 Hepatitis
B
Click here for a glossary
of terms to help you understand the words used
here and by your doctor.
How
many people are affected by hepatitis B?
What happens after infection?
Symptoms of hepatitis B
How is hepatitis B transmitted?
How can hepatitis B infection be prevented?
Diagnosis of hepatitis B
Hepatitis B Management
Hepatitis B Treatment
Patient assistance
Hepatitis B and pregnancy
Hepatitis B in men who have sex with men
(MSM)
Tattoos and Hepatitis B
HIV and HBV
Updated: Nov 2011
The information provided here was compiled
from reputable sources including the U.S. Centers for Disease
Control and Prevention (CDC), the World Health Organization
(WHO) and peer reviewed medical journals. If you have questions
or concerns about this information, please contact HepTREC.
Hepatitis B is caused by the hepatitis B
virus (HBV). The virus primarily affects the liver. The infection
can cause quick, life-threatening liver inflammation, but
this is very rare. For most people, hepatitis B infection
is not noticeable. Even though the infection is not noticeable,
it may lead to slow, progressive liver damage. The liver
damage can include inflammation, liver scarring (fibrosis),
severe liver damage (cirrhosis), and even liver cancer (hepatocellular
carcinoma). Hepatitis B is the leading cause of liver cancer
and 10th leading cause of death in the world. To learn more
about the liver and monitoring liver health, visit the resources section
of this website. Being diagnosed with hepatitis B can be
upsetting, but the good news is that most people with chronic
hepatitis B can expect to live a long and healthy life.
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How many people are affected by
hepatitis B?
According to the CDC, HBV infects 10 to
30 million people worldwide each year and more than 400 million people have chronic hepatitis B infections. Some areas of the world,
particularly parts of Asia , Africa and South America , have
high rates of hepatitis B infection. In areas with high rates
of hepatitis B, most new infections occur in newborns.
More than 1 million Americans are chronically
infected with hepatitis B. Each year 100,000 new infections
occur and five thousand Americans die as a result of hepatitis
B infection. In the U.S. , doctors screen pregnant women
for hepatitis B and if the woman is infected, they make effort
to prevent infection of the baby. Maternal screening and
recommendations to vaccinate all children have significantly
reduced hepatitis B infections in children. Today, the majority
of new infections in the U.S. occur in young adults.
Tenofir (Viread) is the most recent oral medication (a pill) to be FDA-approved (2008), and is currently the most potent oral drug to treat hepatitis B. The virus rarely develops resistance and has few, if any, side effects.
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What happens after infection?
Hepatitis B is often called a "silent
infection" because many infected people have no noticeable
symptoms. When a person is first infected, it is called an ‘acute’ infection.
Some people are able to fight off the virus in the first
few months and get better. If the virus is detectable in
the blood for more than six months, the person is considered
to have a ‘chronic’ infection. The risk of developing
a chronic hepatitis B infection is directly related to the
age at which one becomes infected with the virus. According
to the World Health Organization (WHO):
- 90% of infants exposed to the hepatitis
B virus will develop chronic infections.
- About 50% of exposed children (ages of
1 to 5 years) will develop chronic infections.
- 5-10% of healthy adults who are infected
will develop chronic infection.
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Symptoms of hepatitis B
Most people with hepatitis B have NO symptoms.
They have no idea that they are infected until they see signs
of severe liver damage or a healthcare providers does a hepatitis
B blood test. If symptoms do occur, they can vary in type
and severity.
Common symptoms include:
- Fever
- Fatigue (extreme tiredness)
- Muscle and joint pain
- Nausea and vomiting
Rare Symptoms include:
- Severe nausea and vomiting that could
lead to dehydration
- Jaundice (yellowing of the skin and eyes,
dark urine)
- Bloated or swollen abdomen or stomach.
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How is hepatitis B transmitted?
Hepatitis B is transmitted from person-to-person
through contact with infected blood or infected bodily fluids.
Hepatitis B virus is very infectious- meaning if you are
exposed to the virus, you are likely to be infected.
Transmission of HBV can occur during:
- Unprotected sex
- Birth -from an infected woman to her
newborn
- Direct blood-to-blood contact
- Use of unsterile needles for drug use,
tattoos, piercing and acupuncture
- Sharing razors
- Sharing toothbrushes
- Sharing pierced earrings
- Unsterile medical equipment
HBV is NOT transmitted through casual contact
like coughing, sneezing, hugging, or eating.
Due to the modes of transmission, the following
groups are considered at increased risk for hepatitis B infection
and should be tested for HBV:
- Health care workers and emergency personnel
- Infants born to mothers who are infected
at the time of delivery
- People living in close household contact
with an infected person
- Individuals with multiple sex partners,
past or present
- Individuals who have had unprotected
sex with a potentially infected person
- Individuals who have ever been diagnosed
with a sexually transmitted disease
- Illicit drug users (injecting, inhaling,
snorting, popping pills)
- Men who have sex with men
- Individuals who received a blood transfusion or organ transplant
prior to 1992
- Individuals who get tattoos or body piercing
- Individuals who travel to countries where
hepatitis B is common ( Asia , Africa , South America ,
the Pacific Islands , Eastern Europe , and the Middle East
)
- Individuals born to parents who emigrated
from these areas (see map above)
- Families adopting children from areas
where hepatitis B is common (see map above)
- Individuals with kidney disease or undergoing
kidney dialysis
- Individuals who use blood products for
medical conditions (such as hemophilia, sickle cell disease, hemochromatosis or cancer)
- Residents and staff of correctional facilities
and group homes
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How can hepatitis B infection be
prevented?
The best way to prevent infection is vaccination.
Avoiding exposure to infected blood and bodily fluids can
reduce the risk of acquiring a hepatitis B infection. The
hepatitis B virus is a tough, hardy virus. It can remain
infectious outside the body, even in dried blood or body
fluids, for days.
Hepatitis B vaccine
Hepatitis B vaccine is safe, effective and
available for children and adults. Three doses of the vaccine
are required for optimal protection. The schedule for the
vaccinations is:
- First Injection - At any given time
- Second Injection - At least one month
after the first dose
- Third Injection - Six months after the
first dose
If the schedule is interrupted, it can be
resumed at any time. There is no need to restart the series.
There is an accelerated 4 month vaccination schedule that
is sometimes used for travelers or healthy adolescents.
The CDC recommends that all infants be vaccinated.
Most school districts require proof of hepatitis B vaccination
prior to school entry. Some colleges and universities also
require proof of vaccination. Medical and nursing schools
require HBV vaccination and most hospitals require proof
of vaccination for new nurses, doctors, and laboratory workers.
The vaccine doesn’t help those already infected by
hepatitis B. It also won’t hurt.
Everyone is at some risk for infection, so
everyone should discuss HBV vaccination with a healthcare
provider. As a general guide, the following people should
be vaccinated against HBV:
- All infants at birth and all children
up to age 18.
- Health care professionals and emergency
personnel.
- Sexually active teens and adults.
- Men who have sex with men.
- Sex partners or close family/household
members living with an infected person.
- Families considering adoption, either
domestic or international.
- Travelers to countries where hepatitis
B is common ( Asia , Africa , South America , the Pacific
Islands , Eastern Europe , and the Middle East ).
- Patients with kidney disease or undergoing
dialysis.
- Residents and staff of correctional facilities
and group homes.
Insurance companies usually cover the cost
of vaccines for infants, children and SOME adults. There
is a federal program to help cover the cost of children's
vaccines. Contact your local health department about the
vaccines for children program (VFC). For adults, insurance
providers may require that healthcare providers indicate
a risk factor for HBV in order to be reimbursed for the vaccination.
Some patients are not comfortable disclosing this information.
Insurance companies may not cover the cost of vaccination
for travelers and those with occupational risk for infection
(such as healthcare workers and emergency personnel). These
individuals should ask their employer about receiving the
hepatitis B vaccine or consider paying for the vaccine themselves.
The vaccine is certainly less expensive than an HBV infection!
If a person has a risk factor or wants to be vaccinated,
they should ask their doctor or contact a local health department.
Remember that hepatitis B vaccine does not
protect against hepatitis A or hepatitis C viruses!
Reduce exposure to the virus
You can also prevent infection by minimizing
or eliminating exposure to infected blood and bodily fluids.
- Practice safer sex- use condoms, don’t
touch sexual fluids
- Do not touch other’s blood. Wear
latex or rubber gloves. Use universal precautions!
- NEVER share needles or any injection
drug equipment
- Get only sterile, professional tattoos,
piercings, and acupuncture
- Cover all wounds
- If you believe you may have been exposed
to the virus, call your doctor or health department immediately
- they can help prevent infection.
- Report any occupational needle sticks
to health officials immediately
- Follow first aid guide in the Resources section
of this website.
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Diagnosis of hepatitis B
A simple blood test can diagnose hepatitis
B infection. The tests must be ordered by a healthcare provider
and usually providers order the test only if aware of a particular
risk factor or a patient has symptoms of liver disease. This
makes it is important to discuss potential risk factors for
infection with a healthcare provider. Patients may need to
specifically request a test if they believe they may be infected.
In The U.S., all pregnant women, as well as people emigrating to the U.S from countries where hepatitis B is common should be tested for hepatitis
B.
Laboratory tests for hepatitis B
Since some people with acute infections
are able to fight off the virus, people with one positive
HBV test are usually tested again 6 months later to see if
they fought off the virus or are chronically infected. Interpreting
the blood tests can be confusing, even for doctors and nurses.
Anyone tested for hepatitis B should request a copy of the
laboratory report and discuss it carefully with a healthcare
provider. Important terms that appear in hepatitis B lab
reports include:
Antigen - a foreign substance in
the body, such as proteins of the hepatitis B virus.
Antibody - a protein made by the
immune system in response to antigens. Different types of
antibodies (IgM - produced in response to a new exposure,
and IgG - produced for long-term, lasting immunity) are often
considered in hepatitis B tests.
The following antigens and antibodies are
considered in the diagnosis of hepatitis B:
• HBsAg (hepatitis B surface
antigen): A specific antigen found on the surface of the
hepatitis B virus. A "positive" or "reactive" test
indicates a current, active hepatitis B infection. This
antigen is the earliest indicator of acute hepatitis B
and frequently identifies infected people before symptoms
appear. HBsAg disappears from the blood if the infected
person successfully fights off the infection.
• HBcAg (hepatitis B core antigen):
A specific antigen found on the hepatitis B virus. The
core antigen is found on virus particles but not in the
hepatitis B vaccine. Presence of this antigen indicates
a current infection.
• Anti-HBs [or HBs-Ab] (antibody
to hepatitis B surface antigen): The body produces this
antibody when exposed to the hepatitis B surface antigen.
A positive test can indicate a previous infection or successful
vaccination. The antibody also protects the body from future
HBV infection.
• Anti-HBc [or HBc-Ab] (antibody
to hepatitis B core antigen): The body produces this antibody
when exposed to the hepatitis B virus core antigen. A "positive" or "reactive" test
may mean the person has had contact with HBV. There are
false positives for this test, so interpretation usually
depends on the results of the other HBV tests. Vaccination
will NOT result in production of Anti-HBc antibodies. So,
this test can help distinguish between previously infected
and previously vaccinated individuals. Blood banks routinely
run the anti-HBc test rather than the anti-HBs test.
If a person is diagnosed with a hepatitis
B infection, additional tests may be performed. These tests
will measure the ‘amount’ of virus present in
the blood, and look for hepatitis B e-antigens and antibodies.
Information about e-antigens and antibodies is sometimes
used in treatment decisions.
• HBV DNA: This tests looks for
DNA of the hepatitis B virus in the blood. The test is
usually used in conjunction with the diagnostic tests mentioned
above. It is often used to monitor antiviral treatment
in patients with chronic HBV infections.
• HBeAg (Hepatitis B e-antigen):
The e-antigen is only found in the blood when HBV virus
is present in the blood. In treatment of strains that do
make e-antigen, some doctors will monitor treatment effectiveness
by measuring HBe-antigen. Some types (strains) of HBV do
not make e-antigen; these strains are especially common
in the Middle East and Asia .
• Anti-HBe [HBe-AB] hepatitis
B virus e antibodies: The body produces this antibody when
exposed to the hepatitis B e antigen. Some doctors look
for the presence of this antibody to determine if treatment
is successful.
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Hepatitis B Management
Being diagnosed with hepatitis B can be
upsetting, but the good news is that most people with chronic
hepatitis B can expect to live a long and healthy life. There
is much to consider in the management and treatment of hepatitis
B and new advances occur each year. Finding a doctor that
is up-to-date and easy to communicate with is essential. Ideally the physician should be one who specializes in diseases of the liver.
HBV infection can lead to liver damage.
The virus causes inflammation (irritation and swelling) of
the liver. Over time, the inflammation results in scarring.
Scar tissue can build up over many years and interfere with
liver functions, blood flow through the liver, and result
in death of liver cells. Extensive scarring of the liver
is called cirrhosis. The best ways to check for liver damage
are liver function blood tests and liver biopsies. Ultrasound
tests are frequently used to screen for liver cancer. Please
review the sections of this website about liver functions
and liver damage. Liver damage is the primary reason we are
concerned about HBV.
Since people with hepatitis B likely have,
or will have, some liver damage from their infection, it
is VERY important to prevent additional liver damage. Many
substances can irritate or damage the liver. In people with
healthy livers, they are usually not a big problem, but people
who have chronic hepatitis B need to be extra careful. Remember
that all substances ingested, inhaled, or absorbed through
the skin will pass through the liver. Some things that patients
can do to reduce the possibility of additional liver damage
include:
• Avoid alcohol! Alcohol will
accelerate liver damage (see the hepatitis and alcohol
document in the resources section of the website)
• Get tested for hepatitis
A and, if susceptible, get vaccinated!
• Get tested for hepatitis
C
• Maintain a healthy body
weight
• Eat a healthy, balanced
diet - excess fat can impact the liver
• Remember the rest of your
body. Get regular check ups
• Talk to a doctor about
all medications used (including prescription, over-the-counter,
and herbal medications). Some may interact to damage the
liver.
• Avoid toxic chemicals
at home and in the workplace. (including herbicides, pesticides,
and some cleaning products) Wear protective clothing if you
use them.
• See a doctor regularly
to be monitored for liver damage and liver cancer. Early
diagnosis is essential!
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HBV Treatment
Today, there are no complete ‘cures’ for
chronic hepatitis B. There are “six” FDA approved drugs for adults, five oral and one injectable, two approved drugs for children, and a number of
new drugs under development. These medications are designed
to reduce the amount of virus in the body either by boosting
the immune response or by interfering with replication of
the virus. Reducing the amount of virus decreases the risk
of liver damage from hepatitis B and can even help the liver
recover from damage.
It is important to recognize that not everyone
with hepatitis B needs to be on medication. Each treatment
has risks and benefits, or pros and cons. Treatment decisions
should be made on an individual basis. It is important to
discuss the pros and cons with a doctor knowledgeable about
hepatitis B treatment. Each person has a unique medical history
and personal preferences. These should be considered when
making treatment decisions.
Medications FDA approved as of November 2011:
Lamivudine (Epivir-HBV, Zeffix, or Heptodin)
is an oral medication (a pill) taken once a day. Treatment
usually lasts one year or longer. While there are almost
no side effects, the virus frequently becomes resistant to this drug and possibly others that work by the same mechanisms, within the first year. FDA approved this drug
for use in hepatitis B in 1998.
Adefovir dipivoxil (Hepsera) is an oral
medication (a pill) taken once a day. Treatment usually lasts
for a year or longer. There are few side effects, the most
serious side effect is potential kidney problems, so doctors
need to monitor patients carefully. FDA approved the use
of this drug for hepatitis B treatment (in adults) in 2002.
Entecavir (Baraclude) is an oral medication
(a pill) taken once a day. Treatment typically lasts for
one year. There are few, if any, side effects. FDA approved
this drug for hepatitis B treatment (in adults) in 2005.
Telbivudine (Tyzeka) is an oral medication (a pill) taken once a day. There are few if any side effects. The FDA approved this drug for hepatitis B treatment in 2007. Tyzeka is an FDA category B drug and can be given during pregnancy, but is not recommended during breast feeding. Also it should be used with caution in patients with significant kidney disease.
Tenofir (Viread) is the most recent oral medication (a pill) to be FDA-approved (2008), and is currently the most potent oral drug to treat hepatitis B. The virus rarely develops resistance and has few, if any, side effects.
Pegylated Interferon (Pegasys) is a modified
version of interferon. Pegasys is also administered by injection,
but only one injection per week is required. Treatment typically
lasts 6 months to one year. The drug can cause side effects
such as flu-like symptoms, and depression.* FDA approved
use of Pegasys for hepatitis B (in adults) in 2005.
Combination Therapies (using 2 or more drugs together)”. “Some liver specialists may prescribe several drugs together which have different mechanisms of action for patients with high levels of virus in their bloodstream. These drugs are used for at least a year or longer and have few, if any, side effects.
‘Off-label’ drugs. Some doctors prescribe drugs that have not been FDA approved for the specific use. Typically, the drugs are available and approved for other uses. Such medications may not be covered by insurance and patients should discuss such treatments carefully with their doctor.
Managing side effects of interferon therapy
Interferon therapy can be very effective
in the treatment of chronic hepatitis B. Interferon can produce
side effects in some people and at this time, we have no
way to predict who will and who will not experience side
effects. The number and severity of side effects vary from
person to person. Side effects range from very mild and slight
discomfort, to moderate effects that are inconvenient, to
severe side effects that can lead to temporary disability.
Most side effects can be prevented or managed, so don’t
let fear of side effects prevent you from considering the
option of interferon therapy.
Early Side Effects
• Flu-like (Inflammatory) symptoms
including fever, chills, body aches, headache, and nausea.
TIPS: Taking anti-inflammatory medications
like Ibuprofen and Naproxyn BEFORE the interferon can help
prevent these symptoms. Taken at anytime, these medications
can help reduce the flu-like symptoms. Also, staying hydrated
can help reduce side effects. DRINK PLENTY OF WATER. Avoid
caffeine and other diuretics.
Persisting Side Effects
The side effects that appear later in interferon
use can be difficult to deal with. They usually begin a couple
of weeks or several months into treatment. The side effects
are usually not severe enough to stop therapy and these side
effects can be relieved with use of other medications. Talk
with a doctor about the side effects and try not to reduce
or stop therapy.
• Thinning hair or change in
hair texture – this effect is temporary and stops
when therapy is over.
• Weight loss – this effect
will also stop when treatment is over. Make sure to eat
a healthy diet when on therapy!
• Neutropenia (suppression of
neutrophils, a type of white blood cell). Neutrophils are
a very important part of the immune system. Medications such as Neulasta (one time injection as needed) and Neupogen (daily injections for a week as needed) can help manage neutropenia.
• Depression – interferon
therapy can cause depression as well as depression-related
symptoms like insomnia, irritability, fatigue, crying episodes,
and loss of appetite. Anti-depressants work very well against
interferon-induced depression. Some doctors recommend taking
an antidepressant BEFORE starting interferon treatment.
This should prevent depression from occurring. The dose
of antidepressants can be modified to handle depression
symptoms. If serious depression occurs, it helpful to work
with a psychologist or psychiatrist.
New medications for hepatitis B are under
development. The Hepatitis B Foundation, a nonprofit organization,
provides a listing of approved drugs and clinical trials
for new hepatitis B medications on the HBF Drug Watch section
of their website (www.hepb.org). To learn more about how
clinical trials are conducted, Visit the National Institutes
of Health at www.clinicaltrials.gov.
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Patient assistance
There are numerous organizations offering
assistance and support for people with hepatitis B and those
who just want to learn more about hepatitis B. Patient assistance programs offered by pharmaceutical companies are listed below while additional hepatitis B information can be found in the resources section of the website.
Gilead
Bristol-Myers Squibb
Novartis
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Hepatitis B and Pregnancy
The hepatitis B virus can be transmitted
from mother to infant during birth. Previously in this section
we described how age at infection is related to the likelihood
that the body can fight off the infection. Infants infected
at birth are likely to remain infected throughout their lives.
Because of this fact and the availability of vaccines and
medication to prevent infection, all pregnant women in the
US should be screened for HBV.
If a pregnant woman tests positive for HBV,
her healthcare provider and the health department will contact
her about ways to prevent transmission to her baby and to
other family members. The woman may be started on a drug such as telbivudine which is thought to be safe during pregnancy. All family members should be screened for HBV, and if susceptible, vaccinated against hepatitis B. Family members will likely be screened
for HBV and if they susceptible, they will be vaccinated
against hepatitis B. When the baby is born, it should receive
hepatitis B vaccine immediately and perhaps anti-HBV immunoglobulin
as well. These precautions prevent almost all transmission
of HBV to babies. This tool kit contains a CDC produced handout
about HBV and pregnancy.
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Hepatitis B in Men Who Have Sex with
Men (MSM)
Hepatitis B virus can be sexually transmitted.
It is present in both blood and semen. HBV is reportedly
100 times more infectious than HIV, so it is easier to catch.
The CDC reports that 1 in 3 MSM are exposed to HBV by the
age of 29. An HBV-infected man can spread the virus to another
person by:
• having unprotected anal or
vaginal sex
• coming in contact with semen
from used condoms
• sharing needles for drugs,
piercing, or tattooing
• coming in contact with the
infected person's open sores or blood
• sharing toothbrushes, razors,
nail clippers, etc.
• biting another person
The CDC and other health official recommend
hepatitis B (and hepatitis A) vaccination for all MSM. Vaccination
for MSM should be covered by insurance companies (though
disclosure of MSM status may be required) and is also available
at most public health departments.
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Tattoos and Hepatitis B
HBV infection can occur when blood or bodily
fluids from an infected person get under the skin of another
person. Since blood is present during the tattooing process,
it is possible to be infected with HBV while getting or giving
a tattoo.
HepTREC recommends using only professional,
commercial tattoo galleries that follow safety procedures.
BEFORE getting a tattoo, talk to the staff about safety.
Check to make sure that the establishment:
• Is clean and surfaces are disinfected
• Uses a new, sterile needle
for each client
• Uses separate ink pots for
each client
• Does NOT put ink from used
pots back in the bottle
• Uses new, clean latex gloves
for each client
• Sterilizes all equipment that
is in contact with clients
• Covers new tattoos with a fresh,
sterile bandage
• Disposes of all materials properly.
HepTREC believes all people should avoid
street and prison tattoos. It is difficult or impossible
to sterilize tattoo ink and equipment in prisons, jails,
on the street, or at home. HBV, HCV, and HIV can be transmitted
in very small, invisible amounts of blood.
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HIV and HBV
Because HIV and HBV are spread in similar
ways, most people with HIV have been exposed at some time
to HBV. Depending on geographic location, 8-11% of HIV patients
are also infected with HBV. Now that people with HIV are
living for long periods of time, the hepatitis B virus has
time to slowly attack the liver. A significant percentage
of HIV-positive people are hospitalized with or die from
liver disease related to HBV infection.
Generally, people with HIV have weakened
immune systems and may not be able to fight the HBV virus
as well as people without HIV. The result is that people
co-infected with HIV and HBV may develop HBV-related liver
disease more quickly, may have more extensive scarring of
the liver, and may be more likely to develop liver cancer
than people infected with HBV alone.
Since such a large proportion of HIV patients
also are HBV positive, more and more healthcare providers
are learning how to help their patients stay healthy and
alive with HBV. Many of the medications used to treat HIV
are also effective against HBV. Some HIV medications, however,
may damage the liver. It is important for HIV providers to
consider possible liver damage when prescribing medications.
People with HIV/HBV co-infection should:
•Receive tests for and/or vaccinations
against hepatitis A
•Get tested for hepatitis C
•Limit or eliminate alcohol use
•Take steps to prevent the spread
of HIV and HCV
The journal article in Clinical Infectious
Diseases by M. Nunez provides more detail about treatment
of HBV/HIV co-infected patients. (Nunez M et al. Treatment
of Chronic Hepatitis B in the Human Immunodeficiency Virus-Infected
Patient: Present and Future. Clin Infect Dis 2003;37:1678-1685).
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