History and exam
Key diagnostic factors
common
presence of risk factors
Key risk factors include antenatal exposure, multiple sexual partners, men who have sex with men, injection drug use, family history of hepatitis B virus or hepatocellular carcinoma, incarceration, living in/travel to a highly endemic region, and household contact with an infected individual.
Other diagnostic factors
common
asymptomatic
Approximately 70% of patients with acute hepatitis B virus (HBV) infection are asymptomatic.[69] The vast majority of patients with chronic HBV are asymptomatic until they develop hepatocellular carcinoma, cirrhosis and its complications, or liver failure.
uncommon
jaundice
Present in approximately 30% of patients with acute hepatitis B virus (HBV) infection, and patients >30 years of age are more likely to be symptomatic.[70] Also present in chronic HBV infection with cirrhosis or liver failure.
hepatomegaly
More common in acute than in chronic hepatitis B virus infection.[70]
ascites
More common in patients with chronic hepatitis B virus-related cirrhosis.
fever/chills
Part of serum sickness-like syndrome and present in some patients with acute hepatitis B virus infection.
malaise
Part of serum sickness-like syndrome and present in some patients with acute hepatitis B virus infection.
maculopapular or urticarial rash
Part of serum sickness-like syndrome and present in some patients with acute hepatitis B virus infection.
right upper quadrant pain
May be present in patients with acute or chronic hepatitis B virus (HBV) infection. Present in approximately 30% of patients with acute HBV infection.[70]
fatigue
Present in patients with either acute or chronic hepatitis B virus infection including cirrhosis of liver.
nausea/vomiting
Part of serum sickness-like syndrome and present in some patients with acute hepatitis B virus (HBV) infection. Present in approximately 30% of patients with acute HBV infection.[70]
arthralgia/arthritis
Part of serum sickness-like syndrome and present in some patients with acute hepatitis B virus infection.
palmar erythema
More common in patients with chronic hepatitis B virus-related cirrhosis.
spider angiomata
More common in patients with chronic hepatitis B virus-related cirrhosis.
splenomegaly
More common in patients with chronic hepatitis B virus-related cirrhosis.
asterixis
More common in patients with chronic hepatitis B virus-related cirrhosis including decompensated cirrhosis.
Risk factors
strong
perinatal exposure in an infant born to an HBV-infected mother
Infants born to hepatitis B virus (HBV)-infected mothers are at risk of permucosal transmission of HBV from infective blood or fluids during childbirth.[43] Transplacental transmission in utero and breast-feeding are less likely causes of HBV transmission. The majority of infected infants develop chronic HBV infection if they do not receive post-exposure prophylaxis.
high-risk sexual behaviours
Sexual contact with infected partners is an important method of transmission. In one study, 27% of patients with acute hepatitis B virus (HBV) infection had heterosexual contact with an infected partner or multiple partners, and 13% of patients were men who have sex with men.[44] A meta-analysis found a 2% global prevalence of HBV among female sex workers.[45] HBV is present in large quantities (10⁸ to 10¹ºcopies/mL) in the serum of infected individuals, and it can also be detected in semen, saliva, and leukocytes.[22]
injection drug use
born in highly endemic region
Individuals born in regions of high incidence and prevalence (e.g., Asia, Africa) are at increased risk of infection. People living in, or travelling to, highly endemic regions are also at risk.
family history of HBV, hepatocellular carcinoma, and/or chronic liver disease
People with a family history of hepatitis B virus (HBV) infection, hepatocellular carcinoma, and/or chronic liver disease have an increased risk of infection.
household contact with HBV infection
In the US during the late 1990s, household contacts of an infected individual accounted for approximately 4% of cases of acute HBV infection per year.[44] Continuous close, personal, unapparent or unnoticed contact of infective secretions with skin lesions or mucosal surfaces is thought to be the mode of transmission, because HBV remains viable outside the body for an indefinite period of time.[57] Chronically infected children can inadvertently contaminate environmental surfaces with cuts or open sores. This mode of transmission is felt to account for the majority of the horizontal transmission of HBV in children in hyper-endemic areas.[58]
history of incarceration
Patients with a history of incarceration have a higher risk for hepatitis B virus (HBV) exposure due to associated risk factors (e.g., injection drug use, risky sexual behaviours, tattoos). In one systematic review in Europe, the highest prevalence of hepatitis B surface antigen among three high-risk groups (people who were incarcerated, men who have sex with men, and people who inject drugs) was found in those who were incarcerated (0.3% to 25.2%).[59]
weak
male sex
Men have 1.6 times the risk of hepatitis B virus infection compared with women.[47]
infected with HIV
Up to 10% of individuals infected with HIV are co-infected with hepatitis B virus (HBV), and 80% of HIV patients have serological evidence of HBV exposure.[48]
infected with hepatitis C virus
blood or blood product transfusion
In the US, the rate of transfusion-related hepatitis B virus (HBV) infection is approximately 0.002% per transfusion recipient.[52] Mandatory screening of blood products began in the US and the UK in the early 1970s.
healthcare workers
Historically, healthcare workers and public servants exposed to blood and bodily fluids have had higher rates of HBV infection compared with the general public, from percutaneous or permucosal transmission of hepatitis B virus (HBV). However, the incidence of HBV infection among immunised healthcare workers is now lower than in the general population.[53] Transmission of HBV to patients from infected healthcare workers, including large outbreaks, has been reported.[54][55] Approximately 30% of outbreaks were in situations where infection control policy was not followed. However, this was based on self-reporting and the true incidence is likely to be higher.[56]
haemodialysis
Hepatitis B virus (HBV) has been detected on environmental surfaces and in blood leaks during dialysis sessions.[60] However, few cases of acute HBV infection have been reported in patients undergoing chronic haemodialysis.[47] The pooled prevalence of HBV infection among haemodialysis patients was 7.32% globally. However, this varies based on geographical location, ranging from 4.32% in the US, to 5.52% in Europe, and 9.73% in South America.[61]
solid organ transplantation
HBV infection in solid organ transplant recipients is due to reactivation of previous HBV infection or donor-derived transmission. Donors should be screened using HBsAg, HBcAb, and HBV DNA.[62] Rare cases of unexpected HBV transmission have been reported from donors who are HBV screen negative. The majority are associated with recent donor intravenous drug use and hepatitis C infection, and may be due to HBV infection shortly before donor death (eclipse period infection), or HCV co-infection suppressing HBV replication (occult HBV infection).[63] To expand the donor pool, organs from HBcAb-positive donors are increasingly transplanted after a detailed risk-benefit discussion with patients. Transmision is uncommon with the use of intensive antiviral prophylaxis ± hepatitis B immunoglobulin.[62] All transplant recipients should be tested for HBV at 4-6 weeks post transplant, with additional testing considered at 1 year or if signs and symptoms of liver injury develop. All transplant candidates should receive HBV vaccination.[63]
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