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Hepatitis B
CONTENTS
BACKGROUND
SPREAD
Blood Transfusion:
Sexual Contact:
Daily Contact:
Intravenous Drug Use:
Acupuncture, Tattooing and Body Piercing:
Saliva:
Mother and Baby:
Medical Treatment:
Barbers:
Cultural Factors:
People at High Risk:
ACUTE HEPATITIS B
CHRONIC HEPATITIS B
LATE EFFECTS OF CIRRHOSIS
Haemorrhage
Effect on the brain
Build up of water (ascites)
Liver cancer
DIAGNOSIS
Blood tests
Liver function tests (LFTs)
Liver biopsy
PREVENTION
General Hygienic Measures:
Vaccination:
TREATMENT
Antiviral Treatments:
Complementary treatments
DIETARY ADVICE
CONSIDERATIONS BEFORE THE TEST
Insurance and Mortgage:
Whom to take into Confidence:
Confidentiality:
BACKGROUND
The term hepatitis means inflammation of liver. There are a number of causes
of this which include excessive alcohol consumption, medicines, toxins and autoimmune
disease. The most common cause of hepatitis, however, is infection by viruses. There
are several viruses which can attack and damage liver. The most important of these
are hepatitis A, B, C, D and E viruses. These viruses spread and damage the liver
in different ways. In this article we will discuss Hepatitis B in more detail.
Hepatitis B is a liver disease caused by Hepatitis B virus. According to the
WHO, one third of the world's population has been affected by this virus at some
point in their life. It is very common in the Asian subcontinent, South East Asia,
Far East, Middle East, Africa and Southern Europe. In Europe, one million people
are infected every year. In the UK, the prevalence of the disease is one in one
thousand.
In a study in Karachi, 2.5% of the pregnant women were found to have evidence
of infection with Hepatitis B virus. In Pakistan, there are about 4.5 million carriers
of the virus, which constitutes 4-5% of the whole population.
SPREAD
The virus that causes Hepatitis B is found within body fluids such as blood,
saliva, semen and vaginal secretions. If even a minute amount of blood from an infected
person enters into another person's blood circulation, infection can be transmitted.
This can happen through blood of an infected person coming into contact with an
open wound, cut, or abrasion on a healthy person's body.
In the rest of the world, the commonest mode of spread is from mother to child
or from one child to the other. It is probable that in Pakistan the Hepatitis B
is transmitted from one child to another during early life.
Blood Transfusion:
Blood transfusion is a common mode of transmission of Hepatitis B in some
developing coutries.
In most developed countries, before a person is allowed to donate blood, his
blood is tested to make sure that it does not have hepatitis virus in it and only
healthy people are allowed to act as blood donors.
Unfortunately, in Pakistan and in many other developed countries, this does
not happen and blood donors are not screened for hepatitis. This situation is further
complicated by the tendency amongst general public to get blood from professional
donors instead of from family members at times of need. The majority of these professional
blood donors are intravenous drug users and their blood carries a very high probability
of having Hepatitis virus in it and of causing Hepatitis C in the person who receives
it.
Sexual Contact:
In the UK, Europe and North America, the commonest mode of spread of Hepatitis
B is through unprotected sexual contact. The chances of transmission through sexual
contact are certainly higher if intercourse occurs during menstruation.
Having multiple sexual partners also increases the risk.
Daily Contact:
Daily routine contact for example touching the infected person or using a
teacup would not cause the spread of infection; however it would be wise not to
share personal items such as toothbrushes, nail cutters, scissors or razors with
a person positive for Hepatitis B or C.
Intravenous Drug Use:
Intravenous drug users who share needles are at high risk of getting infected
with blood born viral diseases including Hepatitis B.
This is due to the fact that the injection gear can be soiled with small amounts
of blood and sharing it can spread the virus. Sharing the needles even once can
be sufficient to spread infection.
Acupuncture, Tattooing and Body Piercing:
Some people have been infected due to contaminated needles used in acupuncture,
tattooing and body piercing clinics. The best way to prevent this is to use disposable
needles.
Saliva:
The virus has been found in the saliva, but it is very unlikely that it can
spread through kissing. It would be wise not to use someone else's toothbrush.
Mother and Baby:
Many infected mothers are worried that they may transfer the virus to the
child.
However, if appropriate precautions are taken, the risk is low. During pregnancy
and delivery, the risk of transfer of virus from infected mother to the child is
about 6%. It is not known whether the child is infected inside the womb, during
delivery or just after the delivery. Sometimes the child will have antibodies, which
can last up until 12-18 months. These antibodies are acquired by the child from
the mother and the child itself is not infected. The usual test for infection is
by measuring the quantity of antibodies and therefore this test is not useful in
the child below one year of age. Another test called PCR can, however, detect infection
in the first few months. To carry the child or to kiss the child is harmless. Most
doctors think that if the mother does not have any symptoms, it is not harmful to
breast feed the child, however there is a possibility that if there is an abrasion
in the breast or in the baby's mouth, the infection can be transmitted.
Medical Treatment:
There is evidence that the epidemic of blood born viral diseases like Hepatitis
B in Pakistan is due to reuse of plastic or glass syringes. It should be ensured
that only disposable syringes are used in medical practice. Infection can also spread
due to treatment by unqualified dentists who use unsterilized instruments .
Barbers:
The reuse of razor to shave the head or beard can also cause infection. Only
disposable razors should be used and it is best to avoid going to barbers for a
shave. In the UK, usually the barbers are not allowed to use razor blades. They
only use scissors or machines for hair cutting.
Cultural Factors:
Getting the children's head shaved, circumcision and ear piercing are also
occasions when infection can spread. Only qualified doctors should be consulted
for circumcision. For ear piercing it is important that needles are sterilized.
In Pakistan, intravenous drips, including vitamins are very commonly used for the
so called weakness. This treatment under most circumstances is unnecessary and
dangerous.
People at High Risk:
The following people are at higher risk of infection:
- Intravenous drug users
- Children born to infected mothers
- Spouses or family members of infected person
- Healthcare providers who come in to contact with blood for
example doctors, dentists, nurses and midwives
- Those people who live or work with people with learning disability
- Prisoners
- Working in or travel to countries where this virus is endemic
- Those who have sex with infected people without barrier methods
(condom)
ACUTE
HEPATITIS B
After an acute infection with the virus, no symptoms appear for a period of
1-6 months. This period is called incubation period. Some people never have any
symptoms or have only a mild illness. They may be unaware that they have the infection,
although they can transmit the virus to others. Others have non specific symptoms
such as tiredness, aches and pains, loss of appetite, nausea, vomiting, diarrhea
and fever in combination with the more specific symptoms of pain in the upper right
quadrant of abdomen and Jaundice. Jaundice is easily observed because the white
of the eyes turns yellow. In severe illness the skin also turns yellow, the urine
becomes dark and the stools lighter in colour. Some people can become seriously
ill and need hospitalization.
CHRONIC
HEPATITIS B
If infection lasts greater than six months, it is called chronic. In some
people virus stays in the body for a long period of time or throughout life, but
does not cause any symptoms. These people are called carriers. Many of them are
unaware of the existence of virus in their blood. . The majority of carriers remain
healthy though some develop disease. Most carriers can transmit infection. Some
of them clear the virus after many years. About 25% of the carriers can have liver
disease, which includes long term inflammation and cirrhosis. Cirrhosis or liver
cancer can develop after many years of infection. Cirrhosis is a medical term, which
describes excessive scar tissue in the liver. The inflammation of the liver in Hepatitis
B is a continuous process. Usually when the liver is injured some of the liver cells
die but liver can restore itself to its previous state after repairing itself, and
is not scarred. But if this injury to the liver is repetitive or continuous, the
liver can become scarred. Usually this process starts slowly and can continue for
years without exhibiting any symptoms. This scarring can eventually reach a stage
where most important of liver functions are affected and the liver cannot restore
itself to a healthy state. Symptoms can appear at any time but usually appear late
in this process of scarring. Many symptoms appear when liver starts failing in its
normal functions. The state of cirrhosis is irreversible, although recent research
raises hopes for new medicines, which may slow down or stop the scarring of liver.
LATE
EFFECTS OF CIRRHOSIS
Haemorrhage
The blood draining from the bowels usually goes to the liver before joining
the general blood circulation. Scarring of liver increases resistance to flow of
blood through it and this increases pressure in the veins in the upper part of stomach
and lower part of the gullet because venous blood draining from the gut tries to
find an alternative pathway through these blood vessels. Because of excessive pressure
these blood vessels can rupture and can cause serious blood loss in the form of
vomiting of blood or black tarry stool.
Effect on the brain
Liver rids blood of waste products. In case of weakness or failure of liver,
these waste products can have an effect on the brain. The symptoms can vary from
weak memory to slurring of speech, confusion, difficulty in concentrating and even
coma.
Build up of water (ascites)
Serious weakness of liver can affect the handling of water by the body, which
can lead to a buildup of excess water in the legs and inside the tummy. The buildup
of water around the bowels is called ascites.
Liver cancer
Some people with longstanding cirrhosis can develop liver cancer. One of the
ways to treat liver cancer is liver transplant, as long as cancer has not spread
outside the liver to other parts of the body.
DIAGNOSIS
Blood tests
Hepatitis B can be diagnosed through blood tests. These tests measure antibodies,
which body's immune system makes against the virus. In addition, the virus proteins
can themselves be measured; therefore many tests provide different kind of information
to the doctor.
Liver function tests (LFTs)
These are blood tests, which measure the substances which are released into
the blood circulation as a consequence of damage to the liver cells. However, these
are not a dependable and accurate measure of damage to the liver and do not themselves
give evidence of the presence or absence of virus. LFTs can fluctuate during illness
and sometimes they can be normal but this does not mean that liver has not been
affected.
Liver biopsy
Liver biopsy is an important way to assess damage to the liver. In this test,
the skin is frozen with a local anesthetic and a specimen is taken from inside the
liver with a thin needle. This biopsy is examined microscopically. In most British
hospitals this test can be done as a day case i.e. the patient can go home in the
evening. This test usually causes some pain. The biopsy can give information about
inflammation and scarring of the liver.
PREVENTION
General Hygienic Measures:
Cuts and wounds should be cleaned carefully and covered with the waterproof
bandage. In case of spilling of blood, the floor or other surfaces should be cleaned
with diluted bleach. Items of personal use such as toothbrushes, scissors, razors,
etc should not be shared. Sexual activity should be through safe methods. In case
of potential risk condoms should be used. People who are Hepatitis B positive should
not act as organ, blood or semen donors.
Vaccination:
This allows immunity to develop against the virus. A full course consists
of three injections. The second injection is given one month after the first injection
and a third injection is given six months after the first injection. It is important
to complete the full course; otherwise the prevention may not be effective. A booster
injection is given five years after the first injection. Sometimes the blood test
is done two months after the last injection to see whether the vaccination has been
successful. Some people do not respond to vaccination. In exceptional circumstances,
vaccination timetable can be speeded up, so that the second injection is given one
month after the first injection, the third injection three months after the first
injection and a booster injection a year later.
Anybody who has been exposed to the virus should be given antibodies (immunoglobulins)
because vaccine takes a long time to be effective. In the case of a needle stick
injury to high risk professionals both the immunoglobulins and the vaccine should
be given.
Newborn children born to infected mothers are given an injection of immunoglobulin
at birth so that they are protected against the infection. At the same time the
first dose of vaccination is given. After this further vaccinations are given at
the interval of one and two months and a booster injection a year later.
Spouses, children and other members of household of an infected person should
be given vaccination. The normal and daily contact such as social touching or contact
with toilet seats does not spread infection. Occasional visitors to an infected
person are not at risk. It is believed that virus is killed with hot water, for
example in washing machine using hot water.
Doctors, nurses, dentists, prison officers and other people at risk of occupational
exposure to bodily fluids should be vaccinated.
TREATMENT
In acute illness, most people do not require treatment because there are no
long-term effects on the liver. These people can feel excessively tired and may
require prolonged rest, however they would eventually recover and they are not at
risk of recurrent infection. However, this is not the outcome in everybody.
Those people, in whom the infection persists for more than six months, can
benefit from treatment. These people should regularly consult a gastroenterologist
or a Hepatologist, so that the damage to the liver can be assessed and if necessary
treated.
Antiviral Treatments:
The most commonly used antiviral drug is interferon. This resembles the naturally
produced interferon produced by the body's immune system. The aim of interferon
is to prevent the multiplication of virus and injury to the liver. The injection
is given at least three times a week for a period of at least three months. Usually,
patients can learn to give the injection themselves, the method is very similar
to insulin injection. In some people the treatment is not effective and some people
respond to treatment but the infection can come back after stopping treatment. Those
people who were infected because of the fact that their mothers were carriers, may
not respond to the treatment that well, however the treatment may prevent cirrhosis
and may prevent further transmission of virus.
Another commonly used antiviral drug is called Lamivudine. This drug reduces
the quantity of virus in the body. In addition there are several drugs being developed,
two of these are Adefovir and Enticavir and these have been approved for general
use.
Side effects of antiviral treatments: Interferon can cause undesirable side
effects in most people especially at the start of treatment, although the intensity
of side effects can vary. These include flu-like symptoms, tiredness, headache,
nausea, anaemia and depression in addition to many others. The flu-like symptoms
can be prevented by taking paracetamol prior to the injection. Most people feel
better after a few weeks of treatment. In some people, the side effects are so severe
that they cannot take the full dose of treatment or cannot take the treatment for
a full duration. Because of these side effects different blood tests are necessary
during the course of treatment. It is, therefore, essential to regularly attend
the clinic appointments so that side effects and complications from treatment can
be kept under review.
Complementary symptomatic treatments
Some people consider unconventional or additional treatment in addition to
the conventional treatments for the relief of symptoms . There are many complementary
treatments available such as massage, reflexology, aromatherapy, Tai-chi and meditation.
It has been seen that these treatments are helpful in trying to relieve tiredness
and aches and pains and also can promote a feeling of well being and calm. The traditional
Chinese medicines and herbal medicines are similar treatments.
It is important to consider risks and benefits of complementary therapies
however because not all complementary treatments harmless or beneficial. It is important
to ensure that complementary therapist belongs to a recognized organization and
has understanding of Hepatitis B.
DIETARY
ADVICE
The patients with Hepatitis B want to know whether or not they should use
any special diet. For most people who are otherwise in good health, the answer is
no. Like other people, they should also use a balanced diet in which everything
is taken in moderation and nothing in excess. This would mean that regular meals
are taken; fruits and vegetables are abundantly used; and the use of fat and sugar
is reduced. In addition, most people should take two portions of food per day, which
provide good source of protein for example pistachio, almonds walnuts, meat, chicken,
fish, eggs, lentils, beans, cheese, milk and dairy products. One advantage of taking
a varied diet is that food will be pleasant to take and vitamins and minerals will
be included. Most people who eat or are taking a good diet do not require additional
vitamins. Those people who have symptoms of Hepatitis B may require additional advice
regarding suitable diet. In case of nausea and loss of appetite consultation with
a dietitian may be helpful.
CONSIDERATIONS
BEFORE THE TEST
If you are thinking of getting a test then some issues should be considered.
It may be advisable to consult a professional for example a doctor, counselor or
a drug worker in the UK. In addition to this in some British hospitals Nurses, who
specialize in advising people with hepatitis C, can also give advice.
Insurance and Mortgage:
Most insurance companies will ask the applicants whether they have been tested
for hepatitis B, C or HIV. In case of a positive result, life insurance or mortgage
that is linked to life insurance can be refused or the premium can be increased.
In this case, consult your doctor because many UK consultants can write to the Insurance
or Mortgage Company and can advise them regarding your health and life expectancy.
Whom to take into Confidence:
This is a difficult decision. A positive result can affect the family and
spouses. It is possible that affected people may want to get tested. This should
borne in mind as even now there are misunderstandings in people's minds regarding
this illness. There are instances that people had to leave their job or they were
refused medical or dental treatment or the children received discriminatory treatment
in school. It is always possible to get medical or dental treatment from another
place. Simple precautionary measures can protect medical workers and near relatives.
Confidentiality:
It can be an issue for some people. Most addiction treatment services or GUM
Clinics can do tests for blood borne viral diseases in confidence. However if a
local GP does this test, the result will be registered and he may be required to
disclose the result on certain inquiries, for example in case of medical examination
for employment or insurance.
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