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Hepatitis B Flashcards

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1
Q

What does a HBsAg “positive” test result mean

A

HBsAg = Hepatitis B surface antigen

marker of current infection

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2
Q

What does a anti-HBs or HBsAb “positive” test result mean

A

anti-HBs or HBsAb = Hepatitis B surface antibody

= immunity

either from vaccination
or past hepatitis B infection

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3
Q

What does a anti-HBc or HBcAb “positive” test result mean

A

anti-HBc or HBcAb = Hepatitis B core antibody

indicates previous exposure to the hepatitis B virus

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4
Q 
Interpretation of 
HBsAg positive
Anti-HBs negative
Anti HBc positive 
Anti-HBc IgM positive
A

Acute Hpeatits B infection

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5
Q

What other blood test abnormalities are usually found with acute Hep B infection
(not Hep serology)

A

Increased serum ALT and AST

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6
Q 
Interpretation of 
HBsAg positive
Anti-HBs negative
Anti HBc positive 
Anti-HBc IgM negative
A

Chronic Hepatitis B

infected >6m

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7
Q

Which asymptomatic patients should be screened for hepatitis B?

A 
MSM 
sex workers 
people who inject drugs
HIV-positive patients
sexual assault victims
people from hepatitis B endemic countries (outside of Western Europe, N America and Australasia)
needlestick injury patients  
sexual partners of positive or high-risk patients
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8
Q

What is screening tests of choice for hepatitis B

A

anti-HBcore antibody
+/- hepatitis B surface antigen (HBsAg)

+/- further serology to assess stage of infection and infectivity as appropriate

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9
Q

What test should be done to confirm a patient is immune to hepatitis B

A

anti-HBs = Hepatitis B surface antibody

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10
Q

What is the dosing schedule of an ultra-rapid Hep B vaccination course

A

0, 1, 3 weeks

+ 12 months

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11
Q

What % of patients have an antibody response after the ultra-rapid Hep B Vaccination schedule

A

ultra-rapid Hep B vaccination schedule (0, 1, 3 weeks)
= 80% anti-HBs antibody response by 12 weeks
rises to 95% just prior to the 12 month booster dose

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12
Q

What should be done with the 20% of patients who do not have a Hep B antibody response after the ultra-rapid vaccination course?

A

Consider booster vaccinations - up to 3 further doses

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13
Q

How long does the protection provided by monovalent Hep B vaccination last?

A

> 20 years once immunity confirmed

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14
Q

What impact does HIV infection have on the success of HBV vaccination

A

HIV positive patients show a reduced response rate to HBV vaccine
AND become anti-HBs negative more quickly
double dose vaccine increases response by 13%

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15
Q

Transmission of Hep B

A

sexual
parenteral - exposure to blood / blood products / infected body fluids
vertical - from mother to child
Sharing injecting equipment
Needle stick injury
Non-sterile acupuncture / tattoo needles / piercing

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16
Q

After primary HBV infection what % of infants infected perinatally have persistent HBV?

A

HBV persists in 90% of infants infected perinatally

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17
Q

After primary HBV infection what % of children infected aged 1-5yo have persistent HBV?

A

25–50% of children aged 1–5 years

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18
Q

After primary HBV infection what % of immunocompetent adults have persistent HBV?

A

1–5% of immunocompetent adults or older children develop chronic HBV

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19
Q

Which areas are low prevalence for Hep B (<2%)

A 
Western Europe, 
Northern Europe, 
Central Europe, 
North America, 
Australia.
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20
Q

Complications of Chronic Hep B infection

A

Chronic infection can lead to
liver cirrhosis

hepatocellular carcinoma.

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21
Q

What patient factors increase the risk of Hep B infection?

worldwide

A

injecting drug use
men who have sex with men (MSM)
multiple sexual partners
household / other close contacts of HBV-infected persons
those receiving blood / blood products
patients / staff of haemodialysis centres
people sharing unsterile medical / dental equipment
people providing / receiving acupuncture / tattooing with unsterile devices
healthcare workers
staff / residents of residential accommodation for those with mental disabilities
travellers to areas of high or intermediate HBV prevalence if engaging in exposure-prone activities (including relief aid work or contact sports)
HIV positive people

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22
Q

What impact does HIV have on the acquisition risk of Hep B

A

HIV increases the risk of HBV infection

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23
Q

What impact does HIV have on the risk of developing chronic Hep B

A

The risk of chronicity is increased in HIV positive persons

Chronic HBV infection found in 5–10% of HIV-positive persons
+ show increased rate of progression to cirrhosis + liver cancer
+ higher mortality rate

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24
Q

What is the HBV vaccination made of?

A

monovalent
yeast-derived HBV vaccine
prepared with biosynthetic surface antigen
made using recombinant technology

also a combined hepatitis A/hepatitis B vaccine

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25
What is the typical HBV dosing schedule
typical = 3 doses at 0, 1, and 6 months
26
What is the accelerated HBV dosing schedule
accelerated = 4 doses at 0, 1, 2, and 12 months
27
What HBV surface antibody (HBsAb) levels would indicate successful vaccination?
HBV surface antibody (HBsAb) levels >10 IU/L after a complete vaccine course. >100 IU/L is ideal <10 IU/L is classified as non-response
28
Factors that reduce responses to HBV vaccination
- age >40 years - obesity - male gender - haemodialysis - smoking - immunocompromise - including HIV infection
29
What happens to HBsAb levels over time after successful vaccination?
HBsAb levels decline over time after successful vaccination. After 20 years 18–37% of adults have HBsAb levels >10 IU/L
30
Advice regarding Hep B boosters
Limited evidence regarding the need for booster vaccine doses in healthy individuals. UK guidelines recommend persons at ongoing risk receive a single booster 5 years after completion of the primary vaccine course
31
Which groups of individuals should be offered a Hep B vaccine (not just in SRH settings)
MSM sex workers people who inject drugs People who change sexual partners frequently HIV-positive patients sexual assault victims people from hepatitis B endemic countries (outside of Western Europe, N America and Australasia) needlestick injury patients sexual partners of patients with HBV or at high-risk close contacts of people with HBV families adopting children from high / intermediate countries foster carers individuals receiving regular blood / blood products patients with chronic renal failure, patients with chronic liver disease inmates of custodial institutions, individuals in residential accommodation for those with learning difficulties individuals at occupational risk.
32
What dose of HBV vaccination is recommended for HIV positive patients?
high-dose (40 μg) vaccination should be offered or double dose standard vaccination (i.e. 2x 20μg)
33
What dosing schedule for HBV vaccination is recommended for HIV positive patients?
4 vaccine doses | given at 0, 1, 2, and 6 months
34
following completion of the primary HBV vaccine course, when should HBsAb levels be measured
4–8 weeks after the last vaccine dose | measure HBsAb levels
35
management of a HIV positive initial non-responder to the HBV vaccine
If at 4-8 weeks after the primary vaccine course is completed the HBsAb levels are <10 IU/L = initial non-responder Recommend - 3x further high dose (40 μg) vaccine doses at monthly intervals or 3x standard dose (20 μg) Fendrix vaccine may be preferred (adjuvanted vaccine) Retest for HBsAb in 4–8 weeks revaccination of non-responders may be better delayed until VL suppressed on ART + CD4 count >350
36
Recommendation regarding Hep B vaccination in a HIV positive patient with isolated HBcAb positivity
Offer 1 vaccine dose HBsAb test 2 weeks later if HBsAb >10 = past infection, immune if HBsAb <10 - complete full vaccination course (1, 2 and 6m)
37
management of a HIV positive patient with a HBsAb result of 10 - 100 at 4 - 8 weeks after last HBV vaccination dose
Offer HBV booster | Repeat HBsAb at 4 - 8 weeks after booster
38
If a HIV positive patient is successfully vaccinated for HBV how often is it recommended that they have their if HBsAb checked?
If HBsAb = 10 - 100 at 4 - 8 weeks after last HBV vaccination dose - repeat HBsAg annually If HBsAb = >100 at 4 - 8 weeks after last HBV vaccination dose AND CD4 <350 +/- VL not fully suppressed on ART - repeat HBsAg annually If HBsAb = >100 at 4 - 8 weeks after last HBV vaccination dose AND CD4 >350 and VL suppressed on ART - repeat HBsAg every 2 - 4 years + offer booster to all patients once HBsAg drops to <10
39
management of a patient who presents with suspected acute hepatitis
``` Clinically assess +/- refer for hospital admission order LFT + clotting order hepatitis serology (incl HAV IgM, HBsAg, HCV antibodies/antigen/RNA and HEV serology/PCR) Inform public health ```
40
What is the benefit of anti-virals in acute hepatitis B?
Can prevent acute liver failure (ALF) | improve morbidity and mortality
41
Management of patients with acute Hepatitis B
Clinically assess +/- refer for hospital admission Advise to avoid UPSI (incl oro-anal / oro-genital) Partner notification - include any sexual contact or needle sharing partners infectious period = 2 weeks before onset of jaundice until patient becomes surface antigen negative Advise not to donate organs/semen/blood until non- infectious Hepatitis B = notifiable to public health
42
Management of a patient with newly diagnosed chronic hepatitis B?
``` Refer to a hepatologist - for disease monitoring - liver cancer screening - possible therapy Screen for Hep C, Hep D + Hep A immunity Vaccinate for Hep A if non-immune ``` Partner notification - as far back as any episode of jaundice or to when the infection believed to be acquired Advised to disclose to new sexual partners Advise partners to be vaccinated Arrange Hep B screening for children born to infectious women
43
What is the look back period for a patietn diagnosed with chronic Hep B
look back as far back as any episode of jaundice or to when the infection believed to be acquired May be impractical beyond 3 years Advised to disclose to new sexual partners
44
management of a patient presenting as a contact of a patient with hepatitis B
Screen for HBV infection or immunity Consider hepatitis B immunoglobulin 500 i.u. IM (HBIG) - within 48 hours but works best within 12 hours - no use after > 7days Offer accelerated hep B vaccination - 0, 1, 3 weeks or 0,1, 2 months + booster at 12 months
45
For a contact of Hep B what is the timeframe for administering Hep B immunoglobulin?
within 48 hours works best within 12 hours no use after > 7days
46
After exposure to Hep B vaccination provides some protection from disease development upto what timeframe?
Vaccination theoretically provides some protection from disease when started up to six weeks after exposure
47
What type of virus is Hep B
hepadna DNA virus 8 distinct genotypes (A-H) which vary in geographical distribution, pathogenicity and treatment susceptibility
48
Risk factors for Hep B transmission in sexual history
- multiple partners - MSM - Rimming - CSW - injecting drug use
49
What is HBeAg a marker of?
HBeAg: Hepatitis B e antigen A marker of a high degree of infectivity Correlates with a high level of HBV replication
50
Incubation period of Hep B
Incubation period = 40-160 days
51
Symptoms of Acute Hep B
Asymptomatic - Nearly all infants / children + 10 - 50% of adults prodromal illness: flu-like symptoms Icteric illness: jaundice + anorexia / nausea / fatigue May be more prolonged and severe than in Hep A
52
Symptoms of chronic Hep B
usually asymptomatic | May have fatigue or loss of appetite
53
Signs of acute Hep B
In Icteric phase - jaundice with pale stools and dark urine. Liver enlargement / tenderness signs of dehydration
54
signs of chronic Hep B
often no physical signs After many years - may be signs of chronic liver disease spider naevi finger clubbing jaundice hepato- splenomegaly in severe cases - thin skin / bruising / ascites / liver flap / encephalopathy
55
Complications of acute Hep B
Acute liver failure in < 1% of symptomatic cases carries a worse prognosis than hepatitis A Pregnancy – increased rate of miscarriage / premature labour in acute infection Risk of vertical transmission Mortality < 1% for acute cases
56
Complications of chronic Hep B
``` raised aminotransferases necrosis and inflammation of the liver progressive fibrosis cirrhosis (10 - 50%) Primary liver cancer (10% of cirrhotic patients) ``` Concurrent hepatitis C or HIV = increased risk of progression to cirrhosis and death Concurrent delta virus = increased severity, more rapidly progressive fibrosis, cirrhosis and end- stage liver disease
57
Interpretation of HBsAg Negative Anti-HBs negative or positive Anti HBc positive
Resolved hepatitis B infection Immune to reinfection. May represent occult hepatitis B virus. May be at risk of reactivation of the virus with immunosuppression
58
Interpretation of HBsAg Negative Anti-HBs Positive Anti HBc Negative
Successful vaccination: immunity considered if antibody titre >10 mIU/mL
59
Interpretation of HBsAg Negative Anti-HBs Negative Anti HBc Negative
Non - immune | susceptible
60
What is anti-HBc IgM used for?
To determine acute or chronic Hep B Anti-HBc IgM antibody positive = acute hepatitis B infection
61
For the diagnosis of Chronic Hep B the HBsAg must remain positive for at least.....
6 months
62
What is HBeAg (hepatitis B e antigen) testing used for
For patients with chronic Hep B To determine the phase of disease Hepatitis B e antigen (HBeAg) = a marker of wild type infection usually associated with high circulating viral levels) hepatitis B e antibody (anti-HBe) = a marker of clearance of HBeAg
63
what is the immune tolerance phase of chronic Hep B
initial 15-30 years of infection Hepatitis B 'e' antigen (HBeAg) Positive high hepatitis B virus DNA levels normal ALT Treatment not usually indicated Monitor ALT / HBeAg /. anti-HBe at least every 6 months
64
what is the immune clearance phase of chronic Hep B
HBeAg Positive high levels of hepatitis B virus DNA (usually >20,000 increased ALT patients may spontaneously seroconvert from being positive to negative for HBeAg And develop antibodies to HBeAg (anti-HBe) prolonged immune clearance can cause progressive fibrosis + cirrhosis specialist review consider antiviral treatment
65
what is the immune control phase of chronic Hep B
HBeAg negative anti-HBe positive low or undetectable hepatitis B virus DNA (usually <2,000 Normal ALT USS surveillance for liver cancer every 6 months
66
what is the immune escape phase of chronic Hep B
Represents reactivation of Hep B virus Characterised by chronic infection HBeAg negative increased hepatitis B virus DNA (usually >2000) fluctuating ALT high risk of progression to cirrhosis, liver failure, and hepatocellular carcinoma
67
What further assessment is recommended for patients with Chronic Hep B in the immune escape phase
abdominal examination Look for peripheral signs of chronic liver disease and portal hypertension. ``` full LFTS FBC coagulation studies Hep C screen Hep D test HIV test ``` Hep A vaccination AST > ALT + low platelets may indicate cirrhosis Raised bilirubin, low albumin, or increased prothrombin time may indicate cirrhosis with development of liver failure
68
What blood test results may indicate liver cirrhosis
AST higher than ALT | AND low platelets
69
What blood test results may indicate liver failure
Raised bilirubin low albumin increased prothrombin time
70
Treatment of chronic Hep B
Screen for Hep C, Hep D and HIV Test for Hep A immunity +/- vaccinate Treatment options = Tenofovir DF or tenofovir AF, entecavir or pegylated interferon Lamivudine, Emtricitabine, Tenofovir DF or tenofovir AF will suppress HBV replication during therapy of HIV if given as part of triple antiretroviral therapy USS liver surveillance - for hepatocellular carcinoma - 6-12 monthly Serum alphafeto protein - 6-12 monthly
71
What is the decision to treat chronic Hep B based on
pattern of disease HBV DNA level (>2,000) presence / absence of necro-inflammation and hepatic fibrosis.
72
Without intervention what % of pregnancy patients with | Hep B e antigen +ve chronic Hep B will transmit the virus to the child?
90% vertical transmission if ‘e’ antigen (HBeAg) +ve and HBsAg +ve
73
Without intervention what % of pregnancy patients with | Hep B e antigen -ve chronic Hep B will transmit the virus to the child?
10% vertical transmission if ‘e’ antigen (HBeAg) +ve and HBsAg +ve
74
What % of vertically infected infants will become chronic carriers of Hep B
Most (>90%)
75
Management of infants born to infectious mothers with Hep B
Hep B vaccination at birth Hep B specific Immunoglobulin 200 i.u. IM if mother is highly infectious reduces vertical transmission by 90%
76
When should treatment be considered for Hep B during pregnancy
If HBV DNA >10, 000, 000 Consider Tenofovir monotherapy in the third trimester to reduce risk of transmission to baby
77
Impact of pregnancy on HBV (for the mother)
Hep B activity may increase immediately following pregnancy | Rarely associated with clinical consequences

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