Definition

Hepatitis B is a liver infection caused by the hepatitis B virus (HBV). This disease can manifest as acute or chronic and may lead to death if not treated properly. According to the World Health Organization (WHO) in 2019, an estimated 296 million people worldwide were living with chronic hepatitis B infection, with 1.5 million new cases reported annually. In the same year, it was predicted that hepatitis B infections played a role in 820,000 deaths globally due to complications associated with this virus.

Causes

Hepatitis B is caused by the hepatitis B virus, a member of the Hepadnaviridae family. This virus can be transmitted through vertical means (from mother to child) or horizontally (exposure to infected blood). Vertical transmission typically occurs when an expectant mother becomes infected during pregnancy. On the other hand, horizontal transmission can result from needle wounds, tattoos, piercings, and exposure to infected blood, saliva, semen, vaginal fluids, or menstrual blood. Such exposure may also occur through the repeated use of needles, whether in healthcare facilities, communities, or for illicit drug use. Additionally, individuals with multiple sexual partners are at risk of exposure.

The hepatitis B virus replicates within liver cells and is subsequently released into the blood or other bodily fluids. The infection can occur acutely, resolving spontaneously over a short period, during which the body develops natural immunity to the hepatitis B virus. However, chronic infection is also possible, often remaining asymptomatic until the reactivation phase. This phase is characterized by a significant increase in the virus's genetic material, leading to renewed inflammation of the liver.

Notably, hepatitis B contracted before the age of 5 has a 95% risk of becoming chronic, while cases acquired during adulthood have a chronic risk of only 5%.

The virus can survive outside the body for up to 7 days. During this period, infection may occur if the virus enters an unvaccinated individual. Although symptoms may take 30 to 180 days to manifest after exposure, the virus can be detected within 30 to 60 days post-infection.

Risk factor

Hepatitis B poses varying risks to individuals associated with different factors. Those born in regions where the infection incidence surpasses 2%, such as Indonesia, face an increased risk. Failure to receive vaccination after birth, sharing needles while engaging in narcotic or illegal drug use, and male individuals involved in same-gender sexual relationships are also at higher risk. Additionally, the use of drugs that suppress the immune system, prevalent in autoimmune diseases where the immune system attacks the body, poses a risk. Other factors include receiving blood transfusions, being born to an infected mother, having end-stage renal disease, being HIV/AIDS infected, having hepatitis C infection, living with individuals who have hepatitis B, having multiple sexual partners, having a sexually transmitted disease, being a healthcare worker with higher exposure to bodily fluids or blood, residing in a rehabilitation facility, and being diabetic without vaccination against hepatitis B.

Symptoms

Typically, individuals who have recently been infected with hepatitis B may not exhibit any symptoms. In cases of acute infection, symptoms may include jaundice or the yellowing of the skin and sclera, tea-colored urine, fatigue, nausea, vomiting, and upper right abdominal pain. Acute infections can persist for several weeks and may either resolve on their own or progress to acute liver failure, a potentially fatal outcome. Chronic hepatitis B infections often remain asymptomatic until the reactivation phase, during which similar symptoms to those of acute infection may manifest.

Diagnosis

The diagnostic process for hepatitis B typically begins with a thorough inquiry into the patient's history and relevant risk factors. Following this, a physical examination is conducted to eliminate the possibility of other diseases, as symptoms such as yellowing of the skin can be indicative of various conditions. The doctor may assess the eyes and abdomen for additional clues.

If there is suspicion of hepatitis B, various laboratory tests are performed to assess the disease's progression, the quantity of the virus, and any associated liver damage. These tests are crucial for determining the appropriate therapy. The specific examinations include testing for the surface antigen of hepatitis B (HBsAg), the antigen to another surface of the virus (HBeAg), antibodies to the antigen (anti-HVE), and the genetic material of the virus DNA VHB. Additionally, liver enzyme tests are conducted to assess liver damage. The gold standard for evaluating damage is a biopsy or liver tissue extraction, which is examined under a microscope. Gamma-glutamyl transferase (GGT), alkaline phosphatase (ALP), bilirubin, and blood proteins like albumin and globulin may also be assessed to gauge the worsening of the liver's condition. 

Examinations related to other conditions such as hepatitis C and HIV/AIDS may be carried out to identify concurrent infections or underlying health issues that could complicate medical interventions.

Management

The general approach to managing hepatitis B aims to decrease the viral load, prevent further transmission through vaccination, and enhance the quality of life and safety for infected individuals. The doctor determines the management plan based on laboratory results, utilizing therapies such as interferon and antiviral drugs. Interferon, a protein produced by the body to combat viruses, bacteria, and other harmful agents, is administered through injections for a limited duration. On the other hand, antiviral drugs are taken regularly, often throughout the individual's life.

Once therapy is initiated, regular examinations are necessary for a specified period, typically around three months, to assess treatment response. The patient's adherence to drug consumption significantly influences therapy response, along with virus properties, including resistance to the drugs.

For individuals co-infected with hepatitis C, hepatitis D, or HIV/AIDS, drugs are prescribed to reduce the viral load. Fertile women with hepatitis B are advised to use contraception to prevent pregnancy, as there is a risk of transmission to the child. Pregnant individuals require antiviral drugs to prevent transmission, necessitating close monitoring and routine pregnancy examinations. After childbirth, breastfeeding is generally permitted.

In cases where the infected individual is undergoing cancer therapy, autoimmune therapy, or organ transplantation, hepatitis B examinations are conducted, and treatment is administered if deemed necessary. This comprehensive approach ensures tailored and effective management based on the specific circumstances of each patient.

Complications

The primary complication associated with hepatitis B is the development of liver cirrhosis, which can further progress to liver cancer or hepatocellular carcinoma. In cases where liver cirrhosis has been reached, treatment involves the administration of antiviral medications with close monitoring. Individuals with advanced liver disease may also be advised to consider liver transplantation, provided they meet the necessary criteria to be considered as candidates for the procedure. 

Prevention

The prevention of hepatitis B transmission is primarily achieved through vaccination. Immunization can be carried out actively by exposing parts of the virus to the immune system or passively by injecting immunity into the body. Vaccination applies to both children and adults. According to the immunization chart by the Indonesian Pediatric Society (Ikatan Dokter Anak Indonesia - IDAI) in 2020, newborns are recommended to receive hepatitis B immunization at birth, followed by doses at 2, 3, and 4 months, along with DTP (diphtheria-tetanus-pertussis) and HiB (Haemophilus influenzae type b) immunizations. In adults, hepatitis B vaccination is recommended for individuals with high exposure risks, mental health facility staff, hemodialysis patients, recipients of blood clotting factors, those living with or having sexual contact with infected individuals, men engaging in same-gender sexual activities or with multiple sexual relationships, healthcare workers, individuals using injection narcotics or illegal drugs, and children born to infected mothers. The vaccination schedule includes doses at the identification of risk factors, one month later, and then six months later.

Additionally, other measures to prevent the spread of hepatitis B include:

• Ensuring that individuals who live together or engage in sexual relationships have been vaccinated.
• Using condoms during sexual activity if the partner has not been vaccinated or has immunity problems.
• Avoid sharing toothbrushes or shaving kits.
• Avoid sharing needles.
• Avoid sharing the same glucose blood testing equipment.
• Promptly closing open wounds.
• Cleaning blood spills with a disinfectant.
• Avoiding blood, organ, or sperm donation.

It's important to note that infected individuals can still engage in normal activities, and discrimination against them is forbidden. Sharing food, utensils, and kissing are not means of transmission. Education and understanding are essential to foster a supportive environment.

When to see a doctor?

Obtain medical help without delay if you notice jaundice in an individual close to you. It's important to note that jaundice does not necessarily indicate hepatitis B but may be a symptom of various other conditions. Additionally, if you have risk factors listed for hepatitis B, consult with a doctor early on to prevent the progression of the disease into cirrhosis or liver cancer.

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