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Hepatitis A, B, and C
Hepatitis A is widespread in Indonesia. Hepatitis A is a viral disease that affects the liver. It is transmitted person-to-person and by contaminated food and water, especially in areas with poor sanitation and overcrowding.
Symptoms begin two to seven weeks after infection and can include fever, chills, weakness, loss of appetite, nausea and/or abdominal discomfort followed by jaundice (yellowing of the skin and eyes). Urine may become dark.
Many people, especially children, suffer only a mild flu-like illness with no specific symptoms. In other cases, the jaundice is severe. Occasionally, hepatitis A causes life-threatening liver failure. This is more common in the very young, those with underlying health problems and those over 50 years old.
Vaccination Against Hepatitis A
Hepatitis A vaccination should be considered for all non-immune travelers. As hepatitis A is more severe in persons suffering chronic hepatitis, both hepatitis A and B vaccination is advised for all infected with hepatitis C. Hepatitis A vaccination is also recommended for all infected with hepatitis B.
- Individual hepatitis A vaccination consists of a series of two injections given on days 0 and after six months. Adequate immunity to hepatitis A develops soon after the first dose. The second dose is necessary to ensure sustained immunity.
- A combined hepatitis A and B vaccine is available in many countries. It requires of a series of three injections given on days 0, 30 and after six months. The first two doses are required before immunity to hepatitis A or B can be assumed. The third dose is necessary to ensure sustained immunity to both diseases.
Hepatitis implies a (usually infectious) inflammatory process damaging the liver. The onset is usually insidious with anorexia, vague abdominal discomfort, nausea and vomiting, sometimes joint pains and rash, often progressing to jaundice. Fever may be absent or mild. Severity ranges from being asymptomatic to cases acute liver damage. Chronic active hepatitis is usually (but not always) caused by the hepatitis B virus, and obviously diseased hepatitis B carriers are very common in some areas of the world (up to 20% of the population in certain parts of Asia). Because of this, the hepatitis B virus is the cause of up to 80% of all cases of hepatic (liver) cancer worldwide. The virus is second only to tobacco among known human cancer-promoting agents.
Hepatitis B virus has been found in virtually all body secretions and excretions; however only blood (and serum derived fluids), saliva, semen and vaginal fluids have been shown to be infectious. For transmission to occur the virus infected body fluid must be introduced through the skin. This can be done by contaminated needles and syringes and other IV equipment. Infection can also be spread through contamination of wounds or lacerations. Even a tiny drop of infected fluid can result in infection if it makes contact with the mucous membranes of the mouth, nose or vagina. This is probably the major route of transmission in areas of the world where Hepatitis B is endemic, and in residential institutions.
Transmission of Hepatitis B
Transmission by close personal contact can occur, especially between sexual partners and most frequently between male homosexuals. Communally used razors or toothbrushes have also been occasionally implicated. Note however fecal-oral transmission has NOT BEEN demonstrated.
Incubation period is usually 40 to 180 days, but cases are infective many weeks before the first onset of symptoms so quarantine measures are not really useful. Chronic carrier-states in which the patient is otherwise well but carries the virus can last for many years; equally, chronic states in which the liver is being insidiously damaged by active disease can occur.
Various forms of Hepatitis
Other forms of hepatitis can be produce symptoms similar to the other (A and B) forms of hepatitis. C is the most significant as it is most often transmitted by blood transfusions, and increasingly it is recognized that blood should be tested for this virus. It can have long-term effects similar to although usually not as severe as hepatitis B.
Like hepatitis B, hepatitis C causes inflammation of the liver, caused by viral damage to the main liver cells. Hepatitis C is spread by blood. Blood transfusion has therefore been an important route by which it is passed on. About one potential blood donor in 300 has the virus in Western countries. (Of course this route of infection could be ended by nationwide testing of donated blood).
Other ways of transmitting the disease involve the sharing of needles by drug abusers, and the use of unsterilised tattooing instruments. Sexual intercourse with an infected partner carries a small risk, very much less than the risk of catching AIDS, or even hepatitis B. It seems improbable that family contacts of other kinds can spread the disease. However, in practice it is not possible to discover how a particular patient has been infected in half the cases of the disease, so that all patients with hepatitis C should observe normal hygienic practices scrupulously, and be especially careful in disposing of material contaminated with their blood.
Only a small proportion of hepatitis C infected patients will develop the symptoms of an acute hepatitis, with loss of appetite, mild fever, and jaundice. Whether or not such symptoms develop, between half and three quarters of patients will clear the virus and develop immunity to it, exactly as happens with Hepatitis A and with most viral illnesses such as influenza or measles, for example. But between a quarter and a half of those initially infected will continue to be infected over many years. Some of these people have little or no liver damage, and their only long-term risk is that they may develop primary liver cancer. But half or more of those who are chronically infected will show progressive damage to the liver due to chronic hepatitis C infection.
The risk is similar to that with chronic infection with hepatitis B - a relatively low risk in most Western countries - and a risk that can be minimized by taking care of the liver by avoiding alcohol, adopting a balanced diet, and ensuring that one is protected against hepatitis B by accepting vaccination for it.
The symptoms suffered by those with chronic hepatitis C vary from person to person. Some people have no symptoms until the liver has been quite severely damaged. Others suffer tiredness, fatigue, nausea, and perhaps mild abdominal discomfort. The major threat of this condition is that it slowly damages the liver, with the inflammation leading to scars forming, and eventually, when scarring of the liver starts to impair its ability to perform its normal functions, cirrhosis of the liver results, and in time, this cirrhosis will prove fatal. Fortunately, hepatitis C advances to cirrhosis very slowly - usually over decades rather than years.
If there is a suspicion of chronic active hepatitis from any cause, blood tests are required to show whether hepatitis virus infection is present, and liver function tests can identify those in whom some liver damage is occurring. To establish the severity of liver damage, a liver biopsy may be required. A liver biopsy involves taking a sample of the liver with a specially designed needle. Under local anesthetic, this is passed between the lower right ribs into the center of the liver. The sample taken is about the size of a pin. It takes only a minute or so to get the sample, but the overall procedure involves a full day, because a period of observation is required afterwards to make sure there is no bleeding from the puncture site in the liver itself. In a normal, or even a moderately damaged liver, the risk of any complication of the biopsy is very slight. Very rarely, complications of the biopsy may require surgery to repair the puncture site.
Treatment is available if the benefits outweigh the risks. If blood tests (liver function tests) are abnormal, indicating that some damage to the liver is occurring, but the liver biopsy shows only minor degrees of damage, what is sometimes referred to as "treatment for persisting hepatitis" is not usually undertaken, as the risk and inconvenience of treatment outweigh the potential benefits.
If a biopsy shows progressive liver damage, treatment for "aggressive hepatitis", or the beginning of cirrhosis, can be considered. The only useful treatment so far is with alpha interferon - a natural substance produced in the body as part of the inflammatory response to bacteria and viruses. Given by injection three times a week over several months, this expensive treatment will stimulate a cure in up to a quarter of patients, and will usefully slow the progress of the infection in another quarter or more.
Interferon is not without side effects, but overall, more than half of all patients do benefit to varying degrees.It is imperative that the families be vaccinated against Hep B prior to relocating to Indonesia. Should time not permit then they should at least start the program and they can continue it at a reputable clinic on their arrival in Indonesia .
The vaccination is very effective if given correctly and offers good immunity to hepatitis B. It is now also becoming compulsory from birth in certain developing countries, to prevent the spread of hepatitis B.
How is HBV spread?HBV is found in blood and certain body fluids of people who are infected with the hepatitis B Virus (HBV), fluids such as serum, semen, vaginal secretions, and saliva. HBV is not found in sweat, tears, urine, or respiratory secretions. Contact with even small amounts of infected blood can cause infection.
Hepatitis B virus can be spread by:
- unprotected sex
- injecting drug use
- during birth from mother to child
- contact with blood or open sores of an infected person
- human bites
- sharing a household with an infected person
- sharing items such as razors, toothbrushes, or washcloths
- pre-chewing food for babies or sharing chewing gum
- using unsterilized needles in ear or body piercing, tattooing, or
- acupuncture - so check needles are always taken out of sterile packages in front of you
- using the same immunisation needle on more than one person - insist on a clean needle every time
- casual contact like holding hands
- eating food prepared by a carrier
- kissing on the cheek or dry lip kissing
- sharing silverware, plates, or cups
- visiting an infected person's home
- playing with a child who is a carrier
- sneezing or coughing
- In many countries, hepatitis B is now a routine childhood immunization and need not be repeated. All non-immune travelers should consider vaccination.
- Always use new condoms (preferably brought from your home country, if traveling to a less-developed nation).
- IV drug users should not share needles.
- In healthcare settings, make sure that needles and syringes are new.
- Call International SOS or your corporate medical department if you are hospitalized or before having a blood transfusion.
- Be aware of your risk when assisting anyone with an injury. Protect your skin from contact with bodily fluids.
- Seek medical attention within 24 hours when you accidentally come in contact with someone else's bodily fluids.
Some additional resources for more information on Hepatitis C:
Center for Disease Control
If you have medical-related questions about living in Indonesia to ask of medical professionals, see Ask the Experts.
We trust this information will assist you in making correct choices regarding your health and welfare. However, it is not intended to be a substitute for personalized advice from your medical adviser.
Our appreciation to Dr. Rene de Jongh of International SOS, an AEA Company who has contributed this article in response to an inquiry about Hepatitis in Indonesia.