Background Hepatitis B virus (HBV) causes an acute, often subclinical infection which can progresses to chronic disease with active viral replication. The risk of chronic infection is determined largely by the age at which the virus is contracted. Even in patients who clear the initial infection, the virus may lie dormant; one study found evidence of HBV DNA in 13 of 14 healthy liver donors with serological evidence of past but not current infection (HBV surface antigen (HBsAg) negative, core antibody (HBcAb) positive) . There are case reports of viral reactivation in patients receiving immunosuppressive therapy including rituximab and as such Roche recommend screening all patients to include HBsAg and HBcAb prior to treatment . In our experience not all rheumatology clinical staff are familiar with this guidance.
Objectives Our primary objective was to establish what proportion of patients receiving rituximab through a rheumatology department were fully screened for HBV before and after an education programme. Our secondary objective was to establish what proportion of newly screened patients had evidence of past HBV infection.
Methods We undertook an audit of patients receiving rituximab for all rheumatological indications between January and August 2015 in a unit with a catchment area of 450,000 patients. We recorded the proportion of patients who were tested for HBsAg and HBcAb prior to treatment and then undertook an education programme to clinical staff and updated an electronic blood requesting system before re-auditing patients between September 2015 and January 2016.
Results 89 rheumatology patients received Rituximab between Jan 2015 and August 2015. 43 (48%) had a complete screen (HBsAg and HBcAb) prior to treatment; 37 (42%) had been tested for sAg only; 7 (8%) for HBcAb only and 2 (2%) had neither test. Following an education programme 60 of 68 patients (90%) were fully screened. 38 patients were newly tested for HBcAb and 1 patient was found to be HBcAb positive suggestive of past infection (HBsAg negative). Subsequent analysis for HBV DNA was negative. Following discussion with a hepatologist this patient was treated with lamivudine whilst continuing Rituximab therapy.
Conclusions There is a risk of reactivation of HBV in patients who have evidence of past infection and are treated with rituximab. We found there was some uncertainty regarding the required serological screening blood tests amongst rheumatology staff, highlighted by incomplete testing in 52% of patients receiving Rituximab. Following an education programme, the proportion of patients completely screened rose to 90%. One patient with evidence of past infection was identified.
Marusawa H, Uemoto S, Hijikata M, et al. Latent hepatitis B virus infection in healthy individuals with antibodies to hepatitis B core antigen. Hepatology 2000;31(2):488–95.
Disclosure of Interest None declared