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HEPATITIS B

What is hepatitis B?
Hepatitis B is a serious public health problem that affects people of all ages in the United States and around the world. Each year, more than 240,000 people contract hepatitis B in the United States. The disease is caused by a highly infectious virus that attacks the liver. Hepatitis B virus (HBV) infection can lead to severe illness, liver damage, and, in some cases, death.

The best way to be protected from hepatitis B is to be vaccinated with hepatitis B vaccine, a vaccine which has been proven safe and effective.

Who is at risk for hepatitis B?
About five percent of people in the U.S. will get hepatitis B sometime during their lives. If you engage in certain behaviors, your risk for hepatitis B may be much higher. You may be at risk for hepatitis B if you:

  • have a job that exposes you to human blood
  • share a household with someone who has lifelong HBV infection
  • inject drugs
  • have sex with a person infected with HBV
  • have sex with more than one partner during a six-month period
  • received blood transfusions in the past before excellent testing was available (1975)
  • are a person whose parents were born in Asia, Africa, the Amazon Basin in South America, the Pacific Islands, Eastern Europe, or the Middle East
  • were born in an area listed above
  • were adopted from an area listed above
  • are an Alaska native
  • have hemophilia
  • are a patient or worker in an institution for the developmentally disabled
  • are an inmate of a long-term correctional facility
  • travel internationally to areas with a high prevalence of hepatitis B

The largest outbreak of hepatitis B in the U.S. occurred in 1942 in military personnel who were given vaccine to protect them from yellow fever. It was unknown at the time that this vaccine contained a human blood component which was contaminated with HBV. The outbreak caused 28,585 cases of hepatitis B with jaundice.

How is HBV spread?
HBV is found in blood and certain body fluids of people infected with HBV, fluids such as serum, semen, vaginal secretions, and saliva. HBV is not found in sweat, tears, urine, or respiratory secretions. Contact with even small amounts of infected blood can cause infection.

Hepatitis B virus can be spread by:

  • unprotected sex
  • injecting drug use
  • during birth from mother to child
  • contact with blood or open sores of an infected person
  • human bites
  • sharing a household with an infected person
  • sharing items such as razors, toothbrushes, or washcloths
  • pre-chewing food for babies or sharing chewing gum
  • using unsterilizd needles in ear or body piercing, tattooing, or acupuncture
  • using the same immunization needle on more than one person

Hepatitis B virus IS NOT felt to be spread by:

  • casual contact like holding hands
  • eating food prepared by a carrier
  • kissing on the cheek or dry lip kissing
  • sharing silverware, plates, or cups
  • visiting an infected person's home
  • playing with a child who is a carrier
  • sneezing or coughing

What are the symptoms of hepatitis B?
Most people who get hepatitis B as babies or children don't look or feel sick at all. Similarly, over half of adults who get hepatitis B never have any symptoms or signs of the disease. When they get the blood test results indicating they've had or have the disease they are taken by surprise. If people do have signs or symptoms, they may experience any or all of the following:

  • loss of appetite
  • yellow skin and eyes (jaundice)
  • nausea, vomiting
  • fever
  • weakness, tiredness, inability to work for weeks or months
  • abdominal pain and/or joint pain
  • dark urine

I'm not in a risk group. How did I get hepatitis B virus?
Many people don't know when or how they acquired the infection. Studies have demonstrated that 30-40% of people who acquire hepatitis B infection are unable to recognize risk factors for the disease.

Do people usually recover from hepatitis B?
About 90% of adults recover from HBV after several months. They clear the infection from their bodies and become immune. This means they won't get hepatitis B again. They are no longer contagious and cannot pass hepatitis B on to others. Immune people generally don't develop liver failure or liver cancer from hepatitis B.

Unfortunately, about 10% of adults and most young children who are infected with hepatitis B are unable to clear the infection from their bodies and become carriers of hepatitis B.

How do I know if I have or have had hepatitis B?
The only way to know if you are currently infected with hepatitis B, have recovered, are a chronic carrier, or are susceptible to hepatitis B, is by having blood tests. The three standard blood tests for hepatitis B are the following:

HBsAg (hepatitis B surface antigen): when this is "positive" or "reactive" it means the person is HBV infected at the present time and is able to pass the disease on to others.

Anti-HBc or HBc-Ab (antibody to hepatitis B core antigen): when this is "positive" or "reactive" it may mean the person has had contact with the hepatitis B virus. This is a very complicated test to explain because often the "anti-HBc" is a false-positive. And the interpretation of the test can depend on the results of the other two blood tests. (Although blood banks routinely run an "anti-HBc,"they do not routinely run an "anti-HBs.")

Anti-HBs or HBs-Ab (antibody to hepatitis B surface antigen): when this is "positive" or "reactive" it means the person is immune to hepatitis B. S/he had the disease in the past, won't get it again, and therefore cannot pass it on to others. This test is also usually positive after a person has received hepatitis B vaccine. (To repeat, this test is not routinely done by blood banks.)

Interpretation of the Hepatitis B Blood Test Results

Tests Results Interpretation
HBsAg
anti-HBc
anti-HBs
negative
negative
negative
susceptible
(never infected)
HBsAg
anti-HBc
anti-HBs
negative
neg. or pos.
positive
immune (safe)
will not develop HBV again
HBsAg
anti-HBc
anti-HBs
positive
positive
negative
currently infected,
either acutely or a hepatitis B carrier
HBsAg
anti-HBc
anti-HBs
negative
positive
negative
multiple interpretations possible*

*Notes:

  1. May be recovering from recent HBV infection. (In blood donors, this explanation is extremely rare.)
  2. May be distantly immune and the test is not sensitive enough to detect a very low level of anti-HBs.
  3. May be uninfected with a "false positive" anti-HBc. (In blood donors, this is the case about 80% of the time.)
  4. May be an undetectable level of HBsAg present in the blood and the person is actually a carrier. (This is extremely rare.)

What does it mean if my blood bank said I tested positive for hepatitis B?
If the blood bank told you that your test was "positive," it is important to find out which test was positive. If the "HBsAg" was positive, this means that you are either a carrier of hepatitis B or were recently infected. If only the "anti-HBc" was positive, it is most likely that you either had a "false-positive" test or are immune to hepatitis B. It is important that you understand the full meaning of your test results. If you are not sure how to interpret these test results, call your blood bank for an explanation or have the blood bank send the test results to your physician. You may need to provide written permission for the blood bank to release these results to your physician. Your physician may want to repeat the blood tests or perform additional tests such as a "anti-HBs." Bring this information sheet along with you to your doctor visit.

And remember, you cannot contract hepatitis B from donating blood because the equipment used during this procedure is sterile.

HEPATITIS B CARRIERS

What does it mean to be a hepatitis B carrier?
People who do not recover from hepatitis B are called carriers. There are over one million carriers in the United States today. An HBV carrier is someone who has had hepatitis B virus in her/his blood for more than six months. While about ten percent of adults who acquire HBV infection become carriers, children have a greater risk. The younger the child is at the time of infection, the greater the risk that the child will become a lifelong carrier. Many babies born to carrier mothers will also become carriers of HBV unless the babies are given special shots in the hospital and during the six months after birth to protect them from the infection.

A carrier usually has no signs or symptoms of HBV but remains infected with the virus for years or for a lifetime and is capable of passing the disease on to others. Sometimes HBV carriers will spontaneously clear the infection from their bodies, but most will not. Although most carriers have no serious problems with hepatitis B and lead normal healthy lives, some carriers develop liver problems later. Hepatitis B carriers are at significantly higher risk than the general population for liver failure or liver cancer.

How can I take care of myself if I am a hepatitis B carrier?
A person who has HBV should see a physician every six months to one year. The physician will do blood tests to check how the liver is working and check for early signs of liver cancer. It is best for HBV carriers to avoid alcohol because alcohol can cause injury to the liver. Additionally, your physician should know about all the medicines you are taking, even over-the-counters, because some medicines can hurt your liver. If there are liver test abnormalities, consultation with a gastroenterologist (liver specialist) regarding further management strategies (e.g., your need for treatment, dietary recommendations) is important.

If your liver disease has progressed...
If your liver disease has progressed beyond being a "healthy carrier," here are some extra precautions you should take after discussing the below with your health care professional:

  • Get a yearly influenza vaccination. Patients with severe liver disease (cirrhosis) should also receive pneumococcal vaccine.
  • Get vaccinated against hepatitis A. Hepatitis A can further damage your liver.
  • Don't eat raw oysters. Raw oysters may carry the bacteria Vibrio vulnificus which can cause primary septicemia in individuals with liver disease. Approximately 40% of these septicemia cases are fatal.

What can I do to protect others from HBV infection?
Carriers may feel healthy, but are still capable of passing the hepatitis B infection on to other people. In order to protect others from getting HBV, it is important to protect them from contact with your infected blood and other infectious body fluids, including saliva, semen, and vaginal fluids. Sweat, tears, urine, and respiratory secretions do not contain hepatitis B virus.

What are the long-term effects of hepatitis B?
Each year, approximately 5,000 people in the U.S. die of liver failure related to hepatitis B, and another 1,500 die of liver cancer related to hepatitis B. Hepatitis B is the most common cause of liver cancer worldwide and liver cancer is one of the three most common cancers in the world.

Is there a cure for hepatitis B?
As of this writing, there is only one FDA-approved medicine, interferon alfa-2b, that may help or cure a person who is already infected with HBV. It often has side effects and is reserved for those whose liver enzyme tests are abnormal. Ask your doctor if you are a candidate for interferon therapy. Researchers continue to seek additional cures for hepatitis B.

Why is hepatitis B so serious in pregnant women?
Pregnant women who are infected with HBV can transmit the disease to their babies. Many of these babies develop lifelong HBV infections, and as many as 25% will develop liver failure or liver cancer. All pregnant women should be tested early in pregnancy to determine if they are infected with hepatitis B virus. If the blood test is positive, the baby should be vaccinated at birth with two shots, one of hepatitis B immune globlin and one of hepatitis B vaccine. The infant will need additional doses of hepatitis B vaccine at one and six months of age.

How can hepatitis B be prevented?
Hepatitis B vaccine can provide protection in 90-95% of healthy people. The vaccine can be given safely to infants, children and adults in three doses over an approximate six-month period. Even pregnant women can be safely given these shots if their risk factors warrant it. Hepatitis B shots are very safe and side effects are rare.

At what age are hepatitis B shots routinely given?
In the U.S., hepatitis B shots are routinely recommended for all babies and adolescents. For babies, the first hepatitis B shot is given in the hospital or shortly after birth. All adolescents should receive the vaccine at age 11-12 if they have not been previously vaccinated. Older adolescents should be vaccinated at the earliest opportunity. Any adult or child who is at risk for hepatitis B virus infection can start the vaccine series at any age.

Where can I get hepatitis B shots and how much do they cost?
Check with your clinic first. If your clinic doesn't provide hepatitis B shots or if they are too costly, call your public health department. This vaccine is supposed to be available to all infants in the United States. For infant, child, and adult doses, the price of the vaccine varies widely so be sure to shop around for the best price. Different amounts of the vaccine are given to people of different ages so when you're checking on the price, be sure to let your clinic know the age of the child or adult.

How many shots are needed?
Three shots are needed for the best protection against HBV but some protection is provided from receiving one or two doses. The shots are usually given on a schedule of 0, 1, and 6 months, but there is great flexibility in the timing of these shots. Like all other vaccines, you never have to start the series over again. If you fall behind on the schedule, simply cntinue from where you left off. These shots will not "cure" a person who is already infected with hepatitis B virus, but when given to family members and close contacts who have not yet been infected, the shots will provide protection.

What should I do if I'm in a high-risk group?
If you are in a high-risk group for hepatitis B (groups are listed on page 1) see your doctor or call your public health department to determine whether you should be tested for hepatitis B first or if you should simply receive the shots. These shots may be available for some adults at public health departments, but it's usually a good idea to check with your own doctor first. All people in risk groups should protect themselves from hepatitis B. If you are at risk, every day you delay getting vaccinated increases your chances of getting this highly contagious liver disease. The problems caused by hepatitis B liver cancer and liver failure are too great. See your doctor. If you are in a risk group, get blood tests and/or get vaccinated!!

How does hepatitis B differ from hepatitis A and C?
Hepatitis A, B, and C are all viruses that attack and injure the liver, and all can cause similar symptoms. Usually, people get hepatitis A from eating or drinking contaminated food or water but it may also be sexually transmitted. Hepatitis C, formerly known as hepatitis non-A non-B, is a blood-borne virus that is spread in much the same way as hepatitis B. Both hepatitis B and C can cause life-long liver problems while hepatitis A does not. Vaccines to prevent hepatitis A are now available. There is no vaccine yet for hepatitis C. If you've had hepatitis A or C in the past, it is still possible to get hepatitis B

(from the Hepatitis B Immunization Action Coalition)

HEPATITIS B FACT SHEET (FROM CDC)

CLINICAL FEATURES
  • Jaundice, fatigue, abdominal pain, loss of appetite, intermittent nausea, vomiting
ETIOLOGIC AGENT
  • Hepatitis B virus
INCIDENCE
  • 140,000-320,000 infections/yr in United States
  • 70,000-160,000 symptomatic infections/yr
SEQUELAE
  • Of symptomatic infections, 8400-19,000 hospitalizations/yr and 140-320 (0.2%) deaths/yr;
  • Of all infections, 8,000-32,000 (6%-10%) chronic infections/yr, and 5,000-6,000 deaths/yr from chronic liver disease including primary liver cancer
PREVALENCE
  • Estimated 1-1.25 million chronically infected Americans
COSTS
  • Estimated $700 million (1991 dollars)/yr (medical and work loss)
TRANSMISSION
  • Bloodborne
  • sexual
  • perinatal
RISK GROUPS
  • Injection drug users
  • Sexually active heterosexuals
  • Men who have sex with men
  • Infants/children of immigrants from disease-endemic areas
  • Low socioeconomic level
  • Sexual/household contacts of infected persons
  • Infants born to infected mothers
  • Health care workers
  • Hemodialysis patients
SURVEILLANCE
  • National Notifiable Diseases Surveillance System
  • Viral Hepatitis Surveillance Program
  • Sentinel Counties Studies
TRENDS Incidence increased through 1985 and then declined 55% through 1993 because of wider use of vaccine among adults, modification of high-risk practices, and possibly a decrease in the number of susceptible persons. Since 1993, increases observed among the three major risk groups: sexually active heterosexuals, homosexual men, and injection drug users.
PREVENTION
  • Hepatitis B vaccine available since 1982
  • Screening pregnant women and treatment of infants born to infected women
  • Routine vaccination of infants and 11-12 year olds
  • Catch-up vaccination of high-risk groups of all ages
  • Screening of blood/organ/tissue donors