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Chronic hepatitis B (CHB) is one of the most widespread liver diseases in the world. It is currently incurable and can lead to liver cirrhosis and cancer. The considerable impacts on society caused by CHB through patient mortality, morbidity, and economic loss are well-recognised in the field. This is, however, a narrow view of the harms, given that people living with CHB can be asymptomatic for the majority of their life-long infection. Of less-appreciated importance are the psychosocial harms, which can continue throughout an affected person’s lifetime. Here we review the broad range of these impacts, which include fear and anxiety; financial loss and instability; stigma and discrimination; and rejection by society. Importantly, these directly affect patient diagnosis, management, and treatment. Further, we highlight the roles that the research community can play in taking these factors into account and mitigating them. In particular, the development of a cure for hepatitis B virus infection would alleviate many of the psychosocial impacts of CHB. We conclude that there should be a greater recognition of the full impacts associated with CHB to bring meaningful, effective, and deliverable results to the global community living with hepatitis B.

Chronic hepatitis B virus (HBV) infection is a global public health challenge on the same scale as tuberculosis, HIV, and malaria. The International Coalition to Eliminate HBV (ICE-HBV) is a coalition of experts dedicated to accelerating the discovery of a cure for chronic hepatitis B. Following extensive consultation with more than 50 scientists from across the globe, as well as key stakeholders including people affected by HBV, we have identified gaps in our current knowledge and new strategies and tools that are required to achieve HBV cure. We believe that research must focus on the discovery of interventional strategies that will permanently reduce the number of productively infected cells or permanently silence the covalently closed circular DNA in those cells, and that will stimulate HBV-specific host immune responses which mimic spontaneous resolution of HBV infection. There is also a pressing need for the establishment of repositories of standardised HBV reagents and protocols that can be accessed by all HBV researchers throughout the world. The HBV cure research agenda outlined in this position paper will contribute markedly to the goal of eliminating HBV infection worldwide.

The “Know Hepatitis B” campaign was the first national, multilingual communications campaign to promote testing for hepatitis B virus (HBV) among Asian Americans and Pacific Islanders (AAPIs). This population comprises fewer than 5% of the total U.S. population but accounts for more than half of the up to 1.4 million Americans living with chronic HBV infection. To address this health disparity with a national campaign, CDC partnered with Hep B United, a national coalition of community-based partners working to educate AAPIs about hepatitis B and the need for testing. Guided by formative research, the “Know Hepatitis B” campaign was implemented in 2013 with a two-pronged communications strategy. CDC used available Chinese, Korean, and Vietnamese media outlets on a national level and relied on Hep B United to incorporate campaign materials into educational efforts at the local level. This partnership helped facilitate HBV testing among the priority population.

Infection with the hepatitis B virus (HBV) is a significant public health concern in the US, disproportionately affecting Americans of Asian, Native Hawaiian and Pacific Islander descent, despite the availability of a simple blood test, approved treatments, and an effective vaccine. Hep B United, a national campaign to support and leverage the success of community-based HBV coalitions, convened a partner summit in 2012 to develop a strategic response to the HHS Action Plan for the Prevention, Care, and Treatment of Viral Hepatitis. The resulting community action plan focuses on advancing three areas of the HHS plan: educating providers and communities to reduce health disparities; improving testing and linkage to care to prevent HBV-related liver disease and cancer; and eliminating perinatal HBV transmission.

Patients with chronic hepatitis B virus (HBV) infection are often asymptomatic, but they are at risk for serious health consequences, including cirrhosis, liver failure, and hepatocellular carcinoma if they have active disease, and may need antiviral therapy. As primary care providers, nurse practitioners (NPs) may be the first and sometimes the only health care provider an HBV-infected individual may encounter. This article describes a new algorithm that can aid NPs in knowing whom to screen for HBV infection and how to follow up based on screening results, including what additional tests to order, necessary monitoring, and when to refer.

Chronic infection with the hepatitis B virus can lead to hepatocellular carcinoma and cirrhosis in up to 25% of infected individuals. As many as 2 million individuals in the US may have chronic hepatitis B infection, most of whom immigrated to the US from hepatitis B-endemic regions of the world. A 2010 report from the Institute of Medicine noted that two thirds of patients with hepatitis B are unaware of their infection, and most health care providers do not screen for hepatitis B or know how to manage hepatitis B-positive patients. In 2010, the Hepatitis B Foundation convened a group of primary care providers to consider the existing evidenced-based recommendations and strategies for implementation of hepatitis B screening into routine practice. The group designed an easy-to-use algorithm for screening, initial evaluation, ongoing management, and referral to a subspecialist when appropriate. Internal medicine specialists, including primary care providers and subspecialists, need to understand the steps they can take to address this often under-recognized disorder.

SUMMARY. Chronic infection with the hepatitis B virus (HBV) is a major risk factor for development of end-stage liver disease, including cirrhosis, liver failure and primary liver cancer. There are now seven antiviral agents approved by the United States Food and Drug Administration (FDA) for the management of chronic HBV infection. Despite the fact that there are between 1.4 and 2 million chronic HBV infections in the United States, fewer than 50 000 people per year receive prescriptions for HBV antiviral medications. This report discusses possible explanations for the disparity between the number of people who are chronically infected and the number of people who receive treatment. Explanations for this incongruence include the potentially large number of infected persons who are unscreened and thus remain undiagnosed, and lack of access, including insurance, education and referral to appropriate medical care, particularly for disproportionately infected populations.

Most children with chronic hepatitis B virus infection (persistent hepatitis B surface antigen–positive for >6 months) are asymptomatic and do not generally require treatment. These children are, however, at increased risk for severe complications later in life, including advanced liver disease and liver cancer. On November 11, 2008, the Hepatitis B Foundation, a nonprofit research and disease advocacy organization, convened a panel of nationally recognized North American pediatric liver specialists to consider and recommend an approach for the screening, monitoring, initial management, and referral of children with chronic hepatitis B. The panel developed recommendations to provide guidance to practitioners on determining what additional tests to conduct, how often to monitor on the basis of test results, and when to refer to a pediatric liver specialist to build a partnership between the practitioner and liver specialist to enhance the success of management of children with this lifelong infection.

Data from the 2003-2010 National Health and Nutrition Examination Survey (NHANES) indicate that about 3.6 million people in the United States have antibodies to the hepatitis C virus, of whom 2.7 million are currently infected. NHANES, however, excludes several high-risk populations from its sampling frame, including people who are incarcerated, homeless, or hospitalized; nursing home residents; active-duty military personnel; and people living on Indian reservations. We undertook a systematic review of peer-reviewed literature and sought out unpublished presentations and data to estimate the prevalence of hepatitis C in these excluded populations and in turn improve the estimate of the number of people with hepatitis C in the United States. The available data do not support a precise result, but we estimated that 1.0 million (range 0.4 million-1.8 million) persons excluded from the NHANES sampling frame have hepatitis C virus antibody, including 500,000 incarcerated people, 220,000 homeless people, 120,000 people living on Indian reservations, and 75,000 people in hospitals. Most are men. An estimated 0.8 million (range 0.3 million-1.5 million) are currently infected. Several additional sources of underestimation, including nonresponse bias and the underrepresentation of other groups at increased risk of hepatitis C that are not excluded from the NHANES sampling frame, were not addressed in this study.The number of US residents who have been infected with hepatitis C is unknown but is probably at least 4.6 million (range 3.4 million-6.0 million), and of these, at least 3.5 million (range 2.5 million-4.7 million) are currently infected; additional sources of potential underestimation suggest that the true prevalence could well be higher.

Background An estimated one million people worldwide die each year from complications of chronic hepatitis B infection (CHB), including liver cancer. A disproportionate number of infections and deaths occur in China. The incidence and mortality of liver cancer in Haimen City is among the highest in China, and in the world. A multi-year citywide campaign was aimed at eliminating hepatitis B virus (HBV) infection and significantly reducing the number of liver cancer deaths due to CHB in Haimen City, China. Methods Strategies included a public health information campaign targeting the 1.03 million city residents; specialized health education for leaders and providers to increase adoption of evidence-based HBV management protocols; establishment of health care infrastructure and management systems; and increased prevention and care delivery to key subpopulations (especially pregnant women). Results The project developed and deployed broad-reaching public awareness and health education tools and modules to 280,000 households and at community-based events. More than 90% of targeted healthcare providers and 80% of the community leaders/government officials attended educational seminars during the project period (1,441 health care providers; 1,883 local government officials). A centralized registration and management system for pregnant women was developed and instituted, 100% of pregnant women were enrolled (5,407 women over one year), and all infants born to HBV-infected mothers received one dose of HBIG and the first dose of HBV vaccine by 24 hours of birth. Conclusions Lessons from the implementation phase of the project include the importance of: gaining early and ongoing support from the local government and health bureau for success in reaching the targeted populations; and having project management by a local, experienced, and trusted health expert to navigate implementation and relationships, and help develop culturally and linguistically appropriate materials. Electronic supplementary material The online version of this article (doi:10.1186/1471-2458-14-754) contains supplementary material, which is available to authorized users.

This article informs physician assistants of an algorithm designed for primary care practice to guide the screening of patients for hepatitis B virus infection. The algorithm also provides guidance on evaluation, follow-up, and referral of patients who screen positive. The algorithm is a synthesis of several published, evidence-based practice guidelines and reports.

Here, presented with an evidence-based algorithm, are workshop consensus recommendations on whom to screen for hepatitis B and when to pursue further evaluation and management.

Chronic hepatitis B virus (HBV) infection in children presents a therapeutic challenge for the practitioner. Decisions regarding selection of patients who may benefit from treatment, appropriate timing of treatment, and the choice of antiviral therapy are complex and are compounded by the limited number of drugs that have been studied in children. An expert panel of nationally recognized pediatric liver specialists was convened by the Hepatitis B Foundation on August 11, 2009, to consider clinical practice relative to the therapeutic options available for children. A detailed account of these discussions is provided, and the opinions expressed are based on consensus of the experts, as well as on published evidence when available. The panel concludes that, at this time, there is no established benefit of treatment of children in the immune tolerant phase, and there is a very high risk of development of drug resistance. In addition, there is no indication for treatment of children in the inactive carrier state. For children in the immune active or reactivation phases, liver histology can help guide treatment decisions, and family history of liver disease, especially hepatocellular carcinoma, may argue for early treatment in some cases. Outside of clinical trials, interferon is the agent of choice in most cases. Nucleos(t)ide analogues are secondary therapies, and children who receive these agents require careful monitoring for development of resistance. There are a few situations when treatment is indicated regardless of HBV DNA or alanine aminotransferase levels. There is still much to be elucidated about the appropriate use of HBV therapy in children. Until more clinical data and therapeutic options are available, a conservative approach is warranted.

Dear Sir, In the December 2006 issue of Journal of Viral Hepatitis, Drs. Gish and Gadano made the important point that the current prevalence estimate of 1.25 million individuals in the USA with chronic hepatitis B virus (HBV) infection should be ‘corrected by taking into account HBV prevalence in immigrant populations and current estimates may be as high as 2 million’ [1]. The Hepatitis B Foundation (HBF) agrees with this statement, that the prevalence of chronic HBV infection in the United States is, in fact, significantly greater than the currently accepted estimate. We have performed our own calculation of the chronic hepatitis B prevalence estimate including the high prevalence rates of hepatitis B in immigrant populations. As a result, we estimate the current burden of chronic hepatitis B in the USA to be approximately 2 million people. We reason that an underestimation of the true number of infected individuals in the USA has occurred mostly because the highest-risk populations are under-represented in surveillance studies, and a large percentage of chronically infected individuals remain undiagnosed. Estimates of the number of HBV infections in the USA have been based on serosurvey data from the National Health and Nutrition Examination Surveys for the years 1976–1994 (NHANES II, III), which did not include significant numbers of Asians and Pacific Islanders (API, the ethnic groups most affected by hepatitis B), making it difficult to obtain accurate prevalence estimates [2]. Also, the large influx of foreign born individuals from countries with moderate or high incidence of hepatitis B increases the limitation of the NHANES estimate. Using Census data (2005 American Community Survey) and current prevalence estimates for chronic hepatitis B, we calculate that in APIs alone, there are approximately 832 433 individuals chronically infected with hepatitis B (Table 1). This number was reached using hepatitis B prevalence estimates of 8.9% for foreign and 1.4% for US born APIs [3], based on HBV survey data of API pregnant women. These estimates are conservative in comparison with recent studies, which have found the prevalence among foreign-born APIs to be between 10–15% [4, 5]. Table 1 Estimate of hepatitis B prevalence in the USA, based on census data and prevalence estimates, by ethnicity We calculated a chronic HBV burden of 1 157 137 individuals in the Caucasian, African American, and ‘other’ ethnicities, with a prevalence estimate of 0.42% in these groups (based on NHANES III data [6]) (Table 1). Adding our estimate for the API population (832 433) brings the total burden estimate to 1 989 570. This represents an increase of almost 800 000 individuals from the currently accepted HBV prevalence estimate, and it does not account for undocumented APIs, which could increase the number of chronically infected by another 100 000 (there are an estimated 1 500 000 undocumented APIs in the USA [7]). This calculation also does not include other high-risk groups, such as the incarcerated and homeless populations, which would increase the burden even further. While these calculations have limitations, they are provocative, in that they highlight the strong likelihood that chronic hepatitis B remains an under-recognized disease in the USA, one that deserves greater priority from public health leaders, research institutions and clinicians. The nation needs to support public health surveillance systems that yield reliable state and local data and can be used to calculate more accurate estimates of chronic hepatitis B. As the readers of JVH are aware, chronic hepatitis B infection leads to serious liver disease and early death in up to 25% of individuals [8], and the direct and indirect financial burden of chronic hepatitis B reaches $1 billion each year [9]. It is a leading cause of primary liver cancer (hepatocellular carcinoma), which is rising in both incidence and mortality in the USA, and now ranks 8th among leading causes of cancer death for Americans [10]. In the API population, liver cancer ranks 3rd among causes of cancer death [11]. With the number of new infections remaining steady despite the availability of a vaccine, and the significant rise of primary liver cancer in the USA, it is imperative that hepatitis B be prioritized as an important public health concern. An accurate assessment of the true prevalence of chronic hepatitis B that includes updated estimates from high-risk, undercounted populations, is a crucial first step towards significantly reducing the burden of chronic hepatitis B in this country. The Hepatitis B Foundation calls for action to be taken to allow all individuals in the USA who are chronically infected with hepatitis B to be counted.

In regions where hepatitis B virus (HBV) is endemic, perinatal transmission is common. Infected newborns have a 90% chance of developing chronic HBV infection, and 1 in 4 will die prematurely from HBV-related liver disease. In 2010, the Hepatitis B Foundation and the Haimen City CDC launched the Gateway to Care campaign in Haimen City, China to improve awareness, prevention, and control of HBV infection citywide. The campaign included efforts to prevent perinatal HBV transmission by screening all pregnant women for hepatitis B surface antigen (HBsAg), following those who tested positive, and administering immunoprophylaxis to their newborns at birth. Of 5407 pregnant women screened, 185 were confirmed HBsAg-positive and followed until delivery. At age one, 175 babies were available for follow up testing. Of those, 137 tested negative for HBsAg and positive for antibodies to HBsAg, indicating protection. An additional 34 HBsAg-negative babies also tested negative for antibodies to HBsAg or had indeterminate test results, were considered to have had inadequate immune responses to the vaccine, and were given a booster dose. A higher prevalence of nonresponse to HBV vaccine was observed among babies born to hepatitis B e antigen (HBeAg)-positive mothers and mothers with high HBV DNA titers. The remaining 4 babies tested positive for HBsAg and negative for antibodies, indicative of active HBV infection. The mothers of all 4 had viral loads ≥8×106 copies/ml in the third trimester. Although inadequate response or nonresponse to HBV vaccine was more common among babies born to HBeAg-positive and/or high viral load mothers, these risk factors did not completely predict nonresponsiveness. All babies born to HBV-infected mothers should be tested upon completion of the vaccine series to ascertain adequate protection. Some babies of HBeAg-positive mothers with high viral load may still become HBV infected despite timely immunoprophylaxis with HBV vaccine and HBIG.