Hepatitis B is irritation and swelling (inflammation) of the liver due to infection with the hepatitis B virus (HBV).

Other types of viral hepatitis include:

Hepatitis A Hepatitis C Hepatitis D

See also:

Autoimmune hepatitis Chronic persistent hepatitis Drug-induced hepatitis

Causes, incidence, and risk factors

Hepatitis B infection can be spread through having contact with the blood, semen, vaginal fluids, and other body fluids of someone who already has a hepatitis B infection. Infection can be spread through:

Blood transfusions (not common in the United States) Direct contact with blood in health care settings Sexual contact with an infected person Tattoo or acupuncture with unclean needles or instruments Shared needles during drug use Shared personal items (such as toothbrushes, razors, and nail clippers) with an infected person

The hepatitis B virus can be passed to an infant during childbirth if the mother is infected. Risk factors for hepatitis B infection include:

Being born, or having parents who were born in regions with high infection rates (including Asia, Africa, and the Caribbean) Being infected with HIV Being on hemodialysis Having multiple sex partners Men having sex with men

Most of the damage from the hepatitis B virus occurs because of the way the body responds to the infection. When the body's immune system detects the infection, it sends out special cells to fight it off. However, these disease-fighting cells can lead to liver inflammation.

Symptoms
After you first become infected with the hepatitis B virus:

You may have no symptoms You may feel sick for a period of days or weeks You may become very ill (called fulminant hepatitis)

If your body is able to fight off the hepatitis B infection, any symptoms that you had should go away over a period of weeks to months. Some people's bodies are not able to completely get rid of the hepatitis B infection. This is called chronic hepatitis B. Many people who have chronic hepatitis B have few or no symptoms. They may not even look sick. As a result, they may not know they are infected. However, they can still spread the virus to other people. Symptoms may not appear for up to 6 months after the time of infection. Early symptoms may include:

Appetite loss Fatigue Fever, low-grade Muscle and joint aches Nausea and vomiting Yellow skin and dark urine due to jaundice

People with chronic hepatitis may have no symptoms, even though gradual liver damage may be occurring. Over time, some people may develop symptoms of chronic liver damage and cirrhosis of the liver.

Signs and tests

The following tests are done to identify and monitor liver damage from hepatitis B:

Albumin level Liver function tests Prothrombin time

The following tests are done to help diagnose and monitor people with hepatitis B:

Antibody to HBsAg (Anti-HBs) -- a positive result means you have either had hepatitis B in the past, or have received a hepatitis B vaccine Antibody to hepatitis B core antigen (Anti-HBc) -- a positive result means you had a recent infection or an infection in the past Hepatitis B surface antigen (HBsAg) -- a positive result means you have an active infection Hepatitis E surface antigen (HBeAg) -- a positive result means you have a hepatitis B infection and are more likely to spread the infection to others through sexual contact or sharing needles

Patients with chronic hepatitis will need ongoing blood tests to monitor their status.

Treatment
Acute hepatitis needs no treatment other than careful monitoring of liver and other body functions with blood tests. You should get plenty of bed rest, drink plenty of fluids, and eat healthy foods. In the rare case that you develop liver failure, you may need a liver transplant. A liver transplant is the only cure in some cases of liver failure. Some patients with chronic hepatitis may be treated with antiviral medications or a medication called peginterferon. These medications can decrease or remove hepatitis B from the blood and reduce the risk of cirrhosis and liver cancer. Liver transplantation is used to treat severe, chronic hepatitis B liver disease. Patients with chronic hepatitis should avoid alcohol and should always check with their doctor or nurse before taking any over-the-counter medications or herbal supplements. This even includes medications such as acetaminophen, aspirin, or ibuprofen. See: Cirrhosis for information about treating more severe liver damage caused by hepatitis B.

Support Groups
See: Liver disease support group

Expectations (prognosis)
The acute illness usually goes away after 2 - 3 weeks. The liver usually returns to normal within 4 - 6 months in almost all patients who are infected. Some people develop chronic hepatitis.

Almost all newborns and about 50% of children who become infected with hepatitis B develop chronic hepatitis. Less than 5% of adults who are infected with the hepatitis B virus develop the chronic condition. Chronic hepatitis B infection increases the risk for liver damage, including cirrhosis and liver cancer. People who have chronic hepatitis B can transmit the infection. They are considered carriers of the disease, even if they do not have any symptoms.

Hepatitis B is fatal in about 1% of cases.

Complications
There is a much higher rate of hepatocellular carcinoma in people who have chronic hepatitis B than in the general population. Other complications may include:

Chronic persistent hepatitis Cirrhosis Fulminant hepatitis, which can lead to liver failure and possibly death

Calling your health care provider

Call your health care provider if:

You develop symptoms of hepatitis B Hepatitis B symptoms do not go away in 2 or 3 weeks, or new symptoms develop You belong to a high-risk group for hepatitis B and have not yet received the HBV vaccine.

Prevention
All children should receive their first dose of the hepatitis B vaccine at birth, and complete the series of three shots by age 6 months. Children younger than age 19 who have not been vaccinated should receive "catch-up" doses. People who are at high risk, including health care workers and those who live with someone who has hepatitis B should get the hepatitis B vaccine. Infants born to mothers who either currently have acute hepatitis B, or who have had the infection should receive a special vaccination that includes hepatitis B immune globulin and a hepatitis B immunization within 12 hours of birth. Screening of all donated blood has reduced the chance of getting hepatitis B from a blood transfusion. Mandatory reporting of the disease allows state health care workers to track people who have been exposed to the virus. The vaccine is given to those who have not yet developed the disease. The hepatitis B vaccine or a hepatitis B immune globulin (HBIG) shot may help prevent hepatitis B infection if it is given within 24 hours of exposure. Lifestyle measures for preventing transmission of hepatitis B:

Avoid sexual contact with a person who has acute or chronic hepatitis B. Use a condom and practice safe sex. Avoid sharing personal items, such as razors or toothbrushes. Do not share drug needles or other drug equipment (such as straws for snorting drugs). Clean blood spills with a solution containing 1 part household bleach to 10 parts water.

Hepatitis B (and hepatitis C) viruses cannot be spread by casual contact, such as holding hands, sharing eating utensils or drinking glasses, breast-feeding, kissing, hugging, coughing, or sneezing.

Key facts

Hepatitis B is a viral infection that attacks the liver and can cause both acute and chronic disease. The virus is transmitted through contact with the blood or other body fluids of an infected person - not through casual contact. About 2 billion people worldwide have been infected with the virus and about 350 million live with chronic infection. An estimated 600 000 persons die each year due to the acute or chronic consequences of hepatitis B. About 25% of adults who become chronically infected during childhood later die from liver cancer or cirrhosis (scarring of the liver) caused by the chronic infection. The hepatitis B virus is 50 to 100 times more infectious than HIV. Hepatitis B virus is an important occupational hazard for health workers. Hepatitis B is preventable with a safe and effective vaccine.

Hepatitis B is a potentially life-threatening liver infection caused by the hepatitis B virus. It is a major global health problem and the most serious type of viral hepatitis. It can cause chronic liver disease and puts people at high risk of death from cirrhosis of the liver and liver cancer. Worldwide, an estimated two billion people have been infected with the hepatitis B virus (HBV), and more than 350 million have chronic (long-term) liver infections. A vaccine against hepatitis B has been available since 1982. Hepatitis B vaccine is 95% effective in preventing HBV infection and its chronic consequences, and is the first vaccine against a major human cancer.
Symptoms

Hepatitis B virus can cause an 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 can take several months to a year to recover from the symptoms. HBV can also cause a chronic liver infection that can later develop into cirrhosis of the liver or liver cancer.
Who is most at risk for chronic disease?

The likelihood that an HBV infection will become chronic depends upon the age at which a person becomes infected, with young children who become infected with HBV being the most likely to develop chronic infections. About 90% of infants infected during the first year of life develop chronic infections; 30% to 50% of children infected between one to four years of age develop chronic infections. About 25% of adults who become chronically infected during childhood die from HBV-related liver cancer or cirrhosis. About 90% of healthy adults who are infected with HBV will recover and be completely rid of the virus within six months.

Where is hepatitis B most common?

Hepatitis B is endemic in China and other parts of Asia. Most people in the region become infected with HBV during childhood. In these regions, 8% to 10% of the adult population are chronically infected. Liver cancer caused by HBV is among the first three causes of death from cancer in men, and a major cause of cancer in women. High rates of chronic infections are also found in the Amazon and the southern parts of eastern and central Europe. In the Middle East and Indian sub-continent, an estimated 2% to 5% of the general population is chronically infected. Less than 1% of the population in western Europe and North American is chronically infected.
Transmission

Hepatitis B virus is transmitted between people by contact with the blood or other body fluids (i.e. semen and vaginal fluid) of an infected person. Modes of transmission are the same for the human immunodeficiency virus (HIV), but HBV is 50 to 100 times more infectious Unlike HIV, HBV can survive outside the body for at least 7 days. During that time, the virus can still cause infection if it enters the body of a person who is not infected. Common modes of transmission in developing countries are:

perinatal (from mother to baby at birth) early childhood infections (inapparent infection through close interpersonal contact with infected household contacts) unsafe injections practices blood transfusions sexual contact

In many developed countries (e.g. those in western Europe and North America), patterns of transmission are different than those mentioned above. Today, the majority of infections in these countries are transmitted during young adulthood by sexual activity and injecting drug use. HBV is a major infectious occupational hazard of health workers. HBV is not spread by contaminated food or water, and cannot be spread casually in the workplace. The virus incubation period is 90 days on average, but can vary from about 30 to 180 days. HBV may be detected 30 to 60 days after infection and persist for widely variable periods of time.
Treatment

There is no specific treatment for acute hepatitis B. Care is aimed at maintaining comfort and adequate nutritional balance, including replacement of fluids that are lost from vomiting and diarrhoea. Chronic hepatitis B can be treated with drugs, including interferon and anti-viral agents, which can help some patients. Treatment can cost thousands of dollars per year and is not available to most patients in developing countries.

Liver cancer is almost always fatal, and often develops in people at an age when they are most productive and have family responsibilities. In developing countries, most people with liver cancer die within months of diagnosis. In higher income countries, surgery and chemotherapy can prolong life for up to a few years in some patients. Patients with cirrhosis are sometimes given liver transplants, with varying success.
Prevention

All infants should receive the hepatitis B vaccine: this is the mainstay of hepatitis B prevention. The vaccine can be given as either three or four separate doses, as part of existing routine immunization schedules. In areas where mother-to-infant spread of HBV is common, the first dose of vaccine should be given as soon as possible after birth (i.e. within 24 hours). The complete vaccine series induces protective antibody levels in more than 95% of infants, children and young adults. After age 40, protection following the primary vaccination series drops below 90%. At 60 years old, protective antibody levels are achieved in only 65 to 75% of those vaccinated. Protection lasts at least 20 years and should be lifelong. All children and adolescents younger than 18 years old and not previously vaccinated should receive the vaccine. People in high risk groups should also be vaccinated, including:

persons with high-risk sexual behaviour; partners and household contacts of HBV infected persons; injecting drug users; persons who frequently require blood or blood products; recipients of solid organ transplantation; those at occupational risk of HBV infection, including health care workers; and international travellers to countries with high rates of HBV.

The vaccine has an outstanding record of safety and effectiveness. Since 1982, over one billion doses of hepatitis B vaccine have been used worldwide. In many countries where 8% to 15% of children used to become chronically infected with HBV, vaccination has reduced the rate of chronic infection to less than 1% among immunized children. As of December 2006, 164 countries vaccinate infants against hepatitis B during national immunization programmes - a major increase compared with 31 countries in 1992, the year that the World Health Assembly passed a resolution to recommend global vaccination against hepatitis B.

Hepatitis B Symptoms
What Are the Symptoms of Hepatitis B?

Half of all people infected with the hepatitis B virus have no symptoms.

Symptoms develop within 30-180 days of exposure to the virus. The symptoms are often compared to flu. Most people think they have flu and never think about having HBV infection.

Appetite loss Feeling tired (fatigue) Nausea and vomiting Itching all over the body Pain over the liver (on the right side of the abdomen, under the lower rib cage) Jaundice - A condition in which the skin and the whites of the eyes turn yellow in color Urine becomes dark in color (like cola or tea). Stools are pale in color (grayish or clay colored).

Hepatitis B Symptoms

Half of all people infected with the hepatitis B virus have no symptoms and may never realize that they have been infected. Adults are more likely to develop symptoms than children. For those who do get sick, symptoms usually develop within 1 to 4 months after exposure to the virus. The initial symptoms are often similar to the flu. Common symptoms of hepatitis B include:

Appetite loss Feeling tired (fatigue) Nausea and vomiting Itching all over the body Pain over the location of the liver (on the right side of the abdomen, under the lower rib cage) Jaundice (a condition in which the skin and the whites of the eyes turn yellow in color) Dark urine (the color of cola or tea) Pale-colored stools (grayish or clay colored)

Many types of acute viral hepatitis such as hepatitis A and hepatitis C have symptoms that are indistinguishable from hepatitis B. Fulminate hepatitis is a severe form of acute hepatitis that can be life-threatening if not treated right away. Fortunately, fulminate hepatitis is rare. The symptoms of fulminate hepatitis develop very suddenly and may include:

Mental disturbances such as confusion, lethargy, extreme sleepiness or hallucinations (hepatic encephalopathy) Sudden collapse with fatigue

Jaundice Swelling of the abdomen

Prolonged nausea and vomiting can cause dehydration. Individuals with dehydration may notice these symptoms:

Extreme weakness Confusion or trouble concentrating Headache Lack of urination Irritability

Symptoms of liver damage may include the following:

Fluid retention causing swelling of the belly (ascites) and sometimes the legs Weight gain due to ascites Persistent jaundice Loss of appetite, weight loss, wasting Vomiting with blood in the vomit Bleeding from the nose, mouth, or rectum; or blood in the stool Hepatic encephalopathy (excessive sleepiness, mental confusion, and in advanced stages, development of coma)

What is hepatitis?

The term 'hepatitis' simply means inflammation of the liver. Hepatitis may be caused by a virus or a toxin such as alcohol. Other viruses that can cause injury to liver cells include the hepatitis A and hepatitis C viruses. These viruses are not related to each other or to hepatitis B virus and differ in their structure, the ways they are spread among individuals, the severity of symptoms they can cause, the way they are treated, and the outcome of the infection. What is the scope of the problem? Hepatitis B is an infection of the liver caused by the hepatitis B virus (HBV). It is estimated that 350 million individuals worldwide are infected with the virus, which causes 620,000 deaths worldwide each year. According to the Centers for Disease Control (CDC), approximately 46,000 new cases of hepatitis B occurred in the United States in 2006. In the United States, rates of new infection were highest among people aged 25 to 44 years (3.1 cases per 100,000 population) and lowest among those younger than 15 years of age (0.02 per 100,000). This reflects the major modes of transmission of hepatitis B (sexual transmission, illicit drug use, exposure to infected blood) and the effect of universal vaccination of infants. In the United States, there has been a 75% decrease in newly diagnosed cases of hepatitis B during the past decade. This decrease is attributed to increased vaccination and to heightened public awareness of HIV/AIDS and the resulting safer sexual practices. When a person first gets hepatitis B, they are said to have an 'acute' infection. Most people are able to eliminate the virus and are cured of the infection. Some are not able to clear the virus and have 'chronic' infection with hepatitis B that is usually life-long (see below). In the United States an estimated 800,000 to 1.4 million people are chronically infected with hepatitis B. Hepatitis B is found throughout the world. Some countries have much higher rates of infection than the United States; for example, in Southeast Asia and Sub-Saharan Africa, as many as 15% to 20% of adults are chronically infected with hepatitis B. What kind of a virus is hepatitis B? The hepatitis B virus is a DNA virus, meaning that its genetic material is made up of deoxyribonucleic acids. It belongs to a family of viruses known as Hepadnaviridae. The virus is primarily found in the liver but is also present in the blood and certain body fluids. Hepatitis B virus consists of a core particle (central portion) and a surrounding envelope (outer coat). The core is made up of DNA and the core antigen (HBcAg). The envelope contains the surface antigen (HBsAg). These antigens are present in the blood and are markers that are used in the diagnosis and evaluation of patients with suspected viral hepatitis. How does hepatitis B virus cause liver injury? The hepatitis B virus reproduces in liver cells, but the virus itself is not the direct cause of damage to the liver. Rather, the presence of the virus triggers an immune response from the

body as the body tries to eliminate the virus and recover from the infection. This immune response causes inflammation and may seriously injure liver calls. Therefore, there is a balance between the protective and destructive effects of the immune response to the hepatitis B virus.

What is hepatitis B?

Hepatitis B is a liver disease. Hepatitis * means inflammation of the liver. Inflammation is the painful, red swelling that results when tissues of the body become injured or infected. Inflammation can cause organs to not work properly.
*

See the Pronunciation Guide for tips on how to say the words in bold type.

[Top]
What is the liver?

The liver is an organ that does many important things.

Hepatitis B is a liver disease.

The liver

removes harmful chemicals from your blood fights infection helps digest food stores nutrients and vitamins stores energy

You cannot live without a liver.

[Top]
What causes hepatitis B?

The hepatitis B virus causes hepatitis B. Viruses are germs that can cause sickness. For example, the flu is caused by a virus. People can pass viruses to each other. [Top]
Who gets hepatitis B?

Anyone can get hepatitis B, but some people are at higher risk, including

people who were born to a mother with hepatitis B people who live with someone who has hepatitis B people who have lived in parts of the world where hepatitis B is common people who are exposed to blood or body fluids at work people on hemodialysis people who have had more than one sex partner in the last 6 months or have a history of sexually transmitted disease injection drug users men who have sex with men

[Top]
How could I get hepatitis B?

You could get hepatitis B through contact with an infected persons blood, semen, or other body fluid. You could get hepatitis B from

being born to a mother with hepatitis B having sex with an infected person being tattooed or pierced with unsterilized tools that were used on an infected person getting an accidental needle stick with a needle that was used on an infected person using an infected persons razor or toothbrush sharing drug needles with an infected person

You could get hepatitis B from having sex with an infected person.

You cannot get hepatitis B from

shaking hands with an infected person hugging an infected person sitting next to an infected person

[Top]
What are the symptoms of hepatitis B?

Hepatitis B usually has no symptoms. Adults and children ages 5 and older sometimes have one or more of the following symptoms:

yellowish eyes and skin, called jaundice a longer than usual amount of time for bleeding to stop swollen stomach or ankles easy bruising tiredness upset stomach fever loss of appetite diarrhea light-colored stools dark yellow urine

[Top]
What is chronic hepatitis B?

Hepatitis B is chronic when the body cant get rid of the hepatitis B virus. Children, especially infants, are more likely to get chronic hepatitis B, which usually has no symptoms until signs of liver damage appear. Without treatment, chronic hepatitis B can cause scarring of the liver, called cirrhosis; liver cancer; and liver failure. Symptoms of cirrhosis include

yellowish eyes and skin, called jaundice a longer than usual amount of time for bleeding to stop swollen stomach or ankles tiredness nausea weakness loss of appetite weight loss spiderlike blood vessels, called spider angiomas, that develop on the skin

[Top]

How is hepatitis B diagnosed?

Hepatitis B is diagnosed through blood tests, which can also show if you have chronic hepatitis B or another type of hepatitis. Your doctor may suggest getting a liver biopsy if chronic hepatitis B is suspected. A liver biopsy is a test for liver damage. The doctor uses a needle to remove a tiny piece of liver, which is then looked at with a microscope.

Blood is drawn for hepatitis B testing.

[Top]
How is hepatitis B treated?

Hepatitis B usually is not treated unless it becomes chronic. Chronic hepatitis B is treated with drugs that slow or stop the virus from damaging the liver. The length of treatment varies. Your doctor will help you decide which drug or drug combination is likely to work for you and will closely watch your symptoms to make sure treatment is working. Drugs given by shots include

interferon peginterferon

Drugs taken by mouth include

lamivudine telbivudine adefovir entecavir

Liver Transplantation

A liver transplant may be necessary if chronic hepatitis B causes liver failure. Liver transplantation surgery replaces a failed liver with a healthy one from a donor. Medicines taken after surgery can prevent hepatitis B from coming back.

[Top]
How can I avoid getting hepatitis B?

You can avoid getting hepatitis B by getting the hepatitis B vaccine. Vaccines are medicines that keep you from getting sick. Vaccines teach your body to attack specific germs. The hepatitis B vaccine teaches your body to attack the hepatitis B virus.

The hepatitis B vaccine protects you from infection.

Adults at higher risk of getting hepatitis B and all children should get the vaccine. The hepatitis B vaccine is given through three shots over a period of several months. There is no minimum age for vaccination. The second shot should be given at least 1 month after the first, and the last shot should be given at least 2 months after the second shot but no sooner than 4 months after the first. The hepatitis B vaccine is safe for pregnant women. You need all three shots to be fully protected. If you are traveling to a country where hepatitis B is common, try to get all the shots before you go. If you dont have time to get all the shots before you go, get as many as you can. One shot may provide some protection against the virus. You can also protect yourself and others from hepatitis B if you

use a condom during sex do not share drug needles wear gloves if you have to touch another persons blood do not borrow another persons toothbrush, razor, or anything else that could have blood on it make sure any tattoos or body piercings you get are done with sterile tools do not donate blood or blood products if you have hepatitis B

Wear gloves if you have to touch another persons blood.

[Top]
What should I do if I think I have been exposed to the hepatitis B virus?

See your doctor right away if you think you have been exposed to the hepatitis B virus. The first shot of the hepatitis B vaccine taken with a medicine called hepatitis B immune globulin may prevent you from getting sick. If you are at higher risk of hepatitis B, get tested. Many people do not know they are infected. Early diagnosis and treatment can help prevent liver damage. [Top]
Points to Remember

Hepatitis B is a liver disease caused by the hepatitis B virus. Anyone can get hepatitis B, but some people are at higher risk. You could get hepatitis B through contact with an infected persons blood, semen, or other body fluid. Hepatitis B usually has no symptoms. Adults and children ages 5 and older sometimes have jaundice or other symptoms. Hepatitis B usually is not treated unless it becomes chronic. Hepatitis B is chronic when the body cant get rid of the hepatitis B virus. Children, especially infants, are more likely to develop chronic hepatitis B. Chronic hepatitis B is treated with drugs that slow or stop the virus from damaging the liver. You can protect yourself from getting hepatitis B by getting the hepatitis B vaccine. See your doctor right away if you think youve been exposed to the hepatitis B virus. If you are at higher risk of hepatitis B, get tested. Many people do not know they are infected. Early diagnosis and treatment can help prevent liver damage.

[Top]
Hope through Research

The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) conducts and supports basic and clinical research into many digestive disorders, including hepatitis B.

NIDDK scientists are researching better strategies for using antiviral medicines to treat hepatitis B. Participants in clinical trials can play a more active role in their own health care, gain access to new research treatments before they are widely available, and help others by contributing to medical research. For information about current studies, visit www.ClinicalTrials.gov. [Top]
Pronunciation Guide

adefovir (ad-DEF-oh-vihr) angiomas (an-jee-OH-muhs) biopsy (BY-op-see) chronic (KRON-ik) cirrhosis (sur-ROH-siss) entecavir (INT-ih-CAH-vihr) hepatitis (HEP-uh-TY-tiss) inflammation (IN-fluh-MAY-shuhn) interferon (IN-tur-FIHR-on) jaundice (JAWN-diss) lamivudine (luh-MIH-vyoo-deen) peginterferon (PEG-IN-tur-FIHR-on) telbivudine (tel-BIH-vyoo-deen) vaccine (vak-SEEN) virus (VY-ruhss) [Top]
For More Information

American Liver Foundation 75 Maiden Lane, Suite 603 New York, NY 100384810 Phone: 1800GOLiver (18004654837) or 2126681000 Fax: 2124838179

Email: info@liverfoundation.org Internet: www.liverfoundation.org Hepatitis B Foundation 3805 Old Easton Road Doylestown, PA 18902 Phone: 2154894900 Fax: 2154894913 Email: info@hepb.org Internet: www.hepb.org Hepatitis Foundation International 504 Blick Drive Silver Spring, MD 209042901 Phone: 18008910707 or 3016224200 Fax: 3016224702 Email: hfi@comcast.net Internet: www.hepfi.org National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention Centers for Disease Control and Prevention 1600 Clifton Road Atlanta, GA 30333 Phone: 18003113435 or 4046393534 Email: cdcinfo@cdc.gov Internet: www.cdc.gov/nchhstp Other types of hepatitis exist. The National Digestive Diseases Information Clearinghouse (NDDIC) also has booklets about hepatitis A and hepatitis C:

What I need to know about Hepatitis A What I need to know about Hepatitis C

You can get a free copy of each booklet by calling 18008915389, by going online to www.catalog.niddk.nih.gov, or by writing to
NDDIC 2 Information Way Bethesda, MD 208923570

Hepatitis information for health professionals is also available. You may also find additional information about this topic by visiting MedlinePlus at www.medlineplus.gov. This publication may contain information about medications. When prepared, this publication included the most current information available. For updates or for questions about any medications, contact the U.S. Food and Drug Administration toll-free at 1888INFOFDA (18884636332) or visit www.fda.gov. Consult your doctor for more information. [Top]
Acknowledgments

Publications produced by the Clearinghouse are carefully reviewed by both NIDDK sci
How is the hepatitis B virus spread (transmitted)?

Hepatitis B is spread mainly by exposure to infected blood or body secretions. In infected individuals, the virus can be found in the blood, semen, vaginal discharge, breast milk, and saliva. Hepatitis B is not spread through food, water, or by casual contact. In the United States, sexual contact is the most common means of transmission, followed by using contaminated needles for injecting illicit drugs, tattooing, body piercing, or acupuncture. Additionally, hepatitis B can be transmitted through sharing toothbrushes and razors contaminated with infected fluids or blood. Hepatitis B also may be spread from infected mothers to their babies at birth (so-called 'vertical' transmission). This is the most prevalent means of transmission in regions of the world where hepatitis B rates are high. The rate of transmission of hepatitis B from mother to newborn is very high, and almost all infected infants will develop chronic hepatitis B. Fortunately, transmission can be significantly reduced through immunoprophylaxis (see below). Rarely, hepatitis B can be transmitted through transfused blood products, donated livers and other organs. However, blood and organ donors are routinely screened for hepatitis which typically prevents this type of transmission.
What are the symptoms of acute hepatitis B?

Acute hepatitis B is the period of illness that occurs during the first one to four months after acquiring the virus. Only 30% to 50% of adults develop significant symptoms during acute infection. Early symptoms may be non-specific, including fever, a flu-like illness, and joint pains. Symptoms of acute hepatitis may include:

fatigue, loss of appetite, nausea,

jaundice (yellowing of the skin and eyes), and pain in the upper right abdomen (due to the inflamed liver).

Rarely, acute hepatitis damages the liver so badly it can no longer function. This lifethreatening condition is called "fulminant hepatitis." Patients with fulminant hepatitis are at risk of developing bleeding problems and coma resulting from the failure of the liver. Patients with fulminant hepatitis should be evaluated for liver transplantation. Small studies suggest that the drug lamivudine (Epivir), may be of limited assistance in these cases (see below). What determines the outcome of acute hepatitis B? The body's immune response is the major determinant of the outcome in acute hepatitis B. Individuals who develop a strong immune response to the infection are more likely to clear the virus and recover. However, these patients also are more likely to develop more severe liver injury and symptoms due to the strong immune response that is trying to eliminate the virus. On the other hand, a weaker immune response results in less liver injury and fewer symptoms but a higher risk of developing chronic hepatitis B. People who recover and eliminate the virus will develop life-long immunity, that is, protection from subsequent infection from hepatitis B. Most infants and children who acquire acute hepatitis B viral infection have no symptoms. In these individuals, the immune system fails to mount a vigorous response to the virus. Consequently, the risk of an infected infant developing chronic hepatitis B is greater than 95%. In contrast, only 5% of adults who have acute hepatitis B develop chronic hepatitis B.
What are the symptoms of chronic hepatitis B?

The liver is a vital organ that has many functions. These include a role in the immune system, production of clotting factors, producing bile for digestion, and breaking down toxic substances, etc. Patients with chronic hepatitis B develop symptoms in proportion to the degree of abnormalities in these functions. The signs and symptoms of chronic hepatitis B vary widely depending on the severity of the liver damage. They range from few and relatively mild signs and symptoms to signs and symptoms of severe liver disease such as cirrhosis or liver failure. Most individuals with chronic hepatitis B remain symptom free for many years or decades. During this time, the patient's blood tests usually are normal or only mildly abnormal. Some patients may deteriorate and develop inflammation or symptoms, putting them at risk for developing cirrhosis. Cirrhosis of the liver due to hepatitis B Inflammation from chronic hepatitis B can progress to cirrhosis (severe scarring) of the liver. Significant amounts of scarring and cirrhosis lead to liver dysfunction. Symptoms may include:

weakness,

fatigue, loss of appetite, weight loss, breast enlargement in men, a rash on the palms, difficulty with blood clotting, and spider-like blood vessels on the skin.

Decreased absorption of vitamins A and D can cause impaired vision at night and thinning of bones (osteoporosis). Patients with liver cirrhosis also are at risk of infections because the liver plays an important role in the immune system. Advanced cirrhosis of the liver due to hepatitis B In patients with advanced cirrhosis, the liver begins to fail. This is life-threatening condition. Several complications occur in advanced cirrhosis:

Confusion and even coma (encephalopathy) results from the inability of the liver to detoxify certain toxic substances. Increased pressure in the blood vessels of the liver (portal hypertension) causes fluid to build up in the abdominal cavity (ascites) and may result in engorged veins in the swallowing tube (esophageal varices) that tear easily and may cause massive bleeding. Portal hypertension can also cause kidney failure or an enlarged spleen resulting in a decrease of blood cells and the development of anemia, increased risk of infection and bleeding. In advanced cirrhosis, liver failure also results in decreased production of clotting factors. This causes abnormalities in blood clotting and sometimes spontaneous bleeding. Patients with advanced cirrhosis often develop jaundice because the damaged liver is unable to eliminate a yellow compound, called bilirubin.

Hepatitis B virus and primary liver cancer (hepatocellular carcinoma) Patients with chronic hepatitis B are at risk of developing liver cancer. The way in which the cancer develops is not fully understood. Symptoms of liver cancer are nonspecific. Patients may have no symptoms, or they may experience abdominal pain and swelling, an enlarged liver, weight loss, and fever. The most useful diagnostic screening tests for liver cancer are a blood test for a protein produced by the cancer called alpha-fetoprotein and an ultrasound imaging study of the liver. These two tests are used to screen patients with chronic hepatitis B, especially if they have cirrhosis or a family history of liver cancer. Hepatitis B virus involvement of organs outside of the liver (extra-hepatic)

Rarely, chronic hepatitis B infection can lead to disorders that affect organs other than the liver. These conditions are caused when the normal immune response to hepatitis B mistakenly attacks uninfected organs. Among these conditions are:

Polyarteritis nodosa: a disease characterized by inflammation of the small blood vessels throughout the body. This condition can cause a wide range of symptoms, including muscle weakness, nerve damage, deep skin ulcers, kidney problems, high blood pressure, unexplained fevers, and abdominal pain. Glomerulonephritis: another rare condition, which is inflammation of the small filtering units of the kidney.

How is hepatitis B diagnosed?

Infection with hepatitis B is suspected when the medical history and the physical examination reveal risk factors for the infection or symptoms and signs that are suggestive of hepatitis B. Abnormalities in the liver tests (blood tests) also can raise suspicion; however, abnormal liver tests can result from many conditions that affect the liver. The diagnosis of hepatitis B can be made only with specific hepatitis B virus blood tests. These tests are known as hepatitis 'markers' or 'serology.' Markers found in the blood can confirm hepatitis B infection and differentiate acute from chronic infection. These markers are substances produced by the hepatitis B virus (antigens) and antibodies produced by the immune system to fight the virus. Hepatitis B virus has three antigens for which there are commonly-used tests - the surface antigen (HBsAg), the core antigen (HBcAg) and the e antigen (HBeAg). HBsAg and anti-HBs The presence of hepatitis B surface antigen (HBsAg) in the blood indicates that the patient is currently infected with the virus. HBsAg appears an average of four weeks after initial exposure to the virus. Individuals who recover from acute hepatitis B infections clear the blood of HBsAg within approximately four months after the onset of symptoms. These individuals develop antibodies to HBsAg (anti-HBs). Anti-HBs provides complete immunity to subsequent hepatitis B viral infection. Similarly, individuals who are successfully vaccinated against hepatitis B produce anti-HBs in the blood. Patients who fail to clear the virus during an acute episode develop chronic hepatitis B. The diagnosis of chronic hepatitis B is made when the HBsAg is present in the blood for at least six months. In chronic hepatitis B, HBsAg can be detected for many years, and anti-HBs does not appear. Anti-HBc In acute hepatitis, a specific class of early antibodies (IgM) appears that is directed against the hepatitis B core antigen (anti-HBc IgM). Later, another class of antibody, anti-HBc IgG, develops and persists for life, regardless of whether the individual recovers or develops chronic infection. Only anti-HBc IgM can be used to diagnose an acute hepatitis B infection.

HBeAg, anti-HBe, and pre-core mutations Hepatitis B e antigen (HBeAg) is present when the hepatitis B virus is actively multiplying, whereas the production of the antibody, anti-HBe, (also called HBeAg seroconversion) signifies a more inactive state of the virus and a lower risk of transmission. In some individuals infected with hepatitis B virus, the genetic material for the virus has undergone a structural change, called a pre-core mutation. This mutation results in an inability of the hepatitis B virus to produce HBeAg, even though the virus is actively reproducing. This means that even though no HBeAg is detected in the blood of people with the mutation, the hepatitis B virus is still active in these persons and they can infect others. Hepatitis B virus DNA The best marker of hepatitis B virus reproduction is the level of hepatitis B virus DNA in the blood. Detection of hepatitis B virus DNA in a blood sample signals that the virus is actively multiplying. In acute hepatitis, HBV DNA is present soon after infection, but is eliminated over time in patients' who clear the infection. In chronic hepatitis, levels of HBV DNA often continue to be elevated for many years and then decrease as the immune system controls the virus. HBV DNA levels are sometimes referred to as the 'viral load'. How are the hepatitis B blood tests interpreted? The following table gives the usual interpretation for sets of results from hepatitis B blood (serological) tests.
Most Likely Status* HBsAg anti-HBc anti-HBs HBsAg anti-HBc anti-HBs HBsAg anti-HBc anti-HBS HBsAg anti-HBc IgM anti-HBc anti-HBs HBsAg anti-HBc Tests Results negative negative negative negative positive positive negative negative positive positive positive positive negative positive positive

Susceptible, not infected, not immune

Immune due to natural infection

Immune do to hepatitis B vaccination

Acutely infected

Chronically infected

IgM anti-HBc anti-HBs

negative negative

*Interpretation of the hepatitis B virus blood tests should always be made by an experienced clinician with knowledge of the patient's medical history, physical examination, and results of the standard liver blood tests.

What is the role of a liver biopsy in chronic hepatitis B?

During a liver biopsy, a small sample of liver tissue is collected and examined under the microscope. This test is valuable because this sample reflects the health of the liver. It can show the amount of liver injury (inflammation or cirrhosis). Liver biopsy is not routinely needed to diagnose hepatitis B, but it is used for monitoring the progression of liver damage in people with chronic hepatitis and helping to choose or evaluate treatment options.
What is the natural course of chronic hepatitis B?

The course of chronic hepatitis B is variable and depends on several factors. These factors are the patient's age at which the infection began, the extent of viral multiplication, and the immune system's ability to control the infection. The infection can progress from an:

immune tolerant phase (in which the immune system ignores the virus) immune clearance phase (in which the immune system attempts to eliminate the virus) quiescent phase (in which the virus is less active)

Immune tolerant phase For individuals infected at birth or at a young age, the immune system initially does not react to the hepatitis B virus. This phase of the infection is known as the immune tolerant phase. Despite high levels of virus in the body, there may be little evidence of inflammation and no symptoms. This phase typically lasts for years, even up to two or three decades. It is important to know that the immune tolerant phase is generally not seen in individuals who become infected during adulthood. Immune clearance phase During the third to fourth decade of chronic hepatitis B acquired in childhood, the immune system may start to react to the virus. This is known as the immune clearance phase. In contrast, an infection acquired in adulthood usually begins with the immune clearance phase. In the immune clearance phase, the immune system attacks the hepatitis B virus-infected liver cells in an attempt to clear the virus. This causes inflammation, liver injury, and the

development of scar tissue. Standard liver blood tests are abnormal, and the liver biopsy shows inflammation and/or formation of scar tissue (fibrosis). The severity of liver cell destruction, the degree of fibrosis, and the duration of the immune clearance phase determine the outcome of chronic hepatitis B. The more severe the destruction and fibrosis and the longer the phase, the more likely it is that cirrhosis will develop. Quiescent phase Following the immune clearance phase, the viral infection may enter a less active phase known as the quiescent phase. During this phase, there are no symptoms, the levels of hepatitis B virus become very low, and the standard liver blood tests become normal or nearly normal. Advanced scaring or cirrhosis that may have developed earlier, however, remains. Occasionally, during the quiescent phase, the virus becomes active again. This is known as a "flare," and often is associated with symptoms, abnormal liver blood tests, and further injury to the liver. The flares are caused by reactivation of the immune system against the virus. Flares can be very severe and result in further scarring of the liver. The disease in many of these individuals will progress to cirrhosis and eventually to advanced or end-stage cirrhosis with its associated complications, including liver cancer. Infected individuals who experience a mild immune clearance phase and move into the quiescent phase are known as healthy carriers of hepatitis B virus. These individuals usually have normal liver tests and do not have symptoms; however, they can still transmit the hepatitis B viral infection to others. The risk of hepatitis B virus carriers developing cirrhosis and liver cell cancer is small although the risk is higher as compared to people without chronic hepatitis B.

What medications are used to treat hepatitis B?

Acute infection Acute infection with hepatitis B usually does not require treatment. In rare cases, however, the infection may cause life-threatening liver failure. Patients with liver failure due to acute hepatitis B should be evaluated for liver transplantation. Small studies suggest that the drug lamivudine (Epivir) may be effective in this setting. Chronic infection If a person is chronically infected with hepatitis B and has few signs or symptoms of complications, medications usually are not used. These patients are watched carefully and given periodic blood tests. One test measures the 'viral load,' that is, the amount of viral DNA in the blood. Doctors will recommend treatment if there are signs that the virus is beginning to cause damage or if the viral load is high. Another reason to prescribe medication is if the patient has a positive test for the Hepatitis B e-antigen (HBeAg) in the blood. HBeAg is associated with an increased risk of progression of liver disease and its complications.

In chronic hepatitis B, the goal of treatment is to reduce the risk of complications including cirrhosis and liver failure. However, it takes decades for complications to occur, which makes it difficult to study the effect of medications. As a substitute for waiting years to find out what happens, scientists have used tests like the viral load or liver function tests to evaluate if medicines are working. This is logical because it is known that people who have large amounts of the virus in their blood are at highest risk to get cirrhosis. Up to one-third of people with very high viral loads (more than one million viral copies per milliliter of blood) will develop cirrhosis over a decade, compared to only 4.5% of those with low viral loads (fewer than 300 viral copies per milliliter). Medications can reduce the number of viruses in the body and may be able to eliminate the virus from the bloodstream. Logically, this should lead to them having a low rate of progression to cirrhosis (<1% per year), although large, long-term studies have not been done. Even in people who clear the virus from their blood, low numbers of viruses still live in the liver and other cells. Thus, the medications do not cure the disease, but they can prevent or delay complications and symptoms. People who have a good response to treatment can still transmit the virus. Doctors follow blood tests that measure viral load and liver function and they may recommend liver biopsies to evaluate if the medications are working. The medications in current use for chronic hepatitis B include the interferons and nucleoside/nucleotide analogues. New agents are being developed although they are still under investigation and considered experimental. There are no accepted guidelines that tell how every patient should be treated. As a result, treatment is individualized. Interferon Interferon-alpha has been used to treat hepatitis B for more than 20 years. Interferon-alpha is a naturally occurring protein that is made in the body by white blood cells to combat viral infections. In addition to its direct anti-viral effects, interferon works against the hepatitis B virus by stimulating the body's immune system to clear the virus. Compared to older interferon alpha agents, pegylated interferon alpha, marketed as Pegasys or Pegintron, has a more convenient dosing schedule, may be slightly more effective and suppresses the virus for a longer period of time. Pegylated interferon alpha is given once a week for 48 weeks.

A significant reduction in the viral load or elimination of detectable viral DNA from the blood occurs in two-thirds of persons during treatment. Blood tests for liver functions normalize in approximately 40% people treated with interferon. People who have significant abnormalities in liver function before therapy are more likely to respond to treatment. Those who have normal liver blood tests before treatment are less likely to respond to interferon therapy. Liver biopsy results show improvement in about one-third of patients.

Only 27%-32% of persons who have Hepatitis B e-antigen (HBeAg) in their blood will be able to eliminate HBeAg and produce antibodies against the HBe antigen after treatment with interferon. Relapse may occur after treatment is stopped.

Sustained response (undetectable viral load in the blood, normal liver function tests) occurs in approximately 15% to 30% of patients after the drug is stopped. Although this is not a cure (some virus still lives in the liver and elsewhere), people with sustained response are at low risk for complications of liver disease. If the responder's immune system is compromised, for example through the use of steroids or acquiring HIV, the disease can recur. Periodic monitoring of blood tests can help confirm that the response continues to be sustained. Interferon side effects Interferon causes several side effects including:

fatigue, generalized muscle aches, fever, chills and loss of appetite. These flu-like symptoms occur in approximately 80% of treated patients; mood swings, depression, anxiety and other neuropsychiatric effects may occur; and thyroid gland abnormalities resulting in hypothyroidism (too little thyroid hormone); significant suppression of the bone marrow and production of blood cells; infection; or hair loss may occur.

The side effects may be severe enough that the patient is unable to continue treatment. During treatment, the normal immune response to the virus is stimulated and may cause worsening inflammation in the liver. This is normally a good sign showing that the interferon is working, but more extreme responses may in rare cases cause liver failure. Thus, physicians will monitor blood tests closely during therapy. Persons with unstable liver disease due to cirrhosis usually should not take interferon because of the increased risk of liver failure. Nucleoside/nucleotide analogues Nucleoside/nucleotide analogues (NAs) are man-made chemicals that mimic the nucleosides and nucleotides that are used for making DNA. When the virus tries to use the analogues to make its own DNA, it is unable to make the DNA and, therefore, cannot reproduce. Examples of these agents include adefovir (Hepsera), entecavir (Baraclude), lamivudine (Epivir-HBV, Heptovir, Heptodin), telbivudine (Tyzeka) and tenofovir (Viread).

In patients who have HBeAg in their blood, NAs reduce the viral load, causing the virus to become undetectable in 21% to 67% of patients. Normalization of blood liver tests occurs in 40% to 77%, and loss of HBeAg occurs in approximately 12% to 22% of cases after one year of treatment. Results are better in patients who do not have HBeAg in their blood, with 50% to 90% having non-detectable virus and 60% to 80% having normalization of liver function tests.

In a 2004 study in people who already had cirrhosis from hepatitis B, treatment with lamivudine cut the risk of liver cancer and progressive liver failure by more than 50%. Newer NAs such as entecavir (Baraclude) and telbivudine (Tyzeka) appear to have higher response

rates than older agents such as lamivudine (Epivir-HBV, Heptovir, Heptodin), but there is less experience with these NAs. Unfortunately, the hepatitis B virus may become resistant to NAs over time (see below). Adefovir may be effective against strains of virus that have become resistant to lamivudine and may be added to lamivudine when resistance appears. Simply switching from one NA to another is not recommended because this leads to virus strains that are resistant to multiple medications. Currently, the optimal duration of treatment with nucleoside/nucleotide analogues is uncertain. Persons with HBeAg may be treated until six months after the HBeAg disappears from the blood and is replaced by antibodies (anti-HBe), if this occurs. In persons without HBeAg, the endpoints are less clear. Some experts advocate treating until the viral load (viral DNA) is undetectable and the surface antigen (HbsAg) has been cleared from the blood. Others suggest continuing medications for prolonged periods to suppress the virus. All of these strategies are hampered by the risk of the virus becoming resistant to the medications. Patients who discontinue treatment with NAs should be monitored carefully for recurrent hepatitis, which may be severe. Why does hepatitis B virus become resistant to nucleoside/nucleotide analogues? The major challenge associated with long-term therapy with NAs is the development of viral resistance to the NAs. This resistance results from a change (mutation) in the genetic material of the virus.

For lamivudine (Epivir-HBV, Heptovir, Heptodin), the incidence of resistance is 25% after one year and as high as 50% after three years of treatment. With telbivudine (Tyzeka), resistance rates are 5% to 11% after one year.

Therefore, some guidelines do not recommended lamivudine or telbivudine alone as the first treatment for chronic hepatitis B. For other NAs such as adefovir (Hepsera), resistance is less common after one year of therapy but rises to 30% after five years. Early results with entecavir (Baraclude) suggest that resistance may be uncommon with this agent. When resistance occurs, the viral load may rise or blood liver tests may become abnormal. Is there a preferred treatment for chronic hepatitis B? There are no clear guidelines to recommend which agent to use first in treating chronic hepatitis B. Interferon is given for a defined period of time and may have a more prolonged response after the medication is discontinued than NAs. However, interferon is given as an injection, and side effects often are troublesome. NAs are given as a pill and have few side effects, but the duration of treatment is unclear, and prolonged therapy may be required. NAs may be preferred in patients with unstable disease and cirrhosis because they are thought to be less likely to cause serious flares of hepatitis with more severe liver disease.

What are the effects of alcohol on hepatitis B virus?

Agents that damage the liver are particularly harmful in patients who already have hepatitis B. For this reason, it is recommended that persons with hepatitis B avoid drinking alcohol.
What are the effects of immunosuppressive medications on hepatitis B virus?

Even in people with chronic hepatitis B, the immune system is working to suppress the virus. Medications that suppress the immune system allow the virus to reproduce in large numbers and may cause the hepatitis to flare. Examples of medications that suppress the immune system are:

prednisone: used to treat many diseases, including asthma, inflammatory bowel disease, and certain types of skin disease and arthritis methotrexate (Rheumatrex, Trexall): used to treat certain types of skin disease, arthritis, and cancer; cyclophosphamide (Cytoxan): used to treat some cancers.

If an immunosuppressant drug is stopped, the body's immune system's activity may rebound and cause severe inflammation of the liver.
What is delta hepatitis?

Delta hepatitis is caused by a virus that only infects people who already have hepatitis B. The delta hepatitis virus (also known as hepatitis D or HDV) is an RNA virus, meaning that its genetic material is made up of ribonucleic acid. It is spread through exposure to contaminated blood, especially with illicit, intravenous drug use, and by sexual contact. Delta hepatitis can be acquired at the same time as acute hepatitis B. When this happens, infected people are quite sick but more than 95% are eventually able to eliminate the viruses from their bodies. People who already have chronic hepatitis B can acquire delta hepatitis as well. This often causes severe inflammation of the liver, and the viruses are less likely to be cleared. Delta hepatitis makes chronic hepatitis B much worse. It increases the risk of complications, especially cirrhosis, which occurs in up to two-thirds of patients. There is no vaccine against delta hepatitis. Interferon treatment may cause improvement in the hepatitis, but relapse is common after therapy is stopped. Prevention includes avoiding contaminated needles and practicing safer sex (abstaining or limiting the number of partners, using barrier methods of contraception). Universal vaccination of newborns with hepatitis B vaccine effectively prevents delta hepatitis because the delta hepatitis virus only causes disease in the presence of hepatitis B virus.
What about co-infection with hepatitis B virus and hepatitis C virus?

Hepatitis C is caused by a virus that is spread through contaminated needles or blood products and, less commonly, through sexual intercourse. About 10% of patients with chronic hepatitis B also are co-infected chronically with hepatitis C virus (HCV). The two viruses

interfere with each other and one usually predominates. If hepatitis C is the predominant infection, treatment is directed against the hepatitis C. Patients infected with both viruses are at higher risk for complications of liver disease. There is no effective vaccine against hepatitis C. Persons with hepatitis C should be vaccinated against hepatitis B to prevent coinfection.
What happens in co-infection with hepatitis B virus and HIV?

The human immunodeficiency virus (HIV) and hepatitis B virus are transmitted in similar ways, and it is not uncommon for an individual to have both infections. Persons with HIV who acquire hepatitis B are more likely to become chronically infected with hepatitis B than persons who do not have HIV. The reason for this is thought to be that HIV suppresses the immune system and impairs the ability of the body to eliminate the hepatitis B virus. Some nucleoside/nucleotide analogues (a class of antiretroviral drugs) are used to treat both HIV and hepatitis B, although dosages may vary in the two different infections. Stopping one of these agents when the HIV regimen is adjusted may cause hepatitis to flare.
What is the role of liver transplantation in hepatitis B infection?

Liver transplantation has been successful in patients who have irreversible, life-threatening complications of hepatitis B. This includes patients with liver failure due to end-stage cirrhosis or unusually severe (fulminant) hepatitis. Liver transplantation does not cure hepatitis B, and hepatitis may occur in the new liver. The incidence of recurrent hepatitis has been reduced to less than 10% through use of lamivudine and HBIG in transplant recipients. Use of these agents has also improved long-term survival, with 75% to 85% of patients alive after five years.
What can be done to prevent hepatitis B?

Hepatitis B is a preventable disease. Vaccination and post-exposure prophylaxis have significantly reduced rates of infection. Risk can also be reduced by avoiding unprotected sex, contaminated needles, and other sources of infection. How effective is vaccination for hepatitis B? The hepatitis B vaccine contains a protein (antigen) that stimulates the body to make protective antibodies. Examples of hepatitis B vaccines available in the United States include hepatitis b vaccine-injection (Engerix-B, Recombivax-HB). Three doses (given at 0, 1, and 6 months) are necessary to assure protection. There are also combination vaccines on the market that provide protection against hepatitis B and other diseases. Examples include:

Hepatitis-b-hepatitis-a vaccine - injection (Twinrix), which provides protection against both hepatitis A and hepatitis B. Haemophilus B/hepatitis B vaccine - injection (Comvax) provides protection against hepatitis B and Haemophilus influenzae type b (a cause of meningitis).

Pediarix provides protection against hepatitis B, tetanus, pertussis (whooping cough), and polio.

Hepatitis B vaccines are effective and safe. Up to 95% of vaccinated individuals form effective antibodies when they get the vaccine and are protected from hepatitis B. In healthcare workers, high-risk public safety workers, dialysis patients, and sexual partners of infected persons, a blood test for antibodies is recommended after vaccination to ensure that the person produced antibodies. For the few who do not form antibodies, revaccination may improve response, especially in infants. However, a small proportion of individuals will never respond to hepatitis B vaccination. Side effects from the vaccine are usually mild and include soreness at the site of injection. The risk of serious allergic reactions (anaphylaxis) is less than one per million doses. Vaccination has reduced the number of new cases of hepatitis B by more than 75% in the United States. In the United States, hepatitis B vaccination is recommended for all infants at birth. Older children and adolescents should receive the vaccine if they did not do so at birth. Adults in high risk situations also are advised to receive hepatitis B vaccine. This includes:

health care workers dentists intimate and household contacts of patients with chronic hepatitis B infection public safety workers who may be exposed to blood men who have sex with men individuals with multiple sexual partners dialysis patients injection drug users persons with chronic liver disease residents and staff in institutions that care for persons with developmental disabilities persons infected with HIV persons who require repeated transfusions or blood products.

Centers that serve high-risk individuals are encouraged to provide the vaccine to their clients. Such centers include dialysis units, drug treatment facilities, sexually transmitted diseases clinics and correctional facilities. Some countries have a high prevalence of hepatitis B in their population. Travelers who visit these countries for a prolonged period of time (usually six months) and those who may be exposed to blood or semen should consider vaccination. How effective is hepatitis B immune globulin (HBIG) in preventing hepatitis B?

HBIG is a product that contains antibodies against hepatitis B. When injected, it provides temporary protection against hepatitis B. HBIG is used when people have had significant exposure to the virus. An example would be an accidental needle stick in an unvaccinated health care worker from a needle contaminated with blood from a person with hepatitis B. HBIG should be given as soon as possible after exposure, preferably within seven days. Persons who need HBIG should also receive hepatitis B vaccine. HBIG also is given to patients with hepatitis B following liver transplantation to suppress the hepatitis B virus in the transplanted liver. What is post-exposure immunoprophylaxis for hepatitis B virus? Unvaccinated individuals who are exposed to a known case of hepatitis B or to a person at high risk for hepatitis B should be evaluated by a physician. Examples of such exposures include needle stick injuries in health care workers or sexual intercourse with an infected person. If the exposure is significant, the physician will recommend vaccination and also may recommend an injection of hepatitis B immune globulin (HBIG). HBIG is prepared from the plasma of blood donors and contains antibodies to hepatitis B. Vaccination and HBIG can substantially reduce the risk of disease in persons exposed to hepatitis B if given within one week of a needle stick or two weeks of sexual intercourse. Vaccination provides long-term immunity in people who respond to the vaccine. There is no need for HBIG if an exposure occurs to a vaccinated person who is known to respond to the vaccine; however, a blood test might be drawn to verify that the person did respond to the vaccine. How is transmission of hepatitis B virus from mother to newborn infant prevented? Infected mothers can pass hepatitis B to their newborn infants. All pregnant women should have blood tested to determine if they are infected. Infants born to infected mothers should receive HBIG and hepatitis B vaccine at birth. This is 85% to 95% effective in eliminating the risk of hepatitis B in the infant.
What is new in the treatment of hepatitis B virus?

New agents are under development to treat hepatitis B. Many of these are nucleoside/nucleotide analogues that investigators hope will be more effective than older agents. Experts also are working on treatment guidelines and the use of multi-drug therapy. Vaccination remains the key to preventing hepatitis B and holds the most promise for reducing disease burden.
Hepatitis B At A Glance

The hepatitis B virus is a DNA virus belonging to the Hepadnaviridae family of viruses. Hepatitis B virus is not related to the hepatitis A virus or the hepatitis C virus. Some people with hepatitis B never clear the virus and are chronically infected. Approximately 350 million individuals in the world and one million in the United States are chronically infected with hepatitis B. Many of these people appear healthy but can spread the virus to others.

Hepatitis B infection is transmitted through sexual contact, contact with contaminated blood (for example, through shared needles used for illicit, intravenous drugs), and from mother to child. Hepatitis B is not spread through food, water, or casual contact. Serologic (blood) markers specifically for hepatitis B virus are used to diagnose hepatitis B viral infection. The blood tests can also identify people who are at highest risk for complications. Injury to the liver by hepatitis B virus is caused by the body's immune response as the body attempts to eliminate the virus. In the United States, 95% of adults who get hepatitis B are able to clear the virus and cure themselves of infection. The remaining 5% of adults with acute hepatitis B go on to develop chronic hepatitis B. Those who acquire the infection in childhood are much more likely to have chronic infection. Chronic hepatitis B may lead to cirrhosis or liver failure. Approximately 15% to 25% of persons with chronic infection will die prematurely as a result of the infection. Progression of chronic hepatitis B viral infection occurs insidiously (subtly and gradually), usually over several decades. The course is determined primarily by the age at which the hepatitis B viral infection is acquired and the interaction between the virus and the body's immune system. Treatment with interferons or nucleoside/nucleotide analogues suppresses viral reproduction in about 40% to 90% of patients with chronic hepatitis B. The medications are also effective in reducing inflammation and improving blood tests. This can delay or reduce complications such as cirrhosis. However, most people do not have a permanent response and relapse is common. The medications do not cure the infection. Liver transplantation should be considered for patients with impending liver failure due to acute (initial) infection or advanced cirrhosis. Hepatitis B is preventable through vaccination. All children should receive the vaccine. In addition, adults at high risk for hepatitis B should be vaccinated. Unvaccinated people who are exposed to hepatitis B should be evaluated by a physician to determine if they need specific immune globulin (HBIG).

Reference: Centers for Disease Control and Prevention, "Viral Hepatitis FAQs for the Public," January 15, 2009

When to Seek Medical Care

Call your health care professional if you have any of the following:

Nausea and vomiting that does not go away in 1-2 days The inability to keep down liquids A high fever or fever that persists more than 2 days

Yellow skin or eyes Dark-colored urine (like tea or cola) Pain in the abdomen.

For severe symptoms including confusion or delirium go to a hospital emergency department. You should also contact your health care practitioner if you think you may have been exposed to the hepatitis B virus. If you have chronic hepatitis B infection and think you might be pregnant; or if you are pregnant and think you have been exposed to hepatitis B inform health care practitioner right away.
Hepatitis B Diagnosis

Hepatitis B infection is diagnosed with blood tests. These tests can detect pieces of the virus in the blood (antigens), antibodies against the virus, and viral DNA ('viral load'). Blood tests for HBV are often done when routine blood work shows abnormal liver function tests or in patients who are at an increased risk for exposure. If a patient has had a large amount of vomiting or has not been able to take in liquids, blood electrolytes may also be checked to ensure that the patient's blood chemistry is in balance. Other tests may be ordered to rule out other medical conditions. X-rays and other diagnostic images are needed only in very unusual circumstances. If a patient is diagnosed with chronic hepatitis B, they will need regular visits to their health care practitioner. Blood tests can help determine how active the infection is and whether there has been damage to the liver. Blood tests alone may not be enough to guide treatment in chronic HBV. Other tests include:

CT scan or ultrasound: These diagnostic imaging tests are used to detect the extent of liver damage and may also detect cancer of the liver caused by chronic hepatitis B. Liver biopsy: This involves removal of a tiny piece of the liver. It is usually done by inserting a long needle into the liver and withdrawing the tissue. The tissue is examined under a microscope to detect changes in the liver. A biopsy may be done to detect the extent of liver damage or to evaluate how well a treatment is working.

Hepatitis B Treatment

Acute hepatitis B usually resolves on its own and does not require medical treatment. If very severe, symptoms such as vomiting or diarrhea are present, the affected person may require treatment to restore fluids and electrolytes. There are no medications that can prevent acute hepatitis B from becoming chronic. If a person has chronic hepatitis B, they should see their health care provider regularly.

Self-Care at Home

The goals of self-care are to relieve symptoms and prevent worsening of the disease.

Drink plenty of fluids to prevent dehydration. Although, broth, sports drinks, gelatin, frozen ice treats (such as Popsicles), and fruit juices may be better because they also provide calories. Ask your physician before taking any medications, even those that are over-the-counter. Some medications depend on the liver, and liver damage may impair the body's ability to metabolize these drugs. If you are on prescription medications, check with your physician to see if the doses should be adjusted or if the medication should be temporarily discontinued. Avoid drinking alcohol until your health care practitioner allows it. Individuals with chronic HBV should avoid alcohol for the rest of their lives. Try to eat a diet that provides adequate nutrition. Take it easy. It may take some time for your energy level to return to normal. Avoid prolonged, vigorous exercise until symptoms start to improve. Call your health care practitioner for advice if your condition worsens or new symptoms appear. Avoid any activity that may spread the infection to other people (sexual intercourse, sharing needles, etc).

Medical Treatment

Acute hepatitis B infection Acute hepatitis B infection is not treated with antiviral medications.

If the infected person is dehydrated from vomiting or diarrhea, a doctor may prescribe IV fluids to help them feel better. Medications may also be used to control these symptoms. People with mild symptoms can be cared for at home.

Chronic hepatitis B infection The degree of liver damage is related to the amount of active, replicating (multiplying) virus in the blood and liver. Regularly measuring the amount of HBV DNA ('viral load') in the blood gives your physician a good idea of how fast the virus is multiplying. The treatments now in use are classified as antiviral drugs, because they try to stop the virus from multiplying.

Antiviral agents, while the best therapy known for chronic hepatitis B, do not work in all individuals with the disease.

There are several antiviral agents for chronic hepatitis B approved by the U.S. Food and Drug Administration (FDA). New drugs are always being tested and treatment recommendations are subject to change. Antiviral therapy is not appropriate for everyone with chronic HBV infection. It is reserved for people whose infection is most likely to progress to active hepatitis or cirrhosis. Decisions to start medications for treatment of hepatitis B are made by the patient and health care practitioner, often in consultation with a specialist in diseases of the digestive system (gastroenterologist) or liver (hepatologist). The decision to treat is guided by results of liver function tests, HBV DNA tests, and, frequently, liver biopsies after a complete history and physical examination.

Treatment is usually started when blood tests indicate that liver functions are deteriorating and the amount of replicating HBV is rising. Many people never reach this point. For those who do, the interval between diagnosis and starting treatment is quite variable.

Hepatitis B Medications

All of the following medications described that are used to treat chronic hepatitis B are antiviral medications. They reduce the ability of the virus to reproduce in the body and give the liver a chance to heal itself. These drugs are not a cure for hepatitis B, but they do reduce the damage caused by the virus. Although these medications are similar in some ways, they differ in other important ways. Talk to your health care practitioner about the best medication for you. Pegylated interferon alfa-2b (Pegasys) Pegylated interferon is used alone or in combination with other medications.

Pegylated interferon slows the replication of the virus and boosts the body's immune system to fight the infection. It works best in people who have relatively low levels of HBV DNA (low viral load). Pegylated interferon usually is not given to people whose liver damage has progressed to cirrhosis, because it can make the liver damage worse. Treatment is often given for 48 weeks, which is shorter than for other medications, but pegylated interferon requires regular shots (injections) while other medications are taken orally. Pegylated interferon has unpleasant side effects in many people. The side effects are similar to having the flu. For many people, side effects are so severe that they cannot continue taking the medication. Liver function tests and HBV DNA tests are used to check how well the treatment is working.

Interferon appears to stop the liver damage in up to 40% of people although relapse is possible.

Nucleoside/nucleotide analogues (NAs) Nucleoside/nucleotide analogues (NAs) are compounds that mimic normal building blocks for DNA. When the virus tries to use the analogues, it is unable to make new viral particles. Examples of these agents include adefovir (Hepsera), entecavir (Baraclude), lamivudine (Epivir-HBV, Heptovir, Heptodin), Telbivudine (Tyzeka) and tenofovir (Viread).

NAs reduce the amount of virus in the body. Between 20% and 90% of patients may have levels reduced so far that they become undetectable. Obviously, this is a broad range. The higher success rates are achieved in patients who do not have "hepatitis B e antigen" (HBeAg). HBeAg is detected by a blood test and indicates that the virus is actively multiplying. Side effects are less common than with pegylated interferon. NAs have been associated with changes in body fat distribution, reduced blood cell counts, and increased levels of lactic acid in the blood. Rarely, NAs are associated with a severe flare of hepatitis that can be serious or fatal. HBV may become resistant to NAs over time. NAs do not cure the infection. Relapse is possible even in patients who have had a good response to treatment.

Surgery

There is no surgical therapy for hepatitis B. If liver damage is so severe that the liver starts to fail, liver transplant may be recommended.

Liver transplant is a major process and surgery with an extended recovery period. It also depends on the availability of a matching donor liver. If liver transplant becomes a possibility for an individual, a health care practitioner will discuss the risks and benefits with them.

Hepatitis B Other Therapy

No herbs, supplements, or other alternative therapy is known to work as well as antiviral medication in slowing HBV replication and promoting liver healing in hepatitis B. At this time, no specific herb or herbal preparation is recommended.
Hepatitis B Vaccine

There is a vaccine against the hepatitis B virus (Engerix-B, Recombivax HB). It is safe and works well to prevent the disease. A total of 3 doses of the vaccine are given over several

months. Hepatitis B vaccine is also produced as a combination product which includes other common childhood vaccinations. This can reduce the number of shots that a child needs at a single visit. The following groups should be vaccinated for hepatitis B:

All children younger than 19 years, including all newborns - especially those born to mothers who are infected with HBV All health care and public safety workers who may be exposed to blood People who have hemophilia or other blood clotting disorders and receive transfusions of human clotting factors People who have end-stage renal disease including those who require hemodialysis for kidney disease Travelers to countries where HBV infection is common. This includes most areas of Africa, Southeast Asia, China and Central Asia, Eastern Europe, the Middle East, the Pacific Islands, and the Amazon River basin of South America. People who are in prison People who live or work in residential facilities for developmentally disabled persons People who inject illegal drugs People with chronic liver disease such as hepatitis C People who have multiple sex partners or have ever had a sexually transmitted disease Men who have sex with men Persons with HIV People who have a sexual partner who is an HBV carrier. Household contacts of persons who are carriers of HBV. Anyone who wants to be vaccinated, regardless of risk factors.

Hepatitis B immune globulin (BayHep B, Nabi-HB) is given along with the hepatitis B vaccine to unvaccinated people who have been exposed to hepatitis B.

These include close contacts of people with HBV infection, health care workers who are exposed to HBV-contaminated blood, and infants born to mothers infected with HBV. Giving the immune globulin and the vaccine together in these situations prevents transmission of the disease in 80% to 90% percent of cases.

Follow-up

If an individual has acute hepatitis B, a health care practitioner will draw blood and examine the person periodically to see if the infection is resolving. If the person develops chronic hepatitis B, they will need periodic examinations and blood tests on an ongoing basis. If these tests indicate that the virus is actively damaging the liver, the health care practitioner may suggest a liver biopsy or begin antiviral therapy. The individual will also be given a vaccine against hepatitis A, which is an unrelated virus that may cause severe liver disease in people who already carry hepatitis B. Chronic hepatitis B is associated with hepatocellular carcinoma. Fortunately, this is a rare cancer. A blood test can be used to detect a marker for this cancer or the cancer can be detected by abdominal ultrasound. Persons with chronic hepatitis B are usually screened periodically (every 6 to 12 months) for hepatocellular carcinoma, although it is not clear if this screening improves survival.
Hepatitis B Prevention

In addition to the hepatitis B vaccine, other ways to protect yourself from HBV infection include:

If you are sexually active, practice safe sex. Correct use of latex condoms can help prevent transmission of HBV, but even when used correctly, condoms are not 100% effective at preventing transmission. Men who have sex with men should be vaccinated against both hepatitis A and hepatitis B. If you inject drugs, don't share needles or other equipment. Don't share anything (including grooming products) that might have blood on it, such as a razor, toothbrush, fingernail clippers, etc. Think about the health risks if you are planning to get a tattoo or body piercing. You can become infected if the artist or person piercing you does not sterilize needles and equipment, use disposable gloves, or wash hands properly. Health care workers should follow standard precautions and handle needles and sharps safely. If you are pregnant or think you might be pregnant, tell your health care practitioner if you have any of the risk factors for HBV infection.

Hepatitis B Prognosis

Some people rapidly improve after acute hepatitis B. Others have a more prolonged disease course with very slow improvement over several months, or with periods of improvement followed by worsening of symptoms.

A small group of people (about 1% of infected people) suffer rapid progression of their illness during the acute stage and develop severe liver damage (fulminate hepatitis). This may occur over days to weeks and may be fatal. Other complications of HBV include development of a chronic HBV infection. People with chronic HBV infection are at further risk for liver damage (cirrhosis), liver cancer, liver failure, and death.
Hepatitis B Resources and Information

American Liver Foundation www.liverfoundation.org (800) 465-4837 Hepatitis B Foundation www.hepb.org (215) 489-4900 Hepatitis Foundation International www.hepatitisfoundation.org (800) 891-0707