• Admit the person to hospital if they are seriously ill, otherwise manage in primary care.
• Notify the Health Protection Unit to facilitate appropriate surveillance.
• Confirm the diagnosis with hepatitis serology (if not already confirmed).
• If hepatitis B surface antigen (HBsAg) is detected, refer the person promptly to a specialist (hepatologist, infectious diseases physician, or gastroenterologist — depending upon local protocols).
• Provide the person with information about hepatitis B, including advice on how to prevent transmission of the infection.
• See Information and advice.
• Review the person's current medications.
• Stop any non-essential medication.
• If pain relief is required, suitable options include:
• Ibuprofen.
• Paracetamol — normal dosages can be used, unless there is evidence of moderate or severe liver impairment. If serum bilirubin is greater than 300 micromoles/L or prothrombin time is greater than 3 seconds, reduce to a maximum of 1 g twice or three times a day.
• A weak opioid (such as codeine) may be used if liver impairment is mild. Avoid codeine in severe liver impairment (enhanced sedative effects and reduced clearance).
• If treatment of nausea is required, and liver impairment is mild, offer metoclopramide or cyclizine at normal dosage. Seek specialist advice on the dosage and choice of anti-emetic if the person has more severe liver impairment.
• Itch can be difficult to treat.
• Advise simple measures (such as maintaining a cool, well-ventilated environment, wearing loose clothing, and avoiding hot baths or showers).
• Consider offering chlorphenamine at normal dosage at night (although avoid this in severe liver impairment). This can be increased to use every 4–6 hours if itch is severe. Ursodeoxycholic acid, colestyramine, and corticosteroids are other treatment options — seek specialist advice before prescribing.
• Treatment with antiviral agents is not routinely indicated for acute hepatitis B (except in cases of fulminant hepatitis).

• Inform the Health Protection Unit to facilitate surveillance.
• Partner notification and contact tracing is usually undertaken through the local Health Protection Unit. It includes notifying any sexual contacts or needle-sharing partners during the infectious period (which is usually the 2 weeks before the onset of jaundice, until the person becomes HBsAg negative; although this period may be years in the case of chronic infection).
• Vaccination for hepatitis B should be offered to sexual partners, other household members (including children), and other contacts at high risk.
• Refer all people who test positive for hepatitis B surface antigen (HBsAg) to a specialist (hepatologist, infectious diseases physician, or gastroenterologist — depending on local protocol). Severe chronic hepatitis B requires rapid referral. Referral may involve:
• Further testing (such as detailed serology and measurement of viral load [hepatitis B virus-DNA], testing for immunity to hepatitis A, and screening for hepatitis C and HIV).
• Consideration of antiviral treatment.
• Follow up and monitoring (this may be shared between primary care and secondary care).
• Vaccinate the person against hepatitis A — if they are not immune to hepatitis A.
• Provide the person with information about hepatitis B, and advice on how to prevent transmission of the infection.
• See Information and advice.

• Admit people with severe symptoms and signs of acute hepatitis.
• Refer all people with hepatitis B to an appropriate specialist (hepatologist, infectious diseases physician, or gastroenterologist — depending upon local protocol).
• Children should be referred to a local consultant paediatrician with the relevant expertise.
• Consider referring the person to:
• Genito-urinary medicine department (or other specialist sexual health service), if screening for sexually transmitted infections is appropriate.
• Drug rehabilitation agency (if appropriate).

• Provide the person with information on:
• The natural history of hepatitis B.
• How the disease is spread.
• The meaning of their blood test results — providing a copy if they wish.
• The need for specialist referral, while understanding that immediate treatment may not be required.
• The need for close follow up.
• Inform the person about the availability of patient information resources.
• Discuss the long-term implications for the person's health.
• Give advice to minimize the risk of transmission to partners and contacts. The person should:
• Avoid sharing items that might be contaminated with small amounts of blood (such as toothbrushes, razors, and scissors).
• Avoid unprotected sexual intercourse, including oro-anal and orogenital contact, until they have become noninfectious or their partners have been successfully immunized (as shown by a titre of antibodies to hepatitis B surface antigen [anti-HBs] greater than 10 IU/L).
• Avoid sharing needles and other drug paraphernalia. For information on managing intravenous drug users, see the CKS topic on Opioid dependence.
• Not donate blood, or carry an organ donor card.
• Advise the person to avoid drinking alcohol.

• British Liver Trust (www.britishlivertrust.org.uk)
• A national charity that raises awareness of, and provides information and education on, all forms of liver disease.
• Health and Safety Executive (www.hse.gov.uk)
• Aims to protect people against risks to health or safety arising out of work activities.
• Health Protection Agency (www.hpa.org.uk)
• Provides advice and information on infectious diseases to the general public, healthcare professionals, and the government.
• Hepatitis B Foundation UK (www.hepb.org.uk)
• A charity that raises awareness about the prevention, treatment, and management of hepatitis B. It offers advice and information, and facilitates networking between people with hepatitis B, their families, and professionals.

• For people with acute hepatitis B, repeat hepatitis serology after 6 months to exclude or detect chronic infection, even if liver function tests are normal.
• Persistence of hepatitis B surface antigen (HBsAg) in the serum for 6 months or longer indicates chronic hepatitis.
• All people with chronic hepatitis B should be reviewed at intervals of 1 year (or less) by a physician with appropriate expertise. This is to:
• Monitor progress. Various indicators are used, including:
• ALT (alanine transaminase) and/or AST (aspartate transaminase) levels, in conjunction with trends in hepatitis B virus-DNA (HBV-DNA).
• Loss of positivity to HBsAg qualifies as remission (but is rare).
• Seroconversion (from positive to negative) for hepatitis B e-antigen (HBeAg, an indicator of viral replication) or positivity for antibodies to HBeAg (anti-HBe).
• Screen for hepatocellular cancer in people with cirrhosis.
• Ultrasound examinations and regular determinations of alpha fetoprotein are used to screen people at high risk. This is particularly important for those older than 40 years of age who acquired hepatitis B during childhood and who have cirrhosis.

• Refer all people with hepatitis B to a specialist, for consideration of the need for further treatment.
• Most specialists offer antiviral treatment when there is evidence of at least moderate disease; this is indicated by higher levels of hepatitis B virus-DNA (HBV-DNA) and serum ALT (alanine transaminase), and the findings of non-invasive tests for liver fibrosis or liver biopsy.
• People with severe, advanced liver disease require rapid treatment.
• Only rarely do people with chronic hepatitis B clear the hepatitis B surface antigen (HBsAg) by developing antibodies (anti-HBs). Therefore, the goal of treatment is to:
• Prevent progression of the disease to cirrhosis, end stage liver disease, and hepatocellular cancer.
• Reduce the viral load to stabilize the disease. However, it is not clear whether suppression of viral replication reduces the incidence of hepatocellular cancer.
• Specific treatment from two major groups of antiviral drugs may be initiated:
• Supporting the immune system using interferon therapy.
• Interferon is given as a defined (finite) course of treatment. It causes no virological resistance, but response rates may be low.
• Long-term viral suppression with oral nucleosides or nucleotides.
• Drugs such as tenofovir, entecavir, lamivudine, adefovir, or telbivudine are used.
• Liver transplantation may be required for end-stage disease.
• Follow up is important, even if specific antiviral treatment is not initiated.

• Advise women who are infectious (that is, they are positive for hepatitis B e-antigen [HBeAg]) that there is an increased rate of miscarriage and premature labour. In almost all cases, the baby will become a chronic carrier (unless the infant is immunized).
• Advise pregnant women (and those wishing to become pregnant) who have chronic hepatitis B about the risk of transmission to the baby, and the preventative measures that should be taken (such as vaccination).
• It is the role of the Health Protection Unit to work with the primary care trust and maternity unit to inform the general practitioner of the results of screening, and to agree arrangements for counselling, vaccination, contact tracing, and retesting of the baby at 12 months.
• Advise women with chronic hepatitis B that they can breastfeed their baby — providing the infant has been immunized against hepatitis B.
• An information sheet, How to protect your baby, is available from www.dh.gov.uk (pdf).

For information on contraindications, cautions, drug interactions, and adverse effects, see the electronic Medicines Compendium (eMC) (http://emc.medicines.org.uk), or the British National Formulary (BNF) (www.bnf.org).