Information for Healthcare Providers
Hepatitis B Virus (HBV) Management – Quick Reference Guide
Screening
- Individuals born in areas with HBV prevalence greater than two per cent (includes: Africa, Asia, Eastern & Southern Europe, the Middle East, Asian-Pacific Islands, Indigenous areas, Central and South America, and the Caribbean) and
- Individuals who have travelled or resided in these areas
- Individuals starting immunosuppressive therapy (particularly cancer chemotherapy), or renal dialysis
- Individuals with chronically elevated ALT or AST of unknown origin
- Children, household and/or sexual contacts of HBsAg-positive individuals or those with a family history of HBV
- All pregnant individuals
- Individuals who have sustained an occupational exposure to blood and/or body fluids
- Organ transplant recipients & Individuals who have undergone medical procedures in Canada prior to 1970
- Individuals infected with hepatitis C or HIV
- Individuals with higher-risk sexual activity (eg. unprotected sex, multiple partners, history of STI, MSM)
- Individuals who are currently/previously incarcerated
- Individuals with current/previous substance use with shared paraphernalia (“Works”)
Testing
‘Chronic Hepatitis’ tests HBsAg:
- One positive result denotes HBV infection
- Two positive results ≥ six months denotes chronic HBV
‘Immune Status/Previous Exposure’ only tests anti-HBs:
- May be positive from previous infection or from immunization.
- Check at least once in individuals with risk factors to rule out chronic HBV infection
Initial Work-up
- Labs: CBC, AST, ALT, bilirubin, albumin, creatinine, INR
- Tests of HBV replication: HBeAg, anti-HBe, HBV DNA viral load
- Rule out viral co-infection: hepatitis C (anti-HCV), HIV (HIV serology)
- Screening: abdominal ultrasound
Routine Follow-up
- Counsel on the prevention of HBV transmission
- Provide advice to reduce liver damage and medication considerations with cirrhosis
- Follow HBV DNA and ALT every six to 12 months
- Hepatocellular Carcinoma (HCC) Screening every six months with abdominal ultrasound for men >40 years old (>20 years old, if African descent), women >50 years old, and those with cirrhosis of any age. HCC may occur in the absence of cirrhosis.
Counselling for High-Risk Contacts
High Risk Contacts (Susceptible Sexual, household, occupational)
- Immunize all susceptible contacts of acute and chronic carriers with HBV vaccine
- Immunize and provide hepatitis B Immune globulin (HBIG) to Infants (<12 months old) born to a mom with HBV.
- Sexual contacts: Give a single dose of HBIG within 14 days of the last sexual contact with the case.
- Advise that protection cannot be ensured until vaccine course completed and antibodies tested.
- Counsel on use of condoms to reduce, but not eliminate, risk of transmission
- Pregnancy and breastfeeding is not a contraindication to vaccination or receipt of HBIG. There is no evidence that breastfeeding poses any additional risk to infants of HBV carrier mothers.
- Percutaneous/mucosal injuries (eg. Occupational, bites): managed based on immune status of the exposed (injured) person.
Pre & Post Vaccine Counselling
Pre-Immunization Testing (PIT)
- Routine PIT recommended for anyone at risk of infection.
- Do not delay immunization if a contact’s status is unknown, in favour of PIT.
Post-Vaccine Serology (PVS)
- To assess level of protection against a continual known or repeated potential exposure to HBV
- For vaccinated infants born to infected mothers: PVS should be performed when baby is between nine to 18 months of age.
- For all other vaccinated contacts/exposed (sexual, household, occupational): PVS between one to six months post vaccine.
Vaccine Non-Responders
- For those who fail to show a response to the first series of vaccinations, an additional three-dose series will produce a protective antibody response in 50-70% of recipients.
- Individuals who fail to response to the second and third dose series, are unlikely to benefit from further HBV immunization
Referral
Reasons for referral to specialty care (by a Hepatologist, GI, ID specialist, or a family physician with experience in HBV management):
- If age >40 years old with positive HBV DNA
- If elevated ALT (men >30 U/L, women >20 U/L)
- If evidence of cirrhosis (e.g., low platelets, splenomegaly, hepatic mass or portal hypertension)
- If HBeAg Positive
- If HBeAg Negative, with HBV DNA viral load > 2,000 IU/ml
- Any HBsAg positive patient starting immunosuppressive therapy (even if normal ALT & negative HBV DNA)
Common Acronyms
- HBsAg: hepatitis B surface antigen;
- anti-HBs: hepatitis B surface antibody;
- HBeAg: hepatitis B e antigen;
- anti-HBe: hepatitis B e antibody
Information for Patients
Toronto Public Health (TPH) – Hepatitis B Disease Fact Sheet
Toronto Public Health (TPH) – Hepatitis B Vaccine Fact Sheet
More Information
To speak to one of our investigators, please call 416-338-8400 or email CDCBloodborne@toronto.ca
For more resources on hepatitis, please visit our website at: www.Toronto.ca/hepatitis
Please do not include any Personal Health Information in the emails, to be in accordance with Privacy Legislation.
References
Sherman M et al. Management of chronic hepatitis B: Consensus Guidelines. Can J Gastroenterol 2007;21.5C:24C.
Lok ASF, McMahon BJ. Chronic hepatitis B: update 2009. Hepatology 2009;50(3):1-36.
Ontario Association of Medical Laboratories. Guidelines for ordering diagnostic testing for viral hepatitis. September, 2010
Feld JJ, Ayers M, El-Ashry D, Mazzulli T, Tellier R, Heathcote EJ. Hepatitis B virus DNA prediction rules for hepatitis B e antigen-negative chronic hepatitis B. Hepatology 2007;46:1057-1070.
