What are the recommendations for hepatitis B (HBV) surveillance and management in high-risk patients, such as healthcare workers or individuals from endemic areas, including those with chronic hepatitis B infection?

Hepatitis B Surveillance in High-Risk Populations

All persons with chronic hepatitis B infection require lifelong monitoring with serial ALT and HBV DNA measurements every 3-6 months, combined with hepatocellular carcinoma (HCC) surveillance using ultrasound and alpha-fetoprotein (AFP) every 6 months in high-risk individuals. 1

Initial Evaluation of Chronic HBV Infection

Upon identifying chronic HBV infection, immediate referral to or consultation with a physician experienced in chronic liver disease management is essential, as 15-25% of chronically infected persons face premature death from cirrhosis or liver cancer. 1

The initial workup must include:

• Complete history focusing on: HIV/HCV coinfection risk factors, alcohol consumption patterns, family history of HBV infection and liver cancer, and for those from endemic areas, schistosomiasis exposure 1

• Laboratory assessment: Complete blood count, comprehensive liver panel, HBeAg, anti-HBe, quantitative HBV DNA, HIV testing, HCV antibody, HDV testing, and HAV antibody (if cost-effective based on local prevalence) 1

• Baseline HCC screening: AFP measurement and ultrasound for high-risk patients (Asian men >40 years, Asian women >50 years, any patient with cirrhosis, family history of HCC, Africans >20 years, or any carrier >40 years with elevated ALT and/or high HBV DNA) 1, 2

• Liver injury assessment: Serial ALT/AST measurements, with liver biopsy or noninvasive markers when initial labs suggest liver damage 1

Ongoing Surveillance Protocol

All chronic HBV patients require lifelong monitoring, even those with normal aminotransferase levels. 1 The surveillance intensity depends on disease activity, age, family history, and clinical status.

Routine Monitoring Components:

• ALT measurements: Every 3-6 months to detect disease progression 3
• HBV DNA levels: Periodic quantitative testing to assess viral replication 1, 3
• HBeAg/anti-HBe status: Serial monitoring to track disease phase 3

HCC Surveillance in High-Risk Patients:

Perform ultrasound plus AFP every 6 months in the following populations: 1, 2

• Asian men >40 years
• Asian women >50 years
• All patients with cirrhosis (any age)
• Patients with family history of HCC
• Africans >20 years
• Any carrier >40 years with persistent/intermittent ALT elevation and/or high HBV DNA

The combination of ultrasound and AFP provides superior detection compared to either modality alone, though ultrasound has higher sensitivity and should be the primary screening tool. 2

Healthcare Worker-Specific Considerations

HBV-infected healthcare workers must follow published guidelines and state regulations regarding workplace practices to reduce transmission risk. 1

For healthcare workers performing exposure-prone procedures, monitoring HBV DNA levels provides better assessment of infectivity than HBeAg status alone, as HBeAg-negative individuals can harbor high viral loads and remain infectious. 1 Recent guidelines recommend using quantitative HBV DNA thresholds rather than HBeAg status to determine practice restrictions. 1

Healthcare facilities should ensure that all at-risk workers are tested for HBV markers and vaccinated if susceptible, as approximately 25% of medical and dental students are born in high-endemicity countries. 1

Prevention Counseling for Infected Individuals

Infected persons must receive comprehensive counseling on transmission prevention: 1

• Ensure all household and sexual contacts are tested (HBsAg and anti-HBs) and vaccinated if seronegative 1
• Use barrier protection during sexual activity until partners complete vaccination and demonstrate immunity 1
• Cover cuts and skin lesions; clean blood spills with bleach solution 1
• Avoid sharing items that may contact blood (toothbrushes, razors, injection equipment) 1
• Refrain from donating blood, plasma, tissue, or semen 1

Pregnant women with HBsAg must inform providers so newborns receive hepatitis B immune globulin (HBIG) and vaccine immediately at birth, which is 95% effective in preventing perinatal transmission. 1

Liver Protection Measures

To minimize further liver damage, all HBsAg-positive persons should: 1

• Avoid or limit alcohol consumption (heavy use >20-30 g/day increases cirrhosis risk) 1
• Receive hepatitis A vaccination (2 doses, 6-18 months apart) if chronic liver disease is present 1
• Seek care from providers experienced in hepatitis B management 1

Screening High-Risk Populations

The following groups require testing for HBV infection: 1, 4

• Persons born in high/intermediate endemicity areas
• Men who have sex with men
• Current or former injection drug users
• Dialysis patients
• HIV-infected individuals
• Pregnant women
• Healthcare workers with occupational exposure
• Persons incarcerated or formerly incarcerated
• Persons with history of sexually transmitted infections or multiple sex partners
• Persons with history of HCV infection

Testing should include HBsAg and anti-HBs, with vaccination for seronegative individuals. 1 Anyone requesting HBV testing should receive it regardless of disclosed risk factors. 4

Critical Surveillance Pitfalls

Do not rely solely on AFP for HCC screening—ultrasound is superior and must be the primary modality. 2 Do not delay screening until symptoms develop—HCC surveillance must occur at regular 6-month intervals in high-risk patients. 2 Do not discontinue surveillance after successful viral suppression in cirrhotic patients—screening must continue indefinitely in those with cirrhosis. 2