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• W2775692003 abstract "Hepatitis B Virus (HBV) infection is one of the major causes of morbidity, mortality and healthcare expenditure in India. There are no Indian consensus guidelines on prevention, diagnosis and management of HBV infection. The Indian National Association for Study of the Liver (INASL) set up a taskforce on HBV in 2016, with a mandate to develop consensus guidelines for diagnosis and management of HBV infection, relevant to disease patterns and clinical practices in India. The taskforce first identified contentious issues on various aspects of HBV management, which were allotted to individual members of the taskforce who reviewed them in detail. A 2-day round table discussion was held on 11th and 12th February 2017 at Port Blair, Andaman & Nicobar Islands, to discuss, debate, and finalize the consensus statements. The members of the taskforce reviewed and discussed the existing literature threadbare at this meeting and formulated the ‘INASL position statements’ on each of the issues. The evidence and recommendations in these guidelines have been graded according to the Grading of Recommendations Assessment Development and Evaluation (GRADE) system with minor modifications. The strength of recommendations (strong: 1, weak: 2) thus reflects the quality (grade) of underlying evidence (A, B, C, D). We present here the INASL position statements on prevention, diagnosis and management of HBV in India. Hepatitis B Virus (HBV) infection is one of the major causes of morbidity, mortality and healthcare expenditure in India. There are no Indian consensus guidelines on prevention, diagnosis and management of HBV infection. The Indian National Association for Study of the Liver (INASL) set up a taskforce on HBV in 2016, with a mandate to develop consensus guidelines for diagnosis and management of HBV infection, relevant to disease patterns and clinical practices in India. The taskforce first identified contentious issues on various aspects of HBV management, which were allotted to individual members of the taskforce who reviewed them in detail. A 2-day round table discussion was held on 11th and 12th February 2017 at Port Blair, Andaman & Nicobar Islands, to discuss, debate, and finalize the consensus statements. The members of the taskforce reviewed and discussed the existing literature threadbare at this meeting and formulated the ‘INASL position statements’ on each of the issues. The evidence and recommendations in these guidelines have been graded according to the Grading of Recommendations Assessment Development and Evaluation (GRADE) system with minor modifications. The strength of recommendations (strong: 1, weak: 2) thus reflects the quality (grade) of underlying evidence (A, B, C, D). We present here the INASL position statements on prevention, diagnosis and management of HBV in India. Hepatitis B Virus (HBV) infection is a global health problem and approximately one-third of the world's population or two billion people have been infected and carry serological evidence of past or present HBV infection. According to an estimate, in 2010, about 248 million individuals globally were chronically infected with HBV.1Schweitzer A. Horn J. Mikolajczyk R.T. Krause G. Ott J.J. Estimations of worldwide prevalence of chronic hepatitis B virus infection: a systematic review of data published between 1965 and 2013.Lancet. 2015; 386: 1546-1555Abstract Full Text Full Text PDF PubMed Scopus (415) Google Scholar Of these approximately 15–40% will develop life-threatening liver consequences such as cirrhosis, liver failure and Hepatocellular Carcinoma (HCC), resulting in 600,000 to 1.2 million deaths per year due to HBV.2Puri P. Tackling the hepatitis B disease burden in India.J Clin Exp Hepatol. 2014; 4: 312-319Abstract Full Text Full Text PDF PubMed Google Scholar In recent years many societies like European Association for the Study of the Liver (EASL),3European Association for the Study of the Liver Electronic address: [email protected], European Association for the Study of the Liver. EASL 2017 Clinical Practice Guidelines on the management of hepatitis B virus infection.J Hepatol. 2017; Google Scholar American Association for the Study of Liver Diseases (AASLD),4Terrault N.A. Bzowej N.H. Chang K.-M. et al.AASLD guidelines for treatment of chronic hepatitis B.Hepatology. 2016; 63: 261-283Crossref PubMed Scopus (386) Google Scholar Asian Pacific Association for the Study of the Liver (APASL),5Sarin S.K. Kumar M. Lau G.K. et al.Asian-Pacific clinical practice guidelines on the management of hepatitis B: a 2015 update.Hepatol Int. 2016; 10: 1-98Crossref PubMed Google Scholar World Health Organization (WHO),6Guidelines for the Prevention, Care and Treatment of Persons with Chronic Hepatitis B Infection. World Health Organization, Geneva2015Google Scholar and Korean Association for the Study of the Liver (KASL)7Korean Association for the Study of the Liver KASL clinical practice guidelines: management of chronic hepatitis B.Clin Mol Hepatol. 2016; 22: 18-75Crossref PubMed Scopus (41) Google Scholar have published hepatitis B guidelines. However, while these guidelines are broadly applicable, they may or may not be able to address India-specific issues relating hepatitis B. The epidemiology of HBV in India, the socio-economic and healthcare structure in India, and treatment practices in India, are different from rest of the world. Therefore, the Indian National Association for Study of the Liver (INASL) felt a need to develop ‘India-specific’ consensus guidelines for diagnosis and management of HBV infection. With this aim, the INASL set up a taskforce on HBV in 2016, with a mandate to develop consensus guidelines on various clinical aspects of HBV, relevant to disease patterns and clinical practices in India. These guidelines are also expected to help in developing a framework for future research on affordable management options for HBV in India. The present review summarizes the INASL consensus statements on prevention, diagnosis and management of HBV infection in India. These are the first HBV guidelines published from any society of India. For the purpose of development of consensus statements, the taskforce identified the main contentious issues on various aspects of HBV. Members of the taskforce reviewed the existing literature, especially from India, and developed consensus statements on each of these issues. A 2-day round table discussion was held on 11th and 12th February 2017 at Port Blair, Andaman & Nicobar Islands, to discuss, debate, and finalize the consensus statements. Only those statements that were unanimously approved by the members of the taskforce were accepted. The evidence and recommendations in these statements have been graded according to the Grading of Recommendations Assessment Development and Evaluation (GRADE) system with minor modifications (Table 1). The strength of recommendations (strong: 1, weak: 2) thus reflects the quality (grade) of underlying evidence (A, B, C, D).8Atkins D. Best D. Briss P.A. et al.Grading quality of evidence and strength of recommendations.BMJ. 2004; 328: 1490Crossref PubMed Google Scholar Andaman & Nicobar Islands was chosen as the venue for this meeting because these islands represent the area with one of the highest prevalence of HBV infection in India.Table 1Grading of Recommendations, Assessment, Development and Evaluation (GRADE).CriteriaQuality of evidenceHigh (A)Further research is very unlikely to change our confidence in the estimate of effect.Moderate (B)Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.Low (C)Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.Very low (D)Any estimate of effect is very uncertain.Strength of recommendationsStrong (1)Factors influencing the strength of the recommendation included the quality of the evidence, presumed patient-important outcomes, and cost.Weak (2)Variability in preferences and values, or more uncertainty. Recommendation is made with less certainty, higher cost or resource consumption. Open table in a new tab The natural history of chronic HBV infection has been divided into distinct phases, as initially described by Chen.9Chen D.S. Natural history of chronic hepatitis B virus infection: new light on an old story.J Gastroenterol Hepatol. 1993; 8: 470-475Crossref PubMed Google Scholar These phases are as follows:•Immune-tolerant phase•Immune-active HBeAg-positive phase•Inactive carrier phase•HBeAg-negative immune reactivation phase, and•HBsAg-clearance phase These phases are of variable duration, may or may not be sequential, and not every person infected with HBV will pass through all phases.4Terrault N.A. Bzowej N.H. Chang K.-M. et al.AASLD guidelines for treatment of chronic hepatitis B.Hepatology. 2016; 63: 261-283Crossref PubMed Scopus (386) Google Scholar These phases take into account the presence of HBeAg, HBV DNA levels, ALT values and presence or absence of liver inflammation. However, a single determination of HBV replication markers and disease activity markers does not allow an accurate classification to one of these phases. Serial monitoring of HBeAg, HBV DNA and ALT levels is required in most instances to establish the phase of infection; despite which, some subjects fall into an indeterminate gray area and management needs to be individualized.3European Association for the Study of the Liver Electronic address: [email protected], European Association for the Study of the Liver. EASL 2017 Clinical Practice Guidelines on the management of hepatitis B virus infection.J Hepatol. 2017; Google Scholar Recently EASL has suggested a change in nomenclature of these phases as follows: HBeAg positive chronic infection, HBeAg positive chronic hepatitis, HBeAg negative chronic infection, HBeAg negative chronic hepatitis, and HBsAg negative chronic infection, respectively.3European Association for the Study of the Liver Electronic address: [email protected], European Association for the Study of the Liver. EASL 2017 Clinical Practice Guidelines on the management of hepatitis B virus infection.J Hepatol. 2017; Google Scholar Since, the new nomenclature is easy to understand and simpler to use in dichotomizing infected individuals into those with infection (no liver inflammation or damage) and those with hepatitis (with liver inflammation and/or damage) it should be used widely. However, it may still not eliminate all gray areas as it continues to depend on ALT, which is an imperfect marker of liver injury. INASL has endorsed this new nomenclature for use in India. A summary of features of all the five phases along with the new nomenclature is given in Table 2.Table 2Phases of Chronic Hepatitis B.PhaseOld nameNew nameHBeAgSerum HBV DNAALTLiver histologyPhase IImmune-tolerant phaseHBeAg positive chronic infectionPositive>107 IU/mlNormalMinimal inflammation and fibrosisPhase IIImmune-active HBeAg-positive phaseHBeAg positive chronic hepatitisPositive104–107 IU/mlElevatedModerate-to severe inflammation or fibrosisPhase IIIInactive carrier phaseHBeAg negative chronic infectionNegative<2000 IU/mlNormalMinimal necroinflammation but variable fibrosisPhase IVHBeAg-negative immune reactivation phaseHBeAg negative chronic hepatitisNegative>2000 IU/mlElevatedModerate-to severe inflammation or fibrosisPhase VHBsAg-clearance phase (also known as occult HBV infection)HBsAg negative chronic infectionNegativeUndetectable(HBV DNA can be detectable in liver)Normal, usuallyNo inflammation, minimal fibrosis.HBV DNA (cccDNA) can be detected frequently in the liver Open table in a new tab There is a lack of large-scale population-based studies on the prevalence of HBV in India. Most of the available data is based on blood bank and antenatal screening which has inherent biases and may not truly reflect the true national prevalence.2Puri P. Tackling the hepatitis B disease burden in India.J Clin Exp Hepatol. 2014; 4: 312-319Abstract Full Text Full Text PDF PubMed Google Scholar A meta-analysis of 54 studies on data of point prevalence of hepatitis B from different parts of the country, published in 2007, reported that the true prevalence in non-tribal populations is 2.4% (95% CI: 2.2–2.7%); while the true prevalence among tribal populations is 15.9% (CI: 11.4–20.4%).10Batham A. Narula D. Toteja T. Sreenivas V. Puliyel J.M. Systematic review and meta-analysis of prevalence of hepatitis B in India.Indian Pediatr. 2007; 44: 663-674PubMed Google Scholar However, a recent meta-analysis of 129 studies on 3,764,669 participants, reported that HBV prevalence estimate was 1.46% (95% CI 1.44–1.47).1Schweitzer A. Horn J. Mikolajczyk R.T. Krause G. Ott J.J. Estimations of worldwide prevalence of chronic hepatitis B virus infection: a systematic review of data published between 1965 and 2013.Lancet. 2015; 386: 1546-1555Abstract Full Text Full Text PDF PubMed Scopus (415) Google Scholar Thus it is reasonable to conclude that the prevalence of chronic hepatitis B (CHB) in general population in India may be between 1.4% and 2.7%. It has been estimated that only about one-third of the adult HBV infected subjects in India evolve directly from perinatal infection, while the majority (two-third) become infected during childhood or early adulthood.11Nayak N.C. Panda S.K. Zuckerman A.J. Bhan M.K. Guha D.K. Dynamics and impact of perinatal transmission of hepatitis B virus in North India.J Med Virol. 1987; 21: 137-145Crossref PubMed Scopus (0) Google Scholar However current knowledge of dynamics of HBV transmission is imprecise and present understanding of the role of perinatal transmission and horizontal transmission of this disease among children is based on inadequate evidence.2Puri P. Tackling the hepatitis B disease burden in India.J Clin Exp Hepatol. 2014; 4: 312-319Abstract Full Text Full Text PDF PubMed Google Scholar The contribution by vertical transmission may, in fact, be higher if we look at the high prevalence of HBV replicative markers in HBsAg-positive pregnant women.12Mittal S.K. Rao S. Rastogi A. Aggarwal V. Kumari S. Hepatitis B—potential of perinatal transmission in India.Trop Gastroenterol. 1996; 17: 190-192PubMed Google Scholar, 13Dwivedi M. Misra S.P. Misra V. et al.Seroprevalence of hepatitis B infection during pregnancy and risk of perinatal transmission.Indian J Gastroenterol. 2011; 30: 66-71Crossref PubMed Scopus (0) Google Scholar, 14Pande C. Sarin S.K. Patra S. et al.Prevalence, risk factors and virological profile of chronic hepatitis B virus infection in pregnant women in India.J Med Virol. 2011; 83: 962-967Crossref PubMed Scopus (0) Google Scholar, 15Pande C. Sarin S.K. Patra S. et al.Hepatitis B vaccination with or without hepatitis B immunoglobulin at birth to babies born of HBsAg-positive mothers prevents overt HBV transmission but may not prevent occult HBV infection in babies: a randomized controlled trial.J Viral Hepat. 2013; 20: 801-810PubMed Google Scholar More, better planned, studies are needed to definitively answer this question. Most HBV infections in India are due to genotypes A and D.16Kumar A. Kumar S.I. Pandey R. Naik S. Aggarwal R. Hepatitis B virus genotype A is more often associated with severe liver disease in northern India than is genotype D.Indian J Gastroenterol. 2005; 24: 19-22PubMed Google Scholar, 17Datta S. An overview of molecular epidemiology of hepatitis B virus (HBV) in India.Virol J. 2008; 5: 156Crossref PubMed Scopus (81) Google Scholar, 18Gandhe S.S. Chadha M.S. Arankalle V.A. Hepatitis B virus genotypes and serotypes in western India: lack of clinical significance.J Med Virol. 2003; 69: 324-330Crossref PubMed Scopus (0) Google Scholar, 19Banerjee A. Datta S. Chandra P.K. Roychowdhury S. Panda C.K. Chakravarty R. Distribution of hepatitis B virus genotypes: phylogenetic analysis and virological characteristics of genotype C circulating among HBV carriers in Kolkata, Eastern India.World J Gastroenterol. 2006; 12: 5964-5971Crossref PubMed Google Scholar, 20Banerjee A. Kurbanov F. Datta S. et al.Phylogenetic relatedness and genetic diversity of hepatitis B virus isolates in Eastern India.J Med Virol. 2006; 78: 1164-1174Crossref PubMed Scopus (0) Google Scholar, 21Chattopadhyay S. Das B.C. Kar P. Hepatitis B virus genotypes in chronic liver disease patients from New Delhi, India.World J Gastroenterol. 2006; 12: 6702-6706Crossref PubMed Google Scholar, 22Thakur V. Guptan R.C. Kazim S.N. Malhotra V. Sarin S.K. Profile, spectrum and significance of HBV genotypes in chronic liver disease patients in the Indian subcontinent.J Gastroenterol Hepatol. 2002; 17: 165-170Crossref PubMed Scopus (0) Google Scholar, 23Vivekanandan P. Abraham P. Sridharan G. et al.Distribution of hepatitis B virus genotypes in blood donors and chronically infected patients in a tertiary care hospital in southern India.Clin Infect Dis. 2004; 38: e81-e86Crossref PubMed Google Scholar In two different studies from northern India, genotypes A and D were found to be equally prevalent.16Kumar A. Kumar S.I. Pandey R. Naik S. Aggarwal R. Hepatitis B virus genotype A is more often associated with severe liver disease in northern India than is genotype D.Indian J Gastroenterol. 2005; 24: 19-22PubMed Google Scholar, 22Thakur V. Guptan R.C. Kazim S.N. Malhotra V. Sarin S.K. Profile, spectrum and significance of HBV genotypes in chronic liver disease patients in the Indian subcontinent.J Gastroenterol Hepatol. 2002; 17: 165-170Crossref PubMed Scopus (0) Google Scholar However, another study from the same geographic region reported genotype D to be predominant with a low frequency of genotype A in northern Indian HBV infected patients,21Chattopadhyay S. Das B.C. Kar P. Hepatitis B virus genotypes in chronic liver disease patients from New Delhi, India.World J Gastroenterol. 2006; 12: 6702-6706Crossref PubMed Google Scholar which was similar to the HBV genotype distribution documented from western and southern parts of India.18Gandhe S.S. Chadha M.S. Arankalle V.A. Hepatitis B virus genotypes and serotypes in western India: lack of clinical significance.J Med Virol. 2003; 69: 324-330Crossref PubMed Scopus (0) Google Scholar, 23Vivekanandan P. Abraham P. Sridharan G. et al.Distribution of hepatitis B virus genotypes in blood donors and chronically infected patients in a tertiary care hospital in southern India.Clin Infect Dis. 2004; 38: e81-e86Crossref PubMed Google Scholar In sharp contrast to rest of India, the eastern part of India presents an interesting epidemiologic pattern with three different HBV genotypes (genotypes A, C and D) present in comparable proportions.2Puri P. Tackling the hepatitis B disease burden in India.J Clin Exp Hepatol. 2014; 4: 312-319Abstract Full Text Full Text PDF PubMed Google Scholar, 19Banerjee A. Datta S. Chandra P.K. Roychowdhury S. Panda C.K. Chakravarty R. Distribution of hepatitis B virus genotypes: phylogenetic analysis and virological characteristics of genotype C circulating among HBV carriers in Kolkata, Eastern India.World J Gastroenterol. 2006; 12: 5964-5971Crossref PubMed Google Scholar, 20Banerjee A. Kurbanov F. Datta S. et al.Phylogenetic relatedness and genetic diversity of hepatitis B virus isolates in Eastern India.J Med Virol. 2006; 78: 1164-1174Crossref PubMed Scopus (0) Google Scholar, 23Vivekanandan P. Abraham P. Sridharan G. et al.Distribution of hepatitis B virus genotypes in blood donors and chronically infected patients in a tertiary care hospital in southern India.Clin Infect Dis. 2004; 38: e81-e86Crossref PubMed Google Scholar Consensus Statements•The prevalence of chronic hepatitis B in general population India is between 1.4% and 2.7%. (A)•Predominant mode of transmission is horizontal, however, vertical transmission is also common in India. (B)•Most HBV infections in India are due to genotype A and D. (A) Recombinant hepatitis B vaccine was introduced in 1986 and has gradually replaced the plasma-derived hepatitis B vaccine.24Hepatitis B vaccines.Wkly Epidemiol Rec. 2009; 84: 405-419PubMed Google Scholar The protective efficacy of hepatitis B vaccination is related to the induction of anti-HBs antibodies but also involves the induction of memory T-cells. An anti-HBs concentration of 10 mIU/ml, measured 1–3 months after administration of the last dose of the primary vaccination series is considered a reliable marker of protection against infection.24Hepatitis B vaccines.Wkly Epidemiol Rec. 2009; 84: 405-419PubMed Google Scholar, 25Jack A.D. Hall A.J. Maine N. Mendy M. Whittle H.C. What level of hepatitis B antibody is protective?.J Infect Dis. 1999; 179: 489-492Crossref PubMed Scopus (0) Google Scholar The primary 3-dose vaccine series induces protective antibody concentrations in >95% of healthy infants, children and young adults.24Hepatitis B vaccines.Wkly Epidemiol Rec. 2009; 84: 405-419PubMed Google Scholar, 26Viviani S. Jack A. Hall A.J. et al.Hepatitis B vaccination in infancy in The Gambia: protection against carriage at 9 years of age.Vaccine. 1999; 17: 2946-2950Crossref PubMed Scopus (111) Google Scholar, 27Bialek S.R. Bower W.A. Novak R. et al.Persistence of protection against hepatitis B virus infection among adolescents vaccinated with recombinant hepatitis B vaccine beginning at birth: a 15-year follow-up study.Pediatr Infect Dis J. 2008; 27: 881-885Crossref PubMed Scopus (78) Google Scholar, 28Floreani A. Baldo V. Cristofoletti M. et al.Long-term persistence of anti-HBs after vaccination against HBV: an 18 year experience in health care workers.Vaccine. 2004; 22: 607-610Crossref PubMed Scopus (0) Google Scholar Since 1992, WHO has recommended global vaccination against HBV, and by 2009, 177 countries had already incorporated HBV vaccination in their national immunization programs.2Puri P. Tackling the hepatitis B disease burden in India.J Clin Exp Hepatol. 2014; 4: 312-319Abstract Full Text Full Text PDF PubMed Google Scholar In countries that have implemented universal childhood hepatitis B immunization, this has resulted in a decline in HBV carrier rates and its long-term consequences, including HCC.2Puri P. Tackling the hepatitis B disease burden in India.J Clin Exp Hepatol. 2014; 4: 312-319Abstract Full Text Full Text PDF PubMed Google Scholar, 29Chang M.H. Chen C.J. Lai M.S. et al.Universal hepatitis B vaccination in Taiwan and the incidence of hepatocellular carcinoma in children. Taiwan Childhood Hepatoma Study Group.N Engl J Med. 1997; 336: 1855-1859Crossref PubMed Scopus (1357) Google Scholar Vaccination of infants within 24 h of birth is 90–95% effective in preventing infection with HBV as well as decreasing HBV transmission, if followed by at least two other doses. WHO recommends universal hepatitis B vaccination for all infants, and that the first dose should be given as soon as possible after birth.6Guidelines for the Prevention, Care and Treatment of Persons with Chronic Hepatitis B Infection. World Health Organization, Geneva2015Google Scholar Apart from infants, HBV vaccination is advisable for all children and adults who are not previously vaccinated. Although knowledge about the duration of protection against infection and disease following hepatitis B vaccination is still incomplete, including knowledge on the potential role of natural sub-clinical boosting, there is no compelling evidence for recommending administering a booster dose of hepatitis B vaccine in routine immunization programmes.24Hepatitis B vaccines.Wkly Epidemiol Rec. 2009; 84: 405-419PubMed Google Scholar HBV vaccination is also recommended in people with risk factors for acquiring HBV infection, such as those who frequently require blood or blood products, dialysis patients, recipients of solid organ transplantations, injecting drug users, household and sexual contacts of people with chronic HBV infection, people with multiple sexual partners, as well as health-care workers and others who may be exposed to blood and blood products through their work.24Hepatitis B vaccines.Wkly Epidemiol Rec. 2009; 84: 405-419PubMed Google Scholar Immunosuppressive illnesses, including advanced HIV infection, chronic renal failure, chronic liver disease, coeliac disease and diabetes, are associated with reduced immunogenicity following vaccine administration. For these patients higher vaccine doses or increased number of doses are required. The anti-HBs response of such persons should be tested after they are vaccinated, and those who have not responded should be revaccinated with 1–3 additional doses.30Recommendations of the Advisory Committee on Immunization Practices (ACIP): Use of Vaccines and Immune Globulins in Persons with Altered Immunocompetence. https://www.cdc.gov/mmwr/preview/mmwrhtml/00023141.htm Accessed 20.05.17.Google Scholar Consensus Statements•Universal hepatitis B vaccination is recommended for all infants, and the first dose should be given as soon as possible after birth. (A1)•HBV vaccination is also recommended in people with risk factors for acquiring HBV infection, such as those who frequently require blood or blood products, dialysis patients, recipients of solid organ transplantations, injecting drug users, household and sexual contacts of people with chronic HBV infection, people with multiple sexual partners, as well as health-care workers and others who may be exposed to blood and blood products through their work. (A1)•HBV vaccination is advisable for all children and adults who are not previously vaccinated. (C2)•There is no evidence to support the need for a booster dose of hepatitis B vaccine. (A1)•For immunosuppressed population higher vaccine doses or increased number of doses are required. The anti-HBs response of such persons should be tested after they are vaccinated, and those who have not responded should be revaccinated with 1–3 additional doses. (B1) Once a subject is found to be HBsAg positive, the initial evaluation should include a thorough history and physical examination, with special emphasis on possible mode of acquisition, current phase of infection and stage of disease, need for antiviral treatment, and family history of cirrhosis and liver cancer. Presence of additional risk factors for liver disease such as co-infections with other hepatitis viruses, alcohol abuse, diabetes mellitus, obesity, and metabolic syndrome, if present, should be systematically evaluated. Because tenofovir and possibly also entecavir monotherapy can cause HIV resistance mutations, all HBsAg-positive patients should be screened for HIV before these drugs are used in the treatment of HBV infection. Laboratory tests should include assessment of liver function (AST, ALT, GGT, alkaline phosphatase, bilirubin, serum albumin, serum globulins, CBC and INR), markers of HBV replication (HBeAg, anti-HBe, HBV DNA quantitative), and tests for co-infection with HCV and HIV. Ultrasound examination of the liver is recommended in all patients. Serum HBsAg quantification can be useful, particularly in HBeAg-negative chronic HBV infection and in patients to be treated with pegylated interferon alpha (PegIFN-α).31Gupta E. Kumar A. Choudhary A. Kumar M. Sarin S.K. Serum hepatitis B surface antigen levels correlate with high serum HBV DNA levels in patients with chronic hepatitis B: a cross-sectional study.Indian J Med Microbiol. 2012; 30: 150-154Crossref PubMed Scopus (8) Google Scholar HBV genotype is not necessary in the initial evaluation, although it may be useful for selecting patients to be treated with PegIFN-α, as it offers prognostic information for the probability of response to PegIFN-α therapy and the risk of HCC. In India, testing for antibodies against hepatitis A virus (anti-HAV) is not recommended. In 2002, it was suggested that the upper limit of normal ALT should be updated to 30 U/L for men and 19 U/L for women, based on large data from Italy.32Prati D. Taioli E. Zanella A. et al.Updated definitions of healthy ranges for serum alanine aminotransferase levels.Ann Intern Med. 2002; 137: 1-10Crossref PubMed Google Scholar However, these new ALT cut-offs need to be prospectively validated in India before they can be recommended. Hence, it was decided by the INASL HBV taskforce that the upper limit of normal ALT level should be 40 U/L, as before. If results of blood tests and ultrasonography are equivocal, a liver biopsy or non-invasive test should be performed to determine disease stage and need for antiviral treatment. Liver biopsy provides an assessment of the severity of necro-inflammation and fibrosis, rules out other causes of liver disease, and may be especially useful for persons who lack clear-cut indications for antiviral treatment.33Rastogi A. Sakhuja P. Kumar A. et al.Steatosis in chronic hepatitis B: prevalence and correlation with biochemical, histologic, viral, and metabolic parameters.Indian J Pathol Microbiol. 2011; 54: 454-459Crossref PubMed Scopus (26) Google Scholar, 34Kumar M. Kumar A. Hissar S. et al.Hepatic venous pressure gradient as a predictor of fibrosis in chronic liver disease because of hepatitis B virus.Liver Int. 2008; 28: 690-698Crossref PubMed Scopus (0) Google Scholar Whereas liver biopsy is regarded as the best method to assess the severity of inflammatory activity and fibrosis, non-invasive methods to assess fibrosis severity are also useful. Among non-invasive methods, which include liver stiffness measurements and serum biomarkers of liver fibrosis, the use of transient elastography has been studied most extensively and seems to offer a higher diagnostic accuracy for the detection of advanced fibrosis, cirrhosis, and even portal hypertension.35Li Y. Huang Y.-S. Wang Z.-Z. et al.Systematic review with meta-analysis: the diagnostic accuracy of transient e" @default.
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• W2775692003 title "INASL Position Statements on Prevention, Diagnosis and Management of Hepatitis B Virus Infection in India: The Andaman Statements" @default.
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