Hepatitis B treatment and care in the UK need to evolve to keep pace with the global epidemic

Michael Carter
Published: 09 January 2013

“Persistent HBV [hepatitis B virus] infection has changed its face in the UK,” research published in the online edition of Clinical Infectious Diseases shows. The study found considerable diversity in viral genotype and patient ethnicity, and that only one in three patients were taking therapy. There was extensive use of non-recommended treatment and approximately a third of treated patients had drug-resistant virus. Few people had been tested for co-infections such as HIV. The investigators believe their findings have important implications for those planning hepatitis B services and show the “globilisation” of the epidemic.

Persistent hepatitis B virus infection is associated with progressive liver disease and a high risk of hepatocellular carcinoma.

There are ten known hepatitis B genotypes, each of which has a specific geographical distribution. It is possible that migration has altered the ethnic populations affected by hepatitis B in the UK and the genetic diversity of the virus.

Investigators therefore obtained information on a snapshot sample of people attending specialist hepatology clinics in the UK. Demographic, clinical and laboratory data were collected.

A total of 698 people who received care for chronic hepatitis B infection between 2007 and 2009 were recruited.

“This national cross-sectional study of persistent HBV infection represents a snapshot of current disease burden of patients attending…liver clinics in the UK,” write the authors. “We believe that the patients in this study are likely representative of the clinic population from which they are drawn and that the study provides characterisation of both patients and viruses.”

Most of the patients were men (61%), who were significantly older than female patients (mean age 45 vs 38 years, p < 0.001). Participants originated from 61 different countries and all the major ethnicities were represented, the largest being East and South East Asian (37%), White (25%), South Asian (20%) and Black African (15%).

Overall, 80% of patients were born outside the UK.

Consumption of alcohol is known to accelerate liver damage in the context of hepatitis B infection, and a third of patients were recorded as regularly drinking alcohol.

Just over a fifth of patients were HBeAg seropositive.

Differences were apparent in the treatment and care of men and women. Men were significantly more likely than women to have undergone a liver biopsy (53 vs 23%, p < 0.0001) and to be taking antiviral treatment (45 vs 17%, p 0.0001). A fifth of patients who had undergone a liver biopsy were found to have cirrhosis. Rates of cirrhosis were significantly higher in men than women (24 vs 8%, p = 0.006). There were ten cases of hepatocellular carcinoma, nine of which were in men.

A total of eight hepatitis B genotypes were identified. Genotype D was the most common, representing 31% of all infections. Genotypes A, B and C were each found in approximately a fifth of patients.

There was a strong association between genotype and e antigen status. Patients with genotype A and C viruses were significantly more likely to be e antigen positive (30 and 41% respectively; p = 0.001).

Only a third of patients were taking hepatitis B therapy, with just 18% taking recommended first-line treatment. Approximately a third (31%) of those on treatment were taking lamivudine monotherapy. The investigators found this “disconcerting”, noting that this treatment strategy is not recommended and “associated with rapid development of resistance, severe hepatic flares and decompensation as well as limiting future treatment options.”

Drug-resistant hepatitis B was detected in 27% of patients who had undergone treatment.

Some 16% of patients not currently on therapy had hepatitis B DNA above 2000 iu/ml and ALT levels above the upper limit of normal, “indicating a need for treatment.”

Guidelines recommend that hepatitis B-infected patients should be tested for other viral co-infections. However, only 31% of patients had documented HIV test results. Nine patients were known to be co-infected with HIV. Approximately half the patients had been screened for hepatitis C, and seven patients had antibodies for this infection. Only a third of patients had been tested for hepatitis delta, which “is associated with a more rapidly progressive clinical course” of hepatitis B infection.

“Those planning, commissioning and managing hepatology services must now take host virus diversity into account,” conclude the authors. “Optimal management requires awareness of the variable patterns of chronic HBV in countries of origin.”

Reference

Tedder RS et al. The diversity and management of chronic hepatitis B virus infections in the UK – a wake up call. Clin Infect Dis, online edition, 2013.

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