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Editor's Note: One of the major liver-related challenges that clinicians will face now that hepatitis C is "on the run" is in improving the management of hepatitis B. Significant advances in the diagnosis and treatment of patients with this increasingly common and daunting disorder were presented at The 2015 Liver Meeting® -- the 66th annual meeting of the American Association for the Study of Liver Diseases (AASLD). Investigators highlighted the progress made in clarifying the remaining gaps and existing opportunities in managing patients with hepatitis B, including the development and implementation of simple, cost-effective, and valid screening and diagnostic methodologies, as well as increasing the availability of therapeutic options. Some of the key advances that emerged from the many outstanding presentations are highlighted herein to assist clinicians in ensuring optimal outcomes for their patients.

Who's At Risk?

The AASLD's release of new treatment guidelines and the Centers for Disease Control and Prevention's updating of their screening recommendations have focused our attention on case recognition and treatment of chronic hepatitis B.[1,2] At present, these recommendations include serologic testing for hepatitis B surface antigen (HBsAg) for the following at-risk groups: pregnant women, infants born to HBsAg-positive mothers, household contacts and sex partners of hepatitis B virus (HBV)-infected persons, men who have sex with men, injection-drug users, persons who are the source of blood or body fluid exposures that might warrant postexposure prophylaxis (eg, needle stick injury to a healthcare worker or sexual assault), and persons infected with HIV. Routine testing for HBsAg is also now recommended for an additional population—persons born in geographic regions with an HBsAg prevalence of ≥2%.[2] This presents challenges and opportunities in view of the shifting global demographics and large influxes of refugees into many countries.

HBV Infection in Refugee Migrants

Coppola and colleagues[3] screened for HBV infection in a cohort of over 1200 undocumented or refugee immigrants living in Naples, Italy. The median age of screened subjects was 32 years (range, 12-74 years); 52% arrived from sub-Saharan Africa, 18% from Eastern Europe, 13% from the Indo-Pakistan area, 7% from Northern Africa, and 10% from various other regions. Overall, 9.6% were HBsAg positive, 40% were HBsAg negative/anti-HBc positive, and 50% were seronegative for both. All positive subjects had been unaware of their serologic status. The highest HBsAg seroprevalence was found in migrants from sub-Saharan Africa (14%). Of the HBsAg-positive migrants, 67% were HBV-DNA positive; 14% harbored HBV genotype A, 3% genotype C, 15% genotype D, and 68% genotype E. According to established criteria, 73% were considered asymptomatic carriers, 22% had chronic hepatitis, 2% had cirrhosis, and 2% had cirrhosis plus hepatocellular carcinoma (HCC).

A logistic regression analysis identified the following factors as independently associated with HBV infection: male sex, sub-Saharan African origin, and a low level of education. In view of the high rate of HBsAg seroprevalence in the immigrants investigated, the investigators emphasized the need for broad HBV screening and educational programs, as well as enhanced HBV vaccination and treatment in migrant populations.

Perinatal Transmission of HBV

Because many adults with chronic HBV acquired their infection during the perinatal period, careful attention must be given to ensure proper administration of immunoprophylaxis with HBV vaccine and hepatitis B immune globulin (HBIG) to newborn infants if progress is to be made globally. In addition, given the approximately 10% rate of "breakthrough" HBV infection even after administration of vaccine and HBIG to infants born to highly viremic hepatitis B antigen (HBeAg)-positive mothers, enhanced postpartum surveillance is required.[4]


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