The ABC's of Hepatitis: Get to Know This Viral Disease
Medically reviewed on Nov 19, 2017 by L. Anderson, PharmD.
It's Not Just Alphabet Soup
You may have heard of Hepatitis A, B and C. While the letters may differ, they all have one thing in common - a dangerous inflammation of the liver. Viral hepatitis A, B and C are the most common hepatitis infections in the U.S. Hepatitis usually results from a viral infection and can often be a hidden disease where symptoms may not appear for years or even decades.
What's the Difference Between Hepatitis A, B and C?
Each of these viral hepatitis diseases are caused by a different virus. Hepatitis A is an acute infection that does not become chronic or lifelong. Most people with Hepatitis A can recover without treatment. Hepatitis B and Hepatitis C can also begin as an acute infection, but both can last longer with the virus remaining in your body and leading to long-term liver problems.
There are vaccines to prevent Hepatitis A and B; however, there is not one for Hepatitis C. Plus, if you've had one hepatitis virus, you could still get one of the others.
Hepatitis A: There's a Vaccine For That
Unlike Hepatitis B or C, which can lead to long-term (chronic) hepatitis, Hepatitis A virus is an acute liver infection that lasts a few weeks to several months. It does not cause a lifelong hepatitis infection. The ingestion of fecal matter, usually from consumption of contaminated food or drink, or close contact can result in transmission of the Hepatitis A virus.
Hepatitis A vaccination is recommended for children beginning at age one, as well as travelers to certain countries, and those at high risk, such as men who have sex with men, drug abusers (injection and non-injection), and people with other types of hepatitis.
Hepatitis A Symptoms (or Not)
Hepatitis A does not always cause symptoms. If symptoms do occur, they usually show up 2 to 6 weeks after infection. Adults are more likely than kids to have symptoms.
Typical symptoms can include fever, fatigue, lack of appetite, nausea, vomiting, dark urine, clay-colored stools, and jaundice (yellowing of the skin and eyes). There are no specific treatments for Hepatitis A; most people will recover completely without long-term liver damage. The illness usually clears in 8 weeks, but could rarely last up to 6 months. However, once you recover from Hepatitis A, you develop antibodies that protect you from the virus for life. However, you are still susceptible to Hep B or C.
Are You a Travel Buff? Don't Bring Back Hepatitis A
If you are planning on travel to exotic or undeveloped destinations, a vaccine may be in your future. The Hepatitis A vaccine is an inactive (not live) vaccine given as 2 shots spaced 6 months apart. Protection starts 2 to 4 weeks after the first injection, and a second injection leads to long-term protection.
The Hepatitis A vaccine also comes combined with the B vaccine and is given to adults as 3 shots over a period of 6 months. In addition to the vaccine, consistent hand washing with soap and warm water after using the bathroom, changing a diaper, or before preparing food can help to prevent Hepatitis A infection. Check with the CDC at the online section on Traveler's Health for specific travel destination information, or speak with your doctor.
Hepatitis A Vaccine: Side Effects to Expect
The hepatitis A vaccine first became available in 1995, and since then millions of doses have been given. As proven over the years, the hepatitis A vaccine is very safe and side effects are mild compared to getting the hepatitis A infection itself. In fact, many people do not have any vaccine side effects at all.
Common side effects may include soreness or a lump at the injection site, feeling tired, a headache or a slight fever. Rarely, severe allergic reactions can occur. If you notice a rash, hives, itching, trouble breathing, tightness in the chest, swelling of the mouth, face, lips, or tongue, or unusual hoarseness or wheezing, contact your doctor immediately.
Hepatitis B Infection: It's Catchy
Unlike Hepatitis A, Hepatitis B it is not spread routinely through food or water. Hepatitis B virus is spread when infected body fluids like blood or semen enter the body of a person who is not infected. The virus can also be spread from mother to baby at birth.
Hepatitis B can be either an acute (short-lived) or chronic (long-lasting) infection. The symptoms can last from weeks to lifelong. Acute infection may turn into chronic infection, but not always. High risk activities that can lead to Hepatitis B include direct blood contact, sex with an infected partner, sharing needles or other drug-injecting items, sharing razors or toothbrushes, and needle sticks.
What to Expect: Hepatitis B Signs and Symptoms
About 70 percent of adults will develop symptoms to the acute B virus. Symptoms typically appear about 3 months after infection and can include fever, fatigue, loss of appetite, nausea, vomiting, stomach pain, dark urine, clay-colored stools, joint pain and jaundice (yellow color in the skin or the eyes).
The good news is that once you recover from acute Hepatitis B, you develop antibodies that protect you from the virus for life. Ironically, people with chronic Hepatitis B may not show symptoms for up to 30 years. About 15% to 25% of people with chronic Hepatitis B develop serious liver conditions, such as cirrhosis (scarring of the liver) or liver cancer.
The Hepatitis B Vaccine: You Need-to-Know
There is no medication available to treat short-term, acute Hepatitis B. Rest, adequate nutrition and fluids are important for recovery. Some treatments are available for chronic Hepatitis B, so talk with your doctor. Prevention is key. The Hepatitis B vaccine is given as 3 shots over a 6-month period. Infants are vaccinated starting at birth, and all children younger than 19 years of age who have not been vaccinated.
Any high risk adult should talk to their doctor about getting the 3-dose vaccine series. A 2-dose hepatitis B vaccine for adults, known as Heplisav-B [Hepatitis B Vaccine, Recombinant (Adjuvanted)] from Dynavax, was FDA-approved in November 2017. Heplisav-B is indicated for prevention of infection caused by all known subtypes of hepatitis B virus in adults age 18 years and older. Heplisav-B is the first new hepatitis B vaccine in the US in more than 25 years and the only two-dose hepatitis B vaccine for adults.
Acquiring Hepatitis B during international travel is a possibility in certain regions, so review the CDC for recommendations. In 2017, the CDC added adults with chronic liver disease (such as those with hepatitis C, cirrhosis, fatty liver disease, alcoholic liver disease, autoimmune hepatitis, and elevated liver enzymes) as a group who should receive a HepB vaccination series.
The Specifics: Hepatitis B Vaccine and Treatment
There is no cure for hepatitis B. About 25 percent of people with chronic hepatitis B die from liver scarring (cirrhosis) or liver cancer. However, the Hepatitis B vaccine should be your first line of defense. Antiviral treatments such as interferon alfa-2b (Intron A), lamivudine (Epivir), adefovir (Hepsera), telbivudine (Tyzeka), tenofovir (Viread), tenofovir alafenamide (Vemlidy), and entecavir (Baraclude) can prevent some liver damage in chronic infection.
If you fall into a high risk group for Hepatitis B infection, get tested. Even if you are negative, you can be vaccinated to prevent future infection. Vaccine side effects may include fever, body aches, dizziness, headache and sore injection site.
Hepatitis C: Baby Boomers Take Note
Hepatitis C virus (HCV) is a blood-borne disease and also a top cause of chronic (long-lasting) liver disease and liver cancer. Both the United States Preventive Services Task Force (USPSTF) and the Centers for Disease Control and Prevention (CDC) recommended that all "baby boomers" - those born from 1946 to 1964 - be tested for HCV.
As a chronic disease, HCV can damage the liver over time, leading to scarring, cirrhosis, possible liver cancer and death. To complicate matters, symptoms of HCV may not appear for 20 to 30 years after infection, so the disease may develop quietly for decades. Unlike Hep A and Hep B, there is no vaccine for Hep C, but new treatments have a very high cure rate.
Hepatitis C Virus: How Do I Get It?
HCV is transmitted through contact with infected blood - mainly by sharing needles during drug abuse, an accidental needle stick, renal dialysis, mother to child during childbirth, contaminated tattoo or body piercing equipment, and rarely from unprotected sexual intercourse or blood transfusions.
Over 3 million people in the U.S. are infected with hepatitis C and many have never been tested. Death from HCV usually arises from cirrhosis and liver cancer. As many undiagnosed infections occurred decades ago, death rates are expected to rise. However, new HCV treatments are very effective, and can cure many with HCV. But first, you need to be tested!
What Symptoms of HCV Would I See?
Symptoms for HCV may not appear for decades, that is why it is so important to get tested. HCV can actually clear itself from the body in about 15 percent of people, but most people become infected with the chronic virus.
Early symptoms, in the first 3 months, may include yellow-colored skin or eye sclera (jaundice), weakness, fatigue, poor appetite, nausea and stomach pain. If this early disease does not clear, chronic, long-term symptoms can include weight loss, poor appetite, fatigue, and painful joints. A simple blood test is all that is needed for a diagnosis, although some people may need a liver biopsy.
What's the Latest Treatments for HCV?
Drug treatment for HCV has been rapidly evolving, and many patients can be fully cured now, often without the need for difficult-to-tolerate ribavirin or peginterferon. Oral, direct-acting antivirals for HCV treatment, including Sovaldi (sofosbuvir), Harvoni (ledipasvir/sofosbuvir), and Olysio (simeprevir), were groundbreaking discoveries and direct-acting antivirals are quickly becoming the standard of care in HCV.
Technivie (ombitasvir, paritaprevir and ritonavir) was FDA-approved in July 2015 for HCV, Zepatier (elbasvir/grazoprevir) was approved in January 2016, and Epclusa (sofosbuvir and velpatasvir) in June 2016. Hepatitis viral clearing can occur in 90-99 percent of patients; some in just 12 weeks. However, resistance can develop; therefore, two or more antivirals are used together. Easier side effect profiles -- primarily fatigue and headache -- are making these oral drugs easier to tolerate, too.
Oral HCV Treatments: Weighing Up Your Options
Some newer oral HCV regimens no longer require added ribavirin or peginterferon, two drugs that can be difficult for many patients to tolerate. However, in clinical trials with Sovaldi and Harvoni, common side effects included headache, fatigue, asthenia (lack of energy), diarrhea, insomnia and nausea. Low heart rate (bradycardia) has been noted as a serious effect with both agents.
Olysio has been linked with a severe rash in about 1% of patients. In general, a mild-to-moderate rash occurs in 10-15% of patients; photosensitivity in 6 to 7%, and pruritus/itching in roughly 11%. Patients taking Olysio should avoid the sun when possible and use sun protection when outdoors.
Hep C Latest Approvals: Staying Up-to-Date
New drug approvals for HCV seem to be occurring at lightning speed, so keeping up is important. In January 2016, FDA approved Merck's Zepatier, a once-daily oral NS5A inhibitor and NS3/4A protease inhibitor (elbasvir/grazoprevir) fixed-dose combination, used with or without ribavirin, for the treatment of HCV genotypes 1 and 4. In 12-week treatment periods, a cure was documented in 94 to 100 percent of patients. Common side effects with Zepatier may included headache, stomach upset, and fatigue. In July 2015, Daklinza (daclatasvir) from Bristol-Myers Squibb received FDA clearance for treatment of HCV genotypes 1 or 3. Daklinza is an oral NS5A inhibitor used with sofosbuvir. In patients without cirrhosis who had never had HCV treatment, 98 percent achieved a cure at 12 weeks. Learn more about the different HCV genotypes here.
More Combo Agents in the U.S.
Viekira Pak from AbbVie, a combination HCV treatment, was approved in December 2014, and is used for treatment of genotype 1a and 1b HCV in patients with or without cirrhosis. Viekira Pak is an NS5A inhibitor (ombitasvir), NS3/4A protease inhibitor (paritaprevir), and CYP3A inhibitor (ritonavir) combination co-packaged with a non-nucleoside NS5B palm polymerase inhibitor (dasabuvir). Viekira XR, a single combination tablet of the ingredients in Viekira Pak co-packaged with dasabuvir was approved December 2014. Neither Viekira product is used in patients with moderate to severe hepatic impairment.
Technivie was FDA-approved in July 2015. It's an NS5A inhibitor (ombitasvir), NS3/4A protease inhibitor (paritaprevir), and CYP3A inhibitor (ritonavir) fixed-dose combination used in combination with ribavirin. Technivie in combination with ribavirin is the first regimen approved for genotype 4 HCV infections without the need for interferon. In treatment-naïve patients who cannot tolerate ribavirin, Technivie use without ribavirin may be considered. As with Viekira Pak, Technivie is not used in moderate to severe liver dysfunction.
First Approvals For All Major Forms of HCV
In June 2016 the FDA approved Gilead's Epclusa (sofosbuvir and velpatasvir), a nucleotide analog polymerase inhibitor and pan-genotypic NS5A inhibitor fixed-dose combination for the treatment of chronic hepatitis C virus (HCV) infection in adults. Epclusa is the first drug available to be used for HCV genotypes 1 through 6 in patients with or without cirrhosis.
In studies, 95 to 99 percent of Epclusa-treated patients without cirrhosis or with mild cirrhosis had no virus detected in the blood 12 weeks after finishing the 3-month regimen. In patients with moderate to severe cirrhosis, some of whom required ribavirin, 94 percent were cleared of the virus 12 weeks after finishing treatment. The most common side effects of Epclusa include headache and tiredness.
- either genotype 1, 2, 3, 4, 5, or 6 previously treated with an NS5A inhibitor regimen
- or genotype 1a or 4 previously treated with a sofosbuvir regimen without an NS5A inhibitor.
Vosevi is used in patients without cirrhosis (liver disease) or with compensated cirrhosis who were not successfully treated with other HCV drugs. In studies, 96 to 97 percent of patients who received Vosevi had no virus detected 12 weeks after finishing treatment, suggesting that infections were cured. Common side effects include headache, fatigue, diarrhea, and nausea.
Mavyret: AbbVie's 8 Week Agent for All 6 Genotypes
In August 2017, the FDA) approved AbbVie's Mavyret (glecaprevir and pibrentasvir), the first 8 week treatment for all chronic hepatitis C virus (HCV) genotypes (1-6) in adults without cirrhosis (liver disease) who have not been previously treated.
Glecaprevir inhibits NS3/4A protease and pibrentasvir inhibits NS5A. Specifically, Mavyret is approved for two patient populations:
- Chronic HCV genotype 1, 2, 3, 4, 5 or 6 infection without cirrhosis and with compensated cirrhosis (Child-Pugh A)
- Adult patients with HCV genotype 1 infection, previously treated with an HCV NS5A inhibitor or an NS3/4A protease inhibitor, but not both.
Studies demonstrated that 92 to 100 percent of patients had no virus detected in the blood 12 weeks after finishing treatment, suggesting a cure. The most commonly reported adverse reactions with Mavyret (> 10%) are headache and fatigue.
Hepatitis D and E: Uncommon in the U.S.
Hepatitis D virus (HDV), also known as delta agent, is a blood-borne infection that requires the presence of hepatitis B virus for replication. In fact, hepatitis D causes symptoms only in people who also have a hepatitis B infection. Those with an acute HDV infection usually get better in 3 weeks, and only 10% may develop chronic hepatitis.
Hepatitis E virus, while rare in the U.S., is common around the world. HEV is similar to Hepatitis A, and is spread through contaminated food and water due to poor sanitation and usually results in an acute infection. There are currently no FDA-approved vaccines for Hepatitis D or E.
Finished: The ABC's of Hepatitis: Get to Know This Viral Disease
- FDA Approves Heplisav-B. Drugs.com. Nov. 9, 2017. Accessed 11/19/2017 at https://www.drugs.com/newdrugs/dynavax-announces-fda-approval-heplisav-b-prevention-hepatitis-b-adults-4631.html
- Vosevi Product Label. Gilead July 2017. Accessed July 29, 2017 at http://www.gilead.com/~/media/files/pdfs/medicines/liver-disease/vosevi/vosevi_pi.pdf?la=en
- Centers for Disease Control and Prevention (CDC). Recommended Immunization Schedules for Adults United States, 2017. Accessed Feb. 28, 2017 at https://www.cdc.gov/vaccines/schedules/hcp/adult.html
- U.S. Vaccine Guidelines for Flu, HPV Updated. Drugs.com. Accessed Feb. 27, 2017 at https://www.drugs.com/news/u-s-vaccine-guidelines-flu-hpv-updated-64390.html
- Epclusa Product Labeling. Gilead Sciences. Accessed 04/18/2017 at http://www.gilead.com/
- Vemlidy Product Labeling. Gilead Sciences. Accessed 04/13/2017 at http://www.gilead.com/