Inflammation of the liver (hepatitis) in adults, treatment, symptoms

The liver is a large internal organ located in the upper right abdomen. In all over the world, the most common causes of hepatitis are hepatitis viruses and alcohol. Other causes of hepatitis include medications, chemicals, and toxins, such as some fungicides. This article only covers viral infections.

There are five human hepatitis viruses, and they are named alphabetically in the order in which they are found. Hepatitis A and E viruses are transmitted orally, while B, C, and D viruses are transmitted through the blood. Hepatitis A and E heal on their own and the virus does not remain chronic in the body. Hepatitis B, C, and D remain in the liver and blood of some infected people and cause chronic hepatitis and, if left untreated, often lead to cirrhosis of the liver and sometimes liver cancer.

Acute hepatitis as a disease

For all viruses, only a fraction of infections leads to disease. Infections caused by different hepatitis viruses are very similar in their symptoms, and the causative virus cannot be inferred from the symptoms. The symptoms may include a few days of warmth, vague stomach upset, fatigue, loss of appetite, and feeling sick. Yellowing of the whites of the eyes and skin then appears. Some first notice the urine turning dark. Jaundice and darkening of the urine are caused by bilirubin, which accumulates in the blood due to impaired liver function. Pre-symptoms may be absent or so mild that they go unnoticed. This is the most common course in hepatitis C. On the other hand, the disease can be so mild that there are only intestinal symptoms without jaundice. This is the most common course of hepatitis A and hepatitis E in all but pregnant women.

When to treat?

You should always see a doctor if you suspect viral hepatitis. Identification of the causative agent is important to assess the potential for both medication and disease prognosis, i.e., chronic consequences. During inflammation of the liver, and if there is a chronic carrier of the virus (viruses B, C, and D), alcohol and medicines that affect the liver should be avoided. In contrast, normal exercise and exercise do not adversely affect the course of the disease. No diet can help people with chronic hepatitis. There is no effective treatment for acute (acute) hepatitis caused by any virus. Instead, there are effective drugs for chronic infection caused by the B and C viruses and the prevention of their sequel. There are effective vaccines to prevent hepatitis A and B.

Hepatitis A virus (HAV)

Infection and disease incidence

HAV is only transmitted from the feces of the person who excretes it or through water or food contaminated by them. HAV infection is very common in widespread tropical countries (see the estimated prevalence of hepatitis A virus infection ). In Europe, the virus has been most prevalent in Romania, Bulgaria, and Slovakia. For Finns, the infection is mainly a tourist attraction. However, there have been a dozen small local epidemics and family clusters in Finland in the 21st century. These have been caused by food imported from abroad (e.g. frozen berries) as well as in alcoholic and drug gangs and daycare. where infections have also occurred directly from person to person. Sex between men is also a risk factor for infection.

For a tourist, one day in tropical Africa carries the same risk of infection as a year in Finland or three months in the Nordic countries. In Eastern or Southern Europe, the risk is in between. The two million annual trips of Finns to areas with a high prevalence of hepatitis A lead to the disease of only 10–30 tourists. In 2018, 27 cases of hepatitis A were diagnosed. It has rapidly become rarer in Finland, which has been affected by improved hygiene of imported food and the increasing number of vaccinations taken by tourists.

Disease course and diagnosis

The incubation period of the disease is 15-50 days. HAV does not remain chronic, and the disease almost always heals in 2 to 4 weeks without sequel. Infections in children under 12 years of age are regularly asymptomatic and go undetected. Exhaustion continues for some a few months after hepatitis has subsided. Hospitalization is rarely necessary. Serious diseases leading to liver death are very rare, only one in a thousand. A person with hepatitis A excretes the virus in the feces several days before the onset of symptoms and only needs to be infected until approximately the onset of symptoms. There is no cure. When the disease is suspected, it can be identified in the blood by a virus antibody test.

Birth control

Risky foods that cause infections are the same as food poisoning and tourist diarrhea (see Food Poisoning and Tourist Diarrhea ), and nutritional hygiene is the best prevention. There is a very effective vaccine against hepatitis A infection. Protection against vaccination begins two weeks after the first injection. Lifetime protection is obtained if you take the booster dose 6 to 12 months later. The vaccine then costs the adult a total of about € 120. At least if you travel a lot, vaccination is worthwhile, even though the risk of one regular tourist trip is very small. If you also want protection against blood-borne hepatitis B, you can take the A + B virus vaccine (Twinrix ®). Lifelong protection against both viruses requires three vaccinations, and the price of adult vaccines will then be around € 170. Both vaccines are suitable for both children and adults, and pregnancy is not a barrier to vaccination. To prevent disease and the spread of the virus, the vaccine is used primarily within two weeks of exposure, but gamma globulin injections can also be used.

Men who have sex with men were added to the hepatitis A vaccination target group of the national vaccination program in November 2017, and they receive the vaccination free of charge.

Hepatitis B virus (HBV)

Infection and disease incidence

HBV is transmitted through human blood and sexual contact and from a child born to a mother who carries the virus. The survival of HBV in humankind is based on chronic carriers of the virus. The World Health Organization (WHO) estimates that there are approximately 240 million HBV carriers worldwide. Carriers are most common in Southeast Asia, tropical Africa, and the Amazon River region in South America (see Hepatitis B prevalence). In some places in these areas, one in ten residents carries HBV in their blood from cradle to grave. There, the infection is spread mainly from mother to child during pregnancy or childbirth. Vaccination of all children at birth, as recommended by the WHO, has significantly reduced the burden of disease, especially in South-East Asia, in recent years. In Finland, 235 HBV carriers became known in 2018, but only 49 of these had a Finnish background. Only one in ten diseases were probably acquired in Finland. Thus, the majority of those diagnosed had an old chronic infection. Only four had recent symptoms of hepatitis (average in recent years is 20).

Hepatitis B has become less common in Finland over the past 20 years. This is most likely due to extensive vaccination of at-risk groups (see table ) and needle exchange practices among drug users. According to an antibody test, 7% of Finnish injecting drug users had become infected with HBV in the early 2000s, but even a small proportion of these were carriers of the virus and thus contagious. These are very small proportions internationally. There are less than one in a thousand Finnish carriers of the virus.

One in five children born to a pregnant mother becomes infected if the baby is not protected with a vaccine and an antibody (HBV immunoglobulin) immediately after birth. The fact that the mother is a carrier of the virus does not affect the method of childbirth or prevent breastfeeding.

Most of the infections in Finns in recent years have been acquired through sexual contact. The drug syringe is another common route of infection in many countries, but not in Finland. Occupational infections (mainly in the health care professions), infections transmitted through blood products, and mother-to-child infections are not even detected every year. The most recent infection caused by blood products in Finland is from 2004. According to research, a child carrying HBV in daycare or school does not pose a risk of infection to other children in the care area.

Disease course and diagnosis

The incubation period of the disease is long, 1–6 months. Only one-third develop acute hepatitis with its typical symptoms and jaundice. Arthritis affects one-fifth of those affected. Acute disease is quite mild. Less than one in every 100 people die in the early stages of the disease from severe liver damage (fulminant hepatitis). The worst health threat posed by hepatitis B is chronic hepatitis. 3-5% of those infected remain chronic carriers of the virus. One in five of them will get cirrhosis of the liver if no infection is detected and no antiviral medicine is given. It develops slowly over 10 to 30 years. Cirrhosis increases the risk of liver cancer (see Liver cancer ) by a factor of 100 to 200.

Hepatitis B is detected in the blood by showing the structure of the virus (surface antigen, HBsAg) or viral antibodies (HBcAbM), which can be used to detect infection at the onset of symptoms. If the infection is detected, laboratory tests are always performed to see if HBsAg disappears spontaneously, thus stopping the progression of the disease. If it does not go away within 12 months, it will most often remain chronic. This involves examining the liver for damage and measuring the amount of virus in the blood and determining the subtype of the virus (see Viral Hepatitis Tests ).). This information is needed to make a treatment decision. Most often, the patient’s sexual partners and family members are also asked for tests to detect asymptomatic infections (70% of infections!). In addition, liver function is monitored by blood tests during the active phase of the disease. Hospitalization is rarely necessary.

Treatment of hepatitis B.

The virus cannot be removed from the liver with medication (difference from hepatitis C). The goal of drug therapy is to reduce the number of viruses and thus prevent the development of chronic inflammation, liver cirrhosis, and liver cancer. Treatment is offered to those whose infection remains chronic and who develop hepatitis. Treatment is with an intermittent injection of interferon for 1 to 2 years, at which time one-third of the viral antigen is lost. If interferon does not work, the progression of the disease can be stopped with tablets (nucleoside analogs).

Treatment is chosen based on, among other things, the amount of virus in the blood and the degree of liver damage. The degree of liver damage is determined by blood tests, a special imaging test (for example Fibroscan ® ), and, if necessary, a microscopic examination of a liver specimen. Taking a test piece is rarely needed. Treatment will reduce inflammation in the majority of patients, but continuous prophylaxis with tablet therapy may be required. There are so many side effects associated with interferon treatment that one in ten is unable to get through the course. If the disease progresses despite the treatments, a liver transplant can be used as a treatment. On average, only three of the approximately 60 liver transplants performed in Finland each year are due to chronic hepatitis B or C.

Prevention of hepatitis B.

The virus is not transmitted by contact through intact skin or by kissing. The virus is quickly destroyed when the blood dries, so blood from the environment or drug needles drifting in parks, for example, does not result in infection, even if you put your hands in them. No spread has been reported in daycare or schools, although bloody accidents do occur. Still, children in the daycare group receive free hepatitis B vaccination if there is a virus carrier in the group. In sexual intercourse, HBV is more contagious than HIV and hepatitis C virus, and safe sex similar to that in HIV infection is recommended for prevention (see section 4.4).). The most important thing is to use a condom during sexual intercourse, whether either party is a carrier of the virus if the partner is not protected by vaccination. The free needle and syringe exchange program, which was introduced in Finland mainly due to HIV infection, has also reduced the number of HBV and HCV infections. Viral screening of blood donors in Finland has completely stopped infections of hepatitis viruses through donated blood.

Pregnant women are screened for HBV before prenatal care. Injection of hepatitis B antibody (HBV immunoglobulin) to the child of the mother of the mother immediately after birth or to the victim of the accident after the blood needle injection, together with vaccination, almost completely prevents the transmission of the virus to the child. The child should receive booster vaccines at 1 and 12 months of age. In Finland, unlike in many other countries, not all newborns receive the hepatitis vaccine because the disease is so rare in us. In Finland, HBV is diagnosed in an average of five children under the age of 5 each year. Almost all of these have previously been infected elsewhere than in Finland.

There is a very effective vaccine against hepatitis B infection (see Tourist Vaccinations ). One series of three doses of vaccine (at times 0, 1, 6-12 months) provides lifelong protection. The vaccines in the series cost an adult around € 150. Those at higher risk of infection receive a preventive vaccine free of charge in the Finnish general vaccination program.

Hepatitis C virus (HCV)

Infection and disease incidence

HCV is transmitted through human blood and persists in humankind due to chronic carriers of the virus. The WHO estimates that there are about 71 million carriers of this virus in the world, one-hundredth of all people. Every year, 1.8 million new infections are diagnosed worldwide, and 400,000 die each year from this infection. The carriers are very unevenly distributed (see Worldwide prevalence of hepatitis C virus infection ). In some countries in Africa, South-East Asia, and South America, 5-10% of the population are carriers of the virus. The WHO has set a goal of eradicating HCV from the planet by 2030 using existing effective antiviral drugs.

It is estimated that there are 22,000 HCV carriers in Finland (0.4% of the population), of which 14,000 are estimated to have used injecting drugs. An average of 1,200 new infections is identified each year (in 2018 the number was 1,170). The number has not changed in recent years. Two-thirds of those who carry the virus are men, and most of them are between the ages of 20 and 39. Of those identified annually, only one in ten has a recent infection and associated hepatitis. Others are asymptomatic, and the infection that was once acquired is found in screenings for various reasons. In Finland, therefore, HCV is now mainly an infection among injecting drug users. Of those for whom the mode of infection was known, 90% had injection drug use. In the world, it is estimated that about three out of four injecting drug users carry the hepatitis C virus, which is a multiple compared to hepatitis B virus carriers. In 2018, the majority of infections (84%) were of Finnish origin and had also been acquired in Finland.

Unlike HBV, HCV is rarely transmitted from a virus carrier through sexual intercourse (one infection per approximately 200,000 intercourses), and even a fresh-blooded needle plug rarely results in infection. The risk of infection with a single injection is about 1-2%. Not even one work-related infection is diagnosed in healthcare every year. Before the 1990s, the virus could also get through blood transfusions. As with HBV, mother-to-child infections and blood products and needlestick infections are very rare. The risk of a newborn child getting HCV infection from his mother is about 5%, and infections born to the mother of a newborn child are very rare in Finland. HCV is diagnosed in 3 to 6-year-olds each year, and these are likely to be mainly infections during childbirth.

Disease course and diagnosis

The incubation period of the disease varies from less than a month to four months. Only one in five gets symptoms after infection, and only one in ten gets jaundice (jaundice). The symptoms are typical of viral hepatitis (see above) but milder than in other hepatitis. Infection is usually only detected if liver enzymes are measured in the blood (eg ALT, see Ala-nine aminotransferase (P-ALT)).). Most carriers of the virus do not know they are carriers unless they take the test. This helps the virus to spread to new people. On the other hand, chronic liver disease can insidiously progress to cirrhosis before access to treatment. 70% of all infected people remain chronic carriers of the virus. Liver damage develops approximately as often as in HBV carriers, i.e., 10% develop cirrhosis of the liver within 20 years of infection. Of those who have developed cirrhosis, 1% develop liver cancer each year. In Finland, about one in six HCV carriers who became known in the 21st century have died during follow-up. The deaths are most often due to drugs, accidents, or alcoholic liver disease, rarely the hepatitis C virus as such.

The disease is determined by an antibody test (HCVAb) and by detecting the virus in the blood by a gene amplification method. As in the case of HBV infection the degree of liver damage that has already occurred and the number of viruses in the blood and the sub type of the virus to determine drug susceptibility are determined in preparation for treatment.

Treatment of hepatitis C.

Treatment is offered to all those for whom the infection remains chronic, who have laboratory tests for hepatitis, and who are judged to be able to commit to long-term treatment. Even for injecting drug users, treatment has been successful in Finland. The urgency of treatment depends on the degree of liver damage, but it is sought to be implemented as soon as the infection is detected (by a genetic test on blood). The treatment is a combination of two tablets. In 2017, three-drug combinations have been introduced that are effective against all sub types of this virus. The treatment lasts 8 to 12 weeks. The treatment is well tolerated and is more than 90% successful. When the treatment is successful, the virus is removed from the body (unlike HBV). Treatment is expensive, but it is paid for by the patient’s home community and is cost-effective. Treatment can usually be provided by a health center.

Prevention of hepatitis C.

There is no vaccine or antibody treatment for hepatitis C infection. There is no postpartum protection for the baby of the mother, but the risk of infection for the baby is lower (5%) than for the baby of the HBV mother. HCV is not screened in pregnant women. After blood exposure, if there is a high risk of infection in the situation, a contraceptive can be given. Unlike HBV plaintiffs, most experts believe that an HCV plaintiff does not need to use a condom for sexual intercourse because the risk to the partner is so low. The drug needle exchange program reduces the spread of the virus in the population. Viral screenings of blood donors in Finland have completely stopped infections of hepatitis viruses transmitted through donated blood. In 2016, Finland set a target for HCV:n from the Finnish population by starting treatment for all its carriers, including asymptomatic ones.

Hepatitis D virus (HDV, delta agent)

HDV is transmitted through the blood. Hepatitis D infection can only be acquired in a person with pre-existing chronic HBV infection and as a sign of HBsAg in the blood, or combination with HBV infection. The acute hepatitis of such a co-infection is more severe than individual HBV infections. HDV is almost exclusively an infection among injecting drug users. HDV infections have been diagnosed in Finland in the 2010s 2–6 annually (four in 2018). Infection prevention occurs automatically when HBV infection is prevented. Diagnosis is made by an antibody test or a test for viral genes in the blood.

Hepatitis E virus (HEV)

Infection and prevalence

The infection is caused by water or food contaminated with the feces of the person carrying the virus. Hepatitis E virus is widespread in warm countries with poor hygiene, South and Central Asia, China, and tropical Africa. Globally, it is significant. The WHO estimates that there are 20 million HEV infections each year and that it kills 70,000 people. The dead are victoriously pregnant.

Recent studies using more accurate screening tests show that it is more common in many European countries than previously thought. For example, in the Netherlands, Italy and England, one in five has been diagnosed with antibodies as a sign of infection. Of the four HEV strains, two occur only in humans and two only in animals, causing a so-called zoo noses. Several animal species carry the virus, but for humans, the pig is the most important. In Finland, too, HEV is quite common, especially in piglets, but it is a virus strain that rarely causes human infection, and no cases of human transmission have been reported.

Disease progression, diagnosis, treatment and prevention

The infection is rarely identified because 90% get no symptoms and most of the rest get a very mild disease. Often intestinal symptoms predominate. The link between the disease and the journey is often overlooked because of the long incubation period of the disease, 2 to 10 weeks. Diagnosis is made by antibody testing of blood. The mode of infection and the clinical disease is most similar to hepatitis A. Only a small proportion of infections lead to jaundice. The disease heals on its own in 2 to 4 weeks and there is no cure for it. The virus almost always disappears from the stool as the disease heals. Prolonged viral load is rare.

The nasty specialty of HEV infection is that in pregnant women the disease is severe and can cause liver necrosis. Between 10% and 20% of pregnant recipients die from hepatitis E. The risk of a serious infection is greatest in the 2nd and 3rd trimesters of pregnancy. If a pregnant woman is planning a trip to an area where there is currently an HEV epidemic, care should be taken in the choice of water and food. There is no effective drug for hepatitis E and there is no vaccine to prevent it. It can only be prevented with good nutritional hygiene when traveling to countries where the disease is common.