Hepatitis B



Infections caused by the hepatitis B virus (HBV), a DNA virus that is in the Hepadnaviridae family. HBV can lead to a spectrum of liver disease ranging from acute hepatitis to chronic conditions such as cirrhosis or hepatocellular carcinoma (HCC).



  • Can infect patients of all ages, 80% of cases are in persons aged 30 to 59 (1)
  • Predominant sex: fulminant HBV: male > female (2:1)
  • In the US, ~3,200 cases of acute HBV in 2019 (2)
  • White, non-Hispanic people have the highest rate of acute HBV infection in the United States (2).
  • Overall rate of new infections is down over 80% 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 US


  • In the United States, 1.59 million persons (range 1.25 to 2.49 million) with chronic HBV (3)
  • Asia, the Pacific Islands, and people born in Africa have the largest populations at risk for HBV (4).
  • 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

Family history of HBV and/or HCC

Risk Factors

  • Screen the following high-risk groups for HBV with HBsAg/sAb. Vaccinate if seronegative:
    • Persons born in endemic areas (45% of world)
    • End-stage renal disease (dialysis)
    • IV drug users (IVDUs), past or present
    • Men who have sex with men (MSM)
    • HIV- and HCV-positive patients
    • Individuals with chronic liver disease
    • 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 transplants
    • 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.
  • 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) (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 increases risk of vertical transmission.
  • Continue medications if pregnancy occurs while on an oral antiviral therapy to prevent acute flare.

General Prevention

  • Vaccination
    • Three IM injections at 0, 1, and 6 months in infants or healthy adults
    • All infants at birth and during well-child care visits (age 1 and 6 months)
    • 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 (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 skin 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)
    • Dermatologic conditions (bullous pemphigoid, lichen planus, Gianotti-Crosti syndrome)
    • Cryoglobulinemia (Raynaud phenomenon, arthritis, sicca syndrome)
    • Neurologic/psychological condition (Guillain-Barré syndrome, altered mental status, depression/psychosis)

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