Testing aims to reduce liver damage, premature death
Host Amber Smith: Upstate Medical University in Syracuse, New York invites you to be "The Informed Patient" with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith. New recommendations from the CDC are meant to increase awareness of hepatitis B infection and reduce chronic disease and premature death. So what do patients need to know? For answers, I'm talking with Dr. Sana Zekri. He's an assistant professor of family medicine at Upstate. Welcome to "The Informed Patient," Dr. Zekri.
Sana Zekri, MD: Thank you. It's nice to be here.
Host Amber Smith: These recommendations say all adults should be tested for the hepatitis B virus infection at least once in their lifetime, and that some adults should get periodic testing. Why the emphasis on hepatitis B?
Sana Zekri, MD: I'd like to first start off by talking about what hepatitis B is. It's a hepatic virus. So hepatitis -- "hepat" means liver, and then "itis" means inflammation. So there's many ways that you can develop inflammation of the liver, medications that you take, alcohol use, but then there's also viruses that can cause that in inflammation of the liver. There's hepatitis A, there's hepatitis B, and people have also heard of hepatitis C. There's actually other ones as well. And these hepatitis viruses, some of them have been with mankind for a really, really long time. And hepatitis B is one of the ones that has been with mankind for a long time and has unfortunately resulted in a lot of premature death due to liver disease.
The reason that there's so much emphasis on hepatitis B in particular is that this is something that is mostly found in humans. It's something that can be effectively prevented by knowledge of where it came from. But unfortunately when it takes root, when it takes hold, it's really difficult to get rid of it. And so this increased emphasis on hepatitis B testing and prevention is really aimed at trying to reduce the overall burden of premature death from hepatitis B. That takes hold, takes root in people.
Host Amber Smith: So how would a person know they've been infected?
Sana Zekri, MD: Well, that's actually really difficult. The hepatitis viruses in general can be very quiet viruses. Sometimes they're very angry viruses. So hepatitis B, it actually depends on when you get it in your life. In an adult who gets hepatitis B, they will often have the signs of hepatitis, which is yellowing of the skin. That's called jaundice. They'll have pain or tenderness in the right upper quadrant of the abdomen, like underneath the right side of your ribs. That's where your liver is. They may have nausea. They may have vomiting and fever and get kind of sick.
But actually children who get hepatitis B may have almost no symptoms at all. And it actually makes a difference how much of a symptomology you have. The more symptomatic you are, the more likely it is that your body will fight off the virus; and the less of an illness that you get, the less symptomatic you are. It seems like it makes it more likely that the virus will quietly take hold and take root, and you'll be chronically infected with hepatitis B.
Host Amber Smith: How does it transmit from person to person?
Sana Zekri, MD: So hepatitis B is one of the viruses that can be transmitted in multiple ways. The one that is most concerning, the most problematic, the one that we -- well, two ways that we have really significant concerns about. No. 1 is vertical transmission. So vertical transmission means mom has hepatitis B, and baby gets hepatitis B from mom. And you remember that I said that children who get hepatitis B -- that includes babies -- may have very low symptoms, but they actually 85 to 90% of babies who have hepatitis B at birth go on to develop the chronic infection, which we don't have good effective treatments for.
The other group of people that we're really worried about are people who get blood transfusions or who are regularly being exposed to blood products. Think people who maybe who live in nursing homes and who have to have their blood sugar checked multiple times a day, or people who are in the hospital and have to have labs done on a frequent basis, or patients who are undergoing dialysis. Those are two really high risk groups of people because hepatitis B is very easily transmitted through blood. Hepatitis B can also be transmitted through sexual contact. And when I say sexual contact, I don't mean kissing. And I don't mean breastfeeding. But I do mean sex. Vaginal secretions and semen, they can carry the hepatitis B -- and anal secretions as well -- they can all carry hepatitis B.
Host Amber Smith: So what is involved in testing for hepatitis B? Is it just a blood test?
Sana Zekri, MD: Yeah. Basically, it's blood testing. Yeah. There's several blood tests that are done, but it can all be done in one session. You get several tests that are done all at once. In some cases, hepatitis B has a window in which your body hasn't yet responded to the infection, and your tests may come back negative in the very first period when you get the infection. And in those cases, some people where there's high suspicion, they may need to be retested again, which is part of the reason why the CDC recommends that patients be retested if they're at high risk of getting hepatitis B. So redoing blood tests is not something that's unheard of.
Host Amber Smith: As a doctor of family medicine, what do you do for someone who tests positive?
Sana Zekri, MD: There's acute hepatitis B, which is when a person has the symptoms and they don't feel well, and with that it's mostly watching and waiting and seeing if they're going to clear or not. There are a few antivirals that maybe can help a little bit, but mostly it's watching and waiting and seeing what the body will decide to do.
With chronic hepatitis B, unfortunately, there's not a lot of treatment for it. So it comes down to watching for the problems that can come from hepatitis B. So the problems that can come from hepatitis B are slow damage to the liver that can cause something called cirrhosis, which many people have heard of. But cirrhosis is kind of where the liver is no longer functioning appropriately, and puts you at risk of problems like confusion, puts you at risk of problems like bleeding episodes and unfortunately can also kill you.
And there is also the risk of cancer of the liver. Hepatitis B does increase the risk of cancer of the liver, and that's another thing that as a family medicine doctor, we screen for and we watch out for in patients who have hepatitis B. So we're watching to make sure we know when they develop cirrhosis, and we take appropriate action when they develop cirrhosis. And we're watching to make sure that if they develop liver cancer, we identify it early so that we can treat them early.
The other thing is that when we have patients who are of childbearing age who have hepatitis B, we're very, very careful about making sure that we monitor their hepatitis B. And if they become pregnant, we make sure to take as many steps as possible to ensure that the hepatitis B is not transmitted to their child.
And then finally, we recommend for everyone who does have hepatitis B, we strongly recommend that their partners and the people in their families be vaccinated and immunized against hepatitis B to reduce the risk of transmission to other people.
Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith. I'm talking with Dr. Sana Zekri. He's an assistant professor of family medicine at Upstate, and he sees a variety of patients from birth through the senior years as a doctor of family medicine. We're talking about new recommendations from the CDC about hepatitis B.
Newborn babies now receive a hepatitis B vaccine. Does that mean that when they grow up, they're not going to need to be tested? Does that protect him for life?
Sana Zekri, MD: The hepatitis B vaccine is very, very effective at preventing hepatitis B in childhood, which is the highest risk period. However, there is evidence that the hepatitis B vaccine wanes over time, and particularly after 15 to 20 years, it appears that the hepatitis B efficacy does wane. So people do need to be retested at a later phase as well, especially if they participate in what we consider high risk activities. And so those patients do need to be retested again in the future.
And I think an important thing to point out here is -- and I do encounter this sometimes where people will say, "well, I don't have hepatitis B. You've tested me for hepatitis B during my pregnancy. I don't think that my child needs to be vaccinated against hepatitis B. So you know, I don't have it, so why would I need to do it?" And I think that an important point there is that hepatitis B, unfortunately, is very transmissible and actually can stick around on surfaces for several days. There are some unfortunate incidents where children playing on playgrounds have gotten hepatitis B probably because someone who had hepatitis B got a cut while they were on the playground and another child got it on their hands, or they had a small cut on their hands. This is one of the most transmissible viruses. So I usually recommend that every single child, every single baby, be vaccinated against hepatitis B because that childhood age is the highest risk time for child developing chronic hepatitis B.
And even though members of the family may not have hepatitis B, there could be unknown exposures from outside that we can't control.
Host Amber Smith: What about adults? Can they get vaccinated against hepatitis B?
Sana Zekri, MD: They can, and we actually recommend that they do. We recommend that patients who are at high risk for contracting hepatitis B or patients who have had waning immunity be revaccinated against hepatitis B. And if they've never been vaccinated against hepatitis B, we do recommend that they get the hepatitis B vaccine.
Host Amber Smith: All adults across the board, regardless of their risk?
Sana Zekri, MD: It's recommended to receive at least the first series of vaccines. As to whether or not you have to be revaccinated, that kind of depends on risk, but it is recommended that everyone receive at least the first series of hepatitis B vaccines.
Host Amber Smith: Who are the people who are recommended to undergo periodic hepatitis B testing?
Sana Zekri, MD: People who should undergo periodic hepatitis B testing are people who are considered to be at risk. Now first of all, this is all pregnant women should undergo hepatitis B testing with each pregnancy, similar to H I V testing and hepatitis C testing. Other individuals who are recommended to undergo periodic hepatitis B testing are people who have had a history of sexually transmitted infections, or people who have multiple sex partners, or people who receive money for sex, people who have a history of other types of chronic hepatitis infections, such as hepatitis C, people who are currently or formerly incarcerated, people who were born to individuals who had hepatitis B, people who are born in regions where there's a lot of hepatitis B, and people who inject drugs, have a history of injection drug use, people who have H I V, men who have sex with men, individuals living with people who have hepatitis B, and people who are getting maintenance dialysis, such as patients who have kidney disease, really severe kidney disease and have to get dialysis. And then in general, anyone who has high liver enzymes should be tested for hepatitis B to make sure that's not what's causing their high liver enzymes.
Host Amber Smith: Well, before we wrap up, if someone has a hepatitis B infection that goes undetected because they never got tested, or they just never saw a doctor, what may happen healthwise to them?
Sana Zekri, MD: Unfortunately, we do have examples of people having hepatitis B for a prolonged period of time and not knowing that they have it and it being not detected.
One of the major issues is, of course, transmission to other people, unintentional and unknowing transmission to other people. But from a personal perspective, patients who have chronic hepatitis B are at higher risk of developing cirrhosis, which is the long-term damage to the liver that makes a person at a higher risk of bleeding and confusion, yellowing of the skin and can actually lead to a person's premature death, and they are also at significantly increased risk of developing liver cancer.
Fortunately for the liver cancer part of things, we do have treatments that can help to reduce the damage from liver cancer if caught early.
When it comes to cirrhosis, it's mostly about managing the other risk factors. We don't have great treatments for hepatitis B itself. We only have preventive treatments, but when a person does have chronic hepatitis B, it's important to be monitored to make sure that if there is long-term damage, we can avoid the worst sequelae of it.
Host Amber Smith: Dr. Zekri, I appreciate you making time for this interview. Thank you.
Sana Zekri, MD: Thank you.
Host Amber Smith: My guest has been Upstate doctor of family medicine, Sana Zekri. "The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe. Find our archive of previous episodes at Upstate.edu/Informed. This is your host, Amber Smith, thanking you for listening.