The ABC's of Hepatitis: Get to Know This Viral Disease
Medically reviewed by Leigh Ann Anderson, PharmD. Last updated on June 14, 2021.
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.
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 the past, you could still get one of the others anytime in the future.
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
- travelers to certain countries
- pregnancy if high risk
- close, personal contact with international adoptee
- those who work in a lab researching Hepatitis A
- those at high risk, such as HIV infection, men who have sex with men, drug abusers (injection and non-injection), and people with chronic liver disease or other types of hepatitis
- settings where exposure may be higher (drug addiction services, group homes for developmentally disabled)
- those who are experiencing homeless (per CDC update 2020)
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 of Hep A can include:
- lack of appetite
- nausea, vomiting
- dark urine
- clay-colored stools
- 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 this virus for life. Keep in mind you are still susceptible to Hep B or C.
Travel Buff? Don't Bring Back Hepatitis A
If you are travelong to exotic or undeveloped nations, a vaccine may be in your travel plans, too.
- 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 (Twinrix) 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
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.
However, if you do get any side effects common ones may include:
- soreness or a lump at the injection site
- feeling tired
- a headache or a slight fever.
- rarely, severe allergic reactions.
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
- needle sticks.
What to Expect: Hepatitis B Signs and Symptoms
About 70 percent of adults will develop symptoms to the acute B virus. Symptoms common with liver disease typically appear about 3 months after infection and can include:
- loss of appetite
- nausea, vomiting
- stomach pain
- dark urine
- clay-colored stools
- joint pain
- 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, just like hepatitis A.
Chronic hepatitis B is a lifelong infection and about 15% to 25% of people will develop serious liver conditions, such as cirrhosis (scarring of the liver), liver failure, or liver cancer. Those with chronic hepatitis B do not typically have symptoms or feel ill, and can remain symptom free for 30 years or more. If symptoms appear, they are similar to the symptoms of acute infection listed above, but can be at a more advanced stage of liver impairment.
The Hepatitis B Vaccine: Need-to-Know
There is no medication available to treat short-term, acute Hepatitis B. Rest, adequate nutrition and fluids are important for recovery.
However, some antiviral 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. Brands include: Engerix-B, Recombivax HB.
- Infants are vaccinated starting at birth, and all children younger than 19 years of age who have not been vaccinated.
- In December 2018, Vaxelis was FDA-approved as a hexavalent combination vaccine to prevent diphtheria, tetanus, pertussis, poliomyelitis, hepatitis B, and invasive disease due to Haemophilus influenzae type b in children from 6 weeks through 4 years of age (prior to the 5th birthday).
- Any high risk adult should talk to their doctor about getting the 3-dose vaccine series for Hep B. Primary immunization for persons aged 20 years and older consists of 3 doses (1 mL each) given on a 0-, 1-, and 6-month schedule.
- 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. It is given as two doses (0.5 mL each) one month apart
- Acquiring Hepatitis B during international travel is a possibility in certain regions, so review the CDC guidelines for recommendations.
Related: Recommended Adult Immunization Schedule for ages 19 years or older, United States, 2021 - CDC.
The Specifics: Hepatitis B Vaccine and Treatment
There is no cure for hepatitis B.
About 25% of people with chronic hepatitis B die from liver scarring (cirrhosis) or liver cancer. The Hepatitis B vaccine should be your first line of defense.
Antiviral treatments are available, such as:
- interferon alfa-2b (Intron A), lamivudine (Epivir)
- adefovir (Hepsera)
- tenofovir (Viread)
- tenofovir alafenamide (Vemlidy, Viread )
- 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, but are temporary.
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 (kidney) dialysis
- from mother to child during childbirth
- contaminated tattoo or body piercing equipment
- rarely from unprotected sexual intercourse or blood transfusions.
It is estimated 3 to 4 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 of HCV, in the first 3 months, may include:
- yellow-colored skin or eye sclera (jaundice)
- 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. The development of the oral direct-acting agents has revolutionized the treatment of adults with HCV.
Oral, direct-acting antivirals (DAAs) for HCV treatment are groundbreaking discoveries in medical care:
- Sovaldi (sofosbuvir)
- Harvoni (ledipasvir and sofosbuvir)
- Olysio (simeprevir) - discontinued from US market
- Technivie (ombitasvir, paritaprevir and ritonavir), July 2015 - discontinued from US market
- Zepatier (elbasvir and grazoprevir), January 2016
- Epclusa (sofosbuvir and velpatasvir), June 2016
- Vosevi (sofosbuvir, velpatasvir and voxilaprevir), July 2017
- Mavyret (glecaprevir and pibrentasvir), August 2017
Hepatitis viral clearing can occur in over 90% of patients; some in just 8 weeks. Resistance can develop; therefore, two or more antivirals are used together. Treatment length often depends upon degree of liver damage. Easier side effect profiles -- primarily fatigue and headache -- are making these oral drugs easier to tolerate than older treatments like interferon.
Use of some direct-acting antivirals in children is now approved for various ages, weight and for certain genotypes or liver function depending upon drug:
- Epclusa (3+ years)
- Harvoni (3+ years)
- Mavyret (12+ years or weighing at least 45 kg)
- Sovaldi (3+ years)
Oral HCV Treatments: Weighing Up Your Options
Many new oral HCV regimens no longer require added ribavirin or peginterferon, two drugs that can be difficult for many patients to tolerate.
Side effects can still occur with DAAs. In clinical trials with Sovaldi and Harvoni, common or serious side effects included:
- asthenia (lack of energy)
- insomnia and nausea
- low heart rate (bradycardia)
Hep C Latest Approvals: Staying Up-to-Date
New drug approvals for HCV are many, so keeping up is important.
In January 2016, FDA approved Merck's Zepatier (elbasvir and grazoprevir), a once-daily oral NS5A inhibitor and NS3/4A protease inhibitor, 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% of patients.
- Common side effects with Zepatier included headache, stomach upset (nausea), and fatigue.
In July 2015, Daklinza (daclatasvir) from Bristol-Myers Squibb received FDA clearance for treatment of HCV genotypes 1 or 3. Daklinza has now been removed from the US market.
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.
- Viekira Pak 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 Pak is not used in patients with moderate to severe hepatic impairment. It also has several important drug interactions with CYP450 enzyme system (3A and 2C8), and others
Viekira XR, a single combination tablet of the ingredients in Viekira Pak co-packaged with dasabuvir was approved December 2014; however, Viekira XR has now been discontinued from the US market.
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 was 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.
- Epclusa is approved for children ages 3 and over with chronic HCV types 1-6.
- The most common side effects of Epclusa in adults include headache and tiredness. Children less than 6 years of age may commonly vomit or spit up the drug (in at least 10% of children).
Other options are now available for all 6 forms for HCV, including Gilead's Vosevi (sofosbuvir, velpatasvir and voxilaprevir). Vosevi is used in patients without cirrhosis (liver disease) or with compensated cirrhosis who were not successfully treated with other HCV drugs. Vosevi is used in two groups for re-treatment of HCV:
- either genotype 1, 2, 3, 4, 5, or 6 previously treated with an NS5A inhibitor regimen
- or genotype 1a or 3 previously treated with a sofosbuvir regimen without an NS5A inhibitor.
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). Glecaprevir inhibits NS3/4A protease and pibrentasvir inhibits NS5A.
Mavyret is used to treat adults and children 12 years of age and older or weighing at least 99 pounds (45 kilograms) with chronic (long-lasting) hepatitis C virus:
- Genotypes 1, 2, 3, 4, 5 or 6 infection without cirrhosis or with compensated cirrhosis, or
- Genotype 1 infection in patients previously treated with an NS5A inhibitor or an NS3/4A protease inhibitor, but not both.
In April, 2019, Mavyret was approved as initial treatment for all 6 genotypes in children 12 years and older or weighing at least 45 kg.
In Sept. 2019, the FDA granted approval to shorten the once-daily treatment duration from 12 to 8 weeks in patients that are treatment-naïve with compensated cirrhosis (Child-Pugh A) across all genotypes.
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.
Hep A, B and C are so well-known; so maybe you did not realize there was a hepatitis D and E?
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.
- There is no vaccine for hepatitis D, but it can be prevented in people who are not already HBV-infected by hepatitis B vaccination.
Hepatitis E virus (HEV), 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 E in the U.S.
Finished: The ABC's of Hepatitis: Get to Know This Viral Disease
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- Geddawy A, Ibrahim YF, Elbahie NM, et al. Direct Acting Anti-hepatitis C Virus Drugs: Clinical Pharmacology and Future Direction. J Transl Int Med. 2017;5(1):8-17. doi:10.1515/jtim-2017-0007
- US Dept. of Health and Human Services (HHS). Reproductive Health Facts Sheets. Hepatitis C. Accessed April 20, 2021 at https://www.cdc.gov/hepatitis/hcv/cfaq.htm
- Recommended Adult Immunization Schedule for ages 19 years or older, United States, 2020. US Centers for Disease Control and Prevention (CDC). Accessed April 20, 2021 at https://www.cdc.gov/vaccines/schedules/hcp/imz/adult.html#note-hepa
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