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Hepatitis B virus infection

Key sources
The following summarized guidelines for the evaluation and management of hepatitis B virus infection are prepared by our editorial team based on guidelines from the Center for Disease Control (CDC 2023; 2022), the Infectious Diseases Society of America (IDSA/CDC/NIH/HIVMA 2023), the Society for Maternal-Fetal Medicine (SMFM 2023), the European Association for the Study of the Liver (EASL 2023; 2017), the American Association for the Study of Liver Diseases (AASLD 2021; 2018; 2014), the World Health Organization (WHO 2020; 2015), the U.S. Preventive Services Task Force (USPSTF 2020; 2019), the American Society of Clinical Oncology (ASCO 2020), the Society of Obstetricians and Gynaecologists of Canada (SOGC 2020; 2017), the European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN/NASPGHAN 2020), the American College of Physicians (ACP/CDC 2017), the American College of Gastroenterology (ACG 2016), the Italian Association for the Study of the Liver (AISF 2016), and the American Gastroenterological Association (AGA 2015).
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Guidelines

1.Screening and diagnosis

Indications for screening, general population
Screen all adults aged ≥ 18 years at least once in their lifetime using a triple panel test.
E
Test anyone requesting HBV testing regardless of disclosure of risk.
E
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  • Indications for screening (persons at risk)

  • Indications for screening (pregnancy)

  • Indications for screening (before anticancer therapy)

2.Diagnostic investigations

Pretreatment evaluation: assess baseline renal function and baseline risk for renal dysfunction in all patients before initiating tenofovir or entecavir therapy.
E

3.Medical management

Management of acute hepatitis B virus hepatitis
Do not initiate specific treatment in most (> 95%) adult patients with acute HBV because they will fully recover spontaneously.
D
Initiate nucleoside/nucleotide analogs only in patients with severe acute hepatitis B, characterized by coagulopathy or protracted course, and assess for liver transplantation.
B

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  • Indications for antiviral therapy

  • Goals of antiviral therapy

  • Choice of antiviral regimens

  • Maintenance therapy

  • Management of treatment failure

  • Management of relapse

4.Surgical interventions

Liver transplantation, pre-transplant antiviral therapy, EASL: initiate nucleoside/nucleotide analogs in all patients with HBV-related liver disease on the transplant waiting list.
B

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  • Liver transplantation (post-transplant antiviral prophylaxis)

5.Specific circumstances

Pregnant patients, indications for screening, EASL: obtain screening for HBsAg in the first trimester of pregnancy to identify and reduce the risk of HBV mother-to-child transmission,
A
and consider obtaining HBsAg quantitation as an accurate predictor of HBV DNA level.
B

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  • Pregnant patients (immunization of the mother)

  • Pregnant patients (indications for testing)

  • Pregnant patients (laboratory testing)

  • Pregnant patients (liver imaging)

  • Pregnant patients (hepatitis B immunoglobulin)

  • Pregnant patients (antiviral therapy)

  • Pregnant patients (counseling)

  • Pregnant patients (fetal evaluation)

  • Pregnant patients (delivery)

  • Pregnant patients (immunization of the infant)

  • Pregnant patients (breastfeeding)

  • Pediatric patients (screening)

  • Pediatric patients (antiviral therapy)

  • Pediatric patients (monitoring)

  • Pediatric patients (patients with HIV co-infection)

  • Pediatric patients (patients on immunosuppressive therapy)

  • Pediatric patients (liver transplant recipients)

  • Pediatric patients (non-liver transplant recipients)

  • Pediatric patients (hematologic stem cell transplant recipients)

  • Patients with renal impairment

  • Patients with malignancy

  • Patients with HDV co-infection

  • Patients with HCV co-infection

  • Patients with HIV co-infection

  • Patients on immunosuppressive therapy

  • Patients with extrahepatic manifestations

6.Preventative measures

Immunizations, infants, WHO: administer the first dose of the hepatitis B vaccine in all infants as soon as possible after birth, preferably within 24 hours, followed by 2-3 doses to complete the primary series.
E

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  • Immunizations (adults)

7.Follow-up and surveillance

Monitoring of untreated patients: as per EASL 2017 guidelines, follow-up < 30 years old patients with HBeAg-positive chronic HBV infection not meeting criteria for treatment initiation at least every 3-6 months.
B
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  • Monitoring of treatment response

  • Monitoring of treatment adverse effects

  • Surveillance for HCC

8.Quality improvement

Healthcare workers
Do not disqualify persons from the practice or study of surgery, dentistry, medicine, or allied health fields based on HBV infection alone.
D
Consider initiating nucleoside/nucleotide analogs to reduce transmission risk in healthcare workers performing exposure-prone procedures with serum HBV DNA > 200 IU/mL.
C