Hepatitis E

Doctor talking to senior patient in medical practice

For World Hepatitis Day, Medical News Today spoke with Dr. Alexandra Buzea about hepatitis C — how the infection manifests, what treatments are available, and how to fight harmful stereotypes and misinformation about this illness.

July 28 is World Hepatitis Day, the yearly day of awareness of hepatitis, a viral infection that affects the liver. It can result from different strains of the hepatitis virus: A, B, C, D, or E.

Hepatitis C infections are some of the most common that affect the liver. They are caused by the hepatitis C virus (HCV).

Globally, HCV affected an estimated 71 million people in 2015, and between 2013 and 2016, about 2.4 million people in the United States were living with HCV infections.

If a person does not receive a diagnosis and treatment, an HCV infection can become chronic, leading to a risk of cirrhosis, which is scarring of the liver.

Because initial symptoms of an HCV infection can go undiagnosed for a long time, the Centers for Disease Control and Prevention (CDC) now advise “one-time hepatitis C testing of all adults (18 years and older) and all pregnant women during every pregnancy.”

To better understand how HCV infections manifest, what treatment options there are, and how to combat harmful stereotypes about the condition, MNT has spoken with Dr. Alexandra Buzea.

Dr. Buzea is a vascular surgeon with additional experience in liver, or hepatic, transplantation affiliated with the Ponderas Academic Hospital, in Bucharest, Romania.

We have lightly edited the interview transcript for clarity.

HCV cannot be contracted through hugging, ‘so hug away!’

MNT: What is hepatitis C, and what are its effects on health?

Dr. Alexandra Buzea: HCV is a well-known virus that can affect the liver, both in an acute form and in chronic form. HCV can lead to hepatitis — characterized by inflammation of the liver cells — ranging from a mild form lasting a few weeks to a lifelong disease.

What people need to understand is that this virus, although highly curable, if left untreated, becomes one of the main causes of cirrhosis and liver cancer.

Most people do not exhibit any symptoms, but a few “unlucky” ones may experience fatigue, fever, nausea, vomiting, abdominal pain, and even jaundice.

MNT: How can a person contract HCV?

Dr. Alexandra Buzea: The most common way of becoming infected is through exposure to infected blood. A small quantity of it is enough for someone to contract the virus.

Although the most cited means of infection are through intravenous drug use, unsafe injection practices, contaminated blood transfusions or blood products, or inadequate sterilization of medical equipment, sometimes a small cut on the finger will suffice.

We should also mention other, less common ways of contracting HCV, like unsafe sexual practices or through birth. A mother who has contracted HCV can pass it on to her baby, but not through breast milk.

Hepatitis C is also not transmitted through sharing food or water with an infected person or through hugging them, but small gestures such as these can help them feel loved and safe in their community and help them recover faster — so hug away!

MNT: What are some therapeutic options?

Dr. Alexandra Buzea: Unfortunately, there is no vaccine available at the moment, but there are a few treatment options, and, of course, prevention plays a key role in medical practice.

Antiviral medication, pangenotypic direct-acting antivirals, can cure up to 95% of patients. We have to be aware that only about 30% of patients clear the virus spontaneously in 6 months and do not require treatment.

The rest will develop a chronic infection and will need antiviral medication, usually over 12–24 weeks, depending on the presence or absence of cirrhosis.

For people already infected with HCV, immunization with the hepatitis A and B vaccines is crucial in preventing co-infection and protecting the liver.

‘People need to be more empathetic and minimize the stigma’

MNT: Studies such as this one, published in Public Health Reports in 2016, suggest that baby boomers are the generation with the highest rate of HCV infections. Why is that?

Dr. Alexandra Buzea: HCV infections occur worldwide, but depending on the country, the virus can be concentrated in certain populations and, yes, even in certain age groups.

A few factors to blame could be infection control practices that were historically insufficient in HCV infection, the generation’s low compliance with screening, misinformation, the fear of disease — any disease — and the fact that, in many countries, the genotype distribution remains unknown.

Also, approximately 80% of people do not exhibit any symptoms after infection, or [they] experience general ones, such as fatigue, fever, or nausea, that do not prompt them to seek medical attention right away.

MNT: There are many harmful myths about HCV infections, such as the belief that they are incurable. How might the media and healthcare organisations fight such disinformation and encourage people to seek treatment and support?

Dr. Alexandra Buzea: Healthcare organizations can fight disinformation only through the help of mass media. Any means of communication is encouraged — newspapers, TV, radio, social media apps… even smoke signals, if that leads to a higher understanding of diseases.

However, the information sources must be reliable. The World Health Organization (WHO) and the CDC are trustworthy and offer helpful explanations.

Taking the advice of a neighbor who recommends a tea because they used it and it “helped with liver problems” is not the best idea, because it can delay access to a treatment plan and affect the patient’s general health status.

Our collaborators in public relations carry the burden of developing informative campaigns that reach a broad spectrum of audiences.

I believe that understanding the implications of HCV infections motivates people to seek medical attention and screening, even in the absence of any symptoms.

MNT: Is there anything else you would like to mention to our readers, as we draw to a close?

Dr. Alexandra Buzea: I just want to point out that having an HCV infection is not a death sentence.

It is highly curable, as long as people know about it and seek care from healthcare specialists. As soon as we can diagnose it, we can treat it.

There are therapy options, even in more advanced phases of the disease — hepatic transplant is becoming more and more accessible, and antiviral treatments are increasingly affordable.

People need to be more empathetic with those who have HCV infections and minimize the stigma — if society would stop seeing it as a “shameful” disease, maybe more people would seek help for it without the fear of becoming outcasts.

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The leadership of the Women and Children Health Empowerment Foundation (WACHEF) has disclosed that it treaded extra legitimate miles to facilitate the integration of the testing and management of viral hepatitis B and C into the just adapted Task Sharing /Task Shifting in Taraba state.

The group said the move, which was necessitated by the current high prevalence of the disease in the state and the country at large, compelled the Non- Governmental Organization (NGO), Women and Children Health Empowerment Foundation (WACHEF) to take it upon itself to facilitate the integration of the testing and management of Viral hepatitis B and C into the state Task -Sharing /Task-Shifting policy.

The reasons which was disclosed in Jalingo, the state capital, was said to be geared at ensuring quality and essential health care services across the state and the country.

WACHEF whom The Guardian learnt is a member of The World Hepatitis Alliance (WHA), said the move has become necessary in order to reduced to the barest minimum or eradicate the viral hepatitis, which according to them is fast spreading than Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome from the state.

The Project Director, Ibrahim Malik, who made this known said the integration was made possible following the support from development Research and Project Center, through the Partnership for Advocacy in Child and Family Health.

The process, according to him, was actualised through series of advocacies, consultative, as well as dialogue meetings involving key stakeholders, which he said includes the World Health Organization (WHO), the State Ministry of Health, the State Primary Health Care Development Agency (TSPHCDA), Nigeria Medical Association (NMA), Pharmaceutical Council of Nigeria (PCN), Pharmaceutical Society of Nigeria (PSN), National Association of Nigerian Nurses and Midwives (NANNN), Medical and Health Workers Union (M&HWU) among others.

Viral hepatitis, which according to Malik remains a disease of public health concern, has continued to be on the increase especially in the state, hence the need for collective decision to integrate it in the said policy for essential health care services across the nooks and crannies of the state.

Malik, who said recent survey indicated that Nigeria has 8.4 percent prevalence of viral hepatitis B and 11 percent of hepatitis C, stressed that with all hands on deck, “the possibility of reducing or flushing out the disease from the state and the nation at large is achievable.”

He urged all the relevant stakeholders to join forces with WACHEF to stamp out hepatitis and other childhood diseases from the state.

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A Professor of Clinical Pharmacy, Department of Clinical Pharmacy and Pharmacy Management, University of Nigeria, Okonta Matthew, talks about hepatitis B and ways to avoid it.

What is hepatitis B?

The liver is a vital organ in the body; it is responsible for the biotransformation of nutrients and chemical substances like drugs and alcohol into acceptable forms the body can utilise or excrete as wastes. The liver can be affected or inflamed by any of these chemical substances, viruses or both at anytime to cause this vital organ to be unable to properly carry out its biotransformation role.

When the liver becomes inflamed, the person is said to suffer hepatitis. Hepatitis B refers to an inflammatory disease of the liver caused by hepatitis-B virus.

Anybody could be at risk of hepatitis B; adult or children. In highly endemic area like Nigeria, risk of hepatitis B infection is increased by somebody having unprotected sex with multiple sex partners such as commercial sex workers, having sex with known hepatitis B infected person(s); scarification with unsterilised sharp blades, needles and knives, such as tattooing, circumcision and piercings of the skin; sharing of blades used for hair cutting, injection needles used by drug addicts, in some health facilities especially the ones operated by quacks; having sexual relationship with men, and people that indulge in oral sex; and somebody receiving blood transfusion especially from an infected source.

The age at which a person is infected with hepatitis B influences the extent to which the disease can become chronic.  Infants who are infected with hepatitis B have higher tendencies of developing the chronic form of the disease than children. Less than five percent of normal adolescents and adults infected with hepatitis B develop the chronic infection.

Are there different types of hepatitis B?

Yes, hepatitis B infection is of two different types -the acute hepatitis B and chronic or long-lived type. Acute hepatitis B symptoms can last for a few days to six months and most of these symptoms are mild. In most people with acute hepatitis, symptoms resolve over weeks to months and they are cured of the infection. Chronic hepatitis B is more severe than the acute hepatitis form. Chronic inflammation of the liver can lead to scarring of liver tissue, liver failure, and liver cancer. Chronic hepatitis B is not curable, but it is treatable. The goal of therapy is to reduce the risk of complications, including premature death.

What are the symptoms of hepatitis B?

Most people that suffer from hepatitis B infection do not know that they have such infection until the symptoms begin to manifest or through general screening during recruitment exercise, before blood donation, or any other circumstances. Before some of the symptoms of the infection are manifested, the liver may have been damaged. This is why it is called silent killer. If somebody is with/without symptoms, such a person can be screened for hepatitis B surface antigen (a protein on the surface of the hepatitis B virus). A positive test means the person has an acute or chronic hepatitis B virus infection and can pass the virus to others; hence such a person needs to be treated. Some common symptoms of hepatitis B are abdominal pain, dark urine, clay-coloured bowel movements, joint pain and jaundice (yellow colour of the skin or the eyes) among others.

Any positively tested person requires the attention of gastroenterologist or an appropriately trained physician to further evaluate and treat them properly.

How is hepatitis B diagnosed? 

Based on patient’s presentation, the difference between hepatitis B and other viral hepatitis may not be too obvious. It is essential that laboratory confirmation is done to differentiate between acute and chronic infections.

It can be diagnosed by detection of hepatitis B surface antigen in the blood sample of the person. The laboratory diagnosis can also be used to differentiate the hepatitis B infection types into acute and chronic infection.

How is it treated?

The treatment of hepatitis B is complex, life-long and expensive once diagnosed. Treatment is based on the type of hepatitis B.

Patient needs to be properly counselled before and during the treatment especially when it is the chronic type. Patients must be fully informed of the possibility of passing on the infection to their loved ones if there is any failure in treatment compliance.

Chronic hepatitis B infection can be treated with anti-viral agents to slow down the disease progression to cirrhosis and reduction of liver cancer incidence and improve patient survival.

The drugs that are needed to manage the disease must be prescribed, administered and monitored by a gastroenterologist or any other trained and certified healthcare professional. A patient with acute hepatitis B infection, most times, requires no specific treatment. The patient must be kept in a comfortable state, reduce liver load such as proteinous meal, maintaining adequate nutritional balance and fluid replacement to cover for fluid lost from vomiting and diarrhoea.

Can hepatitis B be cured?

No, but it is treatable. Until this moment, no drug in use has been able to cure patients of hepatitis B but it can be managed. Available medications have only been able to slow down the progression of liver cirrhosis due to chronic hepatitis B infection.

Can one be vaccinated for hepatitis B? 

Yes. It is the major way of preventing hepatitis B infection for a normal or uninfected person that has been proven through negative HBsAg from blood sample screening.   If you are at increased risk for hepatitis B virus infection vaccination is very necessary especially if you belong to any of the categories below: if you are a sex partners of hepatitis B surface antigen -positive persons; if you are sexually active and have had multiple sex partners in the last six months; if you have sexual intercourse with men (gay relationship); if you inject drug and share devices with other users; if you are from susceptible household contacts of HBsAg-positive persons; and if you are a health care and public safety workers at risk of  exposure to blood or blood-contaminated body fluids.

Can hepatitis B cause liver cancer? 

Yes, people with hepatitis B have an increased risk of liver cancer. And these people with hepatitis B are at risk of liver cancer even if they do not have cirrhosis. The most common primary liver cancer in adults is hepatocellular carcinoma called hepatoma. It is caused majorly by hepatitis B worldwide. The common risk factors are chronic hepatitis B infection. Cirrhosis is linked to more than 80 percent of all HCC.

How common is hepatitis B in Nigeria?

Nigeria is an area of high endemicity for HBV with over 70 percent of the population showing evidence of past infection of the virus while average of 13.7 percent still has serological evidence of current infection. Since the current population of Nigeria is about 170 million according to the 2006 national census, the level of current infection is estimated to be 23 million in Nigeria according to current Nigerian treatment guidelines. The ratio of HBV infection in Nigeria is estimated at one in every eight persons. The prevalence of the disease is estimated at three times more than HIV/AIDS according to specialists.

If this disease spread must be arrested and reversed, the following steps may need to be adopted: awareness of the fatality of this HBV infection must be created among Nigerians with every available opportunity, in all institutions, service delivery and gathering points of all sorts; every Nigerian must be encouraged to be screened for HBV at any given opportunity free of charge; all recruitment points must include opportunities to screen for HBV and be willing to do the needful by not discriminating against people who are found to be positive. The government must be able to put up structures such as policies and health facilities to help control and prevent this disease. Thus, vaccine for the immunisation of those infected with HBV albi initio.

Can hepatitis B cause cirrhosis of the liver?

Yes, chronic hepatitis B virus is one of the major causes of liver cirrhosis. It was estimated that more than 200,000 chronic HBV carriers worldwide die of liver cirrhosis annually. Chronic hepatitis B infection contributes to the scarring of the liver tissue and distortion of the liver structure with the associated blood circulatory system leading to liver cirrhosis. These changes develop over time.

Is it true that one can develop cirrhosis even if one doesn’t take alcohol?

Yes, liver cirrhosis is majorly caused by chronic hepatitis B infection, and a greater percentage of hepatitis is caused by viral agents. The majority of the cirrhosis patients that are seen in the hospitals do not consume alcohol yet are cirrhotic. But most of them have HBsAg present in their blood samples, an indication that they have hepatitis B virus infection.

Cirrhosis can also be caused by excessive amount of fat in the liver. Two other common types of liver disease include non-alcoholic fatty liver disease and non-alcoholic steatohepatitis. These are conditions in which the liver contains excessive amounts of fat. People who have non-alcoholic steatohepatitis have excessive amounts of fat in their livers and also have inflammation and scarring of liver tissue. Risk factors of these conditions include: obesity, high blood cholesterol levels, high triglyceride (blood fat) levels and diabetes

Even if excessive alcohol consumption can cause liver cirrhosis, this liver disease can also be developed in non-consumer of alcohol.