Guidelines for preventive activities in general practice

Infectious diseases

Hepatitis B and C

      1. Hepatitis B and C

Infectious diseases | Hepatitis B and C

Screening age bar

0–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–74 75–79 ≥80

*Recommendations will depend upon specific risk factors.

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. 

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.

Hepatitis B

 

Screening

Recommendation Grade How often References
At a minimum, all population groups at high risk (see Box 1) should be offered testing to determine their hepatitis B virus status. Recommended (strong) Single screen with additional testing if the risk factors are continuing 1
 
When testing for hepatitis B, the tests to be ordered are: hepatitis B surface antigen (HBsAg), hepatitis B surface antibody (anti-HBs) and hepatitis B core antibody (anti-HBc).

Positive HBsAg indicates current infection, positive anti-HBs indicates immunity (through vaccination or past infection) and positive anti-HBc indicates past or current infection (this test may occasionally give a false-positive result). A history including country of birth, overseas travel, vaccination and exposure risks, and a physical examination are important to distinguish between possible recent, acute or chronic infection and to guide the addition of anti-HBc IgM testing.
Practice point (for the three qualitative tests) N/A 1

Preventive activities and advice

Recommendation Grade How often References
Infants, children, people with HIV, chronic liver disease and/or hepatitis C and others at high risk* are recommended to receive the hepatitis B vaccine if they are not immune.
*For a complete list of those at high risk, see the Australian immunisation handbook.
Practice point N/A 6
 
Recommend safe sexual practices to prevent hepatitis B and C. Practice point N/A 1,7
Recommend safer injecting practices to minimise transmission of hepatitis B and C, such as needle exchange and minimising the sharing of needles and auxiliary injecting equipment. Practice point N/A 1,7



Hepatitis C

Screening

Recommendation Grade How often References
All individuals with a risk factor* for hepatitis C virus infection should be tested.

The appropriate initial screening test for hepatitis C virus infection is hepatitis C virus serology (hepatitis C virus antibodies), which indicates exposure to hepatitis C virus, either current or past infection.

Hepatitis C virus seronegative people with risk factors* for hepatitis C virus transmission should be screened for hepatitis C virus infection.

*People at risk of hepatitis C virus infection include:
  • those with previous or current injecting drug use
  • those in custodial settings, such as prison
  • those who have ever had an unsterile tattoo or piercing
  • those born in a high-prevalence region
  • MSM
  • those who have evidence of liver disease
  • those who received a blood transfusion or organ transplant before 1990
  • those with coagulation disorders who received blood products or plasma-derived clotting factor treatment products before 1993
  • children born to hepatitis C virus-infected mothers
  • those who have had a needle-stick injury
  • all pregnant women (refer to the First antenatal visit chapter)
  • those infected with HIV or hepatitis B virus
  • sexual partners of a hepatitis C virus-infected person (individuals at higher risk of sexual transmission include MSM and people with hepatitis C virus–HIV coinfection)
  • migrants from high-prevalence regions (Egypt, Pakistan, the Mediterranean and Eastern Europe, Africa and Asia)
Recommended (Strong) At initial consultation and annually if the risk of exposure continues.
3-6 months for people who inject drugs.
7,8
 

Preventive activities and advice

Recommendation Grade How often References
Recommend safe sexual practices to prevent hepatitis B and C. Practice point N/A 1,7
 
Recommend safer injecting practices to minimise the transmission of hepatitis B and C, such as needle exchange and minimising the sharing of needles and auxiliary injecting equipment. Practice point N/A 1,7

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

Box 1. Groups that should be screened for hepatitis B in Australia1,10

Populations with a higher prevalence of chronic hepatitis B

  • People who inject drugs
  • Men who have sex with men
  • Aboriginal and Torres Strait Islander people
  • People living with chronic hepatitis C
  • People who have ever been incarcerated

People born overseas in regions with ≥2% chronic hepatitis B prevalence

  • People born in North-east Asia
  • People born in South-east Asia
  • People born in the Pacific Islands – Māori and Pacific Islander people
  • People born in North Africa
  • People born in Central Asia
  • People born in Southern Europe
  • People born in Eastern Europe
  • People born in Sub-Saharan Africa

Populations with a higher risk of onward transmission and/or adverse outcomes

  • Pregnant women
  • People receiving immunosuppressive therapy
  • Healthcare workers
  • People with other chronic liver diseases (eg metabolic-associated fatty liver disease)
  • People undergoing renal dialysis
  • People living with HIV
  • Household and sexual contacts of people with chronic hepatitis B
  • Children born to mothers with chronic hepatitis B
  • People with multiple sexual partners

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.

  1. Gastroenterological Society of Australia. (GESA). Hepatitis B virus (HBV) consensus statement. GESA, 2021 [Accessed 31 January 2024].
  2. Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine (ASHM). Viral hepatitis mapping project: Hepatitis B. Geographic diversity in chronic hepatitis B prevalence, management and treatment. ASHM, 2021 [Accessed 21 February 2024].
  3. Australian Government Department of Health and Aged Care. Third national hepatitis B strategy 2018–2022. Department of Health and Aged Care, 2019 [Accessed 31 January 2024].
  4. Cancer Council Victoria. Hepatitis B & liver cancer. Cancer Council Victoria, n.d - :~:text=In some countries with high,visit, or getting a tattoo. [Accessed 31 January 2024].
  5. National Cancer Control Indicators. Hepatitis B and hepatitis C notification. National Cancer Control Indicators, 2022 [Accessed 16 May 2023].
  6. Australian government Department of Health and Aged Care. Australian immunisation handbook. Department of Health and Aged Care, 2023 [Accessed 16 May 2023].
  7. Gastroenterological Society of Australia (GESA). Australian recommendations for the management of hepatitis C virus infection: A consensus statement (2022). GESA, 2022 %26 Resources/Clinical Practice Resources/Hep C/hepatitis C virus infection a consensus statement 2022.pdf [Accessed 31 January 2024].
  8. Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine (ASHM). Indications for HCV testing. ASHM, 2020 [Accessed 25 January 2024].
  9. Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine (ASHM). STI management guidelines for use in primary care: Standard asymptomatic check-up. ASHM, 2021 [Accessed 16 May 2023].
  10. Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine (ASHM). Hepatitis B virus testing and interpreting test results. ASHM, 2020 [Accessed 16 December 2023].
  11. Lubel JS, Strasser SI, Thompson AJ, et al. Australian consensus recommendations for the management of hepatitis B. Med J Aust. 2022;216(9):478-–86. doi: 10.5694/mja2.51430.
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  Lifecycle-chart.pdf (PDF 0.12 MB)

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