Hepatitis B Virus (HBV) Infection management

Hepatitis B Virus (HBV) Infection

Definition

Hepatitis B virus (HBV) infection is a viral disease caused by a partially double-stranded DNA virus of the Hepadnaviridae family. HBV primarily affects the liver and may present as acute self-limiting hepatitis, fulminant hepatic failure, chronic hepatitis, cirrhosis, or hepatocellular carcinoma (HCC).

Acute Hepatitis B Infection

Acute HBV infection is defined as new-onset hepatitis B characterized by the presence of hepatitis B surface antigen (HBsAg) and hepatitis B core IgM antibody (anti-HBc IgM). Most immunocompetent adults recover spontaneously with clearance of HBsAg and development of protective anti-HBs antibodies.

Clinical Presentation

• Fever

• Malaise and fatigue

• Anorexia

• Nausea and vomiting

• Right upper quadrant abdominal pain

• Jaundice

• Dark urine

• Hepatomegaly and liver tenderness

Severe/Fulminant Disease

• Altered mental status

• Hepatic encephalopathy

• Coagulopathy

• Spontaneous bleeding

• Ascites

• Coma

Investigations

HBV-Specific Tests

• HBsAg

• Anti-HBc IgM

• HBeAg (if available)

• HBV DNA PCR (where available)

Baseline Assessment

• Liver Function Tests (ALT, AST, ALP, GGT, bilirubin, albumin)

• Full Blood Picture (FBP)

• Renal Function Tests (RFT)

• Coagulation profile (PT/INR)

• Abdominal ultrasound

Management

Non-Pharmacological Treatment

• Adequate hydration

• Nutritional support

• Avoid alcohol

• Avoid hepatotoxic medications and herbal remedies

• Counseling regarding transmission prevention

Pharmacological Treatment

No specific antiviral therapy is recommended for uncomplicated acute HBV infection.

Provide:

• Symptomatic treatment

• Intravenous fluids when indicated

• Management of complications such as acute liver failure

Follow-Up

• Clinical and laboratory reassessment every 4–6 weeks.

• Repeat HBsAg testing at 6 months to determine recovery or progression to chronic HBV infection.

Chronic Hepatitis B Infection

Definition

Chronic hepatitis B infection is defined as persistence of HBsAg for ≥6 months following acute infection.

Clinical Presentation

Common Features

• Often asymptomatic

• Fatigue

• Malaise

• Right upper quadrant discomfort

• Anorexia

Advanced Liver Disease

• Jaundice

• Ascites

• Peripheral edema

• Splenomegaly

• Variceal bleeding

• Hepatic encephalopathy

• Coagulopathy

Extrahepatic Manifestations

• Polyarteritis nodosa

• Glomerulonephritis

• Vasculitis

• Arthritis

• Urticaria

• Peripheral neuropathy

• Thyroiditis

Investigations

Virological Assessment

• HBsAg

• Anti-HBs

• HBeAg

• Anti-HBe

• HBV DNA quantitative PCR

Laboratory Evaluation

• ALT, AST

• Albumin

• Bilirubin

• INR/PT

• Full Blood Picture (FBP)

• Renal Function Tests (RFT)

• HIV testing

Fibrosis Assessment

• APRI Score

• FibroScan® (if available)

Hepatocellular Carcinoma Surveillance

• Alpha-fetoprotein (AFP)

• Abdominal ultrasound every 6–12 months

Additional Imaging

• Abdominal ultrasound

• Doppler ultrasound

• CT scan or MRI when indicated

Indications for Antiviral Therapy

Initiate treatment in any of the following:

Chronic Active Hepatitis

• ALT >2 × upper limit of normal (ULN)

  
  

  AND

• HBV DNA >20,000 IU/mL (HBeAg-positive)

OR

• ALT >2 × ULN

  
  

  AND

• HBV DNA >2,000 IU/mL (HBeAg-negative)

Significant Fibrosis or Cirrhosis

• APRI score >2

• Clinical, radiological, or FibroScan evidence of cirrhosis

Special Groups

• HBV/HIV coinfection

• Persistent abnormal ALT in adults >30 years with elevated HBV DNA

• Patients receiving immunosuppressive therapy

Patients Not Requiring Immediate Treatment

Immunotolerant Phase

• Age <30 years

• High HBV DNA levels

• Normal ALT

• No evidence of fibrosis

Monitor every 6–12 months.

Inactive Carrier State

• Normal ALT

• Low or undetectable HBV DNA

• No fibrosis or cirrhosis

Monitor periodically.

Pharmacological Treatment

First-Line Therapy

A: Tenofovir Disoproxil Fumarate (TDF) (PO)

• 300 mg once daily

Preferred for most adults.

Alternative

Entecavir (PO)

Adults:

• 0.5 mg once daily (treatment naïve)

Lamivudine-resistant infection or decompensated cirrhosis:

• 1 mg once daily

Children 2–18 years:

• Dose according to age and weight

Contraindications and Precautions

Tenofovir

Avoid or adjust treatment in:

• Significant renal impairment (CrCl <50 mL/min)

• Children <12 years where appropriate formulations are unavailable

Entecavir

Dose adjustment required in renal impairment.

Not Recommended

• Lamivudine monotherapy due to high resistance rates.

• Interferon-based therapy due to cost, adverse effects, and limited availability.

Monitoring During Treatment

Every 24–48 Weeks

• ALT

• HBV DNA

• HBeAg/Anti-HBe

• HBsAg

• APRI score

Annually

• Renal function (patients on Tenofovir)

• Growth and development in children

HCC Surveillance

• Abdominal ultrasound

• AFP measurement

Every 6–12 months in high-risk patients.

Treatment Endpoints

Consider treatment discontinuation in non-cirrhotic patients who achieve:

• HBeAg seroconversion to Anti-HBe

• Undetectable HBV DNA

• Persistently normal ALT

• Completion of consolidation therapy

Definite Treatment Endpoint

• HBsAg loss with development of Anti-HBs antibodies

Continue Indefinitely

• Cirrhosis

• Significant fibrosis

• Ongoing viral replication

Prevention

Screening

Screen:

• Household contacts

• Sexual partners

• Healthcare workers

• Patients on hemodialysis

• Recipients of multiple blood transfusions

• Men who have sex with men

• People living with HIV

• Pregnant women

Vaccination

Offer HBV vaccination to:

• All susceptible individuals

• Close contacts of infected patients

• High-risk groups

Counseling

• Safe sexual practices

• Avoid sharing needles, razors, or toothbrushes

• Screen family members and household contacts

Referral

Refer to a hepatologist, gastroenterologist, or specialist physician if:

• Cirrhosis or decompensated liver disease is present

• Hepatocellular carcinoma is suspected

• Treatment failure occurs

• Significant fibrosis is detected

• Fulminant hepatitis develops

Note

For comprehensive management, refer to the National Guidelines for Prevention and Management of Viral Hepatitis (2020) and updated WHO Hepatitis B treatment recommendations.