By Liz Highleyman

Last week the U.S. Centers for Disease Control and Prevention (CDC) released new guidelines for screening and management of people with chronic hepatitis B virus (HBV) infection. The new recommendations were announced at an event in San Francisco's Chinatown since hepatitis B is a particular concern for Asian Americans, many of whom are infected via perinatal transmission.

It is estimated that as many as 1.4 million people in the U.S. are infected with HBV. Over time, the virus can cause severe liver damage, including cirrhosis, hepatocellular carcinoma (liver cancer), and end-stage liver failure.

The new guidelines include updated recommendations designed to increase routine testing for chronic hepatitis B. The CDC now recommends testing for the following groups:

The new guidelines are the first to include information about management of patients with chronic hepatitis B. According to a press release issued by the CDC, "Such guidelines are needed now to assist providers, since most of the effective medications for chronic HBV treatment have become available only in the last 5 years."

Recommended lab tests for people with chronic HBV infection should include a complete blood count and liver panel; tests for markers of HBV replication including hepatitis B "e" antigen (HBeAg), anti-HBe antibodies, and HBV DNA; and tests for coinfection with hepatitis C virus (HCV), hepatitis delta virus (HDV), HIV, and in some cases antibodies against hepatitis A virus (HAV).

The guidelines note that "Therapy for hepatitis B is a rapidly changing area of clinical practice." To date, 7 therapies have been approved for treatment of chronic hepatitis B -- the latest just last month:

Treatment decisions are made on the basis of several factors, including patient age, HBeAg status, HBV DNA viral load, ALT level, and stage of liver disease.

"Optimal duration of therapy has not been established," the guidelines authors wrote. "For HBeAg positive patients, treatment should be continued for at least 6 months after loss of HBeAg and appearance of anti-HBe; for HBeAg negative/anti-HBe positive patients, relapse rates are 80%-90% if treatment is stopped in 1-2 years."

HBV resistance to lamivudine occurs in up to 70% of patients during the first 5 years of treatment, they continued. However, rates of drug resistance are lower with adefovir (30% in 5 years), entecavir (<1% at 4 years), and telbivudine (2.3%-5% in 1 year); combination therapy, especially using different classes of drugs, may further reduce the risk of resistance.

"Coinfection with HIV complicates the management of patients with chronic hepatitis B," the authors added. "When selecting antiretrovirals for HIV treatment, the provider must consider the patient's HBsAg status to avoid liver-associated complications and development of antiviral resistance." Several agents are active against both HBV and HIV, and using any of these as monotherapy can lead to both viruses developing resistance. Furthermore, people with chronic liver disease due to hepatitis B appear to be more prone to drug-related liver toxicity associated with certain anti-HIV medications.

In addition to testing and treatment, the recommendations advise healthcare providers to offer culturally-sensitive ongoing patient education, to begin lifelong monitoring of HBV infected patients for progression of liver disease -- including screening for hepatoceullar carcinoma -- and to help ensure protection of household members and other at-risk contacts of infected individuals.

Unlike hepatitis C, hepatitis B is preventable with a vaccine, which is now part of the standard immunization series for infants. Vaccination is also recommended for all at-risk adults, and "catch up" vaccination is advised for children and adolescents who were not immunized as infants.

9/23/08

Sources
Centers for Disease Control and Prevention. CDC expands testing recommendations for chronic hepatitis B virus infection. Press release. September 18, 2008.

CM Weinbaum, I Williams, EE Mast. Recommendations for identification and public health management of persons with chronic hepatitis B virus infection. Morbidity and Mortality Weekly Report 57(RR08): 1-20. September 19, 2008. Full text.