Liver Disease

Hepatitis A

Hepatitis A is:

• The most commonly seen hepatitis virus
• A type of acute viral infectious disease
• A highly contagious liver disease that has the potential of making the patient critically ill
• Commonly perceived as being contracted during travel but many cases of hepatitis A infection are non-travel related
• Preventable by appropriate vaccination 

Globally hepatitis A affects 1.5 million people on a yearly basis. Some reports indicate that the actual number of infections may be up to 10 times higher since the disease is often asymptomatic (does not have noticeable symptoms) and so goes undiagnosed. In Canada, there were 3500 cases diagnosed in 1991 but less than 400 cases in 2003.  In adults, 25% of the cases required hospitalization. 

Transmission & Risk Factors

This particular virus is transmitted primarily by the fecal-oral route when a person ingests food or drinking water that has been contaminated by the feces of an infected person. Transmission usually occurs in places where people are in close proximity, co-habiting, or ingesting contaminated food or water. The virus can survive in water for up to 10 months.

Other risk factors or routes of hepatitis A infection include:

• Food and drinks prepared by infected personnel who do not follow all safety protocols
• Through consuming contaminated imported food
• Having close contact with an infected person
• Travel in areas were the disease is common – whether living abroad, visiting for pleasure, or visiting for work (Africa, Asia, Latin America, Eastern Europe, Mexico and the Caribbean)
• Children – as it is usually asymptomatic for children, they could unknowingly spread the virus to other children or adults
• Poor sanitation standards
• Eating raw/uncooked seafood and shellfish products

Once infected with hepatitis A the majority of the population will have lifetime immunity against the virus after they recover. However, approximately 15% of the patients do not recover completely and will relapse in a year’s time.

Hepatitis B

Hepatitis B is:

• A common virus
• Approximately 400 million people carry this virus worldwide
• Approximately 75% of Hep B carriers live in Asia
• Amongst the carriers, approximately 20-25% will die of liver cancer or cirrhosis
• In the majority of Asian countries approximately 10% of the population are carriers. Although it is a serious problem imposed on the public health system public awareness of this disease is relatively low. One of the reasons is due to the nature of this disease as a chronic asymptomatic disease (has no noticeable symptoms).

Transmission and Risk Factors

The Hep B virus is spread through blood and other bodily fluids, not food. A common misconception is that if I am careful with what I eat, I will not contract the hep B virus. As mentioned earlier, the majority of the carriers are infected with this virus at birth – vertical transmission (from mother to baby during pregnancy or childbirth).

Other routes of transmission include:

• Coming in contact with contaminated instrument during dental appointments
• Sharing syringes
• Receiving repeatedly used needles that are not cleaned properly during acupuncture
• Body tattoo or piercing with contaminated instruments
• Sexually transmitted
• Receiving contaminated blood products during blood transfusion (rarely happens nowadays)

As with any other illness, the sooner you get treatment for hep B the better the result. The effect and results will certainly be better if the treatment is started at a younger age because much damage may have already occurred to the liver at an older age. There is no current treatment to completely eliminate or cure this virus. However, in the past 10 year it has been proven that drugs can effectively suppress and control the virus to minimize the damage to the liver.

Carrier

“Carrier” is a term often mentioned when we talk about liver disease. What is a “carrier”? How is this state generated? How is it detected? Also, why is it harmful to be a carrier?

When the hepatitis B virus (or any virus) enters the body, our defense system (i.e. immune system) will respond immediately by sending out antibodies to deal with the intruders (i.e. viruses). If the antibodies win the battle, the virus will be wiped out. The person does not become ill as long as the antibody level remains above 10 IU/L. However, a person should have a booster vaccine if his/her antibody level is below 10.

If the level of antibodies remains low after six months, the body will produce another substance called “antigen” to help fight against the virus. Although antibodies and antigens both protect the body from viral invasion, they cannot co-exist peacefully. There will be no antibody when antigen is present. Antigen is a type of antibody that is more neutral. Antigen will try to negotiate with the virus, establishing a “non-aggression pact”. If the antigen cannot wipe out the virus, the virus will remain inside the body without interfering with the body. At this time the body has become a “carrier”.

However, if a person’s immune system has been weakened (for example the person became ill due to another disease) then the originally non-invasive hepatitis viruses may start attacking the body. Therefore, being a carrier is similar to living with your enemy. If your immune response successfully eliminates the subsequent pathogen, then the hepatitis virus will continue to be dormant and stay in the human body until another opportunity for invasion comes.

How would I know if I am a carrier? A single blood test can tell. If the blood test result returns positive, then you are a carrier and has the ability to spread the virus to others.

Content by Dr. Francis Ho, Family Practice

Hepatitis C

Hepatitis C is a virus similar to Hep A and Hep B in that it also attacks the liver. Acute Hep C usually has no warning symptoms so many people are unaware when they are infected. Hep C will stay in the liver long-term. If the virus is not successfully treated the patient will have it for the rest of their life. Such prolonged viral infection is called “chronic” infection. 

Chronic Hep C affects approximately 1-2% of the North American population. British Columbia has one of the highest infection rates in Canada. It is estimated that in B.C. 45 to 60 thousand people have chronic hepatitis C and that many people have yet to be diagnosed. The natural progression of a hepatitis C infection can last for decades. For most of that time Hep C remains silent (no symptoms are noticeable). It is usually not until later stages that it becomes diagnosed during a blood test. Over time, inflammation and scarring of the liver will gradually and slowly develop in hepatitis C patients with about 10-20% of patients developing severe scarring and cirrhosis. After 20-30 years of infection patients are at high risk of being at the last stage of liver failure.

Transmission

Hepatitis C is transmitted through coming in contact with contaminated bodily fluid. There was a period of time where testing for Hep C prior to blood transfusion was not a common practice and prior to 1991 there was no such a thing as a blood test. These days blood is tested for Hep C before any transfusions.

Common routes of infection are due to:

• Drug injection on the street (i.e. using the same needle to inject heroin or cocaine)
• Ingestion of a drug through the nasal canal (i.e. intranasal cocaine)
• In some parts of the world, Hepatitis C is transmitted via unsterilized medical/dental devices.
• In many cases the way a patient became infected with Hepatitis C is unknown

Although Hepatitis B and Human Immunodeficiency Virus (HIV) are sometimes transmitted during sex or child delivery from mother to child, these means of transmission are a lot less common for Hepatitis C.

In terms of risk factors that quickens the onset of cirrhosis, alcohol is definitely one of the factors that need to be repeatedly emphasized. Even a small amount of alcohol is enough to contribute towards promoting the development of cirrhosis. Patients should abstain from drinking alcohol or reduce it to an absolute minimum. Infection of other virus, especially HIV and Hepatitis B, are widely believed to accelerate the natural development of Hepatitis C. Another important point to remember is that Hepatitis C virus not only affects the liver, it may also cause other complications including cryoglobulinemia, and this condition may lead to kidney inflammation and failure, arthritis, and skin ulcers. Non-Hodgkin’s lymphoma (a type of malignant lymphoid tumor) and adult onset diabetes are also related to Hepatitis C.

Fatty Liver

Many people have heard of the term “fatty liver” but may not know exactly what it is. The liver is located in the upper right quadrant of your abdomen within the ribcage. The liver is the second largest organ in the human body (after the skin) and weighs approximately 1400 grams. The liver becomes a fatty liver when 5% or more of it is fat rather than liver tissue.

How does fat travel into the liver? There are two main pathways:

1. Due to the close proximity of liver and intestine, fat cells may enter the liver from the intestine.
2. Liver cells degeneration: liver cells are broken down and turned into fat cells

Some of the main functions of liver cells are:

• Store glycogen (the main storage form of glucose in the body)
• Produce essential body material
• Eliminate metabolic waste
• Store vitamins
• Store minerals like iron and copper- (these are essential building block of red blood cell)
• Make proteins that are important for blood clotting
• Eliminate waste like alcohol, certain drugs (e.g. Tylenols, Warfarin, Amiodarone) and other toxic substances
• Produce bile (stored in the gallbladder) for fat digestion

Hepatitis leading to liver disease and liver cancer is very common and is a major health problem. Hepatitis B data alone shows that China has a tenth of the population (about 130 million) with chronic Hepatitis B infection (carriers). Every minute there is a Chinese person dying from liver disease or liver cancer that originated from Hepatitis B. The majority (80%) of liver cancer are caused by hepatitis. The saying “prevention is better than cure” is accurate. Hepatitis and the resulting liver cancer can be prevented and avoided.

Hepatitis A

Generally transmitted through the intestine. The virus is excreted in the patient’s stool and then passed into the mouth through contaminated food, leading to infection.

Hepatitis A prevention:

• Personal hygiene – always wash your hands prior to preparing food or eating; immediately flush the toilet and wash your hands after using the bathroom
• Food hygiene
  • Hepatitis A virus needs to be cooked at high temperature (100 degrees Celsius) for 5 minutes to be killed so drink boiled water, and clean and cook food thoroughly prior to ingestion
  • Take special note of seafood like oyster, clams, and shellfish
  • Food that hasn’t been consumed should be covered or placed in the refrigerator
• Environmental hygiene – proper disposal of sewage and feces to protect drinking water from contamination

Hepatitis B and Hepatitis C

The route of transmission is similar; mainly by blood or bodily fluid (not food). Because Hepatitis B can survival outside of the body for at least 7 days it is more contagious than HIV by a hundred times.

The following are a few preventive measures:

• Properly disinfect and bandage any wounds
• Do not share razors, toothbrushes, needles, syringes or any other products that have the chance of being contaminated by blood or bodily fluids
• Any medical, dental or other equipment (e.g. acupuncture, tattooing, body piercing, manicure) must be thoroughly disinfected prior to use
• Avoid sexual promiscuity and use condoms properly

Hepatitis Immunization

Can be divided into two types: passive and active immunization

Passive Immunization

Injecting immune globulin gives a brief instant immunity and protection but cannot produce long-term effects. Appropriate for the following situation:

• Hepatitis A (Immune Globulin A)
  • Appropriate for people who have not been infected with Hepatitis A but wanted to have temporary protection or plan to travel to areas where Hepatitis A is prevalent
  • Where Hepatitis A vaccine is not suitable for the patient (due to allergy, or adverse side effects, etc.)
  • Not appropriate for babies who are less than one-year-old
  • Appropriate for people with weak immunity and failed to produce effect to vaccine
• Hepatitis B (Immune Globulin B)
  • Accidental contact with blood containing Hepatitis B virus (e.g. acupuncture), preferably inject within 48 hours coming in contact
  • From sexual contact with Hepatitis B patient, can inject within two weeks
  • Newborn baby of mothers who are carriers, it is very important to receive immunoglobulin injection within 12 hours and the baby can also be vaccinated at the same time

Active Immunization

This is the most effective long-term prevention for Hepatitis A and Hepatitis B. This immunization injects hepatitis vaccine into the body, stimulating the body’s immune system to produce enough antibodies to protect long-term from hepatitis viral infection. Only Hepatitis A and Hepatitis B vaccines are available. There is not yet a vaccine for Hepatitis C or other types of hepatitis.

Hepatitis A vaccine:

Involves a total of two injections. After the first injection the body usually takes two to four weeks to produce sufficient antibodies to fight against the Hepatitis A virus. The second vaccine injection (booster shoot) usually happens within 6-12 months to accomplish long-term immunity (10-20years).

The following people in particular should consider having Hepatitis A vaccine:

• People without Hepatitis A antibody
• People who travel regularly, especially to places where Hepatitis A is prevalent
• People who often ingest uncooked food, especially shellfish and seafood
• People working in the food industry 

Hepatitis B vaccine:

The full course includes three injection within 6 months for the best immune protection. The first and second injection should be a month apart; the second and third injections should be 5 months apart. Hepatitis B antibodies are produced one to two weeks after injection. If the three doses of vaccines are completed in a timely matter about 90-95% of people will produce enough Hepatitis B antibody to enjoy 15 years or more of immunity. People with immunity will not need booster vaccines once a sufficient level of antibody is reached.

The following people should be vaccinated with Hepatitis B vaccine:

• Anybody who has never been infected with Hepatitis B
• The family members, sexual partners and people in close contact with a Hepatitis B carrier 
• Medical personnel as the nature of their work requires coming in contact with patient’s blood and bodily fluids
• People who are using street drugs
• People who are on dialysis
• People who often receive blood transfusion or blood products
• Newborn babies, especially when the mother is a carrier

Twinrix (Combined hepatitis A and B vaccine)

Hepatitis A and Hepatitis B combination vaccine can protect the person from both Hepatitis A and Hepatitis B viral infection. The vaccination also involves 3 injections within 6 months. It will be effective for at least 15 years. The Universal Immunization plan in Canada provides all elementary school students and new born babies with Hepatitis B vaccination. However, there is yet to be a Hepatitis A vaccination program.

Hopefully with a better understanding of hepatitis and its prevention, along with the wide spread of vaccination plans, hepatitis along with its complications and subsequent disease will completely eliminated in the near future.

Content by Dr. Thomas Ho, Family Practice