DESCRIPTION

Hepatitis B infection (HBV), caused by a DNA virus, is often transmitted by body fluids (blood, semen, and vaginal secretions). HBV is a serious global healthcare concern due to the spectrum of liver disease; it can cause ranging from acute hepatitis to cirrhosis and/or hepatocellular carcinoma (HCC).

EPIDEMIOLOGY

ETIOLOGY AND PATHOPHYSIOLOGY

HBV is a DNA virus of the Hepadnaviridae family; two modes of transmission:

• Horizontal: mucosal surface contact with infectious bodily fluids
• Vertical: maternal-to-newborn perinatal

RISK FACTORS

• The following high-risk groups should be screened for HBV with HBsAg. If HBsAg is positive, test for antibodies to HBsAg (anti-HBs) and hepatitis B core antigen (anti-HBc) to distinguish between infection and immunity. Vaccinate if seronegative (2):
  • Household or sexual contacts with hepatitis B; persons born in regions with increase prevalence (Asia, Africa, Eastern Europe); HIV- and HCV-positive patients
  • Persons born in the U.S. who were not vaccinated as infants or whose parents are from regions of high prevalence
  • Individuals with chronic liver disease; pregnant persons; persons with a history of incarceration
• Additional risk factors:
  • Donors and recipients of blood/products; persons on hemodialysis or immunosuppressive therapy; needle stick/occupational exposure; intranasal drug use; body piercing/tattoos; survivors of sexual assault; infants born to mothers positive for Hepatitis B surface antigen

Pediatric Considerations

• Shorter acute course; fewer complications
• 90% of vertical/perinatal infections become chronic.

Pregnancy Considerations

• Screen for HBsAg at first prenatal visit.
• If HBsAg (+), obtain HBV DNA.
• Consider treating patients with high viral load at 28 weeks or history of previous HBV (+) infant with oral nucleos(t)ide medication beginning at 32 weeks to reduce perinatal transmission. Infants born to HBV-infected mothers require hepatitis B immune globulin (HBIG) and HBV vaccine within 12 hours of birth, completing the vaccine series and test for infection and immunity by 9 to 12 months.
• Breastfeeding is safe if HBIG and HBV vaccines are administered and the areolar complex is without fissures or open sores. Avoid oral nucleos(t)ide medications during lactation.
• Continue treatment while pregnant to decrease viral load and decrease the chances of vertical transmission.

GENERAL PREVENTION

• Vaccination
  • Three IM injections at 0, 1, and 6 months in infants or healthy adults
  • Indicated for all medically stable infant weighing ≥2,000 g (4 lb, 6 oz) within 24 hours of birth; unvaccinated infants, children, and adults; all at-risk patients; health care and public safety workers; sexual contacts and household contacts of HBsAg carriers
  • CDC does not recommend administration of >2 complete hepatitis B series except for certain cases related to patients on hemodialysis.
• Other preventive measures
  • Proper hygiene/sanitation by health care workers, IVDUs, and tattoo/piercing artists; barrier precautions, needle disposal, sterilize equipment, cover open cuts; do not share personal items exposed to blood (e.g., nail clipper, razor, toothbrush).
  • Safe sexual practices (condoms)
  • HBsAg carriers cannot donate blood or tissue.
  • Postexposure (e.g., needle stick):
    • HBIG 0.06 mL/kg in <24 hours in addition to vaccination (no more than 7 days after exposure)
    • Second dose of HBIG should be administered 30 days after exposure.

COMMONLY ASSOCIATED CONDITIONS

• HIV, hepatitis C coinfection
• Extrahepatic manifestations include:
  • Serum sickness-like syndrome (fever, erythematous rash, myalgias, arthralgias, fatigue); glomerulonephritis (membranous or membranoproliferative glomerulonephritis, IgA-mediated nephropathy)
  • Polyarteritis nodosa (primary systemic necrotizing vasculitis, high fever, weakness, malaise, loss of weight and appetite); cryoglobulinemia (Raynaud phenomenon, arthritis, sicca syndrome)
  • Neurologic/psychological condition (Guillain-Barré syndrome, altered mental status, depression/psychosis)