Is it okay to not treat hepatitis B if there are no symptoms? The answer may be different from what you think →

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Hepatitis B is an infectious disease caused by infection with the hepatitis B virus (HBV). There are about 70 million hepatitis B virus carriers in my country, and about 300,000 people die from hepatitis B each year.

Many people think they are far away from the hepatitis B virus and that healthy people do not need to be tested for hepatitis B. Some hepatitis B patients also think they have no symptoms and do not need to pay attention to the development of liver disease.

So how should we deal with hepatitis B? Should we get tested for hepatitis B? What should we do if we have liver disease?

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Hepatitis B screening is important!

At the end of 2009, my country's Ministry of Health removed the "two-and-a-half" hepatitis B test from routine physical examination forms (including school enrollment, kindergarten enrollment, employment, health certificate application, etc., except for special industries such as catering, medical care, and beauty), which greatly improved the situation of "hepatitis B discrimination" in society. In 2020, the hepatitis B virus infection rate among children under 5 years old in my country dropped to below 1%, and China no longer had the title of a major hepatitis B country.

It cannot be ignored that the number of hepatitis B infections in China accounts for 1/3 of the world's total, with about 70 million carriers, and about 300,000 people die each year from hepatitis B. Prevention and treatment of hepatitis B is still an important task in China's health industry: in addition to full coverage of hepatitis B vaccination, necessary screening should also be carried out to ensure early detection and early treatment.

Hepatitis B virus (HBV) belongs to the Hepadnaviridae family. It is an enveloped virus with a partially single-stranded and partially double-stranded covalently closed circular DNA genome, and its replication cycle has a reverse transcription process.

HBV is mainly transmitted through blood or body fluids and can cause acute infection, but its main way of causing harm is by causing chronic infection.

In areas with a high incidence of hepatitis B, the most common route of infection is perinatal infection or contact with other people's blood during childhood. This type of infection leads to chronic hepatitis in approximately 95% of cases .

In adults, hepatitis B is mainly transmitted through intravenous drug use and high-risk sexual behavior. Irregular medical care or beauty procedures that cause skin damage can also cause HBV transmission , such as tattoos and acupuncture. The probability of adults developing chronic hepatitis after being infected with HBV is less than 5%.

In addition to the need for hepatitis B testing in specific occupations or during prenatal examinations for pregnant women, screening is also recommended for people in the following situations:

▶ Family members are infected, especially parents infected with hepatitis B;

▶ People who have the above-mentioned high-risk behaviors for hepatitis B transmission;

▶ Those with unexplained abnormal liver function;

If you are not sure about the effectiveness of your previous vaccination, you can also test the hepatitis B two-pair-and-a-half index and determine whether you need to be injected with hepatitis B vaccine for immune booster based on the hepatitis B virus surface antibody (HBsAb) index.

Figure: HBV virus structure, hepatitis B detection indicators and biological and clinical significance

If hepatitis B has no symptoms, do we just ignore it?

The liver is an organ that "works silently" and plays an extremely important role in digestion and metabolism. However, mild or early liver disease often has no symptoms. Even the distress signals sent by a scarred liver can easily be ignored : fatigue, jaundice, abdominal and foot swelling, bruises and abnormal coagulation.

One of the main causes of liver damage is viral hepatitis . Chronic viral hepatitis with a long disease progression period is easy to be ignored. When it is finally discovered, it has already caused irreversible consequences. Therefore, it is very necessary to conduct regular liver function tests to detect liver abnormalities in time and identify the cause to control it .

Chronic infection is dangerous because HBV can cause progressive chronic viral hepatitis . Chronic hepatitis refers to a persistent, progressive hepatitis state that cannot heal itself for more than 6 months . In essence, the virus continues to exist and replicate, and the liver is always in a state of chronic inflammation.

Chronic hepatitis can cause liver cell damage and progressive fibrosis , eventually replacing liver tissue with scar tissue, leaving the liver permanently damaged and unable to function, leading to cirrhosis of the liver . Repeated stimulation of inflammation can eventually lead to hepatocellular carcinoma .

Figure: Chronic viral hepatitis caused by hepatitis B can develop into fatal cirrhosis or liver cancer, while simultaneous infection with hepatitis D can accelerate the progression of the disease.

Even if you are infected with HBV, but the condition is not serious or is under control after treatment, can you be careless?

HBV infection can cause a specific immune response in the body, which can eliminate the virus and reduce the viral content to a certain extent. However, HBV can also integrate into the liver cell genome and become a low-expression but more stable HBV viral precursor DNA! HBV integrated into the genome can persist in the body and avoid elimination by the immune system. When immunity is low or stimulated by alcohol or drugs, this inactive integrated HBV can enter an active replication state again, causing the condition to suddenly worsen .

In addition, integrated HBV DNA is also an important driver of hepatocellular carcinoma and can further promote the occurrence of cancer .

Therefore, even if no active HBV replication is found during physical examinations, or if the hepatitis B carrier has successfully suppressed the viral replication level after treatment, regular check-ups are still required to monitor the condition.

Antiviral therapy is the key to treating hepatitis B

The purpose of hepatitis B treatment is to inhibit HBV replication, reduce the level of liver inflammation, slow down the progression of liver fibrosis and cirrhosis, and prevent the occurrence of liver cancer.

Patients who meet the indications for antiviral treatment should start anti-HBV treatment in a timely manner . Interferon or oral antiviral drugs (such as entecavir, tenofovir, tenofovir alafenamide, etc.) are generally used for antiviral treatment in clinic.

Although it is difficult to completely eliminate HBV through treatment, most hepatitis B patients can achieve the same quality of life and life expectancy as normal people through early and effective treatment.

Doctors will comprehensively assess the patient's risk of disease progression based on serum HBV DNA, ALT levels and the severity of liver disease, as well as factors such as age, family history and concomitant diseases, and decide whether to initiate antiviral treatment .

The "Guidelines for the Prevention and Treatment of Chronic Hepatitis B in China" (2022 edition) has once again updated and expanded the indications for antiviral treatment for chronic hepatitis B. More and more people infected with hepatitis B virus need to start antiviral treatment as early as possible. Even people infected with hepatitis B virus who do not need antiviral treatment temporarily need to be re-examined every 6 to 12 months .

Figure: Flowchart for judging hepatitis B testing, monitoring, and treatment. Adapted from Chinese Journal of Infectious Diseases, Guidelines for the Prevention and Treatment of Chronic Hepatitis B (2022 Edition). This flowchart does not discuss obvious hepatitis symptoms, cirrhosis, liver cancer, chemotherapy, immunosuppressive therapy, etc.

Five questions about hepatitis B

Q: If you have hepatitis B, do you have to go to the hospital regularly? Do you have to take medicine or receive treatment?

Answer: You should go to the hospital for regular check-ups, but whether to take medicine and treatment should depend on your condition.

Q: How does the hepatitis B virus damage the liver?

Answer: The main harm caused by hepatitis B virus infection is chronic viral hepatitis. Both viral replication and the body's immune system in the process of clearing the virus will cause liver cell damage.

Q: Pathologically, how does hepatitis B develop?

Answer: Hepatitis B virus infection leads to chronic liver inflammation and necrosis, which in turn causes liver fibrosis and cirrhosis, and in some patients, can lead to liver cancer.

Q: What is the mechanism of antiviral drugs?

A: There are two major categories of anti-HBV drugs: one is to eliminate HBV by stimulating the body's immune system, such as interferon. The other is to specifically terminate certain stages of HBV replication to achieve the purpose of inhibiting HBV, such as nucleoside (acid) analogs that can inhibit the synthesis of the viral genome by binding to the viral polymerase.

Q: If regular check-ups + correct medication and treatment are taken, can hepatitis B patients live like healthy people?

Answer: Regular check-ups and timely and correct treatment can reduce the risk of cirrhosis and liver cancer. Most hepatitis B patients can live like healthy people.

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in conclusion

Hepatitis B is still a problem that needs to be taken seriously. In addition to full coverage of hepatitis B vaccination, necessary screening should also be carried out to ensure early detection and early treatment. The liver is an organ that "works silently". Friends who have hepatitis must not take it lightly just because the symptoms are not obvious. They must go to the hospital regularly for follow-up examinations to monitor their condition.

Author : Li Qingchao, PhD, Institute of Microbiology, Chinese Academy of Sciences

Reviewer : Xie Yandi, deputy chief physician, Department of Hepatology, Peking University People's Hospital/Peking University Institute of Liver Diseases

References:

[1]https://www.gov.cn/xwfb/2009-12/29/content_1499191.htm

[2]http://www.moe.gov.cn/s78/A15/xss_left/moe_776/s3258/201005/t20100511_87431.html

[3] Jia, H.; Zhuang, H. (2004). “Overview of the Chronic Hepatitis B Symposium.” Chinese Journal of Hepatology. 12(11): 698–699.

[4]Liu J, Zhang S, Wang Q, Shen H, Zhang M, Zhang Y, et al. Seroepidemiology of hepatitis B virus infection in 2 million men aged 21–49 years in rural China: a population-based, cross-sectional study. Lancet Infect Dis. 2016. January;16(1):80–6. 10.1016/S1473-3099(15)00218-2

[5] Liu, J.; Fan, D. (2007). "Hepatitis B in China". The Lancet. 369 (9573): 1582–1583. doi:10.1016/S0140-6736(07)60723-5. PMID 17499584. S2CID 27720470.

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