Hepatitis B

Chronic hepatitis B impacts over 250 million people worldwide, with the majority infected either at birth or during early childhood.¹ If left untreated, chronic hepatitis B can lead to liver cirrhosis, liver failure and hepatocellular carcinoma in up to 25% of those affected, resulting in an estimated 800,000 deaths globally each year.¹ In 2020, there were approximately 222,599 people living with chronic hepatitis B in Australia, accounting for 0.9% of the population.¹ The introduction of the hepatitis B vaccination in the 1980s has reduced new infections and the prevalence of chronic hepatitis B, particularly among younger people.¹  

In Australia, as of 2021, only 72.5% of people living with chronic hepatitis B have been diagnosed, 26% are engaged in care and 12.7% are receiving treatment.² In addition, 70% of all people living with chronic hepatitis B in Australia were born overseas, highlighting the importance of screening based on country of birth, particularly among people born in areas with a high prevalence of hepatitis B.³ 

Exposure to the hepatitis B virus early in life carries the highest risk of chronic infection, whereas exposure during adulthood typically results in a self-limiting acute infection in over 95% of cases.¹ Therefore, most individuals with chronic infection acquired hepatitis B virus during birth or in early childhood, particularly among people born in areas with a high prevalence of hepatitis B. 

Other modes of transmission include sharing of injection equipment or items that may have blood on them, and unprotected sex.⁴ For people growing up in some countries with high rates of hepatitis B, transmission could also occur through injuries involving blood passing between a person living with hepatitis B and another person; having an operation; receiving a blood transfusion; a dental visit; or getting a tattoo.⁴ 

There is no cure for hepatitis B, but there is a vaccination and treatment to manage the infection. It is also important to note that hepatitis B is an infection that carries stigma for certain community groups, and culturally safe care and conversations are required.

Hepatitis C

Hepatitis C is a blood-borne virus that is one of the major causes of liver cirrhosis, hepatocellular carcinoma and liver failure. Within Australia, it was estimated that approximately 117,000 people were living with chronic hepatitis C in 2020. There were 9230 notifications of hepatitis C in 2019, 69% of which in among.⁵ 

Hepatitis C is an infection that is associated with high-risk populations (eg people who inject drugs, immigrants from high-prevalence countries, men who have sex with men [MSM]). For this reason, risks may not be readily disclosed, so screening needs to be done with care and sensitivity to ensure the safety and confidence of patients, as well as helping to find those who are unknowingly living with hepatitis C. 

Hepatitis C is transmitted by a blood-to-blood route. The main transmission routes include the sharing of needles and auxiliary injecting equipment, perinatal transmission and sexual practices that lead to sexual transmission. 

Tattooing and piercing with unsterilised equipment have also been associated with the acquisition of hepatitis C. Hepatitis C is now easily treated with oral medications that offer a 95% cure rate.

Sensitive history gathering is important to ensure people living with yet-to-be-diagnosed infection are not missed.

A non-judgemental attitude and environment will facilitate disclosures on sexual matters. It is important to ask open-ended questions, and to avoid assumptions about sexual orientation by using the term ‘partner’. Gentle enquiry about recent sexual activity, gender, number of partners, contraception (including the use of condoms), travel history and immunisation status helps to inform decision making. In addition, ask about risk factors for blood-borne viruses (hepatitis B, hepatitis C and HIV), such as injecting drug use, tattooing and piercing. Investigations should be explained, and patients should be asked for consent before tests such as HIV or hepatitis C are ordered. Refer to the Sexually transmissible infections chapter for more information.

Hepatitis B

In Australia, routine adolescent Hepatitis B immunisation commenced in 1997 and routine infant Hepatitis B immunisation commenced in May 2000. However, it is important to note that people born in high-risk countries who then moved to and have grown up in Australia and people with other risk factors should be offered testing to determine their status and not assumed that they are immune.⁹

It is important that appropriate consent is obtained, and pre-test counselling is provided before testing for chronic hepatitis B. Given that most people living with chronic hepatitis B are from Culturally and Linguistically Diverse (CALD) communities, it is essential that discussions are held before testing and after diagnosis, and when necessary, with the assistance of an accredited interpreter.¹

Hepatitis C

Screening for hepatitis C should be provided if the patient is HIV positive or there is a history of injecting drug use, because this increases the risk of transmission. If hepatitis C virus antibodies are detected, current infection should be confirmed by testing for hepatitis C virus RNA using a sensitive polymerase chain reaction (PCR) assay.⁶

The hepatitis B immune status of all Aboriginal and Torres Strait Islander people should be documented, and Aboriginal and Torres Strait Islander people should be offered hepatitis B immunisation if they are not immune and not vaccinated.¹¹ 

For specific advice about hepatitis B immunisation for Aboriginal and Torres Strait Islander people, please refer to the Australian immunisation handbook and the National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people.

All pregnant women should be screened for hepatitis B, hepatitis C, HIV and syphilis. Consider screening pregnant women aged up to 29 years for chlamydia (and gonorrhoea, if the patient is at high risk; see Sexually transmissible infections). See the Pregnancy – First antenatal visit  chapter for more information.

Decision making in hepatitis B tool | ASHM 
B positive: A guide for primary care providers | ASHM 
Australian immunisation handbook