Gettysburg Medical Center
The Clinical View
by P.E. Hoffsten, M.D.
27 April 2005

THE  SURPRISE OF HEPATITIS

             Last week’s column about rabies described an innocent act of kindness that lead to a young boy being bitten by a stray cat.  This week’s column relates to a story about a gentleman who acted in a noble and patriot way but got an ugly surprise.

            The gentleman was 56 years old and had been in the auto servicing and repair business for 40 years.  He had served in Viet Nam for a year but had not engaged in risky behavior such as intravenous drug use and he had not been wounded or received blood products.

He was happily married having three grown children with one son enlisted in the military.  Although, he had never done it before, the gentleman felt that it was his patriotic duty to donate blood for those in need.  So he inquired about how to go about donating blood.  He was screened by the routine measures and told that he had an abnormality in his blood that would not allow him to be a donor.  He was advised to see his local physician for further evaluation.

            He wasn’t alarmed but came to the clinic questioning what could be wrong and why couldn’t he donate blood.  Several blood tests were done and demonstrated that he was a carrier for Hepatitis B.  His questions became a flood at that point.

            He first wanted to known how he had gotten the infection.  He was told there was no way to know with any certainty.  It was explained that Hepatitis B is spread by blood contamination from one person to the next but he had no pertinent history that he had acknowledged.  He was told that we didn’t have a clue as to how he got Hepatitis B.

            The second question was how long had he been a hepatitis B carrier.  We were not much help there either.  There was no way to tell when the infection might have occurred in the absence of previous blood tests.  When he went into the service in the 1960’s, screening tests for Hepatitis B were not available.  He had passed life insurance examinations 20 years before so he probably did not have the condition then.

            He wanted to know if he was contagious to his family or others.  His wife was tested and found to be negative.  She was then vaccinated against Hepatitis B.  He was instructed that his blood and semen were infectious if introduced into others.

            Next he wanted to know if his condition was dangerous.  He was instructed that in some individuals serious medical complications could occur including progressive liver failure.  Various examinations were done and he was told that there did not appear to be any dangerous abnormalities at this point.  Assuming that he had been a hepatitis B carrier for more than 3 months, he was instructed that there was no need for any intervention at this time based on the blood tests done.

            He next asked the question if he would ever become non-infectious.  About 80-90% of individuals who contact Hepatitis B eventually become immune to the virus and it is basically eradicated from their body.  Around 10% of individuals who contact Hepatitis B will become lifelong carriers of the virus and be infectious at all times.

            Lastly, he was concerned about available treatment if it was needed.  There are various antiviral drugs available to treat chronic Hepatitis B infection but they are enormously expensive and their long term beneficial impact is yet to be clearly demonstrated.

            Fortunately, in the last 10-15 years, a vaccine against Hepatitis B has become available and is now administered to all children prior to entering school.  These children receive vaccines for polio, hepatitis B, diphtheria, tetanus, and pertussis (whooping cough).  Hopefully, our next generation will be free of Hepatitis B in this country.

            Fortunately, the gentleman above is now 8 years past the time of his original diagnosis and remains clinically stable without evidence of liver damage although his blood is still infectious.

            Hepatitis B virus is only one of seven different known hepatitis viruses.  Hepatitis A virus tends to infect little kids especially in daycare centers.  It is spread by so called “fecal-oral” (Yuk!) transmission where little kids get contaminated.   Most of the time, Hepatitis A virus infection leads to a relatively mild case of hepatitis and resolves completely.  Hepatitis A never results in a chronic carrier state.  A vaccine to prevent Hepatitis A is advised for children in areas where the virus is common.

            The third relatively common hepatitis virus is called Hepatitis C.  It is not clear how this virus is transmitted although we do know that blood transmission occurs.  Fortunately now there are screening tests for Hepatitis B and Hepatitis C to prevent individuals who are carriers of these viruses from ever getting into the blood donor pool.  Different than Hepatitis A which never leads to chronic carrier state and Hepatitis B which leads to a chronic carrier state in about 10% of the people who develop it, Hepatitis C leads to a chronic carrier state in almost 80% of the individuals who ever contact it.  Fortunately, only about 5% of hepatitis cases are due to Hepatitis C but because it does not go away, chronic carriers are relatively common.  There is no vaccine at this time and no meaningful treatment to change the course of those few individuals who go on to develop liver failure and cirrhosis.

            The healthcare providers at your local clinics are aware of the various considerations regarding hepatitis viruses.  Advice on how to prevent these diseases, how to monitor their course and how to treat when needed can be provided.  Fortunately, for the gentleman mentioned above, thus far there has been no need for treatment.  His wife has been immunized and his life has not really changed.