- Q: Why should I be concerned about hepatitis? How serious is it?
The two main strains of hepatitis virus - HBV and HCV - cause significant morbidity and mortality. Hepatitis B is potentially fatal and can cause both acute and chronic disease.
Hepatitis C infection is a common and potentially curable disease but is under-diagnosed (five out of every six people infected are undiagnosed) and, therefore, under-treated. Improving the initial diagnosis of hepatitis could reduce the morbidity and mortality.
A GP is likely to have 13-24 infected patients, based on an average list size of 1,800, partly depending upon local population demographics.
- Q: How is the hepatitis virus transmitted?
HBV can be transmitted in a variety of ways, and is thought to be 100 times more infectious than HIV. The virus is found in the blood and other bodily fluids and the main route of transmission in the UK is via unprotected sex and IV drug use.
The transmission profile being similar to HIV means that many people in high-risk groups may be co-infected. Worldwide, vertical transmission is the most common route of infection.
Other routes of transmission include needlestick injuries in healthcare professionals, transfusion of infected blood products in countries with inadequate screening, and piercing and tattooing with unsterilised equipment.
Hepatitis C is also a blood-borne virus. The major route of transmission of HCV in the UK is sharing injecting equipment.
Risk factors include: blood transfusion (prior to 1991) or blood products (prior to 1987) and being born or spending an amount of time in a high-risk country. This includes healthcare given in early childhood.
A small number of infected patients have acquired their infection through the use of non-sterile surgical equipment. This is most likely in those who have received healthcare in the developing world, such as Eastern Europe and Africa.
Unlike hepatitis A and B, HCV has no vaccine but infection is avoidable through strategies that reduce transmission.
- Q: How would I know if I had hepatitis C?
You may not know for a number of years. A range of symptoms may develop up to 20 years later, including tiredness and lethargy. It is important that if you have or have had any risk factors that you go for viral hepatitis screening. Interferon is indicated as a treatment for HCV but relapses can still occur.
- Q: I work as a hospital cleaner. Should I be vaccinated against hepatitis B?
Health service workers should be vaccinated against hepatitis B. The vaccine to prevent HBV infection has been available since 1982 and western European countries provide a HBV vaccination at birth or in childhood, but the UK does not.
- Q: I am thinking of getting a tattoo. How can I be sure that the tattooist is safe?
It is essential the tattooist has clean premises and modern equipment that can be sterilised. They must use disposable needles and any other equipment that might be in contact with skin and blood.
- Q: I have hepatitis and I am pregnant. Will a C-section reduce the risk of transmission to my baby?
Caesarean section is not recommended for either HBV- or HCV-positive women, but it is recommended when women are co-infected with HIV.
Perinatal transmission is one of the most serious and effective modes of transmitting HBV infection. Whether the baby will get the virus depends on when infection occurred. If it was early in pregnancy, the chances are less than 10 per cent that the baby will get the virus. If it was late in pregnancy, there is up to a 90 per cent chance that the baby will be infected.
Infants who are infected during birth are at high risk (up to 90 per cent) of becoming chronic carriers of the virus; however, appropriate immunisation can prevent this in up to 95 per cent of cases.
Therefore, normal delivery is undertaken and then vaccination of the newborn is essential.
Pregnant women who are chronically infected with hepatitis C may transmit the infection to their infants at or around the time of birth but the risk of transmission is small and has been estimated at between five and six per cent.
Transmission is largely restricted to women who have hepatitis C viraemia during pregnancy or delivery, and mainly in women with high levels of the virus. Elective caesarean section is not indicated for HCV positive mothers.
- Q: How is hepatitis C and hepatitis B treated? Can I receive interferon? What are my options for treatment?
Treatment of hepatitis C and B has markedly improved and early referral is advantageous.
It is now thought that chronic HCV does not progress in a linear fashion and that the disease accelerates with ageing, so most patients with HCV develop long-term cirrhosis.
Furthermore, therapy is more effective when administered in the early stages of the disease.
The most recent NICE guidance advocates treatment for all patients with HCV who want it, including for mild to moderate hepatitis C. The current treatment is combination therapy with pegylated interferon and ribavirin.
This treatment is successful in clearing the virus (defined as no detectable virus) six months after treatment has ceased in 40-80 per cent of those treated, accordingly to genotype. Acute hepatitis B is often self-limiting and usually only requires relief of symptoms.
Treatment of chronic hepatitis B, as with chronic HCV, aims to prevent progression to hepatocellular carcinoma or cirrhosis. Treatment of chronic HBV is, again, weekly injections of long-acting pegylated interferon. Lamivudine is also used and taken orally and works by blocking viral replication.
New treatments for both chronic HBV and chronic HCV are being developed and show great promise for the future.
- Q: Where can I find out further information about hepatitis C and B?
You can find out more information on hepatitis B and measure your risk of hepatitis C by visiting www.nhs.uk and using the online self-assessment tool. Patients looking for more information on hepatitis C can call 0800 451 451. Useful resources include 'Guidance for the prevention, testing, treatment and management of Hepatitis C in Primary Care' published by the RCGP.
Dr Ford is a GP in London and a member of the Sex, Drugs and HIV Task Group at the RCGP
- World Hepatitis Day is on 19 May 2008. For more information see www.nhs.uk/hepc.