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Patient information: Hepatitis B (Beyond the Basics)

INTRODUCTION

The term "hepatitis" is used to describe a common form of liver injury. Hepatitis simply means "inflammation of the liver" (the suffix "itis" means inflammation and "hepa" means liver). Hepatitis B is a specific type of hepatitis that is caused by a virus.

It is estimated that there are more than 300 million carriers of the hepatitis B virus in the world, with over 500,000 dying annually from hepatitis B-related liver disease.

Fortunately, several medications are available for the treatment of chronic hepatitis B, and hepatitis B infection can be prevented by vaccination. Hepatitis B vaccines are safe and highly effective in preventing hepatitis B infection and are now given routinely to newborns and children in the United States and in many other countries. (See "Patient information: Adult vaccines (Beyond the Basics)".)

More detailed information about hepatitis B is available by subscription. (See "Overview of the management of hepatitis B and case examples" and "Investigational treatments of chronic hepatitis B virus infection".)

HOW DID I BECOME INFECTED WITH HEPATITIS B?

There are several ways to become infected with hepatitis B virus.

Contaminated needles — Using contaminated needles can spread the hepatitis B virus. This includes tattooing, acupuncture, and ear piercing (if these procedures are performed with contaminated instruments). Sharing needles or syringes can also spread the virus.

Sex — Sexual contact with someone who is infected is one of the most common ways to become infected with hepatitis B. If you are infected with hepatitis B, make sure your spouse or sex partner gets vaccinated.

Mother to infant — Hepatitis B can be passed from a mother to her baby during or shortly after delivery. Having a Cesarean delivery (also called a C-section) does not prevent the virus from spreading. Experts believe that breastfeeding is safe.

During pregnancy, all women should have a blood test for a marker of hepatitis B virus, called hepatitis B surface antigen (HBsAg). Normally, the HBsAg should be negative.

If the mother's HBsAg test is positive, the infant should be given a shot soon after birth (called hepatitis B immunoglobulin or HBIG). HBIG provides immediate protection to the infant, but the effect only lasts a few months. The infant should get the hepatitis B vaccine at birth, at 1 to 2 months, and at 6 months. Finishing all three doses is important for long-term protection. The infant should have a blood test for hepatitis B infection and for hepatitis B antibody at 9 to 18 months of age; if the antibody test is negative, a fourth dose of the vaccine should be given at that time. In some cases, the mother is also given a medication that reduces the amount of virus in her blood for several weeks before giving birth.

Close contact — Hepatitis B can be spread through close personal contact. This could happen if blood or other bodily fluids get into tiny cracks or breaks in your skin or in your mouth or eyes. The virus can live for a long time away from the body, meaning that it can be spread by sharing household items like toys, toothbrushes, or razors.

Blood transfusion and organ transplantation — Nowadays, it is extremely rare for hepatitis B to be spread through blood transfusion or organ transplantation. Blood and organ donors are carefully screened for markers of hepatitis infection. (See "Patient information: Blood donation and transfusion (Beyond the Basics)".)

In the hospital — In the hospital, hepatitis B virus can spread from one patient to another or from a patient to a doctor or nurse if there is an accidental needle stick. It is rare for a doctor/nurse to pass hepatitis B to a patient. Wearing gloves, eye protection, a face mask, and washing hands can help to prevent spreading the virus.

HEPATITIS B SYMPTOMS

Symptoms due to hepatitis B vary. After a person is first infected with hepatitis B, they can develop a flu-like illness that includes fever, abdominal pain, fatigue, decreased appetite, nausea, and in some cases yellowing of the skin and eyes (jaundice). In the most severe cases, liver failure can develop, which is characterized by jaundice, fluid accumulation, and confusion. However, many patients do not develop symptoms, particularly if the infection occurs in infants and children. Not having symptoms does not necessarily mean that the infection is under control. Most people with chronic hepatitis B have no symptoms until their liver disease is at a late stage. The most common early symptom is feeling tired. Everyone with chronic hepatitis B is at increased risk of developing complications, including liver scarring (called cirrhosis when the scarring is severe) and liver cancer. (See "Patient information: Cirrhosis (Beyond the Basics)".)

Acute hepatitis B — After a person is first infected with hepatitis B, they are said to have acute hepatitis. Most people with acute hepatitis B recover uneventfully.

However, in about 5 percent of adults (1 in 20) the virus makes itself at home in the liver, where it continues to make copies of itself for many years. People who continue to harbor the virus are referred to as "carriers". If liver damage develops because of longstanding infection, the person is said to have chronic hepatitis.

Chronic hepatitis B — Chronic hepatitis B develops more commonly in people who are infected with the virus at an early age (often at birth). Unfortunately, this is common in some parts of the world such as in Southeast Asia, China, and sub-Saharan Africa, where as many as 1 in 10 people have chronic hepatitis B infection.

Many people with chronic hepatitis B have no symptoms at all; other people have symptoms of ongoing liver inflammation, such as fatigue and loss of appetite.

HEPATITIS B DIAGNOSIS

There are a number of tests that can be used to diagnose or monitor hepatitis B infection. (See "Diagnosis of hepatitis B virus infection".) Most of these tests are blood tests and include those that detect:

Hepatitis B surface antigen (abbreviated HBsAg) – HBsAg is a protein on the surface of the hepatitis B virus. This protein shows up in the blood 1 to 10 weeks after exposure to the hepatitis B virus and before a person starts to show symptoms of the infection. In people who recover, this protein usually disappears after 4 to 6 months. Its continued presence suggests that chronic infection has developed.

Hepatitis B surface antibody (abbreviated anti-HBs) – Anti-HBs helps the body's immune system attack the hepatitis B virus. This protein is usually present in people who have recovered or who have been vaccinated against hepatitis B. People with this protein are usually immune to hepatitis B.

Hepatitis B core antibody (abbreviated anti-HBc) – Anti-HBc is usually present throughout the course of infection and stays in the blood after recovery. It is not present in people who have been vaccinated against hepatitis B.

Hepatitis B e antigen (abbreviated HBeAg) – HBeAg is a protein whose presence indicates that the hepatitis B virus is continuing to make copies of itself (replicating). Its presence usually indicates a high level of circulating virus and a high chance of transmission of infection.

Hepatitis B e antibody (abbreviated anti-HBe) – Anti-HBe usually signifies that virus replication has slowed down, but in some variants of hepatitis B, the virus continues to replicate at a rapid rate, and high levels of virus can be found in the circulation.

Hepatitis B DNA (abbreviated HBV DNA) – HBV DNA is the genetic material found in the hepatitis B virus. HBV DNA usually disappears from the blood after a person recovers. HBV DNA is a measure of the concentration of virus in the circulating blood. Doctors use the levels of HBV DNA to decide who is a candidate for treatment with antiviral medicines and to track how well treatment is working.

Other tests – There are many other tests that can reflect the health of the liver but are not specific for hepatitis B. Examples include liver enzyme tests (ALT and AST), bilirubin, alkaline phosphatase, albumin, prothrombin time and platelet count.

A liver biopsy is not routinely needed to diagnose hepatitis B. A liver biopsy is used to monitor liver damage in people with chronic hepatitis, help decide if treatment is needed, and find signs of cirrhosis or liver cancer. More information about liver biopsy is available separately. (See "Patient information: Liver biopsy (Beyond the Basics)".)

WILL I DEVELOP CHRONIC HEPATITIS B?

The likelihood of developing chronic hepatitis B largely depends on your age at the time of infection. Chronic infection develops in about 90 percent of children who are infected at birth, in 20 to 50 percent of children who are infected between the ages of 1 and 5 years, and in less than 5 percent of people infected with hepatitis B during adulthood.

The risk of developing complications of chronic hepatitis B depends on how rapidly the virus multiplies and how well your immune system controls the infection. Drinking alcohol, having chronic hepatitis C, or having HIV infection (the virus that causes AIDS) in addition to hepatitis B increases the chance of complications.

HEPATITIS B TREATMENT

Specific treatment for acute hepatitis B is usually not needed since in about 95 percent of adults, the immune system controls the infection and gets rid of the virus within about six months.

In people who develop chronic hepatitis, an antiviral medication might be recommended to reduce or reverse liver damage and to prevent long-term complications of hepatitis B.

Antiviral therapy — Several antiviral medicines are available to treat hepatitis B. Not all people with hepatitis B need immediate treatment. If you do not need to start treatment immediately, you will be monitored over time to know when hepatitis becomes more active (meaning that antiviral treatment should begin).

Once you start treatment, you will have regular blood tests to see how well the treatment is working and to detect side effects or drug resistance. Monitoring will continue after finishing treatment to detect signs that the infection has come back.

Lamivudine — Lamivudine (Epivir-HBV®) is effective in decreasing hepatitis B virus activity and ongoing liver inflammation. It is safe in patients with liver failure and long-term treatment can decrease the risk of liver failure and liver cancer. (See "Lamivudine monotherapy for chronic hepatitis B virus infection".)

Lamivudine is taken by mouth, usually at a dosage of 100 mg/day. The major problem with lamivudine is that a resistant form of hepatitis B virus (referred to as a YMDD mutant) frequently develops in people who take lamivudine long term. Other medicines are available that are less likely to cause resistance.

Adefovir — Adefovir (Hepsera®) is an alternative initial choice for people who have detectable hepatitis B virus activity and ongoing liver inflammation. An advantage of adefovir compared to lamivudine is that resistance to adefovir is less likely to develop. In addition, adefovir can suppress lamivudine-resistant HBV. (See "Adefovir dipivoxil in the treatment of chronic hepatitis B virus infection".)

Adefovir is taken by mouth, at a dosage of 10 mg/day, for at least one year. Most patients will need long-term treatment to maintain control of the hepatitis B virus. Adefovir is a weak antiviral medicine, and resistance does occur over time. Other medicines are available that are more potent.

Entecavir — Entecavir (Baraclude®) is generally more potent than lamivudine and adefovir. Resistance to entecavir is uncommon in people who have never been treated with antivirals, but occurs in up to 50 percent of people who have used lamivudine. (See "Entecavir in the treatment of chronic hepatitis B virus infection".)

Entecavir is taken by mouth, at a dosage of 0.5 mg daily for patients who have no prior treatment and 1.0 mg daily for patients who have resistance to lamivudine. Most patients will need long-term treatment to maintain control of the hepatitis B virus.

Tenofovir — Tenofovir (Viread®) is more potent than adefovir. Resistance to tenofovir is rare. Tenofovir is taken by mouth, at a dosage of 300 mg daily. Tenofovir is effective in suppressing hepatitis B virus that is resistant to lamivudine, telbivudine, or entecavir. Tenofovir is not as effective in patients with adefovir-resistant hepatitis B. (See "Efficacy of tenofovir disoproxil fumarate in the treatment of adults with chronic HBV infection who do not have HIV infection".)

Telbivudine — Telbivudine (Tyzeka®) is more potent than lamivudine and adefovir. Resistance to telbivudine is common, and hepatitis B virus that is resistant to lamivudine is also resistant to telbivudine. Telbivudine is taken by mouth at a dosage of 600 mg daily. Other medicines are available that are less likely to cause resistance. (See "Telbivudine in the treatment of chronic hepatitis B virus infection".)

Interferon-alpha — Interferon-alpha is an appropriate treatment for people with chronic hepatitis B infection who have detectable virus activity, ongoing liver inflammation, and no cirrhosis. Both conventional interferon and pegylated interferon are approved in the United States. (See "Standard and pegylated interferon for chronic hepatitis B virus infection".)

Interferon-alpha may be considered in young patients who do not have advanced liver disease and do not wish to be on long-term treatment. Interferon-alpha is not appropriate for people with cirrhosis who have liver failure or for people who have a recurrence of hepatitis after liver transplantation.

Interferon is given for a finite duration. Pegylated interferon, a long acting interferon taken once a week, is given for one year. This is in contrast to the other hepatitis treatments, which are given by mouth for many years until a desired response is achieved. Drug resistance to interferon has not been reported.

The disadvantages of interferon-alpha are that it must be taken by injection and it can cause many side effects.

Liver transplantation — Liver transplantation may be the only option for people who have developed advanced cirrhosis. The liver transplantation process is elaborate, involving an extensive screening process to ensure that a person is a good candidate. Thus, not all patients with cirrhosis are eligible, and only those with the most advanced cirrhosis or early stage liver cancer and otherwise good medical and social conditions will be put on the transplant waiting list. Because of the shortage of donors, not all patients on the transplant waiting list will receive a liver transplant.

TIPS TO MAINTAIN LIVER HEALTH

As discussed above, the majority of people with acute hepatitis B spontaneously clear the infection. Those who develop chronic infection should see a doctor with expertise in liver disease (usually a gastroenterologist or hepatologist) who can discuss treatment options.

Vaccinations — Everyone with chronic hepatitis B should be vaccinated against hepatitis A unless they are known to be immune. Influenza vaccination is recommended once per year, usually in the fall. Patients with liver disease should also receive standard immunizations, including a diphtheria and tetanus booster, every ten years. (See "Patient information: Adult vaccines (Beyond the Basics)".)

Liver cancer screening — Regular screening for liver cancer is also recommended, particularly for older individuals, those with cirrhosis, and patients with a family history of liver cancer. In general, this includes an ultrasound examination of the liver every six months.

Diet — No specific diet has been shown to improve the outcome in people with hepatitis B. The best advice is to eat a normal healthy and balanced diet.

Alcohol — Alcohol should be avoided since it can worsen liver damage. All types of alcoholic beverages can be harmful to the liver. People with hepatitis B can develop liver complications even with small amounts of alcohol.

Exercise — Exercise is good for overall health and is encouraged, but it has no effect on the hepatitis B virus.

Prescription and nonprescription drugs — Many medications are broken down by the liver. Thus, it is always best to check with a healthcare provider or pharmacist before starting a new medication. As a general rule, unless the liver is already scarred, most drugs are safe for people with hepatitis B.

An important possible exception is acetaminophen (Tylenol®); the maximum recommended dose in people with liver disease is no more than 2 grams (2000 mg or four extra strength tabs or capsules) in 24 hours. Most acetaminophen tabs or capsules contain 325 or 500 mg.

You should avoid ibuprofen (sold as Advil, Motrin, and store brands), naproxen (sold as Aleve and store brands), and aspirin (sold as Bufferin, Excedrin, and store brands).

Herbal medications — No herbal treatment has been proven to improve outcomes in patients with hepatitis B, and some can cause serious liver toxicity. Herbal treatments are not recommended for anyone with hepatitis B.

Support — Sharing concerns with others infected with hepatitis B can provide support. A number of organizations are available around the world. (See 'Where to get more information' below.)

PREVENT INFECTION OF FAMILY

Acute and chronic hepatitis B are contagious. Thus, people with hepatitis B should discuss measures to reduce the risk of infecting close contacts. This includes the following:

Discuss the infection with any sexual partners and use a latex condom with every sexual encounter.

Do not share razors, toothbrushes, or anything that has blood on it.

Cover open sores and cuts with a bandage.

Do not donate blood, body organs, other tissues, or sperm.

Immediate family and household members should be tested for hepatitis B. Anyone who is at risk of hepatitis B infection should be vaccinated. (See "Patient information: Adult vaccines (Beyond the Basics)".)

Do not share any injection drug equipment (needles, syringes).

Clean blood spills with a mixture of 1 part household bleach to 9 parts water.

Hepatitis B cannot be spread by:

Hugging or kissing

Sharing eating utensils or cups

Sneezing or coughing

Breastfeeding

WHERE TO GET MORE INFORMATION

Your healthcare provider is the best source of information for questions and concerns related to your medical problem.

This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient information: Hepatitis B (The Basics)
Patient information: Cirrhosis (The Basics)
Patient information: Blood or body fluid exposure (The Basics)
Patient information: Vaccines when you have hepatitis C (The Basics)
Patient information: Liver transplant (The Basics)
Patient information: Treatment for hepatitis C (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient information: Adult vaccines (Beyond the Basics)
Patient information: Blood donation and transfusion (Beyond the Basics)
Patient information: Cirrhosis (Beyond the Basics)
Patient information: Liver biopsy (Beyond the Basics)

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Adefovir dipivoxil in the treatment of chronic hepatitis B virus infection
Characteristics of the hepatitis B virus and pathogenesis of infection
Clinical manifestations and natural history of hepatitis B virus infection
Clinical significance and molecular characteristics of common hepatitis B virus variants
Clinical significance of hepatitis B virus genotypes
Combination therapy for chronic hepatitis B virus infection
Epidemiology, transmission, and prevention of hepatitis B virus infection
Hepatitis B virus vaccination
Immunizations for patients with chronic liver disease
Lamivudine monotherapy for chronic hepatitis B virus infection
Investigational treatments of chronic hepatitis B virus infection
Overview of the management of hepatitis B and case examples
Diagnosis of hepatitis B virus infection
Standard and pegylated interferon for chronic hepatitis B virus infection
Telbivudine in the treatment of chronic hepatitis B virus infection
Treatment of hepatitis B in the HIV-infected patient
Entecavir in the treatment of chronic hepatitis B virus infection
Efficacy of tenofovir disoproxil fumarate in the treatment of adults with chronic HBV infection who do not have HIV infection

The following organizations also provide reliable health information.

National Library of Medicine

     (www.nlm.nih.gov/medlineplus/healthtopics.html)

Centers for Disease Control

     (www.cdc.gov/ncidod/diseases/hepatitis/index.htm)

National Institute of Diabetes and Digestive and Kidney Diseases

     (www.niddk.nih.gov)

National Institute of Allergy and Infectious Diseases

     (www.niaid.nih.gov/)

National Foundation for Infectious Diseases

     (www.nfid.org)

American Association for Study of Liver Diseases

     (www.aasld.org)

American Gastroenterological Association

     (www.gastro.org)

American Liver Foundation

     (www.liverfoundation.org)

The Hepatitis B Foundation

     (www.hepb.org)

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Literature review current through: Aug 2014. | This topic last updated: Apr 18, 2013.
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