Frequently Asked Questions for Health Professionals
Index of Questions
- What are the case definitions for reportable HBV infections?
- How many new HBV infections occur annually in the United States?
- What is the rate of new infections in the United States?
- How common is chronic HBV infection in the United States?
- How many deaths can be attributed to chronic HBV infection?
- Who should be screened for HBV?
- What puts a person at increased risk for hepatitis B?
- Who should receive postvaccination testing?
- When should postvaccination testing be done in infants born to people who test positive for HBsAg?
- Are international travelers at risk for HBV infection?
- How long after exposure to HBV can HBsAg be detected in an infected patient’s blood?
- Where can I learn more about HBV serology?
- Who should be vaccinated against hepatitis B?
- Is hepatitis B vaccination recommended in certain settings?
- What are the hepatitis B vaccines licensed for use in the United States?
- What are the recommended schedules for hepatitis B vaccination?
- What are the recommended doses of hepatitis B vaccines?
- Who should not receive hepatitis B vaccine?
- Can a patient receive the first dose of hepatitis B vaccine from one manufacturer and subsequent doses from another manufacturer?
- If there is an interruption between doses of hepatitis B vaccine, does the vaccine series need to be restarted?
- Is it harmful to administer an extra dose(s) of hepatitis B vaccine or repeat the entire vaccine series if documentation of vaccination history is unavailable?
- Can hepatitis B vaccine be administered concurrently with other vaccines?
- How long does protection from hepatitis B vaccine last?
- Why should an infant receive hepatitis B vaccine at birth before hospital discharge, even if the mother is negative for hepatitis B surface antigen (HBsAg)?
- Can hepatitis B vaccine be given during pregnancy or lactation?
- Can pregnant people get the HEPLISAV-B vaccine?
- Can pregnant people get the PreHevbrio vaccine?
- Can hepatitis B vaccine be given to immunocompromised people, such as people on hemodialysis or people with HIV?
- Can hepatitis B vaccine be given after exposure to HBV?
- Should clinicians test people for immunity to hepatitis B before being vaccinated?
- Is there any benefit in or risk associated with vaccinating a person who has been infected with HBV?
- Can anti-HBs levels following vaccination decline over time?
- Are booster doses of hepatitis B vaccine recommended?
- How is HBV infection treated?
- How serious is chronic HBV infection?
- How likely is HBV infection to become chronic?
- What is HBV reactivation?
- Who is at greatest risk for HBV reactivation?
- Are patients undergoing treatment for HCV at risk for HBV reactivation?
- What is HBV/hepatitis D virus (HDV) superinfection?
What are the case definitions for reportable HBV infections?
CDC, in collaboration with the Council of State and Territorial Epidemiologists has developed case definitions to provide uniform clinical and laboratory-testing criteria for the identification and reporting of nationally notifiable infectious diseases. The case definitions for acute, chronic, and perinatal hepatitis B are available at the following links:
How many new HBV infections occur annually in the United States?
In 2020, a total of 2,157 cases of acute hepatitis B were reported to CDC, for an overall incidence rate of 0.7 cases per 100,000 population (1). After adjusting for under-ascertainment and under-reporting, an estimated 14,000 acute hepatitis B cases occurred in 2020 (1).
What is the rate of new infections in the United States?
After a decade of stable rates, the rate of acute hepatitis B abruptly decreased by 32% after 2019. This decrease may be related to fewer people seeking healthcare and being tested for hepatitis B during the COVID-19 pandemic (1). Rates of reported acute hepatitis B decreased among all racial/ethnicity groups during 2005–2012 but have remained largely unchanged during 2013–2019. During 2020, rates of reported cases of acute hepatitis B ranged from a low of 0.2 cases per 100,000 among Asian/Pacific Islander persons to a high of 0.7 case per 100,000 among non-Hispanic White and non-Hispanic Black persons.
How common is chronic HBV infection in the United States?
There is an estimated 580,000 to 1.17 million people with HBV infection in the United States; two-thirds of whom may be unaware of their infection (2). Chronic hepatitis B disproportionately affects people born outside the United States; while accounting for only 14% of the US general population, non–US-born people account for 69% of the US population living with chronic HBV infection (2,3,4).
How many deaths can be attributed to chronic HBV infection?
During 2020, a total of 1,752 hepatitis B-associated deaths among US residents were reported in the US Multiple Cause of Death data from the National Center for Health Statistics, which corresponds to an age-adjusted death rate of 0.45 cases per 100,000 population (5).
What are the signs and symptoms of HBV infection?
Not all people with acute HBV infection have symptoms. Symptoms can range from asymptomatic or mild disease to, rarely, fulminant hepatitis. The presence of signs and symptoms varies by age. Infants, children under 5 years old, and immunosuppressed adults with acute HBV infection are typically asymptomatic. People less than 30 years old are less likely to be symptomatic compared with persons aged 30 years and older (6). When present, signs and symptoms of acute HBV infections can include:
- loss of appetite
- abdominal pain
- dark urine
- clay-colored stool
- joint pain
Most people with chronic HBV infection are asymptomatic and have no evidence of liver disease or injury. However, some people develop chronic hepatitis (elevation of AST/ALT), cirrhosis, or hepatocellular carcinoma (i.e., primary liver cancer).
What is the incubation period for hepatitis B?
When symptoms of acute hepatitis B occur, how long do they usually last?
How is HBV transmitted?
HBV is transmitted from a person who has HBV infection to a person who is not infected through activities that involve percutaneous (i.e., puncture through the skin) or mucosal contact with infectious blood or body fluids (e.g., semen and saliva), including
- a mother to her baby during pregnancy or delivery
- sexual contact with an infected partner
- injection drug use that involves sharing needles, syringes, or drug-preparation equipment
- contact with blood from or open sores
- exposures to needle sticks or sharp instruments
- sharing certain items that can break the skin or mucous membranes (e.g., razors, toothbrushes, and glucose monitoring equipment), potentially resulting in exposure to blood
- through poor infection control practices in healthcare settings (e.g., dialysis units, diabetes clinics).
How long does HBV survive outside the body?
HBV can survive outside the body and remains infectious for at least 7 days (9).
Screening and Testing
Who should be screened for hepatitis B infection?
CDC recommends the following screening practices for HBV infection (10):
Clinicians should screen all adults aged 18 years and older for HBV infection at least once during their lifetime using the triple panel test which includes hepatitis B surface antigen (HBsAg), antibody to hepatitis B surface antigen (anti-HBs), and total antibody to hepatitis B core antigen total anti-HBc).
Clinicians should test all infants born to pregnant people who are HBsAg positive or have other evidence of HBV infection for HBsAg and anti-HBs seromarkers, at 9-12 months of age or 1-2 months after vaccine series completion if the series is delayed.
Clinicians should screen all pregnant people for hepatitis B surface antigen (HBsAg) during each pregnancy, preferably in the first trimester, regardless of vaccination status or history of testing (11). Pregnant people with a history of appropriately timed triple panel screening and without subsequent risk for exposure to HBV (i.e., no new HBV exposures since triple panel screening) only need HBsAg screening.
Who should be periodically tested for hepatitis B?
Clinicians should periodically test susceptible people, regardless of age, who have ongoing risk for exposures, while these risks persist. To ensure increased access to testing, anyone who requests HBV testing should receive it, regardless of disclosure of risk, because many people might be reluctant to disclose stigmatizing risks. For periodic risk-based testing, consider using the triple panel test; or anti-HBc followed, if positive, by HBsAg and anti-HBs.
Susceptible people include those who have never been infected with HBV (i.e., total anti-HBc negative) and either did not complete a HepB vaccine series as recommended by the Advisory Committee on Immunization Practices or who are known to be vaccine nonresponders (11).
What seromarkers are recommended for hepatitis B testing?
During screening, clinicians should test for hepatitis B surface antigen (HBsAg), antibody to hepatitis B surface antigen (anti-HBs), and total antibody to hepatitis B core antigen (total anti-HBc). This is known as a triple panel. For periodic risk-based testing, consider using the triple panel test; or anti-HBc followed, if positive, by HBsAg and anti-HBs.
Clinicians should test all infants born to HBsAg positive people for HBsAg and anti-HBs seromarkers.
Clinicians should test all pregnant people for hepatitis B surface antigen (HBsAg) during each pregnancy, preferably in the first trimester, regardless of vaccination status or history of testing (11).
Clinicians should test pregnant people with a history of appropriately timed triple panel screening and without subsequent risk for exposure to HBV (i.e., no new HBV exposures since triple panel screening) need HBsAg.
For guidance on serologic testing for specific populations, see the resources below:
To learn more about screening, testing, and vaccination, see: https://www.cdc.gov/hepatitis/hbv/HBV-RoutineTesting-Followup.htm
What puts a person at increased risk for hepatitis B?
There are a variety of populations, activities, exposures, or conditions associated with an increased risk for HBV infection, including:
- Infants born to hepatitis B surface antigen (HBsAg)–positive pregnant people
- People born in regions of the world with hepatitis B virus (HBV) infection prevalence of >2%
- U.S.-born people not vaccinated as infants whose parents were born in regions with HBV infection prevalence of >8%
- Injection drug use
- Incarceration in a jail, prison, or other detention setting
- HIV infection
- Hepatitis C virus infection
- Men who have sex with men
- Sexually transmitted infections or multiple sex partners
- Household contacts of people with known HBV infection
- Needle-sharing or sexual contacts of people with known HBV infection
- Maintenance dialysis, including in-center or home hemodialysis and peritoneal dialysis
- Elevated alanine aminotransferase or aspartate aminotransferase levels of unknown origin
Who should receive postvaccination testing?
Testing for immunity is advised only for people whose subsequent clinical management depends on knowledge of their immune status, including
- infants born to people who test positive for HBsAg; https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6439a6.htm
- health care workers and public safety workers at high risk for continued percutaneous or mucosal exposure to blood or body fluids; https://www.cdc.gov/mmwr/preview/mmwrhtml/rr6210a1.htm
- patients on hemodialysis, people with HIV, other immunocompromised people (e.g., hematopoietic stem-cell transplant recipients or people receiving chemotherapy); and
- sex partners of people with chronic HBV infection.
When should postvaccination testing be done in infants born to people who test positive for HBsAg?
For infants born to people who test positive for HBsAg, postvaccination testing should be performed 1–2 months after completion of ≥3 doses of a licensed hepatitis B vaccine series. Testing should not be performed before age 9 months in order to avoid detection of anti-HBs from hepatitis B immune globulin (HBIG) administered during infancy and to avoid detection of HBsAg from vaccine (HBsAg can be transiently positive for 1–18 days after vaccination). Testing at 9 months or later also maximizes detection of late HBV infection. https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6439a6.htm
Are international travelers at risk for HBV infection?
More information about hepatitis B and travel is available from CDC’s Travelers’ Health site.
How long after exposure to HBV can HBsAg be detected in an infected patient’s blood?
HBsAg will be detected in an infected person’s blood an average of 4 weeks (range: 1–9 weeks) after exposure to the virus. About half of patients will no longer be infectious by 7 weeks after onset of symptoms, and all patients who do not remain chronically infected will be HBsAg-negative by 15 weeks after onset of symptoms (8).
Where can I learn more about HBV serology?
CDC offers free online training on the interpretation of hepatitis B serologic test results.
The University of Washington offers free continuing education that includes interpretation of HBV serologic tests.
Who should be vaccinated against hepatitis B?
The Advisory Committee on Immunization Practices (ACIP) recommends hepatitis B (HepB) vaccination among all adults aged 19–59 years and adults >60 years with risk factors for hepatitis B or without identified risk factors but seeking protection.
For additional information on hepatitis B vaccination for adults see Hepatitis B – Vaccination of Adults | CDC
For information on hepatitis B vaccination for infants, children, and adolescents see: recommendations for children see Hepatitis B Vaccination of Infants – Adolescents | CDC
Is hepatitis B vaccination recommended in certain settings?
Yes. In certain health care, evaluation, or treatment settings, a high proportion of clients have known risk factors for HBV infection. ACIP recommends universal vaccination of adults who receive care in those settings, which include:
- sexually transmitted disease treatment facilities,
- HIV testing and treatment facilities,
- facilities providing drug-abuse treatment and prevention services,
- health-care settings targeting services to people who inject drugs,
- correctional facilities,
- health care settings targeting services to men who have sex with men,
- chronic hemodialysis facilities and end-stage renal disease programs, and
- institutions and nonresidential day care facilities for people with developmental disabilities.
What are the hepatitis B vaccines licensed for use in the United States?
There are three single-antigen vaccines, one three-antigen vaccine, and three combination vaccines currently licensed in the United States.
Single-antigen hepatitis B vaccines
- Recombivax HB
Three-antigen hepatitis B vaccines
- PreHevbrio (13)
- Pediarix: Combined hepatitis B, diphtheria, tetanus, acellular pertussis (DTaP), and inactivated poliovirus (IPV) vaccine
- Twinrix: Combined hepatitis A and hepatitis B vaccine
- Vaxelis: Combined DTaP, IPV, Haemophilus influenzae type b, and hepatitis B vaccine
What are the recommended schedules for hepatitis B vaccination?
The vaccination schedule most often used for children and adults is three intramuscular injections, the second and third doses administered at 1 and 6 months, respectively, after the first dose. Alternate schedules have been approved for certain vaccines and/or populations. A new formulation, Heplisav-B (HepB-CpG), is approved for two doses, 1 month apart.
What are the recommended doses of hepatitis B vaccines?
|Hepatitis B Vaccine*, Age Group (yrs)||Dose (µg)||Vol (mL)||Schedule|
|Infants (<1 yr)||5||0.5||3-doses at age 0, 1–2, 6–18 mos|
|Children (1–10 yrs)||5||0.5||3 doses at 0, 1–2, 6 mos|
|Adolescents (11–19 yrs) †||5||0.5||3 doses at 0, 1, 6 mos†
|Adults (≥20 yrs)||10||1|
|Patients on hemodialysis and other immune-compromised persons, <20 yrs§||5||0.5|
|Patients on hemodialysis and other immune-compromised persons, ≥20 yrs||40||1|
|Infants (<1 yr)||10||0.5||3-doses at age 0, 1–2, 6–18 mos|
|Children (1–10 yrs)||10||0.5||3 doses at 0, 1–2, 6 mos|
|Adolescents (11–19yrs)||10||0.5||3 doses at 0, 1, 6 mos|
|Adults (≥20 yrs)||20||1|
|Patients on hemodialysis and other immune-compromised persons, <20 yrs§||10||0.5|
|Patients on hemodialysis and other immune-compromised persons, ≥20 yrs||40||2||4 doses at 0, 1, 2, 6 mos ¶|
|Adults (≥18 yrs**)||20||0.5||2 doses at 0 and 1 mos|
|PreHevbrio (FDA-approved in 2021)|
|Adults (≥18 yrs**)||10||1||3 doses at 0, 1, 6 mos|
|Pediarix (combination hepatitis B, diphtheria, tetanus, acellular pertussis, and inactivated poliovirus)|
|Infants (<1 yr)||10||0.5||3-doses at age 0, 1–2, 6–18 mos|
|Children (1–6 yrs) ††||10||0.5||3 doses at 0, 1–2, 6 mos|
|Vaxelis (combination diphtheria, tetanus, acellular pertussis, inactivated poliovirus, Haemophilus influenzae type b, and hepatitis B)|
|Infants (<1 yr)||10||0.5||3 doses at age 0, 1–2, 6–18 mos|
|Children (1–4 yrs) §§||10||0.5||3 doses at 0, 1–2, 6 mos|
|Twinrix (combination hepatitis A-hepatitis B) ¶¶|
|Adults (≥18 yrs)||20||1||3 doses at 0, 1, 6 mos (standard) or
4 doses at 0, 7d, 21–30 d, 12 mos (accelerated)
* Refer to package inserts for further information. For all ages, when the hepatitis B vaccine schedule is interrupted, the vaccine series does not need to be restarted. If a 3-dose series is interrupted after the first dose, the second dose should be administered as soon as possible, and the second and third doses should be separated by an interval of at least 8 weeks. If only the third dose has been delayed, it should be administered as soon as possible. The final dose of a 3-dose series vaccine must be administered at least 8 weeks after the second dose and should follow the first dose by at least 16 weeks; the minimum interval between the first and second doses is 4 weeks. Inadequate doses of hepatitis B vaccine or doses received after a shorter-than-recommended dosing interval should be readministered, using the correct dosage or schedule. Vaccine doses administered ≤4 days before the minimum interval or age are considered valid. Because of the unique accelerated schedule for Twinrix, the 4-day guideline does not apply to the first three doses of this vaccine when administered on a 0-day, 7-day, 21–30-day, and 12-month schedule. PreHevbrio is a three-antigen HepB vaccine that was FDA approved in 2021.
† A 2-dose schedule of Recombivax HB adult formulation (10 µg) is licensed for adolescents aged 11 through 15 years. When scheduled to receive the second dose, adolescents aged 16 years or older should be switched to a 3-dose series, with doses 2 and 3 consisting of the pediatric formulation administered on an appropriate schedule.
§ Higher doses might be more immunogenic, but no specific recommendations have been made.
¶ Engerix-B for adults on hemodialysis: Administer series of 4 doses (2 mL each) as a single 2-mL dose or as two 1-mL doses on a 0-, 1-, 2-, 6-month schedule. Recombivax HB for adults on hemodialysis is a 3-dose series.
** Data on Heplisav-B and PreHevbrio are currently insufficient to inform vaccine-associated risks in pregnancy. Thus, providers should vaccinate pregnant people needing HepB vaccination with Engerix-B, Recombivax HB, or Twinrix.
†† Pediarix cannot be administered at birth, before age 6 weeks, or at age ≥7 years.
§§ Vaxelis is approved for use as a 3-dose series in children 6 weeks through 4 years of age.
¶¶Twinrix is recommended for people aged ≥18 years who are at increased risk for both HAV and HBV infections.
Who should not receive hepatitis B vaccine?
If a person has had a serious allergic reaction to a prior dose of hepatitis B vaccine, a component of the hepatitis B vaccine, or yeast, the provider should not administer the hepatitis B vaccine. When hepatitis B vaccine is administered as part of a combination vaccine, the provider should check for contraindications to other vaccines.
Can a patient receive the first dose of hepatitis B vaccine from one manufacturer and subsequent doses from another manufacturer?
Yes. When feasible, providers should use vaccines from the same manufacturer to complete the series but should not defer vaccination when the manufacturer of the previously administered vaccine is unknown or when the vaccine from the same manufacturer is unavailable. There are different vaccination schedules for patients receiving vaccines from different manufacturers. For more information on how to complete the vaccination series using vaccine from a different manufacturer, see: Recommendations of the Advisory Committee on Immunization Practices for Use of a Hepatitis B Vaccine with a Novel Adjuvant | MMWR (cdc.gov)
There are limited data on safety and immunogenicity when HepB-CpG is interchanged with HepB vaccines from other manufacturers (14). Additionally, there are limited data on safety and immunogenicity when PreHevbrio is interchanged with HepB vaccines from other manufacturers.
If there is an interruption between doses of hepatitis B vaccine, does the vaccine series need to be restarted?
No. The provider does not need to restart the series, but should consider the following:
- If the vaccine series was interrupted after the first dose, the second dose should be administered as soon as possible.
- The second and third doses should be separated by an interval of at least 8 weeks.
- If only the third dose is delayed, it should be administered as soon as possible.
Is it harmful to administer an extra dose(s) of hepatitis B vaccine or repeat the entire vaccine series if documentation of vaccination history is unavailable?
Can hepatitis B vaccine be administered concurrently with other vaccines?
Yes. Administering hepatitis B vaccine at the same time as other vaccines has not been shown to interfere with antibody response. Providers should use separate body sites and syringes for simultaneous administration of injectable vaccines.
How long does protection from hepatitis B vaccine last?
Studies indicate that immunologic memory remains intact for at least 30 years among healthy people who initiated hepatitis B vaccination at less than 6 months of age (15). The vaccine confers long-term protection against clinical illness and chronic hepatitis B virus infection. Cellular immunity appears to persist even though antibody levels might become low or decline below detectable levels (16). There are ongoing long-term follow-up studies among vaccinated cohorts underway who initiated hepatitis B vaccination at birth, to determine the duration of vaccine-induced immunity (15).
Why should an infant receive hepatitis B vaccine at birth before hospital discharge, even if the mother is negative for hepatitis B surface antigen (HBsAg)?
ACIP recommends that all infants receive hepatitis B vaccine at birth, regardless of the infection status of the mother (11). Infants born to HBV-infected mothers require hepatitis B vaccine and hepatitis B immune globulin (HBIG) within 12 hours of birth to protect them from infection. However, because errors or delays in testing, reporting, and documenting maternal HBsAg status can and do occur, administering the first dose of hepatitis B vaccine soon after birth to all infants acts as a safety net, reducing the risk for perinatal transmission when maternal HBsAg status is either unknown or incorrectly documented at delivery. Also, initiating the hepatitis B vaccine series at birth has been shown to increase a child’s likelihood of completing the vaccine series on schedule (17).
Can hepatitis B vaccine be given during pregnancy or lactation?
Yes. The hepatitis B vaccine contains no live virus, so neither pregnancy nor lactation should be considered a contraindication to vaccination. That said, data on Heplisav-B and PreHevbrio are currently insufficient to inform vaccine-associated risks in pregnancy and are not available to assess the effects on the breastfed infant or on milk production/excretion, thus providers should vaccinate pregnant people needing HepB vaccination with Engerix-B, Recombivax HB, or Twinrix. Limited experience suggests that the developing fetus is at no apparent risk for adverse effects when these hepatitis B vaccines are administered to pregnant people (18). Meanwhile, new HBV infection in a pregnant person might result in severe disease for the mother and chronic infection for the newborn. Pregnant people who are identified as being at risk for HBV infection during pregnancy should be vaccinated and counseled concerning other methods to prevent HBV infection. Pregnant people may be at increased risk for hepatitis B if they have had more than one sex partner during the previous 6 months, are being evaluated or treated for a sexually transmitted infection, have had recent or current injection drug use, or have had a sex partner who tested positive for HBsAg.
Can pregnant people get the HEPLISAV-B vaccine?
There are no published clinical studies of HEPLISAV-B in pregnant people. Available human data on HEPLISAV-B administered to pregnant people are insufficient to inform assessment of vaccine-associated risks in pregnancy. Until safety data are available for HEPLISAV-B, providers should continue to vaccinate pregnant people needing hepatitis B vaccination with a vaccine from a different manufacturer.
Providers and patients can report administration of HEPLISAV-B to a pregnant people to the HEPLISAV-B® Pregnancy Registry, an observational study being conducted in the United States to evaluate pregnancy outcomes in people vaccinated with HEPLISAV-B® within 28 days prior to conception or at any time during pregnancy.
- Toll-free number: 1-844-443-7734
- Email: email@example.com
Providers can also refer the person to a pregnancy exposure registry gathering data on health information from people who take prescription medicines or vaccines when they are pregnant.
Can pregnant people get the PreHevbrio vaccine?
There are no adequate and well-controlled studies of PreHevbrio in pregnant people. Available human data on PreHevbrio administered to pregnant people are insufficient to inform vaccine-associated risks in. Data are not available to assess the effects of PreHevbrio on the breastfed infant or on milk production/excretion.
There is a pregnancy exposure registry that monitors pregnancy outcomes in people exposed to PREHEVBRIO during pregnancy. People who receive PREHEVBRIO during pregnancy are encouraged to contact 1-888-421-8808 (toll-free).
Can hepatitis B vaccine be given to immunocompromised people, such as people on hemodialysis or people with HIV?
Yes. A larger vaccine dose is required to induce protective antibody in patients on hemodialysis, and larger or additional doses might also be necessary for other immunocompromised people. Serologic testing of patients on hemodialysis and other immunocompromised people is recommended 1–2 months after administration of the final dose of the primary vaccine series to determine the need for revaccination. The safety and effectiveness of Heplisav-B and PreHevbrio have not been established in adults on hemodialysis. Detailed guidance on vaccination of patients on hemodialysis and other immunocompromised people is available from the Advisory Committee on Immunization Practices recommendations on adult hepatitis B vaccination [40 pages].
Can hepatitis B vaccine be given after exposure to HBV?
Yes. If a person has been exposed to HBV, providers should give appropriate prophylaxis, as soon as possible but preferably within 24 hours, to effectively prevent infection. The mainstay of postexposure immunoprophylaxis is hepatitis B vaccine, but, in certain circumstances, the addition of HBIG provides increased protection (19, 20).
Should clinicians test people for immunity to hepatitis B before being vaccinated?
Lack of access to serologic testing should not be a barrier to vaccination of susceptible people, especially in populations that are difficult to reach or have limited access to healthcare. Testing is not a requirement for vaccination, and in settings where testing is not feasible or is refused by the patient, the clinician should recommend the person proceed with vaccination.
Clinicians should conduct complete serologic testing (HBsAg, anti-HBs, and anti-HBc) on all adults over 18 at least once in a lifetime so they can appropriately counsel, vaccinate, and/or link the patient to care and treatment.
(See Who should be screened for HBV? for information about who should receive screening.)
Providers should administer the first vaccine dose immediately after the blood sample is collected and sent for serologic testing. It is not harmful to vaccinate people who are immune to HBV infection because of current or previous infection or vaccination, nor does it increase the risk for adverse events.
Is there any benefit in or risk associated with vaccinating a person who has been infected with HBV?
Can anti-HBs levels following vaccination decline over time?
Yes. Following vaccination, anti-HBs levels decline over time. Anti-HBs ≥10 mIU/mL is considered a correlate of vaccine-induced protection for people who have completed an approved vaccination series. Immunocompetent people who achieve an anti-HBs level ≥10 mIU/mL 1–2 months after completing the hepatitis B vaccine series remain protected, even if anti-HBs levels decline to <10 mIU/mL beyond that time (presumably because of persistent cellular immunity). https://www.cdc.gov/mmwr/preview/mmwrhtml/rr6210a1.htm
Are booster doses of hepatitis B vaccine recommended?
Booster doses are not recommended for people with normal immune status who have been vaccinated (15, 21). Only certain people should receive a booster dose in specific situations. For patients on hemodialysis, if annual testing for antibody to hepatitis B surface antigen (anti-HBs) shows a decline to <10 mlU/mL, a booster dose should be administered. For other immunocompromised people (including those with HIV, hematopoietic stem-cell transplant recipients, and people receiving chemotherapy), the need for booster doses has not been determined. When anti-HBs levels decline to <10 mIU/mL, annual anti-HBs testing, and booster doses should be considered for those with an ongoing risk for exposure.
How is HBV infection treated?
Generally, the provider will treat people with acute infection using supportive care depending on their symptoms. There are several antiviral medications available for people with chronic infection (22). It is important to link these patients to care with regular monitoring to prevent liver damage and/or hepatocellular carcinoma.
For pregnant patients who are positive, clinicians should conduct HBV DNA testing. AASLD recommends that pregnant people who test positive for HBsAg with HBV DNA levels of >200,000 IU/ML be provided antiviral therapy to reduce perinatal HBV transmission (23).
For information on practice guidelines to treat chronic hepatitis B, see the American Association for the Study of Liver Diseases’ (AASLD).
How serious is chronic HBV infection?
Approximately 25% of people who become chronically infected during childhood and 15% of those who become chronically infected after childhood die prematurely from cirrhosis or liver cancer. Most remain asymptomatic until onset of cirrhosis or end-stage liver disease (24, 25).
How likely is HBV infection to become chronic?
The risk for chronic infection varies according to the age at infection and is greatest among young children. Approximately 90% of infected infants and 30% of children infected between 1–5 years will remain chronically infected with HBV. By contrast, approximately 95% of infected adults recover completely from HBV infection and do not become chronically infected (26).
What is HBV reactivation?
HBV reactivation is the abrupt reappearance or rise in HBV DNA in a patient with previously inactive chronic or resolved hepatitis B. It is often accompanied by a flare in disease activity with elevation of liver enzymes with or without symptoms. HBV reactivation can be severe, resulting in death (27).
Who is at greatest risk for HBV reactivation?
Patients who test positive for both anti-HBc and HBsAg are at substantially higher risk of reactivation than are those who are positive for both anti-HBc and anti-HBs. Others at risk include people
- undergoing cancer chemotherapy;
- taking immunosuppressive therapy, including
- Rituximab and other drugs that target B lymphocytes (black box warning),
- high-dose steroids, and
- anti-TNF agents;
- with HIV infection who have discontinued therapy with antiretroviral drugs that also have activity against HBV;
- undergoing solid organ or bone marrow transplantation; and
- being treated for HCV coinfection.
For more information on risk, monitoring, and prevention of HBV reactivation, see the American Gastroenterological Association’s Institute Guideline on the Prevention and Treatment of Hepatitis B Virus Reactivation During Immunosuppressive Drug Therapy and AGA Institute Guidelines on Hepatitis B Reactivation (HBVr): Clinical Decision Support Tool.
Are patients undergoing treatment for HCV at risk for HBV reactivation?
Yes, there are reports of HBV reactivation in HCV coinfected patients receiving direct acting antiviral (DAA) therapy for HCV infection (28). Providers should test all patients initiating HCV DAA therapy for HBV infection with HBsAg, anti-HBs, and anti-HBc. People testing positive for HBsAg or anti-HBc should be monitored while receiving HCV treatment. For more information about treating HBV/HCV coinfected patients see: https://www.aasld.org/practice-guidelines/chronic-hepatitis-b
What is HBV/hepatitis D virus (HDV) superinfection?
Superinfection occurs when people with chronic, active HBV infection are subsequently infected with HDV. Superinfection exacerbates the symptoms of the chronic HBV infection and can lead to acute liver failure (see Hepatitis D FAQs for Professionals).
Healthcare providers can submit immunization or vaccine-preventable disease related questions to this e-mail address (NIPinfo@cdc). You will get an answer from a CDC immunization expert, usually within 24 hours.
2. Roberts H, Ly KN, Yin S, Hughes E, Teshale E, Jiles R. Prevalence of hepatitis B virus (HBV) infection, vaccine-induced immunity, and susceptibility among at-risk populations: U.S. households, 2013-2018. Hepatology. 2021(74):2353–65.
3. Wong RJ, Brosgart CL, Welch S, Block T, Chen M, Cohen C, et al. An updated assessment of chronic hepatitis B prevalence among foreign-born persons living in the United States. Hepatology. 2021(74):607–26.
4. American Community Survey 1-year public use microdata sample (PUMS) 2018. Variables: place of birth and decade of entry [Internet]. Suitland, MD: U.S. 2019. Available from: https://www.census.gov/programs-surveys/acs/microdata.html.
5. Centers for Disease Control and Prevention National Center for Health Statistics. Multiple Cause of Death 1999–2020 CDC WONDER Online Database [Available from: https://wonder.cdc.gov/.
6. McMahon BJ, Alward WL, Hall DB, Heyward WL, Bender TR, Francis DP, et al. Acute hepatitis B virus infection: relation of age to the clinical expression of disease and subsequent development of the carrier state. J Infect Dis. 1985;151(4):599–603.
7. Hoofnagle JH, Di Bisceglie AM. Serologic diagnosis of acute and chronic viral hepatitis. Semin Liver Dis. 1991;11(2):73-83.
8. Krugman S, Overby LR, Mushahwar IK, Ling CM, Frosner GG, Deinhardt F. Viral hepatitis, type B. Studies on natural history and prevention re-examined. N Engl J Med. 1979;300(3):101–6.
9. Bond WW, Favero MS, Petersen NJ, Gravelle CR, Ebert JW, Maynard JE. Survival of hepatitis B virus after drying and storage for one week. The Lancet. 1981;1(8219):550–1.
10. Conners EE, Panagiotakopoulos L, Hofmeister MG, Spradling PR, Hagan LM, Harris A, et al. Screening and Testing for Hepatitis B Virus Infection: CDC Recommendations — United States, 2023 (under embargo until March 10, 2023). MMWR – Morbidity & Mortality Weekly Report. 2023.
11. Schillie S, Vellozzi C, Reingold A, Harris A, Haber P, Ward JW, et al. Prevention of hepatitis B virus infection in the United States: recommendations of the Advisory Committee on Immunization Practices. MMWR Recomm Rep. 2018;67(1):1–31.
12. Alter MJ, Arduino MJ, Lyerla HC, Miller ER, Tokars JI. Recommendations for preventing transmission of infections among chronic hemodialysis patients. MMWR Recomm Rep. 2001(50):1–43.
13. Weng M. Universal hepatitis B vaccination in adults aged 19–59 years: updated recommendations of the Advisory Committee on Immunization Practices — United States, 2022. MMWR Morb Mortal Wkly Rep. 2022;71:477–83.
14. Schillie S, Harris A, Link-Gelles R, Romero J, Ward J, Nelson N. Recommendations of the Advisory Committee on Immunization Practices for use of a hepatitis B vaccine with a novel adjuvant. MMWR Morb Mortal Wkly Rep. 2018;67(15):455–8.
15. Bruce MG, Bruden D, Hurlburt D, Zanis C, Thompson G, Rea L, et al. Antibody levels and protection after hepatitis B vaccine: results of a 30-year follow-up study and response to a booster dose. J Infect Dis. 2016;214(1):16–22.
16. Middleman AB, Baker CJ, Kozinetz CA, Kamili S, Nguyen C, Hu DJ, et al. Duration of protection after infant hepatitis B vaccination series. Pediatrics. 2014;133(6):e1500–e7.
17. Yusuf HR, Daniels D, Smith P, Coronado V, Rodewald L. Association Between Administration of Hepatitis B Vaccine at Birth and Completion of the Hepatitis B and 4:3:1:3 Vaccine Series. JAMA. 2000;284(8):978-83.
18. Moro PL, Zheteyeva Y, Barash F, Lewis P, Cano M. Assessing the safety of hepatitis B vaccination during pregnancy in the Vaccine Adverse Event Reporting System (VAERS), 1990-2016. Vaccine. 2018;36(1):50-4.
19. Schillie S, Murphy TV, Sawyer M, Ly K, Hughes E, Jiles R, et al. CDC guidance for evaluating health-care personnel for hepatitis B virus protection and for administering postexposure management. MMWR Recomm Rep. 2013;62(RR-10):1–19.
20. Service UPH. Updated US Public Health Service guidelines for the management of occupational exposures to HBV, HCV, and HIV and recommendations for postexposure prophylaxis. MMWR Recommendations and reports: Morbidity and mortality weekly report Recommendations and reports. 2001;50(RR-11):1-52.
21. Leuridan E, Van Damme P. Hepatitis B and the need for a booster dose. Clin Infect Dis. 2011;53(1):68–75.
22. Terrault NA, Bzowej NH, Chang KM, Hwang JP, Jonas MM, Murad MH, et al. AASLD guidelines for treatment of chronic hepatitis B. Hepatology. 2016;63(1):261–83.
23. Pan CQ, Duan Z, Dai E, Zhang S, Han G, Wang Y, et al. Tenofovir to prevent hepatitis B transmission in mothers with high viral load. New England Journal of Medicine. 2016;374(24):2324-34.
24. Beasley RP. Hepatitis B virus. The major etiology of hepatocellular carcinoma. Cancer. 1988;61(10):1942-56.
25. McMahon BJ. The natural history of chronic hepatitis B virus infection. Hepatology. 2009;49(5 Suppl):S45-55.
26. Fattovich G, Bortolotti F, Donato F. Natural history of chronic hepatitis B: special emphasis on disease progression and prognostic factors. J Hepatol. 2008;48(2):335–52.
27. Hsu C, Tsou HH, Lin SJ, Wang MC, Yao M, Hwang WL, et al. Chemotherapy-induced hepatitis B reactivation in lymphoma patients with resolved HBV infection: a prospective study. Hepatology. 2014;59(6):2092-100.
28. Mücke MM, Backus LI, Mücke VT, Coppola N, Preda CM, Yeh M-L, et al. Hepatitis B virus reactivation during direct-acting antiviral therapy for hepatitis C: a systematic review and meta-analysis. Lancet Gastroenterol Hepatol. 2018;3(3):172–80.