Public health priority: High for newly acquired cases, routine for unspecified cases.
PHU response time: Investigate confirm newly acquired cases and all other confirmed cases within 3 working days. Enter confirmed newly acquired unspecified cases on NDD with 5 working days.
Case management: Investigate likely source of newly acquired cases.
Contact management: Ensure that contacts of newly acquired cases are offered post-exposure prophylaxis. Prevent transmission to household and sexual contacts by determining their immune status and offering vaccination to those who are susceptible to HBV infection.
Only confirmed cases should be notified.
A confirmed case requires laboratory definitive evidence only.
Note: Transient HBsAg positivity can occur in patients following HBV vaccination. This occurs more commonly in dialysis patients and is unlikely to persist beyond 14 days post-vaccination.
A confirmed case requires laboratory definitive evidence and that the case does not meet any of the criteria for a newly acquired case.
Detection of hepatitis B surface antigen (HBsAg), or hepatitis B virus by nucleic acid testing, except where there is prior evidence of hepatitis B infection.
Hepatitis B is to be notified by:
Only confirmed cases should be entered onto NCIMS.
The hepatitis B virus (HBV).
Hepatitis B is usually transmitted by contact with bodily fluids (such as blood, semen or vaginal secretions or saliva) of an infected (HBsAg positive) person. Because of the high concentration of virus in blood in some cases, an extremely small inoculum may be sufficient to transmit infection. The virus must be introduced through broken skin or the placenta or come in contact with mucous membranes for infection to occur.
Modes of transmission include:
Breast feeding does not appear to be a significant route of transmission. Faecal-oral and vector-borne modes of transmission have not been demonstrated. Hepatitis b is not transmitted by kissing on the cheek, coughing or sneezing, sharing food or sharing eating utensils.
Under some conditions, HBV can remain viable on environmental surfaces for at least 7 days.
The typical incubation period from infection to appearance of symptoms is 45 to 180 days, and most commonly 60 to 90 days. early studies however indicate the incubation period may be as short as 32 days, or less. 1,2
Infectivity commences before symptom onset and generally persists while HBsAg remains present.
Following acute infection, the risk of developing chronic HBV infection varies inversely with age, and is also more likely among the immunocompromised. A small proportion of people with chronic hepatitis B will clear the infection spontaneously over time. Chronic infection over years or decades can lead to liver failure or liver cancer in a proportion of those infected.
The usual clinical presentation is characterised by an insidious onset, with anorexia, vague abdominal discomfort, nausea and vomiting, sometimes arthralgia's and rash, often progressing to jaundice. The clinical course is indistinguishable from any other types of acute viral hepatitis. Only a small proportion of acute cases are clinically recognised, as only 30-50% of adults and less than 10% of children have symptoms. Infection is usually asymptomatic in infants.
Within 3 working days of notification by a doctor of a newly acquired case begin follow-up investigation. Unspecified cases are followed up at the discretion of the PHU Director.
Within 5 working days of notification enter confirmed newly acquired and confirmed unspecified cases on NCIMS.
Case management is the responsibility of the treating doctor. PHU staff should assist with investigating the likely source of infection if requested.
Supportive only during the acute phase.
A repeat test for HBsAg is recommended after 6 months to determine the clearance or continued presence of HBsAg. Those still HBsAg positive are defined as having chronic disease and should be counselled accordingly.
Interferon or combination anti-viral therapy can be of value for some people with certain stages of chronic hepatitis B. the treatment is not curative but aims to prevent complications (i.e. liver damage, cirrhosis, liver failure and hepato-cellular carcinoma).
The case or relevant care-giver should be informed about the nature of the infection and the mode of transmission. In particular, advice should be given emphasising that blood and other secretions are infectious until they become HBsAg negative, usually within 2 to 3 months. Those with chronic infection usually remain infectious for life.
Scrupulous attention to standard precautions is important while cases are HBsAg-positive. Surfaces contaminated with blood should be cleaned and properly disinfected.
Objects potentially contaminated with blood (for example razors and toothbrushes) should not be shared with other people and should be kept out of reach of children. Contaminated sharps should be stored in an approved sharps container. Any wound should be covered with an impermeable dressing.
Infected persons (among others) should not share injecting equipment with other people. Disposable needles should only be used once. Infected persons should not donate blood or body parts.
Persons who are HBsAg-positive should be advised that the virus may be transmitted through sexual contact and if the need to practice safe sex. Non-immune sex partners should be immunised against hepatitis B. Sexual partners who have adequate levels of anti-HBc (>10IU/L) are not at risk.
Pregnant or sexually active women with hepatitis B should be told about the risk of hepatitis B infection to newborns of HBsAg positive mothers, and of the importance of prophylaxis and immunisation for such newborns. Infants born to HBV-infected mothers require hepatitis B vaccine and hepatitis B immune globulin (HBIG) within 12 hours of birth to help protect them from infection. The efficacy of HBIG decreases markedly if administration is delayed beyond 48 hours after birth.
Parents or guardians of HBsAg-positive persons with intellectual disabilities or behaviour problems should be alerted to the risk of HBV infection associated with aggressive behaviour, such as biting and scratching.
Instruct persons with acute HBV infections to postpone non-emergency dental care and surgery until their viraemia has cleared. HBsAg-positive persons who seek medical or dental care should notify involved personnel of their hepatitis B status.
Determining the source of infection for newly acquired cases may permit identification of other cases and interrupt the transmission. Information regarding exposures during the period six weeks to six months before onset of the illness should be sought. A longer risk history may be needed for acute cases identified through the detection of HBsAg within 24 months of a negative result. Risk factors for hepatitis B include:
Exposure among health care workers should be managed as per the HIV, Hepatitis B and Hepatitis C - Management of Health Care Workers Potentially Exposed policy
Sexual contacts of the patent while infectious (up to the preceding six months) are at risk of infection.
The treating doctor is responsible for contact tracing. PHU's should work with the Sexual Health Service staff to assist where requested by the doctor. Contacts require counselling, examination and testing, and the empirical treatment. See Therapeutic Guidelines: Antibiotic for details.
The risk of transmission of HBV in the child care setting is usually low, and can be reduced through sound infection control procedures and environmental cleanliness. Toiletry items that could be contaminated with blood or saliva should not be shared. Contaminated objects should be cleaned and disinfected as soon as possible, to prevent transmission. The risk is greatest if the individual HBV DNA levels or is HBeAg-positive, and/or is a child <3 years old who has open skin lesions, demonstrates aggressive scratching or biting behaviour, or has a bleeding disorder. In child cases, the PHU should carefully assess the situation to determine whether or not exclusion of the child from child care or vaccination of classroom contacts is indicated.
Hospitalised patients with acute or chronic HBV infections pose a minimal risk to staff or other patients, given the implementation of standard precautions, and the appropriate pre-exposure use of hepatitis B vaccine. Dialysis units however are a particularly high risk area.
Usually none, unless transmission occurs in a child care centre, dialysis centre, or health care facility through infected environmental surfaces or inanimate objects.
The management of contacts is usually the responsibility of the treating doctor, but PHU staff should ensure that household and sexual contacts of newly acquired cases are tested and then vaccinated if non-immune, and assist in the follow up of contacts of unspecified cases if requested.
Persons with significant opportunity for blood-borne exposure during the infectious period should be identified. The following is a general list of persons considered contacts if exposed to infectious cases:
There is no treatment for acute hepatitis B other than supportive therapy.
Some individuals with chronic hepatitis B benefit from treatment with anti-virals to control replication and reduce the risk of complications. They also require regular monitoring for complications.
Passive immunisation with HBIG (along with active immunisation with hepatitis B vaccine) is used to prevent infection or modify illness due to infection with HBV. To be effective, HBIG must be given as soon as possible after exposure. The exposed person's prior history of hepatitis B infection, vaccination, and vaccine response status (if known) should always be considered, but treatment should not be unduly delayed whilst awaiting test results.
Post-exposure prophylaxis is recommended in the following situations:
HBIG is available by telephoning the Medical Registrar at the NSW Red Cross Blood Transfusion Service on (02) 9234 2444..
Hepatitis B vaccination is also indicated for persons at increased risk of infection because of lifestyle, medical history, occupation, or ongoing intimate contact with a HBV carrier. Vaccination should be recommended to persons at risk who are identified in the course of a HBV case investigation.
For details, refer to the latest Australian Immunisation Handbook, 10th Edition .
In NSW, hepatitis B vaccine is currently available free to:
Further information is available on the immunisation pages of the NSW Health website.
NSW Ministry of Health also funds the provision of hepatitis B vaccine to:
Advise susceptible contacts (or parents/guardians) of the risk of infection and the need for immunisation; counsel them to watch for signs or symptoms of hepatitis occurring within six months of exposure, and to avoid exposing others to potential infection.
If the case is a health care worker who performs exposure prone procedures, the case should be assessed and monitored in accordance with HIV, Hepatitis B or Hepatitis C - Health care Workers Infected Policy
HBsAg and HBV DNA status must be ascertained before recommencing performance of exposure prone procedures. Other health care workers should be reminded of the need for compliance with standard infection control precautions described in the Infection Control Policy and the requirements of their suspected registration boards.
If acute hepatitis B is diagnosed in a person with no known risk factors for HBV infection and circumstances suggest the possibility of health care acquired infection, initiate an investigation and notify Health Protection NSW immediately. The incident may need to be referred to the NSW Blood Borne Virus Advisory Panel (BBVAP) for review.
The Australian Red Cross Blood Service (ARCBS) and Health Protection NSW should be notified immediately if: