A Retrospective Audit on the Clinical Management of Chronic Hepatitis B at Wattyah Health

Centre

Background;

HBV (Hepatitis B Virus) can be transmitted through various means, including parenteral, perinatal,
and sexual contact, with high-risk groups being particularly susceptible to infection. Acute
hepatitis B infection often presents with symptoms such as jaundice, fatigue, and body aches, but
a signi cant portion of patients may not show any symptoms. Approximately 10% of individuals
who contract the virus develop a chronic infection, which carries a signi cant risk of
complications such as cirrhosis, hepatocellular carcinoma, and fulminant hepatitis.

In Oman, HBV infection remains endemic, particularly in community health centers where many
patients have infected or at-risk family members and close contacts. To address this issue, the
Ministry of Health in Oman has implemented prevention and risk management health protocols
over the past three decades. Hepatitis B vaccination is a crucial component of the Expanded
Program on Immunization (EPI) schedule, with vaccination coverage rates exceeding 97% of the
population. Neonates born to HBV-infected mothers receive post-exposure immunization after
birth, and immunization of spouses and family contacts is mandated by policy to reduce the risk
of transmission. Additionally, safety protocols such as screening all blood units for hepatitis B and
providing post-exposure prophylaxis are in place to prevent further spread of the virus.

Fig.1: Noti ed cases of acute viral hepatitis B (HBsAg+) in Oman: 2001-2014

Objective:

This audit aims to review the surveillance and treatment of chronic HBV patients at the health
centre, and comparing this against current treatment standards of care. Re-auditing in one year
will be done in order to asses the impact of education on GP behavior.

Standard:

American Association for the Study of Liver Diseases; European Guidelines for the management
of hepatitis B infection and NICE guidelines for the diagnosis and management of chronic
hepatitis B infection

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 NICE Guidelines Summary
HCC Surveillance
Treatment Criteria Monitoring Criteria Criteria
Offer antiviral treatment to: Monitor ALT levels: Do not offer surveillance
for HCC in:
- Adults aged 30 years and older - HBeAg-positive disease in - People without signi cant
with HBV DNA > 2000 IU/ml and immune-tolerant phase: Every brosis or cirrhosis
abnormal ALT on 2 consecutive 24 weeks (METAVIR stage < F2 or
tests Ishak stage < 3)
conducted 3 months apart. - Increase in ALT levels: Every - HBV DNA < 20,000 IU/ml
12 weeks on at least 3
consecutive occasions
- Adults younger than 30 years - Inactive chronic hepatitis B - Age < 40 years
with HBV DNA > 2000 IU/ml and infection: Every 48 weeks
abnormal ALT,
and evidence of - Consider more frequent
necroin ammation or brosis on monitoring (e.g., every 12-24
liver biopsy or transient weeks) in cirrhosis with
elastography score > 6 kPa. undetectable HBV DNA.
- Adults with HBV DNA > 20,000
IU/ml and abnormal ALT on 2
consecutive tests, regardless of
age or liver
disease extent.
- Adults with cirrhosis and
detectable HBV DNA,
regardless of HBeAg status,
HBV DNA, and ALT levels.
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Methodology:

Patient information was collected using ICD code searches and laboratory test results positive for
acute chronic hepatitis b infection during the years 2011-2022. A total of 82 patient les were
examined, 36 cases were included with the remaining patients excluded due to factors such as
change of address, negative test results, or incorrect labeling to name a few. Chronic infections
were identi ed based on Hepatitis B pro le. This was reviewed to identify the sample’s with
positive HBeAg, HbsAg, AFP levels, viral loads and LFTs in order to identify patients that required
further treatment by a specialist gastroenterologist or those that required more frequent
surveillance. Patient records were also reviewed for completed abdominal ultrasound reports.

In addition to necessary investigations les were reviewed for frequency of visits and whether
clinicians adhered various treatment guidelines.

Results:

Chronic infections represented the overwhelming majority of HBV cases detected at the health
centre. Three quarters of patients are male with the remaining 25% female.

Male Female

25%

75%
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The average age of patients is 42 years of age with the highest concentration of patients in the
30-50 age group.

Chronic HBV Age Distribution

15

10

0
20-30 31-40 41-50 51-60

Regarding HBV status, cases showed an overwhelming majority of patients are HbsAg positive
(89%), and HbeAg negative (86%). Concerning regular surveillance chronic HBV patients the
audit showed that 41% of patients were seen during 2022 and up to this date underwent LFTS
(5.5% were abnormal), 36% had Alpha-fetoprotein (AFP) levels measured, 19% underwent viral
load measurement while 38% never had a viral load done for the total observed duration of the
audit.

Chronic HBV Surveillance

38

25

13

0
LFTs AFP Viral load Liver U/S

Chronic HBV Surveillance

Discussion and Conclusions

The purpose of the audit was to evaluate the compliance with current standards of practice in the
surveillance and treatment of patients with chronic Hepatitis B virus (HBV) infection. The results
revealed a general lack of adherence to HBV surveillance testing. The majority of patients did not
receive the complete set of required tests at regular intervals. In this study, the tests were
assessed on an annual basis instead of the recommended bi-annual frequency suggested by the
AAFP (American Association of Family Physicians).

The most common test performed was LFT (41%) which is highly important in identifying patients
with high viral loads that may require specialist referral and treatment. Viral load was the least
performed surveillance test. Although ALT levels may be normal, persistently high viral loads can
be associated with a higher risk of hepato-cellular carcinoma and more aggressive disease.
Patients with persistently high viral loads may be o ered treatment in order to reduce the
possibility of secondary liver disease.

The audit identi ed two major issues in the management of chronic Hepatitis B (HBV) cases.
Firstly, general practitioners (GPs) showed incomplete testing, and a signi cant number of
patients were lost to follow-up or did not attend monitoring appointments regularly. In many
cases, follow-up appointments were not scheduled or patients failed to attend them. Secondly,
there were shortcomings in the collection and follow-up of HBV blood investigations. Patients' lab
results were not adequately reviewed, appointments for investigation review were not scheduled,
and some lab samples were faulty or rejected due to administrative irregularities.

To enhance regular surveillance of chronic HBV cases, the audit recommends the implementation
of a recorded registry that noti es healthcare providers about patients who require follow-up or
are due for testing. Additionally, patients would bene t from improved counseling and education
on the importance of regular surveillance and testing for better disease management.
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