Chronic hepatitis B is a common and prevalent disease in China, and the whole society is highly concerned about it. Recently, the Chinese Medical Association Hepatology Branch and Infectious Diseases Branch has updated the guidelines for the prevention and treatment of chronic hepatitis B (2010), so we would like to take this opportunity to talk to our patients about the prevention and treatment of chronic hepatitis B.
I. Hepatitis B vaccination
Vaccination against hepatitis B is the most effective way to prevent HBV infection. China’s hepatitis B immunization program has achieved significant results. The surface carriage rate of hepatitis B in the general population has been reduced from about 10% to about 7%, and HBsAg in children under 5 years old is less than 1%. People who are negative for hepatitis B surface antibody and are not infected with hepatitis B can be vaccinated, with emphasis on newborns, infants, adolescents and high-risk groups such as medical personnel, frequent recipients of blood transfusions or blood products, family members of HBsAg-positive people, men who have sex with men or multiple partners, and people who inject drugs intravenously.
Three doses of hepatitis B vaccine are required for the entire course, according to the 0, 1, and 6 month schedule, i.e., the first dose is followed by the second and third doses at 1 and 6 month intervals, each at a dose of 10 micrograms of vaccine, or 20 micrograms for adults. Non-responders can receive 3 additional doses, and if still non-responders can receive one 60-microgram dose of recombinant yeast hepatitis B vaccine.
The protective effect of hepatitis B vaccination for those with antibody responses generally lasts for at least 12 years. Therefore, hepatitis B antibody monitoring or booster immunization is not required for the general population. However, for high-risk groups, hepatitis B antibodies can be monitored, and if the antibody titer is <10 mIU/mL, a booster immunization can be given.
Hepatitis B transmission route and interruption
HBV is a blood-borne disease, mainly transmitted through blood (such as unsafe injection), mother-to-child and sexual contact. There are many hidden blood exposure routes in life, such as medical injections and invasive medical treatment operations, foot trimming, tattoos, earring holes, sharing razors and toothbrushes, etc., which may lead to HBV transmission. Mother-to-child transmission occurs mainly during the perinatal (labor) period, mostly from exposure to the blood and body fluids of HBV-positive mothers during delivery. Unprotected sexual contact with HBV-positive people, especially those who have multiple sexual partners, have an increased risk of HBV infection.
Epidemiological and experimental studies have not found that HBV can be transmitted by blood-sucking insects (mosquitoes, bedbugs, etc.).
The prevention of hepatitis B transmission, in addition to vaccination, but also pay attention to the blockage of the transmission route.
1. Reduce hidden blood exposure.
2, do not share needles, razors and dental equipment.
3, correct sexual behavior. Use condoms to prevent hepatitis B and other blood-borne or sexually transmitted diseases when the health status of the sexual partner is unknown.
3. Newborns of HBsAg positive mothers should be injected with hepatitis B immunoglobulin (HBIG) at a dose of ≥100 IU as early as possible within 24 h after birth (preferably within 12 h of birth), and hepatitis B vaccine should be administered at different sites according to the 0, 1 and 6 month protocol.
Regarding whether hepatitis B mothers can breastfeed, the guidelines state that newborns can receive breastfeeding from hepatitis B surface antigen-positive mothers after hepatitis B immune globulin and hepatitis B vaccine are administered within 12 hours of birth. However, it should be noted that the level of evidence is low and further research is needed.
III. Treatment of chronic hepatitis B
The treatment of hepatitis B has made great progress in the last decade or so. By using a combination of antiviral-based therapies, it is now possible to control and delay the progression of hepatitis B disease and significantly improve the prognosis of the disease and the patient’s quality of life.
Antiviral drugs include interferon and nucleoside analogs. The former includes regular interferon, which is administered every other day, and long-acting interferon, which is administered once a week. The latter include lamivudine, adefovir, entecavir, tipifovir, and tenofovir. In comparison, interferon has a shorter duration of treatment (1 year) and longer-lasting effects after achieving efficacy, but the side effects are greater and the overall efficiency needs to be improved. In contrast, nucleoside drugs are convenient to take, the recent effect is better, but the course of treatment is longer (generally at least 2 ~ 3 years). The specific choice of which drug to use depends on the drug characteristics and the patient’s condition including economic status.
When implementing antiviral therapy for hepatitis B, it is important to emphasize.
1. clarify the goal of treatment. At this stage it is difficult for drugs to completely eradicate hepatitis B. The realistic goals of antiviral therapy are negative viral conversion, e antigen conversion (“major triplet” to “minor triplet”), and normalization of transaminases. The conversion of hepatitis B surface antigen is very difficult to achieve.
2, master the indications. We should take into account the virus level, transaminase level, imaging examination, patient’s age and concomitant diseases, etc. We should avoid both hasty and delayed treatment.
3.Select appropriate drugs and develop a reasonable treatment plan.
4.According to the status of viral response during the treatment process, the treatment plan should be adjusted at the right time to reduce the occurrence of drug resistance and to strive for the maximum therapeutic effect.
The majority of patients should avoid several misconceptions in the process of seeking medical treatment.
Myth #1: Blindly pursuing a complete turnaround of hepatitis B.
It is the dream of many patients to have their hepatitis B virus surface antigen turned negative. But to date, no drug has been developed worldwide that can completely clear the hepatitis B virus. A very small percentage of patients turn surface antigen negative or even develop surface antibodies over time, mainly due to the patient’s own immunity.
There is an analogy to the realistic goal of antiviral treatment for chronic hepatitis B: a negative DNA shift for hepatitis B virus is a “bronze medal”, a negative e antigen shift for hepatitis B virus and the appearance of e antibodies (that is, a “major triplet” to a “minor triplet “The hepatitis B virus surface antigen is negative or even surface antibody is “gold”. In the process of hepatitis B treatment, it is difficult to get the “gold”, but it is good if you can win the “silver”. Winning a “silver medal” means that the body’s immunity to the hepatitis B virus is restored and the virus is permanently suppressed. Winning a “bronze” medal means that the amount of virus replication is reduced and the risk of disease progression is lower. Blindly pursuing the so-called “complete conversion” can often go astray.
Myth 2: Anti-viral therapy requires lifelong medication.
Hepatitis B treatment emphasizes continuous inhibition of viral replication, and antiviral treatment is a relatively long-term process. Some patients take “long-term treatment” as “lifelong medication”, which greatly affects their enthusiasm and confidence in treatment. As mentioned above, it is good to get a “silver medal”. e antigen positive patients who achieve “double standard” after treatment, that is, the viral DNA in the blood is undetectable, while the e antigen serologically converted, and thereafter every six months to recheck, for two consecutive times. If the patient achieves “double attainment” after treatment, i.e., the viral DNA in the blood is undetectable and the e antigen is serologically converted, the patient can be considered for discontinuation of the drug for observation after rechecking every six months. Of course, special patients such as cirrhotic decompensation do not advocate the discontinuation of drugs.
Myth 3: Ignore antiviral therapy.
Some patients feel that hepatitis B antiviral can only control but not cut off the root, so it is better to just protect the liver without antiviral. This is a big mistake. Many chronic diseases are difficult to cut off but can be controlled, and antiviral is the key to controlling hepatitis B. Of course, as mentioned earlier, antiviral should be mastered indications, not blindly.
Myth 4: The earlier you treat hepatitis B, the better.
Chronic hepatitis B goes through immune tolerance, immune clearance, non-replication and reactivation during its long process of change. The immune tolerance period is characterized by high viral replication but no significant liver damage and normal transaminases, and this period is often very long, especially for young patients. This period is often very long, especially in young patients, and the medication is not as effective as desired.