Hepatitis B

Aka: Hepatitis B, Hepadnaviridae Infection, Acute Type B Viral Hepatitis

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II. Epidemiology

  1. Transmission (100 fold more infectious than HIV)
    1. Percutaneous (needlestick) exposure
      1. Sharing non-sterile needles
      2. Tattooing
      3. Health care accidents
    2. Blood Product exposure
    3. Sexual contact
    4. Perinatal exposure
  2. Worldwide
    1. Endemic in sub-Saharan Africa, China, Southeast Asia
      1. Acquired in early life in endemic areas
      2. Chronic Hepatitis BPrevalence: 5 to 20%
    2. Worldwide Prevalence: 300 million infected
  3. U.S.
    1. Acute Hepatitis B Incidence: 21,900 per year (1.1 per 100,000) in 2015
    2. Chronic Hepatitis BPrevalence: Up to 2.4 million (in 2022)
    3. As of 2018, 36% of cases were injection drug related (driven by Opioid epidemic)

III. Pathophysiology

  1. Hepadnavirus (DNA Virus, 42 nm in size)
    1. Family: Hepadnaviridae
    2. Partially double-stranded DNA
    3. Has 10 Genotypes (A-J) and 30 subtypes
  2. Components
    1. Dane particle (entire virus)
    2. Antigens
      1. HBsAg: Outer surface coat encases virus
      2. HBcAg: Inner nucleocapsid core encases genome
      3. HBeAg: Circulating peptide encoded by core gene
    3. Genome
      1. Covalently closed circular dsDNA (cccDNA)
        1. Allows for HBV to persist in the hepatocyte nucleus despite Antiviral therapy
      2. DNA Polymerase (reverse transcriptase)
        1. Required for virus replication
  3. Hardy infectious agent
    1. Stable after 15 years storage at -20 C
    2. Stable on dried glass at room Temperature for 4 weeks
    3. Stable for 4 hours at 60 C
    4. Stable after exposure to antiseptics
      1. Ultraviolet Radiation
      2. Benzalkonium chloride
      3. Alcohol
    5. Inactivated by a few agents
      1. Glutaraldehyde
      2. Formalin
      3. Urea
  4. Hepatitis B Virus present in blood and body secretions
    1. Saliva
    2. Tears
    3. Vaginal secretions
    4. Breast Milk
  5. Timing
    1. Incubation: 60 to 90 days on average

IV. Risk Factors

  1. HIV Infection
  2. Intravenous Drug Abuse
  3. Sexually Transmitted Disease
  4. Hemodialysis patients
  5. Healthcare workers
  6. Travel from endemic areas
    1. Asia and southeast Asia
    2. Pacific Islands
    3. Eskimo
    4. India
    5. Sub-Sahara Africa
    6. Haiti

V. Findings: Signs and Symptoms

  1. See Viral Hepatitis
  2. Incidence of symptoms (subclinical in most cases)
    1. Age <5 years: <10%
    2. Age >5 years: 30-50%
  3. Symptoms
    1. Initial Acute Hepatitis B infection
      1. Nausea
      2. Vomiting
      3. Anorexia
      4. Fatigue (may persist)
      5. Headache
      6. Malaise
      7. Low grade fever
      8. Diarrhea
      9. Right Upper Quadrant Abdominal Pain
      10. Myalgia or Arthralgias
      11. Urticaria may also occur
    2. Later Acute Hepatitis B infection
      1. Jaundice

VI. Differential Diagnosis

  1. Acute Hepatitis Causes

VII. Labs: General

  1. Liver Function Tests
    1. Serum transaminases peaks 1-2 weeks before Jaundice
      1. Alanine Aminotransferase (ALT)
      2. Aspartate Aminotransferase (AST)
    2. Serum Bilirubin (rarely exceeds 20 mg/dl)
      1. Increases after serum transaminases increase
    3. Serum Albumin
      1. Decreased in severe liver disease
    4. Prothrombin Time (with INR)
      1. Increased in severe liver disease
  2. Complete Blood Count
    1. Anemia
    2. Lymphocytosis
  3. Evaluation for complications in high risk patients
    1. See Chronic Hepatitis B

VIII. Labs: Viral Hepatitis

  1. Viral Hepatitis Screening
    1. Anti-HAV Antibody
    2. Anti-HCV Antibody
    3. Acute Hepatitis B Infection Screening
      1. See Hepatitis B Serology (includes indications for screening)
      2. Screening (Identifies most cases of Acute Hepatitis B)
        1. HBsAg
        2. xHBc IgM
  2. Evaluation of positive Hepatitis B Screening
    1. See Hepatitis B Serology (see for stages of Hepatitis B infection)
    2. Additional Hepatitis B Serology
      1. xHBs IgG (test for Immunity)
      2. Anti-HBc Antibody
      3. HBeAg
      4. Anti-HBe Antibody
      5. HBV DNA
  3. Comorbid infection
    1. Anti-HDV Antibody
    2. HIV Test

IX. Management: Prophylaxis of contacts

  1. See Hepatitis B Postexposure Prophylaxis
  2. See Hepatitis B Prophylaxis in Newborns

X. Management: Acute Hepatitis B

  1. Symptomatic management
  2. Antiviral therapy offers no benefit in the acute phase
    1. Mantzoukis (2017) Cochrane Database Syst Rev (3): CD011645 [PubMed]
  3. Hepatitis B spontaneously resolves in 90% of adults within 3-6 months
    1. Recheck HBsAg at 6 months

XI. Management: Chronic Hepatitis B

  1. Definition: HBsAg positive at 6 months (10%)
  2. Management per Chronic Hepatitis B type
    1. Chronic Hepatitis B Infection
    2. Chronic Hepatitis B Carrier

XII. Complications

  1. See Chronic Hepatitis B Infection

XIII. Prognosis: Acute Hepatitis B

  1. Outcome in adults and children over age 5 years
    1. Recovery: 90%
    2. Chronic Active Hepatitis: 10%
    3. Fulminant Hepatitis: <1% (high mortality)
    4. Premature death (Hepatocellular Carcinoma, Cirrhosis) from Chronic Hepatitis B in 25% children, 15% adults
  2. Outcome in children under age 5 years
    1. Chronic infection: 30-90%
    2. Younger ages are associated with the highest risk of Chronic Hepatitis B
      1. Trepo (2014) Lancet 384(9959):2053-63 [PubMed]
  3. Worse prognosis if Hepatitis D also present
    1. Cirrhosis higher risk
    2. Hepatocellular Carcinoma higher risk

XIV. Prevention

  1. Hepatitis B Vaccine
    1. Only 30% of U.S. adults Hepatitis B vaccinated, despite Primary Series and indicated in all adults up to 59 years
  2. Perinatal Exposure
    1. See Hepatitis B Postexposure Prophylaxis in Newborns
  3. Bloodborne Pathogen Exposure
    1. See Hepatitis B Postexposure Prophylaxis
  4. Reactivation of Hepatitis B
    1. More common now with broadening use of tnf agents (e.g. Rheumatoid Arthritis, Crohn's Disease)
    2. Screen for Hepatitis B (HBsAg, HBcAb) before starting tnf agents or Chemotherapy

XV. Resources

  1. CDC NCI Viral Hepatitis B
    1. http://www.cdc.gov/ncidod/diseases/hepatitis/b

XVI. References

  1. Berenguer in Feldman (2002) Sleisenger GI, p. 1285-303
  2. Befeler (2000) Infect Dis Clin North Am 14:617-32 [PubMed]
  3. Lin (2004) Am Fam Physician 69:75-86 [PubMed]
  4. Wilkins (2019) Am Fam Physician 99(5): 314-23 [PubMed]

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Related Studies

Ontology: Hepatitis B (C0019163)

Definition (MEDLINEPLUS)

Hepatitis B is one type of hepatitis - a liver disease- caused by the hepatitis B virus (HBV). Hepatitis B spreads by contact with an infected person's blood, semen or other body fluid. An infected woman can give hepatitis B to her baby at birth.

If you get HBV, you may feel as if you have the flu, or you may have no symptoms at all. A blood test can tell if you have it. HBV usually gets better on its own after a few months. If it does not get better, it is called chronic HBV, which lasts a lifetime. Chronic HBV can lead to scarring of the liver, liver failure or liver cancer.

There is a vaccine for HBV. It requires three shots. All babies should get the vaccine, but older children and adults can get it too. If you travel to countries where Hepatitis B is common, you should get the vaccine.

NIH: National Institute of Diabetes and Digestive and Kidney Diseases
Definition (NCI) A viral infection caused by the hepatitis B virus.
Definition (MSH) INFLAMMATION of the LIVER in humans caused by a member of the ORTHOHEPADNAVIRUS genus, HEPATITIS B VIRUS. It is primarily transmitted by parenteral exposure, such as transfusion of contaminated blood or blood products, but can also be transmitted via sexual or intimate personal contact.
Definition (CSP) hepatitis caused by hepatitis B virus; one method of transmission is by transfusion of contaminated blood or blood products.
Concepts Disease or Syndrome (T047)
MSH D006509
SnomedCT 266195001, 154348008, 186625003, 66071002
LNC LA18126-5
English Hepatitis B, Viral serum hepatitis B, serum hepatitis, hepatitis B infection, hepatitis B infection (diagnosis), viral hepatitis B infection, hepatitis, B virus, Hepatitis B Infection, Hep B, Viral hepatitis B, Hepatitis B [Disease/Finding], hepatitis b viral, hepatitis B, b viral hepatitis, hepatitis viral b, viral hepatitis b, HBV, Serum hepatitis (disorder), Viral serum hepatitis B (disorder), Viral hepatitis type B, Type B viral hepatitis (disorder), Viral hepatitis type B (disorder), Serum hepatitis, Type B viral hepatitis, SH - Serum hepatitis, hepatitis; serum, hepatitis; virus, type, B, serum; hepatitis, virus; hepatitis, type, B, Viral Hepatitis B, Hepatitis B infection
Dutch serumhepatitis, virale hepatitis B, hepatitis; serum, hepatitis; virus, type, B, serum; hepatitis, virus; hepatitis, type, B, hepatitis B, Hepatitis B
French Hépatite sérique, Hép B, Hépatite B, Hépatite virale B
German Hep B, virale Hepatitis B, Serum-Hepatitis, Hepatitis B
Italian Epatite virale B, Epatite da siero, Epatite B
Portuguese Hepatite do soro, Hepatite a vírus B, Hepatite Viral B, Hepatite B
Spanish Hepatitis vírica B, Hepatitis sérica, hepatitis vírica tipo B, hepatitis sérica (trastorno), hepatitis sérica por virus de la hepatitis B (trastorno), hepatitis sérica por virus de la hepatitis B, hepatitis B, hepatitis sérica, hepatitis viral tipo B (trastorno), hepatitis viral tipo B, Hepatitis B
Japanese 血清肝炎, Ｂ型肝炎, Bｶﾞﾀｶﾝｴﾝ, ｹｯｾｲｶﾝｴﾝ, Ｂ型ウイルス性肝炎, Bｶﾞﾀｳｲﾙｽｾｲｶﾝｴﾝ
Swedish Hepatit B
Czech hepatitida B, Sérová hepatitida, Hepatitida B, Virová hepatitida B
Finnish Maksatulehdus B
Russian GEPATIT B, ГЕПАТИТ B
Croatian HEPATITIS B
Polish Zapalenie wątroby B
Hungarian Hepatitis B, serum hepatitis, hepatitis B, Viralis hepatitis B
Norwegian Hepatitt B
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Hepadnaviridae Infections (C0206746)

Definition (MSHFRE) Maladies virales dues aux HEPADNAVIRIDAE.
Definition (MSH) Virus diseases caused by the HEPADNAVIRIDAE.
Concepts Disease or Syndrome (T047)
MSH D018347
English Infections, Hepadnaviridae, Hepadnaviridae Infections, Hepadnaviridae Infection, Infection, Hepadnaviridae, INFECT HEPADNAVIRIDAE, HEPADNAVIRIDAE INFECT, Hepadnaviridae Infections [Disease/Finding]
Swedish Hepadnaviridae-infektioner
Czech Hepadnaviridae - infekce
Finnish Hepadnavirusinfektiot
Russian HEPADNAVIRIDAE INFEKTSII, HEPADNAVIRIDAE ИНФЕКЦИИ
Japanese ヘパドナウイルス科感染症
Croatian Not Translated[Hepadnaviridae Infections]
Polish Zakażenia Hepadnawirusami, Zakażenia hepadnawirusowe, Zakażenie Hepadnawirusami, Infekcje Hepadnawirusami, Infekcja Hepadnawirusami
Norwegian Hepadnaviridae-infeksjoner, Hepadnavirus-infeksjoner
French Infections à Hepadnaviridae, Infections à hépadnavirus
German Hepadnaviridaeinfektionen
Italian Infezioni da Hepadnaviridae
Dutch Hepadnaviridae-infectie, Hepadnaviridae-infecties, Infectie, hepadnaviridae-, Infecties, hepadnaviridae-
Portuguese Infecções por Hepadnaviridae
Spanish Infecciones por Hepadnaviridae
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Acute type B viral hepatitis (C0276609)

Concepts Disease or Syndrome (T047)
ICD10 B16
SnomedCT 76795007
LNC LA10472-1
English Hepatitis B Acute, acute viral hepatitis B infection, acute hepatitis B infection (diagnosis), acute hepatitis B infection, acute type B viral hepatitis, acute hepatitis b, acute b hepatitis, hepatitis b acute, Hepatitis B, acute, Acute type B viral hepatitis, Acute hepatitis B, Acute type B viral hepatitis (disorder)
German Akute Virushepatitis B, akute Hepatitis B
Korean 급성 B형간염
Spanish hepatitis vírica aguda tipo B, Hepatitis B aguda, hepatitis viral aguda tipo B (trastorno), hepatitis viral aguda tipo B, hepatitis viral tipo B aguda (trastorno)
Czech Akutní hepatitida B
Dutch acute hepatitis B, Acute hepatitis B
French Hépatite B aigüe
Hungarian Acut hepatitis B
Italian Epatite B acuta
Japanese ｷｭｳｾｲBｶﾞﾀｶﾝｴﾝ, 急性Ｂ型肝炎
Portuguese Hepatite B aguda
Derived from the NIH UMLS (Unified Medical Language System)

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