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Inactive Hepatitis B: Understanding and Management

Inactive Hepatitis B: Understanding and Management

Inactive hepatitis B is a clinical state of chronic HBV infection distinguished by a lack of active viral multiplication. For most people, the state of "inactive HBV infection" is not harmful to the liver in the manner of traditional chronic HBV infection. In many of them, liver enzyme levels and other indicators of liver inflammation are normal. However, HBeAg- results show that the virus is moderately replicating at low to measurable levels. Nevertheless, HBeAg is normal in some HBeAg- patients. These people might have developed anti-HBe after a period of early youth when they were hepatitis Beantigen-positive and hepatitis B antibody-positive. HBeAg+ chronic HBV infection normally progresses in phases. In the first, or "immune clearance" stage, measurable HBV DNA and means of liver damage, such as elevated liver enzyme levels and/or inflammation and scaring seen on the liver biopsy, are often present.

The population prevalence of inactive hepatitis B varies with the primary endemic region. In Asia, where HBV transmission is endemic, inactive hepatitis B forms a significant public health issue; for example, in a South Korean survey, the primary production of HBsAg in men was 4.64%, the primal creation of antibody to the HBcAg in men was 40.72%, and the overall incidence of chronic hepatitis B in men was 3.66%. In contrast, in the United States, where HBV transmission is non-endemic, inactive hepatitis B is a minor issue because the overall prevalence of antibodies against HBsAg in the United States is 5.6%, while the prevalence of antibodies to HBcAg is 25%. Inactive hepatitis B is also more common in men than in women and in older populations than in younger populations. The annual occurrence of reactivation in the United States for inactive hepatitis B, Asia, seems to represent the region of highest primary prevalence.

Monitoring is a crucial aspect of managing patients with inactive hepatitis B. As there is a risk of progression among a minority of patients, regular monitoring is important. It enables the clinician to identify worsening liver disease early and intervene to prevent further morbidity and mortality. Also, monitoring enables the identification of patients who could benefit from therapy. Moreover, this population is at risk of developing hepatocellular carcinoma, and monitoring allows for early identification of this condition. Furthermore, some patients could revert to normal hepatitis B e-antigen-positive and DNA-positive status.

Clinical Features and Diagnosis

Asymptomatic Nature of Inactive Hepatitis B

The fact that an individual is completely asymptomatic and shows no physical symptoms related to a health condition does not always mean that the condition is clinically less severe. Inactive hepatitis B infection serves as a perfect example of the same. 90% of the individuals with chronic hepatitis B do not have symptoms or the fact that they are infected, but they are at risk of liver damage, cirrhosis, and hepatocellular carcinoma. Therefore, total reliance on the presence or absence of physical symptoms to monitor hepatitis B is dangerous. Digital media and high-speed internet have made it possible for people to access vast resources online, and patients must be in a position to avoid confusion arising out of incorrect health-related information from the World Wide Web.

inactive hepatitis b understanding and management

Laboratory Tests for Diagnosis

Tests for HBV infection are either serological (looking for antigens or antibodies) or molecular (looking for DNA or DNA polymerase) in nature. It is important in the management of chronic hepatitis to quantify the level of viral replication and to identify genotype, given the emerging data on the relationship between genotype and severity of the disease. Analysis of a quantifiable marker, hepatitis B virus DNA (HBV DNA), is important in managing all chronic HBV infections, even if viral replication is below the level considered important in influencing the progression of the hepatic disease. A serum alanine aminotransferase (ALT) test should be carried out in parallel. Generally, this is a marker of hepatitis activity that will be elevated during the immune-active phase of the disease. However, some patients with chronic HBV have persistently normal ALT levels, and studies utilizing liver biopsy as the reference standard have determined that patients with this profile have experienced necroinflammation despite having normal serum ALT levels. If the ALT levels are persistently normal, the decision on clinical management should be based on a liver biopsy.

Management and Follow-up

Lifestyle Modifications and Prevention

Patients diagnosed with inactive hepatitis B should lead a healthy and active lifestyle. A balanced diet and weight management are essential to reduce strain on the liver and reduce the risk of developing HCC. Avoiding drugs and alcohol will also alleviate the burden on the liver and reduce the risk of developing complications. Regular moderate physical activity not only does wonders for the liver but also promotes overall good health. Modifiable lifestyle changes include dietary changes, weight reduction, tobacco cessation, and moderation of alcohol consumption. Despite lacking a proven hepatitis B vaccination efficacy in inactive carriers, patients should be appraised about the potential consequence of contracting acute hepatitis B from an infected source, paying particular attention before foreign travel, particularly to high endemicity areas.

Pharmacological Interventions

Antiviral strategies used for cases with symptomatic active HBV have been used in cases of chronic hepatitis B e antigen-seroconverted hepatitis B. Antiviral therapy (such as lamivudine, tenofovir, entecavir, adefovir, and telbivudine) aim to improve liver inflammation, resolve the consequences of prolonged liver inflammation, and reduce the risk (but not eliminate) the risk of developing hepatocellular carcinoma. There are four drugs for treating CHB that are licensed for use in the UK. These are interferon alfa2b, interferon alfa2a, pegylated interferon alfa2a and alfa2b and lamivudine.

Monitoring and Regular Follow-up

The HBV DNA and ALT levels are the markers that are commonly used, and they indicate viral replication and inflammation, respectively. The guidelines are more uniform in recommending monitoring of the HBV DNA levels almost every six months, but different guidelines vary in monitoring ALT levels. While the AASLD guidelines recommend monitoring the ALT levels for almost three to six months, the EASL guidelines recommend that the ALT levels be checked every six months, and the recommended guidelines by the APASL recommends that the ALT levels are tested every six to twelve months. All the guidelines recommend the assessments of the risks of HCC, and if required, biannual ultrasounds should be conducted to detect HCC. HCC should be strongly suspected in older patients, have a family history of HCC, and have a high HBV DNA load and abnormal ALT levels. Moreover, if the ALT levels are normal and the HBV DNA levels are high, then a liver biopsy is indicated. If cirrhosis is already present in the patient, then monitoring should be practiced more efficiently. If the patient is not properly monitored or if medical treatment is not given properly, then up to 40% of the patients will develop cirrhosis or decompensated liver disease within eight years.

Bibliography

  1. Koffas, A., Kumar, M., Gill, U. S., Jindal, A., Kennedy, P. T., & Sarin, S. K. (2021). Chronic hepatitis B: the demise of the 'inactive carrier'phase. Hepatology International, 15, 290-300. (https://link.springer.com/article/10.1007/s12072-021-10137-2)

  2. de Almeida Pondé, R. A. (2021). Dynamic profile of the HBeAg-anti-HBe system in acute and chronic hepatitis B virus infection: A clinical-laboratory approach. Molecular Biology Reports. (https://link.springer.com/article/10.1007/s11033-020-06056-4)

  3. Shi, Y. & Zheng, M. (2020). Hepatitis B virus persistence and reactivation. bmj. (https://scholar.archive.org/work/kdqy3ujxrngl5j2q2onn4ipf4e/access/wayback/https://www.bmj.com/content/bmj/370/bmj.m2200.full.pdf)

  4. Nguyen, M. H., Wong, G., Gane, E., Kao, J. H., & Dusheiko, G. (2020). Hepatitis B virus: advances in prevention, diagnosis, and therapy. Clinical microbiology reviews, 33(2), 10-1128. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7048015/)

  5. Philips, C. A., Ahamed, R., Abduljaleel, J. K., Rajesh, S., Augustine, P., Abduljaleel, J., & Rajesh, S. (2021). Critical updates on chronic hepatitis B virus infection in 2021. Cureus, 13(10). (https://www.cureus.com/articles/75478-critical-updates-on-chronic-hepatitis-b-virus-infection-in-2021.pdf)

  6. King, H., Xing, J., Dean, H. D., & Holtzman, D. (2020). Trends in prevalence of protective levels of hepatitis B surface antibody among adults aged 18--49 years with risk factors for hepatitis B virus infection---United States, 2003--2014. Clinical Infectious Diseases, 70(9), 1907-1915. (https://academic.oup.com/cid/article/70/9/1907/5522094)

  7. Roberts, H., Ly, K. N., Yin, S., Hughes, E., Teshale, E., & Jiles, R. (2021). Prevalence of HBV Infection, Vaccine‐Induced Immunity, and Susceptibility Among At‐Risk Populations: US Households, 2013‐2018. Hepatology, 74(5), 2353-2365. (https://www.researchgate.net/profile/Kathleen-Ly/publication/352202109_Prevalence_of_Hepatitis_B_Virus_HBV_Infection_Vaccine-Induced_Immunity_and_Susceptibility_among_At-Risk_Populations_US_Households_2013-2018/links/62fe4021ceb9764f7206b792/Prevalence-of-Hepatitis-B-Virus-HBV-Infection-Vaccine-Induced-Immunity-and-Susceptibility-among-At-Risk-Populations-US-Households-2013-2018.pdf)

  8. Spradling, P. R., Xing, J., Harris, A. M., & Ly, K. N. (2022). Estimated prevalence and number of persons with isolated antibody to hepatitis B core antigen and associated occult hepatitis B, United States, 2001--2018. The Journal of Infectious Diseases, 225(3), 465-469. (https://academic.oup.com/jid/article/225/3/465/6319558)

  9. Kuhns, M. C., Holzmayer, V., Anderson, M., McNamara, A. L., Sauleda, S., Mbanya, D., ... & Cloherty, G. A. (2021). Molecular and serological characterization of hepatitis B virus (HBV)-positive samples with very low or undetectable levels of HBV surface antigen. Viruses, 13(10), 2053. (https://www.mdpi.com/1999-4915/13/10/2053/pdf)

  10. de Almeida Pondé, R. A. (2022). ... the serological markers hepatitis B virus surface antigen (HBsAg) and hepatitis B core IgM antibody (anti‐HBcIgM) in the diagnosis of acute hepatitis B virus infection .... Microbiology and immunology. (https://onlinelibrary.wiley.com/doi/pdf/10.1111/1348-0421.12943)