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Viral Hepatitis Prevention, Screening, and Treatment 
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Prevention

Hepatitis A and hepatitis B can be prevented by safe and effective vaccines.  

  • Hepatitis A vaccine (two shots) for persons 12 months and older who need protection against hepatitis A
       
  • Hepatitis B (three shots) for persons of all ages who need protection against hepatitis B
       
  • Hepatitis A and B combination vaccine (three shots) for persons 18 years and older who need protection against hepatitis A and hepatitis B

    There is no vaccine for hepatitis C.

Why You Should Get the Hepatitis A or B Vaccine

  • Hepatitis A and B infection can cause serious liver injury and on occasion even lead to death from liver failure.
       
  • Hepatitis A and B vaccines are very safe.
       
  • Hepatitis A and B vaccines result in protective immunity in more than 95% of those who take all the recommended shots.
       
  • Hepatitis B vaccine has been shown to prevent deadly liver cancer.

Who should get the hepatitis A vaccine?
  • All children 12-23 months old.
       
  • In some states, hepatitis A vaccination of all children has been recommended since 1999. If you have children older than 2 years, ask your doctor or health clinic if they should be vaccinated.
       
  • Men who have sex with men.
       
  • People who use street drugs.
       
  • People with liver disease, including chronic hepatitis B or C, or those undergoing liver transplantation.
       
  • People with clotting factor disorders.
       
  • Laboratory workers who handle live hepatitis A virus.

Who should get the hepatitis B vaccine?

  • Everyone age 18 years and younger.

  • Adults over 18 who are at increased risk for hepatitis B including:   
    • Household contacts and sexual partners of persons who test positive for hepatitis B.
         
    • Household contacts and sexual partners of foreign-born people from parts of the world where hepatitis B is common (such as Asia, the Pacific Islands) should consider getting vaccinated if the hepatitis B status of the foreign-born person is unknown.
         
    • People who practice high-risk sex, including people with more than one sex partner in the previous 6 months, men who have sex with men, and anyone being treated for a sexually transmitted disease.
         
    • People with HIV infection.
         
    • People who inject illegal drugs.
         
    • People who are traveling to areas where hepatitis B is common, including Asia, the Pacific Islands, Africa, the Middle East, and Eastern Europe.
         
    • People whose work-related activities involve exposure to blood in a healthcare, laboratory, public safety, or institutional setting.
    • Selected patients such as those on hemodialysis or those undergoing liver transplantation.

Vaccination is only part of hepatitis prevention that should include practicing safe sex and not sharing personal items that might have blood on them.
  • Limit number of sex partners and use latex condoms every time.
       
  • Do not share razors or toothbrushes.
       
  • If you inject illegal drugs, stop shooting, and get into a treatment program.
       
  • If you cannot stop drug use, do not reuse or share needles or works.

Where You Can Get Vaccinated for Hepatitis A and B   
  • You can be vaccinated in your doctor’s office or health clinic.

References

   1. Prevention of hepatitis A through active or passive immunization: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 1999;48 (No. RR-12):1-42.

   2. Centers for Disease Control and Prevention. www.cdc.gov/hepatitis

   3. Immunization Action Coalition www.immunize.org

   4. Hepatitis B virus: a comprehensive strategy for eliminating transmission in the United States through universal childhood vaccination: Recommendations of the Immunization Practices Advisory Committee (ACIP). MMWR 1991;40 (No. RR-13):1-25.

   5.  Centers for Disease Control and Prevention. Prevention and Control of Infections with Hepatitis Viruses in Correctional Settings. MMWR 2003;52(No. RR-1):34-36.

For further information, consult the American Liver Foundation or the Centers for Disease Control and Prevention .

Screening

What is viral hepatitis screening?  

  • Viral hepatitis is most commonly caused by the hepatitis A, B, and C viruses.
       
  • Hepatitis B and C cause chronic liver injury, but hepatitis A does not.
       
  • Screening tests are used to detect chronic hepatitis B and/or hepatitis C, but not hepatitis A.
       
  • Hepatitis screening can also be performed to detect prior infection with hepatitis A, B, or C as well as response to previous vaccination against hepatitis B.


Screening can be done with simple and inexpensive blood tests.

Why should you get screened for chronic viral hepatitis?

  • People with chronic hepatitis B and C often do not have symptoms until they have advanced liver disease -- cirrhosis and liver cancer.
       
  • Early diagnosis enables people with chronic hepatitis B and C to be evaluated for the severity of their disease and for the need to receive antiviral treatment. Successful response to antiviral therapy can prevent progression of liver disease.
       
  • Early diagnosis enables people with chronic hepatitis B and C to receive counseling on lifestyle changes such as decreasing alcohol consumption, which can reduce the risk of cirrhosis and liver cancer.
       
  • Early diagnosis enables people with chronic hepatitis to receive vaccines that may prevent other infections that can in turn cause severe illness. (see Viral Hepatitis Prevention)

  • Counseling of people with chronic hepatitis B and C can prevent further spread of infection. This is particularly the case with chronic hepatitis B. (see Viral Hepatitis Prevention)

Who should get screened for chronic hepatitis B infection? 

  • All pregnant women.
       
  • All foreign born people (including immigrants and internationally adopted children) from geographic areas with chronic hepatitis B virus prevalence of 2% or greater, including Asia, the Pacific Islands, Africa, and Eastern Europe.
       
  • All unvaccinated U.S. born people with at least one foreign-born parent from geographic areas with chronic hepatitis B virus prevalence of 2% or greater, including Asia, the Pacific Islands, Africa, and Eastern Europe.
       
  • All chronic hemodialysis patients.
       
  • HIV-positive people.
       
  • People with unexplained abnormal liver enzyme levels.
       
  • Children born to hepatitis B-infected mothers after completion of the vaccine series.

What tests should be used for hepatitis B screening?  

Tests to be performed depend on the purpose of the screening. 

  • Hepatitis B surface antigen -- presence indicates active infection, further evaluation is indicated. (see Viral Hepatitis Treatment)
       
  • Hepatitis B surface antibody -- presence indicates immunity, vaccination is not necessary.
       
  • Hepatitis B core antibody (total) -- presence indicates prior or ongoing infection, further evaluation is necessary to differentiate whether infection is ongoing (hepatitis B surface antigen-positive) or resolved (hepatitis B surface antibody-positive).

Who should get screened for chronic hepatitis C infection?  

  • People who ever injected illegal drugs.
       
  • People who received clotting factors made before 1987.
       
  • People who received blood or organs before 1992.
       
  • People who ever received long-term hemodialysis.
       
  • People with unexplained abnormal liver enzyme levels.
       
  • Healthcare, emergency medical, and public safety workers after needlestick or mucosal exposure to hepatitis C-positive blood.
       
  • Children born to hepatitis C-positive mothers.

What tests should be used for hepatitis C screening?   

  • Hepatitis C antibody -- presence indicates prior or ongoing infection, and should be followed with a test for hepatitis C virus RNA. Presence of hepatitis C virus RNA indicates active infection and further evaluation is indicated. (see Viral Hepatitis Treatment)

Where can you be screened for hepatitis B and C?

  • You can be tested in your doctor’s office or health clinic.
       
  • You can purchase a home test kit for hepatitis C at your pharmacy or on the internet.

References

   1. American Liver Foundation 

   2. Veterans Affairs Hepatitis C Website  

   3. NIH Consensus Statement  

   4. Centers for Disease Control and Prevention

For more information please read the following article from The New York Times: Weighing the Options for Hepatitis B

Treatment

What is viral hepatitis and why does it need to be treated? 

  • Viral hepatitis is usually caused by the hepatitis A, B, and C viruses.
       
  • Both hepatitis B and hepatitis C infection can persist in the body and become longstanding infections (chronic).
       
  • These types of viral hepatitis can be readily distinguished by simple blood tests.
       
  • The two most common forms of chronic hepatitis are caused by hepatitis B and C.
       
  • Many people with chronic hepatitis B and C can lead normal lives without developing problems from liver disease.
       
  • But chronic hepatitis B and hepatitis C can also lead to cirrhosis, liver failure, liver cancer, and even death.
       
  • Because patients with chronic hepatitis B and hepatitis C may not feel sick until they develop severe liver problems, they should be identified as soon as possible (see Viral Hepatitis Screening) and treatment should be considered.
       
  • Because hepatitis B and C are different viruses, they require different approaches to treatment.
       
  • Acute hepatitis infection is most commonly caused by hepatitis A and hepatitis B and is not usually treated with specific hepatitis medications.

Treatment of Hepatitis B

Is chronic hepatitis B treatable?

  • Current treatments for hepatitis B are very effective at controlling or suppressing the hepatitis B virus. However, hepatitis B treatment only rarely leads to “cure”.

What treatments are available?

  • There are five drugs approved by the Food and Drug Administration (FDA) for use against hepatitis B.

    These are:   

    • Interferon alfa (Intron A)
         
    • Lamivudine (EPIVIR)
         
    • Adefovir (HEPSERA)
         
    • Entecavir (BARACLUDE)
         
    • Pegylated interferon alfa-2a (PEGASYS)

      Interferons are given by injection. The other three drugs (lamivudine, adefovir, and entecavir) are given by mouth in pill or liquid form.

Should everyone with hepatitis B be treated?   

  • Not everyone with hepatitis B needs treatment. Those with inactive hepatitis B {who test positive for hepatitis B surface antigen (HBsAg) but who don’t have liver damage} generally do not require treatment.
       
  • Hepatitis B treatment should only be considered in those with active liver disease.
       
  • Persons with active liver disease usually have increased liver enzymes, hepatitis B virus detected in blood, and damage shown on liver biopsy if performed.



What are the goals of hepatitis B treatment?
   

  • Prevention of serious and even life-threatening consequences of long-standing infection.
       
  • Lowering of hepatitis B virus levels over a long period that can be measured by blood tests for hepatitis B viral DNA (HBV DNA) and hepatitis B e antigen (HBeAg). These tests measure how the virus multiplies or grows.
       
  • Loss of HBeAg in those who were initially positive, since treatment can generally be safely stopped in these individuals.
       
  • Improving liver tests that will often become normal or close to normal if treatment is successful.
       
  • Loss of hepatitis B surface antigen (HBsAg). This comes closest to a “cure” of the infection but does not occur very often.



What are the chances of responding to hepatitis B treatment?
   

  • Almost all patients can achieve an initial lowering of their blood levels of HBV DNA and liver enzymes.
       
  • Treatment with oral therapy can keep viral levels low and liver enzymes normal over prolonged periods, as long as the virus doesn’t develop resistance to therapy.
       
  • Treatment with interferon/peginterferon can lead to loss of HBeAg in about a third of patients.
       
  • Treatment with oral therapy can lead to loss of HBeAg in about one fifth of patients after one year. Responses will increase further over time.
       
  • Only a small portion of treated patients clear HBsAg.

How long must hepatitis B treatment be taken?   

  • Interferon/peginterferon is given for 6 to 12 months.
       
  • Oral drugs may need to be given beyond one year depending on the response.
       
  • Patients who are negative for HBeAg before therapy often require prolonged and even indefinite treatment to keep the infection under control.

What are the risks of hepatitis B treatment?   

  • Oral hepatitis B drugs are very well tolerated with few side effects. The main concern with their use is the risk that the hepatitis B virus may become resistant and may no longer respond to treatment. Resistance may then lead to a change in therapy including the use of other drugs given alone or in combination.
       
  • Pegylated interferon is associated with side effects that include fatigue, body aches, and mood changes such as depression.
       
  • Since some hepatitis B medications are new, there may be risks that have not yet been identified.  

Hepatitis C

Is chronic hepatitis C treatable?

  • Hepatitis C is very much a treatable condition.

What treatments are available?

Treatment is with interferon (shots) and ribavirin (capsules). There are three interferons approved by the Food and Drug Administration (FDA) that are currently used.

These are:   

  • Pegylated interferon alfa-2b (PEG INTRON)
       
  • Pegylated interferon alfa-2a (PEGASYS)
       
  • Consensus interferon (INFERGEN)



The two pegylated interferons are similar in their response. Less is known about consensus interferon

Should everyone with hepatitis C be treated?   

  • Not everyone with hepatitis C needs treatment.
       
  • Yet everyone with hepatitis C and hepatitis C viral RNA (HCV RNA) in their blood should be considered for treatment.
       
  • Patients with active liver disease or with scarring to the liver should be treated as long as they do not have other medical conditions that prevent them from being treated successfully.
       
  • Those with mild hepatitis C may not need treatment because they may never develop life-threatening problems.
       
  • Some patients have contraindications to interferon treatment such as severe depression or other medical problems and they should not be started on interferon until these medical problems are improved.



What are the goals of hepatitis C treatment?
   

  • Prevention of serious and even life-threatening consequences of long-standing infection.
       
  • Elimination of HCV in blood six months after treatment is completed.

    What are the chances of responding to hepatitis C medications?
       
  • About one half of treated patients clear the hepatitis C virus if they are able to take a complete course of therapy.
       
  • The chances are higher in those infected with certain strains of hepatitis C virus referred to as “genotypes” such as genotype 2 and 3 than in those infected with genotype 1.
       
    • The chances of responding are greatly increased if patients stay on therapy for the recommended duration and also improved if they stay on therapy at the recommended dose.


    How long must hepatitis C medications be taken?
       
    • Treatment duration depends on the HCV genotype responsible for infection.
         
    • For genotype 1, a full year is needed.
         
    • For genotype 2 and 3, six months is usually sufficient.
         
    • Ongoing research is studying whether longer duration is needed for difficult to treat infections and whether shorter durations are sufficient in those with easy to treat infections.


    What are the risks of hepatitis C treatment?
       
    • The most common and troublesome side effects of interferon/peginterferon are fatigue, body aches, and mood changes, including depression.
         
    • The main side effect of ribavirin is damage to red blood cells that may lead to low blood levels (making you anemic).
         
    • Patients on treatment should have blood counts checked regularly so that adjustments to medications can be made if needed.
         
    • Ribavirin can also cause birth defects and it is very important to avoid pregnancy during treatment as well as for at least 6 months after therapy has been stopped.


    Where can you be treated for chronic hepatitis B or chronic hepatitis C?
      
    • Viral hepatitis treatment must be prescribed by a doctor or mid-level provider.
         
    • You can be treated for hepatitis B or C in your doctor’s office or health clinic.


    Additional Resources

       1. American Liver Foundation 

       2. Veterans Affairs Hepatitis C Website 

       3. NIH Consensus Statement 

       4. Centers for Disease Control and Prevention