Hepatitis: Questions and Answers

WHAT IS VIRAL HEPATITIS?
Hepatitis is an inflammation of the liver caused by medications, alcohol, or a variety of other agents including the viruses that cause mumps, measles, herpes and infectious mononucleosis. However, when health professionals talk about viral hepatitis, they usually mean hepatitis caused by the hepatitis A, hepatitis B, or hepatitis C virus.

HOW CAN I PROTECT MYSELF FROM INFECTION?
Because the different viruses that cause hepatitis enter the body in different ways, there are several steps you can take to protect yourself from infection. Good hygiene, proper food preparation, and safe sex are good first steps. For more specific information, see the individual sections for hepatitis A, B and C.

WHAT ARE THE SYMPTOMS OF VIRAL HEPATITIS?
Early symptoms of Viral Hepatitis include:

• Fatigue
• Loss of appetite
• Low-grade fever
• Tenderness in the upper right abdomen
• An altered sense of taste and smell
• Malaise (generalized feeling of discomfort)
• Sore joints and muscles
• Nausea, vomiting and diarrhea

Later symptoms can include:

• Jaundice - abnormally yellow skin & eyes caused by elevated bilirubin ( a byproduct of the breakdown of red blood cells in the blood)
• Darkened urine; light-colored or gray stool

However, many other conditions can cause similar symptoms, including food-borne illnesses, autoimmune disorders, viral or bacterial infections, and reactions to medications or toxins.

HOW IS IT DIAGNOSED?
Although health providers use information about a person's symptoms, health history and behaviors to help make a diagnosis, only blood tests can confirm the diagnosis and pinpoint which type of hepatitis a person has, and the stage of infection.

HOW IS VIRAL HEPATITIS TREATED?
Since there's no medication that can treat the initial acute infection of viral hepatitis, health professionals manage symptoms as they occur and try to help the body's immune system fight the infection. If you have viral hepatitis:

• DO NOT DRINK alcohol. Ask your provider about prescription over-the-counter (OTC) drugs, including birth control pills, vitamins, herbals, Vitamin C and supplements.
• Drink high-calorie fluids such as fruit juices and eat a balanced diet that includes dairy products; meat, poultry or seafood; breads and cereals; and fruits and vegetables. (To control nausea, try eating several smaller meals.)
• Limit activity if your hepatitis is symptomatic; this typically means bed rest at first, progressing to normal activity as symptoms disappear.

Your health professional may recommend hospitalization if you experience severe vomiting or do not feel better after several weeks.

HEPATITIS A
The Centers for Disease Control estimates that 42,000 people were infected with Hepatitis A in 2005. You can become infected by eating or drinking something that has been contaminated with the stool (feces) of someone who has the disease.

This type of transmission is called “fecal-oral. The hepatitis A virus (HAV) can live outside the body for months.

Some facts about Hepatitis A

• The average incubation period (time from exposure to symptoms) for hepatitis A is 28 days (range 15-50 days). Symptoms usually last less than two months, rarely, up to six months.
• The virus usually causes mild illness and is often mistaken for a stomach virus, although occasionally symptoms are more serious. It is rarely fatal and does not cause permanent liver damage.
• The hepatitis A virus does not cause long-term, chronic symptoms that other hepatitis viruses can cause.

What behaviors could put me at risk for infection with the Hepatitis A virus?

• Eating contaminated food, such as undercooked shellfish from contaminated water or food handled by someone who has hepatitis A.
• Using silverware, cups or glasses that an infected person touched with unwashed hands.
• Changing diapers or linens that contain stool from someone with hepatitis A and neglecting to wash your hands.
• Sharing food with an infected person or drinking water contaminated with sewage.
• Oral or anal sexual contact with an infected person.
• Traveling to developing countries where the disease is common.
• Although hepatitis A has been transmitted by blood transfusion, this is very rare. Sharing needles for intravenous drug use has potential for transmission of hepatitis A.

What can be done to prevent Hepatitis A?

• Practice good personal hygiene. Always wash your hands after changing diapers, when cleaning or after using the toilet; and before preparing or eating food.
• Avoid foods that could be contaminated, such as under-cooked shellfish or food that's been prepared by someone who has the virus.
• When traveling to developing countries, drink only bottled or boiled water, don't use ice, and don't eat raw fruits or vegetables unless they've been peeled by you.
• It is also a good idea to get the hepatitis A vaccine when traveling to any developing country.
• If you inject drugs intravenously, do not share needles.
• Caregivers of patients with acute hepatitis A should observe precautions in their contacts with patients for about two weeks if the patient is an otherwise healthy adult, up to six months for a child or immunocompromised patient.

What if I've been exposed?
If you think you've been directly exposed to the hepatitis A virus, visit your health care provider immediately for treatment. Some treatments can help fight the infection if administered in time (hepatitis A vaccine and Immune globulin G). All people who have close household or sexual contact with an infected person also need treatment.

If I'm infected, how do I keep from infecting others?
Always wash your hands well after using the toilet. Don't prepare or handle food for others while you are infectious. Avoid sexual contact with other people until you are fully recovered.

HEPATITIS B
Hepatitis B is a disease caused by the hepatitis B virus (HBV), which is transmitted through Percutaneous (i.e. puncture through the skin) or mucosal (i.e. direct contact with mucous membranes) exposure to infectious blood or body fluids.

In 2003, an estimated 73,000 people in the United States were infected with HBV. People of all ages get hepatitis B and about 5,000 die per year of sickness caused by HBV. This highest incidence of HBV (2005) was among 25-45 years old. Seventy-nine percent of new cases (2001-2005) were associated with high-risk sexual activity or injection drug use. Occupational, health-care, household, and travel exposures accounted for 5% of new cases. In the remaining new cases, patients denied any risk factors. While the initial acute illness is rarely fatal, some people who get hepatitis B are infected for life and run a risk of developing serious, long-term liver diseases such as cirrhosis of the liver or liver cancer which can cause serious complications or death. A safe, effective vaccine that prevents hepatitis B is available. Ask a medical professional if you are at risk for sexual transmission and/or percutaneous or mucosal exposure to blood, and should receive a vaccine.

Some facts about hepatitis B

• The average incubation period is 90 days (range 60-150 days) from exposure to onset of jaundice and 60 days (range: 40-90 days) from exposure to onset of abnormal serum alanine aminotransferase (ALT) levels.
• If symptoms occur, they occur on the average of 12 weeks (range 9-21 weeks) after exposure to hepatitis B virus. Symptoms occur in about 70% of patients. Symptoms are more likely to occur in adults than in children.
• HBsAg (an antibody to the HBV) will be detected in an infected person’s blood on the average of four weeks (range 1-9 weeks) after exposure to the virus. About one out of two patients will no longer be infectious by seven weeks after onset of symptoms and all patients, who do not remain chronically infected, will be HBsAg-negative by 15 weeks after onset of symptoms.
• Chronic infection occurs in less than 5% of infected persons aged over five years, approximately 30% of infected children under five years of age, and approximately 90% of infected death occurs in about 15-25% of chronically infected persons.
• About 30% of the people infected with hepatitis B virus never develop symptoms; but they can become chronic carriers.
• Since some areas of the world have high rates of infection, people from places such as Southeast Asia, South Pacific Islands, sub-Saharan Africa, Alaska, Amazon, Bahia, Haiti, and the Dominican Republic are at risk. Visit the CDC Web site for current prevalence information.

What behaviors could put me at risk?

• Practicing unsafe sex. The more partners with whom you have vaginal, anal or oral contact, the higher your risk of becoming infected with hepatitis B. Abstinence is the most effective way to prevent sex-related transmission. If you have vaginal, anal or oral contact, always use barrier protection. People who have multiple sex partners should ask their health provider about getting vaccinated for hepatitis B. Sixty-three percent of new cases among adults (2001-2005) were sexually transmitted.
• Sharing needles. No matter what drug is injected, whether its crack, heroin or steroids, sharing needles is extremely risky. Similarly, beware of needles that could be contaminated when getting tattoos, having acupuncture or your ears pierced. Select a reputable professional for these services and watch to see that they open new, sterile equipment for your procedure.
• Close, frequent contact with the blood, semen, vaginal secretions or saliva of infected patients. If you are a health care worker, contact your employee health service to receive the vaccine. In the United States, donor selection procedures and routine testing of donors have made transmission of HVB via transfusion of whole blood and blood components a rare occurrence. Manufacturing processes for plasma-derived clotting factor concentrates inactivate the HBV and eliminate the risk of transmission.
• Although HBsAg has been detected in multiple body fluids, only serum, semen, and saliva have been demonstrated to be infectious.
• Hepatitis B is not spread through food or water, sharing eating utensils, breastfeeding, hugging, kissing, coughing, and sneezing or by casual contact.

What can be done to prevent hepatitis B?
If you are at risk of contracting hepatitis B, get vaccinated. The hepatitis B vaccine is an inactivated antigen (genetically engineered; not a live or killed virus). It is administered in a series of three injections over a six-month period. Approximately 95% of persons who receive the three injections obtain full immunity after receiving the vaccine. You are asked to report side effects (rash, nausea, joint pain, and/or fatigue) to your health care provider. (Persons who are allergic to yeast should not receive the HVB vaccine.)

Also, avoid high-risk behaviors and practice good personal hygiene when sharing food, kitchens, and bathrooms - especially if you live with someone who is infected with the hepatitis B virus. The virus can live outside the body for at least seven days. Wear gloves and use a 1:10 dilution of household bleach to clean up blood spills). Don't share razors, toothbrushes or pierced earrings with anyone.

What if I've been exposed?
If you have not been vaccinated against hepatitis B, but are exposed to the virus, your health professional can treat you with hepatitis B immune globulin (HBIG), combined with the hepatitis B vaccination. Studies have shown that HBIG, if given within one week of exposure, is about 75% effective at preventing HBV infection.

If I'm infected, how do I avoid infecting others?

• Don't engage in vaginal, anal or oral sexual contact without a condom/dam.
• Don't donate blood. Bandage all cuts and open sores.
• Don't share anything that could be contaminated with your blood, semen, vaginal secretions or saliva - such as needles, razors or toothbrushes.
• Wash your hands well after using the toilet. Don't prepare or handle food for others while infectious.
• All pregnant women should be screened for hepatitis B. If you have hepatitis B and are pregnant, your baby must receive hepatitis B immune globulin and vaccine at birth.

How is Chronic Hepatitis B Treated?

• There are several antiviral medications available for the treatment of chronic hepatitis B, although it is not always curable.
• Adefovir dipivoxil, interferon alfa-2b, pegylated interferon alfa-2a, lamivudine, entecavir, and telbivudine are six drugs used for the treatment of persons with chronic hepatitis B.

HEPATITIS C
You are at risk for Hepatitis C if you:

• Were notified that you received blood from a donor who later tested positive for hepatitis C
• Have ever injected illegal drugs, even if you experimented a few times many years ago
• Received a blood transfusion or solid organ transplant before July, 1992
• Was a recipient of clotting factor(s) made before 1987
• Have ever been on long-term kidney dialysis
• Have evidence of liver diseases (e.g., persistently abnormal ALT levels)

Hepatitis C is less likely than the other hepatitis viruses to cause serious illness at first (only one-quarter of the people infected actually develop symptoms); about 70% of those infected develop chronic liver disease.

Like hepatitis B, hepatitis C can be spread by contact with infected blood. It can be spread by sexual contact, but this happens infrequently, particularly between monogamous partners. HCV can live outside the body for at least 16 hours, but not more than four days. Wear gloves and use a 1:10 dilution of household bleach to clean up blood spills.

The number of new infections per year has declined from an average of 240,000 in the 1980s to about 26,000 in 2004. Additionally:

• Most infections are due to illegal injection drug use.
• Transfusion-associated cases occurred prior to blood screening; now occurs in less than one per two million transfused units of blood.
• An estimated 4.1 million (1.6%) Americans have been infected with HCV, of whom 3.2 million are chronically infected.
• The risk for perinatal (during birth) HCV transmission is about 4%.
• If co-infected with HIV, the risk for perinatal infection is about 19%.

What behaviors could put me at risk?
You are at risk if you share needles; work with contaminated blood as a health care worker; or have vaginal, oral or anal contact without barrier protection with infected partners.

What can be done to prevent hepatitis C?
Since hepatitis C is transmitted in the same way as hepatitis B, you can help avoid infection by using the same precautions. Follow CDC guidelines regarding sexual practices. Practice good personal hygiene; and never share needles, razors, toothbrushes or pierced earrings with anyone. Currently, there is no vaccine available.

How is chronic HCV infection treated?

• Alpha Interferon/peginterferon and ribavirin are two drugs licensed for the treatment of persons with chronic hepatitis C.
• Interferon can be taken alone or in combination with ribavirin. Combination therapy, using pegylated interferon and ribavirin, is currently the treatment of choice.
• Combination therapy can get rid of the virus in up to five out of ten persons for genotype 1 and in up to eight our of ten persons for genotype 2 and 3.

DELTA HEPATITIS
The delta virus (also known as hepatitis D) is a defective virus that may cause infection only in the presence of hepatitis B infection. The HDV may be acquired at the same time (co-infection) as HBV, or at a later time in a person with chronic HBV infection (super-infection). The symptoms and routes of transmission are similar to those of hepatitis B infection, but the risk of complications is higher. Acute liver failure is more likely with co-infection and cirrhosis is believed to be more common with chronic HBV/HDV infection (super-infection).

HEPATITIS E
Hepatitis E is a liver disease caused by the Hepatitis E virus (HEV). However, it occurs rarely in the United States. It is spread in the same way as Hepatitis A.

References
Centers for Disease Control Web site, search for hepatitis
Red Book: Report of the Committee on Infectious Diseases. American Academy of Pediatrics. 1997
National Digestive Diseases Information Clearinghouse Web site, search for hepatitis
NIH Publication No. 04-4244, December 2003
CME Bulletin, American Academy of Family Physicians, Vol. 6, No. 3, May 2007.
American Liver Foundation Web site
Hepatitis Foundation International Web site
Family Doctor Web site

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