Asian-Pacific Clinical Practice Guidelines on the Management of Hepatitis B: A 2015 Update

Worldwide, some 240 million people have chronic hepatitis B virus (HBV), with the highest rates of infection in Africa and Asia. Our understanding of the natural history of HBV infection and the potential for therapy of the resultant disease is continuously improving. New data have become available since the previous APASL guidelines for management of HBV infection were published in 2012. 

The objective of this manuscript is to update the recommendations for the optimal management of chronic HBV infection. The 2015 guidelines were developed by a panel of Asian experts chosen by the APASL. The clinical practice guidelines are based on evidence from existing publications or, if evidence was unavailable, on the experts’ personal experience and opinion after deliberations. Manuscripts and abstracts of important meetings published through January 2015 have been evaluated. 

This guideline covers the full spectrum of care of patients infected with hepatitis B, including new terminology, natural history, screening, vaccination, counseling, diagnosis, assessment of the stage of liver disease, the indications, timing, choice and duration of single or combination of antiviral drugs, screening for HCC, management in special situations like childhood, pregnancy, coinfections, renal impairment and pre- and post-liver transplant, and policy guidelines. 

However, areas of uncertainty still exist, and clinicians, patients, and public health authorities must therefore continue to make choices on the basis of the evolving evidence. The final clinical practice guidelines and recommendations are presented here, along with the relevant background information.

Below:  Treatment indications for chronic HBV-infected patients with cirrhosis or reactivation of chronic HBV infection

Below:  Treatment indications for noncirrhotic HBeAg-positive chronic HBV-infected patients

Below:  Treatment indications for noncirrhotic HBeAg-negative chronic HBV-infected patients

Below:  Reverse transcriptase mutations associated with drug resistance

Below:  Cumulative incidence of antiviral resistance in long-term studies of NA therapy

Below:  Treatment of CHB infection in HIV infected individuals

Below:  Treatment of HBV–HCV coinfected patients

Recommendations for infected persons regarding prevention of transmission of HBV to others

Have sexual contacts vaccinated

Use barrier protection during sexual intercourse if partner not vaccinated or naturally immune

Do not share toothbrushes or razors

Cover open cuts and scratches

Clean blood spills with detergent or bleach

Do not donate blood, organs or sperm

Can participate in all activities including contact sports

Children should not be excluded from daycare or school participation and should not be isolated from other children

Can share food, utensils, or kiss others

Full article at:  http://goo.gl/1208wm

By:  S. K. Sarin, M. Kumar, G. K. Lau, Z. Abbas, H. L. Y. Chan, C. J. Chen, D. S. Chen, H. L. Chen, P. J. Chen, R. N. Chien, A. K. Dokmeci, Ed Gane, J. L. Hou, W. Jafri, J. Jia, J. H. Kim, C. L. Lai, H. C. Lee, S. G. Lim, C. J. Liu, S. Locarnini, M. Al Mahtab, R. Mohamed, M. Omata, J. Park, T. Piratvisuth, B. C. Sharma, J. Sollano, F. S. Wang, L. Wei, M. F. Yuen, S. S. Zheng, and J. H. Kao

Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India

Division of Gastroenterology and Hepatology, Humanity and Health Medical Centre, Hong Kong SAR, China

Department of Hepatogastroenterlogy, Sindh Institute of Urology and Transplantation, Karachi, Pakistan

Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, China

Genomics Research Center, Academia Sinica, National Taiwan University, Taipei, Taiwan

Department of Internal Medicine, National Taiwan University College of Medicine, Taipei, Taiwan

Graduate Institute of Clinical Medicine, National Taiwan University College of Medicine, Taipei, Taiwan

Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan

Liver Research Unit, Chang Gung Memorial Hospital and University, Chilung, Taiwan

Department of Gastroenterology, Ankara University School of Medicine, Ankara, Turkey

New Zealand Liver Transplant Unit, Auckland City Hospital, Auckland, New Zealand

Department of Infectious Diseases and Hepatology Unit, Nanfang Hospital, Guangzhou, China

Department of Medicine, Aga Khan University, Karachi, Pakistan

Beijing Friendship Hospital, Capital Medical University, Beijing, China

Seoul, Korea

Department of Medicine, University of Hong Kong, Hong Kong, China

Internal Medicine Asan Medical Center, Seoul, Korea

Division of Gastroenterology and Hepatology, National University Health System, Singapore, Singapore

Research and Molecular Development, Victorian Infectious Diseases Reference Laboratory, Melbourne, Australia

Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh

Department of Medicine, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia

Yamanashi Hospitals (Central and Kita) Organization, 1-1-1 Fujimi, Kofu-shi, Yamanashi 400-8506 Japan

Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea

NKC Institute of Gastroenterology and Hepatology, Prince of Songkla University, Songkhla, Thailand

Department of Gastroenterology, G.B. Pant Hospital, New Delhi, India

Department of Medicine, University of Santo Tomas, Manila, Philippines

The Institute of Translational Hepatology, Beijing, China

Treatment and Research Center for Infectious Diseases, Beijing 302 Hospital, Beijing, China

Peking University Hepatology Institute, Beijing, China

Division of Gastroenterology and Hepatology, Department of Medicine, University of Hong Kong, Pofulam, Hong Kong

Department of Hepatobiliary and Pancreatic Surgery, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Key Laboratory of Combined Multi-organ Transplantation, Ministry of Public Health, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310003 Zhejiang Province China

Graduate Institute of Clinical Medicine and Hepatitis Research Center, National Taiwan University College of Medicine, National Taiwan University Hospital, Taipei, Taiwan

S. K. Sarin, Email: moc.liamg@nirasvihs.

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Improving the Identification of Priority Populations to Increase Hepatitis B Testing Rates, 2012

BACKGROUND:

It is estimated that over 40 % of the 218,000 people with chronic hepatitis B (CHB) in Australia in 2011 are undiagnosed. A disproportionate number of those with undiagnosed infection were born in the Asia-Pacific region. Undiagnosed CHB can lead to ongoing transmission and late diagnosis limits opportunities to prevent progression to hepatocellular carcinoma (HCC) and cirrhosis. Strategies are needed to increase testing for hepatitis B virus (HBV) (including culturally and linguistically diverse communities, Aboriginal and/or Torres Strait Islander (Indigenous) people and people who inject drugs). General practitioners (GPs) have a vital role in increasing HBV testing and the timely diagnosis CHB. This paper describes the impact of a GP-based screening intervention to improve CHB diagnosis among priority populations in Melbourne, Australia.

METHODS:

A non-randomised, pre-post intervention study was conducted between 2012 and 2013 with three general practices in Melbourne, Australia. Using clinic electronic health records three priority populations known to be at increased CHB risk in Australia (1: Asian-born patients or patients of Asian ethnicity living in Australia; 2: Indigenous people; or 3): people with a history of injecting drugs were identified and their HBV status recorded. A random sample were then invited to attend their GP for HBV testing and/or vaccination. Baseline and follow-up electronic data collection identified patients that subsequently had a consultation and HBV screening test and/or vaccination.

RESULTS:

From a total of 33,297 active patients, 2674 (8 %) were identified as a priority population at baseline; 2275 (85.1 %) of these patients had unknown HBV status from which 338 (14.0 %) were randomly sampled. One-fifth (n = 73, 21.6 %) of sampled patients subsequently had a GP consultation during the study period; only four people (5.5 %) were subsequently tested for HBV (CHB detected in n = 1) and none were vaccinated against HBV.

CONCLUSION:

CHB infection is an important long-term health issue in Australia and strategies to increase appropriate and timely testing are required. The study was effective at identifying whether Asian-born patients and patients of Asian had been tested or vaccinated for HBV; however the intervention was not effective at increasing HBV testing.

Full article at:  http://goo.gl/ADG29j

By:  van Gemert C1,2, Wang J3, Simmons J4, Cowie B5,6, Boyle D7, Stoove M3,8, Enright C4, Hellard M3,8.

• 1Centre for Population Health, Burnet Institute, Melbourne, Australia. carolinevg@burnet.edu.au.
• 2Department of Epidemiology and Preventative Medicine, Monash University, Melbourne, Australia. carolinevg@burnet.edu.au.
• 3Centre for Population Health, Burnet Institute, Melbourne, Australia.
• 4Cancer Council Victoria, Melbourne, Australia.
• 5WHO Collaborating Centre for Viral Hepatitis, Doherty Institute, Melbourne, Australia.
• 6Department of Medicine, University of Melbourne, Melbourne, Australia.
• 7GRHANITE™ Health Informatics Unit, Health and Biomedical Informatics Centre, University of Melbourne, Melbourne, Australia.
• 8Department of Epidemiology and Preventative Medicine, Monash University, Melbourne, Australia. 
• BMC Public Health. 2016 Feb 1;16(1):95. doi: 10.1186/s12889-016-2716-7.

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