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.
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.
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.
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.
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: