Hepatitis B: migrant health guide
Advice and guidance on the health needs of migrant patients for healthcare practitioners.
Main messages
Healthcare professionals should:
- offer hepatitis B screening, in line with NICE guidance, to people born or raised in countries where the prevalence of chronic hepatitis B 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 receive appropriate care, including vaccinations at birth and at 4 weeks of age (in addition to the routine immunisation schedule), and testing at 12–18 months of age
- ensure that those at risk of infection are immunised against hepatitis B as 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 test appropriately – acute hepatitis B infection is a statutorily notifiable disease and if diagnosed in your patient, you should contact your local health protection team (HPT) about appropriate post-exposure prophylaxis for close contacts of cases of hepatitis B infection
- refer individuals identified as living with hepatitis B for specialist care
- work in partnership with local community services serving migrant populations to provide support to access testing and care
Background
The hepatitis B virus (HBV) causes hepatitis infection (inflammation of the liver) and can also cause long term (chronic) liver damage including hepatocellular carcinoma.
The World 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 to be less than 1%), but can occur
- the highest burden of infection is found in the WHO Western Pacific Region and the WHO African Region, where 97 million and 65 million people, respectively, are living with chronic infection
- 61 million people who are living with chronic infection are in the WHO South-East Asia Region, 15 million in the WHO Eastern Mediterranean Region, 11 million in the WHO in the WHO European Region and 5 million in the WHO Region of the Americas
In the UK, the prevalence of chronic hepatitis B infection is estimated to be 0.6%, or approximately 269,000 people. This increases to 1.5% in London.
In any given year, the majority (over 95%) of people with newly diagnosed chronic hepatitis B infections in the UK are migrants who most likely acquired their infection in their country of birth during early childhood.
Symptoms
Acute infection
Many people have no or mild symptoms during acute infection. Where symptoms do occur, they usually last between 1 and 6 weeks, and can include:
- a high temperature
- tiredness
- right upper quadrant abdominal pain
- nausea
- a rash or hives
- jaundice – which may be less noticeable on brown or black skin – may also occur with dark urine and/or pale stools if cholestasis
- most adults do not have any lasting problems after having a short-term hepatitis B infection, but some develop long-term (chronic) hepatitis
Chronic infection
Most people living with chronic hepatitis B infection are asymptomatic.
Chronic infection leads to persistent infectivity. Approximately 20 to 25% of people living with chronic hepatitis B infection develop progressive liver disease which can also lead to liver cirrhosis and liver cancer. Timely monitoring and treatment can reduce the risk of developing cirrhosis and hepatocellular carcinoma (HCC) once a diagnosis of chronic infection has been made.
The likelihood that a hepatitis B infection will become chronic depends upon the age at which a person becomes infected. Around 90% of infants infected during the first year of life develop chronic infections, compared to 20% to 50% in children infected between 1 to 5 years of age, and up to 5% of adults.
There is an increased risk of chronic infection where immunity is impaired.
Transmission
Hepatitis B is transmitted through contact with infected blood or body fluids and transmission mostly occurs through:
- vaginal or anal intercourse
- blood-to-blood contact through percutaneous exposure (for example sharing of needles and other equipment by people who inject drugs, and needlestick injuries)
- perinatal transmission from mother to child
More rarely, transmission has also occurred following bites from people living with hepatitis B. Transmission following blood transfusion in the UK is very rare as blood donors and donations are screened. Transmission following medical interventions in the UK is also rare but there may be an increased risk of healthcare associated transmission following procedures overseas.
The average incubation period is around 12 weeks (range 40 to 160 days).
Testing
Offer testing to anyone at increased risk of hepatitis B virus infection. This includes migrants from medium or high prevalence countries (all countries in Africa, Asia, the Caribbean, Central and South America, Eastern and Southern Europe, the Middle East and the Pacific islands), and people who inject or have injected drugs.
People whose only identified risk factor for hepatitis B is country of birth should have testing offered and arranged by GPs.Testing for hepatitis B virus is also available in genito-urinary medicine (GUM) clinics or drug treatment services for people accessing these services.
Diagnoses of hepatitis B virus is based on serological markers (antigens and antibodies) in plasma or serum. These markers indicate acute, chronic or past infection, infectivity, and immunity. Refer to NICE guidance or contact your local laboratory in interpreting results, and the need for any additional testing.
Further actions for primary or secondary healthcare professionals diagnosing and managing people living with hepatitis B upon test results should be undertaken as per NICE guidance.
Treatment
Acute infection
There is no specific treatment available for acute hepatitis B. Symptomatic treatment of nausea, 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 HBsAg and HBeAg (serological markers) are cleared.
Chronic infection
If HBsAg 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 antiviral treatment and general management to reduce the risk of infectivity and liver complications.
Although not suitable for all patients, specific treatment with anti-virals may reduce viral replication. Such treatments are initiated by the secondary care specialist. In 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 moderation in alcohol consumption, minimising the risk of transmission including if pregnant, and self-management of their symptoms. Be cautious 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
Prevention and control
Offer hepatitis B vaccine to all individuals at risk from hepatitis B infection, including infants born to mothers living with hepatitis B.
See Hepatitis B: the green book, chapter 18 and Vaccination of individuals with uncertain or incomplete immunisation status
Ask opportunistically about travel plans as patients who travel to visit friends and relatives in countries where the infection is endemic may be at increased risk of acquiring infection.
Some patients may choose or require medical treatment during their trip (such as kidney dialysis, or blood transfusions) which can put them at increased risk of infection with blood borne viruses. Advise patients about this potential risk.
Patients who will receive dialysis abroad (or in 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. If a case is diagnosed, it should be notified to 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. However, it should still be considered up to a week after a single exposure. If 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) can be used, alongside vaccination, to confer immediate passive immunity after exposure to a source with a confirmed hepatitis B infection. Hepatitis B immunoglobulin is available via the UK Health Security Agency (UKHSA).
The Immunoglobulin handbook 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 local health protection team (HPT).
Co-infection with HIV
Globally 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 be offered to HIV-infected individuals and those at risk of HIV.
Resources
UKHSA 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 pages on hepatitis B including detailed information about hepatitis B vaccination.Patient.info has information for patients about hepatitis B and a leaflet on hepatitis B immunisation.
Information about hepatitis B vaccination in different languages can be found at the public health resource library.
HepB Companion is a peer led organisation which supports people living with hepatitis B.
The British Liver Trust is a charity which provides resources for people with liver disease, including a helpline and publications.
The National Travel Health Network and Centre (NaTHNaC) provides country specific travel advice and has produced information on hepatitis B.
Information on hepatitis B and sexual transmission is available at Hepatitis B Terrence Higgins Trust.
Updates to this page
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Rewritten for clarity and update to links.
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Rebranded page to UKHSA. No change to content.
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Updated prevalence statistics, treatment guidance, and guidance on co-infection with HIV.
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Updated and made editorial changes to meet GOV.UK style.
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First published.