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:

Counselling

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

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.

Further investigations

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.