Hepatitis B : Get tested early, and stay healthy longer
I recently had a patient who walked into my OPD with a very worried expression on his face. I could sense from his demeanor that he had received some disturbing news. He was desperately seeking some counsel and solace for his mental state. I noticed that he had come alone. The man gingerly took the seat in front of me when I greeted and invited him inside. He was a middle-aged male, clean shaven except for a thick mustache, dressed in semi-formal attire with open-toed sandals. He looked at me as if the world was crashing around him. I then proceeded to engage him like I normally do with all my patients and enquired the reason for his consultation. He explained to me that he was diagnosed with a cataract in his right eye and had visited the Ophthalmologist for treatment.
During the routine pre-operative workup, an unusual report was the reason for his anxious disposition and the heavy clouds above his head. He was found to be Hepatitis B positive. When I was glancing through his reports, he leaned in and with a cracked, but surprisingly calm voice, explained that he cannot understand how he could be Hepatitis B positive. He was a respected member of the society, a proud teetotaler and except for a propensity to indulge in chocolates late at night or the occasional cold Thumbs-up in the afternoon, had actively stayed away from all the vices known to man. And yet, he exclaimed wistfully, “I am here in front of you with this distressing report.”
This is not an uncommon occurrence in the OPD and is a source of considerable stress and hardship to patients. The best way to cope with the situation, is to approach it in a healthy manner. This can be achieved primarily by being informed, first and foremost, about the disease. The social stigma and myriad myths surrounding Hepatitis B have given all the power to the virus and the disease. This blog article aims to address some of these aspects and try and take back some of the power that we have unknowingly misappropriated to this insidious fiend that takes up residence in the ‘seat of our soul and feelings’ as the liver was called in ancient Greece.
Hepatitis B is a virus that preferentially infects the liver and causes inflammation and damage. Globally, chronic hepatitis B is a major public health challenge with more than 350 million affected individuals. Usually, hepatitis B infection results in acute hepatitis which presents with fatigue, loss of appetite, fever and jaundice. Chronic smokers may find a temporary aversion to cigarettes during the acute phase of the illness and is more commonly noticed with infection due to Hepatitis A (a generally benign and close cousin of the culprit currently under focus (Hepatitis B)). A majority of patients with acute hepatitis will recover from the illness. Only 5-10% of patients will have persistent hepatitis B reports even after 6 months which is termed as chronic hepatitis B.
Chronic hepatitis B needs specific evaluation and treatment by a qualified Gastroenterologist or hepatologist. The common route of infection by hepatitis B is by sexual transmission, transfusion of contaminated blood products, contaminated needles during iv drug abuse or transfer of infected body fluids during surgical procedures and transmission from an infected mother to the foetus before or during the birth of the child, also referred to as, vertical transmission. Apart from these, there are insidious ways in which the virus can enter the body that usually escapes attention. These include, using un-sterile equipment during shaving/grooming at salons, improper equipment for insulin injections and needle-stick injuries during routine blood tests and other evaluation. These are the situations when an incidentally positive Hepatitis B result is discovered down the line like the example mentioned above.
Chronic hepatitis B is a disease with serious implications. If left untreated, it can lead to permanent liver damage (known as cirrhosis), and even liver cancer. Therefore, it needs early recognition and appropriate treatment. There are multiple options that are available for treatment of hepatitis B. Oral drugs are extremely efficient in rapidly clearing the virus from the blood to un-detectable levels. However, the choice, dosage and duration of treatment differs with each patient and is best left to the discretion of a qualified Gastroenterologist/hepatologist. Incidental detection of hepatitis B is a situation that demands a little more than an expected positive report.
The first step would be to confirm he diagnosis by performing the confirmatory tests for hepatitis B known as Enzyme Linked Fluorescent Assay(ELFA)/Enzyme Linked Immunosorbent Assay(ELISA). This should be combined with a full Liver function test and an ultrasound abdomen to assess the status of the liver. In most cases of incidental hepatitis B, the LFT and USG abdomen will be normal. The next step would be to assess whether the virus is actively replicating in the body. The doctor may order specific serology tests of hepatitis B in addition to a quantitative estimation of the viral DNA copies in the blood in order to understand this. The treatment is promptly initiated in case the viral DNA copies are elevated.
In most cases however, the viral DNA will be undetectable in the blood sample. This indicates that the virus is quiescent and is not actively replicating. By and large, a quiescent virus does not cause liver damage. However, it still means that the virus is present in the liver and is waiting on its calling to awaken and start replication. These patients are usually kept on close follow-up with blood tests and USG abdomen at recommended intervals in order to diagnose any activation of the virus early and institute appropriate treatment.
Apart from the medical management of this situation as detailed above, there is a significant aspect of counselling that will go a long way in the management of this situation. Open, transparent conversations with adequate time given to the patient to clear his/her doubts is an essential part of the treatment regimen. The old adage of ‘knowledge is power’ is applicable in these settings and in most situations, knowing about the disease, allaying some of the fears and busting the myths surrounding the illness could have a significant impact on the overall outcome of the illness.
It is my practice to engage with the patient, giving adequate time for the patient to express his/her feelings in addition to laying down the facts of the illness, which I feel is the most important aspect of their treatment. By allowing the patient to express their fears, addressing the social concerns of the disease and provide the right information to bust common myths; results in a more congenial and empathetic atmosphere, one that fosters trust and acceptance of their disease and allows the charting of a road map towards a positive outcome.
Important points with regard to hepatitis B infection:
> It is a common disease and incidental detection is more common than you would imagine
> Incidental diagnosis of hepatitis B is not an indication that you have strayed from the path of righteous principles that you may have set for yourself;there are many insidious ways that you may contract the disease that can escape your attention.
Tips to prevent hepatitis B:
> Make sure that the salon uses brand-new blades for personal grooming.
> Check credentials of the blood transfusion centers, clinics and nursing homes where needles may be used to draw blood.
> The needles should be new and taken out from the sealed pack
> Always get a serology done at the time of pregnancy. There are effective ways to prevent transmission to the foetus as long as the doctor is aware about the diagnosis in case it is positive, .
> Stop alcohol, smoking in case hepatitis is diagnosed, even if it is quiescent. They are additive agents of liver damage and carry a poor prognosis with Hepatitis B.
> Reduce the consumption of carbohydrate-rich diet and fatty food to a reasonable extent. Exercise and active lifestyle is encouraged and can have a multitude of positive effects including prevention of Non-alcoholic fatty liver disease (NAFLD). NAFLD is another agent of liver damage that is avoidable by healthy diet and lifestyle practices.
> MOST IMPORTANTLY, GET VACCINATED! Hepatitis B vaccine is widely available and is an effective, inexpensive way to prevent a disease that is a lifetime diagnosis. In case you are unaware, of whether you have had vaccination in the past, visit a Gastroenterologist who can run some tests that will suggest the need for vaccination/booster doses. It would be a good practice to get these tests done even if the vaccination was done in the past in order to ensure adequate protection.
Be open about the diagnosis with family members who can be a valuable source of encouragement and support. I insist that patients bring in their close family members in order to have an open conversations about the disease and its implications. This inclusive strategy could be extremely useful by creating a string support system for patients struggling with the unexpected burden of an incidental positive hepatitis B report.
In addition, close family members who are not vaccinated /have low levels of protection need to be vaccinated sooner rather than later.
It’s important to remember that, Hepatitis B is not a terminal diagnosis, and the treatment options are usually free of side-effects and extremely effective. Prevention is always better than cure, and Hepatitis B vaccination should be a priority in most patients (after consulting with a Gastroenterologist). Let us strive to change the perception of hepatitis B and remove the stigma that it rides with, using open, un-inhibited dialogues around the issue and a concerted effort towards a world where the virus could remain a distant memory.
Dr. HARSHAVARDHAN RAO B
Professor/ Senior Consultant
MD. DM Gasteroenterology