Hepatitis B & C

Basics
Hepatitis B Hepatitis C
• 6.2% prevalence among 15-84 year • 0.8% worldwide Chronic Hep C, 0.3%
olds; endemic in Hong Kong viremic Hep C in Hong Kong
• Up to 25% of HBsAg carriers may • 70% Hepatitis C infections become
eventually die of chronic liver diseases, chronic
principally hepatocellular carcinoma o Incubation 6-9wk, acute
and cirrhosis – CHP 2014 infection majority
• HCC lifetime risk: M 27% F 8% asymptomatic
• HCC lifetime risk: M 24% F 17%

Hepatitis B Serology Interpretation

Result interpretation Acute Chronic Cleared Vaccine

Anti-HBc IgM + - - -

Anti-HBc (IgG) + + + -

HBsAg + + - -

Anti-HBs - - + +

HBeAg + (6/52) +/- - -

*replicating & infective

Anti-HBe - +/- +/- -

*E seroconversion

HBVDNA High / Low Low / High - -

DDx of Anti-HBc (IgG) +ve:

1. False positive
2. Mutant HBsAg
3. Occult Hep B
4. Active but clearing
5. Cleared but lost anti-HBs
6. Congenital
Serum biomarkers
Objective: predict cirrhosis by blood test

APRI: AST to Platelet Ratio Index

𝑨𝑺𝑻(𝑈⁄𝐿 )
( )
𝑈𝑝𝑝𝑒𝑟 𝑙𝑖𝑚𝑖𝑡 𝑜𝑓 𝑛𝑜𝑟𝑚𝑎𝑙 (𝑈⁄𝐿 )
𝐴𝑃𝑅𝐼 = × 100
𝑷𝒍𝒂𝒕𝒆𝒍𝒆𝒕 𝐶𝑜𝑢𝑛𝑡 (109 ⁄𝐿)

APRI ≤0.3: Unlikely cirrhosis or significant fibrosis

APRI >0.3 and ≤0.5: Unlikely cirrhosis, significant fibrosis possible
APRI >0.5 and ≤1.5: Significant fibrosis or cirrhosis possible
APRI >1.5 and ≤2: Likely significant fibrosis, cirrhosis possible
APRI >2: Likely cirrhosis

• Validated for Dx of significant fibrosis and cirrhosis

o Study for Hep C: APRI cutoff 1.0 is 76% sensitive and 72% specific for cirrhosis
• WHO recommended APRI for non-invasive cirrhosis test in resource-limited settings
• Arrange Fibroscan for APRI ≥ 1 and repeat Q3 years
• Refer specialist for advanced fibrosis (liver stiffness >9 kPa)

FIB-4 Index
(𝑨𝒈𝒆 𝑖𝑛 𝑦𝑒𝑎𝑟𝑠) × (𝑨𝑺𝑻(𝑈⁄𝐿))
𝐹𝐼𝐵 − 4 =
𝑷𝒍𝒂𝒕𝒆𝒍𝒆𝒕 𝑐𝑜𝑢𝑛𝑡 (109 ⁄𝐿) × √𝑨𝑳𝑻(𝑈⁄𝐿)

< 1.45: Cirrhosis less likely

≥ 1.45 and ≤ 3.25: Indeterminate
>3.25: Cirrhosis more likely

• Good accuracy for advanced fibrosis in HCV and fatty liver

• Associated with HCC risk in alcohol users: FIB-4 ≥ 1.75 had increased HCC risk
• DH guideline elaborates on APRI only; “FIB-4 is an alternative non-invasive test to assess liver
fibrosis”

Fibroscan: Transient elastography

- Transient elastography: vibration → shear waves → USG measurement
- 1 dimension USG, no morphologic examination
- kPA of liver stiffness: for diagnosis of F4 (cirrhosis) and distinguish from F0-1 from F2
- CAP: measurement of fat content independent of fibrosis
Public Health
Hepatitis B screening
• Screening for all pregnant persons * done in HK
• Screening at-risk individuals:
o HIV, HCV, Hx STD
o IVDU, MSM, multiple sexual partners, incarcerated
o ESRF
o Household and sexual contacts of HBV-infected persons
• Test: HBsAg, anti-HBs and anti-HBc

Hepatitis B Action Plan1

• Challenges: Lacking specialist access, large undiagnosed
population, diagnosis may not link to care, large case
load of chronic FU especially with antiviral
• WHO goals by 2030:
o 90% diagnosed
o 80% treated
o 90% reduction in incidence
o 65% reduction in mortality

1
AEC 2022 Viva
Action plan
• Awareness
o Update website
o Train OG and midwives
o Pamphlets for pregnant persons
o Add to HIV program: Hep B/C safe
injection and sex practices
o Standardize training materials on HCV
• Surveillance
o Survey + surveillance of hep B, C,
vaccination, and develop local indicators
• Prevention
o MTCT: antiviral use, referrals
o PVST: training, logistics, implement
• Treatment
o Develop resources to facilitate FM care of hep B
o Expand HCV antivirals
o Micro-elimination: dialysis patients with HCV, screen and treat in HIV
o Promote in IVDU

Hepatitis C At-risk Populations

• Injecting drug users
o > 70% Hep C +ve found in IVDU in 2009-2018 HK study
o Globally 60% of injected drug users have current or past Hep C
• MSM
• Recipients of potentially contaminated blood products *not screened pre-1991
• Patients on renal dialysis: 1-2% in HK
• Children born to mothers infected with HCV (Vertical transmission: 4-8%)
• HIV+ patients: reported 6.2% HCV+ worldwise
• Prisoners
• People who have had tattoos or piercings

Hepatitis C Action Plan

• Screening: Prevalence low, for risk-based case finding
o HIV, dialysis
o Piloting in prisoners: 1/2024 HKU study
o Still planning: IVDU – maybe through methadone clinic
• Micro-elimination of Hep C: Dialysis and HIV+ (started)
Exam Approach
Hepatitis B Hepatitis C
Hx • Hepatitis / biliary obstruction symptoms
o Malaise, fatigue (*often in Hep C)
o Decreased appetite, weight loss
o RUQ pain
o Cholestasis: Jaundice, tea colored urine / clay colored stool, pruritis
• Symptoms of chronic liver disease/ bleeding tendency
o Complications: Abdominal distension, LL edema, haematemesis, bleeding
tendency
o Stigmata of liver disease: Spider naevi, breast enlargement, testicular atrophy
o Loss of libido
• Risk factors for hepatitis B/C
o Family history of viral hepatitis
o Immunization history
o Blood transfusion
o Tattooing/ body piercing
o Sharing needles/ sharps
o Unprotected sex
o Prostitution/ MSM
• Other non-viral causes of hepatitis / dLFT
o Alcohol
o OTC medicines/TCM/Herbs/Supplements
o History autoimmune problem
o Weight and exercise (fatty)
• Lifestyle affecting liver health and CA risk
o Diet
o Exercise
o Smoking
• Contacts: current and past sexual and blood/needles contacts

• Hep B Ig given at birth • Risk: Chemsex (use of psychotropic

substance in sex context by MSM)
• Sx: Fatigue *often in HCV, otherwise
most asymptomatic
PE • General: BP/P/T/BW
• Abdominal exam
• Stigmata of chronic liver disease
 Ix • Hepatitis serology • Screen: anti-HCV (Present/past Hep C)
• HBVDNA • Confirmatory: HCV RNA (current)
• Genotype
• For concurrent infections: HIV 1/2 Ab, other STDs
• For complications (cirrhosis, HCC, liver failure)
o CBC LFT AST, INR/ APTT, AFP
o USG liver
o Fibroscan
• Protect liver:
o Healthy weight, diet (avoid fatty liver)
o Quit smoking
o Avoid drinking, unknown med/ supplements/ herbs, uncooked seafood
o Hepatitis A vaccination
• Protect others:
General

o Household and sexual contacts testing and vaccination

o Barrier contraception
o No sharing of toothbrush / razors / needles or lancets, avoid blood contact,
cover wounds and clean blood spills with bleach
o No donation of blood, organs or sperm
• Hepatitis B Vaccination
• No Hepatitis C immunity; continue
avoid risk behaviours after cure
Indications for Entecavir2: Treatment:
1. Any DNA level + advanced fibrosis (> • 2018 updated to recommend Direct
9kpa) / cirrhosis / HCC / Acting Antivirals
decompensated liver failure • Duration 8-12/52
2. DNA > 2000 IU/mL + elevated ALT • >90% HCV is curable
(M >35 F >25) • Aim SVR: HCV RNA -ve in 12/52 after
Less often in FM setting: treatment
3. Patients on anti- Drugs: pan-genotypic regimens are first-line
Antiviral

cancer/immunosuppressive therapy • Protease inhibitors / Nucleotide and

with risk of hep B reactivation non-nucleotide polymerase
(HBsAg + / Anti-HBc + ) inhibitors / NS5A inhibitors
4. Transplant patients with hepatitis B • Examples: Daclatasvir, Epclusa,
infection Vosevi, Maviret
5. Pregnant women with HBV DNA > • Interest: cheapest $600/day, ie
200,000 IU/ml (start at week 24-28 50,400 for 1 course, probably
of gestation and continue for up to cheaper than repeated TACE for HCC
12 weeks after delivery) or sorafenib

2
2022 OSCE Viva
 Indications for Referral: Refer Hepatologist for antiviral
• Co-infection with HIV or HCV
• Pregnant women requiring antiviral
• Immunosuppressive therapy
• Concurrent liver conditions:
autoimmune hepatitis, primary
biliary cholangitis (Fatty liver with
stable LFT and no significant fibrosis
can Mx in FM)
Referral

• Complications from hepatitis B

• Unexplained dLFT ALT >2ULN (ie on
antiviral or despite low HBVDNA)
• Acute hepatitis or acute on chronic
liver failure (ALT >5ULN, hepatic
encephalopathy, jaundice, raised
INR)
• Virological breakthrough on antiviral
treatment
• Abnormal AFP despite ALT N and
liver imaging N
RACGP:
CBC LRFT INR baseline,
LFT +HCVDNA at 12/52 – probably at SOPD
Monitoring

If already developed advanced fibrosis or

cirrhosis, monitoring for HCC/cirrhosis/Cx is
Transient elastography if APRI >1
same as Hep B
USG HCC surveillance for:
• Cirrhosis
• >40y/M or >50y/F
• FHx HCC
Post-exposure Prophylaxis: Hepatitis B
(CHP 1/2014)
• Occupational exposure risk of Hep B infection: 18-30% depending on details
• Hollow-bored, blood-filled needles from a patient positive with HBeAg: 37-62%
• Hep C from needle-stick: 1.8% (range 0-7, greater if source HCV RNA positive)

Management of Hep B exposure:

(Management of NSI: as per protocol)3
1. First Aid
2. Documentation and reporting, counselling
3. Risk assessment: Vaccination Hx and anti-HBs, Source Hx
4. Blood test: Hep B/C/HIV, ALT
5. Post-exposure prophylaxis

• Effectiveness: HBIG in infants born to HBsAg positive mothers decreases transmission from
92% to 54% at 1 year. → + multiple doses: 70-75% effective. → +Hep B vaccination course:
85-95% effective

3
OSCE 2022
Appendix
HK guideline chart
Full Guidance Link | Action Plan link
Exam
Hep B Hep C
- KCC Mock 2020 - NTW Mock 2023
- AEC 2004 Viva
- HCC bad news: AEC 2022
- 2022 OSCE* Viva (Criteria for anti-viral,
NSI protocol, Mx in NSI case w high
risk)
- AEC 2022 Viva
- KWC Mock 2020, 2013