Hepatitis B (HBV) is a virus that infects the liver, and is the most common infectious disease in the world. In the United States, an estimated 850,000 to 2.2 million people live with HBV; about 10% of people living with HIV in the U.S. also have HBV. In recent years there have been increases in HBV cases among people who inject drugs (PWID) and in mother-to-child (known as vertical) transmission in the U.S., directly related to the opioid crisis. Screening, vaccination, and prevention and HBV treatment are essential tools for addressing this public health issue.
Hepatitis B transmission
Hepatitis B is transmitted in much the same way as HIV. It’s spread when blood, semen, vaginal fluids, and other bodily fluids get into a person who does not have the virus or is not protected by immunity (through vaccination or cleared infection). It is also commonly transmitted during birth. The following have been associated with risk of transmission:
- vertical (perinatal) transmission
- condomless sex with an infected partner
- sharing syringes and other drug-injection equipment (cookers, cotton, water, etc.)
- sharing household items such as razors or toothbrushes with an infected person
- other blood-to-blood contact
- occupational exposure from needlesticks or other risks of blood-to-blood contact.
Testing for hepatitis B
Most people who acquire HBV don’t know it because there are rarely signs or symptoms in the acute or chronic stages of infection. Over time, as the liver is damaged, noticeable symptoms may arise, but screening (testing) for the virus is the only way to determine if you have HBV.
Who should get tested:
We have now moved into a universal HBV screening guideline recommendation. This is a very simple way to ensure that everyone is tested and offered a vaccine as indicated. The CDC offers a summary of the 2023 HBV screening and testing recommendations:
Summary of 2023 HBV screening and testing recommendations
- Screen all adults aged 18 years and older at least once in their lifetime using a triple panel test
- Screen pregnant people for hepatitis B surface antigen (HBsAg) during each pregnancy regardless of vaccination status and history of testing
- Expand periodic risk-based testing to include people incarcerated, people with a history of sexually transmitted infections or multiple sex partners, and people with hepatitis C virus infection
- Test anyone who requests HBV testing regardless of disclosure of risk
For our purposes here, don’t worry about understanding what “triple panel test” or “hepatitis B surface antigen” means: Your provider will explain to you when you get the test. The most important thing is to make sure you get tested; ask for a test to make sure.
In addition to these universal recommendations, the CDC recommends testing people at risk of infection, regardless of age and testing history:
- People with a history of sexually transmitted infections or multiple sex partners
- People with hepatitis C infection or a history of hepatitis C virus infection
- People incarcerated or formerly incarcerated in a jail, prison, or other detention setting
- Infants born to HBsAg-positive people
- People born in regions with HBV infection prevalence of ≥2%
- US born people not vaccinated as infants whose parents were born in geographic regions with HBsAg prevalence of >8%
- People who inject drugs or have a history of injection drug use
- People with HIV infection
- Men who have sex with men
- Household contact or former household contacts of people with known HBV infection
- Needle-sharing or sexual contacts of people with known HBV infection
- People on maintenance dialysis, including in-center or home hemodialysis and peritoneal dialysis
- People with elevated liver enzymes
SOURCE: CENTERS FOR DISEASE CONTROL AND PREVENTION (cdc.gov/hepatitis)
Vaccination for hepatitis B
Hepatitis B is vaccine preventable. Vaccination against HBV is safe and highly effective; it is successful over 95% of the time. After the first dose, the vaccine is administered one month and six months later. Adults may be eligible for a two-dose sequence, in which the first dose is administered and the second dose is given at least one month (minimum of 28 days) later. The vaccine remains effective the rest of your life with no need for a booster shot ever.
Who should be vaccinated against HBV:
As with their testing and screening recommendations, the CDC is keeping it simple:
“HepB vaccination is recommended for adults aged 19 to 59 years and adults > 60 years with risk factors for hepatitis B. Adults aged >60 years without known risk factors for hepatitis B may also receive HepB vaccines. Infants and all other persons aged <19 years are already recommended to receive HepB vaccines.”
In other words: Everyone from the age of 19 to 59 should get vaccinated! Universal vaccination is a simple way to make sure that no one falls through the cracks, and takes away the stigma of having to ask people for specific risk factors for HBV. Everyone younger than 19 has already had universal screening recs, so routine vaccines should be happening. If not, get vaccinated whenever you can make it happen…again, with no questions asked.
For anyone over the age of 60, the following risk factors should be considered for hep B vaccination:
Persons at risk for sexual transmission of HBV, including:
- Susceptible sex partners of hepatitis B surface antigen (HBsAg)-positive persons
- Sexually active persons who are not in a long-term, mutually monogamous relationship (e.g., more than one sex partner during the previous 6 months)
- Anyone seeking care for a sexually transmitted disease
- Men who have sex with men
People who are at risk of blood-borne exposures, including:
- People who inject drugs
- Susceptible household contacts of HBsAg-positive persons
- Health care and public safety workers at risk for blood exposure
- Anyone with end-stage renal disease
- Residents and staff of facilities for developmentally disabled persons
Additional people:
- Travelers to regions with intermediate or high rates of endemic HBV infection
- People living with hepatitis C
- People living with chronic liver diseases
- People living with HIV
- Adults with diabetes ages 19–59 years (at the discretion of clinicians for people with diabetes aged 60 and older)
- People who are incarcerated
- Anyone over the age of 60 who wants to be vaccinated.
If a person already has HBV, vaccination offers no protection against disease progression or risk of liver disease. Check for immunity or chronic infection before getting vaccinated.
Most people will clear HBV naturally and achieve immunity. Treatment for HBV is called for in anyone with cirrhosis, regardless of ALT or HBV viral load. Similarly, anyone living with chronic HBV who is undergoing immunosuppressive therapy should be treated to prevent an HBV flare-up. There are other scenarios where a person should be treated.