Hepatitis B: migrant health guide

Main messages

HealthcareSome professionalsmigrants should:

• offer hepatitis B screening, in line with NICE guidance, to people born or raised in countries where the prevalenceUK ofare chronicat hepatitishigher Brisk is intermediate or high (2% or greater)
• offer testing and vaccination to close contacts of people living with hepatitis B, including household and sexual contacts
• ensure babies born to mothers living with hepatitis B receiveinfection appropriatethan care,the includingUK-born vaccinationspopulation. atRefer birth and at 4 weeks of age (in addition to the routineMigrant immunisationHealth schedule),Guide’s andcountry-specific testing at 12–18 months of agepages
• ensure thatwhen thoseconsidering atwhether riskto oftest infectionan areasymptomatic immunisedpatient againstfor chronic hepatitis B asinfection.

  Consider per the Green Book, and Vaccination of individuals with uncertain or incomplete immunisation status

• consider acute hepatitis B infection in patients who present with a compatible clinical picture and testrisk appropriatelyfactors, –and acutetest appropriately.

  Acute hepatitis B infection is a a statutorily notifiable disease.

  Contact and if diagnosed in your patient,local you should contact your local health protection team (HPT) about about appropriate post-exposure prophylaxis and immunisation for close contacts of cases of hepatitis B infection

• referinfection.

  Ensure individualsthat identifiedthose asat livingrisk withof hepatitisinfection Bare forimmunised specialistagainst care

• workhepatitis inB.

  Immunise partnershipbabies withborn local community services serving migrant populations to providehepatitis supportB topositive accessmothers testing and care

follow up appropriately.

Background

The hepatitis B  virusvirus (HBV) causes hepatitis infection (inflammation of the liver)liver), and can also cause long term (chronic) liver damage including hepatocellular carcinoma..

The WorldMortality Health Organization estimates that globally:

• over 254 million people were living with chronic hepatitis B in 2022 and infections resulted in an estimated 1.1 million deaths in the same year, mostly from cirrhosis and liver cancer
• only an estimated 13% of people living with hepatitis B are aware of their infection – mortality is rare during the acute phase of infection (estimated(< to1%), be less than 1%), but can occur
• the.

  Global highestprevalence burden of HBV infection is foundestimated into thebe WHO3.9%. WesternThe PacificWorld RegionHealth andOrganization theestimates WHOthat Africanglobally:

  • over Region,296 wheremillion 97 millionpeople andhave 65 million people, respectively, are living with chronic infectionliver infections
  • 61 millionover 820,000 people whodie areeach livingyear withdue chronicto infectionacute areor inchronic theconsequences, WHOmostly South-Eastfrom Asiacirrhosis Region,and 15 millionliver incancer

  Areas thewith WHOhigh Easternand Mediterraneanintermediate Region,prevalence 11 millionrates in(5%-10% theof WHOadult inprevalence) theof WHOchronic Europeanhepatitis RegionB andinclude:

  • sub-Saharan 5 millionAfrica
  • East in Asia
  • the WHOAmazon
  • southern Regionparts of central and eastern Europe
  • the AmericasMiddle East
  • the Indian subcontinent

  In the UK, the prevalence of chronic hepatitis B infection is estimated to be 0.6%,0.3%, or approximately 269,000180,000 people. This increases to 1.5% in London.people.

  In any given year, the majority (over 95%) of people with newlynew diagnosed chronic hepatitis B infections in the UK are migrants who mostwho likely acquired their infection in their country of birth duringbirth during early childhood.

  Symptoms

  Acute infection

  Many people have no or mild symptoms during acute infection.infection, Wherewhile symptomsothers do occur, they usually last between 1 and 6 weeks, and can include:experience:

  • a highprodromal temperature
  • tiredness
  • rightillness upperthat quadrantincludes abdominalfever, pain
  • nausea
  • aarthralgia, rash or hives
  • jaundicea –rash which(that may beappear lessabout noticeable2 onweeks brownbefore orthe blackonset skinof –jaundice, maythen alsoresolves occurin withacute darkhepatitis urine and/or pale stools if cholestasisB)
  • mostnon-specific adultsmalaise, dofatigue, notfever, havenausea, anyand lastingpoor problemsappetite after(may havingbe amild, short-termespecially hepatitisin Bchronic infection,hepatitis butB)
  • right someupper developquadrant long-termabdominal (chronic) hepatitispain

  Chronic

  jaundice infection

  Most(with peopledark livingurine withand/or chronicpale hepatitisstools Bif infectioncholestasis)

• extrahepatic aremanifestations asymptomatic.

  Chronicsuch infectionas leadsglomerulonephritis, tovasculitis persistentand infectivity.polyarteritis

• signs Approximately 20 to 25% of people living with chronic hepatitis B infection develop progressive liver disease which(in canadvanced alsochronic leadhepatitis toB)

The liveraverage cirrhosisincubation and liverperiod cancer.is Timelyaround monitoring12 andweeks treatment(range can40 reduceto the160 riskdays).

Most ofadults developinginfected cirrhosiswith andHBV hepatocellularfully carcinomarecover (HCC)and oncedevelop alife-long diagnosisimmunity.

Chronic of chronic infection has been made.

The likelihood that aan hepatitisHBV B infectioninfection will become chronic depends upon the age at which a person becomes infected.

Around 90% of infants infected during the the first year of life develop chronic infections, compared to 20% to 50% in children infected infected between 1 to 5 years of of age, and up to 5% of adults.adults .

There is an increased risk of chronic infection where where immunity is impaired.

Chronic infection leads to persistent infectivity, and in about 20% of adults can also lead to liver cirrhosis and malignant change in the liver.

Transmission

HepatitisHBV B isis transmitted through contact with infected blood or body fluids andby transmissionthe mostlyfollowing occurs through:routes:

• vaginalsharing or analuse intercourseof contaminated equipment during injecting drug use
• blood-to-bloodvertical contacttransmission through(mother percutaneousto exposurebaby)
• sexual (fortransmission
• horizontal exampletransmission sharing(non-sexual contact, such as household contact with a person with HBV)
• receipt of needlesinfectious andblood other(via equipmenttransfusion) byor peopleinfectious whoblood injectproducts drugs,(for andexample, needlestickclotting injuries)factors)
• perinatalneedlestick transmissionor fromother mothersharps toinjuries
• tattooing childand body piercing

Testing

MoreTesting rarely,should transmissionbe hasoffered alsofor occurredhepatitis followingB bitesto migrants from peoplecountries living with hepatitisan B.intermediate Transmissionor followinghigh bloodprevalence transfusionof inchronic theinfections UK(2% or greater).

Testing is veryone rarepart asof blooda donorscare andpathway, donationscovering arediagnosis, screened.treatment Transmissionand followingimmunisation, medicalas interventionsoutlined in the UKNICE isguidelines.

Always alsoinclude rarerecent buttravel therehistory mayin bethe aninformation increasedprovided riskon ofthe healthcaretest associatedrequest transmissionform.

A followingguide proceduresto overseas.

the interpretation of serological markers

The averageConsult incubationNICE periodguidance is aroundor 12contact weeksyour (rangelocal 40laboratory toif 160you days).are uncertain about interpreting results.

Testing

Offer

Status	anti-HBc	anti-HBc testingIgM	HBsAg	anti-HBs	HBeAg	anti-HBe
Acute	+	+	+	-	+/-	+/-
Carrier to(low anyoneinfectivity	+	-	+	-	-	+
Carrier at(high increasedinfectivity)	+	-	+	-	+	-
Recovery risk(immunity)	+	-	-	+	-	+/-
Immunity of(after hepatitisvaccination)	-	-	-	+	-	-

Viral Bantigens virusthat infection.denote Thisinfectiousness

Hepatitis includesB migrantssurface fromantigen medium(HBsAg) oris:

• detected highfirst
• produced prevalencein countrieshigh (allconcentrations countriesduring inviral Africa,replication
• cleared Asia,if the Caribbean,acute Centralinfection andresolves

The Southinfection America,is Easterndefined andas Southernchronic Europe,if theit Middlepersists Eastfor andmore than 6 months.

The presence of HBsAg indicates that:

• the Pacificpatient islands),is andinfectious
• viral peoplereplication whois injectoccurring

Hepatitis orB havee injectedantigen drugs.(HBeAg) is:

People

• detected whosesoon onlyafter identifiedHBsAg
• a riskmarker factorof forinfectiousness hepatitisand Bviral isreplication
• also countrynormally ofcleared birthif shouldthe haveacute testinginfection offeredresolves

HBeAg andmay arrangedpersist byin GPs.Testingchronic forinfections.

Note hepatitisthat Bamong virusthose iswho alsoare availableHBsAg inpositive, genito-urinarythose medicinewho (GUM)are clinicsalso  or drugHBeAg treatmentpositive services forare peoplethe accessingmost theseinfectious services.to others.

Antibodies which denote exposure

DiagnosesAntibody ofto the hepatitis B viruscore antigen (anti-HBc): antibody response is baseddivided oninto serological2 markersantibody (antigenssubclasses IgM and antibodies)IgG:

• anti-HBc inIgM plasmasubclass orindicates serum.acute Theseinfection
• anti-HBc markersIgG indicatesubclass occurs during acute, chronic orand pastresolved infection,hepatitis infectivity,B infection and immunity.is Referindicates exposure to NICE guidance orthe contactvirus

One yourantibody localtest laboratorycan indetect interpretingboth results,antibodies, and is reported as total anti-HBc.

Antibody to the needhepatitis forB anye additionalantigen testing.(anti-HBe): antibody is found in individuals who have cleared HBeAg. However, it may fall to undetectable levels over time.

Antibody associated with recovery

FurtherAntibody actionsto forthe primaryhepatitis orB secondarysurface healthcareantigen professionals(anti-HBs): diagnosingdevelopment andof managinganti-HBs peopleis livinggenerally associated with disappearance of HBsAg in those recovering from natural infection. It is also produced in response to hepatitis B uponimmunisation. testIt resultsis shoulda bemarker undertakenof asimmunity peragainst NICEthe guidance.virus.

Treatment

Acute infection

There is no specific treatment available for acute hepatitis B. B. Symptomatic treatment of nausea,  vomitinganorexia, vomiting and other symptoms may be indicated. Liver failure is a rare complication that requires specialist treatment. Antiviral drugs are not needed to treat acute infection.

Following acute infection, follow up the patient to ensure that that HBsAg and and HBeAg (serologicalare markers)cleared areand cleared.that anti-HBs develops denoting naturally acquired immunity.

Chronic infection

If If HBsAg persists persists for more than 6 months then the patient is considered chronically infected. Refer them to a liver specialist for further assessment and consideration of of antiviral treatment and general management to to reduce the risk of infectivity and liver complications.

Although not suitableall forpatients allare patients,suitable, specific treatment with anti-virals may reduce viral replication.replication, clear HBsAg and HBeAg and stimulate production of anti-HBe and anti-HBs. Such treatments are initiated by the secondary care specialist.specialist, Inthrough some areas, shared care arrangements may allow the primary care practitioner to continue to prescribe in liaison with the specialist.

Pregnant women should access hepatitis B testing through antenatal screening. For any pregnant women that tests positive for hepatitis B, ensure that referral to the local specialist team has been made.

Counsel the patient on on moderation in alcohol consumption,consumption minimising the risk of transmission including if pregnant, and self-management of their symptoms., Beand cautioustake care in the prescription of potentially hepatotoxic drugs.

Further guidance on testing and treatment

NICE guidance: Hepatitis B and C testing: people at risk of infection

Hep B&C: RCGP online learning

Prevention and control

Offer hepatitis B vaccine to all individuals at risk from hepatitis B infection, including infants born to mothershepatitis livingB withsurface hepatitisantigen B.positive mothers.

See See Hepatitis B: the green book, chapter 18.

For andcountry-specific Vaccinationtravel ofadvice, individualssee withthe uncertainNational orTravel incompleteHealth immunisationNetwork statusand Centre (NaTHNaC).

Ask opportunistically about travel plans as patients who who travel to visit friends and relatives in in countries where the infection is endemic mayare be at increased risk of acquiring infection.

SomePatients patientswithin this group may choose or require medical treatment during their triptrip, (suchsuch as kidney dialysis, orand bloodsome transfusions)instances whichhave canbeen putrecorded themof atacquisition increased risk of infection with blood borne viruses.viruses in this way. Advise patients about this potential risk.

Patients who will receive dialysis abroad (orneed inimmunising the UK) should be immunised before starting dialysis.

For country-specific travel advice, see the National Travel Health Network and Centre (NaTHNaC).

Acute hepatitis B is a notifiable disease in the UK.UK. If a case is diagnosed, ityou shouldneed beto notifiednotify toyour your local health protection team (HPT). The team will provide information to prevent onward transmission and to immunise any contacts who are at risk of infection.

Post-exposure prophylaxis

Hepatitis B vaccine is highly effective at preventing infection if given shortly after exposure and ideally, within 48 hours of exposure.exposure However,– however, it should still be considered up to a week after a single exposure.  IfSee the exposure is ongoing or likely to occur again a full vaccination course should be given as soon as possible. See Hepatitis B: the green book, chapter 18.

Specific hepatitis B immunoglobulin (HBIG) canwill be used,used alongside vaccination, to confer immediate passive immunityimmunity. afterIt exposuremay togive aimmediate sourcealbeit withtemporary aprotection confirmedafter hepatitisexposure Bby infection.any source. Hepatitis B immunoglobulin is available via the UK Health Security Agency (UKHSA).

The The Immunoglobulin handbook contains contains information, indications and guidance on the use of immunoglobulin preparations for specific diseases, including hepatitis B.

If in doubt about post-exposure prophylaxis, please discuss with your your local health protection team (HPT).

Co-infection with HIV

Globally the the prevalence of hepatitis B infection in HIV-infected people is 7.4%. Some treatments for HIV are also active against hepatitis B. HIV-positive individuals are more likely to develop chronic hepatitis B infection.

Hepatitis B vaccine should should be offered to HIV-infected individuals and those at risk of HIV.

Resources

UKHSA provides  provides guidance, data and analysis on hepatitis B, including information on:

• diagnosis and management
• infants born to hepatitis B infected mothers
• vaccination

NHS Choices has has pages on hepatitis B including detailed informationincluding aboutdetailed hepatitis B vaccination.Patient.info has information for patients about hepatitis B and a leaflet on hepatitis B immunisationvaccination.

InformationPatient.co.uk abouthas hepatitisproduced Ba vaccinationleaflet inon different‘hepatitis languagesB can be found at the public health resource libraryimmunisation’.

HepBThe Companion is a peer led organisation which supports people living with hepatitis B.

The British Liver Trust is is a charity which provides resources for people with liver disease, including a helpline and publications.

The The National Travel Health Network and Centre (NaTHNaC) provides provides country specific travel advice and has produced produced information on hepatitis B.

InformationTAMPEP (European Network for HIV/STI Prevention and Health Promotion among Migrant Sex Workers) publish a leaflet on viral hepatitis B(including hepatitis B) for female sex workers in a range of languages.

The CDA Foundation and sexualPolaris transmissionObservatory ishas availablea atdashboard Hepatitisof country-specific data and global data about hepatitis B Terrenceand HigginsC.

Patient.info Trust.has information for patients about hepatitis B.