Hepatitis B

Last reviewed: 3 Sep 2022
Last updated: 19 Apr 2022
19 Apr 2022

Universal hepatitis B vaccination recommended in adults 19 to 59 years

The Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices (ACIP) now recommends universal hepatitis B vaccination in all adults ages 19 to 59 years.

Previously, a risk factor assessment was recommended to determine vaccine eligibility in this age group. While hepatitis B vaccines have demonstrated safety, immunogenicity, and efficacy over the past four decades, vaccination rates in the US have been suboptimal. The removal of the risk factor assessment in this age group is hoped to increase vaccination coverage and decrease cases of hepatitis B infection.

A risk factor assessment is still recommended for adults 60 years of age and older. However, adults in this age group without known risk factors may still be offered hepatitis B vaccination.

Nearly two million people are estimated to be living with chronic hepatitis B infection in the US. A total of 3192 cases of acute hepatitis B infection were reported in 2019, corresponding to an estimated 20,700 acute infections. The most commonly reported risk behaviors and exposures were injection drug use, multiple sex partners, and surgery, followed by other sexual and bloodborne risk behaviors.

The new recommendations are reflected in the Centers for Disease Control and Prevention’s updated 2022 immunization schedule.

See Management: prevention

Original source of update



History and exam

Key diagnostic factors

  • high risk of exposure
More key diagnostic factors

Other diagnostic factors

  • asymptomatic
  • jaundice
  • hepatomegaly
  • ascites
  • fever/chills
  • malaise
  • maculopapular or urticarial rash
  • right upper quadrant pain
  • fatigue
  • nausea/vomiting
  • arthralgia/arthritis
  • palmar erythema
  • spider angiomata
  • splenomegaly
  • asterixis
Other diagnostic factors

Risk factors

  • perinatal exposure in an infant born to an HBV-infected mother
  • high-risk sexual behaviors
  • injection drug use
  • male sex
  • born in highly endemic region
  • family history of HBV, hepatocellular carcinoma, and/or chronic liver disease
  • infected with HIV
  • infected with hepatitis C virus
  • blood or blood product transfusion
  • healthcare workers
  • household contact with HBV infection
  • history of incarceration
  • hemodialysis
  • solid organ transplantation
More risk factors

Diagnostic investigations

1st investigations to order

  • hepatic panel
  • CBC
  • basic metabolic panel
  • coagulation profile
  • serum hepatitis B surface antigen
  • serum antibody to hepatitis B surface antigen
  • serum antibody to hepatitis B core antigen
  • serum hepatitis B e antigen
  • serum antibody to hepatitis B e antigen
  • serum HBV DNA
More 1st investigations to order

Investigations to consider

  • abdominal ultrasound
  • liver biopsy
  • transient elastography
  • serum liver fibrosis biomarkers
  • alpha-fetoprotein
  • CT/MRI abdomen
  • testing for co-infections
  • drug resistance testing
  • HBV genotype
More investigations to consider

Treatment algorithm


acute HBV infection


chronic HBV infection: adult nonpregnant without co-infection or cirrhosis

chronic HBV infection: adult nonpregnant with cirrhosis

chronic HBV infection: adult nonpregnant with HIV co-infection

chronic HBV infection: adult nonpregnant with hepatitis C co-infection

chronic HBV infection: adult nonpregnant with hepatitis D co-infection

chronic HBV infection: adult pregnant or breast-feeding

chronic HBV infection: children



Jawad Ahmad, MD, FRCP, FAASLD

Professor of Medicine

Division of Liver Diseases

Mount Sinai Hospital

New York



JA declares that he has no competing interests.


Dr Jawad Ahmad would like to gratefully acknowledge Dr Sateesh R. Prakash, Dr Siddarth Verma, Dr Smruti R. Mohanty, and Dr Jared Hossack, previous contributors to this topic.


SRP, SV, and JH declare that they have no competing interests. SRM serves as a speaker bureau for Bristol-Myers Squibb regarding the use of entecavir for the treatment of chronic hepatitis B.

Peer reviewers

George Y. Wu, MD, PhD


Hepatology Section

Department of Medicine

University of Connecticut Health Center




GYW is on the medical advisory boards of Gilead Sciences and Bristol-Myers Squibb.

Lucieni Oliveira Conterno, MD, PhD


Clinical Epidemiology Unit

Marilia Medical School

Sao Paulo



LOC declares that she has no competing interests.

Mamun-Al-Mahtab, MB BS, MSc, MD


Bangladesh Primary Care Research Network




MAM declares that he has no competing interests.

  • Hepatitis B images
  • Differentials

    • Acute hepatitis A virus infection
    • Acute hepatitis C virus infection
    • Chronic hepatitis C virus infection
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  • Guidelines

    • Recommended immunization schedule for adults aged 19 years or older - United States, 2022
    • Recommended immunization schedule for children and adolescents aged 18 years or younger - United States, 2022
    More Guidelines
  • Patient leaflets

    Hepatitis B: should I have the vaccine?

    More Patient leaflets
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