What is Hepatitis | Types, Symptoms, Causes, and More

What is Hepatitis?

Approximately 325 million people worldwide are living with viral hepatitis B and C and the disease also causes many untimely deaths. Hepatitis refers to an inflammatory condition of the liver. Inflammation is swelling that happens when tissues of the body are injured or infected and can damage your liver. It’s commonly caused by a viral infection, but there are other possible causes of hepatitis. These include autoimmune hepatitis and hepatitis that occurs as a secondary result of medications, drugs, toxins, and alcohol. Autoimmune hepatitis is a disease that occurs when your body makes antibodies against your liver tissue.

Symptoms of Hepatitis

The most common symptoms of hepatitis include fever, fatigue, loss of appetite, nausea, vomiting, abdominal pain, dark urine, light-coloured stools, joint pain, and jaundice. Consult a doctor for further investigation if you experience any of these symptoms.

Types of Hepatitis

Hepatitis A, B, C, D, and E are viral illnesses of the liver. It is always a short-term, acute infection, but hepatitis B, C, and D are more likely to become chronic and persistent. Hepatitis E is usually severe, but it can be very deadly for women who are pregnant.

Hepatitis A
Key facts

• Hepatitis A is an inflammation of the liver that can cause mild to severe illness.
• The hepatitis A virus (HAV) is transmitted through ingestion of contaminated food and water or through direct contact with an infectious person.
• Almost everyone recovers fully from hepatitis A with a lifelong immunity. However, a very small proportion of people infected with hepatitis A could die from fulminant hepatitis.
• The risk of hepatitis A infection is associated with a lack of safe water and poor sanitation and hygiene (such as contaminated and dirty hands).
• A safe and effective vaccine is available to prevent hepatitis A.

Overview

Hepatitis A is an inflammation of the liver caused by the hepatitis A virus (HAV). The virus is primarily spread when an uninfected (and unvaccinated) person ingests food or water that is contaminated with the faeces of an infected person. The disease is closely associated with unsafe water or food, inadequate sanitation, poor personal hygiene and oral-anal sex.

Unlike hepatitis B and C, hepatitis A does not cause chronic liver disease but it can cause debilitating symptoms and rarely fulminant hepatitis (acute liver failure), which is often fatal. WHO estimates that in 2016, 7134 persons died from hepatitis A worldwide (accounting for 0.5% of the mortality due to viral hepatitis).

Hepatitis A occurs sporadically and in epidemics worldwide, with a tendency for cyclic recurrences. Epidemics related to contaminated food or water can erupt explosively, such as the epidemic in Shanghai in 1988 that affected about 300 000 people (1). They can also be prolonged, affecting communities for months through person-to-person transmission. Hepatitis A viruses persist in the environment and can withstand food production processes routinely used to inactivate or control bacterial pathogens.

Geographical distribution

Geographical distribution areas can be characterized as having high, intermediate or low levels of hepatitis A virus infection. However, infection does not always mean disease because infected young children do not experience any noticeable symptoms.Infection is common in low- and middle-income countries with poor sanitary conditions and hygienic practices, and most children (90%) have been infected with the hepatitis A virus before the age of 10 years, most often without symptoms (2). Infection rates are low in high-income countries with good sanitary and hygienic conditions. Disease may occur among adolescents and adults in high-risk groups, such as persons who inject drugs (PWID), men who have sex with men (MSM), people travelling to areas of high endemicity and in isolated populations, such as closed religious groups. In the United States of America, large outbreaks have been reported among persons experiencing homelessness. In middle-income countries and regions where sanitary conditions are variable, children often escape infection in early childhood and reach adulthood without immunity.

Transmission

The hepatitis A virus is transmitted primarily by the faecal-oral route; that is when an uninfected person ingests food or water that has been contaminated with the faeces of an infected person. In families, this may happen though dirty hands when an infected person prepares food for family members. Waterborne outbreaks, though infrequent, are usually associated with sewage-contaminated or inadequately treated water.

The virus can also be transmitted through close physical contact (such as oral-anal sex) with an infectious person, although casual contact among people does not spread the virus.

Symptoms

The incubation period of hepatitis A is usually 14–28 days.

Symptoms of hepatitis A range from mild to severe and can include fever, malaise, loss of appetite, diarrhoea, nausea, abdominal discomfort, dark-coloured urine and jaundice (a yellowing of the eyes and skin). Not everyone who is infected will have all the symptoms.

Adults have signs and symptoms of illness more often than children. The severity of disease and fatal outcomes are higher in older age groups. Infected children under 6 years of age do not usually experience noticeable symptoms, and only 10% develop jaundice. Hepatitis A sometimes relapses, meaning the person who just recovered falls sick again with another acute episode. This is normally followed by recovery.

Who is at risk?

Anyone who has not been vaccinated or previously infected can get infected with the hepatitis A virus. In areas where the virus is widespread (high endemicity), most hepatitis A infections occur during early childhood. Risk factors include:

• poor sanitation;
• lack of safe water;
• living in a household with an infected person;
• being a sexual partner of someone with acute hepatitis A infection;
• use of recreational drugs;
• sex between men; and
• travelling to areas of high endemicity without being immunized.

Diagnosis

Cases of hepatitis A are not clinically distinguishable from other types of acute viral hepatitis. Specific diagnosis is made by the detection of HAV-specific immunoglobulin G (IgM) antibodies in the blood. Additional tests include reverse transcriptase polymerase chain reaction (RT-PCR) to detect the hepatitis A virus RNA and may require specialized laboratory facilities.

Treatment

There is no specific treatment for hepatitis A. Recovery from symptoms following infection may be slow and can take several weeks or months. It is important to avoid unnecessary medications. Acetaminophen, paracetamol and medication against vomiting should be avoided.

Hospitalization is unnecessary in the absence of acute liver failure. Therapy is aimed at maintaining comfort and adequate nutritional balance, including replacement of fluids that are lost from vomiting and diarrhoea.

Prevention

Improved sanitation, food safety and immunization are the most effective ways to combat hepatitis A.

The spread of hepatitis A can be reduced by:

• adequate supplies of safe drinking water;
• proper disposal of sewage within communities; and
• personal hygiene practices such as regular handwashing before meals and after going to the bathroom.

Several injectable inactivated hepatitis A vaccines are available internationally. All provide similar protection from the virus and have comparable side effects. No vaccine is licensed for children younger than 1 year of age. In China, a live attenuated vaccine is also available.

Hepatitis B

• Hepatitis B is a viral infection that attacks the liver and can cause both acute and chronic disease.
• The virus is most commonly transmitted from mother to child during birth and delivery, as well as through contact with blood or other body fluids during sex with an infected partner, unsafe injections or exposures to sharp instruments.
• WHO estimates that 296 million people were living with chronic hepatitis B infection in 2019, with 1.5 million new infections each year.
• In 2019, hepatitis B resulted in an estimated 820 000 deaths, mostly from cirrhosis and hepatocellular carcinoma (primary liver cancer).
• Hepatitis B can be prevented by vaccines that are safe, available and effective.

Overview

Hepatitis B is a potentially life-threatening liver infection caused by the hepatitis B virus (HBV). It is a major global health problem. It can cause chronic infection and puts people at high risk of death from cirrhosis and liver cancer.

A safe and effective vaccine that offers 98% to 100% protection against hepatitis B is available. Preventing hepatitis B infection averts the development of complications including chronic disease and liver cancer.

The burden of hepatitis B infection is highest in the WHO Western Pacific Region and the WHO African Region, where 116 million and 81 million people, respectively, are chronically infected. Sixty million people are infected in the WHO Eastern Mediterranean Region, 18 million in the WHO South-East Asia Region, 14 million in the WHO European Region and 5 million in the WHO Region of the Americas.

Transmission

In highly endemic areas, hepatitis B is most commonly spread from mother to child at birth (perinatal transmission) or through horizontal transmission (exposure to infected blood), especially from an infected child to an uninfected child during the first 5 years of life. The development of chronic infection is common in infants infected from their mothers or before the age of 5 years. Hepatitis B is also spread by needlestick injury, tattooing, piercing and exposure to infected blood and body fluids, such as saliva and menstrual, vaginal and seminal fluids. Transmission of the virus may also occur through the reuse of contaminated needles and syringes or sharp objects either in health care settings, in the community or among persons who inject drugs. Sexual transmission is more prevalent in unvaccinated persons with multiple sexual partners. Hepatitis B infection acquired in adulthood leads to chronic hepatitis in less than 5% of cases, whereas infection in infancy and early childhood leads to chronic hepatitis in about 95% of cases. This is the basis for strengthening and prioritizing infant and childhood vaccination. The hepatitis B virus can survive outside the body for at least 7 days. During this time, the virus can still cause infection if it enters the body of a person who is not protected by the vaccine. The incubation period of the hepatitis B virus ranges from 30 to 180 days. The virus may be detected within 30 to 60 days after infection and can persist and develop into chronic hepatitis B, especially when transmitted in infancy or childhood.

Symptoms

Most people do not experience any symptoms when newly infected. However, some people have acute illness with symptoms that last several weeks, including yellowing of the skin and eyes (jaundice), dark urine, extreme fatigue, nausea, vomiting and abdominal pain. People with acute hepatitis can develop acute liver failure, which can lead to death. Among the long-term complications of HBV infections, a  subset of persons develops advanced liver diseases such as cirrhosis and hepatocellular carcinoma, which cause high morbidity and mortality.

HBV-HIV coinfection

About 1% of persons living with HBV infection (2.7 million people) are also infected with HIV. Conversely, the global prevalence of HBV infection in HIV-infected persons is 7.4%. Since 2015, WHO has recommended treatment for everyone diagnosed with HIV infection, regardless of the stage of disease. Tenofovir, which is included in the treatment combinations recommended as first-line therapy for HIV infection, is also active against HBV.

Diagnosis

It is not possible on clinical grounds to differentiate hepatitis B from hepatitis caused by other viral agents, hence laboratory confirmation of the diagnosis is essential. Several blood tests are available to diagnose and monitor people with hepatitis B. They can be used to distinguish acute and chronic infections. WHO recommends that all blood donations be tested for hepatitis B to ensure blood safety and avoid accidental transmission.

As of 2019, 30.4 million people (10.5% of all people estimated to be living with hepatitis B) were aware of their infection, while 6.6 million (22%) of the people diagnosed were on treatment. According to latest WHO estimates, the proportion of children under five years of age chronically infected with HBV dropped to just under 1% in 2019 down from around 5% in the pre-vaccine era ranging from the 1980s to the early 2000s.

In settings with high Hepatitis B surface antigen seroprevalence in the general population (defined as >2% or >5% HBsAg seroprevalence), WHO recommends that all adults have access to and be offered HBsAg testing with linkage to prevention and care and treatment services as needed.

Treatment

There is no specific treatment for acute hepatitis B. Therefore, care is aimed at maintaining comfort and adequate nutritional balance, including replacement of fluids lost from vomiting and diarrhoea. Most important is the avoidance of unnecessary medications. Acetaminophen, paracetamol and medication against vomiting should be avoided.

Chronic hepatitis B infection can be treated with medicines, including oral antiviral agents. Treatment can slow the progression of cirrhosis, reduce incidence of liver cancer and improve long term survival. In 2021 WHO estimated that 12% to 25% of people with chronic hepatitis B infection will require treatment, depending on setting and eligibility criteria.

WHO recommends the use of oral treatments (tenofovir or entecavir) as the most potent drugs to suppress hepatitis B virus. Most people who start hepatitis B treatment must continue it for life.

In low-income settings, most people with liver cancer die within months of diagnosis. In high-income countries, patient present to hospital earlier in the course of the disease, and have access to surgery and chemotherapy which can prolong life for several months to a few years. Liver transplantation is sometimes used in people with cirrhosis or liver cancer in high-income countries, with varying success.

Prevention

WHO recommends that all infants receive the hepatitis B vaccine as soon as possible after birth, preferably within 24 hours, followed by 2 or 3 doses of hepatitis B vaccine at least 4 weeks apart to complete the vaccination series. Protection lasts at least 20 years and is probably lifelong. WHO does not recommend booster vaccinations for persons who have completed the 3-dose vaccination schedule.

In addition to infant vaccination, WHO recommends the use of antiviral prophylaxis for the prevention of hepatitis B transmission from mother-to-child. Implementation of blood safety strategies and safer sex practices, including minimizing the number of partners and using barrier protective measures (condoms), also protect against transmission.

• Hepatitis B
  Hepatitis B is transmitted through contact with infectious body fluids, such as blood, vaginal secretions, or semen, containing the hepatitis B virus (HBV).
  A person can get hepatitis B in many ways, including:
  • Unprotected sex.
  • Sharing dirty needles.
  • Being in direct contact with infected blood.
  • Being transferred from mother to unborn child.
• Hepatitis C
  Hepatitis C comes from the hepatitis C virus (HCV). Hepatitis C is transmitted through direct contact with infected body fluids, typically through injection drug use and sexual contact. A person can get hepatitis C from:
  • Sharing dirty needles.
  • Being in direct contact with infected blood.
  • Unprotected sex.
• Hepatitis D
  This is a serious liver disease caused by the hepatitis D virus (HDV). It is contracted through direct contact with infected blood. Hepatitis D is a rare form of hepatitis that only occurs in conjunction with hepatitis B infection. The hepatitis D virus can’t multiply without the presence of hepatitis B.
• Hepatitis E
  Hepatitis E is a waterborne disease caused by the hepatitis E virus (HEV). It is mainly found in areas with poor sanitation and typically results from ingesting faecal matter that contaminates the water supply. You can get hepatitis E by eating or drinking food or water contaminated with the virus.

Myths and Facts –

Myth: Women with hepatitis should abstain from breastfeeding their babies to avoid passing the infection.
Fact: Hepatitis C and B are not transmitted through breast milk. Although, there is a risk of transmission through cracked nipples. In such a scenario you must speak to your doctor for further assistance.

Myth: People who have hepatitis B or C should not have children because they will pass it on to them.
Fact: That is not true, people with hepatitis B or C can have healthy babies. Timely precautions during pregnancy, adequate testing, and prompt immunization of the baby after birth can stop the spread of hepatitis.

Myth: Your symptoms indicate the type hepatitis you have.
Fact: Patients with hepatitis may show jaundice-like symptoms of loss of appetite, yellow coloured urine, and vomiting. The type of virus can be differentiated only by blood tests.

Myth: Vaccine can protect against all types of Hepatitis.
Fact: Vaccines are available only against Hepatitis A and B.