Hepatitis B: new recommendations for clinicians

New recommendations for the management of hepatitis B in Australia have been released in a bid to improve awareness of chronic hepatitis B among clinicians and to increase detection of cases that currently remain undiagnosed.

The recommendations, published in the Medical Journal of Australia, provide guidance to clinicians for managing hepatitis B and recognising groups at increased risk of hepatitis B virus (HBV) infection, and describe appropriate and timely screening strategies.

The Gastroenterological Society of Australia (GESA) initiated the development of the new resource, and gastroenterology and infectious diseases physicians formulated it with input from primary care physicians and consumer representatives.

“[The statement] covers six main topics that include epidemiology, natural history, diagnosis and monitoring, treatment and complications, and specific subgroups, such as people with viral coinfection, immunosuppressed individuals, those with renal impairment and pregnant women, especially with regard to preventing vertical transmission,” wrote the authors, led by Associate Professor John Lubel, a gastroenterologist and hepatologist at Alfred Health and Monash University.

“The expected benefits of this consensus statement include a standardised approach to the management of hepatitis B across varied health care settings in Australia. At a community level, the benefits of producing locally relevant guidance are ultimately to improve the health care, experience and outcomes of people living with hepatitis B.”

In 2020 an estimated 222,559 people in Australia were living with chronic hepatitis B, representing 0.9% of the population. In Australia, 46.3% of people with chronic hepatitis B were born in the Asia–Pacific region, most frequently in China, Vietnam and the Philippines. Aboriginal and Torres Strait Islander peoples also have higher prevalence, representing 7% of people with chronic hepatitis B.

“Australia has committed to the National Hepatitis B Strategy goals, aiming to improve diagnosis, treatment and care and therefore reduce attributable mortality,” wrote Lubel and colleagues.

“We remain well short of reaching targets, with an estimated 27% of chronic hepatitis B cases remaining undiagnosed, 22.6% receiving care (target 50%) and just 10.7% of people being treated (target 20%).

At that rate, Australia will not reach the Strategy 2022 targets until 2045 for the proportion in care (target 50%) and 2046 for the proportion receiving treatment (target 20%).

“Although the threshold of ≥2% prevalence is the commonly accepted cut-off for HBV screening, there are cost-effectiveness data from similar settings to Australia (US and Netherlands) supporting the application of a threshold below Australia’s average prevalence of 0.9%,” wrote Lubel and colleagues.

“Consequently, many experts suggest universal screening could be extended to Australian adults (aged 20–79 years) in whom hepatitis B status has not been documented.

“In Australia, all clinicians need to recognise groups at increased risk of HBV infection and implement appropriate screening strategies,” Lubel and colleagues concluded.

“Once identified, monitoring and timely commencement of treatment significantly reduces complications of chronic hepatitis B.

“In addition, it is imperative that clinicians understand that in chronic hepatitis B, cirrhosis is not a prerequisite for development of hepatocellular carcinoma (HCC), and non-cirrhotic people with chronic hepatitis B require risk evaluation and, where appropriate, should be enrolled into a HCC surveillance program.”

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