The IX t h Makassed Medical Congress - American University of Beirut

T h e I X t h M a k a s e d M e d i c a l C o n g r e s s
Hepatitis B
VIRAL HEPATITIS
Florence Lacaille MD
Chronic hepatitis B remains a public health problem in many countries, due to the very efficient
neonatal and sexual transmission of the virus, the low rate (increased by alcohol drinking) of
severe complications before late adulthood, and despite the extension of vaccination programs.
Acute hepatitis B is rare in childhood, and may occur very rarely after neonatal transmission, or
after sexual exposure in adolescents.
In children, chronic hepatitis B is mostly asymptomatic, and the children are often « tolerant » to
the virus. However, hepatocarcinoma may develop even at a young age. Cirrhosis may be seen
from adolescence.
The treatment in childhood is difficult. It is most often not the treatment of a disease, but the
prevention of possible complications in adulthood. Therefore it is neither mandatory nor urgent.
Screening for complications of hepatitis B should be done once or twice a year. Vaccination
of people in close contact with the patient (family) is mandatory, in order to prevent horizontal
transmission.
Interferon (preferentially long-acting = pegylated) is efficient only in children with elevated
transaminases and a low viral load. It is not very well tolerated, should not be used before 3-4
years of age and avoided at adolescence, and should be strictly monitored. Nucleot(s)ide
analogues are increasingly used in adults, but the duration of treatment is not well defined, and
may be very long (life long ?). Lamivudine leads to the frequent emergence of resistant mutants
and should not be used alone. Adefovir is not very efficient. Tenofovir, entecavir and telbivudine
have not yet been studied in children. They should not be used outside of a protocol.
Hepatitis C
The virus is only parenterally transmitted, explaining the high rate of contamination in Egypt due
to massive antischistomiasis treatment. Unsafe blood transfusion can also be a cause. The rate of
mother-to-child transmission during pregnancy is low (5%), but it is nowadays nearly the only way
of contamination for children in countries with a safe blood bank system.
The risk of complications in childhood is even lower than for hepatitis B. Cancer has not been
seen, and cirrhosis is extremely rare. Alcohol use should be prevented, and vaccination against
hepatitis A and B implemented.
The treatment, pegylated interferon and ribavirin, depends on the viral genotype. It is very
efficient in genotypes 2 and 3 (over 80% success rate), and totally eliminates the virus. In genotype
1 (the more frequent), it is only 50% efficient. Like in hepatitis B, it does not cure a disease, but
prevents complications later in life. It is therefore neither mandatory nor urgent. It should be
discussed individually, according to the symptoms (usually none), the child’s age, the genotype,
the viral load (to determine the duration, 6 or 12 months), the additional risk factors for the liver
(hepatotoxic treatment, iron overload of a chronic anemia, co-infection with another virus…).
52