totally healthy subjects without liver diseases, especially MAFLD , the leading cause of liver disease worldwide . An Italy study reveals that Male sex, body mass index, glucose, lipids, ferritin, hypertension, and younger age are independent predictors of ALT . Many hepatologists call for the adjustment of the ULN of ALT . In 2019 China guidelines, the ULN remains constant at 50 U/L in males and 40 U/L in females however, many studies have recommended rational values as 35 U/L in males and 23 U/L in females . In 2018 AASLD guidelines, the ALT ULN is modified as 35 U/L in males and 25 U/L in females, as described previously . In 2017 EASL guidelines and 2015 APASL guidelines, the ALT ULN is 40 U/L in both males and females . Therefore, whether patients have normal ALT levels partially depends on the ULN. The ULN values mentioned in this study are consistent with those in the literature.
How Common Is Hepatitis B
Hepatitis B is fairly common in Africa and the western Pacific region. Throughout the world, there are about 292 million people who are infected with chronic hepatitis B. In the U.S., the figure exceeds 2 million people.
The number of infections had been falling in the U.S., but fewer vaccinations among adults combined with the onset of the opioid crisis and injected drug usage has resulted in the numbers rising again. Infected women can pass the infection on to their babies. Children who are infected before age 5 are more likely to have chronic infection than those infected later in life.
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Candidates In The General Population
Antiviral treatment is an effective therapeutic strategy for CHB patients that efficiently suppresses HBV replication, decreases inflammatory necrosis in the liver, reduces the incidence of liver cirrhosis and related complications, and reduces the fatality rate associated with hepatocellular carcinoma and other liver diseases. In the 2019 China guidelines , HBV infection is divided into four phases: immune tolerance, immune clearance, immune control, and immune reactivity, and it is different from the 2015 version . Additionally, the 2019 China guidelines eased the restrictions on indications for antiviral therapy, and reducing the demand for HBV-DNA load. Conversely, the HBV-DNA load is considered for the performance of antiviral therapy in the 2018 guidelines updated by the 2018 AASLD guideline and the 2017 EASL guidelines . For the treatment of HBV infection with normal ALT , antiviral therapy is recommended in patients > 30-years-old with a family history of liver cirrhosis or cancer in the 2019 China guidelines. In another case > 30-years-old without a family history of liver cirrhosis or cancer, a hepatic biopsy was recommended. Although we can refer to many guidelines, there are many patients failed to fulfill the criteria for treatment at follow-up and eventually developed liver fibrosis, cirrhosis, and cancer .
Table 1. Comparison between 2015 and 2019 guidelines.
Table 2. Indications for chronic hepatitis B treatment in 2017 and 2018 guidelines.
How Is Hepatitis B Spread
- Having unprotected sex.
- Sharing or using dirty needles for drug use, tattoos or piercing.
- Sharing everyday items that may contain body fluids, including razors, toothbrushes, jewelry for piercings and nail clippers.
- Being treated medically by someone who does not use sterile instruments.
- Being bitten by someone with the infection.
- Being born to a pregnant woman with the infection.
Hepatitis B is not spread by:
- Kissing on the cheek or lips.
- Coughing or sneezing.
- Hugging, shaking hands or holding hands.
- Eating food that someone with the infection has prepared.
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Management Of Persons Who Are Hbsag Positive
Recommendations for management of all persons with HBsAg include the following:
When seeking medical or dental care, persons who are HBsAg positive should be advised to inform their health care providers of their HBsAg status so that they can be evaluated and managed. The following are key counseling messages for persons with HBsAg:
- HBV is not usually spread by hugging, coughing, food or water, sharing eating utensils or drinking glasses, or casual contact.
- Persons should not be excluded from work, school, play, childcare, or other settings because they are infected with HBV.
- Involvement with a support group might help patients cope with chronic HBV infection.
- HBV infection is a chronic condition that can be treated, and patients should receive prevention counseling and be evaluated for antiviral treatment.
Nucleoside Analogues Or Oral Antivirals
Antivirals, or NAs, slow down or stop the hepatitis B virus from reproducing, decreasing the risk of liver damage. Less liver damage occurs when there is less virus present.
People take NAs orally as a pill and experience very few side effects.
First-line treatments, such as Tenofovir disoproxil and entecavir, are potent and effective in suppressing the virus, but they only work for as long as a person takes them. Discontinuing treatment
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What Are The Risk Factors For Getting Hepatitis B
Due to the way that hepatitis B spreads, people most at risk for getting infected include:
- Children whose mothers have been infected with hepatitis B.
- Children who have been adopted from countries with high rates of hepatitis B infection.
- People who have unprotected sex and/or have been diagnosed with a sexually transmitted infection.
- People who live with or work in an institutional setting, such as prisons or group homes.
- Healthcare providers and first responders.
- People who share needles or syringes.
- People who live in close quarters with a person with chronic hepatitis B infection.
- People who are on dialysis.
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 beverages that contain alochol and tobacco products are crucial components in managing the disease.
You should also visit a doctor familiar with hepatitis B at least annually though 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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Other Reported Adverse Events And Conditions
While serious events and chronic illnesses such as chronic fatigue syndrome, multiple sclerosis, Guillain-Barré syndrome, rheumatoid arthritis and sudden infant death syndrome have been alleged or reported following HB vaccination, no evidence of a causal association has been demonstrated in a number of studies.
What Is Involved In A Liver Transplant
A liver transplant is considered necessary when the liver is damaged and cannot function or in some cases of liver cancer. Your liver is very important. It is responsible for many functions related to making sure that your body stays healthy and is able to digest foods.
You may be eligible for a transplant if you have chronic hepatitis B infection or some of the diseases that may result from it, including liver cancer and cirrhosis. You will have to complete testing and be evaluated before being approved for a transplant. It is likely that you will be placed on a waiting list while an appropriate organ is found.
Donated livers come from two types of donors: living and deceased. Because the liver can regenerate, it is possible to use part of a liver for transplant. The remaining sections in both the donor and the receiver will grow into livers of adequate size.
People who get liver transplants must take anti-rejection drugs for the rest of their lives. These drugs make you more susceptible to infection. However, liver transplants have become more successful over time and continue to improve.
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Monitoring After Antiviral Treatment
Although off-treatment response can persist after cessation of NA therapy, clinical relapse can occur in some patients, and there is a risk of acute hepatitis flare, liver decompensation, or fulminant hepatitis. Therefore, regular monitoring of liver function tests, HBeAg, anti-HBe, and HBV DNA is needed to evaluate the durability of the treatment response, relapse, and deterioration in liver function. In particular, if serum HBV DNA increases after cessation of NA therapy, a more intensive monitoring plan should be implemented to determine whether NA should be re-administered . HBsAg level measurement can help monitor HBsAg reduction or loss in patients without HBsAg loss on cessation of NA therapy . Even in patients in whom HBsAg loss has been achieved, there is the potential risk for reversion of HBsAg or development of HCC . Therefore, serum HBsAg and/or anti-HBs should be monitored, and continuous HCC surveillance should be performed.
1. Cessation of NA therapy is recommended after serum HBsAg loss in CHB patients .
2. In HBeAg-positive CHB patients, cessation of NA therapy could be considered at least 12 months after HBV DNA is undetectable and serum HBeAg loss or seroconversion has been achieved .
3. Long-term treatment should be considered in patients with liver cirrhosis. Indefinite NA therapy is recommended in patients with decompensated liver cirrhosis .
4. Peginterferon alfa is administered for 48 weeks .
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
HBF’s 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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Hepatitis B Reactivation In The Setting Of Immunosuppressive Therapy
Reactivation can occur spontaneously , but it is more frequently observed during immunosuppressive therapy . Immunosuppressive drugs represent the greatest risk of triggering HBVr.13 In the setting of chronic immunosuppressive therapy, both patients with CHB and patients with resolved HBV infection are at risk for HBVr.14 Between 17 and 55% of patients with previous HBV exposure experience HBVr if not prescribed antiviral prophylaxis in this setting.18
Immunosuppressive drugs have been categorized according to their potential to cause HBVr.19, 20 B cellâdepleting agents are among the drugs with the highest risk .13 B cells produce neutralizing antibodies that eliminate circulating viruses, and thus, they play a key role in the humoral immune response, contributing to the control of HBV. B cellâdepleting agents, such as RTX, ocrelizumab, and ofatumumab, are monoclonal antibodies binding to CD20, a cell surface marker on B lymphocytes, thus killing B lymphocytes via cytotoxicity and apoptosis.21 These B cellâdepleting agents are therefore associated with a particularly high risk of HBVr.22
Who Should Be Vaccinated For Hepatitis B
All newborns should be vaccinated. Also, people who are under 18 who were not vaccinated at birth should also get the vaccine. Other groups who should be sure to be vaccinated are those in certain high-risk categories, such as:
- People who have more than one sexual partner.
- Men who have sex with men.
- Adults with diabetes.
- Sexual partners of infected people and people who share households with infected individuals.
- People who are exposed to blood and other bodily fluids, including healthcare and public safety professionals, and people who work in jails and other places taking care of people who cant take care of themselves.
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Treatment Of Chronic Hepatitis B In Children
Vaccination against HBV among young Chinese individuals decreased the HBV infection rate. In recent years, several studies reported gradually increasing the horizontal transmission of HBV in early childhood, and family members may be the main source of infection. Interferons and NAs are the potential treatment options according to the age of young people .
Clinical Biomarkers For Treatment Endpoint
The standard treatment duration of peginterferon alfa is 48 weeks . However, there have been reports that extended dosing could be more effective in HBeAg-negative CHB .
ALT normalization
Normalization of ALT in CHB treatment reflects a decrease in hepatic inflammatory response, mostly associated with undetectable HBV DNA, and reduces clinical deterioration . Normalization of ALT during treatment reflects improvement in cirrhosis and could be considered reflective of treatment goals. However, 1440% of patients with persistently normal ALT could have significant fibrosis , and there is a variety of concurrent liver conditions affecting ALT level, such as non-alcoholic or alcoholic fatty liver . As such, ALT normalization alone is insufficient when determining the endpoint of treatment.
Undetectable HBV DNA
HBeAg loss and/or seroconversion
Quantitative HBsAg level, quantitative HBcrAg level, and HBV RNA
HBV RNA has been introduced as a novel biomarker for cessation of NA therapy . There are also studies that predict off-treatment response with a combination of other indicators, such as HBsAg level or HBcrAg level . However, the value of this indicator has not yet been evaluated as a standardized test, and it is necessary to explore the role of HBV RNA in predicting outcomes after cessation of NA therapy.
HBsAg loss
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