Organised by the World Gastroenterology Organisation, World Digestive Health Day occurs every year on May 29 to help raise awareness of a different chronic digestive disease. This year, the focus is on hepatitis B & C virus infections.
In support of the day, leading experts answer frequently-asked questions on hepatitis, including the symptoms, how to minimise your risk and the outlook for patients with the virus.
Markus is the Chair of the UEG Public Affairs Committee and former Secretary General of the European Association of the Study of the Liver (EASL).
Helena is a member of the UEG Public Affairs Committee and is the EU Policy Councillor for EASL.
What is hepatitis?
Helena Cortez Pinto: Hepatitis is an inflammation of the liver that can be either acute or chronic. Viruses, such as Hepatitis A, B, C, D, or E, can cause it. In other cases, mechanisms of self-aggression are responsible for auto-immune forms of hepatitis. Among viral hepatitis, hepatitis A only presents in acute forms, while hepatitis B, C, D or E can be acute or progress to chronic forms.
What are the most common symptoms of hepatitis?
Helena Cortez-Pinto: The most common symptoms of acute hepatitis are jaundice (yellow colour of the eyes and skin), fatigue, and a slight discomfort in the upper right quadrant. However, it can also present with symptoms very similar to flu, such as fever, tiredness and muscle pain. Urine may also become darker, and lack of appetite as well as nausea can be present.
Is there a cure for hepatitis?
Helena Cortez-Pinto: Yes. Regarding hepatitis A it cures spontaneously in the vast majority of cases and consequently no treatment is needed. With regard hepatitis B, the majority of acute hepatitis cases also cures spontaneously. When this does not happen and a chronic hepatitis develops, a treatment is available that keeps the disease controlled. For hepatitis C, there is now the availability of drugs that allow the cure in about 97% of chronic hepatitis C cases, using 8 to 12 weeks treatment with oral drugs. Regarding hepatitis D, the treatment is so far not very effective. Hepatitis E usually does not need treatment, but if needed there is a treatment that is effective.
Who is most at risk of contracting hepatitis?
Helena Cortez-Pinto: Regarding Hepatitis A, it is transmitted through ingestion of contaminated food and water or through direct contact with an infectious person, so those in higher risk are injecting-drug users, men who have sex with men, as well as people travelling to areas of high endemicity. Regarding hepatitis B, sex-related professionals, those who engage in unprotected sexual activity, as well as people who inject drugs are those most at risk. The major risk for hepatitis C is being through injecting drugs or engaging in unsafe sexual practices.
How can I minimise my risk of contracting hepatitis?
Helena Cortez-Pinto: The best way to minimise the risk of hepatitis A and B is through vaccination, which is very effective. Regarding hepatitis A, those travelling to areas of high endemicity, as well as men who have sex with men, should be vaccinated. Hepatitis B vaccination is part of the national vaccination programme in a large number of countries, implying vaccination of all new-borns. However, adults frequently are not included in these programs, so if they belong to a risk profession or if they are planning to incur in risky conducts, they should be vaccinated. Since there is no vaccination for hepatitis C, the best prevention is not to incur in risky behaviours, such as drug injection. People who inject drugs should be extremely careful with all the material used and not share any of the material that they use.
What is the current treatment process for someone that has hepatitis? Are they different for the different types?
Helena Cortez-Pinto: As mentioned, hepatitis A needs no treatment. Hepatitis B, may need treatment in some acute forms, but that is rare. The treatment for chronic forms may include an injectable drug, for a limited time, but in most cases an oral treatment is used that is well tolerated. This treatment keeps the disease controlled, although a cure is not achieved in most cases. Regarding hepatitis C, we now use an 8 to 12-week treatment with oral drugs, that is effective in more than 95% of cases, leading to the cure of hepatitis C. Regarding hepatitis D, the treatment is so far not very effective, and is usually done with an injectable drug for a limited period of time. Hepatitis E usually does not need treatment, but if needed there is an oral treatment that is effective and time-limited.
Are all forms of hepatitis spread in the same way?
Markus Peck: No, hepatitis A and E are usually spread through polluted water and everything that is produced or washed with it. Hepatitis B, D, and C are spread through blood and blood products, like blood and plasma transfusions or injections with contaminated syringes or other contaminated medical equipment. Hepatitis B (and with it, sometimes D) is also transmitted sexually, which for Hepatitis C is only reported with sexual practices causing mucosal trauma.
What form of hepatitis is most common in Europe and why is this?
Markus Peck: For acute viral hepatitis, this is hepatitis A. Its incidence is difficult to estimate, since it can have quite an indolent course, especially in children, which makes it difficult to differentiate from a flu-like infection. Chronic hepatitis B and C have a fairly balanced prevalence in Europe, with an estimated 4.7 million chronic Hepatitis B and 5.6 million chronic Hepatitis C cases in the EU + European Economic Area (EEA), according to the latest estimation form the European Centre of disease control (ECDC) from 2016. There are large geographic differences with chronic hepatitis B being more prevalent in Southern and Eastern Europe, especially in countries where there is no systematic childhood and risk-group vaccination. Hepatitis C is also more prevalent in Southern and Eastern Europe but is also highly prevalent in some communities in Western and Northern Europe, most notably in PWID’s and increasing also in the MSM-community.
What percentage of hepatitis patients require a liver transplant?
Markus Peck: About 20% of patients with chronic viral hepatitis will go on to develop cirrhosis within 20-30 years of chronic activity and lack of treatment, and will develop decompensation or liver cancer within another 10 years, which would make some of them candidates for liver transplantation. Only a minority of those requiring a transplant will actually be able to receive one due to either comorbidities, advanced age, or lack of organ availability. It is difficult to estimate the percentage of patients with chronic hepatitis receiving a transplant and I have not seen any reliable data on this. In addition, there is great geographic variability within Europe regarding the prevalence of chronic viral hepatitis and access to liver transplantation alike. In a country like Austria, with an estimated prevalence of chronic viral hepatitis of 0.3%, the rough estimate assuming a very low number of new infections and no effective treatment would be about 5% over the course of 20 years. With effective treatment as available today, this percentage will be much lower, as already evidenced by the declining number of patients with chronic viral hepatitis on the liver transplant waiting lists.
Can hepatitis be fatal?
Markus Peck: Yes, even acute hepatitis can be fatal but fortunately only in a small number of cases (<1% of acute infections) by causing acute liver failure. This is more common when acute hepatitis occurs against the background of an already damaged liver and can occur with any type of acute hepatitis (A-E). Chronic hepatitis can be fatal by causing cirrhosis and end stage liver disease as well as liver cancer.
What are your predictions for hepatitis treatment in the future?
Markus Peck: Hepatitis A and E usually only require symptomatic treatment and are self-limiting in most instances. Treatment of chronic viral hepatitis is already very effective; hepatitis C can be cured completely and hepatitis B can be very well controlled with continuous intake of oral drugs. Complete cure from hepatitis B is still an elusive goal but there are many efforts ongoing to achieve it. The but theme today is the quest for global elimination of viral hepatitis, as set as a target by WHO. In order to achieve that, we not only need effective drugs but also a whole range of comprehensive matters that include prevention (including vaccination), finding of infected individuals and linkage to care. Whether this can really be achieved until 2030 in many countries remains to be seen.