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Hepatitis

Hepatitis

Hepatitis A & E

Hepatitis A is a viral liver disease that can cause mild to severe illness. It relates to inflammation (irritation and swelling) of the liver.The hepatitis A virus is transmitted through ingestion of contaminated food and water, or through direct contact with an infectious person.

The hepatitis A virus is one of the most frequent causes of food borne infection. Epidemics related to contaminated food or water can erupt explosively, such as the epidemic in Shanghai in 1988 that affected about 300 000 people. Hepatitis A viruses persist in the environment and can resist food-production processes routinely used to inactivate and/or control bacterial pathogens.

Improved sanitation and the hepatitis A vaccine are the most effective ways to combat the disease

Symptoms: The incubation period of hepatitis A is usually 14-28 days.

Symptoms of hepatitis A virus range from fever, malaise, and loss of appetite, diarrhea, nausea, abdominal discomfort, dark-colored urine and jaundice. Not everyone who is infected will have all of the symptoms.

Who is at risk?

Anyone who has not been vaccinated or previously infected can contract hepatitis A. Risk factors include:

- Poor sanitation
- Lack of safe water
- Injecting drugs
- Living in a household with an infected person
- Being a sexual partner of someone with acute hepatitis A infection
- Traveling to areas of high probability without being immunized.

Treatment

There is no specific treatment for hepatitis A. Recovery from symptoms following infection may be slow and take several weeks or months. Therapy is aimed at maintaining comfort and adequate nutritional balance, including replacement of fluids that are lost from vomiting and diarrhea.

Prevention

Improved sanitation, food safety and immunization are the most effective ways to combat hepatitis A.

The spread of hepatitis A can be reduced by:

- Adequate supplies of safe drinking water
- Proper disposal of sewage within communities
- Personal hygiene practices such as regular hand washing with safe water.

Several hepatitis A vaccines are available. All are similar in terms of how well they protect people from the virus and their side effects. No vaccine is licensed for children younger than one year of age.

Nearly 100% of people develop protective levels of antibodies to the virus within one month after a single dose of the vaccine. Even after exposure to the virus, a single dose of the vaccine within two weeks of contact with the virus has protective effects. Still, manufacturers recommend two vaccine doses to ensure a longer-term protection of about five to eight years after vaccination.

Hepatitis B

Hepatitis B is the most common liver infection in the world and is caused by the hepatitis B virus. The hepatitis B virus enters the body and travels through the blood to the liver. In the liver, it attaches to the liver cells and multiplies. Although the patient may not have any problems at this phase, multiplication of the virus triggers a response from the body's immune system.

Hepatitis B infection can lead to cirrhosis (scarring of the liver), liver failure or even liver cancer unless diagnosed and managed early.

There are probably 350 - 400 million people with chronic (lifelong) hepatitis B infection worldwide.

Hepatitis B infection is considered to be 'acute' in the first 6 months after infection. If hepatitis B virus tests (HBsAg) are positive after 6 months, this is now a 'chronic' (long term) hepatitis B infection, which may last a lifetime.

Symptoms of acute hepatitis B

Symptoms resulting from acute hepatitis B infection are common, with jaundice occurring approximately 12 weeks after initial infection.

The symptoms of acute hepatitis B include:

- Loss of appetite
- Nausea and vomiting
- Tiredness
- Abdominal pain
- Muscle and joint pain
- Jaundice

Many people with acute hepatitis B have no symptoms and never realize they had the infection. A small number of those with acute hepatitis B become very sick in a short period of time. This happens if there is massive damage to the liver and it stops working. This is called acute liver failure.

Symptoms of chronic hepatitis B

Most people with chronic hepatitis B do not have any symptoms of infection so that they feel healthy and may not be aware they are infected. However, other s may experience symptoms, which are similar to those experienced with other forms of viral hepatitis. These can include:

Tiredness, depression and irritability
Pain in the liver (upper, right side of abdomen)
Nausea and vomiting
Loss of appetite
Joint aches and pains.

People with chronic hepatitis B have a significantly increased risk of developing liver cancer.

Disease course

The main predictor of disease course is the duration of infection:

- Infants infected with hepatitis B rarely experience symptoms of acute infection, but 90% will develop chronic or lifelong infection
- Children infected with hepatitis B rarely experience symptoms of acute infection, but 30% will develop chronic or lifelong infection
- Adults or adolescents infected with hepatitis B commonly experience symptoms of acute infection, however less than 5% develop chronic or lifelong infection

Transmission of the virus

Hepatitis B is found in blood and body fluids (saliva, semen, vaginal secretions and breast milk). The most common routes of spreading include:

- Sexual contact
- Sharing of needles / syringes
- Needle stick injuries among healthcare workers
- Reuse of inadequately sterilized needles
- Child-to-child transmission through household contact such as biting
- Sharing personal items such as razors, toothbrushes or nail clippers

Hepatitis B is NOT spread by contaminated food or water, and cannot be spread through casual social contact such as kissing, sneezing, coughing, hugging or eating food prepared by a person with hepatitis B.

Tests for Hepatitis B

To understand the tests, it is important to understand two basic terms:

Antigen - a foreign substance in the body, such as the hepatitis B virus; and
Antibody - a protein that the immune system makes in responses to a foreign substance. Antibodies can be produced in response to a vaccine or a natural infection.

TestAbbreviationWhat it shows

Hepatitis B surface antigen

HBsAg

Shows that the person is infected
with hepatitis B. It can be detected during acute and chronic infection.

Hepatitis B surface antibody

HBsAb or Anti-HBs

Shows that the person has
developed immunity to hepatitis B. It can be detected in people who have    recovered from hepatitis B or been vaccinated against hepatitis B.

Hepatitis B e antigen

HBeAg

Shows that hepatitis B virus
is multiplying.

Hepatitis B e antibody

HBeAb or Anti-HBe

Shows that the person's immune system has responded    against hepatitis B and the virus is not actively replicating.

Hepatitis B core antibody

HBcAb or Anti-HBc

Shows that a person has been infected with hepatitis    B but does not provide any protection against infection.

Hepatitis B virus DNA

HBV DNA

Measures the amount of hepatitis B virus in the    blood and indicates how actively the virus is multiplying.

Other tests are used to check how the liver is working and whether the virus has damaged it :

Liver Function Tests (LFTs): are a group of blood tests that show how well the liver is working. One important test is the AlanineAminotransferase (ALT). The ALT is released from liver cells into the bloodstream when the liver is injured. An ALT level above normal may indicate liver damage. ALT levels are included in the regular monitoring of all chronic hepatitis B patients; this test can also be useful in deciding whether a patient would benefit from treatment, or for evaluating how well a current treatment is working;

Liver biopsy: involves the removal of a small piece of tissue from the liver using a fine needle. The tissue is examined under a microscope to look for inflammation or liver damage; and
AFP: is a blood test which can sometimes detect liver cancer

Treatment

Those who have immunity and normal LFTs do not need treatment. People who are chronically infected but do not have any liver damage also do not need treatment but need close monitoring. However, if a person has liver damage they should consider having treatment for hepatitis B. The decision on when to start treatment is complex and should be made in consultation with a gastroenterologist / hepatologist.

The most common are anti-viral medications taken as tablets each day for a year or longer:

Lamivudine
There are almost no side effects to Lamivudine, however a significant concern is the possible development of hepatitis B virus mutations and antiviral drug resistance after long-term use.

Adefovir
There are almost no side effects except for the possibility of developing virus mutations and antiviral drug resistance.

Entecavir (Baraclude)
Entevavir has potent activity against chronic hepatitis B. There are almost no side effects except for the possibility of developing virus mutations and antiviral drug resistance.

Tenofovir (Viread)
Tenofovir has potent activity against chronic hepatitis B. It is particularly useful in patients who have developed drug resistance to other medications.

Treatment aims are to stop the hepatitis B virus from multiplying, or to reduce the rate of multiplication as much as possible. This decreases the risk of serious liver disease developing later in life and makes it possible for the liver to repair some of the damage and to work better. However, it is very rare that any of these medications will cure hepatitis B infection.

The main side effect of the antiviral tablets is sometimes the hepatitis B virus mutates (changes) during the course of treatment, which means the antiviral tablets are not as effective against the new form of the virus. This is called antiviral resistance.

During treatment, the patient's blood tests are monitored very carefully to look for signs of antiviral resistance. If there are signs of resistance such as elevated liver enzymes and high levels of hepatitis B virus in the blood, the antivirals may be changed.

Lifestyle advice for people with chronic hepatitis B

There are a number of things people with chronic hepatitis B can do to stay healthy, including:

- Limit or avoid alcohol
- Do not smoke
- Eat a healthy, well-balanced diet

Prevention

- Consider being vaccinated
- Practice safe sex (use a condom)
- Wash hands after touching blood or body fluids
- Wear disposable gloves if giving someone first aid, or cleaning up blood or body fluids
- Avoid sharing toothbrushes, razors, needles, syringes, personal hygiene items or any object that may come into contact with blood or body fluids
- Use new and sterile needles / syringes for each injection
- Cover all cuts and open sores with a band aid or bandage
- Wipe up any blood spills and then clean the area with bleaching powder
- Throw away personal items such as tissues, menstrual pads, and bandages in a sealed plastic bag.

Those who have been exposed to the hepatitis B virus and who have not been vaccinated should receive hepatitis B immunoglobulin (HBIG) within 72 hours of exposure, and a dose of hepatitis B vaccine as soon as possible or within 7 days.

Vaccine

Hepatitis B can be prevented with a safe and effective vaccine that has been available since 1982. It is now recommended that all babies and adolescents be vaccinated against hepatitis B. All healthcare workers should also be vaccinated.

Hepatitis C

Hepatitis C is spread by direct blood-to-blood contact. For this reason, it is difficult to get or give hepatitis C unless there is blood transfusion involved.

Routes of spread

The most common way that people get hepatitis C is from sharing needles and anything else that is used to inject drugs, hormones, steroids, vitamins or any other substance that is injected into the body. It is essential to wash your hands to help reduce the risk of getting hepatitis C and also other diseases.

Getting hepatitis C by having sex isn't very common, but it could happen if someone engages in risky behavior - especially "rough sex" or other sexual practices that involve blood. While the risk of spreading hepatitis C is very low it is safe to usecondoms during sex. People who have multiple sex partners or who have other sexual diseases should always use condoms and take other precautions, such as covering any open cuts or wounds during sex. Hepatitis C is also easier to spread while a woman is having her periods. Remember to be safe if there is any blood during sex.

Another way that many people got hepatitis C is from having a blood transfusion. This can include having an operation that required someone to receive blood. Nowadays this route of spread has been virtually eliminated by regular screening for Hepatitis C before transfusing the blood / blood product.

There is a general concern that one can get hepatitis C in other ways, such as by getting a tattoo or piercing or sharing personal hygiene items (toothbrushes, razors, nail clippers). Although there has never been a proven case of spread by these routes, this remains a very real concern.

The good news it that you cannot get or give hepatitis C by sneezing, hugging, breastfeeding, sharing eating utensils or drinking glasses. It does not spread by this type of casual contact.

Safety Tips

Do not share needles or works (cottons, cookers, ties) used to inject drugs, hormones, steroids and vitamins. Do not even share the water. Wash hands before injecting.
Cover any open cuts or wounds.
Sexual transmission is low, but the use of condoms and barriers will help reduce the risk even more.
A mother can transmit hepatitis C to her baby during pregnancy or birth, but this doesn't happen very often.
Do not share any straws to snort drugs, or pipes to smoke crack.
Make sure that in healthcare settings standard safety precautions are being carefully followed.
Do not share any personal hygiene items such as razors, toothbrushes, nail clippers or piercedearrings. Cover personal items and keep them separate from other people you live with.
Make sure tattoo and piercing equipment is sterile. For a tattoo - make sure that a new needleand ink pot is used for each person. For a piercing make sure that a new needle is used and that the package that contains the needle is opened up in front of you.

Tests

There are tests to find out if you have hepatitis C. The first test is to find out if you have ever been infected with HCV. This is called an antibody test. This test only tells you if you have ever been infected. It does not tell you if you actually have the hepatitis C virus in your blood now. There are many other tests used to help find out how far the virus has affected the liver.

Antibody Test

When the hepatitis C virus enters your body, your immune system releases 'antibodies' to fight the hepatitis C virus. If you have hepatitis C antibodies it means that you have been infected with hepatitis C at some point of time. About 2 to 3 people out of 10 people can get rid of the virus by their body's defense systems, but the other 7 or 8 cannot kill off this virus.

Hepatitis C Viral Load

There is a blood test to see if it can find the virus in you. It is called a hepatitis C viral load test. This tells whether you still have the virus in your body and also measures the viral load for treatment. It can help predict the chances of getting rid of the hepatitis C virus from the body with HCV medicines and the response to treatment. But having a lot of virus (high viral load) does not mean that someone is more ill. It does not tell you how much the hepatitis C virus is damaging your body.

ALT Levels

This enzyme is released into the blood by the liver, when the liver is damaged.Many things like alcohol, drugs, toxins, and viruses such as hepatitis C can cause high levels of ALT.

Unfortunately, it is not a perfect test for people with HCV - most people with what we call "normal" ALT levels will have little damage, but some people can still have ongoing liver damage

Genotypes: The types of Hepatitis C

There are six different kinds of hepatitis C. These different kinds of hepatitis C are called genotypes and are numbered 1 to 6. The genotype test is a blood test. Some genotypes are easier to treat with HCV medications. For example, genotype 1 is a little harder to treat than genotypes 2 or 3.

Liver Biopsy

During a liver biopsy, a needle is put into your liver and a sample of liver tissue is taken out.Most people only have mild to moderate pain. The liver biopsy is done while you are awake with local anesthetic injection to blunt the pain. Sometimes an ultrasound is also performed to take a picture of the liver. This will help to decide where to put the needle for the biopsy. Most people are really concerned about having a biopsy because of the pain.

The good news is that only about half of people who have biopsies done have some brief pain that may spread to the right shoulder. Although rare, some people will have to be hospitalized after a biopsy due to pain or from another organ being accidentally hit during the test. After the biopsy is performed the patient will lie on the right side of the body and will be checked for several hours to make sure nothing serious happens.

After the biopsy is done the liver tissue will be sent to another medical person to look at under a microscope and report on the health of the liver.

Symptoms

Some people with hepatitis C have no problems but others can have many. The most common symptom people with hepatitis C say they have is feeling tired a lot (fatigue). Other symptoms people with hepatitis C report are feeling sick, and aches and pains in their muscles, joints and tummy. Some have fevers and may sweat in their sleep. Others feel depressed or worried all the time. Still others say that they can't think or remember as well as they used to before getting hepatitis C. The good news is that for most people it may just mean that your body is fighting the hepatitis C. But talk to your doctor about any of these symptoms you have to make sure they are not serious.

There are other symptoms that people can have if their liver is really damaged and scarred. The term for this condition is called cirrhosis. When you develop cirrhosis the liver cannot perform many of its important functions. There will be many warning signs and symptoms that your doctor will need to know about. For this reason it is important to have regular check-ups with your doctor to keep an eye on you more closely and treat you for some of the symptoms. Click here to read more about cirrhosis. (Link to the cirrhosis section)

Many people with hepatitis C can lead normal lives and will die of something other than hepatitis C. However, some people with hepatitis C will get very sick, but this usually takes many years. The damage caused by hepatitis C usually takes place in the liver. When the hepatitis C virus gets into the liver it can irritate it and cause it to become inflamed like a sore. The inflammation can lead to the liver becoming scarred, and for a few people hepatitis C can lead to a form of cancer of the liver.

There is a simple way to estimate how many people will get sick from hepatitis C:

About 75 out of 100 people who get hepatitis C will develop chronic (long term) infection. About 20 people out of the 75 people who have chronic hepatitis C will become very ill or sick. It usually takes many years to severely damage the liver.

About 2-3 people out of the 75 people who have chronic hepatitis C will get liver cancer.

Treatment

The important point to remember is that hepatitis C usually takes a long time to damage the liver and many people will never get sick from hepatitis C. There are also many things that you can do to stay healthy such as eating a healthy diet, getting lots of exercise, cutting down or stopping alcohol, taking HCV medicines - and many other ways to stay healthy.

If you are thinking about being treated for hepatitis C, there are many things to think about. The decision to treat should be made by you and your doctor based on how hepatitis C is affecting you. You will need to know your viral load, genotype and how much your liver is damaged. The good news is that there are medicines to treat hepatitis C that can get rid of the virus in up to about 70% (7 out of 10 people) of the people who have genotype 1. For people with genotypes 2 or 3, treatment works for about 70-90% (7 to 9 people out of 10). However, treatment is not easy and the decision is a difficult one for most people. There are three medicines (called combination therapy) to treat hepatitis C - interferon, ribavirin and a protease inhibitor. HCV is often treated with a combination of pegylated (peg-alated) interferon and ribavirin for people with genotypes 2 and 3 and the triple combination of pegylated interferon, ribavirin, and an HCV protease inhibitor for people with HCV genotype.

1. However many patients cannot tolerate these medicines and have to discontinue treatment midway.

Liver Transplant for Hepatitis C

Sometimes it might be necessary to go in for liver transplant if the disease is acute. Click here to read more about live liver transplant.