Q: My 35 years old wife has been diagnosed as a case of Hepatitis B during a blood donation camp. Her SGOT/SGPT report is normal, DNA test is also normal; liver biopsy report is also not much significant. Her ultrasound report says fatty liver and nil significant. She gets swelling in her legs, hands and full body and this problem is persisting for the last ten years. She does not take even water from an unhygienic source. She is a born vegetarian. I have myself tested HBsAg negative. I want to know that is there possibility of her becoming free from this disease. What are the precautions need to be taken by her?

A:Hepatitis B can occur both as an acute (or short term) as well as a chronic (or long term) infection. The persistence of hepatitis B surface antigen for more than 6 months is by convention taken as the definition of chronic infection. Most cases of acute infection (about 90-95%) resolve spontaneously without any medication, however, in about 5-10% of individuals the infection can become chronic. The proportion of patients getting the chronic form of infection is higher if the infection is acquired from mother, in infancy or in early childhood. In your wife’s case it appears that she has got the chronic form of hepatitis B infection. India happens to be an intermediate prevalence country for hepatitis B infection, where 2-7% of the population is infected with this virus. The disease is silent in most cases and is manifested serologically by hepatitis B surface antigen (HBsAg) reactivity when blood test is done. The chronic form of infection may manifests itself in four different phases, namely the immuno-tolerant phase (where liver function tests are normal, hepatitis B e antigen is positive, and the virus can be detected in high titres in the blood by the hepatitis B DNA quantitative PCR test), the immune clearance phase (where the liver function tests are transiently abnormal, and the HBV DNA titres come done, there is increased histological activity in liver biopsy, and the patient undergoes seroconversion from e antigen positive to e antigen negative status), immune control phase (where liver function tests are normal, HBV DNA titres are low or undetectable, and the affected person remains HBeAg negative), and finally the immune escape phase (where the HBV DNA titres rise, despite e antigen negativity and liver function gradually deteriorates). It is possible that some patients (about 0.5% per year) will clear the virus on their own without any treatment. If this happens the affected individual will seroconvert from HBsAg positive to a negative status, along with disappearance of HBV DNA from blood. A minority of patients may however experience reactivation of Hepatitis B virus even after initial clearance of the HBsAg from blood. This occurs if the body’s immune system declines because of some reasons.
It is important to remember that HBV DNA level in the blood should not be taken as a marker of disease resolution. HBV DNA levels might be undetectable (or may indeed fluctuate) in e antigen negative infections, and HBsAg is the definitive marker of chronic infection. In your wife’s case it is likely that she is in the e antigen negative immune control phase of the disease (because of her normal liver function tests, absence of any significant liver histology, and undetectable HBV DNA titres [I hope that is what you mean by “normal DNA test”]). The presence of fatty liver as detected by liver ultra-sonograpy might be an incidental finding, and in many patients who are overweight or obese (body mass index >25 in case of overweight, or BMI >30 in case of obesity) this finding may be detected. However, the description of swelling of hands, legs and body may be significant and it needs to be seen if a reduced albumin level in the blood (a protein produced by the liver, whose production may be reduced with liver impairment) is responsible for this phenomenon.
The risks of chronic hepatitis B infection are development of cirrhosis of liver, subsequent development of liver failure, and development of liver cancer in a small proportion of individuals. It must be remembered that these complications develop after many years of disease (often decades), and with modern treatment with antiviral medications and close monitoring many of these complications can be prevented relatively easily. However, chronic hepatitis B constitutes an infection risk to others, and the disease can be transmitted through blood and blood product transfusion (which is rare these days because of blood donor screening), sexual contact, sharing needles and syringes in case of intravenous drug users, from mother to baby, and needle stick or sharps injury in health care setting. In rare cases the disease has been transmitted from health care workers to patients during exposure prone procedures (e.g. surgery) involving a chronic hepatitis B positive health care worker. All patients with chronic hepatitis B should be referred to a liver doctor (hepatologist or medical gastroenterologist), for proper investigation (including a repeat serological test to confirm their diagnosis), long term follow-up and antiviral therapy (if needed). Moreover, all chronic hepatitis B patients should be screened for other blood borne virus infections such as hepatitis C, and HIV because of their common modes of transmission. Not all patients will require immediate antiviral medications, and these decisions are best left to the discretion of an experienced hepatologist.

Household contacts of cases should be screened for hepatitis B by doing a few blood tests (each should be screened for HBsAg - marker of chronic infection, HB core antibody - marker of resolved infection in the absence of HBsAg, and HB surface antibody - marker of immunity in non-exposed individuals if titre >10 miu/ml). Uninfected and non-immune individuals should be offered hepatitis B vaccine at an accelerated course (0, 1 month, 2 month, 12 months). It is important to remember that with modern technology (new diagnostic tests, new antiviral medications and new research knowledge) the outcome of chronic hepatitis B patients are much better and most patients will be able to lead a near normal life with proper treatment and follow-up. Although some of the antiviral drugs are costly, they are generally very well tolerated by patients with few side effects. The best way to tackle this common infection is to increase patient and care giver awareness, so that timely interventions (either in the form of diagnostic tests or antiviral medications) could be offered before it is too late. In advanced and complicated cases some patients might be eligible for a liver transplantation. I wish you all the best and your wife an uneventful recovery.