COVID-19 and adults living with chronic hepatitis B. 

ASHM COVID-19 Regional Advisory Group interim recommendations

  

Prepared by Professor Benjamin Cowie and the ASHM COVID-19 Regional Advisory Group, clinical care and priority populations sub-groups. 

 

UPDATED ON: May 26th 2020.

 

 

The guidance is adapted from the ASHM COVID-19 Taskforce interim recommendations regarding COVID-19 and adults living with chronic hepatitis B.

Disclaimer:  

 

In the general community, people over 60 years of age and people with co-morbidities including hypertension, cardiovascular disease, lung disease, cancer, diabetes and chronic liver disease are at greater risk of poorer outcomes with COVID-19 illness(1-5). Indigenous peoples, particularly those with one or more chronic medical conditions, may be at greater risk of serious COVID-19 illness. Hence people with chronic hepatitis B who are older and/or have co-morbidities are also likely to be at greater risk of having poorer outcomes with the COVID-19 illness. People living with hepatitis B who have cirrhosis are likely to have an increased risk of severe illness due to COVID-19; particular attention must be given to optimising their health and reducing their risk of infection with SARS-CoV-2.

Measures to optimise these patients’ health should include supporting smoking cessation, optimising diabetic and blood pressure control. We do not recommend ceasing or switching away from ACE inhibitors or angiotensin receptor blocker medications: there is no evidence that these agents increase the risk of worse outcomes of COVID-19 illness (6) and ceasing or switching these agents may cause harm to otherwise stable patients.  

Other key measures include encouraging appropriate exercise, maintaining regular appointments via telehealth or face-to- face if required, streamlining dispensing of medication and access to investigations, and actively referring and encouraging patients to attend telehealth appointments with medical and allied health specialists. Clinicians should also consider broader wholistic care approaches, including consideration of Advance Care Planning (7).
 

A small minority of people living with chronic hepatitis B globally are receiving guideline-based care or receiving antiviral treatment (8). Optimising assessment and management of chronic hepatitis B, including initiating antiviral treatment as indicated to prevent progressive liver disease, is important. Further information on the assessment and management of hepatitis B is available at https://www.hepatitisb.org.au/.

 

For patients who are well including those who are stably virologically suppressed on antiviral therapy, scheduling fewer regular appointments, including telehealth visits and deferring hepatitis B viral load and other routine blood tests for up to 6 months is reasonable if this is required based on the current impact of COVID-19 in the population and on resulting pressure on the health system in general. Deferring scheduled FibroScan assessments is also reasonable in most circumstances. 

Surveillance ultrasounds for hepatocellular carcinoma should not be deferred, but consideration should be given to ordering these through community radiology practices where available if they are usually performed in public hospitals. When surveillance gastroscopies for oesophageal varices in patients with cirrhosis are indicated, these should not be routinely deferred but access to these services is likely to become limited. Discussion with the specialist who usually provides these services (e.g. gastroenterologist) is recommended.  

 

  • People living with cirrhosis are at increased risk of invasive pneumococcal disease and of severe outcomes of influenza infection. Appropriate vaccination can help prevent infections and keep people living with liver disease healthy, and also avert the need for medical care or hospitalisation at a time when the health system may be seriously challenged by COVID-19. 
  • All people with chronic hepatitis B should be offered annual vaccination against influenza
  • People with chronic liver disease should be offered vaccination against invasive pneumococcal disease, in line with recommendations in each country. In Australia (for example) people with chronic liver disease are recommended to receive 3 doses of 23-valent pneumococcal polysaccharide vaccine – one at diagnosis, a 2nd dose at least 5 years later, and a 3rd dose at least 5 years after the 2nd dose or at age 65 years, whichever is later. 
  • All people with chronic hepatitis B, including young and well patients should be supported to cease smoking, exercise appropriately, optimise their sleep and adhere to the current national guidelines on alcohol intake(9). Note that for patients living with cirrhosis, no level of alcohol intake is considered safe and they should be supported to cease consuming alcohol. 

 

  • Mental health issues may become more common, or more severe during the COVID-19 pandemic
  • Financial insecurity may impede people meeting their hepatitis B healthcare needs and may lead to housing insecurity
  • Domestic violence rates have escalated globally since SARS-CoV-2 emerged

Clinicians are encouraged to use regular appointments to routinely evaluate these issues in all people with chronic hepatitis B and refer to specialists, community nurses, social workers, peer support, community organisations and other appropriate services, as needed. Clinicians should encourage patients to seek help between appointments if these issues arise.

 

  • Some communities and cultural groups report concern regarding the term ‘social distancing’ and prefer the term ‘physical distancing’
  • Minorities and other groups subject to stigma and discrimination can report concerns about being hospitalised with COVID-19 and having reduced opportunities to use appropriate services (e.g. interpreters). Clinicians should optimise appropriate access to services for minorities and others subject to broader health care inequities
  • Achieving social distancing and self-quarantine may be impossible in in overcrowded houses, prisons, detention centres and in homeless settings. Clinicians should advocate for their patients with chronic hepatitis B who are experiencing these conditions to receive urgent support to optimise their protection against SARS-CoV-2 infection, and to provide the highest possible level of care to those affected by COVID-19 irrespective of the setting
  • People with chronic hepatitis B who are unable to access their usual care for hepatitis B may be concerned about being able to continue required monitoring and treatment. Use of telehealth services, local clinics, and other alternative services (including a broader role for primary care clinicians in the management of hepatitis B) should be explored to address these barriers to usual care

There are no data available that demonstrate that hepatitis B antiviral medications can prevent or otherwise modify the course of infection with SARS-CoV-2. However, people should continue hepatitis B antivirals to manage their chronic hepatitis B if they do become infected with COVID-19. 

 

There is no current evidence that being infected with hepatitis B is associated with a relative increase in the risk of acquiring SARS-CoV-2 infection, or a relative increase in the risk of worse outcomes with COVID-19 illness. 

 

  • Those with cirrhosis
  • Those who have had a liver transplant and therein must take life-long immunosuppressive therapy
  • Those with hepatocellular carcinoma

Early reports on pregnant women with COVID-19 illnesses reveal no excess in maternal deaths, and report that the clinical features and outcomes of COVID-19 illness are not different from non-pregnant women with COVID-19 illness(10-12). Existing evidence suggests people aged under 50 years and females are less likely to have severe outcomes from COVID-19 infection, but more data are awaited to inform the specific situation of pregnant women There has been one report of mother-to-child transmission of the SARS-CoV-2 virus and the neonate developed pneumonia, but recovered fully(11). There are no current data on outcomes of pregnant women with chronic hepatitis B who develop COVID-19 illness and their newborns. Clinicians are advised to seek specialist advice to optimise health outcomes for women with chronic hepatitis B who are seeking to become pregnant, or who are currently pregnant during the COVID-19 pandemic.

 

People with chronic hepatitis B should receive the same supportive treatment for COVID-19 illness as people without chronic hepatitis B, noting that some people with chronic hepatitis B may have cirrhosis, be older and/or have co-morbidities. It has been hypothesised that non-steroidal medications (NSAIDS) may exacerbate COVID-19 illness, (13) although there is limited evidence to support this. Until more data are available, clinicians might consider using paracetamol for management of symptoms of COVID-19 illness, in preference to use of ibuprofen and other NSAIDS. Specialist medical and pharmaceutical advice should be sought for patients with chronic hepatitis B who are hospitalised with COVID-19 illness. Patients with chronic hepatitis B should be included in all appropriate COVID-19 clinical treatment trials.

 

All people with chronic hepatitis B are strongly encouraged to adhere to measures that reduce infection with SARS-CoV-2
Note that recommended measures to protect against SARS-CoV-2 infection may vary between jurisdictions, but in all jurisdictions the following measures are critical:

  • Social/physical distancing
  • Regular hand washing
  • Refraining from touching the face 
  • Cough etiquette
  • Social quarantine following contact with person with proven or suspected COVID-19 illness

 

  1. Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J, et al. Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus-Infected Pneumonia in Wuhan, China. JAMA. 2020.
  2. Wu Z, McGoogan JM. Characteristics of and Important Lessons From the Coronavirus Disease 2019 (COVID-19) Outbreak in China: Summary of a Report of 72314 Cases From the Chinese Center for Disease Control and Prevention. JAMA. 2020.
  3. Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet. 2020;395(10229):1054-62.
  4. Harris A, Yong K, Kermode M. An economic evaluation of universal infant vaccination against hepatitis B virus using a combination vaccine (Hib-HepB): a decision analytic approach to cost effectiveness. Australian and New Zealand journal of public health. 2001;25(3):222-9.
  5. Porcheddu R, Serra C, Kelvin D, Kelvin N, Rubino S. Similarity in Case Fatality Rates (CFR) of COVID-19/SARS-COV-2 in Italy and China. J Infect Dev Ctries. 2020;14(2):125-8.
  6. Vaduganathan M, Vardeny O, Michel T, McMurray JJV, Pfeffer MA, Solomon SD. Renin-Angiotensin-Aldosterone System Inhibitors in Patients with Covid-19. N Engl J Med. 2020.
  7. Thevarajan I, Buising KL, Cowie B. Clinical presentation and management of COVID-19  https://www.mja.com.au/journal/2020/clinical-presentation-and-management-covid-19. 2020.
  8. Global Hepatitis Report, 2017. Geneva: World Health Organization; 2017.
  9. Thomson J, Lin M, Halliday L, Preston G, McIntyre P, Gidding H, et al. Australia's notifiable diseases status, 1998. Annual report of the National Notifiable Diseases Surveillance System. Commun Dis Intell. 1999;23(11):277-305.
  10. Schwartz DA. An Analysis of 38 Pregnant Women with COVID-19, Their Newborn Infants, and Maternal-Fetal Transmission of SARS-CoV-2: Maternal Coronavirus Infections and Pregnancy Outcomes. Arch Pathol Lab Med. 2020.
  11. Yu N, Li W, Kang Q, Xiong Z, Wang S, Lin X, et al. Clinical features and obstetric and neonatal outcomes of pregnant patients with COVID-19 in Wuhan, China: a retrospective, single-centre, descriptive study. Lancet Infect Dis. 2020.
  12. Chen H, Guo J, Wang C, Luo F, Yu X, Zhang W, et al. Clinical characteristics and intrauterine vertical transmission potential of COVID-19 infection in nine pregnant women: a retrospective review of medical records. Lancet. 2020;395(10226):809-15.
  13. Day M. Covid-19: ibuprofen should not be used for managing symptoms, say doctors and scientists. BMJ. 2020;368:m1086.