What is the recommended prevention and treatment for Hepatitis B in adults?

Hepatitis B Prevention and Treatment in Adults

All adults aged 19-59 years should receive hepatitis B vaccination regardless of risk factors, and adults aged ≥60 years with risk factors should be vaccinated as well. 1

Prevention Recommendations

Universal Adult Vaccination

• The Advisory Committee on Immunization Practices (ACIP) recommends universal hepatitis B vaccination for:
  • All adults aged 19-59 years without prior vaccination 1
  • Adults aged ≥60 years with risk factors for HBV infection 1
  • Adults aged ≥60 years without known risk factors may receive HBV vaccines 1

High-Risk Groups Requiring Vaccination

Adults with the following risk factors should be prioritized for vaccination:

1. Sexual exposure risks:

   • Sex partners of HBsAg-positive persons
   • Sexually active persons not in long-term monogamous relationships
   • Persons seeking evaluation/treatment for STIs
   • Men who have sex with men 1

2. Blood exposure risks:

   • Current or recent injection drug users
   • Household contacts of HBsAg-positive persons
   • Healthcare and public safety workers with blood exposure risk
   • Persons on hemodialysis or predialysis 1

3. Medical conditions:

   • Persons with diabetes (especially <60 years)
   • Persons with HIV infection
   • Persons with chronic liver disease (cirrhosis, fatty liver disease, etc.)
   • Persons with hepatitis C infection 1

4. Other high-risk groups:

   • International travelers to regions with HBV prevalence ≥2%
   • Incarcerated persons
   • Residents and staff of facilities for developmentally disabled 1

Implementation Strategies

• In settings with high proportion of at-risk individuals (STD clinics, HIV testing centers, drug treatment programs, correctional facilities), universal vaccination should be offered to all adults who haven't completed the series 1
• In primary care settings, implement standing orders to identify adults recommended for vaccination 1
• Vaccination should be provided without requiring acknowledgment of specific risk factors 1

Vaccination Schedule and Administration

• Standard adult vaccination consists of a 3-dose series (0,1, and 6 months) 1
• Alternative schedules may be used to improve completion rates 1
• No need for revaccination in persons who have documented completion of the vaccine series 1

Treatment for Chronic Hepatitis B

For adults diagnosed with chronic hepatitis B infection:

1. First-line treatment options:

   • Entecavir: 0.5 mg once daily for nucleoside-naïve patients; 1 mg once daily for lamivudine-resistant patients 2, 3
   • Tenofovir: Standard adult dosing 4, 3
   • Pegylated interferon alfa-2a: For selected patients 3

2. Dosage adjustments:

   • For patients with renal impairment, adjust dosing based on creatinine clearance:
     • For entecavir: Reduce frequency to every 48-72 hours when creatinine clearance <50 mL/min 2
     • For tenofovir: Monitor renal function closely 4

3. Treatment considerations:

   • Administer entecavir on an empty stomach (at least 2 hours after a meal and 2 hours before the next meal) 2
   • Monitor for hepatic flares, especially in the first 4-8 weeks of treatment 4
   • The optimal duration of treatment is unknown, but long-term therapy is often required 2

Special Considerations

Pregnant Women

• Screen all pregnant women for HBsAg during early prenatal care 5
• Vaccinate pregnant women at risk for HBV infection 1
• For HBsAg-positive pregnant women, test HBV DNA levels to guide antiviral therapy decisions 5
• Consider antiviral therapy when maternal HBV DNA >200,000 IU/mL to prevent perinatal transmission 5

Common Pitfalls to Avoid

1. Missed vaccination opportunities:

   • Don't wait for patients to request vaccination; proactively offer it 1
   • Don't require patients to disclose specific risk factors before offering vaccination 1

2. Inadequate screening:

   • Studies show that high-risk patients are often not adequately screened or vaccinated 6
   • Patients with diabetes, HIV, and certain age groups are less likely to be vaccinated despite recommendations 6

3. Treatment monitoring failures:

   • Failure to monitor liver enzymes and HBV DNA levels in treated patients 3
   • Not screening for hepatocellular carcinoma in patients with chronic hepatitis B 3

By implementing universal adult vaccination through age 59 years and risk-based vaccination for those 60 and older, healthcare providers can significantly reduce the burden of hepatitis B infection and its complications, including chronic liver disease and hepatocellular carcinoma.