Hepatitis B
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Basics
Description
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).
Epidemiology
Incidence
- 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
Prevalence
- 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.
- 1 million deaths annually
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:
- 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)
-- To view the remaining sections of this topic, please log in or purchase a subscription --
Basics
Description
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).
Epidemiology
Incidence
- 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
Prevalence
- 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.
- 1 million deaths annually
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:
- 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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