Chronic viral hepatitis affects millions of people worldwide. But the tricky part is that people infected with hepatitis viruses may not show symptoms, causing many to be unaware they have this condition.
While many patients with an acute infection fully recover after a few weeks, others develop chronic infection. 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 2023, there were about 3,300 infections with hepatitis A in the U.S., according to the Centers for Disease Control and Prevention (CDC). This is down from about 19,000 cases in 2020. 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 acute infections with about 640,000 adults living with chronic hepatitis B. Fortunately, infection with hepatitis B virus can also be prevented with a vaccine that is recommended shortly after birth, for all adults 19–59 years old and older persons with risk factors. With hepatitis C, about 80% of people who become infected with the virus develop a long-term, chronic infection that can lead to liver disease and liver cancer. In 2023, there were about 69,000 cases of acute hepatitis C, estimates the CDC.
The AMA’s What Doctors Wish Patients Knew™ series gives physicians a platform to share what they want patients to understand about today’s health care headlines.
For this installment, two physicians took time to discuss what patients need to know about hepatitis A, B and C. They are:
- Steven Flamm, MD, a transplant hepatologist in Chicago and director of network development for liver transplantation at Rush University System for Health.
- Lesley Miller, MD, an internist and medical director of a liver clinic in Atlanta.
Rush University System for Health is part of the AMA Health System Member Program, which provides enterprise solutions to equip leadership, physicians and care teams with resources to help drive the future of medicine.
Hepatitis A, B and C affect the liver
“These are three of the primary viruses that affect the liver,” Dr. Flamm said, noting that “there are a lot of viruses such as SARS-CoV-2 … and mono, but these three viruses are the main ones that affect the liver primarily.”
“People think they’re very similar to each other because we call them A, B and C, but they’re actually vastly different,” he said. “The only things they really have in common are they’re all viruses and they all affect the liver, but they’re all very different than one another—the way you get them, what happens to you when you get them, whether they have vaccines or not, how you treat them.”
Transmission of hepatitis A is fecal-oral
To describe the transmission of hepatitis A, “it’s not very appetizing, but it’s fecal contamination,” said Dr. Flamm.
For example, if you go to another country where hepatitis A risk is higher than in the U.S., drinking contaminated water increases your risk. Also, eating raw fruits that were washed in contaminated water can expose you to hepatitis A. In high income countries, hepatitis A is not as common because of better sanitation systems.
“When an adult gets acute hepatitis A, it can be very symptomatic. You can get very tired, headaches, fevers, jaundice—yellow—eyes and feel very, very sick, but in the end, it always goes away,” Dr. Flamm said.
Pregnant women are especially vulnerable, however, to severe cases and even death from hepatitis A.
The hepatitis B virus is spread by bodily fluids
“Hep B is a very different virus. In fact, the entire makeup of this virus is very different than all of the other primary liver viruses, including A and C,” said Dr. Flamm. “Hepatitis B is transmitted by blood or body fluids.”
“In the United States, people get it primarily as young adults when they become sexually active, if they have sex with someone who has active hepatitis B unknowingly, or sharing needles with intravenous drug use and the person using the needle before them has hepatitis B,” he explained. “In other parts of the world, chronic hepatitis B is much more common. In those places, it is most commonly transmitted at childbirth.
“That does not happen in the U.S. because of the availability of the hepatitis B vaccine, which is administered to newborns,” Dr. Flamm added, noting that “chronic hepatitis B is not very common in the United States. We think that about 1.5 million people in the U.S. out of the 330 million people in the country have chronic hepatitis B.”
Hepatitis C is transmitted by blood
“Hepatitis C is what we call an RNA virus. It’s different than B, but it also becomes chronic very frequently—more frequently than B,” Dr. Flamm said, when acquired as an adult. He also noted that “hepatitis C is most commonly transmitted by blood.”
“The way people have acquired hepatitis C is they are intravenous drug users, and they share needles, or they received a blood transfusion before the test for hepatitis C came out,” he said. “The diagnostic test for C came out around 1990, and between 1990 and 1992 they started screening all” donated blood products for hepatitis C in the U.S., so you no longer can get hepatitis C from a contaminated blood transfusion.
“Sexual transmission is much rarer with hepatitis C than with B. But with both B and C, the way transmitted sexually most commonly is from anal receptive intercourse,” Dr. Flamm explained, noting that men who have sex with men have relatively high rates of hepatitis C.
Most don’t know they have hepatitis C
“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.
All adults should get a one-time test
“For hepatitis C, all adults 18 and older 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 due to the opioid epidemic.
Hepatitis B can lead to liver cancer
“When hepatitis B is chronic—it doesn’t always create a problem—however it may cause cirrhosis, which is a sick liver, and people either die or need a liver transplant,” said Dr. Flamm. “And if you get this when you’re a teenager, do you get sick from it when you’re in your 20s? No, you get sick from it when you’re 40, 50 or older.”
“What hepatitis B causes frequently is liver cancer,” he said. “It is cancer that starts in the liver, not starts in another place like the breast and goes to the liver. Liver cancer prognosis varies greatly by stage … but it does improve with early detection and curative treatments such as transplant or resection.”
Get the hepatitis B vaccine
“When you’re pregnant, you’ll go to the doctor and they automatically check you for hepatitis B,” said Dr. Flamm. “And if you have hepatitis B, not only do they refer you to a doctor like me, but they also, when the baby is born, give the vaccine and another product called hepatitis B immune globulin” to the newborn.
The hepatitis B vaccine “prevents transmission of hepatitis from you to your baby. And we've been doing that in the United States since the mid-1980s,” he said. “Consequently, in the United States—and this is true in Europe and other [high income] countries—it is exceedingly rare for any babies to get hepatitis B from their mother.”
“There is data for 40 years about these vaccines. They are highly effective and very safe,” Dr. Flamm said.
The American Academy of Pediatrics continues to recommend giving newborns a dose of the hepatitis B vaccine within 24 hours of birth. Additional doses are recommended at 1–2 months and 6–18 months.
There’s a hepatitis A vaccine too
“You can also prevent hepatitis A by vaccination,” said Dr. Flamm. “There is a very safe and effective vaccination for hepatitis A. It's been out for decades.”
“Current recommendations in the United States are that people get hepatitis A vaccination when they're babies,” he added. “But if for some reason you didn't get it, you certainly should get it if you are going for any length of time to a [low income] country where hepatitis A is endemic.”
The hepatitis A vaccine is recommended for all children 12–23 months old as part of routine childhood vaccination. Also, all children and adolescents 2–18 years old who have not previously received the hepatitis A vaccine should also get this immunization. Beyond that, if you have not received the hepatitis A vaccine as an adult, it is recommended that you get the immunization before traveling abroad.
There’s a cure for hepatitis C
“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 … 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.
“The challenge nowadays is not curing hepatitis C. The challenge nowadays is finding the people who have, it that still haven't been identified,” said Dr. Flamm, noting that “hepatitis C has dramatically declined in the United States in the last 10 years since these new medicines have come out because of the high cure rate.”
Treatment improves health outcomes
“It turns out treating hepatitis C does more than just improve liver disease. There’s a study 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.”
Hepatitis C reinfection is possible
“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.”
“Hepatitis B is a one-time only infection. Hepatitis A is also a one-time only infection. But hepatitis C, if you’re successfully treated, you can get it again, so you have to limit the risk factors for transmission,” said Dr. Flamm. “Just like strep throat, you can keep getting hepatitis C if you are re-exposed.
“The medicine is expensive though,” he added. “If you get hepatitis C, the medicines cost at least $25,000 to $30,000 per course, so we don’t want to have to keep using it over and over again.”
Lower your hep C risk
“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,” she added.
Wash your fruits and vegetables
“If you're not vaccinated for hepatitis A, then you have to be careful what you eat or drink,” said Dr. Flamm. For example, outbreaks of hepatitis A have been linked to imported foods, such as strawberries.
“You can prevent that transmission if you wash your food thoroughly after you buy it before you eat it,” he said. For example, “lettuce, apples, tomatoes, anything that you don’t peel, that you would bite or eat raw. You don’t get hepatitis A because you eat a fruit that you peel, from the inside part like watermelon or cantaloupe or honeydew. But if you eat strawberries or tomatoes where you just pop it into your mouth and don’t clean it very well, you are at risk.”
Recently, outbreaks have been linked to person-to-person spread, primarily among those who are experiencing homelessness and those who use drugs. There have also been high rates of hepatitis A in men who have sex with men.
Don’t share razors or toothbrushes
“You can’t get hepatitis C through casual household contacts like sharing cups, plates, forks, kissing, hugging, shaking hands,” Dr. Miller said. “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,” she 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.”
Practice safe sex
Hepatitis A, 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 … prevention, but for other sexually transmitted infections,” she added.
Take care of your liver health
“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.
We have the tools to eliminate hepatitis C
“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.”
“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.”
