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1. Training of Trainers on Clinical
Management of Viral Hepatitis

2. Learning objectives
At the end of this session, the learners shall understand the
following:
• Issues related to HBV management in special patient groups
• Recommended treatment strategies for such people
• Identify the appropriate treatment strategy for a given patient

3. Acute HBV infection
• Nearly all immunocompetent adults with acute HBV infection
have spontaneous recovery from illness and viral clearance
• Hence, no antiviral therapy needed for uncomplicated
symptomatic acute hepatitis B

4. Severe/ Fulminant Acute HBV infection
• A few patients with acute hepatitis B have
fulminant (acute liver failure) or severe acute hepatitis
• Such patients may benefit from short-term antiviral drugs
(entecavir or tenofovir)
• Duration of treatment in fulminant or severe acute HBV
– is not established till date
– Suggested:
• If HBsAg is lost: 3 months after appearance of anti-HBs
• If HBsAg persists: 12 months after appearance of anti-HBe

5. HBV/HIV co-infection: Outcomes
HIV co-infection results in
• More rapid progression to cirrhosis
• Higher risk for HCC
• Higher liver-related mortality
• Decreased treatment response ( faster decline of CD4, slower
CD4 recovery after ART)
 As compared to HBV monoinfection.

6. HBV/HIV co-infection: other considerations
• Cross-resistance between HIV and HBV drugs
• Increased risk of liver injury ( 17 TIMES )
– ART-related immune-reconstitution can lead to increased
hepatocyte killing >> worsening of liver injury
– Anti-HIV drugs can induce direct hepatotoxicity
• Severe liver injury may lead to fulminant hepatitis and death
Therefore important to consider suppression of HBV

7. HBV/HIV co-infection
• ART shall be started in all co-infected person, regardless of
CD4 count (irrespective of HBV infection)
• Choice of ART should be based on drugs that are active
against both HIV and HBV
– Tenofovir (TDF)
– Lamivudine (3TC)
– Emtricitabine (FTC)

8. HBV/HIV co-infection

9. HBV-HCV coinfection
• Indications for treatment of HBV infection in such patients are
similar to those for HBV mono-infection
• Treatment of HCV infection may lead to increased replication
of HBV
• If treatment is indicated for HBV infection, this should be
started and HBV suppression should be achieved before the
treatment for HCV is instituted

10. Children and adolescents
• Children with HBV infection
– Usually asymptomatic
– Mostly in immune-tolerant phase
• Treatment is not considered in this phase due to
– Low curative response rates
– Concerns about long-term safety
– Risk of drug resistance (immunotolerant -- very high viral load)
• Entecavir is approved for children above 2 years
• Tenofovir is approved for children above 12 years

11. Pregnant women
• Indications for treatment are identical to those for
non-pregnant women
• Tenofovir is recommended
• There is no recommendation on the routine use of antiviral
therapy to prevent mother-to-child HBV transmission
• Hepatitis B in a pregnant woman is not a reason for
considering termination of pregnancy. Similarly, the need for
caesarean delivery should be decided based on obstetric
indications, and not on the presence of HBV infection.

12. Pregnant women
• All infants should receive a birth dose of hepatitis B vaccine
followed by three doses
• Administration of hepatitis B vaccine to pregnant women with
HBV provides no benefit either to the mother or the baby.

13. Care of the baby
 Immunoprophylaxis of hepatitis B virus infection:
– Vaccination
Newborn baby should adminstered a timely first dose ( THE
BIRTH DOSE) of hepatitis B vaccine ( monovalent) as soon as
possible. Ideally within 24 HOURS.
‘THE SOONER THE BETTER’
Site : IM in the anterolateral aspect of mid thigh.
Dose : Birth dose f/b 3 doses ,0.5 ml, @ 6th 10th & 14th week.

14. Immunoglobulin (HBIg): Indicated when risk of transmission is
particularly high i.e.
– Babies born to mothers with HepB who also have detectable
HbeAg and have high viral load.
– Dose : 0.5 ml or 100 IU, IM
– Soon after birth ( within 12 to 24 hours )
 Limb other than the one in which HepB vaccine has been
administered.

15.  Breastfeeding : Mother having HepB may breastfeed her baby
unless there is
1. an exuding injury.
2. disease of nipple or surrounding skin.
 advantage far outweighs risk.
 Timing of testing: If felt that baby needs to be tested for
HepB, should be done only after one year of age.
 Difficult to interpret before this age and may resolves
spontaneously over time.

16. HBV WITH RENAL FAILURE
• Among the newer NA’s, Entecavir may be preferred, because
of high potency, high genetic barrier to resistance, and
favourable renal safety profile.
• All HBsAg- positive candidates should be treated with NA’s
before renal transplantation in order to maintain
undetectable HBV DNA, REDUCED LIVER FIBROSIS & prevent
HEPATIC DECOMPENSATION after renal transplantation.

17. HBV AND TB
• Interestingly first line drugs of Tuberculosis are hepatotoxic.
Recommended:
• Not more than 2 hepatotxic drug if CTP Score <7 in patients
with CLD or liver cirrhosis and stable liver function.
• Only one hepatotoxic drug in those with advanced liver
dysfunction (CTP 8-10).
• And no hepatotoxic drugs with CTP> 10.

18. THANK YOU…