Ordering and interpreting hepatitis B serology
BMJ 2014; 348 doi: https://doi.org/10.1136/bmj.g2522 (Published 17 April 2014) Cite this as: BMJ 2014;348:g2522
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RE: Ordering and interpreting hepatitis B serology
Syed Alam, Timothy J S Cross
Department of Hepatology, The Royal Liverpool Hospital, Prescot Street, Liverpool, L7 8XP, United Kingdom
To the Editor,
Davison and Strasser wrote a comprehensive review on the appropriate tests to order in patients with suspected chronic hepatitis B infection, and how to interpret those results, but two issues require further comment. The first relates to the identification of patients with chronic hepatitis delta infection. This is a diagnosis that often overlooked. In addition, the ability of the hepatitis delta virus to suppress replication of the hepatitis C virus, but more importantly the hepatitis B virus, can often lead clinicians into a false sense of security1,2. The delta virus can also mimic autoimmune hepatitis which could also potentially lead to the incorrect treatment being administered. In a study of 962 consecutive patients diagnosed with chronic hepatitis B infection in the viral hepatitis clinic in Kings college Hospital London, 8.5% of these patients were found to be co-infected with the hepatitis delta virus3. If primary care physicians are to have a greater role in the management of these patients this pitfall should be highlighted. The current NICE guideline in the UK requires testing for HDV in all HBV patients as part of initial assessment by primary care physicians before referral to the specialist care4.
The second point relates to surveillance for hepatocellular carcinoma. The issue of surveillance remains controversial due to the lack of well conducted randomized controlled trials demonstrating its benefits. Surveillance is recommended for patients with cirrhosis who would be fit enough receive treatment (EASL guidelines 2012). Presently, the delivery of surveillance in secondary care is patchy and poor. The guidelines on surveillance testing for HCC have different preferred approaches4,5,6. It may not be appropriate to place this burden on primary care physicians who are already being expected to pick up a greater proportion of work for other chronic conditions. Moreover, the role of surveillance in patients without cirrhosis has not yet been clearly defined particularly in population where the prevalence of chronic hepatitis B infection is low. A recent study has shown that significant volumes of hepatocellular carcinoma can occur in the absence of cirrhosis suggesting that this whole issue requires a new approach and necessitates the development of accurate and sensitive biomarkers that are readily available and less demanding on resources than 6-monthly liver ultrasound7.
References:
1. Hepatitis delta virus.
Hughes SA1, Wedemeyer H, Harrison PM.
Lancet. 2011 Jul 2;378(9785):73-85. doi: 10.1016/S0140-6736(10)61931-9. Epub 2011 Apr 20
2. Hepatitis delta: epidemiology, diagnosis and management 36 years after discovery.
Noureddin M1, Gish R.
Curr Gastroenterol Rep. 2014 Jan;16(1):365. doi: 10.1007/s11894-013-0365-x
3. The increasing prevalence of hepatitis delta virus (HDV) infection in South London.
Cross TJ, Rizzi P, Horner M, Jolly A, Hussain MJ, Smith HM, Vergani D, Harrison PM.
J Med Virol. 2008 Feb;80(2):277-82.
4. Guidance.nice.org.uk/cg165
5. EASL-EORTC clinical practice guidelines: management of hepatocellular carcinoma. J Hepatol. 2012; 56: 908–943
6. Lok, A.S. and McMahon, B.J. Chronic hepatitis B: update 2009. Hepatology. 2009; 50: 661–662
7. Hepatocellular cancer: the impact of obesity, type 2 diabetes and a multidisciplinary team.Jessica Dyson, Bryan Jaques, Dipankar Chattopadyhay, Rajiv Lochan, Janine Graham, Debasish Das, Tahira Aslam, Imran Patanwala, Sameer Gaggar, Michael Cole, et al.
J Hepatol. 2014 January; 60(1): 110–117. Published online 2013 August 23. doi: 10.1016/j.jhep.2013.08.011
Competing interests: No competing interests
Davison and Strasser emphasise the importance of interpreting the hepatitis B serology in clinical practice(1).
As Hepatitis B presents with various serological markers, the test requests may vary according to the indications. If the doctors in the primary care follow the guidelines, unnecessary investigations, referrals(1) and financial burdens can be avoided. These aspects are current public health issues, as liver-disease related deaths are rising year-over-year in the UK, whilst they are diminishing in other European countries(2). Alcoholism, obesity and chronic hepatitis are the leading contributors to chronic liver diseases(3).
In the UK, mandatory hepatitis B vaccination to new-borns, as a national vaccination strategy, should have been introduced long ago, however it hasn’t. As hepatitis B is vaccine preventable, by adopting appropriate and cost- effective immunization strategies, it is possible to minimize the sum spent on investigation and management of this disease. Furthermore, the increasing of HBV vaccination coverage among high risk groups and selected vaccination for households of HBsAg carriers and immigrants from high prevalence areas, could be an additional option to be considered.
1. Scott A Davison,Simone I Strasser Rational testing-Ordering and interpreting hepatitis B serology. BMJ 2014; 348 doi: http://dx.doi.org/10.1136/bmj.g2522 (Published 17 April 2014) Cite this as: BMJ 2014;348:g2522.
2.Department of Health. Chief medical officer publishes her first annual report. 2012. www.dh.gov.uk/health/2012/11/cmo/.
3 Facts about liver disease- British Liver Trust.www.britishlivertrust.org.uk/media-centre/facts-about-liver-disease
Competing interests: No competing interests
Prevalence of chronic hepatitis B in Canada
To the Editor,
The authors Davison and Strasser provide an excellent overview of the appropriate interpretation and use of hepatitis B virus (HBV) serology during clinical practice and management of hepatitis B infected individuals (1). Their summary included a map of HBV prevalence estimates throughout the world to guide recommended screening of those born in countries with a high or intermediate prevalence of chronic infection (Figure 1). I wish to correct an error shown in the Figure regarding the estimated prevalence of chronic hepatitis B infection in Canada. The figure shows an intermediate prevalence (2 to 7%) throughout the country; however, the prevalence of chronic hepatitis B infection in the Canadian-born population is estimated to be low (less than 1%; 2, 3). Canada has a large immigrant population (4), with the majority of new immigrants originating from countries having an intermediate or high prevalence of chronic hepatitis B infection (5, 6). Thus specific populations, such as the Canadian immigrant population or injection drug users (7), are expected to have a higher prevalence than the general population of Canada.
The misconception of intermediate prevalence within Canada may be due to most literature references describing an intermediate or high HBV prevalence throughout the northern regions of Canada, mainly comprising the territories of Nunavut and the Northwest Territories. The Inuit and First Nations populations of these regions have been reported to have HBV prevalence rates >2% (8), though these studies were primarily conducted before universal infant vaccination programmes were implemented in Nunavut and the Northwest Territories approximately 20 years ago. Studies are currently underway to characterize the current prevalence of chronic hepatitis B infection in Nunavut, and preliminary evidence indicates that the prevalence rate has dropped significantly due to a successful vaccination programme.
References:
1. Davison S, Strasser S. Ordering and interpreting hepatitis B serology. BMJ 2014;348:g2522.
2. Rotermann M, Langlois K, Andonov A, Trubnikov M. Seroprevalence of hepatitis B and C virus infections: Results from the 2007 to 2009 and 2009 to 2011 Canadian Health Measures Survey. Statistics Canada Health Reports; 2013. Catalogue no. 82-003-X. (http://www.statcan.gc.ca/pub/82-003-x/2013011/article/11876-eng.pdf).
3. Merrill RM, Hunter BD. Seroprevalence of markers for hepatitis B viral infection. Int J Infect Dis 2011;15(2):e78-e121.
4. Statistics Canada. Immigration and ethnocultural diversity in Canada: National Household Survey, 2011. Statistics Canada; 2013. Catalogue no. 99-010-X2011001. (http://www12.statcan.gc.ca/nhs-enm/2011/as-sa/99-010-x/99-010-x2011001-e...).
5. Wong WWL, Woo G, Heathcote EJ, Krahn M. Disease burden of chronic hepatitis B among immigrants in Canada. Can J Gastroenterol 2013;27(3):137-48.
6. Sherman M, Bilodeau M, Cooper C, Mackie D, Depew W, Villeneuve J, et al. Liver disease in Canada: A crisis in the making. Canadian Liver Foundation Report; March 2013. (http://www.liver.ca/files/PDF/Liver_Disease_Report_2013/CLF_LiverDisease...).
7. Panessa C, Hill WD, Giles E, Yu A, Yu CF, Harvard S, et al. Genotype D amongst injection drug users with acute hepatitis B virus infection in British Columbia. J Viral Hepatitis 2009;16:64-73.
8. Osiowy C, Simons B, Rempel JD. Distribution of viral hepatitis in indigenous populations of North America and the circumpolar Arctic. Antivir Ther 2013;18:467-73.
Competing interests: No competing interests