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Testing for Viral Hepatitis

This information and fact sheet outline the different types of viral hepatitis, the most common ways it is transmitted and the tests used to diagnose it. It also outlines treatments and vaccinations that are available.

Testing for viral hepatitis

What is viral hepatitis?

Inflammation of the liver is known as hepatitis. Sudden inflammation of the liver is known as acute hepatitis. If the liver remains inflamed for months or years, this is known as chronic (long-term) hepatitis.

A common cause of hepatitis is infection with a virus. There are five different hepatitis viruses, which are hepatitis A, B, C, D and E. Viral hepatitis is most commonly caused by hepatitis A, B, C, and E. Left untreated, some types of viral hepatitis can badly damage the liver, causing scarring. This scar tissue is known as cirrhosis, and over time it can stop the liver from working properly. In severe cases, life-threatening conditions such as liver failure (where the liver loses most, or all, of its functions) or liver cancer can occur.

It’s very important to get tested if you think you may have come into contact with the infection because there are highly effective treatments available that can help prevent further damage to the liver. Speak to your GP, who can physically examine you and arrange a blood test to investigate further.   

Hepatitis A (HAV) and E (HEV)

These can be picked up in a number of ways. Most people get them by eating food or drinking water which has been contaminated with infected faeces as a result of poor hygiene or inadequate cooking. Less commonly, they can be transmitted through cuts in the skin or mucous membranes - sharing razor blades, toothbrushes, or needles if injecting drugs are common risk factors. Hepatitis A can be also passed on by having unprotected sex with a person who already has the virus, usually between men who have sex with men. The hepatitis caused by HAV and HEV is usually mild, and doesn’t require treatment, although hepatitis E can occasionally be serious in those with a weakened immune system.  A vaccine is available to prevent hepatitis A - people with cirrhosis and those visiting developing countries should be vaccinated. There is not yet a commercially available vaccine for HEV. Find out more about hepatitis E here.

Hepatitis B (HBV)
This is the most common cause of viral hepatitis worldwide, due to either the infection being passed on from mother to baby at birth or becoming infected in early childhood. Sexual transmission and exposure to other body fluids are also common risk factors. In the UK, hepatitis B is   most commonly transmitted through blood and other bodily fluids – sharing needles to inject drugs or having unprotected sex with someone who already has the virus, for instance. It’s not spread through food or water or ‘casual’ contact, such as holding hands, coughing or sneezing. A vaccine is available to prevent it.

Hepatitis C (HCV)
This is passed on via contaminated blood. Common risk factors include sharing contaminated needles during intravenous drug use, sharing personal items contaminated with blood such as razors, or having unprotected sex with someone who already has the virus.  It can be transmitted from mother to baby during birth.  Previously people have been infected by blood products although these are now rigorously tested in the UK and are safe. Currently, there is no vaccine available but there are very effective treatments available for hepatitis C, so it’s important to get tested if you have ever been at risk.

Hepatitis D (HDV)
You can only get hepatitis D if you already have hepatitis B, as hepatitis D needs the hepatitis B virus to survive in the body. It is usually spread through blood-to-blood contact or sexual contact. It’s possible to become infected with both hepatitis B and D at the same time, or to become infected with hepatitis D at a later date. Having both hepatitis B and D is called co-infection, and chronic (long-term) infection with both increases the risk of developing serious liver diseases such as cirrhosis and liver cancer. If you have been diagnosed with hepatitis B you should be tested for hepatitis D with a separate blood test that looks specifically for anti-hepatitis D antibodies in your blood. If these are found, it means you have been exposed to the hepatitis D virus. There is no vaccine for hepatitis D but if you have been vaccinated against hepatitis B this also protects you from hepatitis D.

 

What are the symptoms of a viral hepatitis infection?

Common symptoms in the early stages of a viral hepatitis infection (also known as the ‘acute’ phase) include a high temperature, fatigue, mild abdominal pain, loss of appetite, jaundice (yellowing of the skin and eyes), nausea and vomiting. However, some people have no symptoms at all.  Patients with chronic (long term) HBV and HCV may not experience symptoms until their liver disease becomes severe, so it’s important to get tested if you think you might be at risk as there are highly effective treatments available

Testing for hepatitis: virology and antibodies

You’ll need to have a blood test, which can be taken by your GP or a nurse at your local clinic, or by hospital staff (a person who is specially trained to take blood is called a phlebotomist). It will then be sent to a laboratory to be tested.

Becoming familiar with some of the main terms used, and the meaning of key test results, will help you to understand more about your condition.

Understanding the importance of antibodies and antigens is a good place to start.

An antigen is a foreign or ‘invading’ toxin or substance that enters the body. Your body’s immune system defends against antigens by producing special proteins that bind to the invader to destroy them. These are antibodies, also known as immunoglobulins (Ig).

The production of antibodies against antigens is known as your ‘immune response’. Many of the following tests are used to measure your immune response to certain viruses – this will tell the doctor if you have been exposed to that virus in the past. Further tests will assess whether you still have the virus or whether your body has got rid of it.

In an acute infection your immune system produces a type of antibody called IgM. This means you have only recently been infected. If you have been infected in the past or have a chronic infection you will have a type of antibody called IgG.

Hepatitis A (HAV) antibody test

This test detects whether you have produced antibodies known as immunoglobulin M and immunoglobulin G against the hepatitis A virus (HAV).

Remember too that the test will also come back positive for IgG if you have had the hepatitis A vaccination. It is presumed that one infection with hepatitis A produces lasting immunity (protection) against further infection.

If you’ve been diagnosed with hepatitis A, you can find out more about the condition, how to manage it and how best to look after yourself by downloading our publication on hepatitis A

Hepatitis B (HBV) antibody and antigen tests

Most people who come into contact with hepatitis B (HBV) will ‘clear’ the virus during the first six months of their infection. During this phase, the condition is known as acute hepatitis B. People who do not clear the virus after six months will be diagnosed as having chronic (long-term) hepatitis B, which can cause liver damage.

Tests are carried out to look for antigens and antibodies in your blood. The results of these may indicate several possibilities:

  • you have been infected by the virus in the past
  • you have a new infection
  • the infection is likely to go away by itself
  • the infection has become chronic (long-term).

These antigens and antibodies are known as serological or viral ‘markers’. Doctors will look for markers in your blood over the course of your infection to see how the virus is progressing and/or responding to treatment. In particular, finding ‘surface’ and ‘e’ antigens known as HBsAg and HBeAg and their corresponding antibodies will help your healthcare team understand more about the pattern of your disease, and how it’s likely to progress.

Hepatitis B surface antigen (HBsAg)

This is a test to find out if you have a current infection. HBsAg is the earliest sign of the virus and disappears from your blood as the infection clears. A positive result indicates infection. If the antigen is not found (negative result), this shows that either you have never been exposed to hepatitis B or that you have recovered from infection and cleared the virus. The term ‘surface’ refers to the outer surface of the virus itself.

Antibodies to hepatitis B surface antigen

This is to detect the protective antibody in your blood that reveals whether you have had previous exposure to hepatitis B. The presence of the antibody anti-HBs (positive result) indicates that you are immune to hepatitis B due to vaccination or recovery from past infection, and are no longer infectious to others.

Hepatitis B envelope-antigen (HBeAg)

This test is used to confirm the presence of HBeAg, which only appears in the blood when the virus is present and is a sign that you are  actively making the virus (and therefore able to pass it on to others). What happens after this antigen is found will depend on how quickly your immune system produces antibodies called anti-HBe.

Antibodies to hepatitis B envelope-antigen (anti-HBe)

This is the test that looks for the anti-HBe antibody produced in response to the hepatitis B e antigen (although anti-HBe is also present in people recovering from acute hepatitis B infection).

In chronic hepatitis B, a positive result usually suggests that only low levels of the virus are likely to be present in your blood.

Anti-hepatitis B core antigen (anti-HBc)

The anti-hepatitis B core antigen is an antibody to the ‘core’ part of the hepatitis B virus, the hepatitis B core antigen. However, this antibody does not provide the protection usually associated with antibodies and is found in people with acute infection, in chronic carriers and in people who have cleared the infection. Doctors will use the results of other tests to interpret the presence of anti-HBc in your blood.

HBV DNA

This important test does not look for antigens or antibodies but monitors the amount of virus in your blood, known as your ‘viral load’. The higher your viral load, the more active your infection will be. Active virus replication, where the virus is making lots of copies of itself, is known as positive HBV DNA. Doctors will be looking for a very low amount or no trace of the virus as a marker of your response to antiviral medication.

Hepatitis B treatments are very effective and can completely suppress the virus in most cases although they don’t usually get rid of it completely. If you are on these medicines it is very important not to miss doses as you cause the virus to become resistant. Luckily they generally have very few side effects. They are also safe in pregnancy.

If you’ve been diagnosed with hepatitis B, you can find out more about the condition, how to manage it and how best to look after yourself by downloading our publication on hepatitis B

Hepatitis C (HCV)

As with hepatitis B, a number of tests will be carried out when you are suspected of having hepatitis C (HCV) or after the virus has been diagnosed. They will be used to follow its progression and to check on your response to treatment. There are now effective treatments available for hepatitis C so it’s important to get tested if you have ever been at risk. See the British Liver Trust website to find out more about hepatitis C and the risk factors associated with it.

HCV antibody test (anti-HCV)

An anti-HCV test looks for any trace of antibodies in your blood. If they are found, this shows that you have been exposed to the hepatitis C virus. This test is unable to reveal whether you have active viral infection.

HCV-RNA

An HCV-RNA test detects the hepatitis C virus in your blood and indicates whether this is an active infection. The presence of HCV viral RNA is a ‘positive’ result while its absence will be ‘negative’. This test may also be used as a follow-up to your treatment to see if you have cleared the virus from your body.

HCV viral load

This test measures the number of viral RNA particles in your blood. Doctors will usually perform these tests over the course of your treatment. Measuring your viral load before and after treatment will show how effectively (or not) the treatment is working.

Viral genotyping

Viral genotyping is carried out to identify the types of hepatitis C virus. There are six major types, known as ‘genotypes’. The most common in the UK is genotype 1.

Treatments are slightly different for different genotypes, and vary between 8 and 16 weeks depending on things like your viral load, whether you have cirrhosis or not and if you have been treated before.

The modern treatments for HCV are very effective with few side effects. Most people treated go on to be permanently cured of the virus.

If you’ve been diagnosed with hepatitis C, you can find out more about the condition, how to manage it and how best to look after yourself by downloading our publication on hepatitis C

Sensitivities around testing for viral hepatitis

Public knowledge about hepatitis is slowly improving but there is still widespread ignorance about who gets hepatitis and how it’s passed on. You may want to discuss your concerns with a health professional or counsellor who is trained to help you cope with a diagnosis of hepatitis and any social difficulties that may come with it, such as:

Insurance and mortgages
Most insurance companies will ask applicants if they have been tested for HIV, hepatitis B and hepatitis C. A positive test result may mean a life insurance policy or a mortgage linked to a life policy could be refused or the premium raised. If this happens, it is worth talking to your doctor as many consultants are willing to write to a mortgage or insurance company stating your health and life expectancy.

Who to tell
This is often a difficult decision but you should consider that a positive result may affect your family and sexual partner(s) and whether these people should also think about testing. If you are HBsAg positive, your partner will need vaccinating if they are negative. Vaccination will completely protect them. With a new partner it is important to use barrier contraceptives (condoms) until they have been vaccinated.

Confidentiality
You may want only certain people to know about your test and results. GUM (genito-urinary medicine) clinics offer a confidential testing service, although in the case of a positive result your GP will become involved when you are referred for ongoing care. Any doctor who diagnoses acute viral hepatitis is legally required to report this information to Public Health England to help reduce the spread of infection.

It’s vitally important to get tested if you think you might be at risk. There are highly effective treatments available that can help to manage symptoms and prevent you developing serious liver disease, so don’t put it off – see your doctor today.

Special thanks to:

Mark Wright, consultant hepatologist at University Hospital Southampton

Emily Lam, lay reviewer.

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