WHO publishes new guidelines on hepatitis B
The World Health Organization (WHO) has published new guidelines on the prevention, diagnosis, and treatment of hepatitis B virus (HBV) infection. The guidelines simplify and expand eligibility for treatment in order to overcome barriers to accessing testing and treatment.
The guidelines provide new and updated evidence-based recommendations on key priority topics from three previous guidelines, including:
Expanded eligibility for antiviral treatment and inclusion of adolescents
Expanded eligibility for antiviral prophylaxis among pregnant women to prevent mother-to-child transmission
Improving diagnostics through use of point-of-care assays and reflex testing and testing for hepatitis D coinfection
New recommendations on who to treat have been included. The WHO recommends initiating antiviral therapy in all adults (including pregnant women) and adolescents with:
Evidence of significant fibrosis or cirrhosis; or
Hepatitis B virus (HBV) DNA levels >2000 IU/mL and an alanine aminotransferase (ALT) level above the upper limit of normal; or
Presence of coinfections, family history of liver cancer or cirrhosis, immunosuppression, comorbidities, or extrahepatic manifestations; or
Persistently abnormal ALT levels (in the absence of access to an HBV DNA assay)
More than 250 million people live with chronic hepatitis B infection. Most of the global burden of disease is due to mother-to-child transmission at, or shortly after, birth.
Summary
Definition
History and exam
Key diagnostic factors
- high risk of exposure
Other diagnostic factors
- asymptomatic
- jaundice
- hepatomegaly
- ascites
- fever/chills
- malaise
- maculopapular or urticarial rash
- right upper quadrant pain
- fatigue
- nausea/vomiting
- arthralgia/arthritis
- palmar erythema
- spider angiomata
- splenomegaly
- asterixis
Risk factors
- perinatal exposure in an infant born to an HBV-infected mother
- high-risk sexual behaviors
- injection drug use
- male sex
- born in highly endemic region
- family history of HBV, hepatocellular carcinoma, and/or chronic liver disease
- infected with HIV
- infected with hepatitis C virus
- blood or blood product transfusion
- healthcare workers
- household contact with HBV infection
- history of incarceration
- hemodialysis
- solid organ transplantation
Diagnostic tests
1st tests to order
- hepatic panel
- CBC
- basic metabolic panel
- coagulation profile
- serum hepatitis B surface antigen
- serum antibody to hepatitis B surface antigen
- serum antibody to hepatitis B core antigen
- serum hepatitis B e antigen
- serum antibody to hepatitis B e antigen
- serum HBV DNA
Tests to consider
- abdominal ultrasound
- liver biopsy
- transient elastography
- serum liver fibrosis biomarkers
- aspartate aminotransferase-to-platelet ratio index (APRI)
- alpha-fetoprotein
- CT/MRI abdomen
- testing for hepatitis D coinfection
- testing for other coinfections
- drug resistance testing
- HBV genotype
Treatment algorithm
acute HBV infection
chronic HBV infection: adult nonpregnant without coinfection or cirrhosis
chronic HBV infection: adult nonpregnant with cirrhosis
chronic HBV infection: adult nonpregnant with HIV coinfection
chronic HBV infection: adult nonpregnant with hepatitis C coinfection
chronic HBV infection: adult nonpregnant with hepatitis D coinfection
chronic HBV infection: adult pregnant or breastfeeding
chronic HBV infection: children
Contributors
Authors
Jawad Ahmad, MD, FRCP, FAASLD
Professor of Medicine
Division of Liver Diseases
Mount Sinai Hospital
New York
NY
Disclosures
JA declares that he has no competing interests.
Acknowledgements
Dr Jawad Ahmad would like to gratefully acknowledge Dr Sateesh R. Prakash, Dr Siddarth Verma, Dr Smruti R. Mohanty, and Dr Jared Hossack, previous contributors to this topic.
Disclosures
SRP, SV, and JH declare that they have no competing interests. SRM serves as a speaker bureau for Bristol-Myers Squibb regarding the use of entecavir for the treatment of chronic hepatitis B.
Peer reviewers
George Y. Wu, MD, PhD
Chief
Hepatology Section
Department of Medicine
University of Connecticut Health Center
Farmington
CT
Disclosures
GYW is on the medical advisory boards of Gilead Sciences and Bristol-Myers Squibb.
Lucieni Oliveira Conterno, MD, PhD
Director
Clinical Epidemiology Unit
Marilia Medical School
Sao Paulo
Brazil
Disclosures
LOC declares that she has no competing interests.
Mamun-Al-Mahtab, MB BS, MSc, MD
Chairman
Bangladesh Primary Care Research Network
Dhaka
Bangladesh
Disclosures
MAM declares that he has no competing interests.
Differentials
- Hepatitis A
- Hepatitis C
- Hepatitis D
More DifferentialsGuidelines
- Guidelines for the prevention, diagnosis, care and treatment for people with chronic hepatitis B infection
- Treatment of chronic hepatitis B
More GuidelinesPatient information
Hepatitis B: should I have the vaccine?
More Patient information
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