Veterans health administration hepatitis B testing and treatment with anti-CD20 antibody administration.
Abstract
AIM: To evaluate pretreatment hepatitis B virus (HBV) testing, vaccination, and antiviral
treatment rates in Veterans Affairs patients receiving anti-CD20 Ab for quality improvement.
METHODS: We performed a retrospective cohort study using a national repository of
Veterans Health Administration (VHA) electronic health record data. We identified
all patients receiving anti-CD20 Ab treatment (2002-2014). We ascertained patient
demographics, laboratory results, HBV vaccination status (from vaccination records),
pharmacy data, and vital status. The high risk period for HBV reactivation is during
anti-CD20 Ab treatment and 12 mo follow up. Therefore, we analyzed those who were
followed to death or for at least 12 mo after completing anti-CD20 Ab. Pretreatment
serologic tests were used to categorize chronic HBV (hepatitis B surface antigen positive
or HBsAg+), past HBV (HBsAg-, hepatitis B core antibody positive or HBcAb+), resolved
HBV (HBsAg-, HBcAb+, hepatitis B surface antibody positive or HBsAb+), likely prior
vaccination (isolated HBsAb+), HBV negative (HBsAg-, HBcAb-), or unknown. Acute hepatitis
B was defined by the appearance of HBsAg+ in the high risk period in patients who
were pretreatment HBV negative. We assessed HBV antiviral treatment and the incidence
of hepatitis, liver failure, and death during the high risk period. Cumulative hepatitis,
liver failure, and death after anti-CD20 Ab initiation were compared by HBV disease
categories and differences compared using the χ(2) test. Mean time to hepatitis peak
alanine aminotransferase, liver failure, and death relative to anti-CD20 Ab administration
and follow-up were also compared by HBV disease group. RESULTS: Among 19304 VHA patients
who received anti-CD20 Ab, 10224 (53%) had pretreatment HBsAg testing during the study
period, with 49% and 43% tested for HBsAg and HBcAb, respectively within 6 mo pretreatment
in 2014. Of those tested, 2% (167/10224) had chronic HBV, 4% (326/7903) past HBV,
5% (427/8110) resolved HBV, 8% (628/8110) likely prior HBV vaccination, and 76% (6022/7903)
were HBV negative. In those with chronic HBV infection, ≤ 37% received HBV antiviral
treatment during the high risk period while 21% to 23% of those with past or resolved
HBV, respectively, received HBV antiviral treatment. During and 12 mo after anti-CD20
Ab, the rate of hepatitis was significantly greater in those HBV positive vs negative
(P = 0.001). The mortality rate was 35%-40% in chronic or past hepatitis B and 26%-31%
in hepatitis B negative. In those pretreatment HBV negative, 16 (0.3%) developed acute
hepatitis B of 4947 tested during anti-CD20Ab treatment and follow-up. CONCLUSION:
While HBV testing of Veterans has increased prior to anti-CD20 Ab, few HBV+ patients
received HBV antivirals, suggesting electronic health record algorithms may enhance
health outcomes.
Type
Journal articleSubject
Anti-CD20 antibodyChemotherapy
Hepatitis B
Hepatitis B antivirals
Hepatitis B reactivation
Lymphoma
Rituximab
Vaccination
Veteran
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https://hdl.handle.net/10161/11950Published Version (Please cite this version)
10.3748/wjg.v22.i19.4732Publication Info
Hunt, CM (2016). Veterans health administration hepatitis B testing and treatment with anti-CD20 antibody
administration. World J Gastroenterol, 22(19). pp. 4732-4740. 10.3748/wjg.v22.i19.4732. Retrieved from https://hdl.handle.net/10161/11950.This is constructed from limited available data and may be imprecise. To cite this
article, please review & use the official citation provided by the journal.
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Christine Marie Hunt
Adjunct Professor in the Department of Medicine

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