Hepatitis A,B,C,D,E

What is a viral hepatitis?

Viral hepatitis is an inflammation of the liver caused by a virus. There exist at least five types of viral hepatitis that are well known. Their symptoms resemble one another, however, their mode of transmission and their evolution within the human organism vary considerably.

What are the symptoms of viral hepatitis?

The majority of individuals infected by the hepatitis A virus have symptoms that may resemble the flu (influenza - fatigue, fever and headaches, etc.), while others may experience abdominal cramps and pains, diarrhea and jaundice (the skin and whites of the eyes develop a yellowish color). Jaundice is also known as "icterus". Symptoms of hepatitis A typically commence approximately one month after the virus has penetrated the organism (this is the incubation period). Hepatitis A causes inflammation, symptoms and then is completely cured by the immune system - no chance of long-term infection. A natural infection by the hepatitis A virus confers life-long immunity; antibodies (one of the defense mechanisms of the immune system) specific to hepatitis A prevent re-infection. In addition to jaundice, your urine may turn dark with bile and the stool (feces) light or clay-colored from lack of bile. Hepatitis A usually takes 2 months to resolve completely. While the outcome of hepatitis A is typically favorable, the occasional patient will die from an acute hepatitis A infection. Patients are usually considred infectious for a week after jaundice has been noticed.

In contrast to hepatitis A, many patients infected by either the hepatitis B or C virus are unaware of their infection (no symptoms) and manage to cure it completely. Those individuals symptomatic from their infection suffer from symptoms similar to those described for hepatitis A above. Symptoms typically commence from one to three months subsequent to penetration of the organism by the virus. It is estimated that approximately 10 % of adults afflicted with an acute hepatitis B infection and 80 % of adults infected with hepatitis C infection will develop chronic longstanding liver inflammation that may lead to long-term complications including cirrhosis and/or liver cancer (hepatoma). Some patients will not completely eliminate the hepatitis B virus and will become carriers of this infection. This means that they may have at all times a small amount of virus in their blood and body fluids. These "carriers" may transmit the infection despite the fact that they are not ill from the virus.

Hepatitis D virus requires the presence of the hepatitis B virus for its survival and manifests itself in a similar fashion. Hepatitis E infection is quite similar to hepatitis A (has an enteric method of transmission -that is to say infection via the digestive tract - contaminated food and water), yet is found more frequently in developing parts of the world (Asia, India and Pakistan, etc.). Heptatitis E is rare in North America. Hepatitis E is particularly serious and even lethal for pregnant women.

How is viral hepatitis transmitted?

Hepatitis A and hepatitis E virus are primarily transmitted via the fecal-oral route (i.e. from the anus to the mouth - for example when hands are not washed after a bowel movement), by human contact, by uncooked foods (shellfish, fruits and vegetables) and by contaminated water. This is one of the reasons why the risk for hepatitis A and E is greater in developing countries...the water is often contaminated with fecal matter or effluent, thereby contaminating everything it comes in contact with. Hepatitis A is frequently responsible for outbreaks in homosexual communities or in men having sex with men, and this secondary to oral-anal sexual contact a.k.a. "rimming".

Hepatitis B and D virus are primarily transmitted via unprotected sexual relations (including oral sex and penetration, whether vaginal or anal), the sharing of contaminated syringes, blood and/or infected biological liquids. Please note, your sexual partner may not be aware of their hepatitis status (they may not feel sick and not know they have the virus). This is where STI testing becomes important, and vaccination is effective at prevention. Hepatitis B may be picked up from your infected mother during birth…this occurs much more frequently in countries endemic (high rates) for hepatitis B (Asia, Africa, etc.).

Finally, hepatitis C virus is transmitted via blood-borne contacts (the sharing of contaminated syringes, blood transfusions, infected re-usable tattoo needles and non-sterilized body piercing instruments). The risk of contracting hepatitis C infection from sexual relations is quite rare, with the exception of men having sex with men (MHSM) where infection rates as high as 10 % have been documented. At birth, infected mothers may pass on hepatitis C to their newborn approximately 5 % of the time. This risk increases to 25 - 30 % if the pregnant women is coinfected with HIV-Hepatitis C.

Water, food or casual contact (school or work) does not transmit Hepatitis B and C.

Who is at risk of a fatal hepatitis infection?

• Patients already suffering from one type of hepatitis who contract a second viral strain. (It is important to prevent a second hepatitis with vaccination, where appropriate).
• Patients with alcohol induced liver disease – hepatitis, cirrhosis or liver cancer (hepatoma).
• Elderly patients.

What about hepatitis B and pregnancy

There are several studies that have demonstrated that it is possible to transmit the hepatitis B virus from the mother to fetus during pregnancy, and from the mother to newborn during delivery. Most gynecologists/obstetricians will test pregnant women early on in their pregnancy and devise a management plan based on the results. Most cases of postpartum neonatal hepatitis B infections can be prevented by early screening and treatment with passive and active vaccination (specific antibodies that protect against hepatitis B are given as immunoglobulins, and the hepatitis B vaccine (within 24 hours of birth) is given so as to stimulate personal antibodies against hepatitis B).

What about hepatitis B and the newborn?

90 % of infants who contract hepatitis B from their mother with hepatitis B infection/carrier status will develop a chronic infection. Once again, it is critical that hepatitis B screening tests be done early on in pregnancy in order that the newborn may be vaccinated and thus escape infection from hepatitis B.

How does HIV/AIDS infection interact with hepatitis B and hepatitis C?

It is important to note the chronic viral hepatitis evolves more rapidly towards cirrhosis in patients who are also infected (co-infected) with HIV/AIDS. In these situations, a more aggressive treatment approach is recommended and warranted. Hepatitis B infection can also have a negative impact on an HIV/AIDS infection as the inflammation caused by the virus may impair the body’s ability to manage and eliminated powerful anti-HIV medications (anti-retrovirals or ART) from the organism. The liver metabolizes a great number of ARTs. Subsequently a chronic hepatitis B or C infection may complicate HIV/AIDS therapy, may limit potential therapeutic choices and may increase possible side effects by cumulative actions on the liver.

How is hepatitis diagnosed?

Obviously a patient suffering from the classical symptoms of hepatitis; jaundice, nausea, diarrhea and fatigue will be suspected of having some sort of hepatitis, with viral hepatitis high on the list. A thorough history by your doctor may help to pinpoint the type of virus involved. The only method available to diagnose, identify and type your viral hepatitis is a blood test.

Is there a treatment for viral hepatitis?

Hepatitis A and E will resolve spontaneously without treatment. Supportive measures may be prescribed to help relieve your symptoms while your body and immune system gets rid of the virus. After a known exposure to the hepatitis A virus, administration of a shot of Immune Globulin within 14 days of exposure should be considered. If administered within a couple of weeks of the exposure, it will usually be effective in preventing or at least ameliorating the disease. Consult your physician!

The future looks bright for individuals living with chronic hepatitis B. Only a decade ago there were no treatment options. Although there is still no complete cure for hepatitis B, there are 6 approved drugs for adults (2 for children) and many promising new drugs in development. Current treatments seem to be most effective in those who show signs of active liver disease.

Not every person with chronic hepatitis B needs to be on medication. You should talk to your doctor about whether you are a good candidate for drug therapy or a clinical trial. Be sure that you understand the pros and cons of each treatment option.

Whether you decide to start treatment or not, it is very important to be seen by a liver specialist or doctor knowledgeable about hepatitis B on a regular basis.

The field of hepatitis B treatment is rapidly evolving. There are several agents currently able to suppress HBV that are licensed in Canada, as follows:

• 3TC (lamivudine, Heptovir)
• adefovir (Hepsera)
• entecavir (Baraclude)
• emtricitabine (FTC, Emtriva)
• interferon-alpha (Pegasys or Pegetron)
• tenofovir (Viread)
• tenofovir and FTC in one pill (Truvada)

Many of these medications (except for entecavir, adefovir and interferon-alpha) also have significant anti-HIV activity and are used for treating this infection. This will be critical if you are co-infected with both HBV and HIV (speak with your physician).

From research to approval, drugs undergo rigorous scrutiny by Health Canada authorities. Once a new medication has been approved by federal regulatory authorities in Canada, it undergoes another review process that helps provinces and territories decided if it will be placed on their list of subsidized medicines. So, the availability of these drugs varies from region to region. Your physician and pharmacist can keep you up to date.

Combination therapy?

Until recently, few anti-HBV agents were available, so therapy generally consisted of using the one available drug at a time (monotherapy) with 3TC. But 3TC's benefits against HBV may not last over the long term, when used alone, as HBV gradually builds up resistance (the capacity to circumvent the medication). With the development and availability of newer drugs, the issue of whether or not to treat HBV with combination therapy arises (similar to the history when HIV treatments were first investigated).

The hope with combination HBV therapy is that it will delay the development of drug resistance. But until more studies are done, the best choice of available agents is not clear. Further research is necessary to improve tolerance and treatment outcomes.

Although these drugs for chronic hepatitis B are approved, they do not provide a complete cure, except in rare cases (a "cure" generally means that a person loses the hepatitis B virus and develops protective surface antibodies).

The drugs, however, significantly decrease the risk of liver damage from the hepatitis B virus by slowing down or stopping the virus from reproducing. As with HIV, it appears that combination therapy will probably be the most effective method of combating chronic hepatitis B infections

When addressing the issue of the treatment of hepatitis C infection, a combination of two antiviral medications (interferon and ribavirin) prescribed over a period of 6 to 12 months appears to be quite effective. The actual treatment duration is determined based on the type of hepatitis C present (genotype), the degree of liver involvement and the initial response to therapy. Current treatment regimens can provide a cure in at least 50 % of patients.

Your physician will assist you in determining the treatment approach best suited to you.

Is a special diet required?

It is not necessary to follow a specific diet as long as one eats in a responsible and healthy fashion as outlined in the Canadian Guide to Healthy Eating. Alcohol can damage the liver, and the combined effects of hepatitis and alcohol are particularly risky. It is important to attempt to refrain from alcohol consumption. When abstinence is impossible, a maximum of 1-2 consummations per day is recommended.

How can I prevent the transmission of my viral hepatitis?

With respect to hepatitis A and E, it is important to rigorously wash one’s hands after bowel movements and before manipulating foodstuffs, drinks or ice-cubes destined for someone else.

If you have hepatitis B, C and/or D:

• Use condoms during sexual relations (oral, vaginal and anal penetration).
• Avoid sharing syringes and/or other drug-related paraphernalia (injection drug equipment).
• Avoid the sharing of your toothbrush, razor, nail-trimmer or file and/or all personal articles that may carry traces of blood.
• Ensure to cover adequately all wounds or open sores with a dressing or bandage.
• Ensure the thorough cleaning of all surfaces that may have been contaminated by your blood (use 1 part ammonia/bleach to 9 parts water).
• Do not donate your blood, organs or sperm for artificial insemination.
• If you are pregnant, your newborn child can be protected by the administration of immunoglobulins within 24 hours of birth (ready-to-protect antibodies against hepatitis) and by the timely use of a hepatitis B vaccination (there is no currently available vaccine against hepatitis C).

How can I avoid contracting viral hepatitis?

Hepatitis A and E:

• Avoid oral-anal sexual contacts.
• If you are traveling to regions where sanitary conditions are poor and at risk of being contaminated by fecal matter (Asia, South America, Mexico or the Caribbean…) you should take precautionary measures. Avoid the consumption of local tap water, ice-cubes, salads, fruits and vegetables that you cannot peel, undercooked shellfish and mobile/street food vendors, etc. These are all potential sources of hepatitis A and/or E.
• Envisage your vaccination against hepatitis A (prior to your departure). This is an excellent and effective vaccination that is given in two doses. The initial dose confers protection or immunity within several weeks of its administration (and lasts for up to one year). The second or booster vaccination confers an immunity that persists for anywhere from 10-20 years – well worth it! Hepatitis A is totally preventable!

Hepatitis B, C and D:

• Avoid unprotected sexual relations (your sexual partner may not feel sick and not know they have the virus). Use a condom!
• Engage in a monogamous sexual relationship (avoid multiple sexual partners)
• Avoid the sharing of syringes or other injection-drug-related paraphernalia.
• Avoid sharing instruments (straws, sniffers, bills, spoons, etc.) used to snort drugs (cocaine, ketamine, etc.)
• Avoid the sharing of toothbrushes, razors, nail trimmers or files and all other personal articles that may be contaminated with traces of blood.
• Immunize yourself against hepatitis B. This is a safe and effective means of preventing hepatitis B, and is currently a childhood vaccination in North America (many young and not so young adults are not immunized). There are three injections over a period of six months that, once complete, confer a long-term immunity or protection against hepatitis B in the majority of people.
• If you have come into contact with hepatitis B, the blood or biological liquids at risk for hepatitis B (within 7 days) then passive immunization with immunoglobulins should be considered. These ready-made antibodies are immediately able to protect against a hepatitis B infection if given within the appropriated time frame. Consult your physician!
• It is important to undergo a hepatitis B screening test prior to, or during pregnancy. In the event of a positive result, your physician will ensure the proper management of your newborn immediately following delivery. Prevention of hepatitis B in your newborn is critical!

Who is eligible for free vaccination against hepatitis B?

• The public health department has at its disposition vaccinations against hepatitis B that are free for those individuals considered to be at high-risk for the viral infection;
• All individuals under the age of 18.
• Individuals diagnosed with a sexually transmitted illness.
• Homeless individuals.
• Injection drug users.
• Men who have sexual relations with men (gay or bisexual).
• Sexual partners or family members of an individual infected with hepatitis B.
• Children between the ages of 8 – 12 are vaccinated at school, free of charge.
• Infants born to carrier mothers
• Patients on dialysis and those with diseases requiring frequent blood products
• Individuals awaiting liver transplants
• Needle stick injuries

Who should consider hepatitis A vaccination?

• Travelers to endemic countries – (poor sanitation); consult a travel medicine clinic
• Men who have sex with men
• Injecting and non-injecting drug users
• Patients with existing liver disease – hepatitis B and/or C
• Patients who require frequent blood products, including hemophiliacs and dialysis patients.