Hepatitis B

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Basics

Description

Systemic viral infection associated with acute and chronic liver disease and hepatocellular carcinoma (HCC)

Epidemiology

Incidence
  • Predominant age: can infect patients of all ages
  • Predominant sex: fulminant hepatitis B virus (HBV): male > female (2:1)
  • In the United States, ~3,200 cases of acute HBV in 2016
  • African Americans have the highest rate of acute HBV infection in the United States.
  • Overall rate of new infections is down 82% since 1991 (due to national immunization strategy). There has been a slight increase in new infections since 2014 (associated with increased IV drug use).
  • Vaccine coverage for the birth dose ~72% in United States

Prevalence
  • In the United States, 800,000 to 1.4 million with chronic HBV
  • Asia and the Pacific Islands have the largest populations at risk for HBV.
  • Chronic HBV worldwide: 350 to 400 million persons
    • 1 million deaths annually
      • Second most important carcinogen (behind tobacco)
      • Of chronic carriers with active disease, 25% die due to complications of cirrhosis or HCC.
      • Of chronic carriers, 75% are Asian.

Etiology and Pathophysiology

HBV is a DNA virus of the Hepadnaviridae family; highly infectious via blood and secretions

Genetics
Family history of HBV and/or HCC

Risk Factors

  • Screen the following high-risk groups for HBV with HBsAg/sAb. Vaccinate if seronegative (1)[A]:
    • Persons born in endemic areas (45% of world)
    • Hemodialysis patients
    • IV drug users (IVDUs), past or present
    • Men who have sex with men (MSM)
    • HIV- and HCV-positive patients
    • Household members of HBsAg carriers
    • Sexual contacts of HBsAg carriers
    • Inmates of correctional facilities
    • Patients with chronically elevated AST/ALT levels
  • Additional risk factors:
    • Needle stick/occupational exposure
    • Recipients of blood/products; organ transplant recipients
    • Intranasal drug use
    • Body piercing/tattoos
    • Survivors of sexual assault
Pediatric Considerations
  • Shorter acute course; fewer complications
  • 90% of vertical/perinatal infections become chronic.
Pregnancy Considerations
  • Screen all prenatal patients for HBsAg (1)[A].
  • 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 (2)[C].
  • Infants born to HBV-infected mothers require hepatitis B immune globulin (HBIg) (0.5 mL) and HBV vaccine within 12 hours of birth.
  • Breastfeeding is safe if HBIg and HBV vaccines are administered and the areolar complex is without fissures or open sores. Oral nucleos(t)ide medications are not recommended during lactation.
  • HIV coinfection increases risk of vertical transmission.
  • Continue medications if pregnancy occurs while on an oral antiviral therapy to prevent acute flare.

General Prevention

Most effective: HBV vaccination series (3 doses)

  • Vaccinate
    • All infants at birth and during well-child care visits
    • All at-risk patients (see “Risk Factors”)
    • Health care and public safety workers
    • Sexual contacts of HBsAg carriers
    • Household contacts of HBsAg carriers
  • 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

Commonly Associated Conditions

HIV, hepatitis C coinfection

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