Hepatitis B - Full Management Guide

Overview

Hepatitis B surface antigen (HBsAg), anti-HBs, and anti-HBc are ordered as part of the routine initial refugee assessment. The interpretation of these three results together is essential for correct management. Do not interpret them individually.

Serology Interpretation

For a detailed serology chart, see the CDC Hepatitis B Serology Interpretation resource at cdc.gov

Susceptible Patients (HBsAg Negative, Anti-HBs Below 10 IU/L, Anti-HBc Negative)

These patients have no immunity to hepatitis B and should be vaccinated.

*     Children: vaccinated through school programs in most provinces

*     Adults from high endemic countries or born in 1981 or after: eligible for hepatitis B immunization through AHS Community Health Centres

*     Other adult refugees: hepatitis B vaccine is covered by the IFHP and can be prescribed by a physician

Isolated Anti-HBc Positive (HBsAg Negative, Anti-HBs Below 10, Anti-HBc Positive)

This pattern has four possible explanations:

1.   Resolved infection with waning anti-HBs (most common in refugees). No further testing usually required. Do not vaccinate as the patient has likely already been exposed.

2.   False-positive anti-HBc. Rare in refugees. More likely in low-risk patients.

3.   Occult hepatitis B infection. Rare but possible. Rule out in patients with HIV or HCV co-infection, signs of liver disease, or planned immunosuppression.

4.   Resolving acute infection. Suspect if the patient had recent symptoms of acute hepatitis. Order anti-HBc IgM to clarify.

If in doubt, discuss with Hepatology or Infectious Diseases.

Active Infection - HBsAg Positive

Manage HBsAg-positive refugee patients as probable chronic hepatitis B from the beginning. Do not wait 6 months to confirm chronicity.

Step 1 - Report the Infection

Hepatitis B is a notifiable disease in Alberta. Contact AHS Communicable Disease Unit:

*     Phone: 403-955-6750

*     Fax: 403-955-6755

Step 2 - Post-Diagnosis Counselling

Disclose in a culturally sensitive manner. Discuss:

*     Modes of transmission: sexual contact, blood-to-blood, mother-to-child (perinatal)

*     That hepatitis B is a chronic manageable infection and not a death sentence

*     Potential long-term complications: cirrhosis, liver failure, hepatocellular carcinoma (HCC)

*     Alcohol: advise significant reduction or abstinence

Step 3 - Complete the History

*     Past episodes of symptomatic hepatitis

*     Family history of hepatitis B or hepatocellular carcinoma

*     Alcohol intake

*     Sexual history

*     Symptoms of cirrhosis: jaundice, leg swelling, easy bruising, confusion

Step 4 - Physical Examination

Look for signs of chronic liver disease and cirrhosis:

*     Jaundice, scleral icterus

*     Spider angiomata, palmar erythema

*     Hepatosplenomegaly

*     Ascites

*     Caput medusae, peripheral edema

Step 5 - Screen Contacts

All close household contacts and sexual partners who are not immune should be screened and offered vaccination if susceptible.

Step 6 - Vaccination for Other Infections

Refer for:

*     Hepatitis A vaccination (if anti-HAV IgG negative)

*     Pneumococcal vaccination

Step 7 - Order Baseline Investigations

*     Quantitative HBV DNA

*     HBeAg and anti-HBe

*     CBC, INR, creatinine

*     ALT, AST, GGT, bilirubin, albumin, total protein, ferritin

*     IgG, IgA, IgM

*     ANA, anti-SMA, AMA, alpha-1 antitrypsin

*     Anti-hepatitis A IgG

*     HIV serology and HCV serology

Step 8 - Begin HCC Screening

Start abdominal ultrasound every 6 months if any of the following apply:

*     Cirrhosis (any cause)

*     HIV or HCV co-infection

*     African descent and age 20 or older

*     Male and age 40 or older

*     Female and age 50 or older

*     Family history of HCC

Step 9 - Hepatology Referral

All patients with chronic hepatitis B should be seen by a Hepatologist. In Calgary, refer through:

*     Calgary Division of Gastroenterology and Hepatology Central Access and Triage: Fax 403-944-6540

Step 10 - Ongoing Follow-Up

*     CBC and ALT every 6 months

*     Quantitative HBV DNA every 12 months

*     Abdominal ultrasound every 6 months if HCC screening criteria are met