Reviewed By: Dr. Kurt Kloss, MD
Last Reviewed Date: Dec 13, 2018
Last Modified Date: Dec 13, 2018
Published Date: Dec 13, 2018
TABLE OF CONTENTS
Chapter 1: Hepatitis A: The Basics
Chapter 2: Hepatitis A Symptoms
Chapter 3: Hepatitis C: The Basics
Chapter 4: Hepatitis C in the Early Stages
Chapter 5: Chronic Hepatitis C Symptoms
Chapter 6: Testing for Hepatitis
Hepatitis A: The Basics
Hepatitis A is a disease that affects the liver and is caused by the hepatitis A virus (HAV). It is a contagious disease that has been on the decline in the United States, and other developed nations, since the introduction of a hepatitis A vaccine in 1995. Despite vaccination, an estimated 25,000 new cases still occur annually. The disease is much more common in developing areas, such as Latin America, the Middle East, Asia, Africa and Eastern Europe, where vaccination is not as widespread.
The term hepatitis means liver inflammation, which can be caused by some drugs, many toxins, regular or excessive use of alcohol, certain diseases and health conditions, as well as infections whether viral or bacterial. Hepatitis A is one of the families of viral infections that, collectively, are the most common cause of hepatitis. Unlike other common forms of viral hepatitis, such as hepatitis B and C; hepatitis A exacerbate itself only as an acute infection, rather than a chronic disease. So, it is the kind that clears without treatment, for the majority of patients. That acute infection can range from a mild illness that lasts a few weeks, to a severe one that lasts several months.
How is Hepatitis A Spread?
The hepatitis A virus is found in the stool of an infected individual. It is spread to others when they come in contact with that infected stool. For instance, outbreaks have happened in groups of people who have eaten at restaurants where an infected employee has failed to wash his hands thoroughly after using the bathroom. He or she will then risk transmitting the virus into the foods he or she handles. Another frequent venue for the transmission of the virus is day care centers where children may get some of their stool on their hands; then, touch toys and other items that other children may put in their mouths during play. Additionally, daycare workers may spread the disease if their hands are not thoroughly washed after getting in contact with soiled diapers.
Hepatitis A Symptoms
Hepatitis A often presents no symptoms for those who are infected; or, symptoms can be very mild for some. About 70 percent of children under the age of 6 display no symptoms from the virus while others experience very mild flu-like symptoms; and, when they do become ill, the infection typically runs its course in less than 2 months. Approximately 30 percent of older children and adults who become infected with hepatitis A will have no symptoms, but about 70 percent will develop symptoms that can include:
- Jaundice, which is yellowing of the skin and whites of the eyes
- Muscle aches or soreness
- Loss of appetite
- Abdominal pain
- Dark, concentrated urine
- Light, clay colored stools
Symptoms of hepatitis A typically appear 2 to 7 weeks after being infected with the virus. Illness can last anywhere from 2 weeks to 6 months. Once a person recovers from hepatitis A, he or she will develop a natural immunity to the virus that, in most, provides lifelong protection against having a relapse.
Hepatitis A Prevention
The most efficient means of preventing hepatitis A infection is vaccination, which is done in a series of 2 injections. While vaccination is a good idea for everyone, it is especially important to: 1) those who suffer from any form of liver disease; 2) people who work in higher-risk environments, such as health care workers and daycare employees; and, 3) anyone who travels to developing nations where the disease is prevalent. If you are not sure whether you have been vaccinated or not, blood testing can determine your immunity status by detecting antibodies to hepatitis A in your blood.
Diagnosis and Treatment of Hepatitis A
Hepatitis A diagnosis begins with an evaluation of any symptoms that may seem present. If an infection is suspected, blood tests are typically ordered, which may include liver function testing, as well as a blood test to look for antibodies indicating a possible infection. The treatment generally consists of having some rest, drinking a lot of fluids and having a nutritious diet to help your body fight the infection. This hold come along with close monitoring of your liver’s proper functioning by your health care team. For most, the infection will clear without further treatment; but, in a small percentage of people, hospitalization may be necessary to ensure against complications as the liver heals. This is normally the case of people with especially severe cases of hepatitis A; or, those who have preexisting liver problems.
Hepatitis C: The Basics
Hepatitis C is a viral infection that can cause some serious liver damage. Just as there are many types of hepatitis, there are also several forms of hepatitis C. In the United States, approximately 3.9 million people have hepatitis C. Type 1 is the most common in this country. Although it is curable, many people go untreated because they do not become aware that they have the condition.
Symptoms of hepatitis C are subtle and may take decades to appear. It's important that you recognize the symptoms as soon as they show up to minimize the associated liver damage.
There are five different types of hepatitis from which hepatitis C emanates. Hepatitis transmission is different for each type. While drinking contaminated water can give you hepatitis A or E, you cannot get hepatitis C in this way. Hepatitis C is usually transmitted by blood when an individual is exposed to the blood of someone who carries the disease. You can also get hepatitis C through sexual intercourse, though the risk is much lower.
Hepatitis C is most commonly contracted through infected needles and other types of medical equipment. Those who inject drugs with non-sterile needles are at a high risk for contracting hepatitis C.
Individuals who received a blood transfusion or organ transplant prior to 1992 may also be at risk for hepatitis C via infected blood that could have been supplied to them at the hospital. Prior to this year, screening methods did not regularly include testing for hepatitis C. Today, hospitals include hepatitis C screenings routinely when blood is donated; so, this is no longer a concern.
In rare cases, an individual may get hepatitis C from a razor, toothbrush, or other personal care item that's contaminated with the blood of an infected person. Those who know they have hepatitis C should not share these personal care kits.
It is possible to pass hepatitis C from a mother to baby. An expectant mother who knows that she has hepatitis C should speak with her health care provider about the condition.
You cannot get hepatitis C through having a casual interaction with an individual. The disease is not passed through saliva, so you cannot contract it from kissing, hugging, sneezing, or coughing. If you know that an individual has hepatitis C, the most important precautions involve practicing safe sex and avoiding any contact with that person's blood. Unfortunately, many people do not know that they have hepatitis C until it's in its later stages and, therefore, may spread it long before they're aware of the condition.
Hepatitis C in the Early Stages
The best time to diagnose hepatitis C is when it's still in the earliest stage, known as the acute stage. If the condition is left untreated, it will worsen; therefore, it becomes more difficult to get treated. The symptoms of hepatitis C are easily confused with other conditions. For those with known exposure, it's particularly important to watch for the associated symptoms.
Symptoms of acute hepatitis C can appear anywhere between four and 15 weeks after initial exposure. These symptoms typically last between two and 12 weeks. Identifying these symptoms early can help you diagnose hepatitis C long before it becomes a chronic disease. Unfortunately, most people do not experience a serious acute period. Some have only mild symptoms while others may have no symptoms at all.
Acute hepatitis C is often mistaken for a common virus. It looks and feels very much like a cold or flu. Once the symptoms have passed, people assume that the virus is gone. However, if hepatitis C is the underlying cause of the symptoms, the disease will continue to worsen until you're left in a much more serious condition, years in the future.
If you know or suspect that you've been exposed to hepatitis C, you should be particularly mindful of symptoms that might indicate the acute stage of this disease. These symptoms include:
- Abdominal pain, particularly on the upper right
- Joint pain
- Muscle pain
- Loss of appetite
Less commonly, individuals may experience dark urine or clay-colored bowel movements. Jaundice is another symptom that can occur with acute hepatitis C, though it's not seen as often at this early stage. Jaundiced individuals will have a yellowish tinge to their eyes or skin.
It's extremely difficult to distinguish hepatitis C from a common viral infection. If you know that you've been exposed to the blood of another individual or to a needle that could potentially be infected, you should speak with your doctor about whether the possibility of having contracted the condition. Keep in mind that infected individuals often don't know about the problem, so you could get hepatitis C even from someone who believes that they do not have the disease.
Treating Acute Hepatitis C
If you have acute hepatitis C, your doctor will typically monitor your condition closely to assess how the disease is progressing. In the acute stage, hepatitis C is treated much the same way as the common viral infections that it mimics. Rest, fluids, and a healthy diet are the best treatments. This may help with the patient's recovery, but it does not impact the likelihood that the disease will progress.
Regardless of how the acute stage is handled, between 75 and 85 percent of those with hepatitis C will develop a chronic condition. Other patients experience a spontaneous clearance of the infection and require no further observation or treatment. Spontaneous clearance of acute hepatitis C usually happens within six months of infection.
Individuals may have a period of undetectable hepatitis C between the acute and chronic stages. For this reason, one negative test isn't sufficient to determine whether an individual had a spontaneous clearance. If you have two negative tests spaced several weeks apart, you can consider it as a successful spontaneous clearance of the disease.
Most patients will go on to have chronic hepatitis C. When the disease reaches this point, your health care provider can discuss the possible treatment options with you. The earlier you diagnose and treat chronic hepatitis C, the better your outcome will be.
Chronic Hepatitis C Symptoms
After the acute stage of hepatitis C has passed, an infected individual may go years before they notice any further signs of the disease. Chronic depression and fatigue can be a sign of hepatitis C, but it's difficult for many people to make the connection since these symptoms can have other underlying causes.
Hepatitis C typically affects the liver. Signs of chronic hepatitis C are usually associated with liver failure. Dark urine, jaundiced eyes and skin, and clay-colored bowel movements are all common signs of liver problems.
If you've had hepatitis C for 20 or 30 years, the disease may have caused a condition known as cirrhosis. Cirrhosis is a term used for liver scarring. Symptoms of cirrhosis include water retention, easy bruising or bleeding, and jaundice. About 10 to 20 percent of people with hepatitis C will eventually develop cirrhosis. You're more likely to have cirrhosis if:
- You are 50 years of age or older
- You are male
- You use alcohol
- You have hepatitis B
- You have HIV
- You have non-alcoholic fatty liver disease
- You take immunosuppressant drugs
Cirrhosis may worsen and lead to liver cancer. Among those who have both hepatitis C and cirrhosis, roughly 3 to 6 percent will develop liver failure, and 1 to 5 percent will get liver cancer.
Though it's less common, hepatitis C may also cause symptoms in other parts of the body. It's possible for the hepatitis C infection to cause the formation of cryoglobulins. These abnormal antibodies inflame the arteries and lead to symptoms such as:
- Joint pain
- A raised purplish rash on the legs
- Discolored fingers or toes with pain in cold temperatures
- Pain or swelling in various parts of the body
Anyone experiencing symptoms such as these should speak with a health care provider immediately. Liver failure is always a serious condition, regardless of whether it's the result of a hepatitis C infection or not. If you believe you're experiencing symptoms of chronic hepatitis C, speak with your doctor about the best way to proceed.
Treating Chronic Hepatitis C
If you are diagnosed with hepatitis C before you developed cirrhosis, your chances of a full recovery are greater. Though it is possible to cure hepatitis C after cirrhosis has occurred, you will still have to deal with the impact of the cirrhosis, which is discussed further in the next section.
Prior to 2011, hepatitis C was treated with interferon and ribavirin. These medications boost the immune system and can help your body overcome the hepatitis C virus. Unfortunately, both drugs have severe side effects.
Since 2011, the United States Food and Drug Administration has approved several other antiviral medications for the treatment of hepatitis C. These have fewer side effects and higher success rates. Some treatments are effective in as little as eight weeks. These include:
- Daclatasvir-sofosbuvir (Sovodak, Darvoni)
- Elbasvir-grazoprevir (Zepatier)
- Glecaprevir-pibrentasvir (Mavyret)
- Ledipasvir-sofosbuvir (Harvoni)
- Ombitasvir-paritaprevir-ritonavir (Technivie)
- Ombitasvir-paritaprevir-ritonavir and dasabuvir (Viekira Pak)
Due to such medications, it's now possible to cure chronic hepatitis C relatively easily. These protease inhibitors restrict proteins to the virus so it cannot reproduce effectively. This will let it die out. Most treatments will cure the disease in less than 24 weeks. The viral cure rate for hepatitis C is, nowadays, over 90 percent.
Your doctor will consider you cured if you achieve a sustained virologic response (SVR). This means that the hepatitis C virus is too low to be detected three months after your treatment cycle is complete.
If you have or have had hepatitis C, you should take extra measures to protect your liver. These include avoiding alcohol and speaking with a health care provider before taking supplements, herbs, or any prescription or over-the-counter medications.
Hepatitis C and Cirrhosis
The hepatitis C virus typically settles in the body's liver cells to reproduce. The virus uses the cell's RNA material to replicate itself, releasing these copies to settle in other liver cells and continue the process. This process causes continuous damage to the liver as long as the virus keeps reproducing. This damage is intensified by the body's own immunological response. As the body fights the virus, it can do additional damage to the liver, which essentially serves as the battlefield for this disease.
Though the liver may only experience inflammation in the early stages of the disease; over time, it will undergo permanent damage and scarring known as cirrhosis. Even if the hepatitis C virus is eliminated, the cirrhosis itself will remain. Cirrhosis has two phases. In the compensated phase, the patient is often asymptomatic and the liver is still functioning well. In the decompensated phase, the liver function is compromised. Cirrhosis can block a proper blood flow in the liver, making it nearly impossible for this organ to do its job.
Between 5 and 20 percent of people with hepatitis C will develop cirrhosis. It usually takes between 20 to 30 years for cirrhosis to develop. If cirrhosis is left untreated, it may lead to liver failure. Cirrhosis is also the leading cause of liver cancer. Over 70 percent of individuals with liver cancer developed this as a result of cirrhosis of the liver. Ultimately, cirrhosis and liver cancer are responsible for 1 to 5 percent of deaths that are related to hepatitis C.
Early symptoms of cirrhosis include a loss of appetite, weight loss, fatigue, and weakness. As the condition progresses, symptoms will include:
- Jaundiced skin and eyes
- Muscle cramps
- Spider veins
- Itching skin
- Swelling of the feet and legs
- A feeling of fullness in the belly
- Difficulty taking deep breaths
If cirrhosis continues to worsen, the patient may develop end-stage liver disease. Symptoms include all of the above as well as easy bruising and bleeding, as well as a difficulty with memory and concentration. The only treatment for an end-stage liver disease is a liver transplant. In the United States, hepatitis C is the leading cause of liver transplants.
Risk Factors for Hepatitis C
Since the symptoms of hepatitis C are so subtle in the earlier stages, it's particularly important for people to understand their risk factors. If you have a high-risk factor for hepatitis C, it's worthwhile to discuss it with your physician. You will then explore the best course of action in regards to hepatitis C testing.
If you were born between 1945 and 1965, you are five times more likely to have hepatitis C than other adults. Roughly 75 percent of people with hepatitis C were born during this period. Transmission of hepatitis C was at its highest between the 1960s and 1980s, which is when most of these baby boomers likely contracted the disease.
Poor infection control procedures may have transmitted the virus to patients via medical equipment. Contaminated blood and blood products were another source of infection during this period, as screening processes for hepatitis C were not yet established. Shared needles or contact with another individual's infected blood may have also helped spreading the virus. Infected individuals rarely know exactly how they got the disease.
Injection drug use is one of the most common risk factors for those who are infected with hepatitis C today. Those who sniff cocaineusing shared equipment have a higher risk factor as well. A massive 80 percent of new drug users get hepatitis C within 12 months.
Others who have a higher risk factor for hepatitis C include health care workers who have suffered needle-stick accidents and people who have high-risk sexual behavior. Infants of mothers who have hepatitis C have a higher risk of carrying the disease as well.
Since hepatitis C is transmitted through infected blood, you should make sure proper sterilization procedures are always used when you are getting tattoos, piercings, acupuncture, and even manicures and pedicures. If you have medical or dental work done in a developing country, sterilization might be a concern as well.
If you live with someone who has a known hepatitis C infection, your risk of contracting the disease is naturally higher. You should never share toothbrushes or other personal hygiene items with someone who is known to carry hepatitis C. Use safe sex practices if you are intimate with this individual. Remember that many cases of hepatitis C are curable. If someone you know has the disease, encourage him or her to speak with a doctor about treatment options.
Testing for Hepatitis
There are three stages to hepatitis C testing. The first step is testing for the antibodies. Individuals will have antibodies to hepatitis C in their blood two to three months after the initial infection. If you test positive for the antibodies, you have or have had hepatitis C. It's still possible at this point that you may not have the disease currently, as some people will clear the virus on their own.
A viral load test is the second step in testing for hepatitis C. It will determine whether someone with antibodies have already cleared the virus from the system or continues to have it. A viral load test can also detect hepatitis C in people who have contracted the disease too soon to already have antibodies. Therefore, a viral load test is important for all individuals, whether the hepatitis C antibodies are present or not.
Your health care provider can order both quantitative and qualitative HCV viral load testing. Qualitative testing is the more sensitive of the two. This one simply determines whether the virus is present or not. Quantitative testing determines how much HCV is in the patient's blood. Your doctor may order repeated HCV viral load tests during the treatment process if you have hepatitis C, as this will indicate how well the treatment regimen is working.
The final test performed for patients with hepatitis C is the HCV genotype testing. This determines which of the eight possible genotypes you have. The specific type of hepatitis C that you're carrying will determine which treatment method is most appropriate for your disease. The most common HCV genotype is 1, which accounts for over 46 percent of cases worldwide and 75 percent of cases in the United States. Genotypes 2, 3, and 4 are less common, while the remaining genotypes are rare or unheard of in the United States.
The Progress of Hepatitis C Treatment
Until recently, only two drugs were approved for the treatment of hepatitis C. Fortunately, there are now several treatment options that have effectively demonstrated higher effectiveness, shorter treatment durations, and fewer side effects. The modern outlook is increasingly favorable for patients who have any of the hepatitis C stages, including those with cirrhosis.
Though most treatments are not for people with decompensated cirrhosis, there are some new options available nowadays for this case. Epclusa is a once-daily tablet that is approved for treatment of HCV genotypes 1 through 6. In combination with Ribavirin, it may be used for those with advanced cirrhosis. Studies showed the cure rate to have an impressive 94 percent after 12 weeks of treatment with Epclusa and Ribavirin for those with HCV 1-6 and decompensated cirrhosis.
The biggest challenge with modern hepatitis C treatments is typically the cost. A 12-week treatment can cost up to $95,000. As treatment options become more widespread and more competitive, prices may drop. Zepatier from Merck boasts a cure rate up to 97 percent with genotype 1 and costs $54,600 for a 12-week treatment, which is an improvement over the other options.
Patients with hepatitis C may be particularly interested in following proposed legislation, which might cap drug costs and make these medications more affordable and accessible to them. The high success rates of the drugs do justify the cost to some, but patients are still faced with the logistics of affording this costly cure.
Hepatitis C is an incredibly widespread disease, so it's crucial for anyone who is at higher risk, or for those experiencing possible symptoms, to know about this danger. Fortunately, blood testing can easily diagnose hepatitis C. This way, you can work with your doctor to determine the next steps. When you identify hepatitis C early, you can often cure the disease before you're facing serious liver damage and potentially life-threatening consequences. Talk to your doctor and find out whether hepatitis C testing is a good idea for you.
Hepatitis C Outbreaks
A recent outbreak of the dangerous disease hepatitis C in New Hampshire has led to more extensive testing. Caused by a traveling medical technician who may have infected more than 30 people, this outbreak is potentially very dangerous for many recent surgical patients. Health officials in New Hampshire are recommending testing to anyone who has had surgery or had been recently admitted to the intensive care unit at Exeter Hospital.
Today Health officials in Maryland announced four new cases at Johns Hopkins Hospital, one at the Baltimore VA Medical Center, six in Kansas and one at the University of Pittsburgh Medical Center in Pennsylvania. If you are concerned that you may have been exposed to Hepatitis C, Health Testing Centers offer liver testing including a blood test for Hepatitis C, as well as Hepatitis C Viral load testing.
This lab technician, the root of the problem, who traveled between multiple facilities was charged with federal drug crimes, due to the fact that he supposedly stole anesthetic drugs from the hospital lab and used them to inject himself. These syringes were placed back into the lab without sterilization. The lab technician, David Kwiatkowski, was hepatitis C-positive and has infected more than 30 people via this mechanism. He was not involved with patient care or any medical procedures.
Hepatitis C: How the cases spread?
Originally, the state of New Hampshire recommended that testing be performed on about 1,300 people who had been treated at this lab since October of 2010. The new recommendations, however, cover a much wider range, causing more than 6,000 people to be eligible for testing. According to the president of the medical staff at Exeter Hospital, the facilities would rather unnecessarily test thousands if that means catching all the people who were potentially infected by the malpractice of this individual. Patients in the ambulatory surgical center at the hospital are not included in the testing recommendation and are thought not to be affected by the outbreak.
The state mailed letters to patients potentially affected by the outbreak during the week of July 27, inviting all affected people to a public discussion at a local high school. The same location was used for the testing clinics, which use a rapid response blood test that offers faster results than normal tests. This allows worried patients to get a definitive negative result in less time. The rapid response test has a much higher false positive rate than conventional tests, however. Patients who test positive will need a standard test performed to confirm infection.
In addition to allegedly causing the outbreak in New Hampshire, Kwiatkowski could be responsible for problems elsewhere in the country. This traveling worker was sent by medical staffing agencies to a range of hospitals throughout the U.S. to work in temporary positions. Since 2007, he has worked in at least six states, including New York, Kansas, Maryland and Michigan. This man was also known at work for his tendency to lie to co-workers, including claiming to have cancer. The lab technician has previously been disciplined for or accused of misbehavior in the past, including falsifying time sheets and stealing anesthetic drugs from an operating room. Co-workers noticed that this employee frequently appeared drugged and were highly suspicious. Unfortunately, most workers at other facilities who noticed that drugs were missing did not report them to law enforcement, allowing the infected individual to obtain employment around the country for much longer than he might otherwise have been able to do.
Hepatitis C is a serious condition that unfortunately doesn't produce symptoms in the majority of newly-infected people. This blood-transmitted condition causes slow damage to the liver, eventually leading to cirrhosis and liver failure. Some patients with chronic hepatitis C will eventually develop liver cancer. Hepatitis C can be cured with anti-viral medications in 5 to 8 out of 10 people, but early detection and treatment is important. This outbreak underlines the importance of getting routine hepatitis C testing, along with tests for other health problems. Even people who do not believe they have been at risk could accidentally develop this disease.
Centers for Disease Control and Prevention. (2016). Hepatitis B and the vaccine (shot) to prevent it: Fact sheet for parents [Fact sheet]. Retrieved from: www.cdc.gov/hepatitis/hbv/vaccchildren.htm
Cropley A, et al. (2017). The use of immunosuppression in autoimmune hepatitis: A current literature review. DOI: doi.org/10.3350/cmh.2016.0089
Heidelbaugh JJ, et al. (n.d.). Cirrhosis and chronic liver failure: Part II. Complications and treatment. www.aafp.org/afp/2006/0901/p767.html
Heidrich B, et al. (2013). Treatment options for hepatitis delta virus infection [Abstract]. DOI: 10.1007/s11908-012-0307-z