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Epidemiology, transmission, and prevention of hepatitis B virus infection

Eng-Kiong Teo, MD
Anna SF Lok, MD
Section Editors
Sheldon L Kaplan, MD
Rafael Esteban, MD
Deputy Editor
Jennifer Mitty, MD, MPH


Hepatitis B virus (HBV) infection is a global public health problem. It is estimated that there are 248 million HBV carriers in the world, of whom roughly 600,000 die annually from HBV-related liver disease [1,2]. The implementation of effective vaccination programs in many countries has resulted in a significant decrease in the incidence of new hepatitis B infection. Nevertheless, HBV infection remains an important cause of morbidity and mortality.

The spectrum of clinical manifestations of HBV infection varies in both acute and chronic disease. During the acute phase, manifestations range from subclinical or anicteric hepatitis to icteric hepatitis and, in some cases, fulminant hepatitis. During the chronic phase, manifestations range from an asymptomatic carrier state to chronic hepatitis, cirrhosis, and hepatocellular carcinoma. Extrahepatic manifestations also can occur with both acute and chronic infection.

This topic review will discuss the epidemiology, modes of transmission, and prevention of HBV infection. The clinical manifestations and natural history of HBV infection as well as hepatitis B vaccination are discussed in detail separately. (See "Clinical manifestations and natural history of hepatitis B virus infection" and "Hepatitis B virus vaccination".)


It is estimated that approximately two billion people worldwide have evidence of past or present infection with hepatitis B virus (HBV), and 248 million individuals are chronic carriers (ie, positive for hepatitis B surface antigen [HBsAg]) [2,3]. The overall prevalence of HBsAg is reported to be 3.6 percent; however, it varies depending upon the geographic area. The prevalence of chronic HBV ranges from <2 percent in low-prevalence areas (eg, United States, Canada, Western Europe) to 2 to 7 percent in intermediate-prevalence areas (eg, Mediterranean countries, Japan, Central Asia, Middle East, and parts of South America) to ≥8 percent in high-prevalence areas (eg, Western Africa, South Sudan) (table 1) [2-4].

The wide range in the prevalence of patients with chronic HBV in different parts of the world is largely related to differences in the age at infection, which is inversely related to the risk of chronicity. The rate of progression from acute to chronic HBV infection is approximately 90 percent for perinatally acquired infection [5], 20 to 50 percent for infections between the age of one and five years [6,7], and less than 5 percent for adult-acquired infection [6].

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Literature review current through: Nov 2017. | This topic last updated: Oct 31, 2016.
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  1. Maynard JE. Hepatitis B: global importance and need for control. Vaccine 1990; 8 Suppl:S18.
  2. Ott JJ, Stevens GA, Groeger J, Wiersma ST. Global epidemiology of hepatitis B virus infection: new estimates of age-specific HBsAg seroprevalence and endemicity. Vaccine 2012; 30:2212.
  3. Schweitzer A, Horn J, Mikolajczyk RT, et al. Estimations of worldwide prevalence of chronic hepatitis B virus infection: a systematic review of data published between 1965 and 2013. Lancet 2015; 386:1546.
  4. Zhang Q, Qi W, Wang X, et al. Epidemiology of Hepatitis B and Hepatitis C Infections and Benefits of Programs for Hepatitis Prevention in Northeastern China: A Cross-Sectional Study. Clin Infect Dis 2016; 62:305.
  5. Stevens CE, Beasley RP, Tsui J, Lee WC. Vertical transmission of hepatitis B antigen in Taiwan. N Engl J Med 1975; 292:771.
  6. Tassopoulos NC, Papaevangelou GJ, Sjogren MH, et al. Natural history of acute hepatitis B surface antigen-positive hepatitis in Greek adults. Gastroenterology 1987; 92:1844.
  7. Wasley A, Grytdal S, Gallagher K, Centers for Disease Control and Prevention (CDC). Surveillance for acute viral hepatitis--United States, 2006. MMWR Surveill Summ 2008; 57:1.
  8. Kowdley KV, Wang CC, Welch S, et al. Prevalence of chronic hepatitis B among foreign-born persons living in the United States by country of origin. Hepatology 2012; 56:422.
  9. Ghany MG, Perrillo R, Li R, et al. Characteristics of adults in the hepatitis B research network in North America reflect their country of origin and hepatitis B virus genotype. Clin Gastroenterol Hepatol 2015; 13:183.
  10. Canadian Immunization Guide, 7th ed, Public Health Agency of Canada, Ottowa, Ontario 2006.
  11. Mossong J, Putz L, Patiny S, Schneider F. Seroepidemiology of hepatitis A and hepatitis B virus in Luxembourg. Epidemiol Infect 2006; 134:808.
  12. MacLachlan JH, Allard N, Towell V, Cowie BC. The burden of chronic hepatitis B virus infection in Australia, 2011. Aust N Z J Public Health 2013; 37:416.
  13. Roberts H, Kruszon-Moran D, Ly KN, et al. Prevalence of chronic hepatitis B virus (HBV) infection in U.S. households: National Health and Nutrition Examination Survey (NHANES), 1988-2012. Hepatology 2016; 63:388.
  14. Jung M, Kuniholm MH, Ho GY, et al. The distribution of hepatitis B virus exposure and infection in a population-based sample of U.S. Hispanic adults. Hepatology 2016; 63:445.
  15. Stanaway JD, Flaxman AD, Naghavi M, et al. The global burden of viral hepatitis from 1990 to 2013: findings from the Global Burden of Disease Study 2013. Lancet 2016; 388:1081.
  16. GBD 2013 Mortality and Causes of Death Collaborators. Global, regional, and national age-sex specific all-cause and cause-specific mortality for 240 causes of death, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 2015; 385:117.
  17. Centers for Disease Control. Surveillance for viral hepatitis – United States, 2013 http://www.cdc.gov/hepatitis/statistics/2013surveillance/commentary.htm#hepatitisB (Accessed on October 02, 2015).
  18. Zhou M, Wang H, Zhu J, et al. Cause-specific mortality for 240 causes in China during 1990-2013: a systematic subnational analysis for the Global Burden of Disease Study 2013. Lancet 2016; 387:251.
  19. Alter MJ, Hadler SC, Margolis HS, et al. The changing epidemiology of hepatitis B in the United States. Need for alternative vaccination strategies. JAMA 1990; 263:1218.
  20. Beasley RP, Hwang LY, Lin CC, et al. Incidence of hepatitis B virus infections in preschool children in Taiwan. J Infect Dis 1982; 146:198.
  21. Kim WR, Ishitani MB, Dickson ER, et al. Rising burden of hepatitis B in the United States: Should the other virus be forgotten? (abstract). Hepatology 2002; 36:222A.
  22. Iqbal K, Klevens RM, Kainer MA, et al. Epidemiology of Acute Hepatitis B in the United States From Population-Based Surveillance, 2006-2011. Clin Infect Dis 2015; 61:584.
  23. Harris AM, Iqbal K, Schillie S, et al. Increases in Acute Hepatitis B Virus Infections - Kentucky, Tennessee, and West Virginia, 2006-2013. MMWR Morb Mortal Wkly Rep 2016; 65:47.
  24. Lin CL, Kao JH, Chen BF, et al. Application of hepatitis B virus genotyping and phylogenetic analysis in intrafamilial transmission of hepatitis B virus. Clin Infect Dis 2005; 41:1576.
  25. Ahmed MM, Huang TH, Xie QD. A sensitive and rapid assay for investigating vertical transmission of hepatitis B virus via male germ line using EGFP Vector as reporter. J Biomed Biotechnol 2008; 2008:495436.
  26. Ahmed MM, Huang TH, Xie QD. An improved experimental model for studying vertical transmission of hepatitis B virus via human spermatozoa. J Virol Methods 2008; 151:116.
  27. Huang JM, Huang TH, Qiu HY, et al. Effects of hepatitis B virus infection on human sperm chromosomes. World J Gastroenterol 2003; 9:736.
  28. Hadchouel M, Scotto J, Huret JL, et al. Presence of HBV DNA in spermatozoa: a possible vertical transmission of HBV via the germ line. J Med Virol 1985; 16:61.
  29. World Health Organization. Guidelines on assessing donor suitability for blood donation. http://iacld.ir/DL/elm/whoblooddonorselectionguidelinesonassessingdonorsuitabilityforblooddonation.pdf (Accessed on December 07, 2015).
  30. Goh KT. Prevention and control of hepatitis B virus infection in Singapore. Ann Acad Med Singapore 1997; 26:671.
  31. Zou S, Stramer SL, Notari EP, et al. Current incidence and residual risk of hepatitis B infection among blood donors in the United States. Transfusion 2009; 49:1609.
  32. Stramer SL, Notari EP, Krysztof DE, Dodd RY. Hepatitis B virus testing by minipool nucleic acid testing: does it improve blood safety? Transfusion 2013; 53:2449.
  33. Shang G, Seed CR, Wang F, et al. Residual risk of transfusion-transmitted viral infections in Shenzhen, China, 2001 through 2004. Transfusion 2007; 47:529.
  34. World Health Organization. Hepatitis B fact sheet. http://www.who.int/mediacentre/factsheets/fs204/en/ (Accessed on December 07, 2015).
  35. Nelson PK, Mathers BM, Cowie B, et al. Global epidemiology of hepatitis B and hepatitis C in people who inject drugs: results of systematic reviews. Lancet 2011; 378:571.
  36. Hagan H, McGough JP, Thiede H, et al. Syringe exchange and risk of infection with hepatitis B and C viruses. Am J Epidemiol 1999; 149:203.
  37. Des Jarlais DC, Diaz T, Perlis T, et al. Variability in the incidence of human immunodeficiency virus, hepatitis B virus, and hepatitis C virus infection among young injecting drug users in New York City. Am J Epidemiol 2003; 157:467.
  38. Bialek SR, Bower WA, Mottram K, et al. Risk factors for hepatitis B in an outbreak of hepatitis B and D among injection drug users. J Urban Health 2005; 82:468.
  39. Thompson ND, Perz JF, Moorman AC, Holmberg SD. Nonhospital health care-associated hepatitis B and C virus transmission: United States, 1998-2008. Ann Intern Med 2009; 150:33.
  40. Gerberding JL. The infected health care provider. N Engl J Med 1996; 334:594.
  41. Williams IT, Perz JF, Bell BP. Viral hepatitis transmission in ambulatory health care settings. Clin Infect Dis 2004; 38:1592.
  42. Harpaz R, Von Seidlein L, Averhoff FM, et al. Transmission of hepatitis B virus to multiple patients from a surgeon without evidence of inadequate infection control. N Engl J Med 1996; 334:549.
  43. Centers for Disease Control and Prevention (CDC). Nosocomial hepatitis B virus infection associated with reusable fingerstick blood sampling devices--Ohio and New York City, 1996. MMWR Morb Mortal Wkly Rep 1997; 46:217.
  44. Perry JL, Pearson RD, Jagger J. Infected health care workers and patient safety: a double standard. Am J Infect Control 2006; 34:313.
  45. Enfield KB, Sharapov U, Hall KK, et al. Transmission of hepatitis B virus from an orthopedic surgeon with a high viral load. Clin Infect Dis 2013; 56:218.
  46. Schalm SW, Buster EH. Management of hepatitis B virus infected health care workers based on HBV DNA levels. J Clin Virol 2003; 27:231.
  47. Centers for Disease Control. Updated CDC recommendations for the management of hepatitis B virus–infected health-care providers and students. http://www.cdc.gov/mmwr/pdf/rr/rr6103.pdf (Accessed on October 05, 2015).
  48. Corden S, Ballard AL, Ijaz S, et al. HBV DNA levels and transmission of hepatitis B by health care workers. J Clin Virol 2003; 27:52.
  49. De Feo TM, Poli F, Mozzi F, et al. Risk of transmission of hepatitis B virus from anti-HBC positive cadaveric organ donors: a collaborative study. Transplant Proc 2005; 37:1238.
  50. Hoft RH, Pflugfelder SC, Forster RK, et al. Clinical evidence for hepatitis B transmission resulting from corneal transplantation. Cornea 1997; 16:132.
  51. Fabrizio F, Bunnapradist S, Martin P. Transplanting kidneys from donors with prior hepatitis B infection: one response to the organ shortage. J Nephrol 2002; 15:605.
  52. Huprikar S, Danziger-Isakov L, Ahn J, et al. Solid organ transplantation from hepatitis B virus-positive donors: consensus guidelines for recipient management. Am J Transplant 2015; 15:1162.
  53. Goh KT, Ding JL, Monteiro EH, Oon CJ. Hepatitis B infection in households of acute cases. J Epidemiol Community Health 1985; 39:123.
  54. College of Physicians and Surgeons of British Columbia Resource Manual. Bloodborne Communicable Diseases in Physicians. www.cpsbc.ca. (Accessed on December 06, 2015).
  55. American College of Surgeons. Statement on the surgeion and hepatitis. https://www.facs.org/about-acs/statements/22-hepatitis (Accessed on July 01, 2016).
  56. United Kingdom Department of Health. Health clearance for tuberculosis, hepatitis B, hepatitis C and HIV: New healthcare workers. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/382152/health_clearance_tuberculosis_hepatitis_hiv.pdf (Accessed on July 01, 2016).
  57. Challine D, Chevaliez S, Pawlotsky JM. Efficacy of serologic marker screening in identifying hepatitis B virus infection in organ, tissue, and cell donors. Gastroenterology 2008; 135:1185.
  58. Theodoropoulos N, Jaramillo A, Ladner DP, Ison MG. Deceased organ donor screening for HIV, hepatitis B, and hepatitis C viruses: a survey of organ procurement organization practices. Am J Transplant 2013; 13:2186.