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Updated 13 February 2013

Hepatitis, Viral

"Hepatitis" means that the liver is inflamed. This article discusses the different types of viral hepatitis.

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Summary

  • Hepatitis A and B are common infections in South African children.
  • A significant number of South African adults are hepatitis B carriers.
  • Chronic hepatitis B and C can cause irreversible liver damage.
  • There are safe, effective vaccines against hepatitis A and B.

Description

"Hepatitis" simply means that the liver is inflamed. Signs that indicate that the liver is inflamed include:

  • Pain in the right upper abdomen
  • Fever
  • Nausea and vomiting
  • A yellow tinge to the eyes and skin (jaundice).

There are a variety of causes of liver inflammation. A common cause is excessive alcohol intake, since alcohol is a liver toxin. Many medications are toxic for the liver, for example some of the drugs used to treat tuberculosis (TB). Herbal medicines can also be liver toxins. There are a number of infectious causes of hepatitis, of which the most important are the hepatitis viruses.

Cause

In South Africa, three viruses are very significant causes of hepatitis. These viruses are (not very originally!) named hepatitis A, hepatitis B and hepatitis C. In fact these three viruses are completely unrelated to one another, but they all happen to target the liver during an infection.

The hepatitis A virus reaches the liver after first infecting the gut. This virus is found in the faeces of an infected person. Hepatitis A is usually acquired from hands soiled after using the toilet or changing a nappy, or by swallowing water or food that has been contaminated by human faeces. Uncooked shellfish and raw vegetables contaminated by sewage can also be a route of infection. Sexual contact with an infected person is also a recognised route of infection.

By contrast, hepatitis B and C are blood-borne viruses. Hepatitis B is highly infectious. It is estimated to be about 50 times more infectious than HIV. It is mostly spread by very close contact with an infected person, which allows exchange of minute quantities of blood through tiny grazes or cuts. This sort of spread can occur through:

  • Sex
  • Rough play amongst children
  • Rharing toothbrushes or razors
  • Direct contact with e.g. a bleeding wound.

More specific high-risk circumstances where the spread of hepatitis B can occur:

  • Tattooing or tribal scarification with unsterile implements
  • Between intra-venous drug abusers who share needles and syringes
  • Between patients and staff in hospital settings e.g. haemodialysis units
  • Potentially by blood transfusion. Since all blood donations are screened for Hepatitis B and C prior to use, the risk of acquiring viral hepatitis from a blood transfusion is low - in the region of 1 in 10 000 or less.

The ways that hepatitis C are spread are believed to be similar to hepatitis B, but it is far less infectious than the latter.

Hepatitis B and C can be passed from an infected mother to her baby. (See "complications").

Note that despite the fact that hepatitis B and C are found in the blood, there is no convincing evidence that they are spread by mosquitoes or other biting insects.

Apart from A, B and C, there are at least two more important hepatitis viruses:

  • Hepatitis D virus is only ever found along with hepatitis B; it cannot survive independently. Hepatitis D can worsen the hepatitis induced by hepatitis B.
  • Hepatitis E is an independent hepatitis virus. It is spread in a similar way to hepatitis A, though generally in waterborne outbreaks.

Occasionally, viruses that are not true hepatitis viruses can cause significant liver inflammation. It is not uncommon to have a mild hepatitis during glandular fever (Epstein-Barr virus) or during the similar illness cause by initial infection with Cytomegalovirus. Very, very rarely, and fairly unpredictably, Herpes Simplex virus can cause an aggressive form of hepatitis that is usually rapidly fatal.

When any of the hepatitis viruses reach the liver, they infect the liver cells and multiply inside them. The body's immune system can recognise virus-infected cells and will attempt to destroy these cells. This immune attack by white blood cells causes liver cell damage and inflammation. Certain enzymes that are usually active inside the liver cells are released from damaged cells into the blood and can be detected by blood tests, thus confirming that there is a hepatitis. The liver is also the site of production of certain blood proteins such as albumin and clotting factors, and levels of these proteins may be low in severe or long-standing hepatitis. Liver inflammation will also involve swelling of the liver. Swelling causes blockage of the bile ducts in the liver so that the bile that should flow into the gall bladder is trapped in the liver. Since it cannot escape, the yellow-green bile starts to be absorbed into the blood stream from the liver, and will circulate to the skin and eyes, causing the yellow discoloration known as "jaundice". Swelling of the liver is also what causes pain in the abdomen during hepatitis. (The liver is located in the right upper quarter of the abdomen). A health care professional will often be able to detect that the liver is enlarged and tender during examination of the abdomen.

Symptoms

Many people have no symptoms when they get infected with hepatitis A, B or C. In those who do develop symptoms, the hepatitis viruses tend to be slow in making themselves felt. After a person has become infected, hepatitis A will take about four weeks to cause symptoms, hepatitis B will take about three months and hepatitis C about two months on average.

The early symptoms of viral hepatitis are:

  • Loss of interest in food, especially fatty food
  • Distaste for cigarettes (if you are a smoker)
  • Loss of ability to drink any alcohol
  • Feeling unwell
  • Headache
  • Muscle aches
  • Fever
  • In the case of hepatitis B, joint pains (arthritis) and even a rash can occur.

In established viral hepatitis, symptoms are:

  • Nausea, with or without vomiting
  • Discomfort or pain in the right upper quarter of the abdomen
  • Urine that is an unusual dark reddish-brown
  • Faeces unusually pale in colour
  • A yellowish tinge to the whites of the eyes and the skin.

These symptoms can last for a week or two, or for several weeks or months, depending on the virus and the response of the person infected. In general, adults have worse symptoms and a longer period of symptoms. Pregnant women are at slightly increased risk of severe hepatitis A.

However, many people, especially children, will not be aware that they have ever had hepatitis or even that they have become chronically infected. They may only discover that they have been infected through a blood test. Long-standing viral hepatitis causes liver damage that will become evident through somewhat different symptoms to those above.

Complications

A small number of people (approximately 1 in 100) who get any one of the viral hepatitis viruses may have early severe liver damage at the outset of the illness. Much of the liver can be destroyed, and the person goes into liver failure. This is known as "fulminant hepatitis". Signs that this may be occurring include drowsiness that progresses to coma, and bleeding, usually in the gut. This is an extremely serious situation that will require the person to be cared for in an intensive care unit. This sort of liver failure carries a high risk of death.

The most frequent complication of Hepatitis B and C is that the virus is not cleared by the immune system, but persists in the liver. This is known as "chronic hepatitis". By definition, anyone who has not cleared a hepatitis B or C virus infection after 6 months has chronic viral hepatitis. Around 10% of people who get infected with Hepatitis B will go on to have chronic hepatitis, and with Hepatitis C the risk of chronic hepatitis is about 80%. Hepatitis A does not become chronic, as the virus does not have the capacity to persist.

Most people who become chronically infected with hepatitis B or C have no or few symptoms. They are sometimes referred to as hepatitis carriers and can transmit their infection to other individuals in close contact with them. Some people who become chronically infected with hepatitis B or C will have "chronic active hepatitis", which means that the inflammation is more marked and will cause symptoms of ongoing hepatitis, and will ultimately result in significant liver damage. The liver damage will progress more quickly or slowly depending on how active the infection and inflammation is. On average, serious liver damage from chronic hepatitis will take about 20 years to develop. The end result of ongoing liver damage is cirrhosis of the liver. A cirrhotic liver has undergone many cycles of scarring and re-growth so that it is lumpy, distorted and poorly functioning. Unfortunately, liver cancer is apt to develop in this sort of liver.

A well recognised complication of Hepatitis B is kidney disease. This is an indirect effect, probably due to clumps of virus and anti-virus antibodies being deposited in the kidney filtration system. In children the kidney disease may become apparent as "puffiness", with a swollen face and limbs. In adults the picture is somewhat different, and a common sign would be blood in the urine. Chronic hepatitis C can similarly be complicated by kidney damage.

Mother to child transmission of hepatitis viruses

Hepatitis B and C can be transmitted from an infected mother to her baby. This can happen while the baby is in the uterus, or, more often, during the delivery. The risk of transfer of hepatitis B to the baby is high, whereas in the case of hepatitis C the risk is fairly low. Around 90% of babies will acquire hepatitis B from their mothers if no measures are taken to prevent this. Because of the immaturity of the immune system in new-born babies, in the majority these perinatally acquired infections will become chronic. By comparison, only about 5% of babies acquire hepatitis C from their mothers. Fortunately, in the case of hepatitis B, there are effective ways to prevent mother to baby transmission, provided the mother is identified as being infected. (See Prevention)

Prevalence

Hepatitis A is common in all undeveloped parts of the world where it is mostly acquired by young children. A study in South Africa in 1994 showed that over 90% of black people had been infected with Hepatitis A by adulthood. By comparison, only about 50% of white adults had antibodies indicating past infection. This probably reflects the different socio-economic circumstances and therefore sanitary conditions available to these groups. In highly developed countries, exposure to Hepatitis A is low, with only 10% of adults having been infected. This puts travellers from developed countries at risk of acquiring hepatitis A when they travel to less developed countries.

Hepatitis B is widespread in sub-Saharan Africa and South Africa. In South Africa, up till now, hepatitis B has been particularly common in two age groups: young children and young sexually active adults. Past studies have found that almost 8% of infants less than one year of age and almost 16% of children less than 6 years of age have been infected with hepatitis B and have been unable to clear their infection and remain infectious carriers. Between 10-18% of South African adults are also hepatitis B carriers. Infection with hepatitis B is geographically distributed in South Africa and is more common in the Eastern Cape Province and Kwazulu-Natal. South Africa has had one of the highest rates of liver cancer in the world, and this is linked to the high rate of individuals chronically infected with hepatitis B virus. Since vaccination of all children against hepatitis B was started in 1995, it is hoped that the disease and its complications will soon become far less prevalent.

Hepatitis C infections are less common in South Africa, with around 1% of adults being infected. There is a cumulative risk of exposure over a life-time, and so more infections are seen in older age groups. Also, hepatitis C is more strongly linked to high-risk groups for blood-borne diseases.

Hepatitis D is found in several parts of the world where hepatitis B is prevalent, such as South America and the Mediterranean, but for some reason it is extremely rare in South Africa and therefore will not be discussed further here.

Hepatitis E virus is common in India and South East Asia, where it is recognised to occur in large outbreaks linked to contaminated water. There is some evidence that Hepatitis E occurs naturally in South Africa and neighbouring countries. So far the few definite cases of Hepatitis E in South Africa have occurred in persons who had recently travelled to India, and are therefore believed to have been "imported". Since Hepatitis E seems to be rare in South Africa, it will also not be discussed further here.

When to see a doctor

The symptoms of hepatitis described in Symptoms would require a visit to the doctor. The following are potentially serious symptoms which definitely require medical attention:

  • Persistent vomiting for longer than six hours
  • Extreme drowsiness, confusion or restlessness
  • Unusual bruising or bleeding
  • Jaundice continuing for longer than three weeks

Diagnosis

The symptoms of hepatitis and the fact that viral hepatitis is so common in South Africa will usually lead a health care professional to suspect the disease early on. Blood tests can be done to confirm that there is a hepatitis, and its severity, and these tests can even give some clues as to whether the cause is viral.

However, one cannot tell one type of viral hepatitis from another without specific tests for the different viruses. Laboratory diagnosis of hepatitis A and B requires very straightforward blood tests. In the case of hepatitis B, some additional tests are available that can give information about whether this is a recent or chronic infection, and about how active the virus is.

However, an early or recent hepatitis C infection may not be detected so readily since the usual test only becomes positive when antibodies are produced by the immune system several weeks or months into the illness. Therefore a specialised "PCR" test for the hepatitis C virus may be required in some cases.

A summary table of the tests used to diagnose hepatitis A, B and C; the most important tests are in bold.

TEST NAME            INTERPRETATION
Hepatitis A IgM antibody  if positive, indicates current or recent infection
Hepatitis A IgG antibody     in the absence of hepatitis A IgM antibody, indicates past infection with hepatitis A, and immunity.
Hepatitis B surface (s) antigen  if positive, the person has hepatitis B infection and is infectious
Hepatitis B early (e) antigen   indicates very active infection; the person is highly infectious
Hepatitis B early (e) antibody  usually indicates less active infection
Hepatitis B core IgM antibody usually indicates recent, rather than chronic infection
Hepatitis B core IgG antibody  found in anyone who is or has been infected with hepatitis B
Hepatitis B surface (s) antibody indicates immunity to hepatitis B
Hepatitis C antibody indicates infection either current or recent; but may be negative in early infection
Hepatitis C PCR if positive,indicates current infection

 

Treatment

Home

  • If the person with hepatitis feels unwell enough to be in bed, they should rest in bed. Otherwise, if there is no fever, normal activities can be continued.
  • A temperature of greater than 39 degrees Celsius can be treated with paracetamol. This drug should be used with caution because it is usually processed by the liver and this ability will be impaired in a person with viral hepatitis.
  • A person with hepatitis will probably be inclined to avoid fatty foods. Otherwise a regular diet can be followed. If their appetite is poor, then fruit juice and other liquids should be encouraged.
  • Avoid alcohol.

Medical treatments

An acute hepatitis (a new infection) is not given any specific treatment, because there is no effective treatment available. Recovery is dependent on the person's own immune response to the virus infection. Any of the different complications might require medical treatment in hospital. Even if a person appears to make a full recovery, in the case of hepatitis B and C, follow-up blood tests should be done to show whether the infection has been cleared or whether it has persisted as a chronic infection.

There are limited possibilities for the treatment of chronic viral hepatitis. Chronic active hepatitis is probably best managed by specialists who have experience with the few drug treatments available. Some drugs that are sometimes successful for managing or eradicating chronic viral hepatitis are interferon-alpha, lamivudine (for hepatitis B) and ribavirin (for hepatitis C). A liver transplant may be required to save a person with end-stage liver damage.

Sound general advice for those with chronic hepatitis B can be found at http://www.immunize.org/catg.d/p4120.htm

Prevention

A small percentage of people will die during severe early viral hepatitis and many more from the long-term consequences of chronic infection. As treatment possibilities are limited, avoiding viral hepatitis is most important.

The spread of hepatitis A is prevented by good sanitation systems, clean tap water and basic hygiene, such as washing one's hands after using the toilet, after changing a nappy and before preparing food. Virus is present in the faeces of an infected person from two weeks before symptoms begin to about a week after the start of the illness. A person with hepatitis A should not prepare food at home or at work. If your child has hepatitis A and attends a creche or school, the staff and parents should be notified so that preventive steps can be taken (see Prevention below).

If well, children can return to school and adults to work one week after the onset of hepatitis A, as they will no longer be significantly infectious.

In the case of hepatitis B or C, which take several months to clear from the blood, a person will probably be well enough to return to their normal activities before they become non-infectious. In this case, they should avoid any sort of contact with others that might pose an infection risk (see "cause"). Normal school activities (except for contact sports) or office activities do not pose a risk to others. Follow-up blood tests will show when a person has cleared the virus and is no longer infectious.

Advice on preventing the spread of blood-borne diseases, especially where children are involved, can be found at http://www.pkids.org/universal precautions.htm

Immunoglobulin for preventing hepatitis A and B

"Immunoglobulins" may be more familiarly known as antibodies. Immunoglobulin preparations are produced from donated blood. A proportion of blood donors will be immune to one or more of the hepatitis viruses, and their blood can be used to "harvest" anti-hepatitis immunoglobulin. The immunoglobulin, given by injection to another person, can provide provide them with "instant immunity" against the virus. This is used to protect people who have been exposed to hepatitis A or B and have not been vaccinated in the past. However, the immunoglobulin will not be effective if given too late after exposure when the virus has already established an infection. If you or your child have had known exposure to hepatitis A or B, your doctor would have to assess and discuss with you whether to use immunoglobulin. A common reason for the use of hepatitis A immunoglobulin is the protection of staff, parents and other children in a nursery school outbreak. Hepatitis B immunoglobulin can be used following any accidental exposure to hepatitis B, and is used to protect new-born babies when the mother is infected (see below). Immunoglobulin and a first dose of hepatitis A or B vaccine can be given simultaneously.

The "instant immunity" that a person receives from a dose of immunoglobulin will only last for a few months.

Vaccination

A vaccine against hepatitis A has recently become available. Because hepatitis A tends to be a mild disease in children and does not become chronic, it is not currently considered a high enough health priority for routine vaccination of children in South Africa. However, hepatitis A vaccination is recommended for the following groups:

  • Health care workers
  • Staff in centres where young children are cared for
  • Clients and staff in institutions for the mentally handicapped
  • Workers in the food industry
  • Travellers from countries with low rates of hepatitis A who will be visiting countries where hepatitis A is prevalent

The vaccine consists of hepatitis A virus grown in cell culture and then inactivated or "killed". The vaccine is given by injection in two doses at least one month apart.

In South Africa, vaccination against hepatitis B has been part of the routine childhood immunisation programme since 1995. The vaccine is given to children at the ages of 6, 10 and 14 weeks, along with the oral polio vaccine and "DPT" vaccine. (The other vaccines do not interfere with the hepatitis B vaccine, and there is no increased risk of side-effects when they are given at the same time.)

Up until 1995, hepatitis B vaccine was only given to people in high risk groups, particularly health care workers. Children and adults born before 1995 will probably not have been vaccinated against hepatitis B. It is advisable for young people who are homosexually or heterosexually active to be vaccinated against hepatitis B. When a person is a known hepatitis B carrier, it is important for all family/household members to be vaccinated against hepatitis B. In older children and adults, the vaccine is given in three doses, usually over six months. It is important that three doses of vaccine be given with at least one month spacing between them, in order for good immunity to be achieved.

No vaccine for hepatitis C has been developed as yet.

Preventing mother to baby transmission

The chance of hepatitis B transmission from a mother to her baby can be much reduced if immunoglobulin and vaccine are given to the baby at birth. The baby will then need two subsequent doses of vaccine and should be monitored to see if he or she has been successfully protected. Unfortunately, neither immunoglobulin nor vaccine is available for hepatitis C, but the risk of mother to baby transmission is naturally low.

Written by Dr Jane Yeats MBChB, BSc(Med)(Hons)Biochem, FCPath (SA)Virol Specialist and lecturer, Department of Virology, University of Cape Town and Groote Schuur Hospital.

Reviewed by Dr Eftyhia Vardas BSc(Hons), MBBCh, DTM&H, DPH, FC Path (Virol), MMed (Virol), Clinical Virologist, Director HIV AIDS Vaccine Division, Perinatal HIV Research Unit, Chris Hani Baragwanath Hospital, University of the Witwatersrand and senior lecturer, Department of Infectious Diseases, Faculty of Health Sciences, University of the Witwatersrand.

 
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