Tatyana Kushner
In recognition of Hepatitis Awareness Month, Tatyana Kushner, MD, MSCE, a member of the Blavatnik Family Women’s Health Research Institute, a hepatologist by training, an Assistant Professor in the Departments of Liver Diseases with a joint appointment in Obstetrics, Gynecology, and Reproductive Science at the Icahn School of Medicine answered questions on hepatitis and we decided to share them on our blog. Dr. Kushner, an expert in liver disease, is also the Associate Medical Director of the Hepatitis C and Drug User Health Center of Excellence for the Clinician Education Initiative, which is a program funded by New York State that provides education to providers about hepatitis C.
What is hepatitis?
Hepatitis broadly means inflammation of the liver. Hepatitis has several potential causes. Most commonly we think of viruses that cause hepatitis such as hepatitis A, hepatitis B, hepatitis C, hepatitis D, and even hepatitis E. In addition, there are other causes such as autoimmune conditions that can cause hepatitis, which is called autoimmune hepatitis, as well as nonalcoholic steatohepatitis, or NASH, which is also called “fatty liver disease” and reflects inflammation caused by fat accumulation in the liver.
What are the different types of hepatitis? How do you distinguish them?
The different types of hepatitis include viral hepatitis, autoimmune hepatitis, alcohol hepatitis, and nonalcoholic steatohepatitis—all of which reflect inflammation in the liver caused by different entities. In viral hepatitis, there are five types, which includes hepatitis A, B, C, D, and E. We can distinguish between the types by assessing the patient with a careful history as well as blood tests. For example, blood tests are needed to diagnose hepatitis A, B, C, D, and E to detect virus replication, as well as the presence of some specific viral proteins in the blood. To help diagnosis alcohol hepatitis or NASH, a liver ultrasound may be done that would demonstrate signs of fat in the liver. Rarely, we may also perform a liver biopsy if the blood tests are not definitive—for example, with autoimmune hepatitis, blood tests are available but a biopsy would provide a more definitive diagnosis.
Which form of hepatitis is most severe?
Broadly speaking, hepatitis can be acute or chronic. Acute hepatitis can be very severe and lead to significant liver injury and even liver failure requiring liver transplantation. This can occur with viral hepatitis or autoimmune hepatitis, but fortunately is rare. Chronic hepatitis, which can be caused by hepatitis B and hepatitis C, autoimmune hepatitis, or NASH can lead to long-term liver damage which can lead to cirrhosis (or end stage liver disease) over time, which can also lead to liver failure requiring liver transplantation.
What are the symptoms of hepatitis?
Hepatitis is often completely asymptomatic. That is why it is important to have screening recommendations in place. For example, recently the U.S. Centers for Disease Control and Prevention and the US Preventive Services Task Force (USPSTF) have recommended screening of all adults age 18 to 79 for hepatitis C. Similarly, patients with risk factors and/or pregnant patients are recommended to be screened for hepatitis B. Hepatitis can also present with symptoms, and the common ones are jaundice (yellowing of the skin and eyes) and generalized symptoms like fatigue/malaise or not feeling well in general. If hepatitis has progressed to liver failure or cirrhosis, you can see symptoms like confusion, swelling of the abdomen and legs, and/or bleeding, including blood in the stool and vomiting of blood.
How does one get hepatitis? What are some risk factors?
Different types of hepatitis have different risk factors. For example, hepatitis B and hepatitis C are bloodborne infections, and therefore one acquires them through contact with an infected person’s blood. This can occur with injection drug use, obtaining tattoos with contaminated needles, blood transfusion prior to 1992 (when blood started being screened for hepatitis C), dialysis, and health care exposure. There is also a risk of sexual transmission as well as mother-to-child transmission. In contrast, hepatitis A and hepatitis E are transmitted through contaminated food, water, or human waste. Thus, it can be acquired by consuming contaminated raw meat or water, particularly in developing countries. Other forms of hepatitis, such as alcohol hepatitis, are caused by excessive alcohol use. Autoimmune hepatitis occurs sporadically, especially in persons with a prior history of autoimmune disease in general.
Are there groups more at risk of developing hepatitis?
Yes. Hepatitis C, for example, is most common among persons who inject drugs, as well as people born from the years 1945-1965, the Baby Boomers. High rates of hepatitis C occurred during this time due to lifestyle choices and drug use, as well as health care practices during that time period such as reuse of glass and metal syringes in medical practice. Hepatitis B is much more common in people from regions in Asia and Africa, where it is endemic.
How is hepatitis and the specific form of it diagnosed?
Generally hepatitis can be diagnosed with blood tests, which can distinguish between the different types of viral hepatitis, as well as evaluate for autoimmune hepatitis. Rarely, a liver biopsy can be helpful in particular for diagnosing autoimmune hepatitis.
What are the treatments for hepatitis?
Different types of hepatitis have different types of treatments. For example, for hepatitis B, we have antiviral medications that suppress virus replication, and therefore improve disease outcomes, such as decreasing the risk of developing cirrhosis and liver cancer. Although, there is currently no cure for hepatitis B, there are multiple ongoing clinical trials, including at Mount Sinai, which are evaluating new medications that can cure hepatitis B in the future. For hepatitis C, we have a number of medication regimens available, called directly acting antiviral agents, which cure hepatitis C. This is an exciting recent development in our field, as prior to 2013 these medications had not been available. Now, we can cure virtually everyone with hepatitis C, even with advanced liver disease. For autoimmune hepatitis, we treat with immunosuppressive therapy such as steroids and other steroid-sparing medications. For alcohol hepatitis, the main recommendation is alcohol cessation. In specific instances, we can also treat with steroids if the alcohol hepatitis is very severe. For NASH, or fatty liver disease, lifestyle modification with the goal of weight loss and improved diabetes control, is critical, and we also have multiple ongoing clinical trials for the treatment and prevention of progression of NASH.
How does hepatitis affect pregnancy and childbirth?
Hepatitis is very important to consider in pregnant women. For example, hepatitis B and hepatitis C can be transmitted from the mother to the baby in pregnancy and childbirth. Therefore, we need to screen women for these viruses at the beginning of pregnancy to make sure we take all measures to prevent transmission which can lead to liver problems, and other problems, in the baby. For hepatitis B, we make sure that the baby gets the hepatitis B vaccine, as well as hepatitis B immunoglobulin (another agent that decreases risk of transmission) within 12 hours of birth to decrease risk of transmission. In addition, we recommend treatment with antiviral medication of the mother if she meets criteria. For hepatitis C, we currently do not treat mothers during pregnancy, but this is currently under evaluation. There are obstetrics management measures during the pregnancy that are also important to take in order to decrease the risk of transmission to the baby, such as minimizing invasive fetal monitoring.
Hepatitis can also impact the pregnancy. For example, hepatitis C increases the risk of cholestasis of pregnancy, a pregnancy-specific condition that can have a negative impact on the baby. There have also been studies which suggest an increased risk of preterm birth and gestational diabetes in women who have hepatitis during pregnancy.
Finally, hepatitis can also become more active in the setting of pregnancy. Hepatitis B can “flare” or become more active during pregnancy and in the postpartum period. Hepatitis E, although rare, can be especially severe during pregnancy.
What disparities exist between groups in regard to hepatitis prevalence or treatment?
There are disparities that exist in terms of testing and access to treatment in certain patient groups. For example, due to provider beliefs and insurance restrictions, it has been difficult for people who use drugs, and who are most affected by hepatitis C, to access hepatitis C medications, and therefore obtain a cure for hepatitis C. For example, a recent publication demonstrated significant disparities in outcomes from liver cancer in patients with hepatitis C between African Americans (mostly men) and Caucasian individuals with hepatitis C since the introduction of hepatitis C medications, suggesting that access to medications was inferior in the African American community.
There have also been disparities in testing and monitoring of hepatitis B, which affects a predominantly immigrant patient population. For example, immigrant patient populations, especially those without health insurance, often do not get the appropriate follow up for liver cancer screening as well as access to antiviral therapy, which leads to progression of the disease in these patient groups.
How do we work on reducing these disparities?
Education of health care providers, as well as of patients, is critical in order to reduce these disparities. For example, over the past few years there has been a significant emphasis on educating providers, and creating care models, in order to be able to provide people who use drugs with hepatitis C treatment. Furthermore, over time there has been a gradual reduction in cost of hepatitis C medications, as well as legislation changes, in order to lift insurance coverage restrictions that were targeting people who use drugs.
Providing education to patients about the importance of hepatitis B follow up, and the development of programs through the New York State Department of Health and the New York City Department of Health, dedicated to make sure that patients with hepatitis B are able to access care, are appropriately linked to care, and are not lost to follow up.
What can we do every day to prevent the spread of hepatitis?
It is important to know the current testing recommendations for hepatitis so that everyone gets tested, even if asymptomatic. Measures to decrease transmission, such as practicing safe sex, taking measures to decrease risk associated with drug use, and minimizing health care exposure (i.e. using sterilized techniques, not re-using needles – which is still currently in issue in certain countries abroad) are critical. For patients diagnosed with hepatitis, it is important to engage in care and be treated, in order to decrease community transmission.
Is there anything else you would like to share about hepatitis?
Adults age 18-79 should be tested for hepatitis C. If you test positive, there are excellent treatments available that can cure you. May 19, 2020 is Hepatitis Testing Day. Use this opportunity to get tested or check on the status if you have been exposed or diagnosed with hepatitis. Hepatitis is a leading cause of death worldwide. It is important to seek care if concerned if you develop symptoms such as jaundice. There are treatments available to halt progression of hepatitis such as hepatitis B and autoimmune hepatitis. If you have hepatitis B, come see us in Mount Sinai Institute for Liver Medicine to participate in clinical trials for the cure of hepatitis B. If you are interested in inquiring about additional hepatitis C trainings, visit ceitraining.org.