General Management
Once a patient is diagnosed with CHB, the clinician should ensure the following:
1. Regular surveillance of liver health by looking for signs of liver abnormalities via physical examination, blood tests, and imaging. For more details, see the section on Regular Surveillance.
2. Optimise liver health:
2. Modifiable risk factors (such as hepatitis A vaccination, smoking, alcohol consumption, metabolic chronic disease) should be updated and optimised at every visit.
3. Approximately 1% of patients with CHB may naturally clear the virus (i.e., seroconvert), resulting in negative HBsAg and positive anti-HBs on serology tests. Despite this, they remain at an elevated lifetime risk of developing HCC. The cost-effectiveness of HCC surveillance in these cases is not well studied. International guidelines recommend surveillance (at least with imaging) for patients with cirrhosis, a first-degree relative with HCC, or a long history of CHB infection (over 40 years for males and 50 years for females). Primary care providers should tailor surveillance recommendations for individual patients or refer them to a hepatologist for further management.
Recommended Care Components
Table 1: Recommended Care Components5
| Recommended Tests |
Minimum Frequency*
|
Remarks
|
HbeAg
|
At first visit
|
If positive at first visit, to recheck at age 40 years, or age 35 years if high-risk factors present
if still positive, to consider specialist referral.
|
Liver Function Test
(LFT)
|
At first visit, and minimally alanine aminotransferase (ALT) once every 6 months thereafter
|
Frequency of monitoring and specialist referral to be tailored based on previous ALT values and trends as well as HBeAg status.
|
Alpha-fetoprotein
(AFP)
|
At first visit and once every 6 months thereafter
|
AFP is a tumour marker used for HCC surveillance.
|
Full Blood Count
(FBC)
|
Consider at first visit and once every 6 months thereafter
|
To monitor for thrombocytopenia associated with liver disease.
|
Ultrasound of Hepatobiliary System (U/S HBS)
|
At first visit and annually thereafter
|
Frequency of imaging to be tailored based on HCC risk. For higher risk groups
, 6-monthly imaging may be considered.
Refer to Management: Imaging for more information.
|
Hepatitis A Screening/Vaccination
|
Consider anti-HAV screening and vaccination
|
Unless contraindicated, hepatitis A vaccination should be given to prevent superimposed acute hepatitis A in patients with CHB virus infection.
|
Sexually Transmitted Infections and Hepatitis C Screening
|
Consider screening patients with high-risk behaviours
| |
Metabolic disease screening blood pressure measurement, lipid profile, BMI assessment, diabetes screening |
As per guidance under
Cardiovascular Risk Assessment and
BMI control Care Protocols
|
Development of fatty liver and metabolic risk factors further increases risk of liver cirrhosis and HCC.
|
Influenza Vaccination
|
Annually or per season for:
- Patients with chronic hepatitis or cirrhosis aged 18 to 64 years; and
- All patients aged 65 years or older
|
As recommended under the NAIS.
|
Pneumococcal Vaccination
|
Pneumococcal vaccination is recommended for:
- Patients with chronic hepatitis or liver cirrhosis (does not include hepatitis carriers without liver inflammation/ dysfunction or liver cirrhosis) aged 18 to 64 years (PCV20 OR PPSV23); and
- All patients aged 65 years or older (PCV20; OR PCV13 and/or PPSV23)
Those who have not previously received any pneumococcal vaccine can either receive:
· PCV20;
or
· PCV13 and/or PPSV23 as per prevailing recommendations.
For those who received PCV13 and/or PPSV23 but not completed the recommended vaccination series can either:
· Receive PCV20 to complete the vaccination series;
or
· Complete the vaccination series as per prevailing recommendations using PCV13 and/or PPSV23.
|
For further details on dose schedule for PCV20; or PCV13 and/or PPSV23 based on age and medical conditions, please refer to:
-
Care Protocol on Adult Vaccination;
-
MOH Circular No. 51/2025 dated 21 August 2025 |
*More frequently if clinically indicated, except for vaccination
Refer to
Primary Care Pages – Adult Vaccination Care Protocol for further vaccination-related information.
Consideration for Specialist Referral
1. Raised ALT (Tables 2 and 3)
Table 2: Referral Criteria for Raised ALT
| ALT levels (IU/L) |
Action |
≥1000
|
Refer to A&E immediately
|
1000 > ALT ≥ 200
|
Refer to a gastroenterologist as early as possible
|
ALT < 200
|
Repeat LFT in 3 months. See Table 3.
|
Table 3: Referral Critera for Pesistently Raised ALT Over 3 Months
Repeat ALT levels after 3 months (IU/L)
| Action |
ALT ≥200
|
Refer to Table 2 for management
|
200 > ALT ≥ 120
|
Refer to gastroenterologist within 2 to 6 weeks
|
120 > ALT > Upper limit of normal
|
Refer to gastroenterologist routinely
|
2. Other LFT (non-ALT) persistently raised over 3 months to refer to gastroenterologist routinely
3. Rising AFP or raised AFP above the upper limit of normal
4. HBeAg positive at (i) age ≥40 years or (ii) age ≥35 years with high risk factors
a. Persistent HBeAg positivity may indicate ongoing HBV replication and increased risk of progressive liver disease. Specialist referral enables comprehensive assessment of HBV DNA levels, ALT, fibrosis stage, and hepatocellular carcinoma risk factors to determine disease activity and treatment eligibility, including consideration of antiviral therapy and monitoring for HBeAg seroconversion.
5. Thrombocytopenia
6. Ultrasound findings suspicious for cirrhosis or abnormal lesions
7. Clinical findings of chronic liver disease or liver failure
8. Special populations:
a. Immunocompromised patients:
