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Main messages

Healthcare professionals should:

• offer hepatitis B screening, in line with , to people born or raised in countries where the prevalence of chronic hepatitis B is intermediate or high (2% or greater)
• offer testing and vaccination to close contacts of people living with hepatitis B, including household and sexual contacts
• ensure babies born to mothers living with hepatitis B receive appropriate care, including
• ensure that those at risk of infection are immunised against hepatitis B as per the Green Book, and
• consider acute hepatitis B infection in patients who present with a compatible clinical picture and test appropriately – acute hepatitis B infection is aÌýstatutorily notifiable disease and if diagnosed in your patient, you should contact your localÌýhealth protection team (HPT)Ìýabout appropriate post-exposure prophylaxis for close contacts of cases of hepatitis B infection
• refer individuals identified as living with hepatitis B for specialist care
• work in partnership with local community services serving migrant populations to provide support to access testing and care

Background

The Ìývirus (HBV) causes hepatitis infection (inflammation of the liver) and can also cause long term (chronic) liver damage including hepatocellular carcinoma.

°Õ³ó±ðÌýÌýthat globally:

• over 254 million people were living with chronic hepatitis B in 2022 and infections resulted in an estimated 1.1 million deaths in the same year, mostly from cirrhosis and liver cancer
• only an estimated 13% of people living with hepatitis B are aware of their infection – mortality is rare during the acute phase of infection (estimated to be less than 1%),Ìýbut can occur
• the is found in the WHO Western Pacific Region and the WHO African Region, where 97Ìýmillion and 65Ìýmillion people, respectively, are living with chronic infection
• 61Ìýmillion people who are living with chronic infection are in the WHO South-East Asia Region, 15Ìýmillion in the WHO Eastern Mediterranean Region, 11Ìýmillion in the WHO in the WHO European Region and 5Ìýmillion in the WHO Region of the Americas

In the UK, the prevalence of chronic hepatitis B infection is estimated to be 0.6%, or approximately 269,000 people. This increases to 1.5% in London.

In any given year, the majority (over 95%) of people with newly diagnosed chronic hepatitis B infections in the UK are migrants whoÌýmost likely acquired their infection in their country of birthÌýduring early childhood.

Symptoms

Acute infection

Many people have no or mild symptoms during acute infection. Where do occur, they usually last between 1 and 6 weeks, and can include:

• a high temperature
• tiredness
• right upper quadrant abdominal pain
• nausea
• a rash or hives
• jaundice – which may be less noticeable on brown or black skin – may also occur with dark urine and/or pale stools if cholestasis
• most adults do not have any lasting problems after having a short-term hepatitis B infection, but some develop long-term (chronic) hepatitis

Chronic infection

Most people living with chronic hepatitis B infection are asymptomatic.

Chronic infection leads to persistent infectivity. Approximately which cancer. Timely monitoring and treatment can reduce the risk of developing cirrhosis and hepatocellular carcinoma (HCC) once a diagnosis of chronic infection has been made.

The likelihood that a hepatitis BÌýinfection will become chronic depends upon the age at which a person becomes infected. Around 90% of infants infected during theÌýfirst year of life develop chronic infections, compared to 20% to 50% in children infectedÌýbetween 1 to 5 yearsÌýof age, and Ìý

There is an increased risk of chronic infection whereÌýimmunity is impaired.

Transmission

Hepatitis BÌýis transmitted through contact with infected blood or body fluids and transmission mostly occurs through:

• vaginal or anal intercourse
• blood-to-blood contact through percutaneous exposure (for example sharing of needles and other equipment by people who inject drugs, and needlestick injuries)
• perinatal transmission from mother to child

More rarely, transmission has also occurred following bites from people living with hepatitis B. Transmission following blood transfusion in the UK is very rare as blood donors and donations are screened. Transmission following medical interventions in the UK is also rare but there may be an increased risk of healthcare associated transmission following procedures overseas.

°Õ³ó±ðÌýaverage incubation periodÌýis around 12 weeks (range 40 to 160 days).

Testing

Offer testing to anyone at . This includes migrants from medium or high prevalence countries (all countries in Africa, Asia, the Caribbean, Central and South America, Eastern and Southern Europe, the Middle East and the Pacific islands), and people who inject or have injected drugs.

People whose only identified risk factor for hepatitis B is country of birth should have testing offered and arranged by GPs.Testing for hepatitis B virus is also available in ÌýorÌýÌýfor people accessing these services.

Diagnoses of hepatitis B virus is based on serological markers (antigens and antibodies) in plasma or serum. These markers indicate acute, chronic or past infection, infectivity, and immunity. Refer to Ìýor contact your local laboratory in interpreting results, and the need for any additional testing.

Further actions for primary or secondary healthcare professionals diagnosing and managing people living with hepatitis B upon test results should be undertaken as per .

Treatment

Acute infection

There is no specific treatment available for acute hepatitis B.ÌýSymptomatic treatment of nausea, Ìývomiting and other symptoms may be indicated. Liver failure is a rare complication that requires specialist treatment. Antiviral drugs are not needed to treat acute infection.

Following acute infection, follow up the patient to ensure thatÌýHBsAgÌýand HBeAg (serological markers) are cleared.

Chronic infection

IfÌýHBsAgÌýpersists for more than 6 months then the patient is considered chronically infected. Refer them to a liver specialist for further assessment and consideration ofÌýantiviral treatment and general managementÌýto reduce the risk of infectivity and liver complications.

Although not suitable for all patients, specific treatment with anti-virals may reduce viral replication. Such treatments are initiated by the secondary care specialist. In some areas, shared care arrangements may allow the primary care practitioner to continue to prescribe in liaison with the specialist.

Pregnant women should access hepatitis B testing through antenatal screening. For any pregnant women that tests positive for hepatitis B, ensure that referral to the local specialist team has been made.

Counsel the patient onÌý. Be cautious in the prescription of potentially hepatotoxic drugs.

Further guidance on testing and treatment

Prevention and control

Offer hepatitis B vaccine to all individuals at risk from hepatitis B infection, including infants born to mothers living with hepatitis B.

SeeÌýHepatitis B: the green book, chapter 18 and

Ask opportunistically about travel plans as patients whoÌýtravel to visit friends and relativesÌýin countries where the infection is endemic may be at increased risk of acquiring infection.

Some patients may choose or require medical treatment during their trip (such as kidney dialysis, or blood transfusions) which can put them at increased risk of infection with blood borne viruses. Advise patients about this potential risk.

Patients who will receive dialysis abroad (or in the UK) should be immunised before starting dialysis.

For country-specific travel advice, see theÌý.

Acute hepatitis B is a notifiable disease in the UK. If a case is diagnosed, it should be notified to yourÌýlocal health protection team (HPT). The team will provide information to prevent onward transmission and to immunise any contacts who are at risk of infection.

Post-exposure prophylaxis

Hepatitis B vaccine is highly effective at preventing infection if given shortly after exposure and ideally, within 48 hours of exposure. However, it should still be considered up to a week after a single exposure. ÌýIf the exposure is ongoing or likely to occur again a full vaccination course should be given as soon as possible. SeeÌýHepatitis B: the green book, chapter 18.

Specific hepatitis B immunoglobulin (HBIG) can be used, alongside vaccination, to confer immediate passive immunity after exposure to a source with a confirmed hepatitis B infection. Hepatitis B immunoglobulin is available via the UK Health Security Agency (UKHSA).

°Õ³ó±ðÌýImmunoglobulin handbookÌýcontains information, indications and guidance on the use of immunoglobulin preparations for specific diseases, including hepatitis B.

If in doubt about post-exposure prophylaxis, please discuss with yourÌýlocal health protection team (HPT).

Co-infection with HIV

Globally theÌý. Some treatments for HIV are also active against hepatitis B. HIV-positive individuals are more likely to develop chronic hepatitis B infection.

Hepatitis B vaccineÌýshould be offered to HIV-infected individuals and those at risk of HIV.

Resources

UKHSAÌýprovidesÌýguidance, data and analysis on hepatitis B, including information on:

• diagnosis and management
• infants born to hepatitis B infected mothers
• vaccination

NHS Choices hasÌýÌýincluding detailedÌý.Patient.info hasÌý and a .

Information about hepatitis B vaccination in different languages can be found at the .

is a peer led organisation which supports people living with hepatitis B.

°Õ³ó±ðÌýÌýis a charity which provides resources for people with liver disease, including a helpline and publications.

°Õ³ó±ðÌýÌýprovides country specific travel advice and has producedÌý.

Information on hepatitis B and sexual transmission is available at