by Dr. C.H. Weaver M.D. updated 8/2019
Florida Declares Public Health Emergency in Response to Hepatitis A Outbreak
The Florida Surgeon has declared a public health emergency in Florida in response to the statewide hepatitis A outbreak of 2582 hepatitis A cases between January 1, 2018, and July 27, 2019. As of July 26, 2019, hepatitis A outbreaks have been identified in 25 states since 2016. A total of 22,566 cases, 13,352 hospitalizations, and 221 deaths have been reported.
The 3 states with the largest ongoing outbreaks include Kentucky (4793 cases), Ohio (3234), and West Virginia (2533). The CDC’s Division of Viral Hepatitis emphasizes that the hepatitis A vaccine is the best way to prevent hepatitis A infection.
Under the declaration, the state health agency will request assistance from the US Centers for Disease Control and Prevention (CDC) in controlling and responding to the outbreak. It is also important for Florida health care providers to understand the importance of screening and vaccinating individuals at high-risk for acquiring hepatitis A. Although anyone can contract the virus, high-risk populations include individuals experiencing homelessness, intravenous and non-intravenous drug users, and men who have sex with men.
Hepatitis remains a global and domestic health problem, but the outlook had been improving with new treatments and awareness.
The impact of hepatitis at home and abroad is undeniably significant. The virus, which causes illness and even death, can lead to scarring of the liver (cirrhosis) and liver cancer and affects 400 million people globally. Of those affected around the world, 1.45 million die every year. In fact, hepatitis is the seventh-leading cause of death worldwide, placing it ahead of HIV/AIDS.(1)
According to the Centers for Disease Control and Prevention (CDC), the estimated numbers of new US infections in 2012 for the three most common types of hepatitis (A, B, and C) were as follows: 3,000 for hepatitis A, 19,000 for hepatitis B, and 22,000 for hepatitis C.(2) These numbers have increased substantially in the past 24 months.
Hepatitis is a health problem that we can’t afford not to understand. Hepatitis education, however, is not all about risk and consequence. Individuals need to learn how to protect themselves from infection and about promising treatment for people with chronic infection.
What Exactly is Hepatitis?
To start with a basic definition, hepatitis is inflammation of the liver. Flavia Mendes, MD, a gastroenterology specialist at Gastro Health in Miami, Florida, and an expert in hepatitis management, says that this inflammation can have several causes. “Any agent or condition—such as medications, alcohol, fat, viruses, and autoimmunity, to mention a few—that can cause inflammation or injury to the liver cells can cause hepatitis,” she explains.
When we speak of hepatitis as a global health concern, however, we are primarily talking about viral hepatitis, meaning disease that is caused by one of several viruses. “There are several types of viruses that cause hepatitis,” says Dr. Mendes. “The most common ones are hepatitis A, B, and C.”
Dr. Mendes explains that when an individual is infected with a hepatitis virus, he or she may develop such symptoms as fatigue, jaundice (yellow discoloration of the skin and eyes), and an enlarged liver. A doctor can detect liver inflammation using a blood test to look for liver enzymes that are elevated or by finding an enlarged liver on a physical exam or by ultrasound.
It is also possible, she says, that a person will be infected with a hepatitis virus and not have any symptoms. “In many cases their immune system can clear the virus on its own, and patients will have [only] antibodies in the blood as a marker of previous infection,” she explains of these symptom-free cases.
Getting Specific: Hepatitis A, B, and C
Infection with the hepatitis A, B, and C viruses is caused by a variety of sources; each type has different degrees of prevalence around the world, and all carry distinct long-term risks. Outcomes and treatment options depend on the specific type of virus, which can be determined with a blood test.
Overview. Dr. Mendes explains that people infected with the hepatitis A virus can develop acute disease. This means that hepatitis begins suddenly and might last only a few weeks: “The hepatitis A virus never causes chronic or persistent hepatitis, and once the patient recovers, there is no risk of having persistent inflammation over the years.” As a result, hepatitis A does not lead to cirrhosis.
Even without the risk of chronic disease and cirrhosis, hepatitis A can still be a serious condition. In extreme cases, Dr. Mendes explains, patients might need a liver transplant. Most cases, however, are far less serious. “The majority of patients recover on their own,” she says.
Source. Hepatitis A can be spread through contaminated food and drinks or when an individual handles a contaminated object and then touches his or her eyes or mouth.
Treatment. The generally high rate of recovery is fortunate because there is currently no cure for hepatitis A. According to Dr. Mendes, treatment involves what is known as supportive care, which means controlling symptoms and making sure the patient gets enough nutrition and hydration.
Overview. Like hepatitis A, the hepatitis B virus also causes acute hepatitis. According to Dr. Mendes, the majority of adult patients will spontaneously clear the virus, but in some it can persist and cause cirrhosis over time. She explains that hepatitis B can be more complicated in children, however: “They are less likely to show acute signs of infection but are also less likely to clear the virus. They are therefore more likely to develop chronic hepatitis.”
Source. Hepatitis B is acquired through contact with infected blood, semen, or other body fluids. In adults sexual transmission is the most common mode of infection with hepatitis B.
Treatment. Dr. Mendes explains that acute hepatitis B is not typically treated with medications but that patients with chronic infection should be watched for signs of liver disease. If they start to develop liver disease, she says that treatment includes daily oral antiviral medications: “In most of the cases, patients will require lifelong treatment.” She adds that the daily oral medications for hepatitis B are generally well tolerated.
Overview. Unlike hepatitis A and B, hepatitis C rarely causes acute hepatitis, and the majority of patients have no symptoms. Hepatitis C is less likely to resolve on its own, however. “Only 10 to 15 percent of patients are able to clear the virus on their own,” Dr. Mendes says. As a result, there is a greater risk that hepatitis C will become chronic and lead to cirrhosis and even liver cancer.
Source. Hepatitis C is transmitted through contact with infected blood. This places at risk intravenous drug users who share needles. Individuals who had a blood transfusion prior to 1991 can also be at risk. The blood test for hepatitis C became commercially available in 1990, which has since improved the safety of transfusions.3
Treatment. Over the past year, new medications have been approved for the treatment of hepatitis C. Known as DAAs (direct-acting antivirals), these therapies require a relatively short course of treatment (two to six months), are given orally and are therefore noninvasive, and are well tolerated. “The rates of cure are very high, even in the groups that were harder to treat,” says Dr. Mendes of these newer treatments.
Living with Hepatitis
“Hepatitis can significantly affect quality of life,” says Dr. Mendes, explaining that patients commonly complain of fatigue, which can interfere with work and personal life and has emotional implications as well. Patients can struggle to feel like they are contributing and may not be able to enjoy the activities they once did.
“This can have an impact on personal relationships with friends, spouses, and children,” Dr. Mendes explains, adding, “Some are worried about the stigma that can be associated with the disease and fear isolation.”
Because hepatitis can be spread through drug use and unprotected sex, stigma can be an issue for patients, who may feel shame and fear the judgment of others. The fact is, however, that hepatitis infections can also be spread in many other ways over which the patient has little or no control. Contaminated food and water and infected blood from a transfusion are a few examples, and mothers can also transmit a hepatitis virus to their babies during birth.
Celeste Barmore Parrish of Miami, Florida, knows all too well that a hepatitis infection is not always the result of certain behaviors. The 61-year-old became infected with the hepatitis C virus through a blood transfusion before screening of blood supplies became routine.
Celeste contracted hepatitis C during a scheduled surgery 28 years ago. She has a bleeding disorder known as Von Willebrand disease, which impairs the blood’s ability to clot. Though Celeste had stored her own blood before the surgery to use for a transfusion, her stored blood had spoiled. She then received blood from a blood bank, and unfortunately the donated blood carried the hepatitis C virus. She was subsequently diagnosed with hepatitis C, which has progressed to cirrhosis.
In addition to being shocked by the diagnosis, Celeste was distressed to think that she may have spread the virus to her family (fortunately, they all tested negative). Since the diagnosis she has dealt with symptoms that have affected her overall health and quality of life. “The worst symptom I experienced was the constant itching,” she explains. She learned that certain foods made the itching worse. Even though she avoided the foods responsible and tried a variety of therapies and medications, the itching persisted.
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“Nothing worked!” Celeste says. “I had a large rash on my right leg and went through periods of time when I would sleep 20 hours a day. These episodes would usually last between one and two weeks.”
Treatment for Hepatitis C: Important Progress
Fortunately, for patients like Celeste with hepatitis C, there are effective treatments available as well as some new and very significant advances.
“New treatment regimens [DAAs] have been approved by the US Food and Drug Administration (FDA) for hepatitis C,” Dr. Mendes says. “These new regimens have dramatically improved the outlook for patients with hepatitis C.”
Dr. Mendes explains that these new treatment options have a high cure rate and, importantly, are also more tolerable for the patient. “They evolved from lengthy (six- to 18-month) injection-based treatment with a multitude of side effects and low chances of cure to now all oral medications with a shorter duration of treatment (two to six months).”
These newer FDA-approved oral medications include Harvoni® (ledipasvir/sofosbuvir), Viekira Pak® (paritaprevir/ritonavir/ombitasvir plus dasabuvir), Sovaldi® (sofosbuvir), and Olysio® (simeprevir).
These hepatitis C treatments do have one downside, according to Dr. Mendes, which is their high cost. The expense, she says, can make these therapies inaccessible to some patients.
For Celeste the road to effective treatment has been long and complicated. Initially, her doctor did not want to treat her because she has seizure disorder and there was a risk that treatment would make her seizures worse. Eager for relief from the persistent itching and to regain her quality of life, however, Celeste was determined to find treatment.
“I made the decision to obtain treatment no matter what the side effects were,” she says, “and the doctor finally conceded.”
A year after she was diagnosed with hepatitis C, she started treatment with the drugs interferon (an immunotherapy drug) and ribavirin (an antiviral medication). This regimen, however, did not provide the relief for which Celeste had hoped and caused severe side effects. “Six months into treatment, my viral load had tripled and I had to discontinue treatment,” she says.
At that time Celeste had no clear options. New medications were in clinical trials, but she was not a candidate for these research studies due to her medical history. Then when the newer hepatitis C treatment Sovaldi received FDA approval and became available to patients, Celeste could not use it. By that time she had started seeing Dr. Mendes. “I had just undergone kidney ablation [for kidney tumors],” she explains, “and Dr. Mendes was concerned that if I started treatment, the cancer might return and I would have to stop.”
Eventually, however, Celeste was able to start treatment with Sovaldi. She says that though the medication made her tired and caused constipation, those were minor side effects compared with the complications she had experienced with interferon and ribavirin. Furthermore, Sovaldi appeared to work.
“Having received treatment has changed my life completely,” Celeste explains. “I no longer itch, and I can eat whatever I want.” In addition, testing has confirmed that Sovaldi is in fact working to treat the hepatitis C virus. “I had a nondetectable viral load two weeks after starting treatment,” she says.
Celeste also credits effective treatment with a dramatic turnaround in her personal life. She has been able to move forward with important relationships and make plans. “I realize that it might sound silly to attribute all of my happiness to the fact that I received treatment,” she explains, but she admits that her great outcome with Sovaldi has made it possible for her to move forward in life.
“I am an extremely grateful person, having been given this opportunity to live my life to the fullest,” she says.
For any form of hepatitis, particularly A and B, for which there is currently no effective treatment, early detection can help reduce the risk of long-term complications. Dr. Mendes explains that screening at-risk individuals (such as healthcare workers, intravenous drug users, and people who travel to affected regions) helps identify patients with chronic hepatitis at an early stage. Measures can then be taken to prevent complications related to chronic liver disease— including cirrhosis, the need for liver transplantation, and liver cancer.
Dr. Mendes adds that patients with chronic hepatitis can also help improve their outcomes by avoiding alcohol and maintaining a healthy body weight. “Alcohol may cause liver disease to progress faster, and fat infiltration of the liver can also complicate viral hepatitis,” she explains.
Though good outcomes like Celeste’s are possible with treatment for hepatitis C, preventing any type of hepatitis infection is still a top priority. Of course there are cases like Celeste’s (a contaminated blood transfusion) for which there are no protective measures. In other cases, there is a lot we can do to reduce our risk.
Vaccinations are currently available for hepatitis A and B. These immunizations are recommended for children and, according to Dr. Mendes, anyone who may be at risk. This includes anyone traveling to areas where hepatitis A is prevalent, daycare and healthcare workers, and patients with chronic liver disease.
Dr. Mendes also recommends lifestyle and behavior measures to reduce the risk of a hepatitis infection. Safe sex practices—specifically, using a barrier method such as a condom—can reduce the risk of spread of hepatitis B and C, as can taking precautions against needle sticks for healthcare workers. Efforts to prevent drug use and needle sharing are also a vital step in hepatitis B and C prevention. And, she adds, “hand washing and personal hygiene are important to avoid spreading of hepatitis A.”
A hepatitis virus on its own causes enough undesirable complications to warrant awareness, prevention, and the development of effective treatment. But these measures become all the more pressing in light of the link between hepatitis and liver cancer. In fact, according to the CDC, hepatitis is the leading cause of liver cancer and the most common reason for liver transplantation.
“Hepatitis B can cause liver cancer even in the absence of cirrhosis,” says Dr. Mendes, “whereas hepatitis C usually requires advanced liver disease in order for cancer to develop.” In the case of hepatitis C, new treatments that get rid of the virus help lower the risk of cancer.2
Awareness and Research for a Brighter Future
With an estimated 400 million people around the world currently affected by hepatitis, it is a public health concern that will not be resolved in the near future—but the outlook is improving. With effective screening of blood supplies, education about risk factors, preventive measures such as hand washing and safe sex, and promising treatment, we can look forward to more positive outcomes like Celeste’s.
What Does the Liver Do?
To best understand the impact of hepatitis and liver complications, it is helpful to understand how the liver functions. As the second-largest organ in the body, with a vital role in how we digest food, store energy, and clear toxins, the health of the liver is essential to our well-being.
Some of the liver’s important functions include the following.4
- Converting the nutrients in the food we eat into substances that the body can use, then storing those substances and supplying cells with them when needed
- Taking up toxic substances from the blood—such as alcohol and byproducts of medications—and converting them into harmless substances (detoxifying) or making sure they are released from the body
- Using vitamin K to produce proteins that help blood to clot
- Helping break down old or damaged blood cells
- Breaking down fat and producing energy
- Helping maintain blood sugar by removing excess sugar from the blood or storing and releasing sugar into the blood when needed
- Storing vitamins and minerals and releasing them into the blood when needed
- Metabolizing proteins so that they can be used to produce energy or make carbohydrates or fats
- Converting ammonia—a toxic substance produced when proteins are metabolized—into less toxic urea and releasing it to the kidneys to be passed through urine
- The Global Impact of Viral Hepatitis. World Hepatitis Alliance website. Available at: http:// www.worldhepatitisalliance.org/sites/default/ files/resources/documents/Global%20burden%20 -%20PACT.pdf. Accessed July 2, 2015.
- Viral Hepatitis. Centers for Disease Control and Prevention website. Available at: www.cdc. gov/hepatitis. Accessed July 2, 2015.
- Public Health Service Inter-Agency Guidelines for Screening Donors of Blood, Plasma, Organs, Tissues, and Semen for Evidence. Centers for Disease Control and Prevention website. Available at: http://www.cdc.gov/mmwr/preview/ mmwrhtml/00043883.htm. Accessed July 2, 2015.
- How does the liver work? PubMed Health website. Available at: http://www.ncbi.nlm.nih. gov/pubmedhealth/PMH0072577. Accessed July 2, 2015.