To avoid Hep B reactivation, screen before immunosuppression

An underrecognized problem. CHB affects an estimated 350 million people worldwide⁶ but remains underrecognized and underdiagnosed. An estimated 1.4 million Americans⁶ have CHB, but only a minority of them are aware of their positive status and are followed by a hepatologist or receive medical care for their disease.⁷ Compared with the natural-born US population, a higher prevalence of CHB exists among immigrants to this country from the Asian Pacific and Eastern Mediterranean regions, sub-Saharan Africa, and certain parts of South America.^8-10 In 2008, the Centers for Disease Control and Prevention (CDC) updated its recommendations on screening for HBV to include immigrants to the United States from intermediate and high endemic areas.⁶ Unfortunately, data published on physicians’ adherence to the CDC guidelines for screening show that only 60% correctly screened at-risk patients.¹¹

Individuals with CHB are at risk and rely on a robust immune system to keep their disease from becoming active. During infection, the virus gains entry into the hepatocytes and the double-stranded viral genome is imported into the nucleus of the cell, where it is repaired into covalently closed circular DNA (cccDNA). Research has demonstrated the stability of cccDNA and its persistence as a latent reservoir for HBV reactivation, even decades after recovery from infection.¹²

Also at risk are individuals who have unrecovered from HBV infection and are HBsAg negative and anti-HBc positive. To avert reverse seroconversion, they also rely on a robust immune system.¹³ Reverse seroconversion is defined as a reappearance of HBV DNA and HBsAg positivity in individuals who were previously negative.¹³ In these individuals, HBV DNA may not be quantifiable in circulation, but trace amounts of viral DNA found in the liver are enough to pose a reactivation risk in the setting of immune suppression.¹⁴

Moreover, often overlooked is the fact that reactivation or reverse seroconversion can necessitate disruptions and delays in immunosuppressive treatment for other life-threatening disease processes.^14,15

Universal screening reduces risk for HBVr. Patients with CHB are at risk for reactivation, as are patients with resolved HBV infection. Many patients, however, do not know their status. By screening all patients before beginning immunosuppressive therapy, physicians can provide effective prophylaxis, which has been shown to significantly reduce the risk for HBVr.^8.15

Continue to: Recognizing the onset of HBVr