Hepatitis A, B and C: A Public Health
Susie A. Sami
Dr. Duncan Neuhauser
Generally, hepatitis is defined as inflammation of the liver.
The inflammation can result from multiple sources such as
infection, exposure to alcohol, certain medications, chemicals,
or poisons, or an immune-compromising disorder. Although
currently, there are five distinct hepatic viruses, for purposes
of this chapter, I will only discuss the hepatitis A virus (HAV),
hepatitis B virus (HBV), and hepatitis C virus (HCV).
The liver is a large and vital organ that the body needs to stay
alive. Its most important functions are detoxification of drugs
and other poisonous chemicals (toxins), and storage of vitamins,
sugars, fats and other nutrients. In addition, the liver
manufactures proteins needed to sustain the body, makes bile to
aid in food digestion, and produces clotting factors and other
substances that fight infection.
The liver has an incredible ability to heal itself, but it can
only heal itself if nothing is damaging it. Chronic or on-going
inflammation can cause liver damage. If the damage is not
stopped, the liver becomes hardened and scar-like. This is
called cirrhosis, a condition traditionally associated with
alcoholism. When this happens, the liver can no longer carry out
its normal functions, a condition called liver failure. The only
treatment for liver failure is liver transplant.
The A virus is one of the three most common viruses in the
United States. The other common viruses are B and C.
Whereas hepatitis B and hepatitis C viruses cause chronic
inflammation, hepatitis A does not. A chronic condition means
that it is on going, long-term or life-long. Although the liver
does become inflamed and swollen, it heals completely in most
people without any long-term damage. Once you have had hepatitis
A, you develop lifelong immunity (antibodies) and cannot get the
Hepatitis A is transmitted via a fecal-oral route. Generally, a
person ingests something that has been contaminated with the
feces of an affected person. This occurs with workers in the
food preparation industry (poor hygiene), in children’s day care
centers (overcrowding and poor hygiene) or underdeveloped
countries with poor sanitation and sewage systems.
The virus can also be spread by eating raw or undercooked
shellfish collected from water that has been contaminated by
hepatitis A in the sewage. Additionally, although extremely
rare, the hepatitis A virus can be transmitted through blood
The incubation period for the virus is 15-50 days with an
average of 28 days (1). This means that a person can be
infected without presenting with any symptoms. Because of the
way it is spread, the hepatitis A virus tends to occur in
cyclical epidemics and outbreaks.
Symptoms of hepatitis A usually develop between 2 and 6 weeks
after infection. The symptoms are usually not too severe and
resolve themselves. Symptoms usually last less than 2 months,
although they may last as long as 9 months. About 15% of people
infected with hepatitis A have symptoms that come and go for 6-9
Characteristics of At-risk Populations
Race: Because of the short incubation period, and the
route of transmission, outbreaks in the United States tend to be
cyclical occurring in certain well-defined populations:
Americans Indians, Alaskan natives, and some Hispanic people.
Epidemics occur in these groups every 5-10 years. However,
between epidemics, hepatitis A still occurs at fairly high
rates. For instance, the CDC reports that in 1997, 30,021 cases
were reported to the National Notifiable Diseases Surveillance
System (NNDSS)(2). When adjustments were made for
underreporting, the number of cases reported in 1997 represented
an estimated 90,000 symptomatic cases and 180,000 persons with
HAV infection (2).
Sex: HAV infection has no sex predilection although
homosexual males may have a higher risk of infection than
heterosexual males (3).
Age: In the United States, the highest rate of infection
occurs in children aged 5-14 years (3).
Other people at increased risk for hepatitis A infection are
Household contacts of people infected
Sexual partners of people infected
International travelers, especially to
Military personnel stationed abroad,
especially in developing countries
Men who have sex with other men
Users of illegal drugs (injected or
People who may come into contact with
HAV at work
Workers in professions such as health
care, food preparation, and sewage and waste water
management are not at greater risk of infection than the
People who live or work in crowded
conditions, such as dormitories, prisons, and residential
facilities, or work in or attend daycare facilities are at
increased risk if strict personal hygiene measures are not
Burden of Hepatitis A
According to the Centers for Disease Control and prevention
(CDC), an estimated 100 persons die from acute liver failure due
to the hepatitis A virus. In the 1999 Mortality and Morbidity
Weekly Report, the CDC reported that between 11% and 22% of
persons who have hepatitis A are hospitalized (2). Moreover,
adults who become ill due to hepatitis A lose an average of 27
days of work. For adult cases, the average cost (direct and
indirect) of hepatitis A ranged from $1,817 to $2,459 per case
(2). For children, the average cost per case ranged from $433
to $1,492(2). The total cost in a recent common-source outbreak
involving 43 persons was approximately $800,000. In the United
States alone, according to a CDC data that is unpublished, in
1989, the estimated annual direct and indirect costs were more
than $200 million (2).
The hepatitis A virus is preventable. General
measures consist of good personal hygiene, hand washing,
ingestion of safe drinking water, and proper sanitation.
Additional measures consist of the
HAV immune globulin (IG) and HAV vaccine.
IG is a preparation of
antibodies in the body. It can be safely given to children
under age 2. It is given as an intramuscular injection is
80-90% effective in preventing HAV infection by means of passive
immunity. It can be given within 2 weeks after exposure and is
safe during pregnancy and breastfeeding (2).
HAV vaccine is
currently indicated for use in children aged 2 years or older.
One dose of vaccine leads to the development of antibodies in
88% of adult patients by 15 days and in 99% by 1 month. The
second dose, given 6 months later, leads to immunization in 100%
of the adult patients (2).
The CDC Advisory
Committee on Immunization Practices has recommended universal
vaccination against HAV for children. Currently, 11 states (AZ,
AK, CA, ID, NV, NM, OK, OR, SD, UT, and WA) are implementing the
immunization programs and several others are considering the
The HAV vaccines are given in a series of 2 shots. The second is
given 6-18 months after the first. Protection starts about 2-4
weeks after the first shot is given. The second dose is
necessary to ensure long-term protection. The vaccines are
thought to protect from infection for at least 20 years.
The vaccine must be given before exposure to the virus. They do
not work after exposure. Not everyone needs to have the
hepatitis A vaccines. However, the vaccines are recommended for
the following groups (2):
All children older than 2 years who live in
communities where the number of HAV infections is unusually high
or where there are periodic outbreaks of hepatitis A.
People who are likely to be exposed to HAV at work
(i.e. research laboratories where HAV is stored and handled).
Travelers to developing countries (it must be
given at least 4 weeks before travel)
Adoptee from developing countries
Men who have sex with men
People who use illegal drugs
People who have immune compromising diseases such
People with blood-clotting disorders who receive
From 1995-2001, Samandari et al. (2004) report that
approximately 97,800 hepatitis A cases were averted because of
the implementation of immunization programs(4). Moreover,
sensitivity analysis indicates that the number of averted cases
in this period could range from 45,500 to 172,900. Among
children 2-18 years, vaccination coverage was estimated at 10%
and is attributable to averting 51% cases of hepatitis A
Hepatitis A infections lead to life-long immunity against the
virus. The symptoms are usually mild and tend to resolve on
their own. Deaths due to hepatitis A are very rare. Moreover,
complications such as hepatitis relapse or liver failure will
Hepatitis B is caused by infection with the hepatitis B virus (HBV).
This infection has 2 phases: acute and chronic. Acute (new,
short-term) hepatitis B occurs shortly after exposure to the
virus. A small number of people develop a very severe,
life-threatening form of acute hepatitis called fulminant
Chronic hepatitis B infection with HBV can last longer than 6
months. Once the infection becomes chronic, it may never go away
completely. About 90-95% of people who are infected are able
to fight off the virus so their infection never becomes chronic
(5). Only about 5-10 percent of adults infected with HBV go on
to develop chronic infection (5)
People with chronic HBV infection are called chronic carriers.
About two-thirds of these people do not themselves get sick or
die of the virus, but they can transmit it to other people. The
remaining one third of the people develop chronic hepatitis B.
Worldwide, about 350 million people are chronic carriers of HBV,
of whom, more than 250,000 die from liver-related disease each
year (6). In the United States, hepatitis B is largely a
disease of young adults aged 20-50 years. About 1.25 million
people are chronic carriers, and the disease causes about 5000
deaths each year. Mainly, these deaths occur from complications
due to the development of hepatocellular carcinoma (HCC) or
Unlike HAV, the hepatitis B virus is transmitted from one person
to another via an exchange in blood, also known as blood-borne
transmission. Semen and saliva, which contain small amounts of
blood, also carry the virus. The virus can be transmitted
whenever any of these bodily fluids are in contact with broken
skin or a mucous membrane (in the mouth, genital organs, or
rectum) of an uninfected person. Half of all people infected
with the hepatitis B virus have no symptoms.
According to the CDC, the incubation period for the Hepatitis B
virus is between 45 – 160 days with an average of 120 days.
Symptoms often develop within 30-180 days of exposure to the
Characteristics of At-risk Populations for Hepatitis B
The prevalence of hepatitis B is low in persons younger than 12
years. It does, however, increase for older than 12 years. The
increased prevalence could be attributable to the initiation of
sexual contact which is the major mode of transmission, the
number of sexual partners, and an early age of first
intercourse. Additional risk factors identified in the National
Health and Nutrition Examination Survey III survey are
non-Hispanic black ethnicity, cocaine use, and high number of
sexual partners, divorced or separated marital status, foreign
birth, and low educational level (3).
Because of the implementation of routine vaccinations of infants
in 1992 and adolescents in 1995, the prevalence of HBV is
expected to decline.
Race: The prevalence of the disease is higher among
African Americans (13.7%) than persons of Hispanic origin (5.3%)
or white persons (3.0%)(3).
Sex: Between cohorts ranging in age from 20-59 years,
there were more cases of HBV in men (6.5%) than in women
Age: The longer that a person has the infection, the more
likely it is to develop chronic inflammation. For instance,
infants have a 90% chance, children have a 25-50% chance, adults
have an approximately 5% chance, and persons who are elderly
have an approximately 20-30% chance of developing chronic
Other people who are at increased risk of being infected with
the hepatitis B virus include the following (8):
Men or women who have multiple sex partners,
especially if they don't use a condom
Men who have sex with men
Men or women who have sex with a person infected
People who are diagnosed with other sexually
Injection drug users who share needles
People who receive transfusions of blood or blood
Hemodialysis patients undergoing dialysis for
Institutionalized mentally handicapped people and
their attendants and family members
Health care workers who are stuck with needles or
other sharp instruments contaminated with infected blood
Infants born to infected mothers
In some cases, the source of transmission is never known.
Burden of Hepatitis B
The hepatitis B virus accounts for 5 -10% of chronic end-stage
liver failure and 10-15% of the development of HCC. It is due
to these complications that utilizes most of the health care
expenditures. Margolis et al. estimated that, in 1981,
expenditures due to acute and chronic HBV-related liver disease
was at least $197 million in direct costs and $126 million for
work-loss attributed to the illness (9).
The good news is that infection with HBV is almost always
preventable. According to the CDC, vaccination is recommended
for the following groups (8):
All infants regardless of the potential of
exposure to HBV
All adolescents at high risk of infection (i.e.
injection drug users or multiple sex partners)
People with occupational risk (i.e. medical
employees who come in contact with blood or blood products)
Patients and staff of institutions of the
Chronic recipients of blood transfusions or
certain other blood products
Household contact and sexual partners of HBV
Adoptee from countries where HBV infections are
International travelers especially to countries
where HBV is prevalent
Men who have sex with men
Sexually active men and women identified as
already contracting a sexually transmitted disease
Inmates of long-term correctional facilities
In an article published in JAMA, Hamilton (1983) found that a
program to immunize high-risk medical personnel at the Duke
University Medical Center to be cost-beneficial(10). According
to the study, the program would cost $206,304 in the first year
and by seven years, the cumulative cost of the program would
equal those without the program(10). Hamilton also reports that
at 10 years, there would be a cost saving ($746,742 with the
programs versus $9191,950 without the program)(10).
Global eradication of HBV is achievable (11). The hepatitis
vaccine is effective and safe to use. According to McIntyre
(2001) and Alter (2003), to accomplish such a goal, universal
hepatitis B immunization needs to be integrated into existing
childhood vaccination schedules. The dilemma is in establishing
such a policy worldwide. In 2000, only 116 of 215 countries had
such a policy (12). This number represents only 31% of the
global birth cohorts (12). Complications arising from chronic
HBV-related liver disease are another burden on the health care
system. At-risk adults also need to be immunized to truly
realize the benefits of the vaccine (12).
Hepatitis C is an increasing public health concern in the United
States and throughout the world. The World Health Organization
estimates 170 million individuals worldwide are infected with
hepatitis C virus (HCV) (13). Approximately 15-20% of people
infected develop the acute form of the illness. The remaining
cases develop chronic hepatitis leading to such complications as
cirrhosis, end-stage liver disease, and HCC. Chronic liver
disease because of hepatitis C causes 10,000 deaths each year in
the United States.
HCV is not related to the other viruses that cause hepatitis.
However, like the other hepatic viruses, it is contagious and
spread via the exchange of blood or blood products. Since
sharing of contaminated needles among IV drug users also
involves exchange in blood products, the mode of transmission is
the most common for the HCV.
Prior to 1992, blood transfusions during surgeries with infected
blood, hemodialysis patients, and organ transplants from
affected persons were common modes of transmission for the HCV.
In 1992, a test became available for checking blood for HCV.
Blood and blood products are now tested to ensure that they are
not contaminated. Other less common transmissions of HCV
include the following:
From mother to infant at the time of
Through sexual intercourse with an
infected person. However, having multiple sex partners is a
Needle sticks with HCV-contaminated
blood: This is mostly seen in health care workers. The risk
of developing HCV infection after a needle stick is about
The source of
transmission is unknown in about 10% of people with acute
hepatitis C and in about 30% of people with chronic hepatitis C.
Characteristics of At-risk Populations
Populations at high risk for contracting the HCV are similar to
those of hepatitis B. HCV tends to be more prevalent in males
than females. Other risk factors include persons living below
the poverty level, age of first intercourse less than 18 years
of age, having more than 50 sexual partners over a lifetime,
lifetime use of cocaine, and more than 100 lifetime use of
Race: The prevalence of the disease is higher among
African Americans (4.1%) than persons of Hispanic origin (3.4%)
or white persons (2.0%)(3).
Sex: Between cohorts ranging in age from 20-59 years,
there were more cases of HCV in men (3.4%) than in women
(1.5%)(3). Again, when this data is stratified by race, more
African American (5.8%) and Hispanic (4.1%) men are HCV-infected
than their female counterparts (2.8% and 2.6%,
Age: The age groups for hepatitis C infections are
difficult to ascertain. Historically, 20-39 years have been
known to have high incidence rate of HCV infections. Chronic
hepatitis C has a long latency period, 10-20 years, so persons
may be unknowing carriers. Groups under 15 years of age have
very low incidence rate of infection (5).
Burden of Hepatitis C (14)
The economic burden of hepatitis C is directly related to the
complications such as cirrhosis and HCC. Hospitalization is a
large proportion of the expenditures for HCV-related care. In
1995, approximately 27,000 hospitalizations in the US were
attributed to liver disease due to HCV. This, in turn,
corresponds to a crude incidence of one hospitalization per
1,000 persons infected. The estimated annual total expenditure
for hospitalization due to HCV-related liver disease was between
$129 and $514 million (14). This estimated cost does not factor
in the cost of liver transplantation due to severe cirrhosis or
For physician services, there were an estimated 317,000
physician office visits incurring $23.9 million in expenditure
during 1998. In addition, there were a total cost of $10.5
million emergency department costs and $530 million for
pharmaceutical therapies in 1999. According to Alter’s report,
in the late 1990’s, the total economic impact of HCV-related
liver disease was estimated at $1 to $1.3 billion per year(14).
One method to prevent the incidence of HCV is to modify the
risky behaviors among those most at risk. The high prevalence
of hepatitis C infection among injection drug users (IDU)
indicates a need for such behavior modifying programs. The cost
and illegality of purchasing syringes has made IDU more likely
to share needles. To counter against this practice, many states
have implemented syringe exchange programs (SEP). Data on the
effectiveness of such programs is still inconclusive. In a
study by Hahn et al., the investigators found that although
sterile syringes are accessible to IDU, sharing of needles still
persists. This finding does not suggest that SEP’s are not
working. It does, however, suggest that additional measures are
needed in an attempt to curb the spread of HCV. Several studies
have found that SEP’s are the optimal settings for further
intervention measures(15, 16). In fact, Pollack (2001) suggests
that “more comprehensive harm reduction models, coupled with
referral of active IDUs to treatment, must complement syringe
exchange to successfully contain highly infectious blood-borne
Another program evaluated by researchers is the medically
supervised safer injecting facilities or SIF’s. Wood et al. in
British Columbia, Canada found that IDU were willing to attend
SIF’s (18). Although this program is not currently available in
the US, Wood et al. suggest that the data “indicate a high
potential for immediate community and public health benefits if
SIF’s were presently available.
In an article by Boutwell et al. (2005), the authors estimate
that 15%-40% of persons incarcerated in US prisons are infected
with HCV (19). The authors suggest that “testing, education,
and when appropriate, treatment of prisoners should be a
cornerstone of the public health response to the hepatitis C
epidemic in the United States.”
In a Medline search, I did not find much literature on programs
educating the general public about the hepatitis epidemic in the
US. However, there are many websites that contain educational
materials on hepatitis both government-sponsored as well as
industry-sponsored. Following is only a sample of the websites:
Hepatitis C varies greatly in its long-term effects. Some
people may be infected for 10-20 years before symptoms appear.
Others may never develop the severe complications that go along
with the disease. However, if the cirrhosis or other
complications do develop, then special care is needed to
safe-guard the liver. Persons infected with HCV should avoid
alcohol or other toxins that may further exacerbate the damage
to the liver. Cirrhosis from chronic hepatitis C can lead to
liver failure. If damage is severe, liver transplantation is the
The good news is, according to the CDC, rates of hepatitis C
have been declining in all age groups. In fact, the greatest
decline appears among 25-39 year olds, a group which
historically had the highest incidence rates.
75 Maiden Lane,
New York, NY
700 East Butler
Cedar Grove, NJ
U.S. Centers for
Disease Control and Prevention (CDC) Hepatitis Branch--National
1. CDC. Protection Against Viral
Hepatitis Recommendations of the Immunization Practices Advisory
Committee (ACIP). MMWR 1990;39(RR-2):1-26.
2. CDC. Prevention of Hepatitis A
Through Active or Passive Immunization: Recommendations of the
Advisory Committee on Immunization Practices (ACIP). MMWR
3. Kruszon-Moran D, McQuillan G.
Seroprevalence of six infectious diseases among adults in the
United States by race/ethnicity: data from the third national
health and nutrition examination survey, 1988--94. Adv Data
4. Samandari T, Bell B, Armstrong
G. Quantifying the impact of hepatitis A immunization in the
United States, 1995-2001. Vaccine 2004;22(31-32):4342-50.
5. CDC. Hepatitis Surveillance:
CDC; 2004 September. Report No.: 59.
6. Lavanchy D. Hepatitis B virus
epidemiology, disease burden, treatment, and current and
emerging prevention and control measures. J Viral Hepat
7. WHO. Hepatitis B: World Health
Organization October 2000. Report No.: 204.
8. CDC. Hepatitis B Virus: A
Comprehensive Strategy for Eliminating Transmission in the
United States Through Universal Childhood Vaccination:
Recommendations of the Immunization Practices Advisory Committee
(ACIP). MMWR 1991;40(RR-13):1-9.
9. Margolis H, Schatz G, Kane M.
Development of recommendations for control of hepatitis B virus
infections: the role of cost analysis. Vaccine 1990;8(Suppl
S81-5):S93 - S94.
10. Hamilton J. Hepatitis B virus
vaccine: an analysis of its potential use in medical workers.
11. McIntyre C. Hepatitis B vaccine:
risks and benefits of universal neonatal vaccination. J Pediatr
Child Health 2001;37(3):215-7.
12. Alter M. Epidemiology and
prevention of hepatitis B. Semin Liver Dis 2003;23(1):39-46.
13. CDC. NIH Consensus Statement on
Management of Hepatitis C: National Institutes of Health; 2002
2002 Jun 10-12. Report No.: 19(3).
14. Alter M. Viral hepatitis:
hepatitis C. In: Kim W, Brown Jr. R, Terrault N, El-Serag H,
editors. Epidemiology and the impact of liver disease in the
United States; 2001; Atlanta, GA; 2001.
15. Stancliff S, Agins B, Rich J,
Burris S. Syringe access for the prevention of blood borne
infections among injection drug users. BMC Public Health
16. Tortu S, McMahon J, Hamid R,
Neaigus A. Women's drug injection practices in East Harlem: an
event analysis in a high-risk community. AIDS Behav
17. Pollack H. Cost-effectiveness of
harm reduction in preventing hepatitis C among injection drug
users. Med Decis Making 2001;21(5):357-67.
18. Wood E, Kerr T, Spittal P, Li K,
Small W, Tyndall M, et al. The potential public health and
community impact of safer injecting facilities: evidence from a
cohort of injection drug users. J Acquir Immune Defic Syndr
19. Boutwell A, Allen S, Rich J.
Opportunities to address the hepatitis C epidemic in the
correctional setting. Clin Infect Dis 2005;40(Suppl 5):S367-72.