City Hackney CCG Hepatitis B Pathway Dr Rob

City & Hackney CCG Hepatitis B Pathway Dr Rob Palmer - GPw. SI Gastroenterology - C&H CCG Gastro lead Dr Ray Shidrawi - Consultant Gastroenterologist/Hepatologist

Epidemiology �Hepatitis B is a vaccine preventable infection which can cause chronic liver disease and hepatocellular carcinoma �Rates are increasing �Hackney has the 3 rd highest prevalence in the country �Cost to NHS £ 26 million/year

Natural history of disease �In majority of people, chronic hepatitis B is inactive and does not present significant health problems �A proportion progress to: �liver fibrosis �cirrhosis �hepatocellular carcinoma (HCC) �The progression of liver disease is related to higher levels of HBV viral DNA in the blood (viral load)

The role of GPs in Hepatitis B �Diagnosis �Assessment of disease state: �Non-replicative carriers (viral load >2000) � Require annual surveillance in primary care �High infectivity � Referral to secondary care �Immunisation of contacts / high risk groups

Acute & Chronic Hepatitis B

Who to vaccinate �Babies born to hepatitis B carrier mothers �Sexual partners & household contacts of hepatitis B carriers �IVDU �Sex Workers �Male homosexuals �Individuals receiving blood products �Health care workers �Garbage collectors �Prisoners or other institutionalised individuals �Travellers to endemic areas �Kidney dialysis/CKD patients �Chronic liver disease patients

The vaccination schedule �Preferred method: � 0, 1, 6 month boosters �Rapid schedules: � 0, 1, 2 month (+/- 1 yr) � 0, 7 days, 28 days (+/- 1 yr)

Response to vaccine �Testing for anti-HBs after vaccination is not recommended, except in: �Those at risk of occupational exposure �Renal patients on haemodialysis �Infants of HBV mothers �Further booster at 5 yrs: �Occupational risk �Lifestyle risk of exposure

Pregnancy & Hepatitis B �In 2004, 9. 8% of all antenatal patients at booking were infected with HBV �If infants infected at birth: 90% go on to have chronic hepatitis B �Appropriate Rx of infant at birth reduces transmission by 90% �Breast feeding is safe for mothers with Hep B

Pregnancy & Hepatitis B

Hep B Pathway

New diagnosis of HBs. Ag positive Tests to arrange: �HBV DNA levels (LARGE RED EDTA BOTTLE) �LFTs, inc g. GT, ALT �Clotting screen �HBe. Ag / e. Ab status �Anti-HBc lg. M �Hepatitis C virus antibody (anti-HCV) �Hepatitis delta virus antibody (anti-HDV) �Hepatitis A virus antibody (anti-HAV) �HIV antibody (anti-HIV) �AFP (NOT in pregnancy) �Liver U/S (if over 50 years of age)

Liver USS �One-off scan at aged 50 yrs �No need routinely in younger patients (Usually takes 20 -30 y to develop cirrhosis) �If bloods normal but USS reveals scarring/cirrhosis needs bloods (inc a. FP) and USS every 6/12

Annual Surveillance in Primary Care

Surveillance annually �Bloods: �LFTs �a. FP �HBV DNA viral load �Lifestyle measures: �Alcohol, weight, diet If LFTs abnormal but normal viral load - consider other causes (alcohol, NAFLD, ? liver screen) If AFP raised – repeat after 1 m and 3 m (and USS): refer if upward trend

Refer if…