Rates of hepatitis B among U.S. children and teenagers declined by almost 90 percent between 1991 and 2002, according to a new report from the Centers for Disease Control and Prevention (CDC).
Many researchers attribute the decline to federal recommendations established in 1991 that advised that all infants receive the hepatitis B vaccine, which protects people from this liver-attacking virus that is spread though blood and other bodily fluids. By 1999, the CDC extended the hepatitis B vaccination recommendation to all children under the age of 18 who had not already received the vaccine.
While children and teenagers infected with hepatitis B will usually experience symptoms, many adults do not realize that they are infected with the virus. If untreated, hepatitis B can lead to chronic hepatitis B infection, liver cancer, cirrhosis of the liver or liver failure. Below, Emmet Keeffe, MD, the chief of hepatology at Stanford University Medical Center in California, discusses how to prevent and treat hepatitis B.
Who is at risk for hepatitis B?
Hepatitis B occurs in about 0.3 percent of the adult U.S. population. High-risk populations include people born in Asia, people with parents born in Asia, those who have had blood transfusions before 1992, health care workers, individuals who have had multiple sexual partners, particularly men who have sex with men, and individuals who were ever IV drug users.
What are the symptoms?
If you are a young individual, you're much less likely to have symptoms than if you're an adult. So there are many children that are infected with hepatitis, either hepatitis A, B or C, and never know it in their youth.
When hepatitis B occurs in an adult, 50 percent or more will have symptoms. When symptoms occur, they're typically gastrointestinal in nature, so it's nausea, upset stomach. There may be vomiting. There's often, but not always, fever. And there's a significant amount of what we call malaise, or a general feeling of being run down and fatigued. So it's a flu-like illness, although it's more severe. When viral hepatitis is particularly severe, then the patient will become jaundiced. And the way one notices that is that the whites of the eye become yellow.
How is hepatitis B spread?
Hepatitis B is spread by unprotected sexual contact with an infected individual or through contact with contaminated needles either through intravenous drugs use or through tattooing or body piercing. Fortunately, our blood supply has now been cleaned of hepatitis because all blood donors are checked for hepatitis.
Health
Hepatitis B can also be acquired when physicians and nurses and other health care workers are accidentally stuck with a needle. Fortunately most health care workers have become vaccinated to eliminate the risk.
Avoid sharing personal items that might have particles of blood on them such as a razor or a toothbrush. Also, take precautions if in contact with someone who has a cut or an open wound that's bleeding.
How is hepatitis B diagnosed?
Hepatitis B is diagnosed with a blood test. The first detection is often quite coincidental. It might be identified when you go to get your first life insurance policy, or if you're a good soul and become a blood donor, you'll be notified by the blood bank that you have hepatitis B. Sometimes a liver biopsy is required, in which a piece of the liver is removed so it can be examined.
Do adults need to get vaccinated for hepatitis B?
The recommendations for the Centers for Disease Control and Prevention have evolved over time since the early 1980s when the vaccine first became available. The first recommendations were that all individuals at increased risk for hepatitis B get vaccinated. And that's primarily health care workers and individuals who had frequent sexual contact, particularly men who have sex with men, and individuals who were IV drug users. Later, the CDC realized if we're really going to try to eradicate hepatitis B in the United States, we have to vaccinate all newborns. So the current recommendations for are vaccination for all newborn children and catch-up vaccinations for adolescents and young adults.
How is hepatitis B treated?
Once hepatitis B is detected, you need to consult your physician because it's complicated in terms of what ought to be done next. When you're infected with acute hepatitis B as an adult, there's a 95 to 98 percent chance the virus will go away. Acute hepatitis B usually only needs careful monitoring. About 2 to 5 percent of people will develop chronic hepatitis B infections. Some of these people are what we call healthy carriers. They've had the virus, but it's inactive, and they do not need therapy. Other carriers are in an early phase that we call the immune tolerant phase. They have a high amount of virus, but their body is not reacting against it.
About a third to a half of patients have hepatitis B, and there's ongoing liver damage, and those individuals are candidates for therapy. We have three licensed therapies that can control, and in some cases, eradicate hepatitis B: interferon, lamivudine and adefovir. Also, pegylated interferon is approaching Food and Drug Administration approval because the studies that have been completed so far show promising results.
How likely is it that acute hepatitis B will become chronic?
There's a 2 to 5 percent chance that you will contract chronic hepatitis B. However if you're born from a mother who's a hepatitis B carrier there there's about a 90 percent chance that you'll be chronic. And if you're infected as a 5- or 10-year-old child, there's about a 50 percent chance the virus will be chronic.
What are the complications of chronic hepatitis B?
When hepatitis is chronic, there is a lifelong risk of premature death from either cirrhosis or liver cancer in those that were infected at the time of birth. Beginning around age 35 or 40, we screen people with chronic hepatitis every six months for liver cancer, because if we're going to do anything about liver cancer, we need to detect it early, when it's small, when it can be removed or we can consider liver transplantation.
Who will need a liver transplant?
About 1 in 300 cases of acute hepatitis B may progress to what we call fulminant, or severe, hepatitis B, which poses risk of sudden death, and those people need to be considered for liver transplantation. On the chronic side, we are transplanting patients who have end-stage cirrhosis from hepatitis B and C. For a while we did not transplant hepatitis B patients because the virus invariably returned. But we now use medications after transplant that is effective in preventing the virus from getting into the new liver.
So I have to put in a plug for all of you to get your donor cards. When you get your driver's license, talk to your family members and be an organ donor, because we have a critical organ shortage.
What is the acceptable amount of alcohol consumption for someone with chronic hepatitis B?
We are often asked by patients who have hepatitis B or hepatitis C, "Doc, can I ever have a drink again?" And the answer to that question is complicated. We know clearly from a number of research studies that regular and heavy use of alcohol accelerates the progression of both hepatitis B and C. What we don't know so well is what lower threshold of alcohol use is safe.
So in my practice, I make use of my scientific knowledge and my common sense. If I have an individual who's ever drank heavily or abused alcohol, I tell them when I've diagnosed hepatitis C or B, no more alcohol, ever, because we want to slow down the progression.
What is your advice to people about the prevention and treatment of hepatitis B?
I try to educate my community members that if you're in a risk group, you ought to be evaluated and consult an expert to see if antiviral therapy is something that would be appropriate for you. In the case of my Asian population, there is a certain nonchalance about hepatitis B, because many people in these communities say that, "Mom has hepatitis B. My sister has hepatitis B. They all feel well, and I don't need to see a doctor or be tested."
The other error I see is a lack of recognition of how easily hepatitis B is spread by sexual contact. People all fear HIV or AIDS, but what is not widely known is that hepatitis B is the most easily spread virus by sexual contact.
The main thing I want people with hepatitis to know is that we have made tremendous progress in the past 10 years, both diagnostically and therapeutically. Think about AIDS and the HIV epidemic. We did not have effective therapy 10 to 15 years ago. We now know that that's a virus that we can effectively control. I predict we're going to have the same outcome in hepatitis B and C in the next five to 10 years.
