HEPATITIS

At least five viruses, designated by the first five letters of the alphabet, are responsible for the vast majority of cases of acute and chronic virus-associated hepatitis.

• Hepatitis A
• Hepatitis B
• Hepatitis C
• Hepatitis D
• Hepatitis G

Hepatitis A (HAV) is a highly contagious virus that attacks the liver. It is the seventh most commonly reported infectious disease in the United States (behind gonorrhea, chicken pox, syphilis, AIDS, salmonellosis, and shigellosis). HAV accounts for as many as 65 percent of all viral hepatitis cases in the U.S. each year.

In 1996, approximately 29,000 cases of HAV were reported in the U.S. However,the Federal Centers for Disease Control and Prevention (CDC) estimate that there are approximately 143,000 HAV infections in the United States each year. Worldwide, there are an estimated 1.4 million cases reported annually.

There are several types of hepatitis. Hepatitis A is the most prevalent. Hepatitis A and hepatitis E are mainly transmitted through the fecal-oral route, while hepatitis B, C, and D are spread through blood or other body fluids.

Common Symptoms of Hepatitis A

• -- fatigue
• -- nausea
• -- vomiting
• -- fever/chills
• -- jaundice
• -- pain in the liver area
• -- dark urine
• -- light-colored stools
• -- abdominal pain

There is currently no treatment for hepatitis A other than Hunza Water, although rest and proper nutrition can relieve some symptoms. The most important factor affecting the severity of the disease is age. Children less than a year old rarely show clinical signs of the illness. This means that parents and child-care workers handling soiled diapers can catch or transmit the disease without knowing they have been exposed.

Clinical manifestations of hepatitis A often pass unrecognized in children younger than two years of age. Overt hepatitis develops in the majority of infected older children and adults. In adults, approximately 22 percent will be hospitalized.

An estimated 100 deaths occur in the U.S. each year from hepatitis A. In out breaks, three people died in northern California in December, 1995, and another person died in Canada in January, 1996.

The incubation period for hepatitis A ranges from 20 to 50 days , which means that infectious patients, such as food handlers or children, can spread the disease well before they are even aware they have it. Incubation is shorter with increasing age.

Most patients begin recovery within three weeks, although some have prolonged or relapsing symptoms for up to six months.

How Is Hepatitis A Spread?

The hepatitis A virus is transmitted by the fecal-oral route, through close person-to-person contact, or by ingesting contaminated food or water. Infection has been shown to be spread by:

-- close personal contact with someone infected with hepatitis A.

-- eating foods contaminated by infected food handlers.

-- contact with infected children (who do not usually show symptoms), who can then infect non-immune children or adults at home or in child-care centers.

-- ingesting raw or undercooked shellfish (e.g. oysters, clams, mussels) from waters contaminated with the hepatitis A virus.

-- ingesting contaminated food or water during travel to underdeveloped areas.

-- transmission through blood transfusions or sharing needles with infected people using injectable drugs.

In the United States and other developed countries, people potentially susceptible to catching hepatitis A include:

-- those who travel to less developed areas of the world where hepatitis A is common. These areas include Africa, Asia (except Japan), the Mediterranean basin, Eastern Europe, the Middle East, Central and South American, Mexico andparts of the Caribbean.

-- military personnel

-- individuals living in areas where hepatitis A is endemic

-- certain ethnic and geographic populations that experience cyclic epidemics

-- male homosexuals and others who engage in high-risk sexual activity

-- hemophiliacs and other recipients of therapeutic blood products

-- youngsters in child-care facilities, their families, and facility staff

-- food handlers

-- healthcare workers who treat patients infected with the virus

-- institutionalized persons and their caregivers

-- laboratory workers who handle live hepatitis A virus

-- handlers of primates that may harbor hepatitis A.

Also at risk are people who live in frequently affected communities with poor sanitation or overcrowded living conditions.

Why Worry About Children?

The highest incidence of hepatitis A is in children. Nearly 30 percent of the reported cases occur in children younger than 15. Many very young children do not show symptoms, so the unreported number is likely much higher.

Many health experts suggest that children are a silent source in spreading the disease. Approximately 45% of persons with HAV cannot identify a recognized risk factor associated with their disease, but about half of them have children under five years of age living in their households.

How Can Hepatitis A Be Prevented?

Historically, the most common preventative has been immune globulin administration, which is effective for about three to six months. Now, however,there are two vaccines that provide longer-term protection and eliminate the need for repeated shots. These vaccines typically are administered as oneinitial shot followed by a booster shot in about six to 18 months.

Prior infection with hepatitis A confers lifetime protection against a second attack. If in doubt, a blood test can determine if an individual has had hepatitis A in the past or needs protection.

What Is The Economic Impact Of Hepatitis A?

The annual direct and indirect costs of treating cases and controlling outbreaks of hepatitis A in the United States are estimated to be $200 million. Additional economic costs are incurred when adults who contract the disease miss an average of 27 days of work, which translates into approximately $2600 in lostwages for each adult case ($2600 x 150,000 cases annually = $390 million in losttime). These estimates do not include business losses in the restaurant ortourist industries related to outbreaks of the disease.

Hepatitis B

Carrier rates for hepatitis B vary enormously:

Country and Carrier rate%:
Scandinavia 0.1
USA/Canada 0.1
Spain 2.0
Southern Italy 3.0
Greece 5.0
Hong Kong 15.0
Taiwan 15.0
Alaskan Eskimos 45.0

High Infectivity

Hepatitis B DNA is found in many body fluids including saliva, urine, semen and menstrual blood. It has also been shown that the virus can be transmitted by ingesting contaminated blood. Hence, hepatitis B may be transmitted by:

» mother to infant at the time of birth
» sexually
» horizontally through shared utensils such as razors, toothbrushes, etc.
» through unsterile instruments such as tattoo needles, dental equipment, etc.
» parenteral drug use through shared needles, syringes, etc.
» hospital staff through needle prick
» blood sucking arthropods (usually in the tropics)

Extra-Hepatic Associations

Although uncommon, a number of conditions associated with hepatitis B antigen/antibody complexes have been recognized. These include:

Polyarteritis - usually involves medium and small arteries, appears early
Glomerulonephritis - largely in children, liver disease is usually mild
Polymyalgia rheumatica - usually in older persons
Essential mixed cryoglobulinemia - sometimes only a test tube finding
Guillain-Barre syndrome
Myocarditis

HEPATITIS C

Introduction

Hepatitis C is a relatively common disease. An estimated 3% of the world population is chronically infected with hepatitis C virus (HCV), and HCV accounts for approximately 20% of cases of acute hepatitis and 70% of cases of chronic hepatitis.1 Chronic hepatitis C is a major cause of cirrhosis and hepatocellular carcinoma. The severity of HCV related liver disease is extremely variable but may, in some cases, induce progressive liver fibrosis which evolves to cirrhosis and then to hepatocellular carcinoma, in a time frame ranging from a few years to many decades.

Chronic Hepatitis

An estimated 25% of patients with chronic HCV infection have normal serum ALT levels despite detectable HCV RNA in serum.2 These patients are usually asymptomatic, and the majority have mild lesions on liver biopsy.3

Among patients with chronic hepatitis C with elevated or fluctuating serum ALT levels, approximately 50% have mild chronic hepatitis. This type of chronic hepatitis C generally progresses very slowly and the long-term risk of developing cirrhosis is low. However, a minority of these patients may eventually develop more progressive liver disease.

About 50% of the patients with chronic hepatitis C have moderate to severe chronic hepatitis. The liver biopsy is the most accurate way to distinguish mild from moderate or severe chronic hepatitis and thus assess the prognosis. These patients have a high risk of developing cirrhosis. Age at infection, gender and alcohol consumption are the main factors influencing the progression of fibrosis.4

Cirrhosis and Hepatocellular Carcinoma

For many years HCV related cirrhosis may be silent. Clinical symptoms of portal hypertension or hepatic failure appear late. In patients with HCV related cirrhosis, mortality related to portal hypertension, hepatic failure or hepatocellular carcinoma is 2% to 5% per year.5 End-stage HCV related cirrhosis is the most prevalent indication for liver transplantation. The incidence of hepatocellular carcinoma is high (3% to 10% per year) and justifies systematic monitoring with ultrasonography and alpha-foetoprotein.6

Treatment

Two recent large controlled trials demonstrated that combination therapy with interferon and ribavirin was more effective than interferon alone.7,8 These studies showed that combination therapy for 24 or 48 weeks gives overall sustained response rates of 38% and 41%, respectively versus 6% and 16% with interferon alone. Another study, in patients having relapse after treatment with interferon alone, showed a 50% rate of sustained response with a six-month course of combination therapy versus 5% with interferon alone.9 These results rendered combination therapy as the standard treatment for chronic hepatitis C.10

The main predictors of sustained response are the genotype and baseline viral load. The overall sustained response rate is increased to 64% in patients with HCV genotype 2 or 3, whatever the baseline viral load is, and is 35% in patients with genotype 1 and low viral load. In patients with genotype 1 and high viral load, the sustained response rate depends on the duration of therapy: 28% and 8% with 12 months and 6 months, respectively.7

Conjugation of alpha interferon with polyethylene glycol (pegylated interferon) increases the half-life (90 hours) and improves the pharmacodynamics of the molecule. Therefore, one single injection, once a week is sufficient and the antiviral effect seems significantly improved as compared with standard interferon. A preliminary study showed 36% sustained response with 180 µg of pegylated interferon for 48 weeks as compared with 5% with standard interferon therapy.11

Current trials are assessing the efficacy of pegylated interferon combined with ribavirin. If the improved efficacy related to pegylated interferon on the one hand and to ribavirin on the other hand are additional, combination therapy of pegylated interferon with ribavirin could provide a sustained response of greater than 50%. This optimistic view will hopefully be confirmed.

HEPATITIS D

By Howard J. Worman, M. D.

The hepatitis D virus (also called delta virus) is a small circular RNA virus. The hepatitis D virus is replication defective and therefore cannot propagate in the absence of another virus. In humans, hepatitis D virus infection only occurs in the presence of hepatitis B infection.

Hepatitis D virus infection is transmitted by blood and blood products. The risk factors for infection are similar to those for hepatitis B virus infection. The hepatitis D virus most often infects intravenous drug users.

A patient can acquire hepatitis D virus infection at the same time as he/she is infected with the hepatitis B virus. This is called co-infection. A patient with hepatitis B can be infected with hepatitis D virus at any time after acute hepatitis B virus infection. This is called super-infection.

Hepatitis D virus super-infection should be suspected in a patient with chronic hepatitis B whose condition suddenly worsens. There is usually an obvious history of continued exposure to blood or blood products (eg. an active intravenous drug user). A particularly aggressive acute hepatitis B infection could suggest hepatitis D co-infection. Co-infection or super-infection with hepatitis D virus in a patient with hepatitis B is diagnosed by the presence of antibodies against the hepatitis D virus. IgM antibodies indicate acute infection.

Interferon-alpha is used to treat patients with chronic hepatitis B and hepatitis D infection. Some studies have suggested that a dose higher than that usually used for hepatitis B infection may be beneficial.

Hepatitis G

By Howard J. Worman, M. D.

LINKS: http://cpmcnet.columbia.edu/dept/gi/hepG.html

Hunza Water at www.biophysica.com/hunza.html