TREATMENT & GUIDELINESS

FOR HEPATITIS B-C VIRUS IN PRACTICE CLINIC

DR. LYDIA TANDRI, Sp.PD

 WORLDWIDE, MORE
THAN 290 MILLION
PEOPLE ARE
COMPLETELY
UNAWARE THAT THEY
ARE LIVING WITH A
LIFE-THREATENING
ILLNESS.
 PREVALENSI VHB : GLOB AL ESTIMATES
HBsAg
Positive, %
Taiwan 10.0-13.8
Vietnam 5.7-10.0
China 5.3-12.0
Africa 5.0-19.0
Philippines 5.0-16.0
Thailand 4.6-8.0
Japan 4.4-13.0
Indonesia 4.0 – 8.2
South
2.6-5.1
Korea
HBsAg Prevalence India 2.4-4.7
Russia 1.4-8.0
High (≥ 8%)
Intermediate (2% to 8%) US 0.2-0.5
Low (< 2%) Mast EE, et al. MMWR Recomm Rep. 2006;55:1-33.
Custer B, et al. J Clin Gastroenterol. 2004;38(10 suppl):S158-S168.

Indonesia : Riset Kesehatan Dasar 2013 

Sekitar 22,5 juta (±10%) penduduk Indonesia terinfeksi virus Hepatitis B
DIPERKIRAKAN 170 JUTA ORANG MENDERITA INFEKSI HCV DI
SELURUH DUNIA Prevalensi di Indonesia 0.8-1% (2.5 juta penduduk)

 3-4 juta kasus baru/tahun diseluruh dunia

World Health Organization 2008. Available at: http://www.who.int/ith/es/index.html. Accessed October 28, 2009.
 HBV INCIDENCE IN RSWS

HBV
300

200

100

HBV
 HCV INCIDENCE IN RSWS

HCV
90
80
70
60
50
40
30
20
10
0
2007-2009 2014 2015 2016

HCV
 INCIDENCE HBV/HCV DI MAKASSAR
DALAM RANGKA HARI HEPATITIS SEDUNIA

Populasi Rata2 usia Jumlah (%) Gender

Skreening populasi 2010 22-50 thn 42/485 (8.7%) L>P

HBV

Skreening populasi 2010 26-74 thn 5/485 (1.03%) L>P

HCV

Screening healthcare 2018 25-42 thn 9/389 (2.31%) P>L

HBV

Screening healthcare 2018 25-42 thn 0/389 (0%)

HCV
 INSIDENCE SIROSIS HATI
RS.DR.WAHIDIN SUDIROHUSODO APRIL-AGUSTUS 2018

Populasi Rata-Rata Usia Jumlah (%) Gender

50/65
HBV 32-76 L>P
(76,9%)

HCV
32-76 2/65 (3,0 %) L=P
 INCIDENCE OF HCC
JANUARY 2017 – AUGUST 2018

Gender Rata-rata usia Etiologi

(N=118)
L : 95 orang 40-70 tahun HBV : 89 orang
P : 23 oang HCV : 6 orang
Fatty liver : 4 orang
Unknown : 19 orang
PENULARAN HEPATITIS B

• MAINLY BY EXPOSURE TO INFECTED BLOOD OR BODY SECRETIONS

NEED A BREAK IN SKIN OR MUCUS MEMBRANE
• IN INFECTED INDIVIDUALS, THE VIRUS CAN BE FOUND IN THE BLOOD,
SEMEN, VAGINAL DISCHARGE, BREAST MILK, AND SALIVA. BUT AT
LEVELS 1000-FOLD LOWER THAN IN SERUM

• HEPATITIS B IS NOT SPREAD THROUGH FOOD, WATER, OR BY CASUAL

CONTACT.= NOT FOUND IN URINE, SWEAT, OR STOOL
HEPATITIS : DETEKSI DAN DIAGNOSIS

•
•
• ENZIM HATI, BILIRUBIN, DLL

•
• ANTIBODI

•
• ANTIGEN, HBV-DNA
 IgM Anti-
HBcAg

HBsAg 1st AB to appear; acute infection

Anti HBcAg
HBsAg
appears before
IgG Anti-
not found in blood test
symptoms; used to HBcAg
resolution of acute
screen blood donor; disease & immunity
negative = viral (sole marker after previous (HBsAg-) or chronic (HBsAg +)
clearence vaccination) HBV infection

HBeAg HBV DNA

by product (evidance) of viral active viral replication

replication (↑ infectivity/acute
infection)

waning viral
Anti
replication, 
HBeAg infectivity
Petanda Serologis

Total anti- IgM anti- Anti-

HBsAg HBc HBc HBs Interpretasi

– – – – Tidak pernah terinfeksi

+† – – – Infeksi akut awal; sementara (sampai 18 hari)

setelah vaksinasi

+ + + – Infeksi akut

– + + – Infeksi akut perbaikan

– + – + Peyembuhan setelah infeksi dan kebal

+ + – – Infeksi kronik

– + – – Positif palsu (mudah terinfeksi); infeksi masa lalu;

Infeksi kronik derajat rendah§;

transfer pasif pada bayi yang lahir dari ibu

HBsAg+

– – – + Kebal jika konsentrasi >10 mIU/mL,

transfer pasif setelah pemberian HBIG

1 A threshold of ≥2% or ≥5% seroprevalence was based on several published thresholds of intermediate or high seroprevalence. The threshold used will depend on other country considerations and
epidemiological context.
2 Many countries have chosen to adopt routine testing in all pregnant women, regardless of seroprevalence in the general population, and particularly where seroprevalence ≥2%. A full vaccination schedule
including birth dose should be completed in all infants, in accordance with the WHO position paper on hepatitis B vaccines 2009.6

WHO guidelines on hepatitis B and C testing 2017

WHO TO TEST FOR CHRONIC HBV INFECTION

WHO guidelines on hepatitis B and C testing 2017

WHO TO TEST FOR CHRONIC HBV INFECTION

WHO guidelines on hepatitis B and C testing 2017

 acute infection/ resolving
infection/false positive (confirm
Anti-HCV HCV qualitative)
in serum, liver tissue, peripheral blood
lymphocytes

HCV RNA

quantitative qualitative
 PEMERIKSAAN IMAGING

• USG

• CT SCAN
• MRI
• FIBRO SCAN
PENANGANAN
•
• OBAT YANG MELINDUNGI KERUSAKAN HATI
• ANTIVIRUS
• MEMODULASI SISTIM IMUN

•
• NON-IMUNISASI : POLA HIDUP SEHAT (KONTROL BB,
HINDARI ALKOHOL); SURVAILANS KANKER HATI
• IMUNISASI : VAKSINASI
1. TARGET IDEAL
2. TARGET MEMUASKAN

3. TARGET DIINGINKAN
Summary algorithm for diagnosis, treatment and monitoring1 of chronic HBV
infection

RDT: rapid diagnostic test.

In settings or populations with a low HBsAg seroprevalence <0.4%, confirmation of HBsAg positivity on the same immunoassay with a
neutralization step or a
second different RDT assay for detection of HBsAg may be considered.
3 Laboratory-based Immunoassays include enzyme immunoassay (EIA), chemoluminescence immunoassay (CLIA), and
electrochemoluminescence assay (ECL)

WHO guidelines on hepatitis B and C testing 2017

Summary algorithm for diagnosis, treatment and monitoring1 of chronic HBV
infection

ALT: alanine aminotransferase; APRI: aspartase aminotransferase-to-platelet ratio index; TE: transient elastography;
WHO guidelines on hepatitis B and C testing 2017
Summary algorithm for diagnosis, treatment and monitoring1 of chronic HBV
infection

WHO guidelines on hepatitis B and C testing 2017

ORAL NUKLEOTIDA-NUKLEOSIDA ANALOG HBV

Lok AS, et al. Hepatology. 2009;50:661-661

PEMANTAUAN RESPON TERAPI

Pemeriksaan Waktu pemeriksaan

DNA VHB 3-6 bulan sekali sampai 12 bulan selesai

terapi

HBeAg/Anti HBe 3-6 bulan sekali sampai 12 bulan selesai

terapi

HBsAg/Anti-HBs Awal dan akhir terapi

ALT 3-6 bulan sekali sampai 12 bulan selesai

terapi

Biopsi Sesuai indikasi

USG dan AFP Setiap 6 bulan pada usia >40 tahun

PERHIMPUNAN PENELITI HATI INDONESIA

Konsensus PPHI PPHI INA-ASL
PEMANTAUAN EFEK SAMPING

Terapi Pemeriksaan Waktu pemeriksaan

INTERFERON Darah Lengkap 1 bulan sekali

Penapisan depresi dan Pada setiap kunjungan

gangguan psikiatri

ADEFOVIR ATAU Pemeriksaan fungsi ginjal 1-3 bulan sekali

TENOFOVIR
TELBIVUDIN Penapisan adanya miopati Pada setiap kunjungan
lewat anamnesis dan
pemeriksaan fisik

PERHIMPUNAN PENELITI HATI INDONESIA

Konsensus PPHI PPHI INA-ASL
Panduan Tatalaksana
Di Indonesia 2017

PERHIMPUNAN PENELITI HATI INDONESIA

PPHI INA-ASL
PERKEMBANGAN TERAPI HEPATITIS C

Direct-Acting All-Oral
Antivirals Therapy
(DAAs) 2013 Current
100 95+
Peginterferon 2011 90+
(pegIFN)
80 Ribavirin 2001
Standard (RBV) 70+
Interferon 1998
60 (IFN) 55
1991
42 39
40 34

20 16
6
0
IFN IFN IFN/RBV IFN/RBV PegIFN PegIFN/RBV PegIFN/ DAA + All–Oral
6 Mos 12 Mos 6 Mos 12 Mos 12 Mos 12 Mos RBV + RBV ± DAA±
DAA PegIFN RBV
Many Options in 2016: Current All-Oral Regimens
for Hepatitis C Infection
Regimen Approved Genotypes
Grazoprevir/elbasvir 1, 4
Ombitasvir/paritaprevir/ritonavir 4  Effective options for every
Ombitasvir/paritaprevir/ritonavir + genotype
1
dasabuvir
Sofosbuvir + daclatasvir 1, 3  Single-pill formulations or
2-pill combinations
Sofosbuvir/ledipasvir 1, 4, 5, 6
Simeprevir + sofosbuvir 1, 4
Sofosbuvir/velpatasvir 1, 2, 3, 4, 5, 6

 Effective for all genotypes

HCV Treatment in 2016
 Many highly effective, highly tolerable options
 All-oral therapy for all
 Most pts receive:
– 12 wks of treatment
– 1 pill, once per day
– Ribavirin-free therapy
 Pts with previous pegIFN/RBV treatment easy to cure
 REKOMENDASI SESUAI KONDISI DI
INDONESIA
Genotipe Terapi
Genotipe 1 • Sofosbuvir (400 mg/ hari) + weight based Ribavirin (1000 mg/hari (<75kg);
1200 mg/hari (>75kg)) + PEG-IFN selama 12 minggu
ATAU
• Sofosbuvir (400 mg/ hari) + simeprevir (150mg) dengan ataupun tanpa
Ribavirin selama 12 minggu
• Genotipe
Sofosbuvir
2
harus digunakan dalam bentuk
Sofosbuvir (400mg/ hari) + weight-based Ribavirin (1000 mg/hari (<75kg);
kombinasi, baik dengan
1200 mg/hari Ribavirin
(>75kg)) selama 12 minggu +/- Peg-IFN
• Genotipe
Untuk 3 • Sofosbuvir (400mg/ hari) + weight-based Ribavirin (1000 mg/hari (<75kg);
genotipe 1,4,5,6,
1200 penggunaan
mg/hari (>75kg)) selama 24 minggu sofosbuvir
ATAU
masih memerlukan• Sofosbuvir kombinasi
(400 mg/ hari) + weight dengan Peg-IFN
based Ribavirin (1000 mg/hari (<75kg);
1200 mg/hari (>75kg)) + PEG-IFN selama 12 minggu
selama DAA lainnya belum tersedia
Genotipe 4 • Sofosbuvir (400 mg/ hari) + weight based Ribavirin (1000 mg/hari (<75kg);
1200 mg/hari (>75kg)) + PEG-IFN selama 12 minggu
• Sofosbuvir (400mg/ hari) + weight-based Ribavirin (1000 mg/hari (<75kg);
1200 mg/hari (>75kg)) selama 24 minggu

Genotipe 5 & 6 • Sofosbuvir (400 mg/ hari) + weight based Ribavirin (1000 mg/hari (<75kg);
1200 mg/hari (>75kg)) + PEG-IFN selama 12 minggu
MONITORING FRAMEWORK BEFORE AND DURING
DAA TREATMENT
 Goal Is Elimination of Hepatitis C Infection

2030 WHO Targets

Improve
90% Diagnosed Provider
Education
Treatment
Access
80% Treated
65% Reduced Mortality Monitoring Secure
and Political
Evaluation Commitment

National
Partnership
Planning Development

Capacity
Assessment

WHO. Towards the elimination of hepatitis B and C by 2030.

Mitruka K, et al. MMWR Morb Mortal Wkly Rep. 2015;64:753-757.
TERIMA KASIH