For Professionals How is Hepatitis Diagnosed and Treated?

The most common symptoms of hepatitis B occur within 25-180 days following exposure and include:

Fast fact

An estimated 30% of people infected with the hepatitis B virus have no recognizable signs or symptoms.

loss of appetite
nausea and vomiting
fever
weakness or tiredness
abdominal pain in the area of the liver (upper right quadrant)
dark urine and light-colored stool
joint pain
yellowing skin and eyes (jaundice)

How can you be sure if a patient has hepatitis B?

An estimated 30% of people infected with hepatitis B have no recognizable signs or symptoms and do not know how or when they became infected.

The only way the disease can be positively identified is by conducting a hepatitis B blood panel. This is a simple three-step test and is not usually included in the routine blood tests of a physical examination. However, the results of each individual test can be difficult to interpret for both health care professionals and patients. Therefore, it is strongly recommended that written results of all three standard tests be reviewed before a diagnosis is made. Patients should also receive copies of their test results for future reference.

Blood Tests

There are three standard blood tests for hepatitis B:

HBsAg (surface antigen test) is part of the hepatitis B virus that is found in the blood of someone who is infected. POSITIVE indicates that the hepatitis B virus is present.
HBsAb or anti-HBs (surface antibody test) is produced in response to the hepatitis B virus or vaccine. POSITIVE indicates your immune system has successfully developed a protective antibody against the hepatitis B virus and may provide long-term protection against future infection.
HBcAb or anti-HBc (core antibody test) does not provide any protection or immunity against the hepatitis B virus but can also indicate a false positive. POSITIVE indicates that a person may have been exposed to the hepatitis B virus and is usually present in those who are chronically infected.

Although anti-HBs and anti-HBc may be found in the blood of individuals who are immune to hepatitis B, the presence of HBsAg indicates infection with the hepatitis B virus. Patients with levels of HBV in their blood may test positive for HBeAg (e antigen) or HBV DNA.

The following chart can help providers, patients and families evaluate the results of a blood panel:

Test	Results	Interpretation	Action
HBsAg HBsAb HBcAb	Negative (-) Negative (-) Negative (-)	NOT IMMUNE- has not been infected but is still at risk for possible future infection- needs vaccine	Get the vaccine
HBsAg HBsAb HBcAb	Negative (-) Positive (+) Negative or positive (-/+)	IMMUNE- has been vaccinated or recovered from previous infection- cannot infect others	Vaccine is not needed
HBsAg HBsAb HBcAb	Positive (+) Negative (-) Negative or positive (-/+)	Acute INFECTION or CHRONIC infection- hepatitis B virus is present- can spread the virus to others	Find a knowledgeable doctor for further evaluation
HBsAg HBsAb HBcAb	Negative (-) Negative (-) Positive (+)	UNCLEAR- several interpretations are possible- all 3 tests should be repeated	Find a knowledgeable doctor for further evaluation

As part of the THINK B initiative, the American Liver Foundation will be conducting education programs and outreach activities to help inform health care providers and professionals about how to properly diagnosis and treat hepatitis B. For more information about these programs, please write to thinkb@liverfoundation.org.

For patients diagnosed with hepatitis B there are existing and emerging treatments available to them. In recent years, significant advances in biomedical research have resulted in the delivery of safe, effective treatments for chronic hepatitis B. Additionally, the landscape for many promising new hepatitis B drugs continues to grow, providing enormous hope for those infected and more options for physicians treating infected patients. Although not every person with chronic hepatitis needs to be treated, those who show signs of active liver disease may benefit from the currently available drugs.

When to initiate treatment

While treatment can help keep patients healthier longer and can provide a number of improving effects, it is important to note that not all patients who are positively identified with the virus will need to initiate treatment. The decision of when to initiate treatment for a patient is based upon extensive evaluation and treatment guidelines that exist to help physicians make decisions as to the proper treatment approaches for a patient.

What are the current treatments?

To date, the U.S. Food and Drug Administration (FDA) has approved several treatment options for adults and children, and there are other treatments in development.

Approved Hepatitis B Drugs in the United States

Interferon-alpha (Intron A) is given by injection several times a week for six months to a year. The drug can cause side effects such as flu-like symptoms, depression, and headaches. Approved in 1991 and available for both children and adults.
Pegylated Interferon (Pegasys) is given by injection once a week usually for six months to a year. The drug can cause side effects such as flu-like symptoms, depression and other mental health problems. Approved May 2005 and available only for adults.
Lamivudine (Epivir-HBV, Zeffix, or Heptodin) is a pill that is taken once a day, with almost no side effects, for at least one year or longer. A primary concern is the possible development of hepatitis B virus resistance during and after treatment. Approved in 1998 and available for both children and adults.
Adefovir dipivoxil (Hepsera) is a pill taken once a day, with few side effects, for at least one year or longer. The primary concern is that kidney problems can occur while taking the drug. Approved September 2002 and available only for adults. Pediatric clinical trials are being planned.
Entecavir (Baraclude) is a pill taken once a day, with almost no side effects, for at least one year. It is considered to be the most potent oral antiviral drug for chronic hepatitis B to date. Approved April 2005 and available only for adults. Pediatric clinical trials may be planned for the future.
Telbivudine (Tyzeka) is a pill taken once a day, with almost no side effects, for at least one year. It is associated with a fairly high rate of drug resistance and is ineffective in patients who have lamivudine-resistant hepatitis B.

Although the FDA has approved these six drugs for chronic hepatitis B, they do not provide a complete cure, except in rare cases (a "cure" generally means that a person loses the hepatitis B virus and develops protective surface antibodies).

The drugs, however, significantly decrease the risk of liver damage from the hepatitis B virus by slowing down or stopping the virus from reproducing. As with HIV, it appears that combination therapy will probably be the most effective method of combating chronic hepatitis B infections.

The goals of HBV treatment are:

Sustained suppression of HBV replication

HBV DNA undetectable in serum
HBeAg to anti-HBe seroconversion
HBsAg to anti-HBs seroconversion

Remission of liver disease

Normalization of serum ALT levels
Improvement in liver biopsy findings

Improvement in clinical outcome

Prevention of liver failure and liver cancer
Increased survival

*It is important that patients are routinely screened for liver cancer.

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