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Patient education: Hepatitis B (Beyond the Basics)

AUT H OR : Anna SF Lok, MD
S E CT ION E DITOR : Rafael Esteban, MD
DE PUT Y E DITOR : Jennifer Mitty, MD, MPH

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: Dec 2023.

This topic last updated: Oct 04, 2023.

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INTRODUCTION

The term "hepatitis" is used to describe a common form of liver injury. Hepatitis simply means
"inflammation of the liver" (the suffix "itis" means inflammation and "hepa" means liver).
Hepatitis B is a specific type of hepatitis that is caused by a virus.

It is estimated that there are more than 295 million carriers of the hepatitis B virus in the
world, with over 800,000 dying annually from hepatitis B-related liver disease.

Fortunately, hepatitis B infection can be prevented by vaccination. Hepatitis B vaccines are safe
and highly effective in preventing hepatitis B infection and are now given routinely to
newborns and children in the United States and in many other countries (see "Patient
education: Vaccines for adults (Beyond the Basics)"). For people who do develop chronic
hepatitis B, several medications are available for treating the infection.

More detailed information about hepatitis B is available by subscription. (See 'Professional

level information' below.)

HOW DID I BECOME INFECTED WITH HEPATITIS B?

There are several ways people become infected with hepatitis B virus.
Contaminated needles — Using contaminated needles can spread the hepatitis B virus. This
can happen if people who use injection drugs share needles or syringes. It is also possible to
spread hepatitis B through tattooing, acupuncture, or body piercing (if these procedures are
done with contaminated instruments). You can lower your risk by making sure your
practitioner follows careful sterilization procedures.

Sex — Sexual contact with someone who is infected is one of the most common ways to
become infected with hepatitis B. If you are infected with hepatitis B and have a regular sexual
partner(s), they should be tested for the infection and vaccinated if necessary.

Childbirth — Hepatitis B can be passed from a pregnant person to their baby during or shortly
after childbirth. Having a Cesarean birth (also called a C-section) does not prevent the virus
from spreading. Experts believe that breastfeeding is safe for people with hepatitis B.

To help prevent transmission from mother to infant, all pregnant people should have a blood
test for a marker of hepatitis B virus, called hepatitis B surface antigen (HBsAg). Normally, the
HbsAg should be negative. If the pregnant person is HbsAg-positive, they should be referred to
a specialist. (See 'Preventing transmission to a baby during childbirth' below.)

Close contact — Hepatitis B can be spread through close personal contact. This could happen
if blood or other bodily fluids get into tiny cracks or breaks in your skin or in your mouth or
eyes. The virus can live for a long time away from the body, meaning that it can be spread by
sharing household items like toys, toothbrushes, or razors. However, it is not spread through
touching, shaking hands, or sharing a meal or cooking utensils. (See 'Preventing infection of
close contacts' below.)

Blood transfusion and organ transplantation — Nowadays, it is extremely rare for hepatitis B
to be spread through blood transfusion or organ transplantation. Blood and organ donors are
carefully screened for markers of hepatitis infection. (See "Patient education: Blood donation
and transfusion (Beyond the Basics)".)

In the hospital — In the hospital, hepatitis B virus can spread from one patient to another or
from a patient to a doctor or nurse if there is an accidental needle stick. It is rare for a
doctor/nurse to pass hepatitis B to a patient. Wearing gloves and washing hands can help to
prevent spreading the virus. Discarding needles and syringes after use and proper sterilization
of surgical equipment also prevents spread of the virus.

HEPATITIS B SCREENING
Experts recommend that all people age 18 years and older be screened at least once for
hepatitis B. This is because the infection can lead to complications if a person does not know
that they have it. Different tests can be used for screening. (See 'Hepatitis B diagnosis' below.)

Pregnant people should be rescreened for hepatitis B during each pregnancy. If a test shows
that the person does have hepatitis B, there are steps that can be taken to lower the risk of
transmitting hepatitis B to their baby. (See 'Preventing transmission to a baby during
childbirth' below.)

Screening is not generally needed for people who have been fully vaccinated against hepatitis
B and have a had a blood test confirming that they are immune to the virus.

HEPATITIS B SYMPTOMS

Symptoms due to hepatitis B vary. After a person is first infected with hepatitis B, they can
develop a flu-like illness that includes fever, abdominal pain, fatigue, decreased appetite,
nausea, and in some cases yellowing of the skin and eyes (jaundice). In the most severe cases,
liver failure can develop, which is characterized by jaundice, fluid accumulation (swelling in the
legs or abdomen), and confusion. However, many people do not develop symptoms,
particularly if the infection occurs in infants and children. Not having symptoms does not
necessarily mean the person is not infected or that the infection is under control. Most people
with chronic hepatitis B have no symptoms until their liver disease is at a late stage. The most
common early symptom is feeling tired. Everyone with chronic hepatitis B is at increased risk
of developing complications, including liver scarring (called cirrhosis when the scarring is
severe) and liver cancer. (See "Patient education: Cirrhosis (Beyond the Basics)".)

Acute hepatitis B — After a person is first infected with hepatitis B, they are said to have
"acute" hepatitis. Most people with acute hepatitis B recover uneventfully.

However, in about 5 percent of adults (1 in 20) the virus makes itself at home in the liver, where
it continues to make copies of itself for many years. People who continue to harbor the virus
are referred to as "carriers". If liver damage develops because of longstanding infection, the
person is said to have "chronic" hepatitis.

Chronic hepatitis B — Chronic hepatitis B develops more commonly in people who are infected
with the virus at an early age (often at birth). Unfortunately, this is common in some parts of
the world such as in Southeast Asia, China, and sub-Saharan Africa, where as many as 1 in 10
people have chronic hepatitis B infection.
Many people with chronic hepatitis B have no symptoms at all; other people have symptoms
such as fatigue and loss of appetite.

HEPATITIS B DIAGNOSIS

There are a number of tests that can be used to diagnose or monitor hepatitis B infection.
Most of these tests are blood tests and include those that detect:

● Hepatitis B surface antigen (abbreviated HBsAg) – HBsAg is a protein on the surface of

the hepatitis B virus. This protein shows up in the blood 1 to 10 weeks after exposure to
the hepatitis B virus and before a person starts to show symptoms of the infection. In
people who recover, this protein usually disappears after 4 to 6 months. Its continued
presence suggests that chronic infection has developed.

● Hepatitis B surface antibody (abbreviated anti-HBs) – Anti-HBs helps the body's

immune system attack the hepatitis B virus. This protein is usually present in people who
have recovered or who have been vaccinated against hepatitis B. People with this protein
are usually immune to hepatitis B.

● Hepatitis B core antibody (abbreviated anti-HBc) – Anti-HBc is usually present

throughout the course of infection and stays in the blood after recovery. Its presence
indicates current or past infection. It is not present in people who have been vaccinated
against hepatitis B.

● Hepatitis B e antigen (abbreviated HBeAg) – HBeAg is a protein whose presence

indicates that the hepatitis B virus is continuing to make copies of itself (replicating). Its
presence usually indicates a high level of circulating virus and a high chance of
transmission of infection. Its absence usually indicates a lower level of circulating virus.

● Hepatitis B e antibody (abbreviated anti-HBe) – Anti-HBe usually signifies that virus

replication has slowed down, but in some variants of hepatitis B, the virus continues to
replicate at a rapid rate, and high levels of virus can be found in the circulation.

● Hepatitis B DNA (abbreviated HBV DNA) – HBV DNA is the genetic material found in the
hepatitis B virus. The HBV DNA "viral load" is a measure of the concentration of virus in
the circulating blood.

HBV DNA usually disappears from the blood after a person recovers from acute infection.
In people with chronic hepatitis B infection, HBV DNA levels in the blood can vary
 depending on the balance between the person's immune system trying to control the
virus and the virus trying to replicate (make more copies of itself).

In people with chronic hepatitis B infection, doctors use the levels of HBV DNA to decide
who needs treatment with antiviral medicines and to track how well treatment is
working.

● Other tests – There are many other tests that can reflect the health of the liver, but are
not specific for hepatitis B. These include liver enzyme tests (alanine aminotransferase
[ALT] and aspartate aminotransferase [AST]), bilirubin, alkaline phosphatase, albumin,
prothrombin time, and platelet count. As an example, an abnormally high ALT in the blood
indicates liver damage. Although liver damage can be caused by a virus (such as hepatitis
B virus), it can also be caused by alcohol, drugs, fat accumulation in the liver ("fatty liver"),
or other diseases.

A liver biopsy (in which a needle is inserted into the liver to remove a small piece of tissue for
testing) is not routinely needed to diagnose hepatitis B virus infection. A liver biopsy is used to
monitor liver damage in people with chronic hepatitis, help decide if treatment is needed, and
find signs of cirrhosis or liver cancer. (See "Patient education: Liver biopsy (Beyond the
Basics)".)

The severity of liver disease or degree of liver damage can also be determined by other
methods, without the need for liver biopsy. This may involve blood tests or tests to measure
liver stiffness. In general, these tests are accurate in being able to tell early fibrosis (scarring)
from advanced fibrosis or cirrhosis (when the scar tissue is severe). However, they cannot
determine specific stages of fibrosis or determine the degree of inflammation.

WILL I DEVELOP CHRONIC HEPATITIS B?

The likelihood of developing chronic hepatitis B largely depends on your age at the time of
infection. Chronic infection develops in about 90 percent of children who are infected at birth,
in 20 to 50 percent of children who are infected between the ages of 1 and 5 years, and in less
than 5 percent of people infected with hepatitis B during adulthood.

AM I AT RISK OF GETTING CIRRHOSIS OR LIVER CANCER?

The risk of developing complications (such as cirrhosis, liver failure, or liver cancer) depends
on how rapidly the virus multiplies and how well your immune system controls the infection.
For people with chronic hepatitis B, the risk of developing complications is:

● Higher in men than in women, and with increasing age.

● Increased by drinking alcohol, having chronic hepatitis C or D (a virus that is dependent

on hepatitis B), or having HIV infection (the virus that causes AIDS).

In addition, being overweight or having diabetes increases the risk of having fatty liver (fat
accumulation in the liver), which can increase the rate of liver disease progression in people
with hepatitis B.

HEPATITIS B TREATMENT

Should everyone be treated? — Specific treatment for acute hepatitis B is usually not needed
since in about 95 percent of adults, the immune system controls the infection and gets rid of
the virus within about six months.

In people who develop chronic hepatitis, an antiviral medication might be recommended to

reduce or reverse liver damage and to prevent long-term complications of hepatitis B.
However, not everyone with hepatitis B needs immediate treatment. If you do not need to start
treatment immediately, you will be monitored over time to know when hepatitis becomes
more active (at that point you may begin antiviral treatment).

Once you start treatment, you will have regular blood tests to see how well the treatment is
working and to detect side effects or drug resistance. Monitoring will continue after finishing
treatment to determine if the infection has come back. Treatment should not be stopped
without discussing this with your doctor because, in some cases, the virus can come back
quickly, causing severe liver injury.

Antiviral medications — If your doctor thinks you should be treated, there are two types of
antiviral medications that can be used, nucleos(t)ide analogs (these are oral medications that
you take daily) and interferon (an injectable medication). Most people receive an oral
medication; however, your doctor will discuss these choices with you.

Nucleos(t)ide analogs — Nucleos(t)ide analogs are oral antiviral medications that can be used
to treat hepatitis B. In some people with advanced cirrhosis, treatment with one of these
medications can reverse liver failure and eliminate the need for liver transplantation. (See 'Liver
transplantation' below.)
Entecavir and tenofovir are the most commonly used oral antiviral medications. These
medications are more potent and are less likely to cause the virus to develop resistance
compared with nucleos(t)ide analogs that were previously used (eg, lamivudine). (See
'Entecavir' below and 'Tenofovir' below.)

Most people will need long-term treatment to maintain control of the hepatitis B virus. In some
cases, lifelong therapy is needed.

Entecavir — Entecavir (brand name: Baraclude) is a recommended treatment for people who
have not been treated with oral antivirals before. Although resistance to entecavir is
uncommon in people who have never received antiviral therapy, it can occur in up to 50
percent of people who have used lamivudine for treatment of hepatitis B.

Tenofovir — Tenofovir is a recommended treatment for both people who have been and those
who have never been treated with oral antivirals for hepatitis B. Tenofovir is available in two
formulations: tenofovir disoproxil fumarate (brand name: Viread) and tenofovir alafenamide
(brand name: Vemlidy). For most people, tenofovir alafenamide is preferred, if it is available.

Tenofovir is effective in suppressing hepatitis B virus that is resistant to other antiviral agents,
such as lamivudine, telbivudine, adefovir, or entecavir. Resistance to tenofovir has not been
reported.

Pegylated interferon-alfa — Pegylated interferon-alfa is an appropriate treatment for people

with chronic hepatitis B infection who have detectable virus activity, ongoing liver
inflammation, and no cirrhosis.

Pegylated interferon-alfa may be considered in young people who do not have advanced liver
disease and do not wish to be on long-term treatment. It is not appropriate for people with
cirrhosis who have liver failure or for people who have a recurrence of hepatitis after liver
transplantation.

Pegylated interferon is an injection taken once a week, and it is given for one year. This is in
contrast to the other hepatitis treatments, which are given by mouth for many years until a
desired response is achieved. Drug resistance to interferon has not been reported.

The disadvantage of pegylated interferon-alfa is that it can cause many side effects.

Liver transplantation — In some cases, liver transplantation may be the only option for people
who have developed advanced cirrhosis. The liver transplantation process involves an
extensive screening process to ensure that a person is a good candidate. Thus, not all people
with cirrhosis are eligible, and only those with the most advanced cirrhosis or early stage liver
cancer and otherwise good medical and social conditions will be put on the transplant waiting
list. Because of the shortage of donors, not everyone on the transplant waiting list will receive
a liver transplant.

TIPS TO MAINTAIN LIVER HEALTH

As discussed above, the majority of people with acute hepatitis B spontaneously clear the
infection. Those who develop chronic infection should see a doctor with expertise in liver
disease (usually a gastroenterologist or hepatologist) who can discuss treatment options.

Vaccinations — Everyone with chronic hepatitis B should be vaccinated against hepatitis A

unless they are known to be immune. Influenza vaccination is recommended once per year,
usually in the fall.

People with chronic hepatitis B should be vaccinated against SARS-CoV2 (the virus that causes
COVID-19). The COVID vaccines are safe for people with chronic hepatitis B. People with
cirrhosis may have more severe illness if they get COVID-19, and some medications used to
treat severe COVID-19 may make hepatitis B virus more active.

People with liver disease should also receive other standard immunizations, including a
diphtheria and tetanus booster, every 10 years. (See "Patient education: Vaccines for adults
(Beyond the Basics)".)

Liver cancer screening — Regular screening for liver cancer is also recommended, particularly
for older individuals, those with cirrhosis, and people with a family history of liver cancer. In
general, this includes an ultrasound examination of the liver plus a blood test for alpha-
fetoprotein (AFP) every six months.

Diet — No specific diet has been shown to improve the outcome in people with hepatitis B. The
best advice is to eat a normal healthy and balanced diet and to maintain a normal weight. (See
"Patient education: Diet and health (Beyond the Basics)".)

Alcohol — Alcohol should be avoided since it can worsen liver damage. All types of alcoholic
beverages can be harmful to the liver. People with hepatitis B can develop liver complications
even with small amounts of alcohol.

Smoking — Smoking is harmful for your health and should be avoided. In addition, smoking
has been shown in some studies to increase the risk of liver cancer in people with hepatitis B.
(See "Patient education: Quitting smoking (Beyond the Basics)".)
Exercise — Exercise is good for overall health and is encouraged, but it has no effect on the
hepatitis B virus. Exercise is not harmful to the liver, even in people with chronic hepatitis or
cirrhosis.

Prescription and nonprescription drugs — Many medications are broken down by the liver.
Thus, it is always best to check with a healthcare provider or pharmacist before starting a new
medication. As a general rule, unless the liver is already scarred, most drugs are safe for
people with hepatitis B.

An important possible exception is acetaminophen (sample brand name: Tylenol); the

maximum recommended dose in people with liver disease is no more than 2 grams (2000 mg
or four extra strength tabs or capsules) in 24 hours. Most acetaminophen tabs or capsules
contain 325 or 500 mg. Many over-the-counter cold and headache medicines under different
names may contain acetaminophen.

You should avoid ibuprofen (sample brand names: Advil, Motrin), naproxen (sample brand
name: Aleve), and aspirin if you have cirrhosis.

Herbal medications — No herbal treatment has been proven to improve outcomes in people
with hepatitis B, and some can cause serious liver toxicity. Herbal treatments are not
recommended for anyone with hepatitis B.

Support — Some people find it helpful to connect with and get support from others living with
hepatitis B. A number of organizations are available around the world. (See 'Where to get more
information' below.)

PREVENTION

Preventing infection of close contacts — Acute and chronic hepatitis B are contagious. Thus,
people with hepatitis B should discuss measures to reduce the risk of infecting close contacts.
This includes the following:

● Discuss the infection with any sexual partners and use a latex condom with every sexual
encounter (unless the sexual partner(s) is known to be immune to hepatitis B).
● Do not share razors, toothbrushes, or anything that might have blood on it.
● Cover open sores and cuts with a bandage.
● Do not donate blood, body organs, other tissues, or sperm.
● Immediate family, household members, and regular sexual partners should be tested for
hepatitis B. Anyone who is at risk of hepatitis B infection should be vaccinated. (See
 "Patient education: Vaccines for adults (Beyond the Basics)".)
● Do not share any injection drug equipment (needles, syringes).
● Clean blood spills with a mixture of 1 part household bleach to 9 parts water.

Hepatitis B cannot be spread by:

● Hugging or kissing
● Sharing eating utensils or cups
● Sneezing or coughing
● Breastfeeding

Preventing transmission to a baby during childbirth — If a pregnant person tests positive for
hepatitis B surface antigen, certain steps can be taken to decrease the risk of transmitting the
virus to their baby

. These include:

● Antiviral medications – Antiviral medications may be recommended for the mother if

the amount of virus in her blood (viral load) is high. These medications are used to
decrease the viral load. You may be referred to a specialist to help decide if you need
medications and what medications to use.

● Hepatitis B immunoglobulin – Infants should be given a shot soon after birth called
hepatitis B immunoglobulin (HBIG). HBIG provides immediate protection to the infant,
but the effect only lasts a few months.

● Hepatitis B immunizations – Infants should also receive the hepatitis B vaccine series.
Completing the vaccine series is important for long-term protection.

The first dose of hepatitis B vaccine should be given at birth. In some countries (including
the United States), two other doses are typically required to complete the vaccine series;
these can be administered along with their regular childhood immunizations at
approximately 1 and 6 months of age. However, in other countries, children routinely
receive three doses of the hepatitis B vaccine in addition to the birth dose (ie, a total of
four doses).

These infants should have a blood test for hepatitis B surface antigen and for hepatitis B
surface antibody at 9 to 12 months of age or one to two months after the last dose of
hepatitis B vaccine if immunization is delayed. If the results of the antibody test are
negative, additional vaccination is needed.
Preventing HBV reactivation — If a person with chronic HBV infection needs to take
medications that suppress their immune function, HBV can reactivate (multiply very quickly)
and cause damage to the liver. These types of medications include cancer chemotherapy, high
dose steroids, and other "immunosuppressive" medications that may be used to treat
conditions such as Crohn's disease, rheumatoid arthritis, and psoriasis.

Reactivation of HBV can be prevented by taking an HBV antiviral medication (see 'Antiviral
medications' above). If you are diagnosed with a new health condition or prescribed a new
medication, it is important to let all your doctors know that you have hepatitis B, so they can
make sure you are treated properly or refer you to a specialist if needed.

WHERE TO GET MORE INFORMATION

Your healthcare provider is the best source of information for questions and concerns related
to your medical problem.

This article will be updated as needed on our web site (www.uptodate.com/patients). Related
topics for patients, as well as selected articles written for healthcare professionals, are also
available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a
patient might have about a given condition. These articles are best for patients who want a
general overview and who prefer short, easy-to-read materials.

Patient education: Hepatitis B (The Basics)

Patient education: Cirrhosis (The Basics)
Patient education: Blood or body fluid exposure (The Basics)
Patient education: Liver transplant (The Basics)
Patient education: Treatment for hepatitis C (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more
sophisticated, and more detailed. These articles are best for patients who want in-depth
information and are comfortable with some medical jargon.

Patient education: Vaccines for adults (Beyond the Basics)

Patient education: Blood donation and transfusion (Beyond the Basics)
Patient education: Cirrhosis (Beyond the Basics)
Patient education: Liver biopsy (Beyond the Basics)
Professional level information — Professional level articles are designed to keep doctors and
other health professionals up-to-date on the latest medical findings. These articles are
thorough, long, and complex, and they contain multiple references to the research on which
they are based. Professional level articles are best for people who are comfortable with a lot of
medical terminology and who want to read the same materials their doctors are reading.

Characteristics of the hepatitis B virus and pathogenesis of infection

Hepatitis B virus: Clinical manifestations and natural history
Clinical significance and molecular characteristics of common hepatitis B virus variants
Clinical significance of hepatitis B virus genotypes
Epidemiology, transmission, and prevention of hepatitis B virus infection
Hepatitis B virus immunization in adults
Immunizations for adults with chronic liver disease
Hepatitis B virus: Overview of management
Hepatitis B virus: Screening and diagnosis in adults
Pegylated interferon for treatment of chronic hepatitis B virus infection
Treatment of chronic hepatitis B in patients with HIV
Entecavir in the treatment of chronic hepatitis B virus infection
Tenofovir and adefovir for the treatment of chronic HBV infection

The following organizations also provide reliable health information.

● National Library of Medicine

(www.nlm.nih.gov/medlineplus/healthtopics.html)

● Centers for Disease Control

(www.cdc.gov/ncidod/diseases/hepatitis/index.htm)

● National Institute of Diabetes and Digestive and Kidney Diseases

(www.niddk.nih.gov)

● National Institute of Allergy and Infectious Diseases

(www.niaid.nih.gov/)

● National Foundation for Infectious Diseases

(www.nfid.org)
 ● American Association for Study of Liver Diseases

(www.aasld.org)

● American Gastroenterological Association

(www.gastro.org)

● American Liver Foundation

(www.liverfoundation.org)

● The Hepatitis B Foundation

(www.hepb.org)

[1-6]
REFERENCES

1. Lok AS, McMahon BJ. Chronic hepatitis B: update 2009. Hepatology 2009; 50:661.

2. Sorrell MF, Belongia EA, Costa J, et al. National Institutes of Health Consensus
Development Conference Statement: management of hepatitis B. Ann Intern Med 2009;
150:104.
3. Liaw YF, Leung N, Guan R, et al. Asian-Pacific consensus statement on the management of
chronic hepatitis B: a 2005 update. Liver Int 2005; 25:472.
4. European Association For The Study Of The Liver. EASL clinical practice guidelines:
Management of chronic hepatitis B virus infection. J Hepatol 2012; 57:167.

5. Sarin SK, Kumar M, Lau GK, et al. Asian-Pacific clinical practice guidelines on the
management of hepatitis B: a 2015 update. Hepatol Int 2016; 10:1.
6. Terrault NA, Lok ASF, McMahon BJ, et al. Update on prevention, diagnosis, and treatment
of chronic hepatitis B: AASLD 2018 hepatitis B guidance. Hepatology 2018; 67:1560.

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Topic 4575 Version 24.0

Contributor Disclosures
Anna SF Lok, MD Grant/Research/Clinical Trial Support: Aligos [Hepatitis B virus]; AstraZeneca [MAFLD];
KOWA [MAFLD]; Target Pharma [NAFL, hepatitis B virus, PBC]. Consultant/Advisory Boards: Abbott
[Hepatitis B virus]; Arbutus [Hepatitis B virus]; Chroma [Hepatitis B virus]; Enochian [Hepatitis B virus];
GlaxoSmithKline [Hepatitis B virus]; Grifols [Hepatitis B virus]; Novo Nordisk [MAFLD]; Pfizer [Hepatitis B
virus]; Roche [Hepatitis B virus]; Target [Hepatitis B virus, PBC, and NAFLD treatment]; Virion [Hepatitis B
virus]. All of the relevant financial relationships listed have been mitigated. Rafael Esteban,
MD Grant/Research/Clinical Trial Support: Gilead [Hepatitis B]. Consultant/Advisory Boards: Abbvie
[Hepatitis C]; Gilead [Hepatitis C]. Speaker's Bureau: Gilead [Hepatitis C]. All of the relevant financial
relationships listed have been mitigated. Jennifer Mitty, MD, MPH No relevant financial relationship(s)
with ineligible companies to disclose.

Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
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