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Systemic viral infection associated with acute and chronic liver disease and hepatocellular carcinoma (HCC)


  • Predominant age: can infect patients of all ages
  • Predominant sex: fulminant hepatitis B virus (HBV): male > female (2:1)
  • In the United States, estimated 38,000 new infections in 2009, 70% due to IV drug use
  • African Americans have the highest rate of acute HBV infection in the United States.
  • Overall rate of new infections is down 82% since 1991 (due to national immunization strategy).
  • U.S. vaccine coverage for the birth dose of HBV increased from 68.6% in 2011 to 71.6% in 2012.

  • In the United States, 800,000–1.4 million people have chronic 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 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 infective via blood and secretions for at least a week following exposure.

Family history of HBV and/or HCC

Risk Factors

  • The following high-risk groups should be screened for HBV with HBsAg/sAb and subsequently vaccinated if seronegative (1)[A]:
    • Persons born in endemic areas (45% of world)
    • Hemodialysis patients
    • IV drug users (IVDUs), 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 (AST/ALT)
  • Additional risk factors:
    • Needle stick/occupational exposure
    • Recipients of blood/products; transplanted organ recipients
    • Intranasal drug users
    • Body piercing/tattoos
    • Survivors of sexual assault

MarkerAcute infectionChronic infectionInactive carrierResolved infectionSusceptible to infectionVaccinated
HBV DNAPresentPresentLow–negative
ALTMarked elevationNormal to mildly elevatedNormalNormal

Pediatric Considerations
  • Shorter acute course; fewer complications
  • 90% of vertical/perinatal infections become chronic.
Pregnancy Considerations
  • Universal prenatal screening with HBsAg (1)[A]
  • High viral load at 28 weeks should prompt consideration to begin treatment with oral nucleos(t)ide medicines at 32 weeks to reduce perinatal transmission (2)[C].
  • Infants born to HBV-infected mothers require HB immune globulin (HBIg) (0.5 mL) and HBV vaccine within 12 hours of birth.
  • Breastfeeding is safe if HBIg and HBV vaccine are administered and the areolar complex is without fissures or open sores. Oral nucleos(t)ide medications are not recommended for lactating mothers.
  • 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 and during well-child care visits (3-shot series)
    • 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

HIV coinfection, hepatitis C coinfection

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