Acute or Chronic Infection

• Report the infection to the appropriate public health agency

Hepatitis B is a nationally notifiable disease in Canada. Unless reporting is done automatically by the laboratory, the ordering physician should directly notify the local public health agency in charge. An adequate public health investigation should then be performed to notify and offer testing to potential contacts.

• Appropriate post-diagnosis counselling

Disclose the diagnosis to the patient in a culturally-sensitive manner, using an interpreter if required. Explain the various modes of hepatitis B transmission (and how to avoid transmitting the virus - condoms, no sharing of razors, no blood donation, etc.). They should understand the potential consequences of the infection (hepatocellular carcinoma, cirrhosis) as well as the concept of chronic infection.

They should know that there is no cure at the moment and that while some people can clear the infection by themselves, most patients will be chronically infected (for decades or life). Explain that treatment is only offered in certain hepatitis B patients at risk of disease progression, and that additional investigations are required to decide if they require treatment at this time.

• Complete the history

Inquire about any potential history of symptomatic hepatitis in the past. Ask about any family history of hepatitis B, hepatocellular carcinoma or any other liver disease. Alcohol intake as well as sexual history should be addressed. Ask about any potential symptom of cirrhosis on history (jaundice, abdominal distension, history of upper GI bleeding, constitutional symptoms - anorexia, weight loss, fatigue).

• Complete the physical exam

Look for any potential sign of liver disease/cirrhosis - jaundice, spider angiomata, gynecomastia, ascites, hepatosplenomegaly, caput medusae, palmar erythema, asterixis, etc.

• Screen contacts

Close family members as well as sexual contacts should be screened for hepatitis B and offered vaccination if susceptible. This should usually be organized by the local public health agency.

• Vaccination

Once the hepatitis A serology has been ordered, chronic hepatitis B patients should be referred for specific immunizations - pneumococcal and hepatitis A (if non-immune).

• Order the initial blood tests

The following baseline tests should be ordered after a chronic hepatitis B diagnosis:

Quantitative HBV DNA, HBeAg, anti-HBe, CBC, INR, creatinine, urea, electrolytes, ALT, AST, GGT, albumin, total bilirubin, anti-Hep A IgG, HIV and HCV serologies

The following tests can also be considered if another liver disease is suspected:

Ferritin, iron studies (hemochromatosis) / Gamma globulins levels, AMA, ANA, anti-SMA (autoimmune hepatitis) / Alpha-1 antitrypsin levels (alpha-1 antitrypsin deficiency)

• Begin hepatocellular carcinoma screening

Screening for hepatocellular carcinoma (HCC) with an abdominal ultrasound q6 months should be initiated if the chronic hepatitis B patient fulfills one the following criteria:

- Any patient with cirrhosis
- Any patient with HIV or HCV co-infection
- People of African descent 20 years of age or older
- Men 40 years of age or older
- Women 50 years of age or older
- Any patient with a family history of HCC

• Hepatology referral

All chronic hepatitis B patients should be seen by a Hepatologist at some point. However, unless there are potential indications for treatment (elevated HBV DNA or ALT, HIV/HCV co-infection, cirrhosis), patients do not have to be seen right away by the specialist. Pregnant patients with hepatitis B are an exception and should be seen as soon as possible by a specialist.

• Follow-up blood tests

Unless advised otherwise by the specialist, chronic hepatitis B patients should have follow-up blood tests done every 6 months to make sure there are no signs of disease progression. At the Calgary Refugee Health Program, we usually do the following tests:

- CBC and ALT q6 months
- Quantitative HBV DNA q12 months