Hepatitis B

Hepatitis B infection is of two types based on the period between exposure to the virus and onset of initial symptoms. 

Acute infection

Acute infection is a common type of hepatitis B infection. However, in most of these cases, the infection is usually not severe and it takes time for the symptoms of hepatitis B infection to manifest. It takes one to four months from the time the virus enters the body to the onset of infection and then to the appearance of the first symptoms. If symptoms occur, they usually last for several weeks, but some people may have fatigue for as long as six months.

Chronic infection

A person is said to have chronic HBV infection if his/her blood sample shows the presence of an antigen known as hepatitis B surface antigen (HBsAg) for at least six months. Antigens are proteins found on the surface of HBV. Presence of HBsAg in the bloodstream is one of the earliest signs of HBV infection. 

Current studies support the concept of three distinct stages of HBV infection, which can be used to describe acute and chronic HBV infections. These are:

• First stage
  The first stage (“immune tolerant” phase) is the initial stage of the infection. There is evidence of the hepatitis B virus in the bloodstream, which can be detected by the presence of hepatitis B e antigen (HBeAg-a viral protein) in the blood. The serum levels of the liver enzyme transaminase are, however, normal at this stage (this enzyme is used to assess liver function). When a child or an adult has an acute HBV infection, this stage represents the incubation period before the body’s immune system responds to the HBV infection.
• Second stage
  In the second stage (“immune response stage”), the inflammatory process causes the destruction of HBV-infected cells, thereby increasing the transaminase levels. If this phase lasts for more than six months, then the infection is termed as a chronic HBV infection.
• Third stage
  The third stage (“inactive carrier state”) marks the end of active viral replication. In the blood, HBeAg is negative, hepatitis B e antibody (anti-HBe) is formed, and the transaminase levels become normal. A low level of the HBV genetic material may still be present. Most of the adults with acute HBV infection rapidly enter this stage.

The symptoms may vary depending on whether the infection is acute or chronic.

Acute hepatitis B

Symptoms of acute hepatitis B, if they appear, can include:

• General body aches and pains.
• A fever of 38⁰C (100.4 F) or above.
• A feeling of being unwell.
• Loss of appetite.
• Fatigue.
• Nausea.
• Vomiting.
• Abdominal pain.
• Dark urine.
• Clay-coloured or grey-coloured stools.
• Yellowing of the skin or the eyes (jaundice).

Chronic hepatitis B

Most people with chronic hepatitis B do not manifest any obvious signs and symptoms and may remain symptom-free for many years together. When symptoms do appear, they are similar to those of an acute infection. Symptoms may include an aversion to food, cigarettes, and intermittent, mild to moderate, right upper abdominal pain. Certain blood tests that account for the liver function may begin to show abnormal values at this stage. 

Causes

The hepatitis B virus spreads when a body fluid contaminated with the hepatitis B virus enters the body of another person who is not infected. The virus can spread by the following modes:

• During childbirth, hepatitis B can spread from an infected mother to her newborn baby.
• Unprotected sex with an infected partner.
• Direct contact of a healthy person with the blood or open wounds of an infected person.
• Getting a tattoo or body piercing in unhygienic conditions with unsterilized instruments.
• Medical/ dental treatment with non-sterilised equipment.
• Sharing needles, syringes, or other drug equipment.
• Blood transfusion using hepatitis B contaminated blood. This can happen in facilities where the blood is not tested for hepatitis B prior to transfusion.
• Sharing items such as toothbrushes, razors with an infected person.

Many people with hepatitis B virus infection are not aware that they are infected, as they might not show symptoms immediately. However, they may still spread the virus to others. 

Risk factors

People at highest risk of hepatitis B infection are as follows:

• Babies born to mothers who already have a hepatitis B infection.
• People born or raised in a country where an infection with hepatitis B virus is common.
• People with a history of any sexually transmitted disease (STD).
• Sexual partners of people infected with hepatitis B.
• Close contact with someone (such as a family member) who has a long-term (chronic) hepatitis B infection.
• Homosexual males.
• Health care and public health workers who are exposed to blood during routine medical, surgical, and sterilisation procedures.
• Drug addicts who share needles and syringes.
• Unprotected sex (inclusive of anal and oral sex).
• People with multiple sexual partners.
• Travellers visiting places where the infection is common.
• People who are on dialysis.

Hepatitis B is found throughout the world, but in certain areas, as mentioned below, it is more common:

• The Indian subcontinent
• Some parts of South America
• Middle East
• East and Southeast Asia
• Pacific Islands
• Sub-Saharan Africa
• Southern parts of central and eastern Europe 

For hepatitis B prevention, hepatitis B vaccine is the mainstay. WHO recommends hepatitis B vaccination of all infants, immediately after birth, preferably within 24 hours.

In most cases of HBV infection, one of the following two schedules is followed:

Three-dose schedule

• The first dose is to be given when the child is born.
• The second and third doses are to be given along with the first and third doses of DPT vaccine (diphtheria, whooping cough, and tetanus vaccine).

Four-dose schedule

• A dosage at birth is followed by three monovalent or combined vaccine doses and is commonly given with other routine vaccines for infants.
• The protection acquired through this vaccine lasts for at least 20 years. In most cases, the protection against HBV is life-long. WHO does not recommend any booster vaccination.

Apart from vaccination, there are other easy ways to help stop the transmission of hepatitis B:

• After any exposure to blood, thoroughly wash your hands with soap and water. See your physician immediately to prevent infection and get immunised. If possible, take the person along whose blood your skin got exposed to.
• Always use protection during sexual intercourse. Do not have unprotected sex unless you are very sure that your partner is not infected.
• Ensure that new sterile needles are used for tattoos, acupuncture, or body piercing.
• Avoid direct contact with blood and bodily fluids of an unknown person.
• Clean blood spills with a fresh bleach solution diluted in water in the ratio 1:9.
• Cover all cuts carefully.
• For blood transfusions, always opt for certified facilities that screen blood for hepatitis B and other blood-borne infections.
• Avoid sharing of sharp items like toothbrushes, razors, earrings or body rings or nail clippers.
• Discard sanitary napkins/tampons after double wrapping them in a paper.
• Stay away from drug abuse.
• If you are traveling to a region where hepatitis b is common, ask your doctor about taking the hepatitis B vaccine.

Hepatitis B and pregnancy

When a woman is pregnant, it is recommended that she should be screened for HBsAg, (hepatitis B surface antigen) irrespective of previous test results or vaccinations. The chances of transmission of hepatitis B during amniocentesis (a test to detect genetic disorders, chromosomal abnormalities in the baby prior to its birth) are low. Women with chronic hepatitis B can continue breastfeeding if the infant receives HBIG (Hepatitis B Immunoglobulin) passive prophylaxis and vaccine active prophylaxis.

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Apart from a detailed medical history and symptomatic assessment, your doctor will advise you to take certain tests to aid in diagnosis.

Blood tests

• Liver function tests
  These are a set of tests for liver enzymes and blood proteins, which help in assessing the liver function. These tests include:
  • Alanine aminotransferase (ALT)
  • Aspartate aminotransferase (AST)
  • Albumin
  • Serum bilirubin
  • Alkaline phosphatase
  • Prothrombin time
  • Alpha-1 antitrypsin
  • 5' nucleotidase
  • Gamma-glutamyl transpeptidase (GGT)
• Hepatitis B Surface Antigen (HBsAg)
  It is a protein on the surface of the hepatitis B virus and is detected in the blood in case of acute or chronic hepatitis B infection. A positive result means that the person has an infection by the hepatitis B virus and is capable of passing the virus to others.
• Hepatitis B Surface Antibody (anti-HBs)
  It is an antibody that is produced against HBsAg as part of the body’s normal immune response. A positive test means that the person is protected from infection or is immune because he was previously vaccinated against the virus or has recovered from an acute infection and hence cannot get hepatitis B again.
• Total Hepatitis B Core Antibody (anti-HBc)
  It is an antibody produced by the body in response to the hepatitis B virus “core antigen". A positive test means a person is either presently infected with the hepatitis B virus or was infected in the past.
• IgM Antibody to Hepatitis B Core Antigen (IgM anti-HBc)
  It is used to identify acute infection. A positive test means the person was infected with the hepatitis B virus in the last six months.
• Hepatitis B e Antigen (HBeAg)
  It is a protein found in the blood that is present during an active hepatitis B infection. A positive test means that the person has high levels of virus in the blood and can easily spread the virus to others.
• Hepatitis B e Antibody (HBeAb or anti-HBe) 
  It is an antibody that is produced by the body in response to the “e” antigen of the hepatitis B virus. A positive test means that the person has chronic hepatitis B virus infection but has a low risk of developing liver problems due to low levels of the virus in the blood. However, the person can spread the infection to others.
• Hepatitis B Viral DNA 
  This test detects the presence of hepatitis B virus DNA in a person’s blood. A positive test means that either the virus is multiplying in a person’s body and hence, the person is highly contagious or that he/she is at an increased risk of liver damage if he/she has chronic hepatitis B infection.

Imaging tests

Liver ultrasound may be performed to see the extent of liver damage.

Acute hepatitis B  
In acute infection, management is mostly supportive and aims at restoring the overall health of the person. Usually, medicines are not prescribed. Doctors recommend adequate nutritional balance, hydration, and rest.

Chronic hepatitis B
A chronic infection is usually treated with oral antiviral medicines like tenofovir or entecavir. Treatment aims to prevent or slow down the development of cirrhosis and to reduce the chances of progressing to liver cancer. The treatment only suppresses the replication of the virus. It does not bring about the cure. Therefore, most people must continue to take treatment life-long.

Lifestyle management

There are many lifestyle changes that can help people to manage hepatitis b infection more effectively. Here are some tips:

• Avoid alcohol and smoking as both can damage the liver, which is already injured by the hepatitis B virus during HBV infection.
• Before you start taking any herbal remedies or vitamin supplements, it is important to consult your doctor because some of these alternative treatments could potentially cause liver damage or even interfere with your prescribed drugs.
• Do not take any over-the-counter drugs (for example, paracetamol) without consulting your doctor as many of these drugs are processed by the liver and may cause damage to it.
• Avoid eating raw or undercooked shellfish like scallops, mussels, or clams as they have bacterial contamination by an organism called Vibrio vulnificus, which is very toxic to the liver.
• Avoid inhalation of strong fumes like from paint thinners, household cleaning products, nail polish removers, as they are potentially toxic.
• Have a healthy diet consisting of lots of vegetables and fruits, whole grains. Cabbage, broccoli, and cauliflower particularly have a protective action on the liver.
• Look out for moulds on nuts, corn, groundnut, sorghum, and millet before using them. Presence of moulds indicates the presence of “aflatoxins” which are harmful to your liver.
• Exercise regularly.
• Protein, fluid and salt intake must be controlled based on the severity of the disease to a level such that they do not worsen liver inflammation.

Prognosis

• Acute hepatitis B 
  Most people recover completely and develop life-long immunity. Around 1% of people with acute HBV infection develop acute liver failure.
• Chronic hepatitis B 
  Most people who develop chronic HBV infection have minimal symptoms. The outcome is better in children as compared to adults, but as it is a long-term liver infection, it may lead to liver failure, cirrhosis, and liver cancer.

Complications

Complications related to hepatitis B infection occur if a chronic HBV infection is left untreated. These complications include:

• Cirrhosis (liver scarring)
  Symptoms usually appear only after extensive liver damage happens. Some of the symptoms are as follows:
  • Fatigue.
  • Itchiness of skin.
  • Loss of appetite.
  • Loss of weight.
  • Feeling sick.
  • Pain or swelling in the abdomen.
  • Ankle swelling.

Though there is no cure for cirrhosis, it is possible to slow-down its progression. A liver transplant may be required in case of severe liver damage.

• Liver cancer
  There is a 1 in 20 chance of developing liver cancer in people suffering from cirrhosis due to hepatitis B. The symptoms include:
  • Loss of appetite.
  • Weight loss.
  • Easy satiety.
  • Feeling unwell.
  • Jaundice.
• Fulminant hepatitis B
  Less than 1 in 100 cases of acute hepatitis B can develop fulminant hepatitis B, which can lead to:
  • Collapse.
  • Confusion.
  • Fluid accumulation in the abdominal cavity (ascites).
  • Severe jaundice.
  • Disturbed sleeping pattern.
  • Coma.
  • Bleeding in the digestive tract and other organs due to a reduced blood-clotting function of the liver.
  • Hepatic encephalopathy, which is a psychiatric condition seen in people with an advanced liver disease where the brain function deteriorates severely

Hepatitis means swelling or inflammation of the liver. When the liver gets inflamed, many of its functions get affected, as most liver functions are interrelated. When the hepatitis B virus infects the liver, the condition is called hepatitis B infection.

Globally, hepatitis B virus (HBV) infection is a significant health problem. According to the studies conducted by the World Health Organization (WHO), over 2 billion people have been reported to be infected with hepatitis B virus. Out of these, approximately 24 crore individuals have chronic liver infections. Every year, more than 7,80 000 people die due to acute or chronic hepatitis B infection.

India accounts for one-fifth of the global population, hence, a large proportion of the worldwide HBV burden is found in India. 10-15% of the worldwide HBV carriers are found in India. Studies estimate that India has around 4 crore HBV carriers.