Hepatitis BAbout Hepatitis B
Viral hepatitis is inflammation of the liver caused by a virus. There are five different hepatitis viruses, hepatitis A, B, C, D and E.
Transmission: Hepatitis B is transmitted through contact with the blood or other body fluids (i.e. saliva, semen and vaginal fluid) of an infected person. It can be passed on from mother to child during childbirth.
Prevention: There is a vaccination that can prevent infection. If you have not been vaccinated, to reduce chances of exposure it is best to use condoms, and to avoid sharing needles or items such as toothbrushes, razors or nail scissors with an infected person. It is also wise to avoid getting tattoos or body piercings from unlicensed facilities.
Treatment: A variety of antiviral drugs are available which slow the replication of the virus and occasionally result in its clearance. Children born to mothers infected with hepatitis B should also be vaccinated within 12 hours of birth, as this can prevent an infection that will most likely progress to chronic hepatitis B.
Reference: Originally published by Hepatitis Australia via worldhepatitisday.org
About Hepatitis B
Hepatitis B is the most common liver infection in the world and is caused by the hepatitis B virus. The hepatitis B virus enters the body and travels to the liver via the bloodstream. In the liver, the virus attaches to healthy liver cells and multiplies. This replication of the virus then triggers a response from the body’s immune system. People are often unaware they have been infected with the hepatitis B at this stage.
The liver is the main site of hepatitis B viral multiplication. Hepatitis B infection can lead to cirrhosis (scarring of the liver), liver cancer or liver failure if it is not diagnosed and managed.
Worldwide, 240 million people have been infected with hepatitis B and about 780,000 people die every year due to the consequences of hepatitis B. Hepatitis B prevalence is highest in sub-Saharan Africa and East Asia. Most people in these regions become infected with the hepatitis B virus during childhood (WHO Hepatitis B Fact Sheet).
High rates of chronic infections are also found in the Amazon and the southern parts of Eastern and Central Europe. In the Middle East and the Indian sub-continent, an estimated 2–5% of the general population is chronically infected (WHO Hepatitis B Fact Sheet). Other groups at higher risk of hepatitis B infection include Indigenous Australians, people participating in high risk sexual activity and people who inject drugs (O’Sullivan, B.G., et al; 2004).
In Australia, 213,300 people are chronically infected with hepatitis B (Kirby Institute, Annual Surveillance Report (ASR) 2015-p12). However, nearly half of those living with chronic hepatitis B in Australia are undiagnosed (WHO Regional Reference Laboratory for Hepatitis B).
Deaths from primary liver cancer are climbing faster than any other cause of cancer death in Australia and untreated chronic hepatitis B is a major contributor (National Liver Cancer Prevention Policy, 2012). Most people diagnosed with liver cancer in Australia die within one to two years – many in the first month after diagnosis.
Hepatitis B infection is considered to be ’acute‘ during the first 6 months after infection. If hepatitis B virus tests (HBsAg+) are positive after 6 months, then a person is considered to have ’chronic‘ (long term) hepatitis B infection which can last a lifetime.
Please click here to watch an interview with Professor Narci Teoh explaining what you need to know about hepatitis B. The video is also available in Chinese Mandarin. (Filmed 17 July 2013).
Kirby Institute. HIV, viral hepatitis and sexually transmitted infections infections in Australia: Annual Surveillance Report 2015 (View)
WHO regional Reference Laboratory for Hepatitis B, Victorian Infectious Diseases Reference Laboratory, Melbourne, Victoria, July 2014.
World Health Organisation (WHO) (2015). Hepatitis B Factsheet. Retrieved July 2015.
MacLachlan JH, Allard N, Towell V, Cowie BC. The burden of chronic hepatitis B virus infection in Australia, 2011. Aust N Z J Public Health 2013;37(5):416-22.
O’Sullivan, B.G., Gidding, H.F., Law, M., Kaldor, J.M., Gilbert, G.L. & Dore, G.J. (2004). ‘Estimates of chronic hepatitis B virus infection in Australia’, 2000. Australian and New Zealand Journal of Public Health. 28(3), pp.212–6.
Transmission of Hepatitis B
Hepatitis B is found in blood and in body fluids, including semen and vaginal fluids. Even though studies have shown minute quantities of the virus can be present in saliva, tears and breast milk, they are not considered to be in high enough levels to transmit the virus.
The most common ways hepatitis B is spread include:
- mother-to-baby, though it is to be noted that the Australian vaccination program has significantly reduced this risk through the administration of the vaccine within 12 hours of birth.
- sexual contact
- sharing of injecting equipment
- needlestick injuries in a health care setting
- reuse of unsterilised or inadequately sterilised needles
- child-to-child transmission through contact such as biting
- sharing personal items such as razors, toothbrushes, or hair and nail clippers
Hepatitis B is NOT spread by contaminated food or water, and cannot be spread through casual or social contact such as kissing, sneezing or coughing, hugging, or eating food prepared by a person with hepatitis B.
To avoid transmission of hepatitis B:
- consider being vaccinated (see below for more details);
- practice safer sex (use a condom)
- wash hands after touching blood or body fluids
- wear disposable gloves if giving someone first aid, or cleaning up blood or body fluids
- avoid sharing toothbrushes, razors, needles, syringes, personal hygiene items and grooming aids or any object that may come into contact with blood or body fluids
- use new and sterile injecting equipment for each injection
- cover all cuts and open sores with a bandaid or bandage
- wipe up any blood spills and then clean the area with household bleach
- throw away personal items such as tissues, menstrual pads, tampons and bandages in a sealed plastic bag.
People who have been exposed to the hepatitis B virus and who have not been vaccinated should receive hepatitis B immunoglobulin (HBIG) within 72 hours of exposure, and a dose of hepatitis B vaccine as soon as possible or within 7 days of the exposure from their general practitioner or local emergency department.
Disease Course of Hep B
The disease course of hepatitis B is very complex. The main predictor of disease course is age of infection:
- infants infected with hepatitis B rarely experience symptoms of acute infection, but 90% will develop chronic or lifelong infection
- children infected with hepatitis B rarely experience symptoms of acute infection, but 30% will develop chronic or lifelong infection
- adults or adolescents infected with hepatitis B commonly experience symptoms of acute infection, however less than 5% develop chronic or lifelong infection. (Dore, G; et al; 2006)
Dore, G., Wallace, J., Locarnin, S., Desmond, P., Gane, E. & Crawford, D. (2006). Hepatitis B in Australia—Responding to a diverse epidemic.
Testing for Hepatitis B
Many people with hepatitis B have no signs of illness and do not realise they have the virus in their body. Hepatitis B is diagnosed through various blood tests, which look for markers of the hepatitis B virus in the blood. You can ask your doctor about having a blood test for hepatitis B.
To understand the tests, it is important to understand two basic medical terms:
- antigen—a foreign substance in the body, such as the hepatitis B virus; and
- antibody—a protein that the immune system makes in responses to a foreign substance. Antibodies can be produced in response to a vaccine or a natural infection.
Other test results may indicate some liver damage and prompt the doctor to suggest a test for hepatitis B. These test may also be conducted once a person is diagnosed to help identify changes in liver function and support decisions regarding the timing of treatment. Some of these test include:
- Liver Function Tests (LFTs): are a group of blood tests that show how well your liver is working. One important test is the Alanine Aminotransferase (ALT). The ALT is released from liver cells into the bloodstream when the liver is injured. An ALT level above normal may indicate liver damage. ALT levels are included in the regular monitoring of all chronic hepatitis B patients; this test can also be useful in deciding whether a patient would benefit from treatment, or for evaluating how well a current treatment is working;
- Fibroscan (transient elastography) is a non-invasive test used to check for possible liver scarring; and
- Alpha-fetoprotein: is a blood test which can sometimes detect liver cancer
Symptoms of Hepatitis B
The symptoms of hepatitis B depend on whether a person has acute or chronic hepatitis B infection.
Symptoms of Acute Hepatitis B
Symptoms resulting from acute hepatitis B infection among adults are common, with jaundice occurring approximately 12 weeks after initial infection.
The symptoms of acute hepatitis B include:
- loss of appetite
- nausea and vomiting
- abdominal pain
- muscle and joint pain
- jaundice (yellowish eyes and skin, dark urine and pale-coloured faeces/poo).
Many people with acute hepatitis B have no symptoms and never realise they had the infection. A very small percentage of people with acute hepatitis B become very sick in a short period of time. This happens if there is massive damage to the liver and it stops working. This is called ‘fulminant hepatitis’. (Lin, K.W. & Kirchner, T.J. 2004)
Symptoms of Chronic Hepatitis B
Most people with chronic hepatitis B do not have any symptoms of infection which means they may feel healthy and not be aware they are infected. However, other people may experience symptoms which are similar to those experienced with other forms of viral hepatitis. These can include:
- tiredness, depression and irritability
- pain in the liver (upper, right side of abdomen)
- nausea and vomiting
- loss of appetite
- joint aches and pains.
People with chronic hepatitis B have a significantly increased risk of developing liver cancer.
Lin, K.W. & Kirchner, T.J. (2004). ‘Hepatitis B’. American Family Physician. 69 (1), pp.75–82.
Treatment for hepatitis B
Treatment for hepatitis B is used to manage the effects of the infection but is not a cure. In general, people who are chronically infected but do not have any signs of current liver damage will not need treatment. However, it is important to closely monitor liver health with regular (6 monthly) liver function tests. When a person has signs of liver damage they should consider having treatment for hepatitis B. The decision on when to start treatment is complex and should be made in consultation with your doctor or a gastroenterologist with an interest in hepatitis B.
The Australian Government through the Pharmaceutical Benefits Scheme (PBS) funds several different medications to treat chronic hepatitis B. The most common are anti-viral medications taken as tablets each day for a year or longer:
Entevavir has potent activity against chronic hepatitis B. There are almost no side effects except for the possibility of developing virus mutations and antiviral drug resistance.
Tenofovir has potent activity against chronic hepatitis B. It is particularly useful in patients who have developed drug resistance to other medications.
There are almost no side effects to Lamivudine, however a significant concern is the possible development of hepatitis B virus mutations and antiviral drug resistance after long term use.
In Australia, Adefovir is only funded for people who have developed a hepatitis B virus mutation after taking Lamivudine. There are almost no side effects except for the possibility of developing virus mutations and antiviral drug resistance.
A less common form of treatment is with interferon.
- PEGYLATED INTERFERON (PEGASYS®) is given by injection once a week, usually for 6 months to a year. The drug has many potential side effects, such as flu symptoms and depression, but can control the virus in a third of patients without need for long term medication
Hepatitis B treatment is suitable for people who are classified as being in a particular stage of hepatitis B infection, which is characterised by:
- increased virus activity and liver inflammation demonstrated by elevated liver enzymes (ALT)
- inflammation and activity in the liver as seen in the results of a liver biopsy
- high levels of hepatitis B virus (HBV DNA) in the blood.
Access to treatment is dependent on a person meeting these criteria.
Treatment aims are to stop the hepatitis B virus from multiplying, or to reduce the rate of multiplication as much as possible. This decreases the risk of serious liver disease developing later in life and makes it possible for the liver to repair some of the damage and to work better. (Keefe, E.C et.al; 2004) However, it is very rare that any of these medications will cure hepatitis B infection.
The main side effect of the antiviral tablets (Lamivudine, Adefovir and Entecavir) is sometimes the hepatitis B virus mutates (changes) during the course of treatment, which means the antiviral tablets are not as effective against the new form of the virus. This is called antiviral resistance.
During treatment, the patient’s blood tests are monitored very carefully to look for signs of antiviral resistance. If there are signs of resistance such as elevated liver enzymes and high levels of hepatitis B virus in the blood, the antiviral tablets will be changed.
Keefe, E.C., Dieterich, D., Han, S-H. et al. (2004). ‘A treatment algorithm for the management of chronic hepatitis B virus infection in the United States’. Clinical Gastroenterology and Hepatology. 2, pp.87–106.
Vaccination for Hep B
Hepatitis B can be prevented with a safe and effective vaccine that has been available since 1982. In Australia, the hepatitis B vaccination program commenced in 1988, targeting groups at particularly high risk of infection. It is now recommended that all babies and adolescents be vaccinated against hepatitis B. The program continues and ensures that babies and adolescents have access to free hepatitis B vaccine.
The Australian Immunisation Handbook (NHMRC 2013) recommends that the following groups are vaccinated against hepatitis B:
- babies and young children
- household contacts (other than sexual partners) of people with acute and chronic hepatitis B
- sexual contacts of people with acute and chronic hepatitis B
- dialysis patients and people with impaired renal function in whom dialysis is anticipated
- Individuals with HIV and other adults with weakened immune systems
- Aboriginal and Torres Strait Islander people*
- people who have migrated from countries where hepatitis B is endemic*
- people who inject drugs *
- sex industry workers*
- men who have sex with men*
- recipients of certain blood products *
- individuals with chronic liver disease and/or hepatitis C *
- residents and staff of facilities for persons with intellectual disabilities *
- individuals adopting children from overseas
- liver transplant recipients *
- inmates and staff from long-term correctional facilities *
- healthcare workers, dentists and all people directly involved in patient care and/or the handling of human tissue, blood or body fluids
others at risk including:
- police, members of the armed services and emergency services staff
- long-term travellers to regions with high endemicity
- staff of child day-care centres
- people playing contact sport.
- embalmers, tattooists and body-piercers
* Individuals should consider the combined hepatitis A/hepatitis B vaccine.
Children born after the 1st of May 2000 receive hepatitis B vaccine shortly after birth while they are in hospital and further doses at 2, 4 and 6 months of age.
In order to obtain maximum protection against hepatitis B, adults should receive three doses of the vaccine at zero, 1 and 6 months intervals.
A post-vaccination blood test, to assess if the vaccine course has been effective in producing protection against hepatitis B infection, is recommended four weeks after the third dose of the hepatitis B vaccine for people in the following categories: some would say all adults!
- people at significant occupational risk (e.g. healthcare workers whose work involves frequent exposure to blood and body fluids)
- people at risk of severe or complicated disease (e.g. people with pre-existing liver disease not related to hepatitis B and adults with weakened immune systems)
- people in whom a poor response to the hepatitis B vaccination is expected.
Side effects of the hepatitis B vaccine are not common, however, a small number of people report pain at the injection site and/or a mild fever after the injections
National Health and Medical Research Council (NHMRC) 2015. The Australian Immunisation Handbook 2015 10th Edition (with updates). www.immunise.health.gov.au