Hepatitis

The word hepatitis means an inflammation of the liver. Inflammation can be caused by:

virus
bacteria
trauma
drugs
alcohol
medications (including overuse of over the counter products).

Diagnostic tests need to be performed to establish the type of hepatitis and the ability of the liver's functioning. At times a liver biopsy may need to be done.

Liver inflammation that is specific and also known as viral hepatitis includes hepatitis A, B, C, D, E, F and G. We are mainly concerned with A, B and C on this web page. D, E, F and G are rare viruses.

In the U.S. there are 325,000 new cases of hepatitis diagnosed annually and it is believed that five million people are chronically infected. While most patients recover fully from hepatitis, those that do not can suffer grave and serious life-long lasting illness with debilitating effects. In a small number of cases death is the end result. This is a terrible consequence for a disease that is preventable in many cases -- preventable because of the new vaccines for hepatitis A and B that are considered safe and effective in preventing infection. Now persons who find themselves in high risk groups for infection can discuss the feasibility of vaccination with their health care provider. For them this is very good news indeed.

Besides discussing hepatitis A, B and C and other causes of hepatitis, we will also evaluate the new vaccines for hepatitis A and B and take a look at other methods of prevention.

Basic Information

The hepatitis A virus (HAV) is usually transmitted by food or by direct or indirect contact with fecal matter, including fecal contaminated water. It can be acquired by eating raw or undercooked shellfish or contaminated food in a restaurant. Even at the finest restaurants, hepatitis A has been discovered in infected food handlers who unknowingly contaminate the food they are preparing. Tourists from the U.S. who travel to destinations such as South or Central America, Asia, Russia or other places where hepatitis A is endemic are at increased risk for getting the virus.

Transmission can also occur from direct contact with an infected patient either in a household or sexual situation.

The most common method of hepatitis A virus transmission is fecal-oral. Because hepatitis A is excreted via body waste, direct or indirect contact with feces is a form of transmission. Those who engage in the sexual act of rimming are at risk because of possible oral/anal contamination. Sexually active gay males are a high risk group. A recent study showed a 33% infection rate for gay males compared to a 12% infection rate for straight males

IV drug users also form a risk group. It cannot be assumed that an injecting drug user with jaundice has hepatitis B since outbreaks of hepatitis A among injecting drug users is common.

From time to time local outbreaks of hepatitis A occur, one of the most recent locations being Northern California, where since 1993, specifically in Shasta County, many cases have been reported. About a year ago there was a large outbreak in the Midwest; the culprit: infected strawberries. Recently there was an outbreak in Queens, New York.

Hepatitis A is sometimes seen in day care centers and in homes for the disabled (places where children and adults are institutionalized) and also on military bases.

Still the origin of infection in 40% of the 150,000 cases reported annually in the U.S. is unknown. What is known is that hepatitis A is a highly contagious disease that can have serious health complications for certain patients.

Symptoms

Symptoms can vary with some infected individuals having no symptoms at all. But if you are infected with hepatitis A and do have symptoms, you will experience them during the first 4 weeks of infection.

Symptoms can include:

jaundice -- the yellowing of the skin or whites of the eyes caused by excess bilirubin in the blood
flu-like symptoms (fever, chills, fatigue)
nausea
dark urine
light colored stools
a vague sense of fullness in the abdomen or even pain
diarrhea
loss of appetite
anorexia
vomiting

Diagnosis/Treatment

The diagnosis of hepatitis A is made by a blood test that is positive for the antibody to the virus. Liver function tests will be abnormally elevated, sometimes to quite high levels. The incubation period is 2 to 6 weeks.

Since hepatitis A is a virus there is no cure and no specific treatment such as prescribing an antibiotic. After you have been diagnosed by your health care provider, a treatment will be recommended that is right for you. Most patients recover at home, usually with plenty of bed rest. It is estimated that only 15% of patients require hospitalization. Avoiding alcohol and fatty foods and eating a diet high in protein is usually advised. Again, getting proper rest for 1--4 weeks after your diagnosis is very important.

Almost all patients infected with hepatitis A fully recover within a 6-month period during which time they might continue to experience symptoms described above. However, once recovered, few patients sustain serious health problems. Even pregnant women infected with hepatitis A and their newborns tend not to have serious complications.

There is a small percentage of patients at risk for liver failure including those with alcoholic hepatitis or those who have chronic hepatitis with cirrhosis or patients older than 60 years. There are approximately 100 deaths per year in the U.S. due to severe hepatitis A. But this infection is not associated with chronic liver disease.

An open relationship with your health care provider is important from diagnosis to follow-up. Your health-care provider may feel it is prudent to give temporary immunization with immune serum globulin to those individuals that you have had contact with but this must be done no later than 2 weeks after exposure. You should not have intimate contact with others until you are no longer infectious. Remember this is a highly contagious disease so every bit of conscious care taken not to unknowingly spread the virus does count. For instance the virus is spread through fecal contamination, then hand-to-mouth contact so by using the bathroom and forgetting to wash your hands, then preparing food or touching your own mouth or someone else's could be a relatively easy way for the disease to spread. Your health care provider will want to make you and other household members aware that careful and frequent hand washing is important not just for you but for persons caring for you as well. You should use separate glasses, plates and silverware than other household members. Proper hygiene such as washing your genitals and anus before engaging in sexual intercourse can help reduce the risk of contracting hepatitis A. And the proper use of a latex condom has shown to be effective in reducing the risk of transmission.

Follow-up with your health care provider may include further liver function tests, discussions about any symptoms that may b e continuing and, if you have not been exposed to hepatitis B, you may wish to consider being vaccinated for it in order to decrease your risk of liver damage. You've already had hepatitis A -- and hepatitis B is a more serious illness that can have long-term debilitating effects. Also, relapses of hepatitis A can occur -- some estimate the figure at nearly 20% -- but there is no way to identify the patient who will sustain a relapse.

BASIC INFORMATION

Hepatitis B (HBV) is transmitted by sexual contact with an infected individual, or from contaminated blood, or by using unsterilized needles or by sharing needles during IV drug use.

Many cases of hepatitis B are contracted by coming into contact with contaminated bodily fluids such as saliva, semen and vaginal secretions. Thus it is a STD (sexually transmitted disease) and having unprotected oral, vaginal or anal sex with an infected individual puts you directly at risk for becoming infected as well. It is actually now regarded as a common STD and is much more infectious than HIV for instance. With an annual number of approximately 240,000 cases reported in the U.S., it is believed that 30--60% of these cases were contracted through sexual transmission.

Hepatitis B can also be transmitted from an infected mother to her baby. This is called perinatal HBV infection and the rate of infection in babies born to infected mothers is 10% to 85%. This is a dangerous, debilitating condition for the infant because chronic HBV infection develops in almost 90% of these infected infants who are at high risk for chronic liver disease. Even if the infant was fortunate enough to escape perinatal HBV infection, there is a good chance within the first 5 years of life the child will acquire chronic HBV infection through person to person contact with the infected mother.

As with hepatitis A, there are many cases -- up to 30% -- whose transmission comes from unknown and unidentified sources in the general population.

90% of those diagnosed with hepatitis B will recover fully but for the others there can be severe complications to be dealt with. In fact, 1% of patients die from the disease during the acute stage while others (an estimated 10% of infected adults) will be left with a chronic form of hepatitis B that allows them to be carriers -- in other words, to be in a chronic state of infectivity where they can affect others without knowing it. Many of these carriers remain well for many years after the infections resolves, while others become ill with ongoing liver disease and damage which could eventually lead to cirrhosis or scarring of the liver and liver failure. This scarring does not allow the liver to remove toxic substances from the blood and if the liver is chronically scarred hepatocellular cancer can occur. Also cirrhosis can cause bleeding from veins in the esophagus or accumulation of fluid in the body.

Symptoms

The symptoms for hepatitis B are often "silent" or insidious.

They can include:

Nausea
Fatigue
Abdominal pain
Loss of appetite
Jaundice (yellowing in the eye and skin due to a pigment that cannot be properly disposed of by the liver during acute infection)
Fever
Darkening of the urine

The severity of the symptoms varies from individual to individual but does not reflect the severity of the disease.

TREATMENT/DIAGNOSIS

Hepatitis B has a long incubation period, sometimes taking up to 6 months to appear. It is diagnosed by a blood test that is positive for the antibody to the virus. Liver function tests will be abnormally elevated for those who test positive for the virus.

Unfortunately, though most individuals with hepatitis B recover fully in a few months and do not have a recurrence, 10% will go on to develop chronic liver disease which may over time lead to cirrhosis of the liver as discussed above.

Treatment for hepatitis B is not specific. Plenty of rest for a month after diagnosis is indicated -- bed rest may be advised as well until jaundice disappears. A diet high in protein and low in fat is usually advised, along with the intake of plenty of fluids. Avoiding alcohol is essential.

Do not have sexual contact with an infected individual. Those who have contact with the patient should have temporary immunization with hepatitis B immunoglobulin in addition to the hepatitis B vaccine. To be effective this must be given within 2 weeks of exposure. This combination is also recommended for babies born to mothers infected with the virus. People who are chronic hepatitis B carriers are infectious to both sexual and household contacts as well -- even though they look and feel well and may be unaware they are even infected.

Remember, though hepatitis B is rarely fatal it is a very serious disease with possible complications leading to liver failure, cirrhosis, liver cancer and even death. So follow-ups with your health care provider are important and may include further liver function tests, discussions about any symptoms that may be continuing and, if you have not been exposed to hepatitis A, you may wish to consider being vaccinated for it in order to decrease your risk of liver damage.

Vaccines for hepatitis A and B

The old adage "prevention is worth a pound of cure" is appropriate when considering being vaccinated for hepatitis A and B. Hepatitis A, and most especially hepatitis B, can have serious health complications, as we have seen -- but the good news is there is a vaccine for both.

A discussion with your health care provider may help define your risk for either disease. It may be recommended that you be vaccinated for hepatitis A if you are a tourist or student in countries where this is a common illness, or if you are a member of the military. A vaccine for hepatitis B may be recommended for those in higher risk groups, i.e. if you have more than one sexual partner or engage in unprotected sex, share needles that may have been contaminated or work in a health care setting (paramedics, viruses, police, doctors, dentists, lab technicians). The Center for Disease Control (CDC), the American Liver Foundation and many health care providers recommend vaccination with hepatitis B for the above mentioned.

A blood test can be administered to determine whether you have been exposed to either hepatitis A or B before you begin the vaccine. Both vaccines are considered safe and effective.

The hepatitis A vaccine is given in 2 doses. Studies show that 99% to 100% of patients respond to one dose; long-term protection is achieved with the second dose.

The hepatitis B vaccine is given in 3 doses, over a 6-month period, the first and second dose given at least 1 month apart. The third dose, for long-term prevention, must be given at least 4 months after the third dose. Hepatitis B vaccine is effective in stopping HBV infection in sexual, as well as household contacts of those with chronic HBV.

Hepatitis C is thought to be acquired mainly by exposure to infected blood or blood products, though sexual transmission is considered a possible way the virus is spread. So is IV drug use. But origin in 40% of the 1 per 10,000 individuals in the U.S. per year who contract the disease is unknown. It is known that hepatitis C accounts for the majority of cases that follow a blood transfusion.

Diagnosis is made by a blood test which should show elevated liver enzymes. But hepatitis C tests have a high false negative, therefore hepatitis C should be identified via a PCR test. Symptoms may include jaundice, darkening of the urine, fatigue, nausea, vomiting and itching.

There is no "cure" for hepatitis C, nor a vaccine. However there are new drugs on the horizon to aid in treatment. It is a disease that can have serious health consequences. Unfortunately in 50% of cases, hepatitis C becomes chronic. In these cases, symptoms vary with some patients remaining well and others developing severe inflammation of the liver which could lead to cirrhosis and liver failure.

Treatment should include plenty of bed rest, avoidance of alcohol and fatty foods and any substances that are toxic to the liver. If you are unsure what these substances are, contact your health care provider. In addition, avoid sexual contact when infected and do not share needles if you are an IV drug user in case they are contaminated.. If you are caring for someone with this disease take necessary precautions to avoid infection, such as thorough hand washing and using your own eating and drinking utensils. Symptoms usually subside on their own, but it could take up to four months.

Chronic hepatitis occurs when inflammation to the liver cells last longer than 6 months. Its prevalence is about 2 in 1,000 patients. Most patients recover with chronic persistent hepatitis. But up to 50% of patients with chronic active hepatitis die within 5 years of becoming symptomatic.

Chronic hepatitis is diagnosed by a liver biopsy. Treatment usually depends on the cause. Your health care provider will evaluate each patient individually and may prescribe drugs that help reduce liver inflammation or specific drugs to treat chronic hepatitis caused by immune deficiency. In severe stages of liver failure, a liver transplant may be the only option.

A patient with hepatitis C and chronic hepatitis should be carefully followed by a health care provider.

Hepatitis can also be acquired through ingesting toxic substances such as drugs or alcohol, herbal medications and bacterial infections.

Additionally, those with infections of both hepatitis B and C are at higher risk for HIV infection. Also when an HIV infected person develops hepatitis B there is a greater risk for chronic HBV infection. Also an HIV infected person may not respond to the hepatitis B vaccine and should be re-tested several months after the third dose of the vaccine.

Most cases of hepatitis B are sexually transmitted and cases of hepatitis A and C are thought to be sexually transmitted as well.

If you are diagnosed with hepatitis which may have been sexually transmitted, your health care provider will want to check for the presence of other sexually transmitted diseases such as gonorrhea, chlamydia, syphilis and herpes.

Also, if you are diagnosed with hepatitis that may have been sexually transmitted, a discussion about HIV testing and counseling is very important and indicated. When a person has at least one sexually transmitted disease, studies have shown that the risk for HIV transmission is much more likely. This is thought to be due to the body's altered defense mechanism when it is infected with an STD.

Should you even suspect that you have symptoms of hepatitis or another STD (sexually transmitted disease) please see your health care provider promptly.

Additional Resource(s):

The CDC National STD Hotline 800-227-8922
Hepatitis Hotline: 800-891-0707
Hepatitis Foundation International 800-465-4837