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Basics

Description

Systemic viral infection that may cause acute and chronic liver disease and hepatocellular carcinoma (HCC)

Epidemiology

Incidence
  • Predominant age: All ages
  • Predominant sex: Fulminant hepatitis B virus (HBV): Male > Female (2:1)
  • In the US, estimated 38,000 new infections in 2009, 70% due to IV drug use
  • African Americans: Highest rate of acute HBV infection in the US
  • Overall rate of new infections down 82% since 1991 (due to national immunization strategy)
  • US vaccine coverage increased from 68.6% in 2011 to 71.6% in 2012 for the birth dose of HepB (1)[A]

Prevalence
  • In the US, 800,000–1.4 million people have chronic hepatitis B virus (HBV).
  • Asia and the Pacific Islands have the largest populations at risk for HBV.
  • Chronic HBV worldwide: 350–400 million persons:
    • Per year: 1 million deaths:
      • 2nd most important carcinogen (behind tobacco)
      • Of chronic carriers, 25% die of cirrhosis or HCC
      • Of chronic carriers, 75% are Asian

Etiology and Pathophysiology

HBV is a DNA virus of the family Hepadnaviridae.

Genetics
Family history of HBV and/or HCC to determine exposure and future HCC risk

Risk Factors

  • Screen high-risk groups with HBsAg/sAb (1)[A]:
    • Persons born in endemic areas (45% of world)
    • Hemodialysis patients
    • IV drug users (IVDU), 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 aspartate aminotransferase/alanine aminotransferase (ALT/AST)
  • Vaccinate all above groups if negative.
  • Additional risk factors:
    • Needle stick/occupational exposure
    • Recipients of blood/products; transplanted organ recipients
    • Intranasal drug users
    • Body piercing/tattoos

AcuteChronicInactiveResolved
Markerinfectioninfectioncarrierinfection
HBsAg+++
HBsAb+
HBcAb+IgM–IgM; +total/IgG++
HBeAg+±
HBeAb±+±
HBV DNAPresentPresentLow–negative
NegativeALTMarked elevationTransient mild elevationNormal

Pediatric Considerations
  • Shorter acute course; fewer complications
  • 90% of vertical/perinatal infections become chronic
Pregnancy Considerations
  • Screen all pregnant women for HBsAg (2)[A].
  • High viral load at 28 weeks should prompt consideration for treatment with oral nucleos(t)ide medicines from 32 weeks to reduce perinatal transmission.
  • Infant of HBV-infected mother needs HB immune globulin (HBIg) (0.5 mL) plus HBV vaccine within 12 hours of birth and HBV series at 0, 1, and 6 months (2)[A].
  • Breastfeeding is safe if HBIg and HBV vaccine are administered and nipples are without fissures. Oral nucleos(t)ide medications are not recommended in lactating mothers. Risk and benefits must be assessed.
  • HIV coinfection significantly 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
    • 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, IVDU, and tattoo/piercing artists:
    • Barrier precautions, needle disposal, sterilization of 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 and vaccination

Commonly Associated Conditions

Arthritis, polyarteritis nodosa, membranous glomerulopathy, anemia (including aplastic anemia), dermatitis, cardiomyopathy, hepatitis D virus infection, metabolic syndrome

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