HEPATITIS B

ESSENTIALS OF DIAGNOSIS

- Caused by hepatitis B virus (HBV)

- Acute illness is often asymptomatic
- Can lead to chronic carrier state—more likely if acquired earlier in life
- Treatment of acute illness is supportive
- Vaccination available
- Hepatitis B immunoglobulin indicated for post-exposure prophylaxis along with
vaccination

I) Pathogenesis
Hepatitis B is caused by infection with hepatitis B virus (HBV), an hepadnavirus.
The incubation period is 6 weeks to 6 months. Concentration of HBV is highest in blood,
with lower concentrations found in other body fluids such as wound exudates, semen, vaginal
secretions, and saliva.
HBV is more infectious and relatively more stable in the environment than other blood-borne
pathogens such as hepatitis C virus (HCV) and HIV.
HBV is transmitted by percutaneous or mucous membrane exposure to blood or body fluids
that contain blood. The primary risk factors associated with infection among adolescents and
adults are unprotected sex with an infected partner, history of other STDs, and illegal
injected-drug use. HBV is a reportable disease.

II) Prevention
Two products are available for hepatitis B prevention: hepatitis B immune globulin (HBIG)
and hepatitis B vaccine. HBIG provides temporary (3–6 months) protection from HBV
infection and is typically used as post-exposure prophylaxis, either as an adjunct to hepatitis
B vaccination in previously unvaccinated persons or alone in persons who have not
responded to vaccination. HBIG is prepared from plasma known to contain
high concentrations of anti-HBs. The recommended dose of HBIG is 0.06 mL/kg.
Hepatitis B vaccine contains hepatitis B surface antigen (HBsAg) produced by recombinant
DNA technology and provides protection from HBV infection when used for both pre- and
postexposure vaccination. There are multiple vaccines available, which have different
schedules depending on the specific product. All products require a series of multiple doses
over varying time frames, and which regimen is selected depends on local availability and the
age of the patient.
The vaccine should be administered IM in the deltoid muscle and can be administered
simultaneously with other vaccines.
Prevention of perinatal infection can be achieved through routine screening of all
pregnant women for HBsAg and immunoprophylaxis (both HBIG and hepatitis B
vaccine) of infants born to HBsAg-positive mothers or mothers whose HBsAg status is
unknown.
Prevention in infancy and childhood can be achieved by routine infant vaccination, and
vaccination of previously unvaccinated children and adolescents through age 18 years. Adults
who are previously unvaccinated but at increased risk for HBV, such as health care workers,
sex workers, men who have sex with men, persons in correctional facilities, intravenous drug
users, or household contacts of persons known to carry HBV, should also be vaccinated.
Hepatitis B vaccination is recommended for all unvaccinated adolescents, all unvaccinated
adults at risk for HBV infection, and all adults seeking protection from HBV infection.
Hepatitis B vaccine should be offered to all unvaccinated persons attending STD clinics or
seeking treatment for STDs in other settings.
This vaccine may be administered in pregnancy if necessary.
Unvaccinated persons or those known not to have responded to a complete hepatitis B
vaccine series should receive both HBIG and hepatitis vaccine as soon as possible (preferably
≤24 hours) after a discrete, identifiable exposure to blood or body fluids that contain blood
from an HBsAg-positive source. Hepatitis B vaccine should be administered
simultaneously with HBIG at a separate injection site, and the vaccine series should be
completed by using the age-appropriate vaccine dose and schedule. Exposed persons who
are in the process of being vaccinated but who have not completed the vaccine series should
receive HBIG and complete the vaccine series. Exposed persons who are known to have
responded to vaccination are considered protected.
Patients known to be chronic carriers of HBV should be counselled to have their household
contacts and sex partners immunized, use condoms for sexual intercourse, and cover cuts and
skin lesions to prevent transmission to others.

III) Clinical Findings

A. Symptoms & Signs

Approximately 70% of patients with acute hepatitis B are asymptomatic, with the remainder
having jaundice.
Rarely patients will present with fulminant hepatic failure.
A serum sickness-like syndrome may develop during the prodromal period, followed by
constitutional symptoms, anorexia, nausea, jaundice, and right upper quadrant discomfort.
The symptoms and jaundice generally disappear after 1 to 3 months, but some patients have
prolonged fatigue even after normalization of serum aminotransferase concentrations.
Patients with chronic hepatitis B are generally asymptomatic, unless they develop significant
cirrhosis or have extra hepatic manifestations. Patients may report nonspecific symptoms
such as fatigue. Physical examination may be normal, or there may be stigmata of chronic
liver disease, or decompensated cirrhosis.
B. Laboratory Findings
Diagnosis of acute or chronic HBV infection is by serology. Because HBsAg is present in
both acute and chronic infection, the presence of IgM antibody to hepatitis B core antigen
(IgM anti-HBc) is diagnostic of acute or recently acquired HBV infection. Antibody to
HBsAg (anti-HBs) is produced after a resolved infection and is the only HBV antibody
marker present after vaccination.
The presence of HBsAg and total anti-HBc, with a negative test for IgM anti-HBc, indicates
chronic HBV infection. The presence of anti- HBc alone might indicate a false-positive result
or acute, resolved, or chronic infection.
IV Complications
The most serious, yet rare complication is acute liver failure and death, which occurs in 1%
of reported cases.
Becoming a chronic carrier of HBV is also a potential complication of acute infection.
Among persons with chronic HBV infection, the risk for premature death from cirrhosis or
hepatocellular carcinoma is 15–25%.
V Treatment
The treatment of acute HBV is supportive care. There are no specific effective antiviral drugs
available at this time.
Patients who have chronic HBV infection should be managed by physicians with specific
expertise of chronic liver disease. The agents interferon, lamivudine, adefovir, dipivoxil,
telbivudine, and entecavir may be used to treat chronic HBV infection.
VI Prognosis
Acute hepatitis B is usually a self-limited condition, and if the affected patient does not
become a chronic carrier, complete recovery is expected in the majority of cases. Chronic
carrier status is associated with the potential complications previously described.
 HEPATITIS C

ESSENTIALS OF DIAGNOSIS
- Caused by hepatitis C virus (HCV), an RNA virus
- Primarily transmitted by parenteral route; rarely sexually transmitted
- Up to 85% of affected patients become chronic carriers; of these, up to 70% will
develop chronic liver disease
- No effective vaccine
- No effective treatment for acute disease
- Chronic HCV can be treated with combination therapy of pegylated interferon and
ribavirin
I) Pathogenesis
Hepatitis C is caused by hepatitis C virus (HCV), a small single-stranded RNA virus. HCV
RNA can be detected in blood 1–3 weeks after exposure, and antibodies to HCV (anti-HCV)
may be detected in the blood as early as 8–9 weeks post-exposure. As with hepatitis B,
hepatitis C may manifest as an acute or chronic illness and is the most common chronic
blood-borne infection.
HCV is transmitted through parenteral exposures to contaminated blood, usually through use
of injected drugs and, to a lesser extent, through exposures in health care settings as a
consequence of inadequate infection-control practices.
Sexual transmission of HCV had been considered to occur rarely, although it is observed,
especially among HIV-infected persons. Ten percent of patients with acute HCV infection
report contact with a known HCV-infected sex partner as their only risk for infection.
II) Prevention
No vaccine for hepatitis C is available, and prophylaxis with immune globulin is not effective
in preventing HCV infection after exposure. Therefore, prevention is focused on reducing
transmission and reducing chronic liver disease in HCV-infected persons by identifying them
and providing medical management and antiviral therapy, as indicated.
Although sexual transmission occurs rarely, condom use is still advisable. Screening of
patients who are at risk of HCV is the key to reducing transmission. Patients presenting to
STD clinics or in correctional facilities should be offered screening for HCV. All patients
with HIV infection should also be screened. Other risk factors for which HCV testing is
recommended include prior blood transfusion or solid organ transplant
before July 1992, prior transfusion of clotting factor concentrates produced before 1987,
long-term dialysis, and signs and symptoms of liver disease.
To reduce the risk for transmission to others, HCV-positive persons should be advised not to
donate blood, body organs, or semen; not share any personal items that might have blood on
them (eg, toothbrushes and razors); and cover cuts and sores.
HCV-positive women do not need to avoid pregnancy or breastfeeding. However, they
should be advised that approximately 6 of every 100 infants born to HCV-infected woman
become infected. This infection occurs predominantly during or near delivery, and no
treatment or delivery method has been demonstrated to decrease this risk. The risk is
increased by the presence of maternal HCV viremia at delivery and also is
greater if the woman is coinfected with HIV. HCV has not been shown to be transmitted
through breast milk, although HCV-positive mothers should consider abstaining from
breastfeeding if their nipples are cracked or bleeding. Infants born to HCV-positive mothers
should be tested for HCV infection and, if positive, evaluated for the presence of chronic
liver disease.
III) Clinical Findings
A. Symptoms & Signs
Patients newly infected with HCV typically are either asymptomatic or have a mild clinical
illness. As a result, most infected persons remain unaware of their infection because they feel
well and therefore serve as a source of transmission to others as well as being at risk for
chronic liver disease and other HCV-related chronic diseases for decades to come.
B. Laboratory Findings
Testing for antibodies to HCV (anti-HCV) is recommended for screening of asymptomatic
persons based on risk factors or a recognized exposure. Nucleic acid PCR testing to detect
HCV RNA is necessary to confirm the diagnosis of current HCV infection in a patient
with a positive anti-HCV. Elevated ALT levels are suggestive of chronic liver disease.
III) Complications
Chronic HCV infection develops in up to 85% of HCV-infected persons, and of these, up to
70% will develop evidence of active liver disease.
IV) Treatment
Patients who have been determined to be anti-HCV positive should be evaluated for the
presence of active infection, presence or development of chronic liver disease, and possible
treatment. Combination therapy with pegylated interferon and ribavirin is the treatment of
choice for patients with chronic hepatitis C. Providers should consult with gastroenterology
or infectious disease specialists who are familiar with the most current management options
for HCV.
Prognosis
Cirrhosis occurs in up to 50% of chronically infected patients. In patients with cirrhosis, there
is a risk of subsequent hepatic decompensation and also of hepatocellular carcinoma, the
latter risk being up to 3% per year. Death may occur as a consequence of these complications.