Ep 230 – Hepatitis B

In this episode, Dr James Waldron is joined by Dr Rik Fijten, a GP with an extended role in gastroenterology, to discuss hepatitis B, the third instalment in a four-part hepatology series. Why are emergency departments (EDs) finding so much hepatitis B through opt-out blood-borne virus testing? Who is most at risk and why is hepatitis B such an important health inequalities issue? The discussion covers how hepatitis B is often missed, what primary care can do better, and how earlier detection can help prevent cirrhosis and liver cancer.

Key take-home points

• Hepatitis B is often hidden in plain sight. People can live with chronic hepatitis B for decades without symptoms, and normal liver function tests do not rule it out. Testing only people with abnormal results will miss cases.
• Hepatitis C is now largely a cure and elimination story. Hepatitis B is more about finding people earlier, vaccination, treatment, monitoring, contact protection and reducing long-term risk of cirrhosis and hepatocellular carcinoma.
• There is significant underdiagnosis: the UK Health Security Agency (UKHSA) estimates that around 268,767 people are living with chronic hepatitis B in England, but only around 43.6% have been diagnosed. That means a large number of people are living with chronic infection unknowingly.
• Approximately 90% to 95% of healthy adults with acute hepatitis B clear the virus spontaneously within six months without treatment. The likelihood of clearance is strongly age-dependent, with 60% of children aged 1 to 5 years and only 10% of infants infected perinatally clearing the infection naturally.
• Hepatitis B is a major health inequalities issue. In England, chronic hepatitis B is strongly linked with migration from countries where hepatitis B is more common, and UKHSA reports that most new chronic hepatitis B diagnoses are in people born outside the UK. Many people acquired it at birth or in early childhood. It is a common misconception that it is usually about “risky behaviour”.
• ED opt-out blood-borne virus testing has had a substantial impact. Although the programme was often discussed in relation to HIV, it has found large numbers of people with hepatitis B. In the first-wave evaluation, the number needed to test to find one new diagnosis was 240 for hepatitis B, compared with 1,276 for hepatitis C and 1,916 for HIV.
• Primary care has several chances to find people who would otherwise be missed. New patient checks, diabetes reviews, NHS Health Checks, antenatal history, inclusion health work and routine blood test appointments can all be opportunities to ask about country of birth, previous testing, household contacts, prison history, injecting drug use and medical or cosmetic procedures in higher-risk settings.
• A positive hepatitis B surface antigen result indicates current infection and should prompt further assessment, referral and clear safety-netting.
• A positive result is not just an individual diagnosis. If someone has hepatitis B, household and sexual contacts may need testing and vaccination. Good care means thinking beyond the index patient.
• A negative surface antigen and negative core antibody with a positive surface antibody result indicates immunity following vaccination. A negative surface antigen with a positive core antibody and a positive surface antibody result indicates immunity following prior hepatitis infection.
• Stigma can be a barrier to diagnosis. Hepatitis B testing should be framed as routine preventive healthcare, not as a judgement about someone’s behaviour, background or identity. A useful phrase is: “This is about prevention, not blame.”
• Coding is part of clinical safety. Practices should be able to tell whether a patient has active chronic hepatitis B, resolved infection, vaccine immunity, incomplete vaccination, specialist follow-up or has been lost to follow-up. A vague historic hepatitis B code should not just sit in the record unexplored.

Key references

1. UKHSA. 2025. https://www.gov.uk/government/publications/hepatitis-b-in-england/hepatitis-b-in-england-2025.
2. UKHSA. 2025. https://www.gov.uk/government/publications/bloodborne-viruses-opt-out-testing-in-emergency-departments/public-health-evaluation-of-bbv-opt-out-testing-in-eds-in-england-33-month-final-report-2025.

Key resources

1. Hep B Companion. https://www.hepbcompanion.org/.
2. Liver UK (formerly British Liver Trust). https://liveruk.org/about-liver-disease/conditions/hepatitis-b/.