Recommendations for screening, monitoring, prevention, prophylaxis and therapy of Hepatitis B virus reactivation in patients with haematological malignancies and patients who underwent haematological stem cell transplantation - a position paper

Hepatitis B virus (HBV) infection reactivation is associated with high morbidity and mortality in patients with haematological malignancy and/or haematopoietic stem cell transplantation (HSCT) however information on this issue is limited. The scope of this position paper is to provide recommendations on HBV screening, monitoring, prophylaxis, treatment and vaccination in the patients described above.METHODS: - These recommendations were developed from one meeting of experts attended by different Italian scientific societies as well as from a systematic literature review (through December 31, 2016) on HBV infection in haematological patients and in patients who underwent HSCT published in the same issue of this journal. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology was used to provide a grading of each recommendation's quality. QUESTIONS ADDRESSED: These recommendations provide the answers to the following questions:1. HBV screening and monitoring: Who should be screened before starting chemotherapy (CHT)? Which screening tests should be used? Should HBV-DNA detection be used to monitor HBV reactivation before starting antivirals? What is the best timeline to monitor HBV reactivation?; 2. Prophylaxis in HBsAg-positive patients: Which antiviral drugs should be used to treat HBsAg-positive patients? How long should antiviral prophylaxis be given to HBsAg-positive patients?; 3. Prophylaxis in patients with resolved HBV infection: Which patients with resolved HBV-infection should receive antiviral prophylaxis? Which antiviral drug should be used? How long should antiviral prophylaxis be given?; 4. HBV infection management strategy in autologous (auto-HSCT) and allogeneic HSCT (allo-HSCT): Which HSCT recipients should receive antiviral prophylaxis? Which antiviral drug should be used? How long should antiviral prophylaxis be given?; 5. Should third generation anti-HBV drugs be preferred to first or second generation antiviral drugs in the treatment of HBV reactivation with or without hepatitis flare in haematological patients; 6. Immunization against HBV in patients with haematological malignancies and/or patients who underwent HSCT: Should patient with haematological malignancies and/or those who underwent HSCT be vaccinated? Which HBV vaccination schedule should be adopted? RECOMMENDATIONS: Hematologic patients should be screened for HBV (HBsAg plus anti-HBc, and HBV DNA in HBV-positive) before CHT. HBV DNA levels should be monthly monitored in all HBV-positive patients who do not receive prophylaxis. HBsAg-positive haematologic patients and those undergoing HSCT, should be receive third-generation antivirals as prophylaxis. Anti-HBc-positive lymphoma patients and those receiving HSCT should receive antiviral prophylaxis. All HBV-negative haematologic patients should be vaccinated for HBV. The acquisition of data from well-designed studies is desirable in the near future.