Prevention of hepatitis B reactivation in patients requiring chemotherapy and immunosuppressive therapy

Implementation of a Hepatitis B Screening Program in Patients Receiving Systemic Anti-Cancer Therapy

Cancer patients receiving non-endocrine therapies are at risk of hepatitis B virus (HBV) reactivation (HBVr). Guidelines recommend HBV screening prior to treatment. The Ottawa Hospital Cancer Center implemented a screening pilot for all patients receiving FOLFOX-based regimens between January and April 2023. We assessed the pilot from a quality improvement perspective. Charts were retrospectively reviewed, and patient and disease characteristics were collected. The primary endpoint was to identify the proportion of patients who underwent HBV screening prior to treatment start. Univariate analyses assessed the association between baseline characteristics and failure to screen. Quality metrics were also reviewed. There were 32/42 patients (76.2%) who completed screening, and 5 (11.9%) had a positive screen. The majority of eligible patients (59.5%) completed screening prior to the first treatment as intended. Four of five patients who tested positive were referred to Infectious Diseases. Of those, one received antivirals for chronic HBV. There were no treatment delays due to pending screening and no HBV reactivation. Receipt of prior systemic therapy was significantly associated with failure to screen (55 vs. 95%, OR 17.1 (95% CI 1.92-153), p = 0.011). The results of this pilot highlight the importance of building HBV screening into standardized treatment plans and engaging all team members to ensure high levels of screening. Prior systemic therapy receipt was associated with failure to screen, and thus, programs should include education on the necessity of screening as recommended by medical guidelines.

Hepatitis B Virus Reactivation in Cancer Patients Receiving Chemotherapy-A Systematic Review and Meta-Analysis

Hepatitis B virus (HBV) reactivation is a critical concern for patients with a diagnosis of cancer receiving chemotherapy worldwide. Our aim was to assess the rate of HBV reactivation during chemotherapy globally. We systematically reviewed PubMed, Embase, Scopus, and Google Scholar databases for chemotherapy-related HBV reactivation studies from inception until July 2023. A random-effects model was used to estimate the pooled reactivation rate. Total 86 studies involving 21,297 patients were included, comprising 62 and 24 studies from Eastern and Western regions. Pooled results indicated a 9% reactivation rate (95%CI: 7%-13%, I2 = 95%). Reactivation rates were 10% (95%CI: 7%-14%, I2 = 92%) for hematological malignancies and 5% (95%CI: 3%-9%, I2 = 94%) for solid tumors. Presence of HBV DNA, HBeAg, and HBsAg were correlated with reactivation rates of 29% (95%CI: 10%-60%, I2 = 91%), 23% (95%CI: 14%-36%, I2 = 78%), and 15% (95%CI: 11%-20%, I2 = 90%), respectively. For patients with positive anti-HBe Ab, anti-HBc, and anti-HBs Ab serology, pooled reactivation rates were 7% (95%CI: 3%-14%, I2 = 81%), 4% (95%CI: 3%-7%, I2 = 85%), and 3% (95%CI: 2%-6%, I2 = 80%), respectively. With antiviral prophylaxis, reactivation rates were 1% (95%CI: 0%-17%, I2 = 59%), 1% (95%CI: 0%-5%, I2 = 0%), 4% (95%CI: 2%-9%, I2 = 85%), and 6% (95%CI: 3%-12%, I2 = 32%) for patients receiving tenofovir, entecavir, lamivudine, and telbivudine, respectively. Patients with a diagnosis of cancer undergoing chemotherapy face increased risk of HBV reactivation. This analysis raises public awareness and serves as a resource for future clinical trials.

Seroprevalence of hepatitis B and C viruses and some possible associated factors among cancer patients at the Oncology Treatment Center, Gondar, Northwest Ethiopia: A cross-sectional study

BACKGROUND

Cancer patients are prone to infections such as hepatitis B virus (HBV) and hepatitis C virus (HCV), which pose a major public health challenge, especially in developing countries. However, little is known about the magnitude of these infections among cancer patients in Ethiopia. Thus, this study determined the prevalence of HBV and HCV in cancer patients at the Oncology Treatment Center, Gondar, Northwest Ethiopia.

MATERIALS AND METHODS

An institutional-based cross-sectional study was conducted on 115 cancer patients from 15 April to 22 July 2023 at the Oncology Treatment Center, Gondar, Northwest Ethiopia. Sociodemographic, clinical, and other relevant data were collected using a pretested structured questionnaire. Five milliliters of venous blood were collected using a vacutainer tube, serum was harvested and tested for HBV and HCV using a one-step HBsAg and anti-HCV test strip with further confirmation through an ELISA test kit. Data were analyzed using SPSS version 20 and Fisher exact test was used to determine the association between HBV/HCV infection and associated factors.

RESULTS

Out of 115 cancer patients, the majority (62.6%) were females. The median age was 50 (IQR; 40-56) years. The overall prevalence of HBV and HCV infections was 4.3% (95% CI; 0.6-8%) and 6.1% (95% CI; 1.7-10.5%), respectively. Sex was significantly associated with the prevalence of HCV (p = 0.011) with higher anti-HCV positivity in males (14%) than in females (1.4%).

CONCLUSIONS

In this study, the prevalence of HCV was higher and the HBV prevalence was intermediate in cancer patients. To reduce the burden of HBV and HCV infections, it is crucial to provide access to HBV and HCV screening services, strengthen vaccination, and improve prompt treatment in cancer patients.

[Chronic hepatitis B in rheumatic diseases: issues of screening and reactivation of infection: A review]

Patients with rheumatic diseases infected with hepatitis B virus (HBV) are difficult to manage not only due to the presence of risk factors for the development and rapid progression of liver cirrhosis, but also due to the likelihood of reactivation of this infection. Despite the successes achieved in the fight against HBV, the virus cannot be completely defeated due to the presence of hidden forms of the disease, escaping the field of vision of a rheumatologist and an infectionist. Based on the results of the analysis of current publications, the paper presents the rationale for a complete immunological screening of patients with rheumatic diseases when prescribing antirheumatic therapy. The issues of the role of COVID-19 in the exacerbation of chronic viral hepatitis B, antiviral prevention and monitoring are discussed, the classification of antirheumatic drugs according to the risk of HBV reactivation is presented.

Epstein-Barr virus reactivation correlates with worse outcomes for patients exposed to hepatitis B virus after haploidentical hematopoietic stem cell transplantation

Hepatitis B virus (HBV)has a high, chronic infection rate in Asian populations, but only few studies have analyzed the effect of Epstein-Barr virus (EBV) or Cytomegalovirus (CMV) reactivation in patients exposed to HBV after haploidentical hematopoietic stem cell transplantation (haplo-HSCT). This study aimed to assess the clinical outcomes of these patients. We conducted a retrospective research including 61 patients exposed to HBV after undergoing haplo-HSCT. The patients were classified into two groups: the CMV reactivation group and no CMV reactivation group. The results were compared between the two groups using the K-W test for continuous variables, Pearson's chi-square test for categorical variables, Kaplan-Meier curves to estimate overall survival (OS) and leukemia-free survival (LFS), and a Cox proportional hazards model to analyze multivariable influences. The 3-year cumulative HBV reactivation rate was 8.2%. The median duration of HBV reactivation was 16 months (16-22 months) after haplo-HSCT. The CMV reactivation group had a higher cumulative incidence of HBV reactivation than the group without CMV reactivation. The EBV reactivation was substantially higher in the CMV reactivation group compared to that in the no CMV reactivation group (37.0% vs.5.9% respectively; P = 0.002). Furthermore, EBV reactivation was a risk factor for 1-year LFS and 1-year OS. Based on our data, EBV reactivation was related to worse outcomes in patients exposed to HBV after haplo-HSCT, whereas CMV reactivation was not.

Risk of hepatitis B reactivation in patients with myeloproliferative neoplasms treated with ruxolitinib

Classical Philadelphia-negative myeloproliferative neoplasms (MPNs), i.e., polycythemia vera, essential thrombocythemia, and primary/secondary myelofibrosis, are clonal disorders of the hematopoietic stem cell in which an uncontrolled proliferation of terminally differentiated myeloid cells occurs. MPNs are characterized by mutations in driver genes, the JAK2V617F point mutation being the most commonly detected genetic alteration in these hematological malignancies. Thus, JAK inhibition has emerged as a potential therapeutic strategy in MPNs, with ruxolitinib being the first JAK inhibitor developed, approved, and prescribed in the management of these blood cancers. However, the use of ruxolitinib has been associated with a potential risk of infection, including opportunistic infections and reactivation of hepatitis B. Here, we briefly describe the association between ruxolitinib treatment in MPNs and hepatitis B reactivation.

Entecavir: A Review and Considerations for Its Application in Oncology

Entecavir (ETV) is a drug used as a first-line treatment for chronic hepatitis B (CHB) virus infection because it is a guanosine nucleoside analogue with activity against the hepatitis B virus polymerase. The ETV dosage can range from 0.5 mg to 1 mg once a day and the most common side effects include headache, insomnia, fatigue, dizziness, somnolence, vomiting, diarrhea, nausea, dyspepsia, and increased liver enzyme levels. In addition to its conventional use, ETV acts as an inhibitor of lysine-specific demethylase 5B (KDM5B), an enzyme that is overexpressed in breast, lung, skin, liver, and prostate tumors and is involved in the hormonal response, stem cell regeneration, genomic stability, cell proliferation, and differentiation. The KDM5B enzyme acts as a transcriptional repressor in tumor suppressor genes, silencing them, and its overexpression leads to drug resistance in certain tumor types. Furthermore, the literature suggests that KDM5B activates the PI3K/AKT signaling pathway, while reducing KDM5B expression decreases AKT signaling, resulting in decreased tumor cell proliferation. In silico studies have demonstrated that ETV can inhibit tumor cell proliferation and induce apoptosis by reducing KDM5B expression. ETV also appears to inhibit PARP-1, has a high genetic barrier, reducing the chance of resistance development, and can also prevent the reactivation of the hepatitis B virus in cancer patients, which have proven to be significant advantages regarding its use as a repurposed drug in oncology. Therefore, ETV holds promise beyond its original therapeutic indication.

Case report: An occult hepatitis B virus infection reactivation in an HIV/HCV coinfected patient during an immune reconstitution inflammatory syndrome

The natural history of occult hepatitis B virus infection (OBI) and the mechanism involved in HBV reactivation are only partially understood. As regards people living with HIV (PLWH), HBV reactivation is estimated to occur with an incidence ratio of 0.019 cases per 100 person-year. Here we report the case of OBI reactivation in a HIV/HCV co-infected patient followed for 25 years at our Infectious Diseases Unit, but, unfortunately, lost to follow-up about 19 months after Direct-acting antivirals (DAAs) treatment. At re-engagement, blood tests showed high replication of plasmatic HIV-RNA along with severe immunosuppression and normal levels of liver enzymes. However, 3 months after ART reintroduction, an immune reconstitution inflammatory syndrome (IRIS) was diagnosed with high detectable HBV-DNA load and transaminase elevation. Our case report shows how the balance between the virus and the host immune system is quite a dynamic process that might significantly impact the course of the disease. The aim of this case report is to bring to the attention of physicians that, although OBI reactivation is a rather rare occurrence, even amongst PLWH, its potential consequences compel to a high alertness on the matter. Therefore, especially in patients with an impaired immune system and on a tenofovir or lamivudine-sparing regimen, HBV serological and virological markers should always be strictly monitored, even in the absence of a hepatitis flare.

Hepatitis B functional cure and immune response

Hepatitis B virus (HBV) is a hepatotropic virus, which damage to hepatocytes is not direct, but through the immune system. HBV specific CD4+ T cells can induce HBV specific B cells and CD8+ T cells. HBV specific B cells produce antibodies to control HBV infection, while HBV specific CD8+ T cells destroy infected hepatocytes. One of the reasons for the chronicity of HBV infection is that it cannot effectively activate adoptive immunity and the function of virus specific immune cells is exhausted. Among them, virus antigens (including HBV surface antigen, e antigen, core antigen, etc.) can inhibit the function of immune cells and induce immune tolerance. Long term nucleos(t)ide analogues (NAs) treatment and inactive HBsAg carriers with low HBsAg level may "wake up" immune cells with abnormal function due to the decrease of viral antigen level in blood and liver, and the specific immune function of HBV will recover to a certain extent, thus becoming the "dominant population" for functional cure. In turn, the functional cure will further promote the recovery of HBV specific immune function, which is also the theoretical basis for complete cure of hepatitis B. In the future, the complete cure of chronic HBV infection must be the combination of three drugs: inhibiting virus replication, reducing surface antigen levels and specific immune regulation, among which specific immunotherapy is indispensable. Here we review the relationship, mechanism and clinical significance between the cure of hepatitis B and immune system.

Hepatotoxicity Induced by Biological Agents: Clinical Features and Current Controversies

Novel biological agents including cytokines and recombinant fusion proteins are increasingly prescribed for cancer, rheumatologic, autoimmune, and inflammatory diseases, and are currently being evaluated in hepatocellular carcinoma (HCC). They are classified by their mechanism of action and include tumor necrosis factor-alpha (TNF-α) antagonists, T cell mediated antitumor inhibitors, interleukin receptor antagonists, and immune checkpoint inhibitors (ICIs). Some ICIs cause frequent hepatotoxicity with a variable clinical, biochemical, and serological presentation, especially in patients receiving another immunomodulatory agent. Half of the cases of liver damage induced by biological agents spontaneously regress after drug withdrawal, but the others require steroid therapy. Unfortunately, there are no widely accepted recommendation for the use of corticosteroids in these patients, even though international cancer societies have their own guidelines. Differentiating drug-induced autoimmune hepatitis (DIAIH) from classic AIH is challenging for pathologists, but liver biopsy is valuable, particularly in cases with unclear clinical presentation. Interesting, novel histological patterns have been described in liver damage induced by these agents (i.e., endothelitis, ring granuloma and secundary sclerosing cholangitis associated with lymphocytic infiltration of cytotoxic CD8+T cells). Here, we describe the clinical and biochemical characteristics of patients with hepatotoxicity induced by TNF-α antagonists and ICIs. Controversial issues involved in the administration of corticosteroid therapy, and hepatitis B virus (HBV) reactivation induced by immunosuppressive therapy are also discussed.

Prevention of HBV Reactivation in Hemato-Oncologic Setting during COVID-19

Onco-hematologic patients are highly susceptible to SARS-CoV-2 infection and, once infected, frequently develop COVID-19 due to the immunosuppression caused by tumor growth, chemotherapy and immunosuppressive therapy. In addition, COVID-19 has also been recognized as a further cause of HBV reactivation, since its treatment includes the administration of corticosteroids and some immunosuppressive drugs. Consequently, onco-hematologic patients should undergo SARS-CoV-2 vaccination and comply with the rules imposed by lockdowns or other forms of social distancing. Furthermore, onco-hematologic facilities should be adapted to new needs and provided with numerically adequate health personnel vaccinated against SARS-CoV-2 infection. Onco-hematologic patients, both HBsAg-positive and HBsAg-negative/HBcAb-positive, may develop HBV reactivation, made possible by the support of the covalently closed circular DNA (cccDNA) persisting in the hepatocytic nuclei of patients with an ongoing or past HBV infection. This occurrence must be prevented by administering high genetic barrier HBV nucleo(t)side analogues before and throughout the antineoplastic treatment, and then during a long-term post-treatment follow up. The prevention of HBV reactivation during the SARS-CoV-2 pandemic is the topic of this narrative review.

Reactivation of Occult Hepatitis B Virus Infection During Long-Term Entecavir Antiviral Therapy

Up to now, it has not been clear whether occult hepatitis B virus (HBV) infection (OBI) can be treated with antiviral therapy whether OBI can develop drug resistance gene mutation or not. We report a middle-aged female patient with OBI who showed HBV reactivation (HBVr) during more than 3 years of intermittent entecavir (ETV) antiviral therapy: seropositive HBV surface antigen (HBsAg), increased e antigen (HBeAg), and repeatedly elevated serum HBV DNA. Genotype analysis showed that the patient was infected with HBV type B. Genetic sequencing of HBV showed the mutants of S143T, D144G, and G145R in the S gene region, and the mutant of site 1896 in the pre-Core region coexisted with the wild type (G1896A/G). No mutation was found in other HBV gene segments. Drug resistance gene analysis found RtL229W mutant, resistant to lamivudine but sensitive to ETV and other nucleoside analogs. This case of OBI provides us with the following clinical experiences: Firstly, it is necessary to detect HBV genotype, mutation, and drug-resistant genes at the initial diagnosis, which can be helpful for reasonable treatment. Secondly, identifying the risk factors and mechanisms associated with HBVr could help quantify the risk of HBVr and manage the clinical consequences. Thirdly, the OBI patients with hepatitis B e antigen-positive, HBV DNA > 1 × 103 IU/ml should be recommended regular and continuous antiviral therapy as soon as possible to prevent the occurrence of hepatocirrhosis and hepatocellular carcinoma (HCC).

Late Hepatitis B reactivation after treatment with rituximab

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Patients with past hepatitis B virus (HBV) infections that undergo immunosuppression are in risk of HBV reactivation.

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Antiviral prophylaxis in patient with previous contact with HBV treated with rituximab is recommended by current guidelines.

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The duration of antiviral prophylaxis in patients with hematologic malignancies treated with rituximab remains controversial.

There is a large reservoir of individuals with past hepatitis B virus (HBV) infection that are in risk for HBV reactivation when immunosuppressed. On the setting of hematologic malignancy, the malignancy itself and currently used treatments, especially anti-CD20 agents, have risk of HBV reactivation. Antiviral prophylaxis is recommended by some international societies. We present a case of HBV reactivation more than 12 months after stopping rituximab containing treatment and 6 months of antiviral prophylaxis with entecavir, in a patient with HBV functional cure. The patient was restarted on antivirals and again obtain functional cure. The antiviral was stopped 1 year after seroconversion and the patient followed for another year without evidence of new reactivation. Most literature supports the use of antiviral prophylaxis in patients treated with rituximab. However, there are still conflicting indications and no consensus regarding the duration of prophylaxis. This clinical case and review of the literature supports a longer prophylaxis duration (more than 18 months after finishing rituximab treatments) instead of standard 12 months prophylaxis.