Hepatitis B Carrier

By Ruby Lai 21/7/2006

 1. Who to screen 2. Clarify whether a true HB carrier 3. Counsel on contact tracing for those HBsAg+& HBsAb + w/o vaccination 4. Hep B Vaccination 5. Surveillance of hepatitis, cirrhosis, CA 6. Current treatment available & management guideline

Cases discussion
1. M/21 no Hx of blood test on Hep B status 2. M/35, Hep B vaccine 5 years ago, request check Hepatitis B status. 3. F/34 , husband Hep B carrier 4. F/40 detected HBsAg 3 months ago as first time, request repeat Hepatitis B Status 5. M/45, Known Hep B carrier, moderate drinker,

Who to screen
Health Care worker Family history of Hep B carrier Adolescent or Adult no hx of vaccination, esp. high risk group e.g. multiple sexual partner, frequent blood transfusion, injecting drug, sexual partner Hep B carrier. People with compromised immunity
post-vacc serology need for the above group

True Hep B carrier

The risk of carrier rate: 90-95% perinatal transmission 30% children age 1-5 5-10% older children, adolescent, adult Route of transmission: perinatal, paternal, sexual China & South East Asia high prevalence >8% Carriers

True Hep B carrier

Once HBsAg detected, it should be repeated at least 6 months later to confirm the true Hep. B Carrier Status So usually advise repeat HBsAg & HBsAb one year later Persist HBsAg confirm Carrier status.

Contact Tracing
Sexual partner Children Parent Sibling

Hepatitis B vaccination
Regimen 0, 1, 6 is widely used Efficacy >95% seroconversion rate Post vaccination serology usually not need exact some special group of people Routine boostering not recommended after 3 doses

Hepatitis B vaccination
1st & 2nd dose not <4 weeks and Not >12 weeks 3rd dose not evidence of efficacy after 10 months More tight schedule earilar protection

 Hypo-responder-anti-HBs titre 0-10mIU/ml Non-responder -anti-HBs titre Factor: Obesity, male sex,smoker, older age, immunocompromised status. Suggest repeat 3 standard dose 18-25% respond in 2nd course

When to start Surveillance

To increase the chance of intervention and improve survival, Early detection of subclinical HCC By AFP (Alpha-fetal protein) By USG Liver Sensitivity for AFP alone(74.2%), USG Liver Alone (81.9%)

How frequent
A single tumour <3cm carries a reasonable chance of cure
Most rapidly growing HCCs took 4.6 months to grown to 3cm 4-6 monthly USG is a reasonable interval Other studies found annual surveillance as effective

Case 1
M/21 no Hx of blood test on Hep B status Management: 1. Born in HK? 2. Vaccination program completed 3. If vaccine before, low risk, no need to check 4. If vaccine before high risk, check 5. If no vaccine, check

Case 2
M/35, Hep B vaccine 5 years ago, request check Hepatitis B status. Management: 1. Check if only high risk group 2. Boostering usually not required because of natural boostering

Case 3
F/34 , husband Hep B carrier Management: 1. Suggest check Hep B status

Case 4
F/40 detected HBsAg 3 months ago as first time, request repeat Hepatitis B Status Management: 1. Suggest recheck HBsAg and HBsAb 6 to I year after the last blood test 2. Advise husband and sibling, parent to check HBsAg status 3. Advise healthy life style and regular liver assessment if Hep B carrier confirmed

Case 5
5. M/45, Known Hep B carrier, moderate drinker, Management: 1. Advise quit alcohol 2. Advise family member to check Hep B status 3. Regular liver assessment including ALT, AFP, USG liver in 4-6 months interval

Current Management for Chronic Hepatitis

Antiviral Treatment - Lamivudine - Adefovir - Interferon Alfa (IFN-) ? Traditional Chinese Herbal Medicine

Lamivudine
Benefit: 1. HBeAg seroconversion durability of respond after cessation of treatment is 38%-77% Problem: 1. Lamivudine resistent Mutant (14%, 38%, 49%,66%, 69% in first, 2nd, 3rd, 4th & 5th yrs of treatment ) 2. Relapsing rate 36-54% in 3 years, most occur in first year 3. Duration of treatment 1 year or more

Adefovir
Benefit: 1. low resistent 2. Problem: 1. Cost high 2. HBeAg seroconversion rate on 12% 3. ALT raise again after stop the treatment 4. Duration of treatment 1 year or more

Interferon Alfa
Benefit: 1. Short duration 4-6 months 2. Lack of resistent mutants Problem: 1. High cost 2. Side effect (Early Flu like symptom: chill, headache, fever, malaise, tachycardia, myalgia, arthralgia

When to start Tx
a) HBeAg+ CHB with ALT >2x ULN & compensated liver should be observed for 3-6 months for spontaneous seroconversion from HBeAg to HBeAb(HKP7/04, AA) if after 3-6 months ALT remains >2x ULN & HBV DNA >10^5 copies/ml consider Tx (HKP7/04)

When to start Tx
b) HBeAg- CHB with HBV DNA >10^5 copies/ml & ALT >2x ULN on repeated testing (HKP7/04), at least 1 month between observations (AP)

c) HBV cirrhosis with HBV DNA >10^4 (HKP7/04, AA) d) ALT in a rising trend or with ALT> 5xULN (AP)

When to start Tx
ALT >2x ULN & HBV DNA <10^5 copies/ml (arbitrary cut-off, there is no known level of HBV DNA below which there is no disease progression) ALT elevated but < 2x ULN

Hep B carrier with normal ALT not indicated for treatment

Thank You