Hepatitis B

“Hepar” is the Greek word for liver, hence the name hepatitis. Since there are different hepatitis viruses and forms of hepatitis, doctors give them different letters, from A to E.

Hepatitis B, formerly known as “serum hepatitis”, is an inflammation of the liver caused by the hepatitis B virus. The virus is spread, for example, through unprotected sex, through blood or by an infected mother passing it on to her new-born baby.

Hepatitis B is often mild or completely unnoticed and clears up on its own in a matter of weeks. But sometimes the infection becomes chronic. People are then more likely to develop cirrhosis of the liver and liver cancer long-term.

The rule of thumb is that a third of those with acute infections have no symptoms, another third have quite non-specific symptoms, and, finally, the last third also suffer from jaundice.

The non-specific symptoms include:

• exhaustion, generally feeling unwell and loss of appetite
• nausea
• joint pain
• slight fever

If the person also has jaundice, also known as icterus, the white part of the eyes and the skin become a light yellow. This is because the inflamed liver is no longer able to pass the hemoglobin breakdown product, called bilirubin, into the intestine properly. At the same time, this makes the stool lighter, but the urine darker, because the bilirubin is now secreted via the kidneys.

Hepatitis B viruses are mainly contained in the blood of infected people, but also in their saliva, tears, sperm, vaginal discharge and in the colostrum (foremilk), albeit in significantly lower concentrations. This means the virus can be transmitted in different ways.

In Western countries, many people are infected through sex, most commonly people who change their sexual partners frequently, young adults for example.

The virus is also spread through infected blood, for example when exchanging needles when consuming drugs. Other routes of infection may include having a tattoo or piercing done with non-sterile needles and injury to the skin or mucous membranes. An infection through contaminated blood supplies however has now become an absolute rarity because of systematic tests.

If a pregnant woman is infected with hepatitis B, she might pass it on to her baby while giving birth. In fact, this is one of the most common ways the disease is transmitted worldwide. But in Germany it is much less common for the disease to be passed from mother to baby.

Hepatitis B is one of the most common infectious diseases worldwide. At least two billion people have either had hepatitis B at some point in their lives or are currently affected by it. But in Germany only about two to four thousand new cases of hepatitis B are reported to the Robert Koch Institute each year.

The viruses replicate permanently in the body in approximately three percent of the world’s population – these people have a chronic infection. The proportion of people permanently carrying the virus is especially high in countries south of the Sahara and in East Asia for example. In Western Europe, on the other hand, it is less than one percent of the population, with the figure for Germany even lower.

All in all, the hepatitis B vaccination, which is already recommended in infancy, should contribute significantly to the infection becoming less and less of an issue in Germany.

When talking of a hepatitis B infection, a distinction is made between an acute infection and a chronic one.

An acute infection

Once a person is infected, they can start to see the first non-specific symptoms on average after 60 to 120 days, meaning it is often no longer possible to determine the source of infection afterwards. There is a danger of infected people infecting others just a few weeks before the onset of symptoms.

Some people also have jaundice in the days following the onset of the illness. This goes away again after several weeks. More than 90 percent of adults recover from the disease without any complications and have life-long immunity. In very rare cases, an acute hepatitis B infection becomes serious and is associated with liver failure.

As is known today, hepatitis B viruses survive unnoticed in the liver cells in very small amounts even after an acute infection has cleared up, with the immune system keeping the viruses under control. But this kind of hidden (occult) infection can potentially become active again if the immune system is very weak, for instance due to treatments that suppress the immune system.

Chronic hepatitis B

Chronic hepatitis B, on the other hand, is when a certain part of the virus shell known as the HBs antigen can be detected in the blood for more than six months. This is the case in up to ten percent of infected people. Chronic hepatitis B can also be contagious if the virus continues to replicate rapidly in the body.

Often, a chronic infection does not cause any symptoms and is detected by chance when elevated liver values are noticed. But – very similar to the acute form of the infection – non-specific symptoms, such as exhaustion, loss of appetite or achy muscles and joints, may appear. Occasionally there are flare-ups that cannot be distinguished from an acute infection. Over time, chronic hepatitis B can lead to cirrhosis of the liver and liver cancer.

Dual HBV and HDV infection

In rare cases, someone infected with hepatitis B also becomes infected with the hepatitis D virus. Like the hepatitis B pathogen, this virus is spread through infected blood and body fluids. But HDV needs the hepatitis B virus as a helper virus to replicate in the body. This means that only those already infected with hepatitis B can get hepatitis D. This dual infection is usually more severe and leads much more often to chronic and serious courses of the disease than hepatitis B on its own.

Vaccination offers effective protection against hepatitis B and is even recommended for infants and young children. Children who are not vaccinated should be by the time they reach puberty and no later than the age of 18.

It is also important for adults in certain risk groups to get vaccinated against hepatitis B with three vaccine doses. These groups include:

• healthcare professionals
• people with immune deficiency, HIV-positive people, dialysis patients, patients with pre-existing liver damage
• people at high risk of sexual transmission
• drug users
• people who have close contact with those who have a chronic infection, for instance in families, communal accommodation, psychiatric facilities or prisons

Vaccination is also advised for extended vacations, usually in combination with a vaccine against hepatitis A.

As well as getting the active hepatitis B vaccination, it is also possible to be injected with ready-made antibodies against the virus (passive immunization). This may be necessary, for example, if non-vaccinated people have come into contact with a patient’s infected blood. Passive vaccination provides immediate protection and bridges the gap until the body’s defenses build up their own immunity through the vaccine administered at the same time.

This strategy is also used in new-born babies whose mothers are infected with hepatitis B. They receive a first dose of the vaccine and also the antibodies within 12 hours of being born. Otherwise there is an extremely high risk of them developing chronic hepatitis B. Pregnant women with a high viral load should be given antiviral treatment, i.e. a drug known as a virostatic agent, by their third trimester.

Hepatitis B is diagnosed using a blood test to detect certain parts of the virus or certain antibodies. Depending on the results of the laboratory tests, doctors will be able to work out whether someone is infected with it, has had a previous hepatitis B infection or whether they are effectively protected by vaccination.

Symptoms such as nausea and pain can be treated with medication. Physical rest and a high-carbohydrate and low-fat diet are recommended. An acute hepatitis B infection can generally be nursed at home. The patient would have to go to hospital only if the infection were serious. Antiviral treatment is only recommended if the person’s liver function is already impaired and they are at risk of liver failure.

Chronic hepatitis B is usually treated with medication over the long-term. This medication very effectively stops the virus from replicating. Drugs known as nucleotide analogues and nucleoside analogues disrupt the replication of the viral genome. Time-limited treatment with the protein alpha-interferon can stimulate the immune system and help the body to get the virus under control.

Do you want to know whether having a hepatitis B vaccine before traveling makes sense or is required? The Robert Koch Institute provides essential information about travel vaccinations and related links.