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Dip GUM > Hepatitis B > Flashcards

Hepatitis B Flashcards

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
Q

What is the typical HBV dosing schedule

A

typical = 3 doses at 0, 1, and 6 months

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26
Q

What is the accelerated HBV dosing schedule

A

accelerated = 4 doses at 0, 1, 2, and 12 months

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27
Q

What HBV surface antibody (HBsAb) levels would indicate successful vaccination?

A

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

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28
Q

Factors that reduce responses to HBV vaccination

A
  • age >40 years
  • obesity
  • male gender
  • haemodialysis
  • smoking
  • immunocompromise - including HIV infection
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29
Q

What happens to HBsAb levels over time after successful vaccination?

A

HBsAb levels decline over time after successful vaccination.
After 20 years 18–37% of adults have HBsAb levels >10 IU/L

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30
Q

Advice regarding Hep B boosters

A

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

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31
Q

Which groups of individuals should be offered a Hep B vaccine
(not just in SRH settings)

A

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
Q

What dose of HBV vaccination is recommended for HIV positive patients?

A

high-dose (40 μg) vaccination should be
offered
or double dose standard vaccination (i.e. 2x 20μg)

33
Q

What dosing schedule for HBV vaccination is recommended for HIV positive patients?

A

4 vaccine doses

given at 0, 1, 2, and 6 months

34
Q

following completion of the primary HBV vaccine course, when should HBsAb levels be measured

A

4–8 weeks after the last vaccine dose

measure HBsAb levels

35
Q

management of a HIV positive initial non-responder to the HBV vaccine

A

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
Q

Recommendation regarding Hep B vaccination in a HIV positive patient with isolated HBcAb positivity

A

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
Q

management of a HIV positive patient with a HBsAb result of 10 - 100 at 4 - 8 weeks after last HBV vaccination dose

A

Offer HBV booster

Repeat HBsAb at 4 - 8 weeks after booster

38
Q

If a HIV positive patient is successfully vaccinated for HBV how often is it recommended that they have their if HBsAb checked?

A

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
Q

management of a patient who presents with suspected acute hepatitis

A 
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
Q

What is the benefit of anti-virals in acute hepatitis B?

A

Can prevent acute liver failure (ALF)

improve morbidity and mortality

41
Q

Management of patients with acute Hepatitis B

A

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
Q

Management of a patient with newly diagnosed chronic hepatitis B?

A 
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
Q

What is the look back period for a patietn diagnosed with chronic Hep B

A

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
Q

management of a patient presenting as a contact of a patient with hepatitis B

A

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
Q

For a contact of Hep B what is the timeframe for administering Hep B immunoglobulin?

A

within 48 hours
works best within 12 hours
no use after > 7days

46
Q

After exposure to Hep B vaccination provides some protection from disease development upto what timeframe?

A

Vaccination theoretically provides some protection from disease when started up to six weeks after exposure

47
Q

What type of virus is Hep B

A

hepadna DNA virus

8 distinct genotypes (A-H) which vary in geographical distribution, pathogenicity and treatment susceptibility

48
Q

Risk factors for Hep B transmission in sexual history

A
  • multiple partners
  • MSM
  • Rimming
  • CSW
  • injecting drug use
49
Q

What is HBeAg a marker of?

A

HBeAg: Hepatitis B e antigen
A marker of a high degree of infectivity

Correlates with a high level of HBV replication

50
Q

Incubation period of Hep B

A

Incubation period = 40-160 days

51
Q

Symptoms of Acute Hep B

A

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
Q

Symptoms of chronic Hep B

A

usually asymptomatic

May have fatigue or loss of appetite

53
Q

Signs of acute Hep B

A

In Icteric phase - jaundice with pale stools and dark urine. Liver enlargement / tenderness
signs of dehydration

54
Q

signs of chronic Hep B

A

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
Q

Complications of acute Hep B

A

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
Q

Complications of chronic Hep B

A 
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
Q

Interpretation of
HBsAg Negative
Anti-HBs negative or positive
Anti HBc positive

A

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
Q

Interpretation of
HBsAg Negative
Anti-HBs Positive
Anti HBc Negative

A

Successful vaccination: immunity considered if antibody titre >10 mIU/mL

59
Q

Interpretation of
HBsAg Negative
Anti-HBs Negative
Anti HBc Negative

A

Non - immune

susceptible

60
Q

What is anti-HBc IgM used for?

A

To determine acute or chronic Hep B

Anti-HBc IgM antibody positive = acute hepatitis B infection

61
Q

For the diagnosis of Chronic Hep B the HBsAg must remain positive for at least…..

A

6 months

62
Q

What is HBeAg (hepatitis B e antigen) testing used for

A

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
Q

what is the immune tolerance phase of chronic Hep B

A

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
Q

what is the immune clearance phase of chronic Hep B

A

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
Q

what is the immune control phase of chronic Hep B

A

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
Q

what is the immune escape phase of chronic Hep B

A

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
Q

What further assessment is recommended for patients with Chronic Hep B in the immune escape phase

A

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
Q

What blood test results may indicate liver cirrhosis

A

AST higher than ALT

AND low platelets

69
Q

What blood test results may indicate liver failure

A

Raised bilirubin
low albumin
increased prothrombin time

70
Q

Treatment of chronic Hep B

A

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
Q

What is the decision to treat chronic Hep B based on

A

pattern of disease
HBV DNA level (>2,000)
presence / absence of necro-inflammation and hepatic fibrosis.

72
Q

Without intervention what % of pregnancy patients with

Hep B e antigen +ve chronic Hep B will transmit the virus to the child?

A

90% vertical transmission
if
‘e’ antigen (HBeAg) +ve
and HBsAg +ve

73
Q

Without intervention what % of pregnancy patients with

Hep B e antigen -ve chronic Hep B will transmit the virus to the child?

A

10% vertical transmission
if
‘e’ antigen (HBeAg) +ve
and HBsAg +ve

74
Q

What % of vertically infected infants will become chronic carriers of Hep B

A

Most (>90%)

75
Q

Management of infants born to infectious mothers with Hep B

A

Hep B vaccination at birth
Hep B specific Immunoglobulin 200 i.u. IM if mother is highly infectious

reduces vertical transmission by 90%

76
Q

When should treatment be considered for Hep B during pregnancy

A

If HBV DNA >10, 000, 000
Consider Tenofovir monotherapy
in the third trimester
to reduce risk of transmission to baby

77
Q

Impact of pregnancy on HBV (for the mother)

A

Hep B activity may increase immediately following pregnancy

Rarely associated with clinical consequences

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