Hepatitis B (HBV, Hep B)

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What Is Hepatitis B?

Hepatitis B is an infectious hepatitis caused by the hepatitis B virus (HBV). This infection has two possible phases; 1) acute and 2) chronic.

  1. Acute hepatitis B refers to newly acquired infections. Affected individuals notice symptoms approximately 1 to 4 months after exposure to the virus. In most people with acute hepatitis, symptoms resolve over weeks to months and they are cured of the infection. However, a small number of people develop a very severe, life-threatening form of acute hepatitis called fulminant hepatitis.
  2. Chronic hepatitis B is an infection with HBV that lasts longer than 6 months. Once the infection becomes chronic, it may never go away completely.

Most infected adults are able to fight off the virus so their infection is cured. A low percentage of adults infected with HBV go on to develop chronic infection. Children are at much higher risk for chronic infection. A majority of infected young children will fail to clear the virus from their bodies and go on to develop chronic infection.

About two-thirds of people with chronic HBV infection are chronic carriers. These people do not develop symptoms, even though they harbor the virus and can transmit it to other people. The remaining one third develop "active" hepatitis, a disease of the liver that can be very serious.

  • The liver is an important organ that filters toxins out of the blood, stores energy for later use, helps with digestion, and makes substances that fight infections and control bleeding.
  • The liver has an incredible ability to heal itself, but long-term inflammation caused by HBV can result in permanent damage.
  • Scarring of the liver is called cirrhosis, a condition traditionally associated with alcoholism but one that is also caused by chronic active hepatitis B infection as well as other conditions. When this occurs, the liver can no longer carry out its normal functions and may fail completely. The only treatment for liver failure is liver transplant.
  • Chronic hepatitis B also can lead to a type of liver cancer known as hepatocellular carcinoma.
  • Any of these conditions can be fatal. About 15% to 25% percent of people with chronic hepatitis B die of liver disease.

Hepatitis B is the most common serious liver infection in the world.

In the United States, hepatitis B is largely a disease of young adults aged 20-50 years.

The good news is that infection with HBV is usually preventable because there is an effective vaccine. Use of the vaccine has resulted in a large decrease in the number of new infections reported in the United States each year.

Hepatitis:A Visual Guide to Hepatitis

How is Hepatitis B Transmitted? How Do You Get Hepatitis B?

The hepatitis B virus is known as a blood-borne virus because it is transmitted from one person to another via blood or fluids contaminated with blood. Another important route of transmission is from an infected mother to a newborn child, which occurs during or shortly after birth.

  • Direct contract with blood may occur through the use of dirty needles during illicit drug use, inadvertent needle sticks experienced by healthcare workers, or contact with blood through other means. Semen, which contain small amounts of blood, and saliva that is contaminated with blood also carry the virus.
  • The virus may be transmitted when these fluids come in contact with broken skin or a mucous membrane (in the mouth, genital organs, or rectum) of an uninfected person.

People who are at an increased risk of being infected with the hepatitis B virus include the following:

  • Men or women who have multiple sex partners, especially if they don't use a condom
  • Men who have sex with men
  • Men or women who have sex with a person infected with hepatitis B virus
  • People with other sexually transmitted diseases
  • People with HIV or hepatitis C
  • People who inject drugs with shared needles
  • People who receive organ transplants or transfusions of blood or blood products (exceedingly rare these days)
  • People who undergo dialysis for kidney disease
  • Institutionalized mentally handicapped people and their attendants, caregivers, and family members
  • Health care workers who are stuck with needles or other sharp instruments contaminated with infected blood
  • Infants born to infected mothers
  • People born outside the United States in areas where hepatitis B is common
  • People who travel to areas of the world where hepatitis B is common

In some cases, the source of transmission is never known.

You cannot get hepatitis B from the following activities:

  • Having someone sneeze or cough on you
  • Hugging someone
  • Shaking a persons hand
  • Breastfeeding your child
  • Eating food or drinking water
  • Casual contact (such as an office or social setting)

Hepatitis B Treatment

What is the treatment for hepatitis B?

Prevention is vital to avoid hepatitis B virus infection. The current recommendation is that all children be vaccinated. Additionally, the following individuals should receive the hepatitis B vaccine:

  • adults at high risk (health care workers),
  • household contacts of infected persons,
  • individuals on hemodialysis,
  • intravenous drug users, and
  • persons with multiple sexual partners.

What Are the Symptoms of Hepatitis B?

Half of all people infected with the hepatitis B virus have no symptoms and may never realize that they have been infected. Adults are more likely to develop symptoms than children. For those who do get sick, symptoms usually develop within 1 to 4 months after exposure to the virus. The initial symptoms are often similar to the flu.

Common symptoms of hepatitis B include:

  • Appetite loss
  • Feeling tired (fatigue)
  • Nausea and vomiting
  • Itching all over the body
  • Pain over the location of the liver (on the right side of the abdomen, under the lower rib cage)
  • Jaundice (a condition in which the skin and the whites of the eyes turn yellow in color)
  • Dark urine (the color of cola or tea)
  • Pale-colored stools (grayish or clay colored)

Other types of acute viral hepatitis such as hepatitis A andhepatitis C have symptoms that are indistinguishable from hepatitis B.

Fulminate hepatitis is a severe form of acute hepatitis that can be life-threatening if not treated right away. Fortunately, fulminate hepatitis is rare. The symptoms of fulminate hepatitis develop very suddenly and may include:

Prolonged nausea and vomiting can cause dehydration. Individuals with dehydration may notice these symptoms:

  • Extreme weakness
  • Confusion or trouble concentrating
  • Headache
  • Lack of urination
  • Irritability

Symptoms of liver damage may include the following:

  • Fluid retention causing swelling of the belly (ascites) and sometimes the legs
  • Weight gain due to ascites
  • Persistent jaundice
  • Loss of appetite, weight loss, wasting
  • Vomiting with blood in the vomit
  • Bleeding from the nose, mouth, or rectum; or blood in the stool
  • Hepatic encephalopathy (excessive sleepiness, mental confusion, and in advanced stages, development of coma)
Hepatitis:A Visual Guide to Hepatitis

When Should I Call the Doctor for Hepatitis B?

Call your health care professional if you have any of the following:

  • Nausea and vomiting that does not go away in 1-2 days
  • The inability to keep down liquids
  • A high fever or fever that persists more than 2 days
  • Yellow skin or eyes
  • Dark-colored urine (like tea or cola)
  • Pain in the abdomen.

For severe symptoms including confusion or delirium go to a hospital emergency department.

You should also contact your health care practitioner if you think you may have been exposed to the hepatitis B virus.

If you have chronic hepatitis B infection and think you might be pregnant; or if you are pregnant and think you have been exposed to hepatitis B inform health care practitioner right away.

How Is Hepatitis B Diagnosed?

Hepatitis B infection is diagnosed with blood tests. These tests can detect pieces of the virus in the blood (antigens), antibodies against the virus, and viral DNA ('viral load'). Blood tests for HBV are often done when routine blood work shows abnormal liver function tests or in patients who are at an increased risk for exposure. If a patient has had a large amount of vomiting or has not been able to take in liquids, blood electrolytes may also be checked to ensure that the patient's blood chemistry is in balance.

Other tests may be ordered to rule out other medical conditions.

X-rays and other diagnostic images are needed only in very unusual circumstances.

If a patient is diagnosed with chronic hepatitis B, they will need regular visits to their health care practitioner. Blood tests can help determine how active the infection is and whether there has been damage to the liver.

Blood tests alone may not be enough to guide treatment in chronic HBV. Other tests include:

  • CT scan or ultrasound: These diagnostic imaging tests are used to detect the extent of liver damage and may also detect cancer of the liver caused by chronic hepatitis B.
  • Liver biopsy: This involves removal of a tiny piece of the liver. It is usually done by inserting a long needle into the liver and withdrawing the tissue. The tissue is examined under a microscope to detect changes in the liver. A biopsy may be done to detect the extent of liver damage or to evaluate how well a treatment is working.

What Is the Treatment for Hepatitis B?

Acute hepatitis B usually resolves on its own and does not require medical treatment. If very severe, symptoms such as vomiting or diarrhea are present, the affected person may require treatment to restore fluids and electrolytes. There are no medications that can prevent acute hepatitis B from becoming chronic.

If a person has chronic hepatitis B, they should see their health care provider and determine if medical treatment is appropriate.

Are There Home Remedies for Hepatitis B?

The goals of self-care are to relieve symptoms and prevent worsening of the disease.

  • Drink plenty of fluids to prevent dehydration. Broth, sports drinks, gelatin, frozen ice treats (such as Popsicles), and fruit juices are preferred because they also provide calories.
  • Ask your physician before taking any medications, even those that are over-the-counter. Some medications depend on the liver, and liver damage may impair the body's ability to metabolize these drugs. If you are on prescription medications, check with your physician to see if the doses should be adjusted or if the medication should be temporarily discontinued.
  • Avoid drinking alcohol until your health care practitioner allows it. Individuals with chronic HBV should avoid alcohol for the rest of their lives.
  • Try to eat a diet that provides adequate nutrition. Take it easy. It may take some time for your energy level to return to normal.
  • Avoid prolonged, vigorous exercise until symptoms start to improve.
  • Call your health care practitioner for advice if your condition worsens or new symptoms appear.
  • Avoid any activity that may spread the infection to other people (sexual intercourse, sharing needles, etc).

What Is the Medical Treatment for Hepatitis B?

Acute hepatitis B infection

Acute hepatitis B infection is not treated with antiviral medications.

  • If the infected person is dehydrated from vomiting or diarrhea, a doctor may prescribe IV fluids to help them feel better. Medications may also be used to control these symptoms.
  • People with mild symptoms can be cared for at home.

Chronic hepatitis B infection

The degree of liver damage is related to the amount of active, replicating (multiplying) virus in the blood and liver. Regularly measuring the amount of HBV DNA ('viral load') in the blood gives your physician a good idea of how fast the virus is multiplying. The treatments now in use are classified as antiviral drugs, because they work by stopping the virus from multiplying.

  • Antiviral agents, while the best therapy known for chronic hepatitis B, do not work in all individuals with the disease.
  • There are several antiviral agents for chronic hepatitis B approved by the U.S. Food and Drug Administration (FDA). New drugs are always being tested and treatment recommendations are subject to change.
  • Antiviral therapy is not appropriate for everyone with chronic HBV infection. It is reserved for people whose infection is most likely to progress to active hepatitis or cirrhosis.
  • Decisions to start medications for treatment of hepatitis B are made by the patient and health care practitioner, often in consultation with a specialist in diseases of the digestive system (gastroenterologist),  liver (hepatologist), or an infectious disease specialist.
  • The decision to treat is guided by results of liver function tests, HBV DNA tests, and, frequently, liver biopsies after a complete history and physical examination.

Treatment is usually started when blood tests indicate that liver functions are deteriorating and the amount of replicating HBV is rising. Many people never reach this point. For those who do, the interval between diagnosis and starting treatment is quite variable.

Hepatitis:A Visual Guide to Hepatitis

What Are The Medications for Hepatitis B?

All of the following medications used to treat chronic hepatitis B are antiviral medications. They reduce the ability of the virus to reproduce in the body and give the liver a chance to heal itself. These drugs are not a cure for hepatitis B, but they do reduce the damage caused by the virus. Although these medications are similar in some ways, they differ in other important ways. Talk to your health care practitioner about the best medication for you.

Pegylated interferon alfa-2b (Pegasys®)

Pegylated interferon is used alone or in combination with other medications.

  • Pegylated interferon slows the replication of the virus and boosts the body's immune system to fight the infection.
  • It works best in people who have relatively low levels of HBV DNA (low viral load).
  • Pegylated interferon usually is not given to people whose liver damage has progressed to cirrhosis, because it can make the liver damage worse.
  • Treatment is often given for 48 weeks, which is shorter than for other medications, but pegylated interferon requires regular shots (injections) while other medications are taken orally (by mouth).
  • Pegylated interferon has unpleasant side effects in many people. The side effects are similar to having the flu. This medication can also cause or worsen depression. For many people, side effects are so severe that they cannot continue taking the medication.
  • Liver function tests and HBV DNA tests are used to check how well the treatment is working.
  • Interferon appears to stop the liver damage in up to 40% of people although relapse is possible.

Nucleoside/nucleotide analogues (NAs)

Nucleoside/nucleotide analogues (NAs) are compounds that mimic normal building blocks for DNA. When the virus tries to use the analogues, it is unable to make new viral particles. Examples of these agents include adefovir (Hepsera®), entecavir (Baraclude®), lamivudine (Epivir-HBV®, Heptovir®, Heptodin®), Telbivudine (Tyzeka®) and tenofovir (Viread®).

  • NAs reduce the amount of virus in the body. Between 20% and 90% of patients may have levels reduced so far that they become undetectable. Obviously, this is a broad range. The higher success rates are achieved in patients who do not have "hepatitis B e antigen" (HBeAg). HBeAg is detected by a blood test and indicates that the virus is actively multiplying.
  • Side effects are less common than with pegylated interferon. NAs have been associated with changes in body fat distribution, reduced blood cell counts, and increased levels of lactic acid in the blood. Rarely, NAs are associated with a severe flare of hepatitis that can be serious or fatal.
  • HBV may become resistant to NAs over time.
  • NAs do not cure the infection. Relapse is possible even in patients who have had a good response to treatment.

Is Surgery a Treatment for Hepatitis B?

There is no surgical therapy for hepatitis B.

If liver damage is so severe that the liver starts to fail, liver transplant may be recommended.

  • Liver transplant is a major process and surgery with an extended recovery period.
  • It also depends on the availability of a matching donor liver.
  • If liver transplant becomes a possibility for an individual, a health care practitioner will discuss the risks and benefits with them.

What Other Therapy Is Available for Hepatitis B?

No herbs, supplements, or other alternative therapy is known to work as well as antiviral medication in slowing HBV replication and promoting liver healing in hepatitis B. At this time, no specific herb or herbal preparation is recommended.

What Is the Hepatitis B Vaccine?

There is a vaccine against the hepatitis B virus (Engerix-B, Recombivax HB). It is safe and works well to prevent the disease. A total of 3 doses of the vaccine are given over several months. Hepatitis B vaccine is also produced as a combination product which includes other common childhood vaccinations. This can reduce the number of shots that a child needs at a single visit.

The following groups should be vaccinated for hepatitis B:

  • All children younger than 19 years, including all newborns - especially those born to mothers who are infected with HBV
  • All health care and public safety workers who may be exposed to blood
  • People who have hemophilia or other blood clotting disorders and receive transfusions of human clotting factors
  • People who have end-stage renal disease including those who require hemodialysis for kidney disease
  • Travelers to countries where HBV infection is common. This includes most areas of Africa, Southeast Asia, China and Central Asia, Eastern Europe, the Middle East, the Pacific Islands, and the Amazon River basin of South America.
  • People who are in prison
  • People who live or work in residential facilities for developmentally disabled persons
  • People who inject illegal drugs
  • People with chronic liver disease such as hepatitis C
  • People who have multiple sex partners or have ever had a sexually transmitted disease
  • Men who have sex with men
  • Persons with HIV
  • People who have a sexual partner who is an HBV carrier.
  • Household contacts of persons who are carriers of HBV.
  • Anyone who wants to be vaccinated, regardless of risk factors.

Hepatitis B immune globulin (BayHep B, Nabi-HB) is given along with the hepatitis B vaccine to unvaccinated people who have been exposed to hepatitis B.

  • These include close contacts of people with HBV infection, health care workers who are exposed to HBV-contaminated blood, and infants born to mothers infected with HBV.
  • Giving the immune globulin and the vaccine together in these situations prevents transmission of the disease in 80% to 90% percent of cases.

What Is the Follow-up for Hepatitis B?

If an individual has acute hepatitis B, a health care practitioner will draw blood and examine the person periodically to see if the infection is resolving. If the person develops chronic hepatitis B, they will need periodic examinations and blood tests on an ongoing basis. If these tests indicate that the virus is actively damaging the liver, the health care practitioner may suggest a liver biopsy or begin antiviral therapy. The individual will also be given a vaccine against hepatitis A, which is an unrelated virus that may cause severe liver disease in people who already carry hepatitis B.

Chronic hepatitis B is associated with hepatocellular carcinoma. Fortunately, this is a rare cancer. A blood test can be used to detect a marker for this cancer or the cancer can be detected by abdominal ultrasound. Persons with chronic hepatitis B are usually screened periodically (every 6 to 12 months) for hepatocellular carcinoma, although it is not clear if this screening improves survival.

How Do You Prevent Hepatitis B?

In addition to the hepatitis B vaccine, other ways to protect yourself from HBV infection include:

  • If you are sexually active, practice safe sex. Correct use of latex condoms can help prevent transmission of HBV, but even when used correctly, condoms are not 100% effective at preventing transmission. Men who have sex with men should be vaccinated against both hepatitis A and hepatitis B.
  • If you inject drugs, don't share needles or other equipment.
  • Don't share anything (including grooming products) that might have blood on it, such as a razor, toothbrush, fingernail clippers, etc.
  • Think about the health risks if you are planning to get a tattoo or body piercing. You can become infected if the artist or person piercing you does not sterilize needles and equipment, use disposable gloves, or wash hands properly.
  • Health care workers should follow standard precautions and handle needles and sharps safely.
  • If you are pregnant or think you might be pregnant, tell your health care practitioner if you have any of the risk factors for HBV infection.

Is Hepatitis B Curable?

Some people rapidly improve after acute hepatitis B. Others have a more prolonged disease course with very slow improvement over several months, or with periods of improvement followed by worsening of symptoms.

A small group of people suffer rapid progression of their illness during the acute stage and develop severe liver damage (fulminate hepatitis). This may occur over days to weeks and may be fatal.

Other complications of HBV include development of a chronic HBV infection. People with chronic HBV infection are at further risk for liver damage (cirrhosis), liver cancer, liver failure, and death.

Hepatitis B Resources and Information

American Liver Foundation
www.liverfoundation.org
(800) 465-4837

Hepatitis B Foundation
www.hepb.org
(215) 489-4900

Hepatitis Foundation International
www.hepatitisfoundation.org
(800) 891-0707

Reviewed on 11/21/2017

Medically reviewed by Robert Cox, MD; American Board of Internal Medicine with subspecialty in Infectious Disease

REFERENCES:

Centers for Disease Prevention and Control. Disease Burden from Viral Hepatitis A, B, and C in the United States.
<http://www.cdc.gov/hepatitis/HBV/StatisticsHBV.htm>

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