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Hepatitis A, B & C

What is Hepatitis?

'Hepatitis' refers to viral infections that cause inflammation of the liver. Hepatitis A, B and C are the most common types. Each have different causes and symptoms.

Hepatitis A

Hepatitis A is the most common of the seven known types of viral hepatitis. Infection with the hepatitis A virus leads to inflammation of the liver, but complications are rarely serious.

How hepatitis A is spread

The hepatitis A virus (HAV) is found in the faeces of someone infected with the virus. It only takes a tiny amount of faeces getting inside another person’s mouth to cause hepatitis A infection. Personal hygiene, such as careful hand washing, can minimise the risk of the virus being passed on.

HAV is a common infection in many parts of the world where sanitation and sewage infrastructure is poor. Often people become infected with HAV by eating or drinking contaminated food or water.

Hepatitis A is also classed as a sexually transmitted disease (STD) because it can be passed on sexually, particularly during activities such as anilingus (rimming). The washing of genital and anal areas before sex, and the use of condoms or dental dams can help to prevent this risk.

Hepatitis A can affect all age groups. Once a person is exposed to the virus it takes between 2 and 6 weeks to produce symptoms.

Signs and symptoms of hepatitis A

It is possible to experience mild or no symptoms whatsoever, but even if this is the case the person’s faeces will still be infectious to others. Many people who become infected with HAV will have symptoms that include:

  • A short, mild, flu-like illness;
  • nausea, vomiting and diarrhoea;
  • loss of appetite;
  • weight loss;
  • jaundice (yellow skin and whites of eyes, darker yellow urine and pale faeces);
  • itchy skin;
  • abdominal pain.

The infection usually clears in up to 2 months, but may occasionally recur or persist longer in some people. Once a person has been infected and their body has fought off the virus they are permanently immune. Occasionally symptoms may be severe and require monitoring in hospital.

There are rarely any complications with hepatitis A infection. Permanent damage to the liver is very unlikely, but in extremely rare cases the infection can be fatal, particularly in older people.

Where to go for help

If you have any symptoms or you are worried you may have been infected with hepatitis A, you should discuss your worries with a doctor. They may be able to run tests themselves, or else will refer you to someone who can.

Some countries have specific sexual health clinics that can help you directly.

What does a positive test result mean?

HAV is tested for using a blood test. A positive test result means the patient has either had a past infection or is currently infected. The type of antibody detected in the test will indicate whether the infection is current or has been cleared. A patient who tests positive may be asked about recent contacts and sexual partners that may need to be tested too. A patient who has already had the infection and fought it off is naturally immune to HAV.

What does a negative test result mean?

A negative test result means the patient is not infected with Hepatitis A. If the patient is believed to be at high or ongoing risk of infection, a doctor may advise immunisation.

Treatment for hepatitis A

There is no specific treatment for HAV and most people fight off the virus naturally, returning to full health within a couple of months. The doctor will advise avoiding alcohol and fatty foods as these can be hard for the liver to process and may exacerbate the inflammation.

Patients should get plenty of rest and eat a nutritious diet. They should also ensure they do not spread HAV by washing their hands after using the toilet and before preparing food. Patients with more severe symptoms may be monitored in hospital for a short period.

Hepatitis A immunisation

Hepatitis A immunisation is given in a series of injections. The first single injection in the arm gives protection for a year. The second booster injection at 6 to 12 months extends protection for up to 10 years.

The hepatitis A vaccine may be routinely recommended for young children living in areas with high incidence of hepatitis A, and anyone travelling to countries where hepatitis A is endemic. In addition, immunisation may be recommended for people whose sexual practices are likely to put them at risk.

Immunisation may also be recommended to prevent hepatitis A developing if a person suspects they have been exposed to the virus.

Follow-up

Someone who is infected with hepatitis A should limit the amount of alcohol they drink. Their doctor may also offer dietary advice.

The doctor will advise about any precautions necessary to avoid infecting others with the virus.

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Hepatitis B

Hepatitis B is similar to hepatitis A in its symptoms, but is more likely to cause chronic long-term illness and permanent damage to the liver if not treated.

How hepatitis B is spread

The hepatitis B virus (HBV) is very common worldwide, with more than 350 million people infected. Those with long term HBV are at high risk of developing liver cirrhosis or liver cancer.

Hepatitis B is most frequently passed on through the exchange of bodily fluids with an infected person. HBV is estimated to be 50 to 100 times more infectious than HIV. 1

HBV can be spread in the following ways:

  • By unprotected (without a condom) penetrative sex (when the penis enters the anus, vagina or mouth) with someone who is infectious. Also by sex that draws blood with someone who is infected.
  • By sharing contaminated needles or other drug-injecting equipment.
  • By using non-sterilised equipment for tattooing, acupuncture or body piercing.
  • From an infected mother to her baby, most commonly during delivery. Immunisation of the baby at birth prevents the transmission of hepatitis B.
  • Through a blood transfusion in a country where blood is not screened for blood-borne viruses such as HBV.

Hepatitis B cannot be spread through sneezing, coughing, hugging or coming in contact with the faeces of someone who is infected.

Signs and symptoms of hepatitis B

Many people who become infected with HBV experience mild symptoms or no symptoms at all, but they may still carry the infectious virus and pass it on to others. When symptoms do appear they are similar to those of hepatitis A and may include:

  • A short, mild, flu-like illness;
  • nausea, vomiting and diarrhoea;
  • loss of appetite;
  • weight loss;
  • jaundice (yellow skin and whites of eyes, darker yellow urine and pale faeces);
  • itchy skin.

If symptoms become severe then a person with hepatitis B may be admitted to hospital.

Most adults infected with the hepatitis B virus fully recover and develop life-long immunity. Between 2% and 10% of individuals infected as adults will become chronic carriers, which means they will be infectious to others and can develop chronic liver damage. Infected children, especially newborn babies, are much more likely to become chronic carriers.

If a person lives with hepatitis B infection for a number of years then they may develop the following complications:

  • chronic hepatitis
  • liver cirrhosis
  • liver cancer

Where to go for help

If you have any symptoms or you are worried you may have been infected with hepatitis B, you should discuss your worries with a doctor. They may be able to run tests themselves, or else will refer you to someone who can.

Some countries have specific sexual health clinics that can help you directly.

What does a positive test result mean?

A positive test result could indicate either of the following:

  • A past infection. This means the patient has already been in contact with hepatitis B and their immune system has succeeded in fighting off the virus. The patient will then have a natural immunity to the virus.
  • The patient is a carrier. This means the patient is carrying HBV and can pass it on to others. The person may not display any symptoms but could be at risk of developing chronic liver disease.

A doctor may perform a number of different types of test to distinguish between current and past infections, and to estimate how infectious a patient with a current infection may be.

What does a negative test result mean?

This result generally means the patient has never been infected with HBV and therefore has no natural immunity against the virus. If the person suspects they may have been recently exposed to HBV, the doctor may advise them to take a repeat test to confirm their negative status, and may also advise immunisation against hepatitis B.

Treatment for hepatitis B

In most countries a patient with a positive test result will be referred to a specialist who will carry out further tests to determine the degree to which hepatitis B may be affecting the liver, and what may be the best treatment options. In these tests a small sample of liver tissue may need to be taken (a liver biopsy).

In the majority of patients with active HBV, symptoms will not be severe and treatment will not be required. The patient will be monitored and after a few months the patient’s immune system should fight off the virus, giving the patient natural immunity.

In around 5% of adults, 30-50% of young children (aged 1-4), and 90% of infants, HBV infection will become chronic. The virus is more deadly to the young and those that are infected at birth have a 25% chance of developing a life-threatening liver-related illness.

Antiviral medication is given as treatment to those with chronic symptoms to help prevent further liver damage. These medications may be injected or given in pill form. Examples are Interferon Alpha, Lamivudine and Baraclude. Treatment usually lasts 6 months, during which time the patient will be carefully monitored.

Regardless of whether the infection is producing symptoms or not, the patient will be advised to avoid alcohol, get plenty of rest and maintain a healthy diet.

Hepatitis B immunisation

Three immunisation injections are given over a period of 3-6 months. A blood test is taken once the course of injections is completed to check they have worked. Immunity should last for at least 5 years.

Follow-up

A patient with an active infection will be advised to have regular blood tests and physical check-ups to monitor the virus, even if they are not receiving treatment. All carriers of HBV should expect to be referred to specialist services.

The doctor or nurse may advise the patient to avoid alcohol, fatty foods and follow a low-salt diet. They will also describe any precautions necessary to ensure the patient avoids infecting others with the virus, such as not sharing toothbrushes or shaving equipment.

It is important to use a condom for penetrative sex to prevent passing on the virus. Sexual partners of the patient should be tested and immunised against HBV (if not already infected).

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Hepatitis C

Hepatitis C, like other forms of hepatitis, causes inflammation of the liver. The hepatitis C virus is transferred primarily through blood, and is more persistent than hepatitis A or B. 2

How hepatitis C is spread

The hepatitis C virus (HCV) can be spread in the following ways:

  • By sharing drug-injecting equipment (needles, heating spoons, etc). This is the primary transmission route for HCV outside sub-Saharan Africa.
  • By using non-sterilised equipment for tattooing, acupuncture or body piercing. This can be a problem in countries where tattooing or scarification is a traditional ritual practice.
  • Through exposure to blood during unprotected sex with an infected person. Blood may be present because of genital sores, cuts or menstruation. Sexual transmission is an uncommon way of becoming infected with hepatitis C.
  • Rarely, from an infected mother to her baby during childbirth. The risk may be greater if the mother is also infected with HIV.
  • Through blood transfusion. In many developing countries blood is not screened (tested) for the hepatitis C virus. All blood for transfusion in the UK and USA is tested.
  • By sharing equipment used to snort cocaine. Usually this is a rolled banknote, which can become contaminated with blood from a person’s nose.

Hepatitis C cannot be passed on by hugging, sneezing, coughing, sharing food or water, sharing cutlery, or casual contact.

Signs and symptoms of hepatitis C

Many people do not have symptoms when they become infected with hepatitis C. Symptoms may emerge later, taking anywhere between 15 and 150 days to develop. Occasionally a person will not develop any symptoms and their immune system will successfully clear the virus without their knowledge. An infected person without symptoms can still act as a carrier and pass the virus on to others.

Symptoms may include:

  • A short, mild, flu-like illness;
  • nausea and vomiting;
  • diarrhoea;
  • loss of appetite;
  • weight loss;
  • jaundice (yellow skin and whites of eyes, darker yellow urine and pale faeces);
  • itchy skin.

About 20% of individuals who become infected with HCV will clear the virus from their body within 6 months, though this does not mean they are immune from future infection with HCV.

The other 80% of people will develop chronic hepatitis C infection, during which the virus may cause mild symptoms or no symptoms at all. These people will however carry the hepatitis C virus for the rest of their lives and will remain infectious to others.

If a person lives with hepatitis C infection for a number of years then they may develop the following complications:

  • chronic hepatitis
  • liver cirrhosis
  • liver cancer

If symptoms become severe then a person with hepatitis C may be admitted to hospital for monitoring and treatment.

Where to go for help

If you have any symptoms or you are worried you may have been infected with hepatitis C, you should discuss your worries with a doctor. They may be able to run tests themselves, or else will refer you to someone who can.

Some countries have specific sexual health clinics that can help you directly.

The tests for hepatitis C

Tests for the hepatitis C virus have only been available since 1989. A doctor can diagnose hepatitis C by carrying out blood tests that detect HCV antibodies in the blood.

What does a positive test result mean?

The first test searches for HCV antibodies in the patient’s blood. A positive result shows that the person has been exposed to the hepatitis C virus and their immune system has responded by producing antibodies.

This may mean that the patient is a carrier of the hepatitis C virus. Alternatively, the patient may have recently cleared an HCV infection and still have antibodies in their blood. Further tests will be conducted to find out whether the patient has a current infection.

A specialist will carry out a blood test that looks for the genetic material of the hepatitis C virus itself instead of the antibodies. This test will identify whether the virus is still present.

If the patient has successfully cleared the virus, this does not mean they are immune to reinfection.

What does a negative test result mean?

A negative result generally means the patient has never been infected with HCV. However, as the tests rely on the detection of antibodies to HCV, and the antibodies can take some months to develop, the doctor may advise the patient to take a repeat test if they believe they may have been recently exposed to the virus.

Treatment for hepatitis C

To determine the extent to which the liver has been affected by hepatitis C, other tests may be carried out. These include liver function tests, which measure substances (specific proteins and enzymes) in the patient’s blood, showing how effectively the liver is working. A liver biopsy may also be carried out. A fine hollow needle is passed through the skin into the liver and a small sample is taken. The sample is then examined under a microscope to gauge the amount of liver damage (inflammation, scarring and cirrhosis).

Treatment combines the antiviral drugs interferon and ribavirin. Although treatment has improved in recent years, the success rates vary depending on which genotype the patient has and how long they have had hepatitis C. In 2011, the FDA approved a new drug called Victrelis (for the treatment of the genotype 1 strain of hepatitis C). When taken alongside existing drugs, Victrelis cured more than 60 percent of patients in clinical trials compared to between 20-40 percent of patients when existing drugs were taken alone. 3 Unlike other drugs for hepatitis C, Victrelis is a protease inhibitor, similar to those used to treat HIV. Adherence to this drug is essential to prevent drug resistance.

The antiviral drugs may cause significant side effects that may be intolerable for some people. These include:

  • headaches
  • flu-like symptoms
  • nausea
  • tiredness
  • body aches
  • depression
  • skin rashes

A patient will also require regular check-ups to monitor their progress. It is important to remember that if HCV treatment is effective and the infection is cleared, this does not mean the patient has future immunity to hepatitis C.

Follow-up

If a patient has been diagnosed with hepatitis C infection, they will be advised to have regular blood tests and physical check-ups. The World Health Organisation (WHO) now recommends following up a positive HCV test with nucleic acid testing (NAT) to confirm the diagnosis of a chronic infection. 4

The infected person should limit the amount of alcohol they drink as alcohol puts strain on the liver. The doctor may also advise avoiding fatty foods and following a low-salt diet.

Prevention

Currently, there is no vaccine for hepatitis C, but research is in progress. Like HIV, HCV can mutate easily, which makes vaccine development complicated. As no vaccine exists, all measures should be taken to prevent HCV transmission.

Injecting drug users should never share any needles, syringes or mixing spoons, as blood can be transferred between users.

Infection through penetrative sex does occur, although it is not common. If a person is infected with HCV, it is advisable for them to use a condom for penetrative sex to ensure they do not pass on the virus to their partners through any open genital cuts or sores.

People should avoid sharing toothbrushes, shaving equipment (especially razors), or anything else that may be contaminated with infected blood.

The doctor will advise the patient of any precautions necessary to avoid infecting others with the virus.

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