Viral hepatitis: Questions and Answers

I will conduct a session of questions and answers:

Question 1
True story: A couple from Taiwan came to visit their son (who is a physician) and his family in the States.  The daughter-in-law wouldn’t allow them to eat in the same table, lest they would pass along the HBV to her children and herself, as they apparently had “hepatitis B”.  Do you think this daughter-in-law did the right thing to protect her family?

Answer
We do not know the serology status of the parents’ serology, but assume for the worst scenario that they had positive HBsAg and HBeAg with no antibodies, which means they had active viral replication with high infectivity.  The mode of transmission of hepatitis B is through blood/body fluid (viruses are present in blood, saliva, and semen), not the fecal-oral route.  It is perfectly safe to sit down to share the same dish in the same table.

The parents needed education that they cannot share tooth brushes or shaving equipment with others; they need to know how to handle the open wounds.  It is not necessary to have separate plates or cups but if the daughter-in-law so insisted, then it is OK to do so to please her.  Sometime I wonder would she do the same if it were her own parents. 

If one family member has chronic hepatitis B, then the rest of the family members need to take hepatitis B vaccine unless they already have HBs antibody.

Question 2
Rumor had it that the chef in one of your favorite restaurants has hepatitis B, shall you stop patronize the restaurant?

Answer
I am not aware any state law prohibits one with chronic hepatitis B or C to work in a restaurant as there was no evidence that one can get hepatitis B or C from a food handler without direct blood-to-blood contact.  The same is also true that a surgeon with chronic hepatitis B should be allowed to operate.

One may argue that the chef may be tasting the food and put it back to the pan while cooking, I certainly hope no chef (with or without hepatitis B) has this kind of practice.

Question 3
Is hepatitis B a sexually transmitted disease (STD)?

Answer
Yes, hepatitis B virus (HBV) is much more easily transmitted sexually than HIV or hepatitis C virus (HCV).

Although HCV is not efficiently transmitted sexually, the chance is not zero; it can happen, especially among HIV-infected persons.

Mode of transmission for hepatitis B in developed countries, such as USA, is IV drug use, STD and needle sticks, etc., whereas vertical transmission from mother to infant is the predominant way in Asia, including Taiwan.  Let’s not forget some got it from acupuncture.

Blood transfusion has been safe from hepatitis C in USA since 1992 when the test to detect HCV was developed.

Question 4
Vertical transmission: How the pregnant mother passes along the virus to the infant?

Answer
One may assume that HBV was passed from mother to the baby/fetus via placenta; wrong! That was not the case.  Observation has shown that it occurs during the child birth when mother’s body fluid comes in contact with infant’s mucosal membrane.  One study from China says only 3.7% was transmitted in uterus.

The high protective efficacy (95%) when the infant was given vaccine upon birth proves this is the case, if the fetus was infected while still in uterus, then the vaccination upon birth wouldn’t work as well.

Question 5
Why hepatitis A was not covered in your talk?

Answer
There is no such a thing as chronic hepatitis A.  The great majority fully recovered.  That is not to say we don’t have to take hepatitis A seriously.  Fulminant hepatitis A can be fatal, and the incidence of which seemed to be climbing for unknown reason over the past decade or two.

Infection by hepatitis virus triggers an immune response in our body.  When the immune response gets out of hand the killer T lymphocytes attack and destroy the infected liver cells.  Too much immune response is not necessary a good thing.  It is not due to the more virulent virus.

Question  6

What’s diabetes got to do with hepatitis B?

Answer

There were 29 outbreaks of hepatitis B in long-term care facilities in the States from 1996 to 2011, of these 25 involved adults with diabetes receiving assisted blood sugar monitoring.  This prompted Advisory Committee for Immunization Practice (ACIP—part of CDC) to investigate the risk of diabetics getting hepatitis B.

This led to ACIP recommendations in October 2011 that “hepatitis B vaccine should be given to adults with diabetes who are aged 19 through 59 years whether they live in a long-term facility or not.”

The data (of how susceptible ones with diabetes to hepatitis B) for those who are diabetics and are aged ≥60 years is less evident and the vaccination decision is at the discretion of the treating clinician.

Primary hepatitis B infections become chronic more frequently in immunosuppressed persons, such as hemodialysis patients and persons with HIV and diabetes.

(more questions to come!)