New HBV diagnosis - what now?
Having made a new diagnosis of HBV infection, there are several steps to cover with your patient. These will typically require a number of steps to cover adequately. These steps include:
Notification to the health department (if applicable in your jurisdiction)
Further investigations required for all patients with chronic hepatitis B
Discussion of testing and vaccination of contacts
Vaccination against hepatitis A (in susceptible patients)
Decision - do I need to refer my patient to a specialist?
Counselling of patient (and ideally partner/family)
This should be done in the patients preferred language, ideally using a professional interpreter whenever possible.
Aspects to cover include:
Natural history, modes of transmission (and how transmission does not occur), and risk reduction
The availability of effective treatments, which are funded by the PBS
The need for regular long-term (often lifelong) monitoring - at least annually
Alcohol minimisation, smoking cessation, weight management, IDU harm reduction as appropriate
Adequate time to answer questions - consider arranging an extended consultation in the near future
Offer written and online resources that are linguistically appropriate
Notification requirements for clinicians vary depending on your jurisdiction and whether the case of HBV is acute or chronic: see your State or Territory here for details.
Notification of acute and chronic HBV by is required by laboratories in all States and Territories.
|Test||Why the result is important|
|HBeAg / Anti-HBe serology, HBV DNA viral load||Identify phase, prognosis, and treatment need|
|HAV, HCV, HDV, and HIV serology||Co-infection, need for vaccination (HAV)|
|LFTs||Inflammatory activity, synthetic function|
|FBE||Low platelets could suggest cirrhosis|
|Clotting studies||Help establish synthetic function|
|α-foetoprotein||Screening for HCC|
|Abdominal ultrasound incl. portal venous doppler||Cirrhosis, portal hypertension and HCC|
Testing and vaccination of contacts
This is an important aspect of looking after the patient and the community.
Certainly it can be difficult - especially if the contacts do not usually attend your practice. Recent evidence suggests less than a third of adult contacts of people notified with chronic hepatitis B are vaccinated.
If the contacts are not seen in your practice, or you are otherwise concerned about confidentiality and privacy, then this website provides a letter which you can download, fill in your practice's details, then give to the patient to give to their contacts.
In most states and territories, vaccination is available free of charge for household and sexual contacts of people with hepatitis B. See the Notification and immuisation page for more information on eligibility and ordering the vaccine.
Which patients need to be referred to a specialist?
This question is difficult to answer generically. Like with any subspecialty topic, some GPs are very experienced, and others less so.
Aspects to consider when considering this question include:
Could this patient require treatment? especially if the patient has an elevated HBV DNA viral load AND elevated ALT
Could this patient require a biopsy for staging?
Is there any evidence of advanced liver disease, either clinically or on test results?
Does this patient require hepatocellular carcinoma (HCC) surveillance?
Are there any co-morbidities or complexities in this case? (co-infection, pregnancy, immune compromise)
Unless confident with these issues, consider referring ANY newly diagnosed patient to a hepatitis specialist for initial assessment, consideration of therapy, and determination of a management / monitoring plan.