eMedicine Specialties > Pediatrics: General Medicine > Infectious Disease

Hepatitis B: Follow-up

Author: Poonam Sharma, MD, Assistant Professor, Department of Pathology, Creighton University Medical Center and Veterans Affairs Medical Center; Director of Pathology Course, School of Pharmacy and Health Professions, Creighton University Medical Center
Coauthor(s): Meera Varman, MD, Assistant Professor, Department of Pediatrics, Section of Pediatric Infectious Diseases, Creighton University School of Medicine; Alexander T Kessler, MD, Consulting Staff, Northside Medical Specialties, LLC; Athena P Kourtis, MD, PhD, Assistant Professor, Department of Pediatrics, Divisions of Infectious Diseases and Epidemiology, Emory University School of Medicine
Contributor Information and Disclosures

Updated: May 1, 2008

Follow-up

Further Inpatient Care

• Most patients do not require hospital care. Patients with clinically severe illness may require hospitalization.
• A prolonged prothrombin time, low serum albumin level, hypoglycemia, and very high serum bilirubin values suggest severe hepatocellular disease; patients with these findings require prompt hospital admission.

Further Outpatient Care

• An HB_s Ag-positive finding in an infant, which is rare, indicates failure of immunoprophylaxis, and the third vaccine dose is not necessary.
• Breastfeeding is acceptable and does not pose a risk of transmitting hepatitis B virus (HBV) to infants who have begun prophylaxis.
• Reserve routine screening using ultrasonography and alpha-fetoprotein determination for patients with severe chronic active hepatitis, cirrhosis, or both.⁵

Deterrence/Prevention

• Hepatitis B is one of the major diseases that can be prevented with vaccination. Two types of recombinant hepatitis B vaccines are licensed for use in the United States; both are effective and safe.
• Universal vaccination refers to the administration of HBV vaccine to all infants as a part of the routine childhood immunization schedule and to all children younger than 11 or 12 years who have not previously received a vaccine. Rapid (0-, 1-, and 2-mo) and standard (0-, 1-, 6-mo) schedules have identical efficacy.
• Passive immunization refers to the administration of preformed human or animal antibody, in the form of hepatitis B immunoglobulin (HBIG), to patients after or just before exposure.
  • The current recommendation for neonates of mothers who are HB _s Ag positive is to administer HBIG 0.5 mL intramuscularly with the first dose of recombinant HBV vaccine within 12 hours of birth.
  • After immunization, serology should be tested for HB _s Ag and anti-HB _s at age 9-18 months.
  • In infants of infected mothers, combined treatment with the vaccine and HBIG has 79-98% efficacy in preventing chronic HBV infection.
• Patients on dialysis and those who are immunocompromised need to be evaluated annually for hepatitis B; if the anti HB _s Ab level is less than 10 mIU/mL, a booster dose is recommended. 
• Testing of hepatitis serology for immune response is recommended for high-risk groups such as homosexuals and bisexuals, patients on dialysis, sexual and household contacts of hepatitis B carriers and patients with human immunodeficiency virus (HIV) infection. 
• After 3 primary doses of the vaccine, if no serologic response with anti-HB _s  of 10 mIU/ml is noted, reimmunization with a 3-dose series is recommended. If the response if still negative, they are unlikely to mount antibody with additional doses. 
• Twinrix is a combination of hepatitis B (Engerix-B, 20 mcg) and hepatitis A (Havrix, 720 ELU) vaccine approved for people aged 18 years or older in a 3-dose schedule administered at 0 months, 1 month, and 6 or more months later.
• For preterm infants who weigh less than 2000 g and are born to mothers with unknown HB _s Ag status, 0.5 ml HBIG should be given within 12 hours. The birth dose should not be counted, and 3 additional doses are given according to recommendations.

Complications

• Fulminant hepatitis is the most feared complication of viral hepatitis. Fulminant hepatitis is observed primarily in hepatitis B (>50% of fulminant hepatitis cases) and in hepatitis D infection. Patients typically present with signs and symptoms of hepatic encephalopathy that may evolve to deep coma. Usually, the liver is small, and the prothrombin time is excessively prolonged.
• The most severe complications of chronic hepatitis B infection are cirrhosis and hepatocellular carcinoma.
• Rare complications of viral hepatitis are as follows:
  • Pancreatitis
  • Myocarditis
  • Atypical pneumonia
  • Aplastic anemia
  • Transverse myelitis
  • Peripheral neuropathy

Prognosis

• Among patients with acute hepatitis B, 90% have a favorable course and recover completely.
• Patients of advanced ages and those with serious underlying medical disorders, such as congestive heart failure, severe anemia, and diabetes mellitus, may have a prolonged course and are more likely to have severe hepatitis.
• The prothrombin time is the best indicator of the prognosis in patients with acute hepatitis.
• Although fatality rates for most cases of hepatitis B are low, patients ill enough to be hospitalized for acute hepatitis B have a 1% fatality rate.
• In patients with persistent infection, 10-30% develop chronic hepatitis. Of patients with chronic hepatitis, 20-50% of patients progress to cirrhosis, and approximately 10% of those who progress to cirrhosis may develop hepatocellular carcinoma.

Patient Education

• Educate patients who are HB _s Ag carriers about safe-sex practices and universal vaccination benefits.
• For excellent patient education resources, visit eMedicine's Hepatitis Center and Children's Health Center. Also, see eMedicine's patient education articles Hepatitis B and Immunization Schedule, Children.

Miscellaneous

Medicolegal Pitfalls

• Failure to screen a pregnant mother or a mother who presents in labor without having received prenatal care and whose hepatitis B status remains unknown could lead to physician liability because the baby may not have received optimal prophylaxis and is at risk for chronic hepatitis B.
• Failure of the physician to either notify an infected person identified with blood screening or other tests or provide appropriate counsel regarding transmission (eg, sexual contact, needle sharing) may lead to the exposure of additional people to hepatitis B.

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