Hepatitis B Virus
Hepatitis B virus (HBV) is a double-stranded DNA virus in the Hepadnaviridae
The transmission electron micrograph (TEM) at right shows numerous hepatitis B virus (HBV) virions, also known as Dane particles.
In infected persons
HBV is found in highest concentrations in the blood, and lower concentrations in
saliva, semen, vaginal secretions, and wound exudates. HBV can remain
viable for >7 days on environmental surfaces at room temperature.
The average incubation period is 90 days from time of
exposure to onset of symptoms, but may vary from 6 weeks
to 6 months [1,2,5].
Acutely infected individuals develop clinically apparent hepatitis with
loss of appetite, nausea, vomiting, fever, abdominal pain and jaundice . Some
may have dark urine and gray stool  .
About one half of acute HBV infections in adults are symptomatic . About 1% of cases
result in acute liver failure and death.
Public Health Image Library (PHIL)
transmission accounts for most adult HBV infections in the United States .
Approximately 25% of the regular sexual contacts of infected individuals will
themselves become seropositive. 
10-20% of women seropositive for HBsAg transmit the virus to their neonates
in the absence of immunoprophylaxis. In women who are seropositive for both
HBsAg and HBeAg vertical transmission is approximately 90% . In patients with acute hepatitis B vertical transmission occurs in up to 10%
of neonates when infection occurs in the first trimester and in 80 -90% of
neonates when acute infection occurs in the third trimester .
Chronic infection occurs in about 90% of infected infants, 30% of infected
children aged <5 years , and 2%--6% of adults. Among persons with chronic HBV
infection, the risk of death from cirrhosis or hepatocellular carcinoma is
HBV infection does not appear to be cause birth defects, but there appears
to be a higher incidence of low birth weight among infants born to mothers with
acute infection during pregnancy . In one small study acute maternal hepatitis (type B or nontype B) had no
effect on the incidence of congenital malformations, stillbirths, abortions, or
intrauterine malnutrition. However, acute hepatitis did increase the incidence
of prematurity .
Who to test 
- Test all pregnant women at the first prenatal visit for hepatitis B surface
- Women admitted for delivery who have not had prenatal HBsAg testing should
have blood drawn for testing .
- Send a copy of the original lab report to the hospital.
- “More than 90% of women found to be HBsAg-positive on routine screening will
be HBV carriers, routine follow-up testing later in pregnancy is not necessary
for the purpose of screening. In special situations, such as when the mother is
thought to have acute hepatitis, when there has been a history of exposure to
hepatitis, or when particularly high-risk behavior such as parenteral drug abuse
has occurred during the pregnancy, an additional HBsAg test can be ordered
during the third trimester” 
- Test all susceptible contacts (including all family members) with hepatitis B
panel (HBsAg, antiHBc, antiHBs).
- Screening and vaccination of susceptible contacts should be done by the
family's pediatrician, primary health-care provider, or the physician evaluating
the clinical status of the HBsAg-positive pregnant women.
Interpretation of the Hepatitis B Panel
Tests Results Interpretation
immune due to natural infection
immune due to hepatitis B vaccination
* 1. May be recovering
from acute HBV infection.
2. May be distantly immune and test not sensitive enough to to detect
low level of anti-HBs
3. May be susceptible with a false positive anti-HBc.
4. May be undetectable level of HBsAg present in the serum and the
person is actually a
Accessed May 7, 2008
The presence of HBsAg idicates ongoing HBV infection, and in newly
infected persons, HBsAg is the only serologic marker detected during the
first 3--5 weeks after infection. In persons who recover from HBV infection,
HBsAg is usually eliminated from the blood in 3--4 months, and anti-HBs
A positive HBsAg in the absence of IgM anti-HBc is indicative of chronic
infection. If positive, this test result should be reported to state perinatal
immunization or HBV prevention programs to ensure proper case management of the
mother and appropriate postexposure immunization of her at-risk infant . The baby's health-care provider should be notified about the mother's HBsAg-positive
status and receive hepatitis B immune globulin (HBIG) and HBV vaccine.
Two available hepatitis B vaccines for
immunization are Recombivax HB® (Merck and Co., Inc.) and
Engerix-B (SmithKline Beecham Biologicals).
- Pregnancy is not a contraindication to
- For vaccination of adults 20 years of age and older:
- 1-mL dose by intramuscular injection
into the deltoid muscle, at initial visit, then one month and six months after
the first dose, for a total of three doses
- Consult package inserts for details.
Postexposure Prophylaxis for Susceptible Pregnant Women [1, 13]
Newborns Born to Hepatitis B Carriers 
- Newborns born to hepatitis B carriers should receive
hepatitis vaccine AND hepatitis B immune
globulin (HBIG) within 12 hours of birth.
The treatment of acute HBV infection is supportive. Patients should be
hospitalized if they have coagulopathy, encephalopathy , or severe debilitation
Persons with chronic hepatitis B should be referred to health-care
professionals with experience in the treatment of hepatitis B for treatment with
alpha-interferon or lamivudine . Interferon does not appear to adversely affect the embryo or fetus. However,
the data is limited, and the potential benefits of interferon use during
pregnancy should clearly outweigh possible hazards [7-9]. Initial data do not suggest
that Lamivudine is teratogenic . Lamivudine
has been used in the latter half of pregnancy in attempt to prevent perinatal
transmission of hepatitis B virus infection with mixed success [11,12]
Pregnant Hepatitis B carriers should be advised to
- Obtain vaccination against hepatitis viruses A as indicated.
- Abstain form alcohol use
- Avoid hepatotoxic drugs such as acetaminophen (Tylenol) that may worsen liver
- Not donate blood, body organs, or other tissue.
- Not share any personal items that may have blood on them (e.g., toothbrushes
- Inform the infant’s pediatrician, OB/GYN, and labor staff that they are a
hepatitis B carrier.
- Make sure their baby receives hepatitis B vaccine at birth, one month, and six
months of age as well as H-BIG at birth.
- Be seen at least annualy by their regular medical doctor.
- Discuss the risk for transmission with their partner and discuss the need for
counseling and testing
- Liver function testing is recommended for women who test positive for HBsAg
The following recommendations from The Society of Obstetricians and
Gynecologists of Canada may be helpful in counseling women considering
SOGC Recommendations 
• “The risk of fetal hepatitis B infection through amniocentesis is low.
However, knowledge of the maternal hepatitis B e antigen status is valuable in
the counselling of risks associated with amniocentesis.
• For women infected with hepatitis B, hepatitis C, or HIV, the addition of
noninvasive methods of prenatal risk screening, such as nuchal translucency,
triple screening, and anatomic ultrasound, may help in reducing the age-related
risk to a level below the threshold for genetic amniocentesis.
• For those women infected with hepatitis B, hepatitis C, or HIV who insist on
amniocentesis, every effort should be made to avoid inserting the needle through
the placenta. “
Although cesarean delivery has been proposed as a means of reducing mother to
child transmission (MCT) of HBV  The mode of delivery does not appear to
have a significant effect on the interruption of HBV maternal-baby transmission
by immunoprophylaxis . Delivery by cesarean section for the purpose of
reducing MCT of HBV is note presently recommended by either the CDC  or the
With appropriate hepatitis B immunoprophylaxis, breast-feeding poses no
additional risk for transmission from infected hepatitis B virus carriers
Centers for Disease Control
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