Hepatitis B in England: Progress, Challenges and the System Wide Approach Needed for Elimination

The hepatitis B virus (HBV) remains a significant public health challenge in England, despite progress achieved through vaccination programmes, strengthened surveillance and the integration of testing into high‑impact clinical settings. The World Health Organisation’s (WHO) 2016 Global Health Sector Strategy on Viral Hepatitis set a historic ambition: the elimination of viral hepatitis as a public health threat by 2030, defined as a 90% reduction in new infections and a 65% reduction in mortality compared with 2015 levels.

This strategy catalysed a shift towards whole‑system approaches to identification, prevention and treatment. England has aligned itself with these goals, yet the burden of HBV—and the gaps in diagnosis and care—highlight the need for intensified efforts across primary care, emergency medicine, specialist services and public health systems.

The Epidemiological Picture: HBV in England

England continues to experience substantial HBV prevalence, with ongoing undiagnosed infection representing a major barrier to elimination. HBV can be spontaneously cleared, but if not causes chronic infection, associated with long‑term complications including cirrhosis and hepatocellular carcinoma (HCC). Chronic HBV infection often develops silently, with many people being unaware they have the virus for years.

Recent evidence from the emergency department (ED) opt‑out testing programme suggests that HBV prevalence in England may be higher than previously estimated. 1,957 people were newly diagnosed with hepatitis B during the first 24 months of ED opt‑out testing across 34 sites, with many people lacking historical risk indicators or previous testing history (Public health evaluation of BBV opt-out testing in EDs in England, 24-month report 2024 – GOV.UK). This suggests England’s HBV burden remains under‑recognised and highlights the importance of universalised testing strategies.

Further analysis from the 33‑month evaluation of the NHS England‑funded ED opt‑out programme reinforced this, indicating that HBV was the bloodborne virus most efficiently identified via this approach, with a Number Needed to Test (NNT) to identify a person with the virus of 240—substantially lower than for HCV (1,276) or HIV (1,916) (Public health evaluation of BBV opt-out testing in EDs in England, 33-month final report 2025 – GOV.UK) . In total, across participating EDs, more than 7 million bloodborne virus tests were conducted between April 2022 and December 2024, with approximately 70% uptake among eligible ED attendees—a striking demonstration of both scalability and population impact.

The fact that three‑quarters of people tested had no prior record of BBV testing underscores a persistent system‑wide issue: many people living with HBV remain undiagnosed. As WHO’s elimination framework stresses, diagnosis is the crucial gateway to care and prevention. England’s success will depend heavily on expanding equitable testing access across multiple healthcare settings.

The Role of the WHO 2016 Viral Hepatitis Elimination Strategy

The WHO 2016 strategy provided a unifying vision through five strategic directions: information for focus, interventions for impact, delivering for equity, financing for sustainability and innovation for acceleration. Central to this strategy is the scale‑up of testing, vaccination and antiviral treatment.

England has incorporated these principles into its national approach, particularly through:

universal newborn vaccination,
targeted immunisation of people who have high‑risk factors,
strengthening surveillance data, and
cross‑programme collaboration (e.g., HIV, HCV and HBV alignment through the NHS England elimination programmes).

However, unlike hepatitis C—with its curative treatments and nationally coordinated elimination programme—hepatitis B elimination requires a more complex prevention‑focused model centred around vaccination, lifelong monitoring and antiviral therapy.

Findings From ED Opt‑Out Testing: A Model for Scalable Impact

The UKHSA 33‑month evaluation demonstrates that ED opt‑out testing is one of the most effective high‑volume, high‑impact strategies for identifying undiagnosed HBV in England. The programme also confirmed strong linkage to care, enabled by clinical teams and peer engagement mechanisms.

ED testing also revealed important epidemiological trends. People diagnosed through this route frequently lacked documented risk factors, supporting earlier UKHSA observations that universal opt‑out models reach people who may never be identified through risk‑based or symptomatic testing pathways.

There are broader implications of these findings: far more people in the UK may be living with hepatitis B than previously estimated, strengthening the case for expanding opt‑out testing to all emergency departments nationwide and ensuring that pathways beyond diagnosis are adequately resourced.

Guideline Context: Primary Care and System Responsibilities

Primary care remains a cornerstone of HBV management. NICE guideline CG165 (Overview | Hepatitis B (chronic): diagnosis and management | Guidance | NICE) outlines essential responsibilities including patient education, baseline assessment, referral to specialist services, antiviral therapy consideration and ongoing monitoring for liver disease and HCC.

These guidelines emphasise informed decision‑making, long‑term care planning and the importance of supporting people to remain engaged in monitoring and treatment.

UKHSA’s clinical and public health guidance further stresses timely vaccination, early diagnosis and prevention of onward transmission through public health measures, particularly for people exposed via household, occupational or perinatal routes

To achieve WHO’s elimination goals, these guidelines must now be applied more consistently across the health system, supported by improved data sharing and integrated care pathways.

A Whole‑System Approach: What England Needs Next

Expand opt‑out testing beyond EDs

Evidence from the national programme clearly demonstrates that ED opt‑out testing identifies large numbers of undiagnosed cases and reaches populations not engaged in traditional services. Scaling this approach to every ED in England would be beneficial.

Opportunities also exist for opt‑out or routinely offered HBV testing in:

maternity services (given perinatal transmission routes),
primary care (especially through vaccine status reviews),
prisons,
addiction services, and
community health settings.

Strengthen hepatitis B literacy and education in primary care

Given that HBV requires long‑term monitoring, primary care clinicians must be equipped with:

up‑to‑date guideline summaries,
practical tools for interpreting HBV serology,
clear pathways for onward referral, and
consistent vaccination guidance.

The absence of widespread clinician confidence in HBV testing and interpretation remains a well‑documented barrier.

Improve data integration and surveillance

The ED opt‑out evaluations showed substantial variation in uptake between sites, attributed partly to local systems and digital infrastructure differences (e.g., automated ordering of tests). National elimination efforts require:

unified dashboards,
consistent coding of HBV diagnoses,
cross‑sector data linkage, and
improved tracking of long‑term outcomes.

Ensure timely linkage to care

While HIV linkage rates exceeded 90% in UKHSA’s 24‑month evaluation, engagement for HBV and HCV was lower, highlighting the importance of dedicated care coordination and shared‑care models between specialist hepatology and primary care.

Address health inequalities

HBV disproportionately affects communities with links to higher‑prevalence countries/regions. Tailored, culturally competent strategies—including community partnerships and multilingual resources—are essential to increase awareness, testing and vaccination uptake.

Conclusion

Hepatitis B elimination in England is achievable, but only through a coordinated and ambitious whole‑system response. The WHO’s 2016 strategy established a global blueprint; the recent UKHSA ED opt‑out evaluations show that England has access to high‑yield, scalable testing interventions capable of transforming diagnosis. The challenge now is to integrate these approaches across health and community settings, strengthen primary care capability, and ensure robust pathways for long‑term monitoring and treatment. By doing so, England can move decisively toward meeting its 2030 elimination commitment and preventing avoidable deaths from chronic liver disease.