Hepatitis B Pathway - Adult Leeds

Click here for further information Click here for further information Click here for further information Click here for further information Click here for further information Click here for further information Click here for further information Click here for further information Click here for further information Click here for further information Click here for further information Click here for further information Click here for further information Click here for further information

1.  Background information

Quick info:

The content of this pathway has been agreed and approved by the Dept of Hepatology (LTHT) and the Leeds CCGs.

Clinical content has been provided by Dr Rebecca Jones and Dr Mark Aldersley, Consultant Hepatologists (LTHT) and also sourced from Map of Medicine National Pathways.

Back to top

3.  Updates to this care map

Quick info:

Pathway Developed: December 2014

To be reviewed: December 2016

Back to top

4.  Hepatitis B - clinical presentation

Quick info:

Presentation:

  • most patients will be asymptomatic
  • symptoms, if present, are those of chronic liver disease:
    • weight loss
    • nausea
    • fatigue
    • anorexia
    • loss of appetite
    • signs of liver decompensation may be present in those with advanced liver disease, eg:
      • jaundice
      • ascites
      • hepatic encephalopathy

Occasionally, chronic hepatitis B presents with extrahepatic manifestations:

  • glomerulonephritis
  • vasculitis
  • polyarteritis

People with chronic hepatitis B may also be identified:

  • following screening tests for people at high risk
  • through follow up, after a diagnosis of acute hepatitis B
  • because of abnormal liver function tests (LFT):
    • the most common abnormalities are mild increases in levels of alanine transaminase (ALT) and aspartate transaminase (AST)
    • ALT levels may be only mildly elevated (less than 100 IU/L)   the progression to chronic infection is indicated when this persists for more than 6 months after acute hepatitis B
    • alkaline phosphatase levels tend to be normal (or nearly normal)
  • bilirubin and albumin levels, and prothrombin time, are usually normal, unless liver disease is severe and advanced

History:

  • intravenous (IV) drug use
  • blood transfusions or products
  • high risk sexual behaviour
  • healthcare intervention in an endemic area (dialysis etc)
  • ethnic origin, country of birth
  • tattoos or piercings
  • occupational risk of exposure
  • family history of hepatitis B virus (HBV) or hepatocellular carcinoma (HCC)
  • alcohol consumption

Examination:

  • any stigmata of chronic liver disease:
    • organomegaly
    • signs of decompensated liver disease

Back to top

5.  Screening for hepatitis B in high risk groups

Quick info:

Antenatal screening for hepatitis B is routinely offered to all pregnant women.

Consider opportunistic screening of people at high risk of hepatitis B, particularly for those who:

  • are more likely to have been exposed to hepatitis B, such as:
    • immigrants from areas with a high prevalence
    • injecting drug users
    • sex workers
  • have been sexually assaulted
  • have sustained a needlestick injury
  • are HIV-positive

In people at high risk of hepatitis B, consider:

  • offering the first dose of hepatitis B vaccine; and
  • taking blood for serology testing at the same appointment
  • if serology tests later show immunity, do not give the remaining doses of vaccine

People at high risk of hepatitis B include:

  • injecting drug users and their close contacts, including sexual contacts
  • people who change sexual partners frequently, particularly men who have sex with men
  • history of previous sexual transmitted infections (STIs), including HIV, or HCV infection
  • current or previous sex workers and their clients
  • household contacts of people with hepatitis B (a case or a carrier), including close family, carers and sexual contacts
  • people from or travellers to a country with a high prevalence:
    • South Asia
    • Africa
    • Mediterranean
    • South America
    • Eastern Europe
    • Caribbean
    • South Pacific islands
  • infants born to women with chronic hepatitis B infection
  • people with an occupational risk (such as healthcare workers, laboratory staff, prison staff and morticians)
  • people residing in institutions including children, young offenders, prison inmates and immigration detainees
  • individuals receiving regular blood or blood products (such as people with haemophilia) and their carers
  • people with chronic renal failure or chronic liver disease

Take this opportunity to enquire about:

  • alcohol intake
  • cardiovascular risk factors   possible metabolic syndrome

Back to top

6.  Investigation Abnormal LFTs

Quick info:

Anyone with a raised ALT should be considered for a Hepatitis B test - See 'Abnormal ALT pathway' for more details.

Back to top

7.  Hepatitis B Screen

Quick info:

Screening test is the Hepatitis B surface Antigen (HBsAg) and Hepatitis B core Antibody (HBcAb) They will also request a confirmatory test

Back to top

8.  HBsAg negative HBcAb negative

Quick info:

Hepatitis B surface antigen (HBsAg) negative and anti-hepatitis B core antigen (anti-HBcAg) negative indicates:

  • no active infection
  • no development of immunity
  • consider vaccination in these patients, especially those who are high risk

Further investigation to identify cause of deranged liver tests may be necessary.

Back to top

9. Hepatitis B surface antigen (HBsAg) positive

Quick info:

All patients found to be HBsAg-positive should be assessed by the viral hepatitis service in Leeds.

Back to top

10. HBsAg negative and anti-HBcAb positive

Quick info:

Hepatitis B surface antigen (HBsAg) negative and anti-hepatitis B core antibody (anti-HBcAb) positive indicates:

  • previous exposure; and
  • that immunity has developed
  • review risk factors for other blood-borne viruses and test as appropriate
  • discuss safer-sex practices (may be at risk of STIs)

Further investigation to identify cause of deranged liver tests is necessary. See 'Abnormal ALT pathway'.

If these patients require high dose chemotherapy in the future there is a risk of reactivation of infection (e.g. chemotherapy for bone marrow transplantation, leukaemia, lymphoma).

Back to top

12. Investigations

Quick info:

The following investigations should be done prior to referral.

Full Hepatitis B serology

  • HBsAg
  • HBeAg
  • HBeAb
  • HBcAb
  • HBV DNA

Tests for other blood-borne viruses

  • HIV
  • Hepatitis C
  • Hepatitis D (as per NICE)

Other tests

  • Abdominal / Liver Ultrasound
  • FBC
  • U+E
  • LFT
  • Liver autoantibodies
  • Immunoglobulins

Back to top

14. Red Flag

Quick info:

Refer jaundice patients or those with an ALT > 500 urgently (may be acute or acute-on-chronic flare).

Pregnant women should also be referred urgently as they may require treatment for several weeks prior to delivery.

Back to top

15. Consider if at risk of infection and vaccinate if so

Quick info:

See 'Screening for hepatitis B in high risk groups' box for high risk groups.

Back to top

16. Counselling and vaccination of contacts Notify Health Protection

Quick info:

Consider screening and vaccination in:

  • sexual contacts and needle sharing partners of the patient
  • babies of infected mothers at birth   the normal course of vaccination should be completed
  • all family and household contacts of the patient

Vaccinate the person against hepatitis A   if they are not immune to hepatitis A. Test for response to Hepatitis B vaccine:

  • 1-2 months after last dose in contacts
  • 3-9 months after last dose in babies of infected mothers

Counselling:

  • provide the person with information about hepatitis B, and advice on how to prevent transmission of the infection
  • advise patients:
    • to reduce alcohol consumption   advise the person to avoid drinking alcohol
    • risks of transmission:
      • use barrier intercourse if hepatitis B virus (HBV) status/vaccination of patient unclear
      • do not share tooth brush, razors, hair clippers
      • cover open cuts, scratches
      • clear blood spills with bleach, disinfectant
      • do not donate blood or semen

NB:

  • children should not be excluded from school or out of school activities
  • food utensils can be shared safely

Back to top

17.  Refer Hepatology (Viral Hepatitis Clinic)

Quick info:

Refer jaundice patients or those with an ALT > 500 urgently (may be acute or acute-on-chronic flare). Pregnant women should also be referred urgently.

Key Dates

Published: 15-Jan-2015, by Leeds
Valid until: 31-May-2019

Back to top