What the Infection Preventionist Needs to Know About Hepatitis B Marwan Sweedan, M.B.Ch.B, CIC, CTBS

Disclosure No relevant conflicts of interest or financial relationship exist.

Overview and framework What is hepatitis and what are the types of viral hepatitis. Global distribution and challenges of viral hepatitis. Hepatitis B overview. Hepatitis B transmission and population at risk. Hepatitis B screening and result interpretation. Occupational health and vaccination. Exposure management. Framework World Health Organization Centers for Disease Control and Prevention APIC text

Hepatitis

A global challenge Viral Hepatitis B & C Affecting 325 Million people globally. 1.34 million death every year. Root causes of liver cancer. It has become a major killer due to lack of global attention. [1][2] Global health sector strategy on viral hepatitis 2016-2021

Hepatitis B According to WHO: HBV can cause an acute and chronic disease. An estimated 257 million people are living with HBV. In 2015, HBV resulted in 887,000 deaths. Mostly from complications. HBV is an important occupational hazard for healthcare workers. It can be prevented by currently available safe and effective vaccination.

Hepatitis B (continue) Geographically; the percentage of general population infected are: 6.2% in the WHO Western Pacific Region. 6.1% in the WHO African Region. 3.3% in the WHO Eastern. Mediterranean Region. 2.0% in the WHO South East Asia Region. 1.6% in the WHO European Region. 0.7% in the WHO Americans region.

Hepatitis B (continue) According to the CDC, in the USA: In 2016, a total of 3,218 cases of acute HBV were reported to the CDC from 48 states. The overall incidence rate for 2016 was 1.0 cases per 100,000 (After adjusting for under-ascertainment and under-reporting, an estimation 20,900 acute HBV cases occurred in 2016) [3] The incident of acute HBV is declined from 1990-2014

Hepatitis B transmission Hep.B virus can survive outside the body for at least 7 days. Incubation period range 60-150 days after exposure (APIC text 30-180 days) Transmitted (exposed to blood and body fluids such as saliva, menstrual, vaginal and seminal fluids). Needle sticks or sharp instrument exposure. Contact with blood or open sores of an infected person. Birth to an infected mother. (in highly epidemic areas) Injection drug use that involves sharing needles, syringes, or drug-preparation equipment. Sharing items such as razors or toothbrushes with an infected person. Sex with an infected partner.

Hepatitis B transmission (continue) Hep.B is not transmitted or spread through: Food or water. Sharing eating utensils. Breastfeeding. Hugging and kissing. Hand holding. Coughing or sneezing

Population at risk Health care and public safety workers. Hemodialysis patients. A child born to infected mothers. Injectable drug users. Sex partners of infected persons. Homosexual men. Household contacts of known persons with chronic HBV infection.

How to screen for HBV Screening should be done so that persons can be classified into the appropriate hepatitis B category and properly recommended to receive vaccination, counseling, and linkage to care and treatment. Screening should include testing for three HBV screening seromarkers: HBsAg. Antibody to HBsAg [anti-HBs]. Antibody to hepatitis B core antigen [anti-HBc])

HBV screening interpretation CDC offers an online training that covers the serology of hepatitis B and other types of viral hepatitis, available at  https://www.cdc.gov/hepatitis/resources/professionals/training/serology/training.htm Interpretation of Hepatitis B serologic test results PDF file https://www.cdc.gov/hepatitis/hbv/pdfs/serologicchartv8.pdf

HBV screening interpretation HBsAG Anti-HBs HBeAg Anti-HBe Anti-HBc Acute HBV + IgM Window Chronic HBV High infectivity IgG Chronic HBV low infectivity Recovery Immunized First Aid for the USMLE step 1, 2017 edition

HBV screening The following persons should be screened for three HBV sero-markers ([HBsAg], [anti-HBs], and [anti-HBc]) : Persons born in countries with 2% or higher HBV prevalence. Persons who inject drugs. HIV-positive persons. Household and sexual contacts of HBV-infected persons. Homosexual men. Persons requiring immunosuppressive therapy. Persons with end-stage renal disease (including hemodialysis patients). Blood and tissue donors. Persons infected with hepatitis C. Persons with elevated alanine aminotransferase levels (>19 IU/L for women and >30 IU/L for men). Incarcerated persons. Pregnant women (HBsAg only is recommended) Infants born to HBV-infected mothers (HBsAg and anti-HBs are only recommended)

Occupational health and vaccination Employee health care personnel. At time of hire, Healthcare Providers potential for exposure should be determined and their vaccination status assessed. Post vaccination screening is advised for personnel at ongoing risk for blood exposure to determine the response Non-employee health care personnel.

CDC recommended Vaccines for Healthcare Workers If you don’t have documented evidence of a complete HBV vaccine series, or if you don’t have an up-to-date blood test that shows you are immune to hepatitis B (i.e., no serologic evidence of immunity or prior vaccination) then you should get the 3-dose series (dose #1 now, #2 in 1 month, #3 approximately 5 months after #2). Get anti-HBs serologic tested 1–2 months after dose #3 For more information about the Hepatitis B vaccination https://www.cdc.gov/vaccines/vpd/hepb/index.html#vacc

Vaccines Single-antigen hepatitis B vaccines ENGERIX-B® RECOMBIVAX HB® HEPLISAV-B™ Combination vaccines PEDIARIX®: Combined hepatitis B, diphtheria, tetanus, acellular pertussis (DTaP), and inactivated poliovirus (IPV) vaccine. Cannot be administered before age 6 weeks or after age 7 years. TWINRIX®: Combined Hepatitis A and hepatitis B vaccine. Recommended for persons aged ≥18 years who are at increased risk for both Hepatitis A virus and HBV infections.

Management of exposure https://www.cdc.gov/MMWR/preview/mmwrhtml/rr5011a1.htm

Management of exposure

Management of exposure

Management of exposure

Discussion

References https://www.who.int/features/qa/76/en/ [1] https://www.who.int/en/news-room/fact-sheets/detail/hepatitis-b [2] CDC. Viral Hepatitis Surveillance–United States, 2016. 2018. [3] Abara WE, Qaseem A, Schillie S, McMahon BJ, Harris AM, High Value Care Task Force of the American College of P, et al. Hepatitis B Vaccination, Screening, and Linkage to Care: Best Practice Advice From the American College of Physicians and the Centers for Disease Control and Prevention. Ann Intern Med. 2017;167(11):794-804. [4] APIC text of infection Control and Epidemiology, Volume III, chapters 97,100,101,103