Hepatitis, Viral

Description

Hepatitis B, Acute

Hepatitis B, Chronic (Non-HIV Co-infection)

Hepatitis B, Chronic (HIV Co-infection)

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*Notifiable medical condition.

DESCRIPTION

Hepatitis caused by one of the hepatotropic viruses, hepatitis A, B, C, D and E.

HEPATITIS B, ACUTE

ICD-10 code: B16.0-2/B16.9

GENERAL MEASURES

• Bed-rest until acute phase has resolved.
• Avoid alcohol during the illness and for ≥ 6 months after clinical recovery.
• Screen sexual contacts of patients with acute hepatitis B. Non-immune contacts (negative for hepatitis B surface antibodies) should receive hepatitis B active immunisation (see: Adult vaccination).

MEDICINE TREATMENT

For nausea and vomiting: (R11)

• Metoclopramide, IV/oral, 10 mg 8 hourly as required.

Hepatitis B virus: prophylaxis following exposure e.g. needle stick injury S61.0 + (W46.22+Z20.5+Z29.8)

• Persons at risk can be protected by passive immunisation with hyper immune serum globulin prepared from blood containing anti-HBs.
• It is essential that all categories of healthcare workers (HCW) at risk of contact with bodily fluids, including cleaning staff and home-based or family caregivers, are screened and fully vaccinated against hepatitis B if nonimmune.
• All occupational exposure incidents must be adequately documented for possible subsequent compensation.
• Recommended post-exposure management for HCW exposed to infectious material from patients with infectious hepatitis B (either surface antigen or e antigen positive).

Check vaccination status and antibody response of HCW (See table below for management depending on immunity):

Table 1.1: Prophylaxis following Hepatitis B exposure

Vaccination status and antibody response status of HCW	Source patient status & treatment
	HBsAg positive	HBsAg negative	HBsAg unknown
Unvaccinated OR vaccination incomplete	- HBIG, IM, 500 units* - Hep B vaccine (3 doses at monthly intervals)	- Initiate Hep B vaccination (month 0, 1 and 6)	- HBIG, IM, 500 units* - Hep B vaccine (3 doses at monthly intervals)
Vaccinated AND HBsAb ≥10 units/mL#	No treatment	No treatment	No treatment
Vaccinated AND HBsAb <10 units/mL	- HBIG, IM, 500 units* - Repeat Hep B vaccine (3 doses at monthly intervals)	- Initiate Hep B vaccination (month 0, 1 and 6)	- HBIG, IM, 500 units* - Repeat Hep B vaccine (3 doses at monthly intervals)

* HBIG and first dose of vaccine to be given simultaneously, but at different sites.
# If the delay in obtaining HBsAb results is more than 24 hours initiate treatment as for vaccinated AND HBsAb <10 units/mL.

HEPATITIS B, CHRONIC (NON-HIV COINFECTION)

ICD-10 code: B18.0-2/B18.8-9

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Consult the most recent Hepatitis Guidelines from the National Department of Health for comprehensive monitoring recommendations.

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DESCRIPTION

• HBV is most commonly transmitted horizontally in children <5 years of age. Vertical mother to child transmission and adult transmission, sexually or through a parenteral route, can also occur.
• Acute infection may be asymptomatic or present as acute hepatitis.
• A proportion of patients develop chronic hepatitis (defined as abnormalities listed in the table below persisting for >6 months), which can result in cirrhosis and hepatocellular carcinoma.
• It is essential to know the HIV status of all patients with chronic hepatitis B before considering therapy.
• Antiviral therapy is not indicated for acute hepatitis B infection.

There are 5 potential phases of chronic hepatitis B infection which determine the need for treatment:

Table 1.2: Phases of Chronic Hepatitis B infection

Serology	Viral load (HBV DNA) IU/mL	ALT	Management LoE:IIIxx
1. HBeAg-positive chronic HBV infection Immune Tolerant
- HBsAg positive - HBeAg positive	>20 000 (usually >200 000)	Normal	- Treatment not routinely needed, but should be followed up. - Treat only if on immunosuppressive therapy to prevent hepatitis B flares.
2. HBeAg-positive chronic hepatitis B Immune clearance
- HBsAg positive - HBeAg positive	>20 000	Elevated	- Treatment required.
3. HBeAg-negative chronic HBV infection Immune Control
- HBsAg positive - HBeAg negative	<2 000	Normal	- Treatment not routinely needed, but should be followed up. - Treat only if on immunosuppressive therapy to prevent hepatitis B flares.
4. HBeAg-negative chronic hepatitis B Immune Escape
- HBsAg positive - HBeAg negative	>2 000	Elevated	- Treatment required.
5. Occult hepatitis B
- HBsAg negative - HBsAb negative - HB IgG core Ab positive	<200	-	- No follow-up required. - Treat only if on immunosuppressive therapy to prevent hepatitis B flares.

HBsAg: hepatitis B surface antigen; HBsAb: hepatitis B surface antibody; HBIG: hepatitis B immunoglobulin

Treat all patients with cirrhosis regardless of ALT level, HBeAg status and HBV viral load, to prevent hepatitis B flares that will lead to decompensation. Screen all categories of healthcare workers (HCW) at risk of contact with bodily fluids, including cleaning staff, home-based or family caregivers and vaccinate against hepatitis B if not immune (see: Management of close contacts of patients with hepatocellular carcinoma).

MEDICINE TREATMENT

If eGFR > 50mL/min:

• Tenofovir disoproxil fumarate (TDF), oral, 300 mg daily.

LoE:III^xxi

If eGFR 15-50mL/min (or on haemodialysis):

• Tenofovir alafenamide (TAF), oral, 25 mg daily.

LoE:IIb^xxii

Aims of treatment

HBeAg-positive disease:

• Sustained HBsAg loss off therapy, with/without the development of anti-HBs, and
• Suppression of HBV DNA to undetectable or low (<2000 IU/mL) levels, and
• Normalisation of ALT, and
• Sustained HBeAg loss and seroconversion to anti-HBe

HBeAg-negative disease:

• Sustained HBsAg loss off therapy, with/without the development of anti-HBs, and
• Suppression of HBV DNA to undetectable or low (<2000 IU/mL), and
• Normalisation of ALT.

Table 1.3: Monitoring tests whilst on tenofovir

Monitoring whilst on tenofovir

Monitoring test	When to perform test
Serum phosphate and urine protein	Baseline
INR	Baseline, Week 4
Serum creatinine	All patients: Baseline Patients on TDF: Month 3, month 10, and every 12 months thereafter.
ALT	Baseline, Week 4, and every 12 weeks thereafter
FBC+Diff	Baseline, Week 4, and every 12 weeks thereafter
HBeAg and Anti-HBe	HBeAg-positive patients: Every 12 months
HBsAg	HBeAg-positive patients: HBsAg every 6 months after anti-HBe seroconversion HBeAg-negative patients: HBsAg every 6 months with persistently undetectable HBV DNA
HBV DNA levels	HBeAg-positive patients: 12 months after HBeAg seroconversion

Adapted from: National Department of Health, National guidelines for the management of viral hepatitis, 2019. Available at www.health.gov.za

Duration of tenofovir treatment:

• HBeAg-positive patients: discontinue 12 months after HBeAg seroconversion and in association with persistently normal ALT levels and undetectable HBV DNA levels.
• HBeAg-negative patients: Long-term therapy unless HBsAg seroconversion is achieved
• Cirrhotic patients: Lifelong treatment.

REFERRAL

Failure of, or contraindications to, tenofovir disoproxil fumarate and tenofovir alafenamide.

HEPATITIS B, CHRONIC (HIV CO-INFECTION)

See chapter: HIV and AIDS.

HEPATITIS C, CHRONIC

Consult a specialist.

Click here for the pdf.

Click here for the NEMLC Recommendations for medicine treatement (2020-4 review cycle).

Click here for the 29 July 2025 circular.

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Standard Treatment Guidelines And Essential Medicines List For South Africa, Adult Hospital level, 2020-4_Version 1_July 2024

Chapter 1: Alimentary tract; 1.2 Hepatic Disorders; 1.2.4 Hepatitis, Viral