- The 5 identified forms of viral hepatitis affect about 400 million people worldwide
- More than 600,000 die each year from illness associated with chronic hepatitis B; for hepatitis C, the figure is about 350,000
- Hepatitis A is among the most common foodborne infections and can cause serious outbreaks. In developing countries, 90% of children are infected by age 10
- Most people with chronic hepatitis don’t know they have it
Sources: WHO fact sheets on Hepatitis B (No204), C (No 164), & A (No 328), July 2013
Definition
Hepatitis is an inflammation of the liver. Acute infection of some types of hepatitis can lead to chronic infection, potentially causing liver diseases including cirrhosis and cancer. It can be developed as a result of alcoholism or medications, but is most commonly caused by viral infection. Five distinct hepatitis viruses have been identified: A, B, C, D and E. Together they affect about 400 million people worldwide. Hepatitis A, B, and C are the most commons types.
Hepatitis B and C, which can lead to chronic hepatitis, are particularly prevalent. They are leading causes of liver cancer, liver cirrhosis and mortality1,2,3. Cirrhosis due to hepatitis is one of the main reasons for liver transplants2.
The means of transmission differs according to the type of viral hepatitis (see chart). Vaccines are available for HAV and HBV; otherwise hygiene and education contribute to prevention. During the acute phase, hepatitis may cause “flu-like” symptoms (e.g. nausea, vomiting), jaundice, white stools, and dark urine. Yet viral hepatitis is largely asymptomatic nature, so most people don’t know they are affected. That’s why viral hepatitis is called a “silent epidemic”.
Means of potential viral hepatitis transmission
|
Means |
HAV |
HBV |
HCV |
HDV |
HEV |
| Food and water contamination | most common | no | no | HDV infection is linked to HBV infection. | most common |
| Blood e.g. through transfusion; contaminated instruments in healthcare settings; sharing needles among drug users | no | yes | yes | rare | |
| Sex with an infected person | rare | yes | yes | rare | |
| Mother-to-child transmission | rare | yes | yes | rare |
Diagnosis
Hepatitis can be difficult to diagnose because it can be asymptomatic or symptoms may be non-specific.
- Non-specific or absent symptoms (90% of cases):
- pain in right hypochondrium - fever
- nausea and vomiting - arthralgia
- urticaria
- Specific symptom (≤ 10% of cases)4:
- icterus (jaundice)
- Severe form: fulminant hepatitis
- clinical signs: hepatic encephalopathy
- biological signs: prothrombin level (< 50%) ; transaminase level not correlated with the severity of fulminant hepatitis
When a patient is suspected to have hepatitis knowing their background often helps clinicians orient their diagnosis.1,2 People at higher risk include:
- HIV-infected individuals are at higher risk of both hepatitis B and C. An estimated ¼ of HIV-infected people in the US are also HCV-infected2
- Men who have sex with men2
- Injection drug-users2
- People in healthcare facilities and correctional facilities2
- Healthcare workers2
- Most people from low-resource countries will contract hepatitis A in childhood1,2
- Asians and Pacific Islanders are at higher risk of hepatitis B2
Because the different types of hepatitis cause similar symptoms during the acute phase, serological tests are important to determine the type of virus and when it was contracted. Once the serology results have been obtained (and possibly a liver biopsy performed to evaluate severity),appropriate treatment and management measures can be implemented.
Viral Hepatitis: Quick Guide to Serologic Markers
|
Situation |
Hepatitis |
Serologic markers |
| Acute hepatitis |
A
B
C
D
E
|
Anti-HAV IgM |
| Chronic hepatitis | B C |
HBsAg / Anti-HBc, then HBe Ag / Anti-HBe |
| Prenatal HBV screening | B |
HBsAg: if HBsAg + : • Mother: monitored for HBe Ag / Anti-HBe and • Newborn: quantitative anti-HBs after vaccination |
| At-risk groups | B C |
Anti-HBc |
| HBV vaccination | B |
Pre-vaccination: Quantitative Anti-HBs Total • if - → vaccinate • if + → quantitative HBsAg / Anti-HBc Total Post-vaccination: quantitative anti-HBs Total |
| HAV vaccination | A |
Patient > 30 years: Total anti-HAV • if - → vaccinate |
Prevention / Treatment
Prevention
The incidence of viral hepatitis is not distributed equally around the world. This is mainly due to lack of access to prevention measures in low-resource populations and countries. For this reason, the WHO global policy for the prevention and control of viral hepatitis aims to tailor responses to the specific national or regional context3. In general, this falls into alignment with essential global health strategies. For hepatitis, the most important prevention strategies are universal access to childhood vaccination for hepatitis B; improved hygiene and practices in and out of the healthcare setting; and screening.
Vaccination: Effective vaccines are available for hepatitis A and B2,3. The vaccine for HBV also protects against HDV, since HDV only affects populations already infected with HBV.
- Universal vaccination in childhood is showing very good results in containing the number ofHBV infections.
- Vaccination is helping to reduce mother-to-child transmissions (principal transmission for HBV)
- Awareness and vaccination programs are also part of reducing the spread among adults, in particular at-risk groups. Vaccination is compulsory for some at-risk groups in some countries
Hygiene: Proper hygiene is an important prevention method for all types of viral hepatitis. This includes:
- Clean drinking water and hygienic food handling
- Proper hand washing
- Safer sex
- Injection drug users: not sharing needles and needle exchange programs
- Health-care settings: fundamental infection control measures; aseptic techniques; no reuse of needles and syringes; safe injection practices
Screening: Screening of people in at-risk populations and of blood products is helping to reduce the spread of hepatitis2,3.
Treatment
Treatment for the various types of hepatitis varies greatly, as does treatment of acute versus chronic illness.
Hepatitis A
Usually resolves on its own. Treatment of symptoms includes rest and elimination of alcohol.
Hepatitis B
Acute HBV infection is not usually treated in immunocompetent adults, as it should resolve naturally.
Current treatments for chronic HBV5:
- Pegylated Interferon alpha (Peg-IFN)
- Nucleotides analogues (NAs):
- First line: Entecavir (ETV), Tenofovir( TDF)
- Second line: Adefovir, Telbuvidine, Lamuvidine
- Liver transplant can be considered for decompensated cirrhosis
- Therapeutic monitoring recommended during, at the end of treatment, and at a period after end of treatment
Hepatitis C
No specific treatment for acute HCV.
Reference treatment for chronic HCV6:
- Genotype 1 (60% patients) Pegylated-interferon-α + ribavirin + Direct Antiviral Agent (Boceprévir or Telaprévir)
- Other genotypes: Peg IFN + ribavirin
- Treatment duration: 48 weeks for genotype 1, 24 weeks for other genotypes
- Intermediate criterion to determine therapeutic efficacy: sustained viral response
- Duration and efficacy of therapy depends on the genotype
- Treatment monitoring should be done:
- At T0 before starting therapy,
- Regularly after several weeks of therapy, generally at weeks 4, 12, 24, 36, 48, etc.
- Depending on genotype, drugs, viral response
- New triple therapy treatments to become available in 20147:
- PegIFN + RBV+ Sofosbuvir or Simeprevir
- PegIFN-free regimens will also be available in 20147:
Hepatitis D
No specific treatment for acute HDV. See prevention and treatment of its helper virus, HBV.
Hepatitis E
Generally, no specific treatment for acute HEV, although treatment with Ribavirin may be effective. For immunocompromised patient, immunosuppressive treatment may be lowered. Otherwise, treatment is usually focused on relieving signs and symptoms.
Guidelines
- WHO: Global policy report on the prevention and control of viral hepatitis in WHO member states. 2013.
- WHO: Guidance on prevention of viral hepatitis B and C among people who inject drugs. 2012.
- CDC: Recommendations for Routine Testing and Vaccination for Chronic Hepatitis B virus Infection. 2008.
- CDC: Recommended Testing Sequence for Identifying Current Hepatitis C Virus (HCV) Infection. 2013
- American Association for the Study of Liver Disease/Infectious Diseases Society of America. Recommendations for Testing, Managing, and Treating Hepatitis. 14.02.2014
- World Gastroenterology Organisation Practice Guideline for Hepatitis B. 2008.
- European Association for the Study of the Liver. EASL Clinical Practice Guidelines: Management of chronic hepatitis B virus infection. 2012.
- European Association for the Study of the Liver. EASL Clinical Practice Guidelines: Management of hepatitis C virus infection. 2013.
- Health Protection Agency (UK). Guidance for the Prevention and Control of Hepatitis A Infection. 2009.
REFERENCES
1) WHO fact sheets: Hepatitis A (No 328), B (No204), and C (No 164), July 2013
2) CDC website: http://www.cdc.gov/hepatitis/
3) WHO: Global policy report on the prevention and control of viral hepatitis in WHO member states. July 2013.
4) Lefrère JJ, Lunel F, Marcellin P, Pawlotsky JM, Zarski JP. Guide pratique des hépatites virales. MMI Ed, Paris, 1998.
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