Hepatitis A, B & C

Reporting viral hepatitis

To leave a voicemail, call the reporting line: 360-778-6150.
Send copies of clinical notes, case report forms, or labs to 360-778-6103.

For hepatitis C, fill out the reporting form:
HCV Reporting Form

Reporting requirements

Within 24 hours—acute hepatitis A, B or E.
Within 3 days—hepatitis C (acute), hepatitis D (acute or chronic) and pregnant women who test positive for hepatitis B surface antigen.
Monthly—newly diagnosed chronic hepatitis B or C.

HAV guidelinesHBV guidelinesHCV guidelines

Transmission risk

Hepatitis A can lead to large-scale outbreaks. Its fecal-oral or contaminated water/food transmission route, extended incubation period, and robust ability to withstand degradation in the environment contribute to its ability to trigger large and long-lasting outbreaks. It is critical to promptly investigate suspected hepatitis A infections to aide in public health interventions.

Work or childcare exclusions

School-aged children with hepatitis A should not return to school until their diarrhea has ceased.

Food handlers, healthcare workers, and childcare workers or attendees should not return to that setting until they are no longer considered infectious. The infectious period ends when diarrhea has resolved and at least 7 days have passed since the onset of jaundice.

Hepatitis A vaccine as prevention

The prevalence of people experiencing HAV infections has decreased over time in the United States due to regular scheduled HAV vaccinations for children. However, there are many other populations who would benefit from HAV vaccination. These include:

  • All persons diagnosed with HIV infections for a year or more
  • Persons who have penises and have sex with other persons with penises
  • Persons who use recreational or illegal drugs
  • Persons experiencing unstable housing or homelessness
  • Persons with chronic liver disease, including but not limited to hepatitis B/C infections, cirrhosis, and more
  • Pregnant persons with identified risk factors such as international travel, recreational drug use, or unstable housing
  • Persons who utilize service settings that focus on populations with a high proportion of risk factors, such as group homes, shelters for those without stable housing, and medical facilities that serve these populations
  • Eligible persons who are traveling to areas with intermediate or high prevalence of HAV
  • Members of a household with a newly adopted child from a country where HAV is common

Testing and diagnosis

It is important to consider all potential causes of acute hepatitis when evaluating someone with symptoms that could be hepatitis A. The most common confirmatory lab is a positive HAV IgM indicative of an antibody response to an acute infection. This should be paired with a congruent clinical presentation, including observed jaundice, elevated bilirubin, or elevated ALT >200 IU/L.

False positive HAV IgM can occur, especially with older individuals who are asymptomatic.

Treatment

There is no treatment specific to HAV infection. Treatment should be supportive based on the individual’s medical needs.

Transmission risk

Hepatitis B virus (HBV) is a blood-borne pathogen. It can be spread through contact with blood, especially shared drug paraphernalia, sexual fluids, and birth. It is completely unrelated to the viruses that cause other forms of hepatitis including hepatitis A, C, D, and E. Someone experiencing an acute hepatitis B infection can be infectious before symptom onset and until the infection is resolved. Unfortunately, many people never experience symptoms of acute hepatitis and the original infection may go unnoticed. Approximately 5-10% of these individuals will go on to develop a lifelong, chronic HBV infection.

Perinatal transmission risk

Perinatal HBV transmission is also a significant risk, and as many as 90% of acute perinatal HBV infections go on to become lifelong, chronic infections. This is why perinatal interventions are so important.

Hepatitis B vaccine as prevention

Infants:

Infants should get their first dose of HBV vaccine at birth, aiming to complete the series at 6-18 months of age. The birth dose of HBV vaccine is an important part of preventing long-term illness in infants and stopping the spread of HBV in the United States.

Children and adolescents:

All children and adolescents younger than 19 years of age who have not yet gotten the vaccine should be vaccinated.

Adults (recommendations updated in 2022):

Hepatitis B vaccine is now recommended for all adults aged 19-59 years regardless of risk factors, and anyone 60 years or older with risk factors. Hepatitis B vaccine may also be offered to all adults 60 years and older who wish to be vaccinated.

See the updated CDC Recommended Adult Immunization Schedule for ages 19 and older.

Risk factors:

  • People whose intimate partners have hepatitis B (either acute or chronic infections)
  • Sexually active persons who are not in a long-term, monogamous relationship
  • People seeing evaluation or treatment for a sexually transmitted disease
  • Victims of sexual assault or abuse
  • People with penises who have sexual contact with other people with penises
  • People who share needles, syringes, or other drug-injection equipment
  • People who live with someone infected with hepatitis B
  • Health care and public safety workers at risk for exposure to blood or body fluids
  • Residents and staff of facilities for developmentally disabled people
  • People living in jail or prison
  • Travelers to regions with increased rates of hepatitis B
  • People living with chronic liver disease, kidney disease on dialysis, HIV infection, infection with hepatitis C, or diabetes

This information was retrieved from the CDC Vaccine Information Statements page on Hepatitis B

Diagnosing Hepatitis B

Acute infection:

The most important serological marker to differentiate between an acute and chronic HBV infection is Hepatitis B core IgM antibody (anti-HBc IgM). If this lab is positive and other serological markers or viral markers are positive, especially paired with acute symptoms of hepatitis, the person is likely experiencing an acute HBV infection.

Chronic infection:

In order to have the most thorough understanding of the stage of infection when chronic infection is suspected, consider all of the following labs:

  • Hepatitis B surface antigen (HBsAg)
    • Would be positive in an acute or chronic infection
  • Total HB core antibodies (Total anti-HBc)
  • HB core IgM antibodies (IgM anti-HBc)
    • Would be positive in an acute infection, negative all other times
  • Antibodies to HB surface antigen (Anti-HBs)
    • Would be positive after recovering from a past infection or from vaccination
    • A sign of immunity
  • HBV DNA (either qualitative or quantitative)
    • A negative HBV DNA does not help rule out infection, as some people can be “low-level” carriers with viral loads less than the minimum detectable range

If you need help interpreting hepatitis B labs to determine the infection stage of your patient, please call 360-778-6100 or email CommunicableDisease@whatcomcounty.us. Our hepatitis team works Mon-Fri and would be happy to assist you.

 

Transmission risk

Hepatitis C is a blood-borne pathogen and can be transmitted through blood- most commonly through shared drug equipment, sexual fluids contaminated with blood, and birth. It is less likely to be transmitted through sex than hepatitis B but precautions with intimate partners should still be taken. People who received blood products or transplants prior to 1992 should be screened for hepatitis C as the United States did not routinely screen blood products or transplant donors prior to 1992.

Most people who have a hepatitis C infection never develop symptoms. Only about 20-30% of people who are infected with hepatitis C will have acute symptoms of hepatitis. People can go many years without knowing they have this infection, which is why routine screening based on risk factors is highly encouraged and harm reduction skills are critical.

Harm reduction as prevention

There is no vaccine currently available to prevent infection with hepatitis C, which is why harm reduction and addressing individual risk factors is so important. Some harm reduction topics include:

  • For those who inject drugs, connect them with syringe exchange programs to help them access enough supplies that they will not need to share supplies with others (click here for Whatcom County’s Syringe Services Program)
  • For those living with someone who is infected with hepatitis C, counsel on ways to prevent transmission within the home – don’t share razors, toothbrushes, nail clippers, or glucose monitoring supplies
  • For those who are sexually intimate with someone who is infected with hepatitis C, counsel on barrier protection during sex to avoid transmission (especially for vaginal or anal intercourse)

Treatment

Treatment for hepatitis C is now much more effective and accessible with multiple antiviral pills available to prescribe. If you are a primary care provider, consider expanding your practice to treat people infected with hepatitis C. One of the main barriers to treatment now is accessing a provider who is willing to treat hepatitis C. Often, people are referred to a specialist and it may take several months and several appointments before treatment is initiated. The more we can incorporate hepatitis C treatment into the primary care model, the more people will be able to access treatment easily.

If you have a client who is interested in hepatitis C treatment but does not have a primary care provider and/or health insurance, you can reach out to us at CommunicableDisease@whatcomcounty.us for assistance.

Resources for providers:

HCV Guidance: Recommendations for Testing, Managing, and Treating Hepatitis C (American Association for the Study of Liver Diseases and Infectious Diseases Society of America)

UW Viral Hepatitis Project ECHO (2021-2022 flyer; a weekly video conference call providing mentorship for clinicians in treatment of hepatitis B and hepatitis C)

Testing

While antibody testing is fast and convenient for hepatitis C, there should be a plan in place for further testing if the antibody test is positive. Most importantly, clinicians and public health need to know whether or not the hepatitis C RNA viral load is positive or negative before recommending treatment. Most labs offer an automatic “reflex to RNA” option when antibody testing is positive. If your facility is unable to do viral load testing, then you should refer anyone with a positive hepatitis C antibody to another provider who can do viral load testing.

Hepatitis C

Resources and Links

Hepatitis Elimination

Washington State Department of Health

State and National Hepatitis Organizations

  • Hepatitis Education Project —provides educational materials and support for patients with hepatitis.
  • Hepatitis C Online – addresses diagnosis, monitoring and management of hepatitis C virus infection.
  • Hepatitis Network for Education and Testing (HepNET) – a CDC corporative agreement between NASTAD (National Alliance of State and Territorial AIDS Directors), NVHR (National Viral Hepatitis Roundtable), and NACCHO (National Association of County and City Health Officials) focused on improving the health of people who inject drugs (formed in 2022).

Vulnerable Populations

Viral Hepatitis in Specific Settings

Professional Articles