What doctors wish patients knew about hepatitis A, B and C

Viral hepatitis is a global epidemic that affects millions of people worldwide. But the tricky part is that infections with the hepatitis viruses may not show symptoms, causing many to be unaware they have this condition. In fact, many people who have acquired viral hepatitis do not realize they are infected.

And while many patients with an acute infection fully recover after a few weeks, others develop chronic infections. That is why it is vital that patients know the ABCs of viral hepatitis and understand when to seek help.

Hepatitis refers to inflammation of the liver, which is a vital organ that processes nutrients, filters the blood and fights infections. The most common types of viral hepatitis in the U.S. are hepatitis A, B and C. In 2020, there were 19,900 infections with hepatitis A in the U.S., according to the Centers for Disease Control and Prevention (CDC). The good news is that hepatitis A does not cause chronic infection and is easily prevented with a safe and effective vaccine that is recommended for all children at age 1, and for adults who may be at risk.

For hepatitis B, there were about 14,000 new infections and about 880,000 adults with chronic hepatitis B. Fortunately, hepatitis B can also be prevented with a vaccine that is recommended shortly after birth and for all adults 19–59 years old, and older persons with risk factors. With hepatitis C, more than half of people who become infected with the virus develop a long-term, chronic infection that can lead to liver disease and liver cancer. In 2020, there were about 66,700 new hepatitis C infections, says the CDC.

The AMA’s What Doctors Wish Patients Knew™ series provides physicians with a platform to share what they want patients to understand about today’s health care headlines.

For this installment, Lesley Miller, MD, medical director of the Grady Liver Clinic and professor of medicine in the general internal medicine division of the Emory University School of Medicine, took time to discuss what patients need to know about viral hepatitis.

“When I first started treating hepatitis C in 2004, I used to say the incidence is down, the prevalence is down—we’re just dealing with this existing population of people with hepatitis C who may or not be aware of their status,” said Dr. Miller. “But that’s all changed now with the opioid epidemic. Cases are alarmingly on the rise, particularly among young people.

“So, among 20-to 40-year-olds, we see cases rising the most,” she added, noting that “we can’t get a handle on the hepatitis C epidemic without actively testing and treating in these groups.”

This also adds to why the life expectancy in the U.S. has seen a drop and “that was really the impetus behind the change in CDC’s screening recommendations,” Dr. Miller said. The current recommendation is for physicians to screen all persons 18 or older at least once in their lifetime for hepatitis C.

“It used to be: Just screen baby boomers—people born between 1945 and 1965—in addition to people with risk factors, but the reason they changed the guidance is that we as medical professionals are not always comfortable having conversations about risk,” she added. “It involves asking people about their sexual habits and their drug-use habits. And that’s not always a comfortable conversation for everybody. So, people who were only supposed to be screened based on risk factors, including younger people, were getting missed.”

“When you first get infected with hepatitis B, it is usually noticeable, so you’ll have a gastrointestinal illness with symptoms like abdominal pain, jaundice, vomiting, or fever,” Dr. Miller said.

“With hepatitis C on the other hand, we very rarely catch acute infections because they are usually asymptomatic,” she said. “They call hepatitis C the silent killer because most people don’t know that they’ve been infected because the acute phase doesn’t really cause symptoms—only 40% of people with hep C know they have it.”

“Then even with chronic infection, people don’t usually develop symptoms until their liver disease is really advanced,” Dr. Miller said. “You could have hepatitis C for 10, 20, 30 years and never have any symptoms, even while developing liver scarring.”

“That’s why it’s so important to get tested because people may think that if they had it, they would know. But the truth is that most people have no symptoms at all, so the only way to find out is to get tested,” Dr. Miller said.

“For hepatitis C, all adults 18 and up should get a one-time test. This is a really nice, straightforward recommendation to follow because unlike a lot of things we do in preventive health—mammograms, colonoscopies—that we have to repeat periodically, this is a one-time test for most people,” Dr. Miller said. “The vast majority of people just need it once and then they’re done—if you’ve had a test once in your lifetime and you haven’t had any risk exposure since then, you’re good.”

“The exception to that is people who are at ongoing risk. For example, people who are actively injecting drugs should be tested annually,” she explained. “The other point the CDC made in their updated recommendations for hepatitis C screening is that pregnant people should be screened with each pregnancy,” as there has been an “alarming rise” in cases among pregnant people, again due to the opioid epidemic.

“We—for the first time—have this cure and it is an amazing cure. The medications—called direct acting antivirals—cure more than 95% of people with a simple eight- to 12-week course that’s really easy to tolerate,” said Dr. Miller. “When you imagine the burden of hepatitis C—2.4 million Americans are affected—but now there’s a cure for this chronic disease, it’s pretty miraculous.”

Unfortunately, “when the medications first came out, they were super expensive—about $90,000 for a 12-week course of medication or about $1,000 a pill,” she added. “But it’s different now. The prices have come down and it’s gotten less expensive than it used to be.”

“Medication access can still be a challenge, but there are solutions. In the population I work with, about half of our patients are uninsured, but even for patients without insurance in our clinic, we’re able to treat them through patient-assistance programs,” Dr. Miller said. “For insured patients, there is a prior authorization process, so it’s  burdensome, but we can access medications for nearly all patients.”

“Sometimes the biggest issue is accessing somebody who can provide that treatment, not necessarily accessing the medications themselves,” she said.

“It turns out treating hepatitis C does more than just improve liver disease. There’s a study that just came out in JAMA where they looked at close to 250,000 people treated with direct-acting antivirals for hepatitis C, and not only did  treatment decrease overall mortality and liver-related outcomes, but it improved outcomes from nonliver-related diseases as well.”

For example, hepatitis C treatment “improved outcomes with diabetes, chronic kidney disease, cardiovascular disease and non-liver cancer,” she said. “It was really amazing evidence in a well-done study that curing hepatitis C not only improves liver outcomes, but it improves other health outcomes as well.”

Get the latest public health news

Get the tools and resources you need to face the latest public health issues. 

Subscribe Now

“That’s why it’s really important for folks who are at ongoing risk for infection—meaning people who are actively injecting drugs and sharing equipment—to get treated, and we should use harm reduction strategies to lower the risk of reinfection,” Dr. Miller said. “It’s a really important priority population for us to treat because we can’t eliminate hepatitis C—which is our goal—without treating everybody.”

“For people who are at highest risk for getting infected—or reinfected—we really try to counsel them about how to make that risk as low as possible,” Dr. Miller said. “So, if you’re injecting, don’t share equipment and do utilize syringe-exchange programs or any avenue you can to basically ensure that you’re not using anything contaminated with somebody else’s blood.”

“You can’t get hepatitis C through casual household contacts like sharing cups, plates, forks, kissing, hugging, shaking hands,” Dr. Miller explained. “But you can get it in ways that you may not think. So, because it’s passed through the blood, even microscopic blood can be a risk for transmission.”

“For example, we recommend not sharing razors or toothbrushes,” Dr. Miller explained. “If you have hepatitis C and somebody uses an item which could have microscopic blood on it, that could be a route of transmission.”

Hepatitis B and C “can be sexually transmitted,” Dr. Miller reiterated. “So, if you have multiple sex partners, it’s a good idea to use barrier protection,” such as condoms and dental dams.

That advice applies “not just for hepatitis C and B prevention, but for other sexually transmitted infections,” she added.

“Whether it’s hepatitis B or C, taking care of your liver health while you’re waiting for treatment or even after treatment is really important,” Dr. Miller said. That means “getting vaccinated for the other kinds of hepatitis you don’t have, for example getting vaccinated for hepatitis A and B if you have hepatitis C.”

“It is also important to maintain a healthy diet because of fatty liver disease, which is also on the rise and has replaced hep C as a leading cause of liver transplant,” she said, noting that “having fatty liver disease along with hepatitis B or C can accelerate that liver damage.”

“Avoiding alcohol while you have chronic viral hepatitis is really important too,” Dr. Miller added.

“Hepatitis C was only discovered in 1989 and now we have a call from the World Health Organization to eliminate hep C by 2030—it’s an extremely short timeline in the history of infectious diseases,” Dr. Miller said. “The fact that they would even create that short of a timeline speaks to the fact that it’s doable.”

The White House also recently proposed a program to eliminate hepatitis C from the United States through improved testing and paying for treatment.

“We have all of the tools we need. We have an accurate, easy to administer test. We have excellent treatments that are safe, well tolerated and really effective. It’s just about putting those things together, getting people to know their status and have access to treatment,” she said. “We have all the tools we need to literally wipe this disease off the planet in a few years, which is pretty incredible.”