Hepatitis: Causes, Risk factors, Types, burdens on pregnancy, infants and children; treatment and Preventive measures.

Hepatitis is a medical condition described as inflammatory status of the liver cells which can result to damages that disrupt liver functions, creating severe health problems throughout the body. In simple terms, hepatitis implies injury to the liver structure, characterized by presence of swollen cells that alter the liver’s performance of hundreds of tasks that are essential for quality health and life. At less than six months or longer, hepatitis is considered acute or chronic respectively.
Generally, there may be limited or no signs and symptoms during the attack of hepatitis. We must be mindful that certain forms of hepatitis can be symptomless and fatal. Hepatitis has different types and causes, with related signs and symptoms. There are several strains of viral hepatitis including hepatitis D, E, F and G which mostly share similar signs and symptoms; and may or may not exist without the most common types of hepatitis. The most common types which can be very fatal, requiring more focus are hepatitis A, B and C. Other types of hepatitis can occur due to excessive consumption of alcohol, autoimmune dysfunction and toxic substances like certain drugs or medications.
Globally, there are more than 600 million cases of hepatitis causing above 1 million deaths annually among different races, ages, genders and economic status in developing and developed nations. There is evidence of hepatitis infection in animals which serve as reservoir for human infection.
Hepatitis A, B, C, D and E are of greatest public health concern because of the burden of huge economic cost, illness and death they cause; added to their potential for outbreaks and epidemic spread. Generally, hepatitis attacks account for significant ratio of healthcare expenditures in both developing and developed nations, with potential for rise in several developing economies.
Often, several people are unaware that they have hepatitis. In the absence of other infections or super infections and pregnancy, most patients infected with hepatitis A or B recover fully without complications. Hepatitis C can progress to chronic stage, leading to cirrhosis. Hepatitis D and E can result to the dreaded complication of hepatitis-induced fulminant liver failure especially in vulnerable populations like pregnant women and infants.
There are various available and effective treatment options depending on which type of hepatitis the attacked suffers. Some forms of hepatitis can be prevented through immunizations, lifestyle modifications or precautions. Hepatitis can be self-limiting (healing without treatment) or can progress to scarring of liver cells (fibrosis) and cirrhosis or liver cancer needing liver transplant. Early consultation with medical experts is essential for prompt intervention of hepatitis challenges.
Types and modes of transmission of hepatitis
There are several types of hepatitis with various characteristics and modes of transmission. The three main types caused by different viruses are referred to as hepatitis A, B and C. The A type can be acute; lasting for not more than six months while types B and C can be chronic, lasting for above six months. The two other identified unique viral hepatitis are D and E. Generally, hepatitis A and E are typically transmitted through oral contact with contaminated food or water. Hepatitis B, C and D are usually common among people who expose themselves to infected body fluids. We want to examine the characteristics of these viral hepatitis along with other non-viral types.
Hepatitis A Virus (HAV) can expose people to cases of mild, severe and life threatening liver infections especially in the areas of the world with low socioeconomic status where inadequate sanitation and large concentration of populations are accommodated. HAV can cause outbreaks and epidemics, spreading through infected food, water or direct close contact with infected persons especially children aged 5–14 years. Here most people recover fully and remain immune to future hepatitis A virus infection for life. Most people infected with this virus normally get free within two months without any long-term untoward effects. Therefore, it is regarded as an acute and short-term disease among other types of hepatitis.
Hepatitis B Virus (HBV) is a major cause of global health challenge among millions of adults and children at varying rates. Most adults infected with the HBV recover within 90 days and achieve lifelong immunity. Infected body fluids such as blood, vaginal secretions or semen are most common ports for HBV. Sharing of contaminated needles and having unprotected sex with HBV infected person increases the risk. Direct transmission may occur through transfusions of HBV-contaminated blood or blood products and contaminated injection procedures. There is high level of risk to healthcare workers who may be careless over accidental needle stick injuries while caring for infected-HBV patients and travelers to nations or areas where the infection is most common. Also HBV can be transferred to an infant during birth or from family members in early childhood. High percentage of infected infants will get into chronic infection and severe health problems, such as liver cancer and cirrhosis which may lead to death.
At room temperature, HBV can survive for about seven days outside the body. Hepatitis B can be acute and self-resolving or it can be chronic, leading to end-state liver diseases – cirrhosis and liver cancer. Immunization can stop initial infection. Presently, there is no cure for HBV but antiviral drugs can treat chronic cases.
Hepatitis C Virus (HCV) is one source of viral liver infections that may occur as acute or chronic, and it is contagious. Hepatitis C is mostly percutaneous (under the skin) infection. It is commonly transmitted through contact with infected blood or blood products primarily by sharing of needles or equipment for drugs especially narcotics that can be injected, and rarely sexual contact. Needle-stick injuries, essentially due to poor/lack of conscious infection control in healthcare facilities can promote exposure. It is reported that cleaning contaminated needles and syringes with alcohol, rinsing them with soap and water; and even air-drying them for several days will not kill the virus.
Most people can live with HCV without realizing that they have it. HCV is a lifelong infection in more than 80% of people because it has no vaccine presently. Therefore, it is very necessary for people to avoid any contact that will likely exposure them to hepatitis C virus infection. Today, it can clear from the system even without treatment. It simply means that if the virus does not disappear from the body within six months, the infection becomes chronic with close to billion copies of the virus inside the body cells; and it is only curable through the use of drugs.
Hepatitis D Virus (HDV) infection is a severe liver disease which is possible only in those who are infected with HBV through direct contact with infected blood. Reports show that hepatitis D is a rare form of viral hepatitis that only infects and multiplies in the presence of hepatitis B virus infection. The co-infection of HDV and HBV can be very serious and fatal. Hepatitis B vaccines can provide protection against HDV infection.
Hepatitis E Virus (HEV) is mostly transmitted through the oral consumption of contaminated water or food. HEV is a common cause of hepatitis outbreaks in developing parts of the world and is increasingly recognized as an important cause of hepatitis disease in developed countries especially in pregnant women. Though safe and effective vaccines against HEV infection are developed but they are scarce for now.
Alcoholic hepatitis
Alcoholic hepatitis can cause fast rate of mortality within a month due to the presence of cirrhosis and hepatocellular carcinoma. Men are more prone to this type of hepatitis but women who are alcoholics with high body fat are at higher risk of developing alcoholic hepatitis with its complications. Other contributing factors to this type of hepatitis in different populations are obesity, hepatitis C co-infection and poor nutritional status.
Causes of hepatitis
The major causes of hepatitis can be categorized into the following: infection, metabolic, ischemic, idiopathic and autoimmune.
Infection: The infectious pathogens are mostly viruses and bacteria. Globally, the familiar causes of major hepatitis especially in developing countries are viruses. Five different viruses cause hepatitis A, B, C, D and E. Hepatitis A and E are related, being self-limiting illnesses that do not lead to chronic hepatitis. Both are transmitted through the oral-fecal channel. Hepatitis B, C and D are mainly transmitted through various direct contacts with blood, mucus membrane, semen or other body fluids of infected person(s). Hepatitis D which is usually chronic; causes fulminant hepatitis and cannot be in the absence of hepatitis B.
Bacterial infection of the liver mostly causes liver abscesses, acute hepatitis or chronic liver disease. The pathogens usually involved are different species of enteric bacteria.
Metabolic: The metabolic causes include toxins, drugs, alcohol and non-alcoholic fatty liver disease. Generally, varieties of chemicals including certain medications, industrial toxins, herbal and dietary supplements can cause toxic and drug-induced acute or chronic hepatitis. The toxins and drugs can cause liver injury or failure, direct cell damage; and alterations of cell structure and metabolism.
Toxic causes of hepatitis include overuse or overdose of medications and exposure to poisons. Accidental or intentional exposure through ingestion, inhalation and skin absorption of industrial toxins such as carbon tetrachloride can cause hepatitis. Also the consumption of wild toxic mushroom-amanita phalloides-can cause hepatitis.
The drugs which easily expose people to liver injury or hepatitis includes analgesics such as paracetamol (mainly); antibiotics such as nitrofurantoin, trimethoprim-sulfamethoxazole, isoniazid, erythromycin and amoxicillin-clavulanate; anticonvulsants such as phenytoin and valproate; cholesterol-lowering statins; steroids such as oral contraceptives and anabolic steroids. Highly active anti-retroviral drugs, herbal remedies and dietary supplements are possible agents of hepatitis.
Excessive alcohol intake is directly responsible for significant causes of hepatitis and cirrhosis globally. Alcoholic hepatitis account for a wide range of severe cases of cirrhosis, liver cancer, permanent damage or liver failure which usually develop after years of constant exposure to alcohol. Several years of alcohol consumption in excess of 80 grams a day in men and 40 grams a day in women (1 beer or 4 ounces of wine is equivalent to 12 grams of alcohol) often results to alcoholic hepatitis.
Non-alcoholic liver disease is common in some people with little or no history of alcohol use. This liver disease is mainly associated with many factors including obesity, diabetes, metabolic syndrome, hypertriglyceridemia and insulin resistance.
Ischemic: Ischemic hepatitis occurs due to the low blood flow to the liver during the attack of vascular insufficiency, shock, sepsis or heart failure. This type of hepatitis hardly causes permanent liver damage because the condition often resolves if any of the above underlying causative factors is promptly and successfully treated.
Idiopathic: Neonatal hepatitis is attributable to a variety of undefined causes typically from mother to child or perinatal infections from hepatitis viruses and syphilis.
Autoimmune: Autoimmune causes of hepatitis involve genetic predispositions that are characteristic of certain populations. Human parasites such as protozoa, certain worms and plasmodium can cause liver inflammation and activation of the immune response, resulting in signs and symptoms of hepatitis. Autoimmune hepatitis is a chronic disease following abnormal immune response against the liver cells. This type of hepatitis can be asymptomatic, acute or chronic and can cause fulminant liver failure. The factors in favour of the disease here, are believed to be genetically modulated. It can also be triggered by viruses, liver transplant and drugs such as nitrofurantoin, methyldopa and hydralazine. Autoimmune hepatitis usually affects male and female of different age groups presenting classic signs and symptoms of autoimmunity such as fatigue, anemia, nephritis, amenorrhea, ulcerative colitis, arthritis, maculopapular rash, anorexia, pleurisy, acne and thyroiditis. The occurrence of autoimmune hepatitis is about thrice in women than in men.
Signs and symptoms of hepatitis
Generally, hepatitis can exhibit mild/severe or no signs and symptoms. Obvious signs and symptoms mostly appear and persist from about 2 weeks to 6 months after infection. The signs and symptoms occur within two phases.
The initial phase of hepatitis is known as the acute (less than 6 months) within which liver failure and death can occur. Here patients show signs and symptoms which are non-specific and related to mild flu. The common manifestations are diarrhea, regular episodes of abdominal pain, unexplained weight loss, persistent fatigue, muscle or joint aches, dark-coloured urine, enlarged organs including liver and spleen, headaches, bone marrow depression, pale stools, elevated white blood cells, jaundice (yellow skin, white eyes and tongue), loss of appetite, nausea, mild fever and vomiting.
The chronic phase (more than 6 months) presents signs and symptoms similar to acute, in addition to signs and symptoms specific to liver dysfunction with long-standing inflammation and damage to the organ. Patients can experience severe and progressive liver scarring, failure (cirrhosis) and cancers; ascites (abdominal fluid), swelling of the lower extremities, hives, blood in the feces or vomit and confusion. Other associated signs and symptoms are acne, amenorrhea (lack of menstrual period) in women and hirsutism (abnormal hair growth).
Complications of hepatitis
Some of these major complications are generally associated with hepatitis. They include:
• Fulminant hepatitis/massive hepatic cell death which shows complex results of sepsis, gastric bleeding, cerebral edema and failure of kidney and respiratory cells
• Liver scarring, failure, cancer and death
• Ascites (abdominal fluid)
• Bleeding disorders
• Portal vein hypertension
• Liver encephalopathy leading to memory loss, severe fatigue and reduced mental acuity.
Modifiable risk factors of hepatitis
There is need to be mindful of these controllable aggravators/promoters of hepatitis globally. They include:
 Unhealthy lifestyle
 Excessive body weight
 Smoking
 Lack of appropriate physical activity
 Unhealthy diet
 Excessive alcohol consumption
The population most vulnerable to hepatitis infection
The highest rates of hepatitis infections are observed among:
• Men who have sex with men
• People (including health workers) prone to occupational exposures
• People with blood clotting disorders
• People with history of bite by infected human, chronic liver disorder and multiple transfusions
• People who receive tribal marks, tattoo and circumcision with razor and other unsterile sharp objects
• Unprotected active or multiple sexual partners
• Patients on cancer chemotherapy
• Travelers to/from hepatitis endemic areas
• All women during pregnancy
• Intravenous/injection drug users/abusers
• Organ transplant and dialysis patients
• Neonates and infants exposed to infected maternal blood and vaginal secretions during birth and breastfeeding
• People training or having sex with infected animals
• People living with HIV
• People who are not vaccinated or previously hepatitis infected
• People with history of long-term daily alcohol consumption and unexplained liver disease
• People who engage in self-medication with certain drugs and supplements
Diagnosis and treatment of hepatitis
Hepatitis can be diagnosed through medical history, physical examination for such as abdominal pain or tenderness or skin/eye yellowing, laboratory tests and procedures to determine hepatitis types. Diagnosis of hepatitis is made on the basis of some or all of the following which are patient’s observed signs and symptoms, medical history including sexual and substance use history, blood tests, liver biopsy and imaging.
Essentially, treatment options for hepatitis will depend on age of patient and diagnosis which defines the patient’s health status (obese, alcoholic, smoker and/or diabetic), severity/type of disease (acute versus chronic) and cause. The goals of the treatment are to break transmission, reduce viral replication and stop multiplication of cancerous cells in the body. Since liver cancer can be fatal within few months, an infected person requires ongoing medical evaluation and monitoring of the liver for damage or worsening of the disease with ultrasound every 6 months.
Some types and cases of hepatitis can heal without intervention, but some can progress to scarring of the liver or cirrhosis, requiring expert medical treatment in accordance with the World Health Organization (WHO) recommendation. Presently, there is want of effective treatment for hepatitis D. Aggressive supportive therapy and hospitalization for appropriate medical interventions are necessary, especially in severe cases or pregnancy. Generally, it is essential to adequately replenish nutrients and fluids to avoid dehydration; take sufficient rest to check sudden exhaustion. Other treatments include psychotherapy and psychosocial evaluation.
Someone who is unvaccinated should be vaccinated within 14days of exposure to hepatitis pathogen. In addition to the administration of appropriate drugs by medical experts, hepatitis patients need active weight control measure, early morning intake of high-calorie diet; and complete abstinence from cigarette smoking and alcohol consumption.
Prevention of hepatitis
Hepatitis infection or re-infection can be dangerous and difficult to treat. Therefore, the public are advised to take side with relevant preventive measures against possible infection.
The goals of preventing hepatitis infections are to reduce to zero level, hospital visits and admissions which can result to huge medical expenses especially on neonates, pregnant women, children and adolescents. Also there is need to check timely, the bad consequences of liver problems.
Many hepatitis types are preventable with appropriate and effective vaccination/immunization typically completed within the first six months of childhood. A series of two vaccinations (protective and booster doses) are also available for adults including all healthcare providers and travelers. Vaccination protection lasts for at least 20 years but it is usually lifelong.
There is urgent need for screening of all pregnant women for hepatitis virus at their first prenatal visit for early medical interventions if needed. Also early and routine medical screening is essential for all. There is dire need for sustained improvements in food and water hygiene, public health policies, awareness creation/education and supply of effective vaccines in health facilities to reduce global cases of hepatitis. Since hepatitis virus can survive inside fingertips for about four hours, we must wash our hands with soap after using the restroom, changing diapers and before preparing or eating food.
Our house surfaces should be cleaned with household bleach or disinfectants. There is need to avoid contaminated water, food, raw fruits, vegetables and shellfish. Endeavour to drink only commercially bottled or boiled water and eat properly cooked fresh and hot foods. People should avoid unprotected practices especially during wastes disposal, medical emergencies and abusive sexual intercourse. Contaminated toothbrush, razor, blood, devices, needles, acupuncture or other skin perforators should not be shared. Since certain supplements and medications do affect liver status and functions negatively, it is safer to use any under expert medical supervision.

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