Hepatitis B - Update

Objectives

  1. Discuss the impact of Hepatitis B infections on healthcare and the diagnostic work-up of the patient infected with this virus.
  2. Describe the different ways in which the Hepatitis B virus can be transmitted between adults and to children through perinatal transmission and breastfeeding.
  3. Discuss the effectiveness of and recommendations for immunoprophylaxis against Hepatitis B and the potential treatment options for chronic infections.

Article

Update on Hepatitis C

Hepatitis B Update

Authors: Craig V. Towers, M.D., Patricia D. Hastings RN, BSN, MSN

Objectives: Upon the completion of this CNE article, the reader will be able to:

  1. Discuss the impact of Hepatitis B infections on healthcare and the diagnostic work-up of the patient infected with this virus.
  2. Describe the different ways in which the Hepatitis B virus can be transmitted between adults and to children through perinatal transmission and breastfeeding.
  3. Discuss the effectiveness of and recommendations for immunoprophylaxis against Hepatitis B and the potential treatment options for chronic infections.

Background and Healthcare Impact:

Hepatitis B was the first primary hepatitis virus discovered and reported upon in JAMA by Blumberg et al in 1965. Because the spread of this virus is primarily by a percutaneous or permucosal pathway, it was originally called serum hepatitis. Hepatitis B (HBV) is a circular DNA virus that is 42 nanometers in size. It is unique in that it is double stranded for two-thirds of its length and single stranded for the remaining third. It also contains its own DNA polymerase enzyme. Eight distinct serotypes exist. These are primarily important when performing epidemiology studies. All HBV particles contain a group-reactive determinant labeled "a" along with 2 sets of sub-determinants designated "d" or "y" and "w" or "r". The "w" was then found to have 4 different variants w1, w2, w3, and w4. Thus eight distinct serotypes have been identified, which are ayw1, ayw2, ayw3, ayw4, ayr, adw2, adw4 and adr.

Many patients are at increased risk for being a chronic carrier of Hepatitis B. These include the ethnic groups of Asians, Eskimos, Pacific Islanders, Haitians, and Sub-Saharan Africans. Other risk factors include male homosexual activity, prostitution, intravenous drug usage, patients with multiple tattoos, prior blood transfusion recipients, hemodialysis patients, hemophiliacs or other patients with bleeding disorders, and individuals who work in hospitals or chronic care facilities.

At the present time, there are 200 to 250 million carriers worldwide. The carrier rate in the United States ranges between 0.1% and 1% depending upon the population tested (or from 1 in 100 to 1 in 1000 persons). Individuals who become chronically infected have a 10% to 25% chance of progressing to cirrhosis and a 200 fold increased risk for developing hepatocellular carcinoma.

If an adult becomes acutely infected, there is about a 10% chance of becoming a chronic carrier. This chronic carrier state can lead to the development of chronic persistent hepatitis, chronic active hepatitis, cirrhosis, or hepatocellular carcinoma, as stated above. Table 1 puts this information into better perspective.

Table 1: 
Significance of an acute HBV infection in the adult population
(Assuming 1000 Adults are infected)

  • Number with symptoms 250
  • Number asymptomatic 750
  • Number of fulminant cases (liver failure, DIC, etc.) 1 to 5
  • Number who become chronic carriers 100
  • Number who develop cirrhosis / hepatocellular carcinoma 15 to 25

Diagnosis:

The laboratory testing involved with Hepatitis B is one of the more difficult areas in understanding this infection. In the general laboratory evaluation, 5 distinct blood tests are available, which are:

  1. Hepatitis B surface antigen (HBsAg) (originally called the Australia Antigen)
  2. Antibody to hepatitis B surface antigen (anti-HBsAg)
  3. Antibody to hepatitis B core antigen (anti-HBcAg)
  4. Hepatitis B e antigen (HBeAg) and
  5. Antibody to hepatitis B e antigen (anti-HBeAg).

The IgG antibody to the hepatitis B core antigen develops shortly after infection and usually remains positive for life. Some laboratories also offer an IgM antibody to the core antigen and this in conjunction with a positive HBsAg is more indicative of an acute HBV infection. The hepatitis B core antigen itself (HBcAg) is not available as a blood test. It is demonstrated primarily in liver biopsy specimens.

The other marker that develops shortly after infection is the presence of hepatitis B surface antigen or HBsAg and this remains positive until the patient becomes immune. If immunity occurs, then the antibody to the hepatitis B surface antigen or anti-HBsAg develops. There is a subset of the population that never produces an antibody to the surface antigen and these patients are considered to be chronically infected or are chronic carriers. The presence of an e antigen only signifies active viral replication and a more infectious state. The presence of antibody to the e antigen implies that the patient has a lower infectivity capability but does not exclude the possibility of transmission.

A patient who becomes immune to a hepatitis B infection will be positive for anti-HBcAg as well as anti-HBsAg. Over a long period of time, the antibody to the surface antigen may become non-detectable; whereas, the presence of the anti-HBcAg usually remains positive.

Patients who become chronic carriers will also have a positive anti-HBcAg, however, they never produce the anti-HBsAg. Instead, chronic carriers will continue to be HBsAg positive. Therefore, a positive IgG anti-HBcAg only denotes that an HBV infection occurred sometime in the past. The anti-HBcAg antibody is not protective and does not kill the virus. On the other hand, the anti-HBsAg antibody is protective and does result in immunity. A breakdown of the potential laboratory results is seen in Table 2 along with an explanation for the laboratory findings.

Table 2: The potential meaning of various Hepatitis B blood test results.

Possible Results

HBsAg

Anti-HBsAg

Anti-HBcAg

HBeAg

Anti-HBeAg

1.

+

2.

+

+

+

3.

+

+

+

4.

+

+

5.

+

+/–

6.

+

+

+/–

7.

+

8.

+

+

+

+/–

+/– *

  1. Acute HBV infection (very early stages)** or chronic HBV carrier state (with low levels of non-detected anti-HBcAg).
  2. Acute HBV infection** or chronic HBV carrier state (that is highly infectious).
  3. Acute HBV infection** (later stages) or chronic HBV infection (lower infectious status, but still infectious).
  4. Acute HBV infection** or chronic HBV infection (without HBeAg or Anti-HBeAg).***
  5. Window state between the disappearance of HBsAg prior to the development of anti-HBsAg** or evidence of past HBV infection with a low level undetected anti-HBsAg.
  6. Recovery from acute infection or infection in the remote past.
  7. Infection in the remote past with a low level undetected anti-HBcAg or a person who is status post hepatitis B vaccination.
  8. Late acute infection with early detection of antibodies (anti-HBsAg and anti-HBeAg) prior to the disappearance of the antigens, HBsAg and HBeAg, or a very rare unusual entity where the HBsAg is one serotype of the anti-HBsAg is for a different serotype.

* HBeAg and anti-HBeAg essentially never exist at the same time. However, the ability to detect antibodies has improved so much that this may occur transiently when a patient is developing anti-HBeAg as the HBeAg is disappearing.
** In this setting, an anti-HBcAg IgM antibody test might be helpful since a positive IgM denotes recent infection.
*** In some patients, HBeAg and anti-HBeAg never develop.

Transmission of HBV:

The transmission of hepatitis B is through a percutaneous or permucosal route. Therefore, transmission from person to person primarily occurs in the following ways:

  • Through Blood or Blood Products
  • Through IV Drug abuse
  • Through contaminated or unsterilized needles (i.e. tattooing, ear-piercing, acupuncture, and needle sticks in the healthcare setting)
  • Sexually
  • Perinatal Transmission
  • Contact through breaks in the skin or through mucus membranes (i.e. a splash in the eyes with contaminated fluid)

Hepatitis B surface antigen has been detected in essentially every body fluid with the highest concentrations found in blood, saliva, and semen.

Transmission of HBV through blood products at one time was a significant problem; however, now through the advent of testing donated blood, this risk is down to approximately 1 in 200,000 units transfused. The percutaneous spread is still significant in the IV drug abuse population and other exposures to potentially infected needles. This is due to the very high viral loads that are seen with this infection. For example, a high viral load for someone infected with HIV or Hepatitis C (HCV) is at concentrations of 104 to 105 viral particles per ml of blood. In comparison, viral loads for Hepatitis B can reach levels of 1012 to 1014 viral particles per ml of blood. Therefore, the risk of becoming infected following a needle stick exposure to HBV is much greater than the risk of becoming infected with HIV or HCV.

Sexual transmission is also significant when compared to other viral infections. Up to 40% of spouses will become infected after contact with a partner who has an acute infection. This rate is lower per contact if the partner is a chronic carrier; however, it increases based on the number of exposures. Perinatal transmission is a significant problem in parts of Asia and Sub-Saharan Africa and is a major concern because of the high rate of chronic carriers that develop. This is discussed further below.

With Hepatitis B, once infected the disease onset is slow and insidious. The first thing to appear (usually within 1 to 4 weeks) is the presence of HBsAg. This is followed by the development of anti-HBcAg. The elevation in liver function tests and the occurrence of clinical symptoms (including jaundice, dark urine, light colored stools, and right upper quadrant pain) can take 1 to 6 months to develop with an average of 2 to 3 months. The majority of patients (approximately 75%), however, do not have clinical symptoms that result in a diagnosis of hepatitis. Many of these will be asymptomatic or only have prodromal symptoms similar to that of the flu.

Vertical Transmission of HBV:

Vertical transmission of the hepatitis B virus from the mother to the neonate is a major concern. Studies have shown that up to 70% to 90% of neonates can become chronic carriers of the disease if they do not receive appropriate immunoprophylaxis following delivery, especially if the mother is HBeAg positive or has an acute infection in the third trimester. It is important to note that even if the HBsAg positive mother is HBeAg negative or even if she has a positive anti-HBeAg antibody, transmission to the neonate can still occur and immunoprophylaxis is indicated. A similar significance table is presented in Table 3. Note the differences in potential long-term outcome of a neonate infected with hepatitis B compared to that of an adult.

Table 3: 
Significance of an acute HBV infection in the newborn population
(Assuming 1000 Neonates are infected)
(Assuming an equal distribution of patients – HBeAg positive & negative)

  • Number with symptoms 250
  • Number asymptomatic 750
  • Number of fulminant cases (liver failure, DIC, etc.) 1 to 5
  • Number who become chronic carriers 600
  • Number who develop cirrhosis / hepatocellular carcinoma 150

The transmission from the mother to the infant primarily occurs at the time of birth due to exposure to infected maternal blood or vaginal secretions. The recommended treatment of the newborn that is delivered of an HBsAg positive mother involves a dose of hepatitis B immune globulin (HBIG) followed by the hepatitis B vaccine series (given at birth, one month, and six months). If an infant receives this prophylaxis following delivery, the risk that the child will become a chronic carrier falls to about 5% to 10%.

Breastfeeding in a patient who is HBsAg positive is controversial. HBsAg has been found in breast milk in several studies; however, most of these have not shown an increase in the neonatal infection rate. It is of utmost importance, however, that these infants are adequately treated with both HBIG and the full vaccine protocol.

Several studies evaluated populations of pregnant women to determine the incidence of a positive HBsAg result. These studies found that only 50% of hepatitis B surface antigen positive mothers would be identified if screening were only performed for risk factors. Due to these studies, the Centers for Disease Control and the American College of Obstetricians and Gynecologists, recommended that routine prenatal blood test screening include the hepatitis B surface antigen blood test.

Since the development of the hepatitis B vaccine in 1982, the rate of acute hepatitis B viral infections in the United States has not changed. Epidemiology studies reveal that approximately 200,000 to 300,000 acute HBV infections occur in the United States each year. Perinatal hepatitis B infections only account for a small proportion of the total picture (approximately 20,000 cases). Research has shown that there is a significant incidence of child-to-child transmission of this virus. Therefore, the American Academy of Pediatrics and the Centers for Disease Control now recommend that all children receive the hepatitis B vaccine series in a hope that this will prevent future child-to-child transmissions and sexual transmissions and eventually decrease the rate of new cases in the United States.

Treatment:

Unfortunately, there is no cure for hepatitis B once a person becomes infected. The treatment of chronic carriers of Hepatitis B primarily consists of interferon alpha-2b alone or in combination with other treatment modalities. This treatment is similar to the treatment of chronic Hepatitis C infected individuals. However, long-term effectiveness is seen in less than 50% of treated individuals. Another potential treatment option for patients chronically infected with HBV is the use of Lamivudine, a medication used in treating HIV.

The best treatment approach for HBV is to prevent infection through the use of immunization. If a person is exposed to the virus through blood or sexual transmission, the treatment requires both hepatitis B immune globulin (HBIG) in conjunction with the hepatitis B vaccine. If a person wants to prevent a future risk of infection, the treatment primarily involves the hepatitis B vaccine series. Table 4 below depicts one approach to managing HBV immunoprophylaxis.

The immunogenicity of the hepatitis B vaccine is excellent with over 90% to 95% of the vaccinated population developing antibody to the hepatitis B surface antigen following the third injection. It is important to note that the site of vaccine injection is important. Adults should receive an intramuscular injection (IM) in the deltoid region. Intradermal injections and gluteal injections have resulted in lower response rates. For infants, an injection in the anterolateral thigh is preferable due to the smaller deltoid muscles.

The original vaccine, Heptavax, was created by purifying HBsAg from the blood of carriers. When a person is infected with HBV and is a chronic carrier, their blood contains the full virion, which consists of the core DNA encapsulated by the HBsAg surface protein. In addition, their blood will contain millions of tubules and 22 nanometer spheres that consist of only the HBsAg protein. These spheres of HBsAg were purified to create the original vaccine. The vaccine was extremely safe because it went through a 3-step purification process of pepsin, urea, and formalin. However, the vaccine today is created in the laboratory through recombinant DNA in yeast, and therefore does not carry any risk for transmitting infection. These vaccines are Recombivax and Engerix-B.

Table 4: Recommendations for Immunoprophylaxis of Hepatitis B

  1. Perinatal Exposure:
    Give 0.5 cc of HBIG at birth followed by 0.5 cc of the hepatitis B vaccine* within 7 days of birth (most now give the vaccine at the same time as HBIG in opposite anterolateral thighs). The vaccine is repeated at one month of age and at 6 months of age. Then check for HBsAg and anti-HBsAg at 12 to 15 months of age (the presence of HBsAg signifies treatment failure whereas the presence of anti-HBsAg signifies treatment success). If both are negative, a vaccine booster should be given.
  2. Postexposure prophylaxis against a known HBV carrier – but the exposed individual has been vaccinated:
    Check for the presence of anti-HBsAg and if positive, no treatment is indicated. If negative, give 0.06 cc/kg of HBIG single injection ASAP (but within 14 days) of contact along with a booster injection of the vaccine.
  3. Postexposure prophylaxis from a known HBV carrier – but the exposed individual has not been vaccinated:
    Give 0.06 cc/kg of HBIG single injection ASAP (but within 14 days) of contact and administer the vaccine series. Another option is to first draw blood from the exposed person for anti-HBcAg/anti-HBsAg and then give 0.06 cc/kg of HBIG single injection. If the test results are negative then administer the vaccine series, if positive, the exposed person was already previously infected and the vaccine is not indicated.
  4. Postexposure prophylaxis from a known source with unknown HBsAg testing status – but the exposed individual has been vaccinated:
    Test the source for HBsAg and the exposed person for anti-HBsAg. If the exposed individual is positive for anti-HBsAg, then no treatment is indicated. If the source is positive and the exposed person is negative for the antibody, give 0.06 cc/kg of HBIG single injection and administer a vaccine booster. If the source is HBsAg negative but the exposed individual is also negative for the antibody, only administer the vaccine booster.
  5. Postexposure prophylaxis from a known source with unknown HBsAg testing status – and the exposed individual has not been vaccinated:
    Test the source for HBsAg and the exposed person for anti-HBcAg/anti-HBsAg. If the source is HBsAg positive and the exposed individual is negative for the antibodies, give the exposed person 0.06 cc/kg of HBIG single injection and administer the vaccine series. If the source is HBsAg negative and the exposed individual is negative for the antibodies, then administer the vaccine series. If the exposed person is positive for the antibodies, then he or she was already previously infected and the vaccine is not indicated.
  6. Postexposure prophylaxis from an unknown source – but the exposed individual has been vaccinated:
    Test the exposed person for anti-HBsAg. If the test is positive for the antibody, then no treatment is indicated. If the test is negative for the antibody, administer a vaccine booster.
  7. Postexposure prophylaxis from an unknown source – and the exposed individual has not been vaccinated:
    Test the exposed person for anti-HBcAg/anti-HBsAg. If the exposed individual is negative for the antibodies, administer the vaccine series. If the exposed individual is positive for the antibodies, then he or she was already previously infected and the vaccine is not indicated.

* Hepatitis B vaccine doses for an infant and children under the age of 10, is generally 0.5 cc or half the adult dose. The adult dose and children over the age of 10 is generally 1.0 cc. Heptavax comes at a concentration of 20ug of HBsAg per cc, Recombivax HB is 10ug of HBsAg per cc and Engerix-B is at a concentration of 20ug of HBsAg per cc.

References or Suggested Reading:

  1. Blumberg BS, Alter HJ, Visnich S: A "new" antigen in leukemia sera. JAMA 1965;191:541.
  2. Ahtone J, Maynard JE. Laboratory Diagnosis of Hepatitis B. JAMA 1983;249:2067-69.
  3. Chau KH, Hargie MP, Decker RH, et al. Serodiagnosis of recent hepatitis B infection by IgM class anti-HBc. Hepatology 1983;3:142-49.
  4. Hoofnagle JH, Seeff LB, Bales ZB, et al. Type B hepatitis after transfusion with blood containing antibody to hepatitis B core antigen. N Engl J Med 1978;298:1379-83.
  5. Beasley RP. Hwang LY, Lin CC, Chien CS. Hepatocellular carcinoma and hepatitis B virus. Lancet 1981;2:1129-33.
  6. Hoofnagle JH. Chronic hepatitis B. N Engl J Med. 1990;323:337-9.
  7. Lohiya GS, Pirkle H, Nguyen H, et al. Hepatocellular Carcinoma in Hepatitis B Surface Antigen Carriers in Eight Institutions. West J Med 1988;148:426-29.
  8. Krugman S, Holley HP, Davidson M, et al. Immunogenic effect of inactivated hepatitis B vaccine comparison of 20 ug and 40 ug doses. J Med Virol 1981;8:119-21.
  9. Francis DP, Handler SC, Thompson SE, et al. Prevention of hepatitis B with vaccine:Report of the CDC multicenter efficacy trial. Ann Intern Med 1982;97:362-69.
  10. Beasley RP, Trepo C, Stevens CE, Szmuness W. The e Antigen and Vertical Transmission of Hepatitis B Surface Antigen. Am J Epidemol 1977;105:94-98.
  11. Tong MJ, Thursby M, Rakela J, et al. Studies on the Maternal-Infant Transmission of the Viruses Which Cause Acute Hepatitis. Gastroenterol 1981;80:999-1004.
  12. Sinatra FR, Shah P, Weissman JY, et al. Perinatal transmitted acute icteric hepatitis B in infants born to hepatitis B surface antigen-positive and anti-hepatitis B e-positive carrier mothers. Pediatrics 1992;70:557-59.
  13. Tong MJ, Sinatra FR, Thomas DW, Nair PV, et al. Need for immunoprophylaxis in infants born to HBsAg-positive carrier mothers who are HBeAg negative. J Pediatr 1984;105:945-47.
  14. Beasley RP, Hwang LY, Lee GCY, Lan CC, et al. Prevention of perinatally transmitted hepatitis B virus infections with hepatitis B immune gloublin and hepatitis B vaccine. Lancet 1983;2:1099-1102.
  15. Wong VCW, Ip HMH, Reesink HW, Lelie PN, et al. Prevention of the HBsAg carrier state in newborn infants of mothers who are chronic carriers of HBsAg and HBeAg by administration of hepatitis-B vaccine and hepatitis-B immunoglobulin. Lancet 1984;1:921-926.
  16. Beasley RP, Stevens CE, Shiao I-S, Meng H-C. Evidence against breast-feeding as a mechansim for vertical transmission of hepatitis B. Lancet 1975;2:740-41.
  17. DeMartino M, Appendino C, Resti M, et al. Should hepatitis B surface antigen positive mothers breast feed? Arch Dis Childhood 1985;60:972-74.
  18. Wistrom J. Intramuscular vs Intradermal Hepatitis B Vaccination:A 6-Year Follow-up. JAMA 1995;273:1835-36.
  19. Cruz AC, Frentzen BH, Behnke M.Hepatitis B: A case for prenatal screening of all patients. Am J Obstet Gynecol 1987;156:1180-3.
  20. Summers PR, Biswas MK, Pastorek JG, et al. The pregnant hepatitis B carrier: Evidence favoring comprehensive antepartum screening. Obstet Gynecol 1987;69:701-04.
  21. Malecki JM, Guarin O, Hulbert A, Brumback CL. Prevalence of hepatitis B surface antigen among women receiving prenatal care at the Palm Beach County Health Department. Am J Obstet Gynecol 1986;154:625-6.
  22. Jones MM, Schiff ER, O’Sullivan MJ, Medina M, Reddy KR, et al. Failure of Centers for Disease Control Criteria to Identify Hepatitis B Infection in a Large Municipal Obstetrical Population. Ann Int Med 1987;107:335-37.
  23. Hepatitis B Virus: A Comprehensive Strategy for Eliminating Transmission in the United States Through Universal Childhood Vaccination. MMWR 1991;40(RR-13):1-19.
  24. Alter MJ, Hadler SC, Margolis HS, et al. The changing epidemiology of hepatitis B in the United States. Need for alternative vaccination strategies. JAMA 1990;263:1218-22.
  25. Franks AL, Berg CJ, Kane MA, et al. Hepatitis B virus infection among children born in the United States to Southeast Asian refugees. N Engl J Med 1989;321:1301-5.
  26. Universal Hepatitis B Immunization. Committee on Infectious Diseases. Pediatr 1992;89:795-800.
  27. Di Bisceglie AM, Fong TL, Fried MW, et al. A randomized, controlled trial of recombinant alpha-interferon therapy for chronic hepatitis B. AM j Gastroenterol 1993;88:1887-92.
  28. Perrillo RP, Schiff ER, Davis GL, et al. A randomized controlled trial of interferon alfa-2b alone and after prednisone withdrawal for the treatment of chronic hepatitis B. N Engl J Med 1990;323:295-301.
  29. Dienstag JL, Perrillo RP, Schiff ER, et al. A preliminary trial of Lamivudine for chronic hepatitis B infection. N Engl J Med 1995;333:1657-61.
  30. MciIntosh EDG, Bek MD, Burgess MA, et al. Molecular evidence of transmission of hepatitis B in a day-care center. Lancet 1996;347:118-9.

About the Author(s)

Patricia D. Hastings has been a registered nurse involved in clinical practice for more than 25 years. She currently is a Women’s Health Nurse Practitioner for Desert Mountain Obstetrics & Gynecology Group. Prior to this, she was the Clinical Director of Obstetrics and Women’s Services at John C. Lincoln-North Mountain Hospital in Phoenix, Arizona and was a Case Manager for Vista Care Hospice. She is a member of AWHONN and is a certified Fetal Heart Monitoring Instructor. She is also a member of the ANA and is participating in the Advanced Practice Chapter of the Arizona Nurses Association.

She received her BSN and then her MSN from Wichita State University followed by a postmaster’s Women’s Health Nurse Practitioner Certification from Arizona State University. She has provided several presentations regarding nursing concerns related to Women’ Health Care and has frequently lectured on normal and high-risk obstetrical issues. She has practiced clinically in Kansas, California, and Arizona.

Examination

  1. Hepatitis B
    1. is a circular RNA virus.
    2. is unique in that it is single stranded for two-thirds of its length
    3. contains its own DNA polymerase enzyme.
    4. has eighteen distinct serotypes.
    5. has a small straight portion that is DNA
  2. Patients who are at increased risk for being a chronic carrier of Hepatitis B include all of the following except.
    1. Asians, Eskimos, and Sub-Saharan Africans
    2. individuals who work in the shellfish industry
    3. homosexual activity and prostitution
    4. patients with multiple tattoos
    5. hemodialysis patients
  3. At the present time, there are
    1. 100 to 200 million carriers worldwide with a carrier rate in the United States ranging between 0.5% and 5% depending upon the population tested.
    2. 1 to 2 billion carriers worldwide with a carrier rate in the United States ranging between 1% and 2% depending upon the population tested.
    3. 200 to 250 thousand carriers worldwide with a carrier rate in the United States ranging between 0.1% and 1% depending upon the population tested.
    4. 200 to 250 million carriers worldwide with a carrier rate in the United States ranging between 0.1% and 1% depending upon the population tested.
    5. 2 to 2.5 billion carriers worldwide with a carrier rate in the United States ranging between 1% and 10% depending upon the population tested.
  4. Individuals who become chronically infected with HBV have a
    1. 1% to 2% chance of progressing to cirrhosis and a 100 fold increased risk for developing hepatocellular carcinoma.
    2. 5% to 10% chance of progressing to cirrhosis and a 500 fold increased risk for developing hepatocellular carcinoma.
    3. 50% to 65% chance of progressing to cirrhosis and a 300 fold increased risk for developing hepatocellular carcinoma.
    4. 25% to 50% chance of progressing to cirrhosis and a 600 fold increased risk for developing hepatocellular carcinoma.
    5. 10% to 25% chance of progressing to cirrhosis and a 200 fold increased risk for developing hepatocellular carcinoma.
  5. If an adult becomes acutely infected with Hepatitis B, there is about a ______ of becoming a chronic carrier.
    1. 10% chance
    2. 40% chance
    3. 50% chance
    4. 70% chance
    5. 90% chance
  6. The laboratory testing involved with Hepatitis B is one of the more difficult areas in understanding this infection. In the general laboratory evaluation, all of the following are available as blood tests except
    1. anti-HBsAg
    2. HBcAg
    3. anti-HBcAg
    4. HBsAg
    5. anti-HBeAg
  7. The presence of the e antigen signifies
    1. that the patient has become immune.
    2. that the patient has become a chronic carrier.
    3. active viral replication and a more infectious state.
    4. that the patient has a lower infectivity capability.
    5. that the patient will respond better to the vaccine.
  8. A patient who becomes immune to a hepatitis B infection will be
    1. positive for anti-HBcAg as well as anti-HBsAg.
    2. negative for anti-HBcAg as well as anti-HBsAg.
    3. negative for anti-HBcAg only if positive for anti-HBsAg.
    4. positive for anti-HBeAg but not anti-HBcAg.
    5. positive for anti-HBcAg as well as HBsAg.
  9. A positive IgG anti-HBcAg denotes
    1. that the killer antibody has developed.
    2. that the individual is now protected against future infection.
    3. that the patient is highly infectious.
    4. that the patient has a lower infectivity capability.
    5. that an HBV infection occurred sometime in the past.
  10. The spread of Hepatitis B between individuals primarily occurs in all of the following ways except
    1. through blood or blood products
    2. sexually
    3. through IV drug abuse
    4. contaminated shellfish
    5. from mother to baby
  11. The current estimated risk of transmitting an HBV infection per unit of blood transfused from units that are negative in laboratory testing is
    1. 1 in 50,000
    2. 1 in 3,000
    3. 1 in 300,000
    4. 1 in 200,000
    5. 1 in 700,000
  12. Sexual transmission is also significant when compared to other viral infections. Up to ______ of spouses will become infected after contact with a partner who has an acute infection.
    1. 90%
    2. 74%
    3. 10%
    4. 5%
    5. 40%
  13. Vertical transmission of the hepatitis B virus from the mother to the neonate is a major concern. Studies have shown
    1. that up to 70% to 90% of neonates can become chronic carriers of the disease if they do not receive appropriate immunoprophylaxis following delivery.
    2. that up to 30% to 40% of neonates can become chronic carriers of the disease despite receiving appropriate immunoprophylaxis following delivery.
    3. that up to 70% to 90% of neonates can become immune from the disease if they just receive HBIG following delivery.
    4. that up to 30% to 40% of neonates can become immune from the disease if they receive both HBIG and vaccine following delivery.
    5. that up to 70% to 90% of neonates can become chronic carriers of the disease if they are delivered by cesarean section.
  14. The transmission of HBV from an infected mother to the infant primarily occurs
    1. in utero early on in gestation.
    2. in utero late in gestation.
    3. at the time of delivery.
    4. after delivery through breastfeeding.
    5. around the time of conception.
  15. Which of the following statements regarding breastfeeding is true?
    1. Breastfeeding in a patient who is HBsAg positive should not be allowed.
    2. If HBsAg is found in breast milk, this will result in a neonatal infection.
    3. It is of utmost importance, that these infants are adequately treated with both HBIG and the full vaccine protocol.
    4. HBsAg has not been detected in breast milk.
    5. Breastfeeding in a patient who is anti-HBcAg positive should be allowed, but not if she is anti-HBeAg positive.
  16. Which of the following statements is true?
    1. Since the development of the hepatitis B vaccine in 1982, the rate of acute hepatitis B viral infections in the United States has decreased by 95%.
    2. Epidemiology studies reveal that only 2,000 acute HBV infections occur in the United States each year.
    3. Perinatal hepatitis B infections account for the majority of annual infections at 200,000 cases per year.
    4. Research has shown that there is a significant incidence of child-to-child transmission of this virus.
    5. The American Academy of Pediatrics and the Centers for Disease Control now recommend that all children receive the hepatitis B vaccine series in a hope that this will prevent future transmission from shellfish.
  17. The best treatment approach for HBV is
    1. the use of interferon alpha-2b.
    2. to prevent infection through the use of immunization.
    3. the use of prednisone.
    4. the use of Zidovudine.
    5. the use of Lamivudine.
  18. The immunogenicity of the hepatitis B vaccine is excellent with over ______ of the vaccinated population developing antibody to the hepatitis B surface antigen following the third injection.
    1. 90% to 95%
    2. 80% to 83%
    3. 70% to 78%
    4. 60% to 67%
    5. 55% to 61%
  19. It is important to note that the site of vaccine injection is important. Adults should receive
    1. an intramuscular injection (IM) in the anterolateral thigh
    2. an intramuscular injection (IM) in the deltoid region
    3. an intradermal injection
    4. an intramuscular injection (IM) in the gluteal region
    5. an intramuscular injection (IM) in the posterolateral thigh
  20. One of the current Hepatitis B vaccines made through recombinant DNA in yeast is?
    1. Heptavax
    2. MMR
    3. HyperRHO
    4. Tdap
    5. Engerix-B