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Patient information: Hepatitis B (Beyond the Basics)
Author
Anna SF Lok, MD
Section Editor
Rafael Esteban, MD
Deputy Editor
Peter A L Bonis, MD
Disclosures
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: May 2012. | This topic last updated: Oct 4, 2011.
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 "Serologic 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 is a protein that 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 a protein that helps the body's
immune system attack the hepatitis B virus. This protein 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 is a protein that helps the immune
system attack the hepatitis B virus. Its appearance 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. Resistance to tenofovir is uncommon. (See "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.
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.