A chronic hepatitis B diagnosis requires follow-up, with clinical tests and patient education, including1,2:

  • A thorough medical history assessment and physical examination, followed by laboratory tests
  • Information regarding modes of transmission, the potential course of their disease, their current status, and next steps in disease management

Providing patients with education about their disease may help empower them to participate in their care.

Post-diagnosis follow-up and testing

Following a positive test result for chronic hepatitis B infection, patients will require a thorough history and physical examination and laboratory tests.2

  • History and physical examination to assess:
    • Risk factors for viral hepatitis
    • Family history of HCC
    • Route of transmission
    • History of alcohol use
    • Presence of comorbid diseases
    • Duration of infection
    • Risk factors for HIV coinfection

  • Laboratory tests may include:
    • Serial testing for HBV DNA and ALT
    • HBeAg and anti-HBe
    • LFTs, including CBC, PLT, HFP, and PT
    • HCC screening
    • Urinalysis
    • HBV genotype
    • Tests for antibodies to HAV, HCV, HDV, and HIV
    • Transient elastography or liver biopsya

a Liver biopsy is optional for patients indicated for treatment, but may be helpful in those with normal ALT and >35-40 years of age.2


In the United States, the most common routes of transmission are through childbirth and sexual contact. Both acute and chronic hepatitis B infection may also be transmitted through any type of exposure to bodily fluids, such as blood and semen.3

  • Perinatal transmission is the major route by which hepatitis B infection is perpetuated in endemic populations4
  • Children born to mothers infected with chronic hepatitis B, who are not perinatally infected, remain at risk of horizontal transmission, so vaccination should be considered5

There are many myths about how hepatitis B is transmitted, which is why appropriate patient education about the virus and common routes of transmission is important.6

HBV modes of transmission7

HBV modes of transmission

To download a brochure offering recommendations for patients to help prevent transmission, visit hepBsmart.com

Chronic hepatitis B is a dynamic disease characterized by shifting phases of varying duration and pathology. Not all patients will go through each phase (including resolution).2

Regular testing, including HBeAg status, ALT, and HBV DNA, will help identify the patient's current phase of chronic hepatitis B infection and therefore the course of action required.2,8

  • Even though treatment is not always indicated, patients will require lifelong monitoring2

Natural course of CHB infection9

Natural causes of CHB infection

The terms "inactive carrier" or "healthy carrier" can be misleading. A hepatitis B carrier is someone who has chronic hepatitis B infection. Many chronically infected patients do not show symptoms and have normal liver function tests, but are still at risk for hepatocellular carcinoma and liver damage. Therefore, ongoing surveillance is critical.6,10

Chronic hepatitis B is often asymptomatic, so patients may not feel the need to follow up with their healthcare provider. It is important that patients understand that without appropriate management, their disease could have serious consequences.11,12

  • Hepatitis B can lead to serious liver disease and is the cause of up to 50% of HCC cases worldwide3

Chronic hepatitis B disease progression13

Chronic hepatitis B disease progression Hepatitis B Disease Progression

aChronic infection is defined as HBsAg+ for ≥6 months.8

Risk factors for cirrhosis and HCC

Cirrhosis HCC
Host factors
  • Presence of fibrosis14
  • Older age10
  • Diabetes15
  • Presence of cirrhosis17
  • Older age17
  • Male gender17
  • Family history of HCC17
  • Obesity and/or diabetes17
  • African or Asian Race17
Viral/Disease factors
  • HBV DNA level8,10,14
  • Elevated qHBsAg8,10
  • Elevated ALT8
  • HBeAg-8,10
  • HBV viral genotype (ie, genotype C has been associated with more rapid and frequent progression to cirrhosis than B)10,14
  • Basal core promoter mutation16
  • HBV DNA level8,18,19
  • Elevated qHBsAg8,18
  • HBeAg+8,20
  • Elevated ALT and AFP17
  • HBV viral genotype (ie, higher incidence in genotype C than B)8,18
  • History of reversions from anti-HBe to HBeAg21
  • Basal core promoter mutation17,19
  • Precore mutation19
Environmental factors
  • Coinfection with HCV, HDV, or HIV8,10
  • Heavy alcohol consumption8,10,14
  • Coinfection with HCV, HDV, or HIV8,10,17
  • Heavy alcohol consumption8,10,17

AFP=alpha-fetoprotein; ALT=alanine aminotransferase; anti-HBe=antibody to hepatitis B e-antigen; CBC=complete blood count; CHB=chronic hepatitis B; HAV=hepatitis A virus; HBeAg=hepatitis B e-antigen; HBV=hepatitis B virus; HBV DNA=hepatitis B virus deoxyribonucleic acid; HCC=hepatocellular carcinoma; HCV=hepatitis C virus; HDV=hepatitis D virus; HFP=hepatic function panel; HIV=human immunodeficiency virus; LFT=liver function test; PLT=platelet test; PT=prothrombin time; qHBsAg=quantitative hepatitis B surface antigen.