Hepatitis B and C are very common and contagious viruses and it is therefore important for anyone who may be infected to be tested and treated properly.
Contents - Hepatitis B and Hepatitis C
- What is chronic hepatitis?
- Why should we worry about chronic hepatitis?
- What precautions should those with chronic hepatitis take?
- Who should be tested for hepatitis B and C?
- Treatment for hepatitis B
- Treatment for hepatitis C
Hepatitis B and C are the two most common viruses known to cause long term, or chronic, infection of the liver. Chronic hepatitis B affects 350 million people worldwide and chronic hepatitis C, 125 million. The vast majority of people with hepatitis B contracted the virus from their mother during pregnancy or at birth; they are often unaware of the infection until it causes liver problems later in life. Most people with hepatitis C have contracted this through contact with contaminated needles (i.e. vaccination, blood fusion, and recreational drugs). Both can be contracted sexually but this is much more likely with hepatitis B than C. Hepatitis C often causes few or no symptoms and therefore the majority of people with chronic hepatitis are unaware that they have the virus during the incubation period. Hepatitis B and C can cause ‘acute’, in other words short-lived infections, or more long-term infection, ‘chronic’ in medical language. In adults, acute hepatitis B is often cleared by the patient without treatment, though the person can be very unwell during the infectious period. In children and especially babies, the immune system is not strong enough to do this and chronic infection follows. Hepatitis C clears spontaneously in only 15–30% of people infected acutely, though they are often not unwell, or only slightly unwell during this period. There is a highly effective vaccine for hepatitis B but NOT (yet) for hepatitis C.
There are three main issues with these viruses. Firstly, between 10 and 25% of patients will develop cirrhosis which can progress to liver failure and the person will often die without a liver transplant. Secondly, even a mild case of chronic hepatitis B increases the risk of developing liver cancer (hepatocellular carcinoma, also referred to as HCC). This is also a risk with hepatitis C but only if the disease progresses to cirrhosis. Finally, unless those infected are aware of the problem there is a risk that they will pass the virus onto other people as hepatitis is a contagious condition. It is very important, therefore, that those carrying the virus are diagnosed properly and given treatment when necessary.
It is important for those with chronic hepatitis to avoid sharing objects that could be contaminated with blood, such as toothbrushes, razors and needles. Close contact with others and food preparation are NOT risk factors and those infected should not be concerned about living with and caring for others. It is perfectly safe for healthcare workers to continue to work with chronic hepatitis so long as they do so with occupational health advice and do not carry out certain procedures. It is usually suggested that those living with someone with hepatitis B receive vaccination.
The transmission is mainly by blood products, especially unsterile needles, and particularly in the case of hepatitis B, from mother to child and sexual contact. Those who should definitely consider being tested include:
- Anyone born in an area with a high prevalence of chronic hepatitis (particularly Asia, sub-Saharan Africa, South America and southern and eastern Europe).
- Those who have had a tattoo unless sterile equipment could be guaranteed.
- Those who received any blood product before 1992 (testing did start before this in many ‘developed’ countries).
- Those who have ever received blood products in other countries.
- Sex workers and their customers.
- People who have had multiple sexual partners.
- Anyone who has ever had renal dialysis.
- Those with elevated liver function blood tests.
- Persons who have ever (even if only once) injected illegal drugs or shared equipment for nasal absorption.
- Anyone with a close member of the family positive for chronic hepatitis without a known cause.
- Current or previous residents of correctional institutions.
Testing and serology interpretation requires only a simple blood test (looking for the hepatitis surface antigen [HbsAg] plus antibody to the core of the virus [HbcAb], for hepatitis B and a test for antibody to hepatitis C [HCV Ab]). Tests which require only a spot of blood exist and reliable salivary tests are being developed for hepatitis B.
Hepatitis B goes through different stages in the body. In babies and children the virus often lives in high numbers in the body but the immune system does not try to fight it and the person suffers few ill-effects. In this stage, called the ‘immune-tolerant phase’ current treatments have little effect. The person is however, very infectious to others. Later the immune system tries to eradicate the virus, leading to inflammation in the liver and is called the ‘immune-active phase’. Treatment in this phase can help to make the virus enter the third ‘low-replication phase’ where the level of the virus drops to very low levels and the risk of liver damage and tumours is much lower. A fourth phase ‘reactivation’ can occur, sometimes because of changes in the virus to variant forms. Some patients become infected with another virus called Hepatitis D or delta virus. This ‘piggy-backs’ on hepatitis B; it cannot live on its own in the body. Patients who are infected with hepatitis B and the delta virus are more likely to run into problems and treatment is often needed to prevent this.
Current treatment for hepatitis B is either a 6–48 month course of injections of a naturally occurring protein ‘Interferon’, usually self-administered by the patient, daily to weekly; or oral medication, of which entecavir and tenofovir are the most modern and commonly used. Interferon causes quite a few side effects but is only needed for a limited time and is more effective than the tablets. Oral treatments often need to be given for a very long time, sometimes indefinitely.
Patients with chronic hepatitis B should remain under specialist care because of the need of monitoring to detect any liver tumours early enough for successful treatment. Certain people – African men and women over the age of 20, Asian men over 40, Asian women over 50, anyone with advanced scarring or cirrhosis or anyone with a family history of liver cancer, should have regular ultrasound scans of the liver (every six to twelve) to detect early changes of hepatocellular carcinoma which can be treated. It is now recognised that the risk of HCC is related to the length of the infection and the follow up is also important as it is likely that in the next few years much more potent tablet forms of treatment may become available which may treat the disease more effectively than at present.
Interferon-based treatments for hepatitis C have been available for over a decade but are associated with low success with Genotype 1 infection, the most common form of the virus. All the presently available treatments do frequently cause side-effects and some find them difficult to tolerate. An expert Specialist Nurse is very important in supporting patients through the treatment course. Huge advances are currently being made in developing new oral medications with many scientific studies currently underway with great promise. Two of these new agents are now available, Telaprevir and Boceprevir; however they need to be taken in addition to current treatment and are both expensive and increase the chance of side-effects. Patients in whom the standard treatment was not successful may be very good candidates for these new drugs. There is currently debate amongst specialists whether newly diagnosed patients should have the newly released medication, standard therapy or wait for medicines being researched now. There is a lot of hope in the future in hepatitis C therapy!
The most important step is for those at risk of contracting viral hepatitis to be tested and, those found to have hepatitis B or C to then be referred to a specialist clinic for treatment. Any qualified doctor should be able to carry out the simple tests required for diagnosis. Nobody need be embarrassed about having the test done if they feel they may be at risk; it is better to know! If confidential testing is needed, sexual health clinics will do this anonymously and probably more reliably than online testing solutions.
We believe that the most important approach is to encourage everyone at possible risk to undergo the simple tests required to detect any possibility of hepatitis B or C infection. Those referred are seen rapidly and given appropriate information and reassurance that the condition will be properly assessed and managed, with the right treatment given whenever this is needed.