GPAtlas🧭 When to suspect
Hepatitis B is a liver infection caused by the hepatitis B virus (HBV), spread through infected blood and body fluids – including unprotected sexual contact, sharing of injecting equipment, and most importantly mother-to-baby (vertical) transmission at birth. The UK is a low-prevalence country, and most chronic infection here is found in people who acquired it perinatally or in early childhood in a higher-prevalence region. The defining feature is that most acute and chronic infection is silent – usually detected through screening, contact tracing, or incidentally on a blood test requested for another reason.
A minority present with an acute hepatitis: a flu-like prodrome (fatigue, anorexia, nausea, low-grade fever, arthralgia) followed by right upper quadrant discomfort and, in some, jaundice with dark urine and pale stools. Jaundice appears in roughly 30–50% of infected adults but only about 10% of children. The incubation period is long – around 6 weeks to 6 months (typically ~3 months) – and acute infection occasionally progresses to fulminant hepatic failure.
Outcome is driven by age at infection: over 90% of immunocompetent adults clear the virus and recover with lifelong immunity, whereas up to 90% of infants infected at birth develop chronic infection – the reason the neonatal immunisation programme matters so much. Chronic hepatitis B is defined as persistence of hepatitis B surface antigen (HBsAg) for 6 months or more, and carries a long-term risk of cirrhosis, liver failure, and hepatocellular carcinoma (HCC – primary liver cancer).
The key skills in primary care are threefold: test the right risk groups (because infection is usually asymptomatic), refer every HBsAg-positive patient, and recognise acute liver failure or decompensation.
| Higher background risk / exposure | Behavioural, sexual & clinical risk |
|---|---|
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• Born or brought up in a country of intermediate or high HBV prevalence (much of Asia, sub-Saharan Africa, the Middle East, Eastern and Southern Europe) |
• People who inject drugs – current or past – and their sexual partners |
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• Migrants from, or extensive travellers to, those regions |
• Men who have sex with men, people with multiple partners, and commercial sex workers |
|
• Household and close family contacts of a person with hepatitis B |
• Sexual contacts of an infected person |
|
• Babies born to HBsAg-positive mothers |
• People with HIV or hepatitis C (shared transmission routes) |
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• Blood or blood products, or tattoos, piercings, medical or dental procedures, with non-sterile equipment abroad |
• People on haemodialysis, those about to start immunosuppression or chemotherapy, and people in prison |
Source: NICE CG165 · UK Health Security Agency
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