Hepatitis B

Background information

Testing

Treatment

Prevention and control

Patient information (English only)

Patient information (English and other languages)

Other useful resources

References

Background information

• Globally, approximately two billion people have been infected with HBV, of whom 350 million are chronically infected. Overall an estimated 600,000 persons die each year due to the acute or chronic consequences of hepatitis B infection [1]. 
• Areas with the highest prevalence rates of chronic hepatitis B include south east Asia, Africa, the middle and Far East, and southern and eastern Europe [2].
• In the UK, the prevalence of chronic hepatitis B infection is estimated to be 0.3% (approximately 180,000 people). 
• In any given year, the majority (96%) of chronic hepatitis B infections added to the existing numbers of such infections in England and Wales, are likely to be in individuals born in countries with an intermediate or high prevalence [3].
• The hepatitis B virus (HBV) causes hepatitis (inflammation of the liver) and can also cause long term liver damage. Mortality is rare during the acute phase of infection (less than 1%), but can occur.
• Many people have no symptoms during acute infection, while others can experience:
  • flu-like illness (sore throat, tiredness, joint pains, loss of appetite)
  • nausea 
  • vomiting
  • abdominal discomfort and jaundice with dark urine 
• HBV may be transmitted through contact with infected blood or body fluids by the following routes:
  • sharing or use of contaminated equipment during injecting drug use 
  • vertical transmission (mother to baby) 
  • sexual transmission 
  • receipt of infectious blood (via transfusion) or infectious blood products (for example clotting factors) 
  • needlestick or other sharps injuries 
  • tattooing and body piercing 
• The average incubation period is 40-160 days [2].
• Most adults infected with HBV fully recover and develop life-long immunity.
• The likelihood that an HBV infection will become chronic depends upon the age at which a person becomes infected. About 90% of infants infected during the first year of life develop chronic infections, compared to 30% to 50% of children infected between one to four years of age, and up to 10% of adults [2]. The risk of chronic infection is increased where immunity is impaired.
• Chronic infection leads to persistent infectivity and can also lead to liver cirrhosis and malignant change in the liver. Approximately 25% of adults who become chronically infected during childhood later die from HBV-related liver cancer or cirrhosis.

For further background information, please see the Public Health England (PHE) hepatitis B page. 

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Testing

The Advisory Group on Hepatitis with contributions from the HPA has prepared a document that is currently out for consultation which recommends case finding for chronic hepatitis B in individuals from countries with a prevalence of hepatitis B infection ≥2% (indicated by high and intermediate categories on the specific infectious diseases country pages of this website). This document also recommends ensuring that there are care pathways in place for those who are found to be infected.

Some guidance relating to hepatitis B testing is included in the RCGP document: Guidance for the prevention, testing, treatment and management of Hepatitis C in primary care [external link] .

Sample required for diagnosis: a clotted blood (2-6ml) sample should be sent to your local laboratory.

Always include recent travel history in the information provided on the test request form.

A guide to interpretation of serological markers (please discuss with your local laboratory if uncertain)
 

Viral antigens that denote infectiousness:

• Hepatitis B surface antigen (HBsAg) - the earliest to be detected; high concentrations are produced during viral replication. This antigen is cleared if the acute infection resolves; if it persists for more than six months then the infection is defined as chronic. Presence of the antigen indicates that the patient is infectious and that viral replication is occurring.
• Hepatitis B e antigen (HBeAg) - detected soon after HBsAg, is a marker of infectiousness and viral replication. This antigen is also normally cleared if the acute infection resolves. In chronic infections it may persist.

Note that among those who are HBsAg positive, those who are also HBeAg positive are the most infectious to others.

Antibodies which denote exposure:

• Antibody to the hepatitis B core antigen (anti-HBc) - antibody response is divided into two antibody subclasses IgM and IgG. The anti-HBc IgM subclass is indicative of acute infection whereas the anti-HBc IgG subclass is found during acute, chronic and resolved hepatitis B infection and is a marker of exposure to the virus. Both antibodies maybe detected in one antibody test and reported as total anti-HBc.
• Antibody to the hepatitis B e antigen (anti-HBe) - antibody is found in individuals who have cleared HBeAg. However it may fall to undetectable levels over time. 

Antibody associated with recovery:

• Antibody to the hepatitis B surface antigen (anti-HBs) - development of anti-HBs is generally associated with disappearance of HBsAg in those recovering from natural infection. It is also produced in response to hepatitis B immunisation. It is a marker of immunity against the virus.

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Treatment

Acute infection

Treatment of acute hepatitis B is symptomatic. Liver failure is a rare complication that requires specialist treatment. Following acute infection the patient should be followed up to ensure that HBsAg and HBeAg are cleared and that anti-HBs develops denoting naturally acquired immunity.

Chronic infection

If HBsAg persists for more than six months then the patient is considered chronically infected and should be referred to a specialist for consideration of antiviral treatment and further management. Patients with chronic hepatitis B infection should be referred to the local secondary care specialist for further assessment and general management to reduce the risk of infectivity and complications. Although not all patients are suitable, specific treatment with anti-virals may reduce viral replication, clear HBsAg and HBeAg and stimulate production of anti-HBe and anti-HBs. Such treatments are initiated by the secondary care specialist, though shared care arrangements may allow the primary care practitioner to continue to prescribe in liaison with the specialist. The patient should be counselled on moderation in alcohol consumption and care should be taken in prescription of potentially hepatotoxic drugs.

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Prevention and control

Hepatitis B vaccine should be offered to all individuals at risk from hepatitis B infection, including infants born to  hepatitis B surface antigen positive mothers. For further information see Chapter 18 of Immunisation against Infectious Disease (more commonly known as "The Green Book" [external link]).

For country specific travel advice please consult the National Travel Health Network and Centre [external link] (NaTHNaC).

Opportunistically ask about travel plans as patients who travel to visit friends and relatives in countries where the infection is endemic are at increased risk of acquiring infection. Patients within this group may also choose/need to undergo medical treatment during their trip e.g. dialysis, and some instances have been recorded of acquisition of blood borne viruses in this way. Patients should be counselled about this potential risk. Patients who will be receiving dialysis abroad should be immunised prior to dialysis commencing.

Acute hepatitis B is a notifiable disease in the UK. If a case is diagnosed it should be notified to your local HPT who will ensure that information is provided to prevent onward transmission and to immunise any contacts who are at risk of infection.

Post exposure prophylaxis

Guidance on post exposure prophylaxis is available in Chapter 18 of Immunisation against Infectious Disease (more commonly known as "The Green Book" [external link]).

Hepatitis B immunoglobulin is available via Public Health England. Please call 0208 200 6868.

The Immunoglobulin Handbook, contains information, indications and guidance for the use of immunoglobulin preparations for specific diseases including hepatitis B.

If in doubt about post exposure prophylaxis please discuss with your local HPT.

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Patient information (English only)

Patient UK leaflet on hepatitis B immunisation [external link]

NaTHNaC hepatitis B leaflet for travellers [external link]

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Patient information (English and other languages)

British Liver Trust leaflets [external link] in a range of languages

Hepatitis B foundation UK leaflets [external link] in a range of languages

Hepatitis B: how to protect your baby [external link] (Department of Health information leaflet) Available in English, Arabic, Bengali, Chinese, French, Greek, Gujarati, Hindi, Portuguese, Pubjabi, Somali, Swahili, Turkish, Urdu

Viral hepatitis (including hepatitis B) information for female sex workers [external link] and STI, AIDS and Hepatitis B information for transgender sex workers [external link] is available in a range of languages from TAMPEP (European Network for HIV/STI Prevention and Health Promotion among Migrant Sex Workers)

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Other useful resources [external links]

Chronic viral hepatitis in migrants [external link] training video from HPA migrant health event 12 November 2012

Hepatitis B Foundation UK [external link] UK based charity which raises awareness about the prevention, treatment and management of hepatitis B virus (HBV) infection and facilitates networking between patients and/or families affected by HBV infection.

The British Liver Trust [external link] a charity which provides resources including a website, helpline and publications for people with liver disease.

National Travel Health Network and Centre [external link] (NaTHNaC) - for country specific travel advice.

NaTHNaC Hepatitis B information for health professionals [external link]

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References

1. World Health Organization Hepatitis B Factsheet [external link]
2. Public Health England Hepatitis B page 
3. Health Protection Agency. Migrant Health: Infectious diseases in non-UK born populations in England, Wales and Northern Ireland. A baseline report - 2006

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