Hepatitis B Overview

Hepatitis is a general term that means inflammation of the liver. The liver can become inflamed as a result
of infection, a disorder of theimmune system, or exposure to alcohol, certain medications, toxins, or
poisons.

• Hepatitis B is caused by infection with the hepatitis B virus (HBV). This infection has 2 phases:
acute and chronic.
o Acute (new, short-term) hepatitis B occurs shortly after exposure to the virus. A small
number of people develop a very severe, life-threatening form of acute hepatitis called fulminant
hepatitis.
o Chronic (ongoing, long-term) hepatitis B is an infection with HBV that lasts longer than 6
months. Once the infection becomes chronic, it may never go away completely.
o About 90-95% of people who are infected are able to fight off the virus so their infection
never becomes chronic. Only about 5-10 percent of adults infected with HBV go on to develop
chronic infection.
o HBV infection is one of the most important causes of infectious hepatitis.

• People with chronic HBV infection are called chronic carriers. About two-thirds of these people
do not themselves get sick or die of the virus, but they can transmit it to other people. The remaining
one third develop chronic hepatitis B, a disease of the liver that can be very serious.
o The liver is an essential organ that the body needs to stay alive. Its most important
functions are filtering many drugs and toxins out of the blood, storing energy for later use, helping
with the absorption of certain nutrients from food, and producing substances that fight infections
and control bleeding.
o The liver has an incredible ability to heal itself, but it can only heal itself if nothing is
damaging it.
o Liver damage in chronic hepatitis B, if not stopped, continues until the liver becomes
hardened and scarlike. This is called cirrhosis, a condition traditionally associated with alcoholism.
When this happens, the liver can no longer carry out its normal functions, a condition called liver
failure. The only treatment for liver failure is liver transplant.
o Chronic hepatitis B also can lead to a type of liver cancer known ashepatocellular
carcinoma.
o Any of these conditions can be fatal. About 15-25 percent of people with chronic
hepatitis B die of liver disease.

• Hepatitis B is the most common serious liver infection in the world. Worldwide, about 350 million
people are chronic carriers of HBV, of whom, more than 250,000 die from liver-related disease each
year.

• In the United States, hepatitis B is largely a disease of young adults aged 20-50 years. About
1.25 million people are chronic carriers, and the disease causes about 5000 deaths each year.

• The good news is that infection with HBV is almost always preventable. You can protect yourself
and your loved ones from hepatitis B.

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

• Many types of acute viral hepatitis have similar symptoms (hepatitis A, hepatitis C).

• Fulminant hepatitis is an unusual illness. It is a severe form of acute hepatitis that can be life
threatening if not treated right away. The symptoms develop very suddenly.
o Mental disturbances such as confusion, lethargy, extreme sleepiness or hallucinations
(hepatic encephalopathy)
o Sudden collapse with fatigue
o Jaundice
o Swelling of the abdomen

• Prolonged nausea and vomiting can cause dehydration. If you have been vomiting repeatedly,
you may notice these symptoms:
o Feeling tired or weak
o Feeling confused or having difficulty concentrating
o Headache
o Not urinating
o Irritability

• Symptoms of liver failure may include the following:

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

Hepatitis B Causes

• The hepatitis B virus is known as a blood-borne virus because it is transmitted from one person
to another via blood.
o Semen and saliva, which contain small amounts of blood, also carry the virus.
 o The virus can be transmitted whenever any of these bodily fluids come in contact with
the broken skin or a mucous membrane (in the mouth, genital organs, or rectum) of an uninfected
person.

• People who are at increased risk of being infected with the hepatitis B virus include the following:
o Men or women who have multiple sex partners, especially if they don't use a condom
o Men who have sex with men
o Men or women who have sex with a person infected with HBV
o People with other sexually transmitted diseases
o People who inject drugs with shared needles
o People who receive transfusions of blood or blood products
o People who undergo dialysis for kidney disease
o Institutionalized mentally handicapped people and their attendants and family members
o Health care workers who are stuck with needles or other sharp instruments
contaminated with infected blood
o Infants born to infected mothers

• In some cases, the source of transmission is never known.

• The younger you are when you become infected with the hepatitis B virus, the more likely you
are to develop chronic hepatitis B. The rates of progression to chronic hepatitis B are as follows:
o 90% of infants infected at birth
o 30% of children infected at age 1-5 years
o 6% of people infected after age 5 years
o 5-10% of infected adults

• You cannot get hepatitis B from the following activities:

o Being sneezed or coughed on
o Hugging
o Handshaking
o Breastfeeding
o Eating food or drinking water
o Casual contact (such as an office or social setting)

Hepatitis B

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.

What is hepatitis?

The term 'hepatitis' simply meansinflammation 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.
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 life-threatening 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

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 todetoxify 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-fetoproteinand 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.

What can be done to prevent hepatitis B?

Hepatitis B is a preventable disease.Vaccination and post-exposure prophylaxishave 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 ofmeningitis).

• 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.