Closing the Knowledge Gap: Hepatitis B Reactivation in Immunosuppression

Background The usage of immunosuppressive medications (ISMs), and specifically disease modifying anti-rheumatic drugs (DMARDs), in a wide range of internal medicine subspecialties has increased the risk of hepatitis B virus re-activation (HBVr). We assessed the understanding of HBVr using a Canada-wide survey. Methods An electronic survey was sent to 521 members of the Canadian Rheumatology Association (CRA). The questions focused on the knowledge of screening, monitoring and management of patients with chronic or past infection with HBV in the setting of starting ISMs.The results were compared to the American Gastroenterology Association (AGA) guidelines. Results A total of142 respondents were included in the analysis (response rate = 27.3%). Over 50% of the respondents would order unnecessary tests such as anti-HBs or anti-HBc for monitoring a HBsAg positive patient on an ISMs. There were 43% of responders who answered incorrectly to starting anti-viral prophylaxis for HBsAg positive patients on synthetic DMARDs (sDMARDs). Conclusion There are some knowledge gaps amongst physicians managing rheumatology patients with chronic or past infection with HBV in the setting of ISMs. The AGA guidelines were summarized and incorporated into a user-friendly guide.

HBsAg Positive Patient Characteristics in Hospital and Blood Donation Camps

Background. Prevention of the residual risk of transfusion transmitted hepatitis B virus infection (HBV) is mostly dependant on serological screening of blood donors for HBsAg and antibody to hepatitis B core antigen (anti-HBc Ab). This study aimed to study the prevalence of HBsAg and anti-HBc Ab and to compare the profile of blood donors attending a blood donation camp and people attending a hospital based camp. Methods. In the blood donor camp, all the blood units were screened for HBV, (HBsAg and anti-HBc), and in the hospital based camp, screening was done for HBsAg alone. Baseline demographic characteristics were noted. Results. The number of blood bank donors was 363 (47.5%) and hospital camp attendees was 402 (52.5%). Prevalence of HBsAg positivity was similar in both the groups at 1.7% and 1.9%, respectively. Anti-HBc Ab positivity (Total) was 6% among the blood donors; Overall prevalence of HBV infection in this group was 3.2%. Conclusion. Policy for checking the collected blood unit by 3 tests for anti-HBc, anti-HBsAb, and HBsAg should be reconsidered to possibly achieve the zero risk goal of transfusion transmitted HBV infection. Blood obtained from a vaccinated donor may give an added protection to the recipient.

Molecular Epidemiology of an Outbreak of Fulminant Hepatitis B

A nosocomial outbreak of hepatitis B occurred among the inpatients of a hematology unit. Nine of the 11 infected patients died from fulminant hepatitis. An investigation was conducted to identify the source of infection and the route of transmission. Two clusters of nosocomial hepatitis B were identified. The hepatitis B virus (HBV) genome from serum samples of all case patients, of one HBsAg-positive patient with acute reactivation of the infection, and of eight acutely infected, unrelated cases was identified by PCR amplification of viral DNA and was entirely sequenced. Transmission was probably associated with breaks in infection control practices, which occurred as single events from common sources or through a patient-to-patient route, likely the result of shared medications or supplies. Sequence analysis evidenced close homology among the strains from the case patients and that from the patient with reactivation, who was the likely source of infection. Molecular analysis of viral isolates evidenced an accumulation of mutations in the core promoter/precore region, as well as several nucleotide substitutions throughout the genome. The sequences of all patients were compared with published sequences from fulminant and nonfulminant HBV infections.