Executive Summary: Primary Care Management of Hepatitis B – Quick Reference (HBV-QR)

The Public Health Agency of Canada’s Centre for Communicable Diseases and Infection Control developed the Quick Reference with input from a working group consisting of hepatologists, laboratory specialists, public health practitioners, and primary care physicians having expertise in HBV, HIV and related co-infections.

The HBV-QR is a concise clinical resource to guide primary care and public health practitioners making day-to-day decisions related to the prevention, screening and management of HBV in patients at risk for or infected with hepatitis B.

The document is intended to provide information to public health and clinical professionals and does not supersede any provincial/territorial legislative, regulatory, policy and practice requirements or professional guidelines that govern the practice of health professionals in their respective jurisdictions, whose recommendations may differ due to local epidemiology or context. The content of the Quick Reference is divided into the following modules:

Module 1: Who Should Be Tested for HBV?

• Provides a checklist of risk factors for acute and chronic infection and indications for screening and testing.

Module 2: Approach to HBV Screening and Testing

• Explains the significance of the serological markers of HBV; provides guidance on the approach to test selection; and highlights that the choice of tests should be based on patient history and clinical presentation.

Module 3: Interpretation of HBV Diagnostic Test Results

• Provides guidance in a table format for interpretation of HBV serologic test results (i.e., HBsAg, anti-HBs,anti-HBc, and anti-HBc IgM) and recommended  actions.

Module 4: Initial Management of Patients with HBsAg-Positive Results

• Is an algorithm which highlights the interface between primary care and public health once a positive HBsAg result is detected and reported by the laboratory. The wording of the algorithm reflects the reality that in most cases, public health will initiate follow up directly with the diagnosing healthcare provider as a result of having received a positive report directly from the laboratory. However, this does not remove the responsibility on the part of the practitioner to report hepatitis B to public health where it is a legislated responsibility.

Module 5: Natural History and Management of Acute HBV

• Describes the incubation period, signs and symptoms, and clinical course of infection for acute hepatitis B. It outlines baseline laboratory testing and lists indications for repeat testing to confirm/rule out chronic infection. It also lists indications for urgent referral to a specialist for patients with a severe presentation.

Module 6: Initial Evaluation of Confirmed Chronic HBV

• Provides guidance on baseline clinical evaluation and initial laboratory/imaging evaluation of patients with confirmed chronic infection, and lists indications for urgent referral to a specialist.

Module 7: Natural History of Chronic HBV

• Describes the phases of chronic HBV and the associated serological markers (i.e., HBeAg, HBV DNA, ALT), and explains their relationship to liver inflammation, histological activity, degree of fibrosis and the risk for progression to cirrhosis and hepatocellular carcinoma (HCC). 

Module 8: Long-Term Management of Confirmed Chronic HBV

• Outlines the recommended frequency of serological and histological monitoring, with the goal being to prevent progression to cirrhosis, HCC and liver decompensation. Provides a table of suggested follow-up by phase of infection as determined by serological and histological findings.

Module 9: Treatment of Chronic HBV and Monitoring of Patients on Treatment

• Lists the currently approved treatment options for chronic HBV in Canada. Provides general information on the decision to treat, treatment initiation and the duration of therapy. It also provides guidance for ongoing monitoring of patients on treatment and indications for follow-up with a specialist. For in-depth information on the selection of patients for treatment and treatment options/regimens, practitioners are referred to the Management of Chronic Hepatitis B: Canadian Association for the Study of the Liver Consensus Guidelines 2012.

Module 10: Prevention and Vaccination Checklist

• Summarizes the eligibility criteria for publically funded HBV vaccine programs in Canada. It includes a checklist which prompts practitioners to discuss and offer vaccine to patients where appropriate. For pregnant women who are HBsAg positive, it highlights the importance of referring to a specialist before the third trimester of pregnancy; it also discusses the appropriate timing of, and indication for, initiation of treatment in order to prevent vertical transmission. It provides guidance on when treatment can be discontinued postpartum; however, it should be noted that the discontinuation of treatment is only applicable if the mother does not require ongoing therapy for hepatitis B.

Module 11: Patient Education and Counselling

• Provides practitioners with guidance on counselling for all patients to reduce the risk of transmission, and specific advice for pregnant women and patients with acute HBV. It also provides general guidance to help patients with chronic HBV reduce their risk of liver damage and specific advice for patients with cirrhosis.  It should be noted that for patients with cirrhosis, acetaminophen can be taken in reduced doses as prescribed by a healthcare provider.

To obtain an electronic copy of the HBV-QR, please send an e-mail request to the Centre for Communicable Diseases and Infection Control of the Public Health Agency of Canada at the following address: ccdic-clmti@phac-aspc.gc.ca