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	ACT-HBV.com welcomes your questions regarding hepatitis B, and will be posting submitted questions and answers provided by Expert Council and Special Committee members. New questions and answers will be posted on a monthly basis, so please submit your questions and see them answered on ACT-HBV.com. This Month's Questions I recently underwent testing for hepatitis. My blood work revealed that I had a reactive HBsAg level of >250 IU/mL, am anti-HBeAg negative, anti-HBe positive, anti-HBs negative, and anti-HBc negative. My HBV DNA level was 5 IU/mL, my ALT level was 76 U/L (up from 53 U/L 8 months ago), and my AST level was 30 U/L. My liver ultrasound report showed that my liver was of normal size and that parenchymal echogenicity was increased. There were no focal defects, and margins were regular. The intrahepatic biliary channels were not dilated, the IVC and intrahepatic veins were of normal caliber, and the portal vein and its branches were not dilated. I was vaccinated for hepatitis B in 2003. Does my condition seem very serious, and should I start on medication? One of my physicians recommended lamivudine, but another said I am not in the active stage of the disease but am an inactive carrier, so that no treatment should be started. Further, he believes that I should not have been vaccinated and that it is because of that vaccine that I developed my condition. He has given me pioglitazone and alpha-locopherol acetate as he suspects I have a fatty liver, which may lead to non-alcoholic steatohepatitis. Is there a specific diet or exercise regimen I should follow to prevent the development of this? I have a small stone in my left kidney for which I would like to undergo lithotripsy, but am not sure if I could still undergo this procedure if I was receiving medication. You bring up several questions. First, do you have hepatitis B and, if so, how did you develop it given that you were vaccinated? There does, in fact, appear to be evidence of hepatitis B based on the detection of HBsAg in your blood. This infection may have been present prior to vaccination, as I assume a screening test was not performed before you received your shot. Just to be certain, I would have your HBsAg level checked one more time. Next, is treatment required? You report your HBV DNA level as 5 IU/mL. This is low, so treatment would not be required at this time, but it is important to have your HBV DNA monitored and tested again in 6 months. If HBsAg is confirmed positive at that time, I would recommend lifelong monitoring, with treatment possibly indicated later. You then ask about your high liver enzyme levels. You should be evaluated for other causes of liver disease. If it is determined that you do have a fatty liver, the best approach is diet and weight loss. Optimal weight and the correction of metabolic abnormalities such as diabetes, insulin resistance, and hyperlipidemia would be important. Finally, you ask if lithotripsy can be performed? Based on the laboratory values you have provided, lithotripsy can be performed if indicated, as risk is not affected by mild liver enzyme elevations or the hepatitis B carrier state. However, you did not indicate your platelet levels or prothrombin time; these should be checked. If I am feeling the symptoms of hepatitis B for the first time, could this be a sign of acute hepatitis B? Could the pain I feel in the area of the liver mean that my body is fighting off the virus? I have been feeling the pain for the last 3 months. From your question, I am unclear as to whether you have had an official diagnosis of acute hepatitis B or not. Patients who have recently become infected with the hepatitis B virus (HBV) can certainly have discomfort in the upper right corner their abdomen, where the liver is. They can also experience symptoms of nausea, vomiting, fatigue, dark urine, jaundice (skin turning yellow), icterus (eyes turning yellow), and loss of appetite. If you think you may be at risk for hepatitis B, I would recommend that you see your doctor and get a simple blood test. If the test shows no infection, I would also recommend getting vaccinated against HBV infection so that you will be protected from becoming infected in the future. If the test shows that you were recently infected, you will need further evaluation to be certain that you clear your infection. I am a 51-year-old man and was diagnosed with hepatitis B 18 months ago. I received 36 weeks of treatment with peginterferon alfa-2a 180 mg/wk, and telbivudine 600 mg/day, after which the peginterferon was discontinued. My viral DNA loads were as follows: Baseline: 4 „e 107 c/mL (and I was HBeAg-negative) Week 2: 1.27 „e 107 c/mL Week 8: 1.75 „e 107 c/mL Week 18: 1700 c/mL (at this point I reached seroconversion) Week 24: <300 c/mL Week 30: <300 c/mL Week 36: 321 c/mL I wonder if mutants are developing. What is your advice? Should I continue taking telbivudine or should I change to another drug? If you think I should change, which drug would be best? Personally, I think you have too little virus and that it is too early for resistance to be developing. Likely the 321 c/mL value is either what we call a ˇ§blipˇ¨ or a meaningless bump in the viral count or a false-positive result that is completely meaningless. I would not worry about resistance as long as your viral count remains below 10,000 c/mL. Good luck! A 25-year-old man was undergoing merchant navy training. During a routine medical checkup he was found to be hepatitis B surface antigenˇVpositive. One year later he was found to be hepatitis B e antigenˇVpositive. His viral DNA load was 7.8 „e 107 c/mL. He consulted a gastroenterologist who advised him to undergo testing before beginning specific antiviral therapy. The tests were positive for surface and envelope antigen, but his liver biopsy was normal and no cirrhotic changes were found. Due to financial constraints, the man was prescribed lamivudine instead of an interferon. He has been receiving this for last 6 months. My question is, if he marries a woman who has been immunized with the hepatitis B vaccine, what is the risk that she could become hepatitis BˇVpositive? Your 25-year-old gentleman is potentially highly contagious as a result of his HBeAg status and large viral burden. Immunized individuals are believed to have complete protection from HBV transmission. However, individuals who are not fully immunized have a high likelihood (25% to 59%) of contracting HBV in a heterosexual relationship. Five percent have inadequate antibody production with the first vaccine series. Consequently, this gentlemanˇ¦s future spouse should document adequate antibody to HBsAg (>10mIU/mL). Once documented, there is no recommendation for booster administration. The choice of antiviral therapy poses a different challenge. High viral burden puts this gentleman at very high risk for developing hepatocellular carcinoma or liver failure. Lamivudine has statistically decreased mortality due to HBV in a large cohort of patients. However, 38% of subjects taking lamivudine develop resistance within 2 years, and 69% will have resistance by 5 years. Thus, by 5 years 69% will be experiencing little benefit of lamivudine therapy. Additionally, lamivudine resistance leads to possible cross-resistance to telbivudine and entecavir. These factors make lamivudine less desirable, yet lamivudine is substantially less expensive and may be the only affordable therapy in resource-limited situations. In November 2007 I underwent a pre-employment screening for hepatitis A and B, and my results showed that I was non-reactive for the antibodies and antigens. However, an annual STD panel performed shortly thereafter showed that I was positive for hepatitis antigens and negative for hepatitis antibodies. I am currently receiving the hepatitis B vaccination series. Is it possible to be negative for the antibody but positive for the antigen? Yes, there have been reports of patients having positive HBsAg findings during and shortly after vaccination. In a case such as this, your antigens need to be retested in 1 and 3 months and your antibodies need to be retested in 6 months. Recently I was diagnosed with hepatitis B at the time of my first pregnancy. Unfortunately, my pregnancy had to be terminated. The doctor took blood and told me to come back a week later, which was when I found out I had hepatitis B. I didn’t know what that was, but my husband knew and was shocked. I was surprised to see his reaction and then shocked to realize what this could mean and to realize that he might have contracted it also. Fortunately, 8 years ago he received a vaccination against it, but recently got tested anyway, and the result was negative. Four years ago I had a complete blood test and everything was perfect. My current test results showed that I was HBsAg-positive, HBcAb-positive, HBsAb-negative, HBeAg-negative, HBeAb-positive, HBV DNA–negative, had an elevated HBV viral load, normal AST, normal ALT, normal GGT, normal bilirubin, normal albumin, normal cholesterol, and normal ultrasound. I don’t recall any pain before the diagnosis, but a week after that I started to feel pain in the right side of my abdomen. I wonder if that was a result of the medication the doctor gave me after my pregnancy was terminated. I very much want to try to have children, but can I do that with my disease status? Very briefly, HBV infection does not prevent pregnancy so your condition should not prevent you from having children. However, your HBeAg status puts you at high risk of transmitting the infection to your newborns so you need close monitoring and clinical care and your newborn would need a hepatitis B vaccine and HBIG within 12 hours of birth, followed by a one-time administration of all the hepatitis B vaccine doses as recommended in the 2005 ACIP/CDC recommendations, with appropriate post-vaccination testing for HBsAg and anti-HBs of your infant after completion of the hepatitis B vaccine series. My sister was recently diagnosed with HCV-1a. She and I used to share cigarettes when I had cold sores. Recently I started experiencing joint pain in my hands and elbows as well as weakness and difficulty picking up things. I’ve never had joint pain like this although rheumatoid arthritis runs in my family. About 3 weeks ago I experienced a rash on my chest and arms but the water here has a lot of chlorine in it so I thought that may be the cause, but now I am a little concerned as everything started to happen very quickly. It’s unclear whether you were exposed to hepatitis B or C. If it was hepatitis C, you shouldn’t worry because it is extremely unlikely you could get it by sharing a cigarette, even if you had cold sores at the time. Currently in the United States, hepatitis C is almost always spread by sharing, or coming in contact with, contaminated needles. However, hepatitis B could be spread through open sores. Early in the course of infection a person can experience joint pain similar to what you’ve described, but these almost always disappear in 1 to 2 weeks and are often followed by nausea, loss of appetite, and even yellow eyes and yellow skin (jaundice). You should be tested for viral hepatitis B as well as hepatitis A and C. If you are found to have hepatitis B, your close contacts should be tested as well. If they are found to be negative for it, they should receive the hepatitis B vaccine. If your symptoms of arthritis do not go away in 1 to 2 weeks, you should see a doctor as you could have rheumatoid arthritis, especially if it runs in your family. If you do have rheumatoid arthritis, early treatment can reduce the chances that will cause permanent damage to your joints. I was vaccinated for hepatitis B in 2003. I received three major injections. In 2007, during my annual medical check-up, the following was reported: Anti-HBeAg Negative Anti-HBe antibody Positive, 12.4 Anti-HBs antibody Negative Anti-HBc Negative HBV DNA (PCR) 5 IU/mL One of my doctors has recommended that I take Zeffix™ (lamivudine oral solution, 5 mg/mL). The other doctor says there is no need for treatment yet. I am confused. What do you recommend? Your recent blood work is compatible with ongoing chronic HBV infection. If you had been successfully vaccinated before developing an infection, you would have developed a neutralizing antibody (anti-HBs), and HBV DNA would not be detected in your blood. The HBV DNA, even at the low level that you have, means that the virus is reproducing, although not very actively. Thus, the fact that HBV DNA can be detected at all in your blood means that you are infected. Most likely, because of your very low level of virus, you are what we call an "inactive HBV carrier." This means that you are very unlikely to have liver disease from the infection, and you have a limited ability to infect other people with whom you are in close contact (such as family members or a wife or husband). Your medical report did not show the levels of your liver enzymes, but, for inactive carriers, these would be within normal limits. We generally do not treat patients who are inactive carriers. Treatment will not be effective while the virus is in a relative resting stage and is not reproducing very much. However, being an inactive HBV carrier does mean that you have some risk of getting liver cancer. Therefore, you should have an ultrasound examination of your liver once every year. You also need blood testing—your doctor will determine how often to do the blood tests based on your age. If any of your liver enzymes are elevated, it is possible that you may have a condition called "HBeAg negative chronic hepatitis B." This may be why one doctor wants to treat you. Although your HBV DNA levels are very low right now, in HBeAg negative chronic hepatitis B, they can fluctuate (go up and down). I can’t be positive that you have this condition without knowing your past ALT values and your past HBV DNA values, if they have been measured previously. If either (or both) ALT and HBV DNA have been fluctuating, this may be what you have. Because HBeAg negative chronic hepatitis B can progress and cause liver damage, you may require long-term antiviral therapy. In summary, we generally do not treat inactive HBV carriers, but we do treat HBeAg negative chronic hepatitis B. If treatment is started, we do not generally use Zeffix (lamivudine) as first-line therapy, because there is a high probability that the virus will become resistant to this drug, and the drug will no longer be effective. Incidentally, what appears to be missing from your lab test results, in addition to the ALT and AST liver enzymes, is the HBsAg test. If you are HBsAg positive, this would reaffirm that you are indeed infected. My husband is HBV positive. How long does it take from time of contact to determine a positive result? Should I and my daughter be tested? If your husband is positive for hepatitis B surface antigen (HBsAg), the contact could have occurred from weeks to years before the positive test. More information is needed to determine his current condition, such as his alanine aminotransferase (ALT) level, HBV DNA level, and hepatitis B e antigen (HBeAg) status (positive or negative). You, your daughter, and all persons who have had household contact with your husband should be screened for HBV. A 6-year-old patient with no vaccination against hepatitis B virus (HBV) sustained an open wound injury of the head and was taken to the hospital, where he received care. According to the father of the patient, the razor may not have been sterile, as it was used for the previous patient. The injury occurred on a Friday evening, and testing for HBV infection for the patient was not available, neither in the primary care setting nor in the hospital. The patient was taken to the private immunization center, where vaccine against hepatitis B and hepatitis B immune globulin (HBIG) were available. The price of HBIG is very high, however, and the patient’s father wants to know if the boy definitely needs to receive this specific treatment. It will take more than 48 hours from the time of suspected exposure to get the HBsAg testing done and make a decision to give the patient HBIG. Is it still reasonable for the patient to receive HBIG later than 48 hours since exposure? The recommendation is for the HBIG dose to be administered within 48 hours of exposure, and not later than 1 week after exposure. (This is according to the instruction on "Human Hepatitis B Immunoglobulin” of the European Pharmacopoeia.) These questions may be surprising, but they are an indication of the problems we have in the country: low level of health care, rising knowledge about expensive medications, and not enough trust with regard to immunization. The child in this question had a possible parenteral exposure to HBV from an unknown person via a possibly contaminated surgical instrument. He had not been vaccinated against hepatitis B in the past. Guidelines on vaccination of persons with potential HBV exposure issued in the United States by the Centers for Disease Control and Prevention are as follows: HBsAg-Positive Exposure Source • Persons who have written documentation of a complete hepatitis B vaccine series and who did not receive postvaccination testing should receive a single vaccine booster dose. • Persons who are in the process of being vaccinated but who have not completed the vaccine series should receive the appropriate dose of hepatitis B immune globulin (HBIG) and should complete the vaccine series. • Unvaccinated persons should receive both HBIG and hepatitis B vaccine as soon as possible after exposure (preferably within 24 hours). Hepatitis B vaccine may be administered simultaneously with HBIG in a separate injection site. The hepatitis B vaccine series should be completed in accordance with the age-appropriate vaccine dose and schedule Exposure Source with Unknown HBsAg Status • Persons with written documentation of a complete hepatitis B vaccine series require no further treatment. • Persons who are not fully vaccinated should complete the vaccine series. • Unvaccinated persons should receive the hepatitis B vaccine series with the first dose administered as soon as possible after exposure, preferably within 24 hours. The vaccine series should be completed in accordance with the age-appropriate dose and schedule Source: Morbidity and Mortality Weekly Report, December 8, 2006 / 55(RR16);30-31. The exposure in this case was only speculative, and, even if there had been an exposure, the HBsAg status of the instrument is not known. Therefore, the most pertinent recommendations are those for Exposure Source with Unknown HBsAg Status. The child should begin the hepatitis B vaccine series as soon as possible. HBIG is not indicated in this setting. We are adopting a baby girl from China. At 4 months of age, she had tests that showed she was HBsAg negative, HBsAb negative, anti-HBs negative, anti-HBe positive, and HBeAg negative. What does this mean? Does she have hepatitis B? You are describing a young infant who has antibody to HBeAg in her blood. There are several possible explanations for this, and further testing and time will be needed to determine which is accurate: 1) She acquired hepatitis B from her mother, but the level of the surface antigen is too low to detect. This is rare, but possible, depending on the test and its accuracy. 2) The antibody in her blood is maternal antibody that was transferred across the placenta, and her mother either had or has hepatitis B. Many antibodies cross the placenta and can last for 1 year or more in newborns. In most instances, they are protective, but anti-HBe does not protect the infant from hepatitis B. If this is the case, the antibody should go away by the time she is 12 to 15 months of age. 3) This is a false-positive test, meaning that it can be positive in some people who don’t have and never had hepatitis B. In any case, further testing will help to sort this out. When the baby is brought to the United States, she should undergo another set of tests, this time including ALT measurement (a liver test) and HBV DNA, which will show whether the virus is actually present. If the tests are the same as now, she should undergo hepatitis B vaccination, since she does not have immunity. My nephew was recently found to be HBsAg positive during a routine check-up. He was asymptomatic except for some tiredness. His lab results: HBsAg positive HBeAg negative HBV DNA 180000 copies/mL LFT normal What should be the management plan for him? Will antiviral drugs or peginterferon be useful? Should he have any other lab tests? The answers to your questions depend in part on his age. A liver biopsy might be required. Your nephew most likely has HBeAg-negative chronic hepatitis B, which means that his infection involves the precore or core promoter hepatitis B virus. According to generally accepted guidelines, patients need treatment for chronic hepatitis B if their HBV DNA level is greater than 10,000 copies/mL (or 2,000 IU/mL), which your nephew has, and if their ALT level is elevated, whether or not they have significant disease as detected on liver biopsy. If your nephew is older than 35 to 40 years of age, his doctor might consider doing a liver biopsy in order to help determine the need for treatment. His options for treatment are either peginterferon or a drug such as adefovir or entecavir. The advantages of peginterferon are that it is taken for a fixed length of time, and there is no development of antiviral drug resistance. (Once the virus develops resistance to the drug, the drug is no longer effective.) The disadvantages are that peginterferon must be taken by injection, and side effects frequently occur. The other two drugs mentioned are taken in pill form. This, along with the fact that they have no side effects, are their advantages. Their main disadvantage is that drug resistance does develop. After 5 years of taking adefovir, 30% of patients will have developed resistance. The rate of drug resistance is lower for entecavir: after 4 years of taking entecavir, less than 1% of patients will have developed resistance. My brother is HBeAg positive. I want to know what medicine he is going to take. Is his condition serious? Is it contagious? Do I need to separate the things the he uses, like a spoon and fork? His doctor advised him to have another test, for HBV DNA. However, this test is very expensive. My brother is not taking any medicines right now because the doctor is waiting for the result of the HBV DNA test. Here are the results of his previous tests: HBeAg (Elfa) positive Patient's count - 4.48 Anti HBe (Elfa) negative Patient's count = 11.27 ALT 34 We would need more information than just the HBeAg status and the ALT level to know what medications would be appropriate for your brother. Right now, it is likely that he does not need medication immediately, but he should complete the work-up with his doctor. The HBV DNA test is key. He should not consider taking any treatment until he has that test performed. The medications (as well as some of the tests) are very expensive, so he will need insurance, or he will need to take part in a study to have the medications provided, if he needs them. One study that might be suitable is called REALM, sponsored by Bristol-Myers Squibb. It would provide medications if he qualifies. There are other studies as well. You do not need to separate your cooking or eating utensils from his, but you should not share toothbrushes, razors, and similar things that could expose you to his blood. If your brother has active hepatitis B, it is contagious. My brother underwent testing for HBsAg and the result was reactive (3.515), which, according to his doctors, means he is positive for hepatitis B. My aunt, who is a doctor, told him to have a ProTime® test and a test for HBeAg. The results of his tests were as follows: HBeAg nonreactive ProTime L9.70 sec (Control, 12.90 sec; % activity, 100%; INR, 0.81; reference ranges, 10.00–14.00) What does all of this mean? Your brother is infected with hepatitis B virus (HBV). The test for HBeAg is negative, which suggests that the virus might be less active. The normal ProTime test probably means that his liver is functioning well and is not failing. However, in order to tell what the status of his infection is, he needs to have liver function tests done, including measurement of ALT (also called SGPT), AST (also called SGOT), albumin, and total bilirubin, as well as a platelet count and an HBV DNA level. If his albumin and bilirubin are normal, this will confirm that his liver is functioning well and not failing. If his platelet count is low (below 120,000), this may mean that he has a lot of scarring in his liver. If his ALT or AST are elevated and his HBV DNA is high (more than 10,000 copies/mL or 2,000 IU/mL), this means that he may have active damage going on in his liver and might need to be treated or at least have a liver biopsy to see how extensive his damage is. If all of the above tests are normal (or below the levels stated), he probably has “inactive hepatitis B,” which means that his own immune system is keeping the virus down. If he has inactive hepatitis B, he should still have his blood checked for ALT and AST once or twice each year for the rest of his life, because the hepatitis virus could reactivate at any time and start damaging his liver without him feeling sick or knowing it. If his ALT or AST becomes abnormal, his doctor should then check his HBV DNA again. If it is elevated, the doctor should evaluate him to see whether he should begin therapy, or he might recommend that he have a liver biopsy. Also, all family members, including brothers, sisters, his children, and anyone living in his house, should be tested for HBsAg and anti-HBs. Persons who are negative for both tests should receive a hepatitis B vaccine series to protect them from getting hepatitis B. Family members who are negative for HBsAg but positive for anti-HBs have had hepatitis B and recovered. These people are protected for life and do not need any further testing. If anyone is found to be HBsAg positive, they should follow the same procedure of investigation as outlined for your brother. I have had a sexual partner for 3 months and have only just been told that she is a hepatitis B carrier. I made an appointment to take blood tests at the first available date. What do you suggest? You need to be tested for HBsAg. If you are positive, you should see a liver specialist, who can test you for HBV anti-HBs. If you are negative for anti-HBs, you need to receive the hepatitis B vaccine, even if HBsAg is also negative. If you are positive for anti-HBs, you do not need to receive vaccination. You are immune and do not need to take any further steps. Until you can have your blood tests done, you should practice safe sex and avoid exposure to blood. Your partner, who is HBsAg positive, needs to see a liver expert. My age is 38 and my weight is 72 kg. I am jobless and experiencing depression, since I have two school-age children. A few days ago, I had gastritis, and I still have that stomach problem a little bit. I took medicine for it. Yesterday I had liver function tests at two different laboratories. I know that I have a liver problem. My values were as follows: HBsAg negative Anti-HCV negative Total bilirubin 0.7 ALT (SGPT) 215 AST (SGOT) 87 ALP 386 I am not able to go to a specialist. Kindly let me know what treatment I should start now, and is there any danger to my life due to this SGPT 215? What medical treatment should I have? Submitted 5/8/07 First, I would be happy to review all of your test results if they are from a reliable laboratory. Second, I am glad to see that you are negative for hepatitis B and hepatitis C. However, the type of hepatitis that you have (NBNC hepatitis) requires a very extensive work-up to find out the cause of it. You would need to have tests for nonalcoholic steatohepatitis (NASH), Wilsons's disease, alpha-1 antitrypsin deficiency, and many other conditions. A liver biopsy would also be helpful. But, before doing all of those tests and getting a liver biopsy, you need to have a good-quality ultrasound examination of your liver. Please do try to see a liver specialist at your earliest convenience. The liver specialist would give you a good check-up all at one time. This would limit the cost as much as possible and be better than your going to different doctors and getting many different tests on your own. You need to tell the liver specialist about any medicines you have been taking. I assume that you don't drink alcohol. There are many good treatments for liver disease, but first the exact cause of your liver problem needs to be determined. The liver specialist will help you find the right treatment. I have a number of questions regarding my recent diagnosis of HBeAg-negative disease. What do the terms active and inactive cirrhosis mean, and how can one distinguish between them? Do HBeAg-negative patients with inactive disease show inflammation on liver biopsy? Can a patient with HBeAg-negative disease show wide swings in HBV DNA levels—say, from below 10,000 to over 200,000 c/mL from one year to the next? If so, does this mean that the disease is going into a state of remission? Submitted 5/4/07 The terms active and inactive are poor, as they may refer to high and normal liver enzyme levels, respectively. That said, liver biopsy should be able to distinguish active from inactive disease and establish whether there is inflammation. As to whether inflammation will appear on liver biopsy in an HBeAg-negative patient with inactive disease, I would think probably not. It is typical that HBV DNA levels will swing as widely as you have described, but your disease would be considered to be in remission only if your HBV DNA level is undetectable and your ALT level is normal. My 3-year-old son was diagnosed with hepatitis B upon his arrival in the US from an orphanage in Ethiopia. He completed 6 months of interferon treatment about 6 months ago. Recent blood work shows the following: Anti-HBe reactive HBeAg nonreactive HBV DNA 547 DNA (final) 976 What does this mean, and what are the possibilities for continued treatment, if needed? Submitted: 4/9/07 n order to fully answer this question, it would be ideal to have a little more information. For example, is his ALT (liver enzyme) normal now? What are the units of the HBV DNA number—are they units/mL or copies/mL? Typically, with or without treatment, at some point in the natural history of chronic hepatitis B infection, the hepatitis B e antigen (HBeAg) becomes negative, the antibody to e (anti-HBe) becomes positive, the HBV DNA level becomes low (less than 500 units/mL or less than 1000 copies/mL), and the ALT becomes normal. This is known as seroconversion. Treatment is used to hasten this process, because the amount of liver damage is somewhat proportional to how long the ALT remains abnormal while the HBV DNA level is high. It appears that your son may have already reached the point of successful e Ag seroconversion. This is usually associated with the end of liver damage. If that is the case, no further treatment is needed. At this point, he needs only to have blood tests and an ultrasound about once a year. In a minority of people (but not an insignificant number), the liver disease can become active again, with or without the reappearance of e antigen on blood testing. Additional treatment would be needed at that time. So there are two reasons to continue monitoring your child: (1) for early detection of re-activation, and (2) for liver cancer surveillance. Remember that all other members of your family should be vaccinated for hepatitis B and should have the required blood tests to be sure that the vaccine successfully induced immunity. I live with a person who has hepatitis B. We share the same cutlery and use the same bathroom. Is it likely that I can become infected with the disease? Submitted 4/4/07 The possibility of contracting hepatitis B from a housemate is a true concern even if there is no sexual intimacy. Nonsexual household transmission appears to occur in the range of 3% to 6%. One factor that influences your risk of contracting HBV from an infected housemate is your immune status. If you already have antibody to hepatitis B surface antigen, either by past exposure or by vaccination, you are not considered at risk to contract a new case of hepatitis B. If your housemate has a high viral load (as measured by HBV DNA in the blood) and has hepatitis B e antigen present in the blood, he or she is more likely to transmit HBV. Risks inherent in your relationship and behavior play a major role in transmission. HBV can be transmitted across mucous membranes in the mouth, anus, and genital region. Besides blood, HBV is found in semen, saliva, and vaginal secretions, and can survive for up to 7 days on environmental surfaces if they are not cleaned. Public health recommendations state that individuals who live with an HBV carrier should receive the vaccine series if they are not already immune. I was told several years ago when I donated blood that my blood had the presence of antigens to HBV. Nobody elaborated on which kinds, and being ignorant of the different types I didn’t pursue it further. I recently had blood (liver) tests performed. I’m not sure which ones specifically, but I told my doctor of the previous “antigens to HBV” diagnosis, and she sent me a letter simply stating that “The labs indicate no hepatitis infection found, liver tests all normal.” Is it possible that I’ve completely cleared whatever HBV infection I had previously, and I’m now home free for life? Submitted 3/23/07 Without knowing the specificity of the test, it is difficult to make a proper diagnosis. There are in general two types of tests for hepatitis B: one for the presence of virus (HBsAg or HBeAg) and one for the detection of antibodies to the virus (anti-HBc, anti-HBe, or anti-HBs). If the former is positive, you have active infection; if the latter is positive, you have likely recovered from a previous infection. If your doctor’s letter indicated that you had previous antigens to HBV diagnosis and “no hepatitis infection found, liver tests all normal,” it is likely you have the latter. But to be sure you should contact your doctor and ask specifically the type and name of the tests performed. What is the current recommendation for administering the hepatitis B vaccine to a woman who just found out she is pregnant? Submitted 3/22/07 According to the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention, “Hepatitis B vaccination is recommended for all unvaccinated adults at risk for HBV infection and for all adults requesting protection from HBV infection.” If you have a risk factor for hepatitis B this is especially important, but it is not a requirement for you to receive the vaccine. In addition, the ACIP recommendations state that “Pregnancy is not a contraindication to vaccination.” The one available study found no adverse effects on the fetuses of women who received the hepatitis B vaccine. In addition, it is important to remember that the available vaccines contain only part of the surface coating of the virus, no whole or live virus particles, so there is no risk of infection of the fetus. I have been diagnosed with HBV; I am not sure whether it is acute or chronic. In early January 2007 my AST level was 786 IU/L; now it is 54 IU/L. In addition, my HBV DNA level is 1010 IU/mL, and something on the form my doctor gave me says that I have a 3.0 log IU when the normal range is <1.6. Does this sound look acute or chronic disease? I have not undergone any antibody tests yet. Submitted 3/8/07 The tests that you have undergone cannot separate acute from chronic hepatitis B. An AST level of 786 IU/L with a change downward to 54 IU/L is consistent with acute hepatitis B that has gotten better; unfortunately, it is also consistent with a self-limited episode of reactivated hepatitis B in someone who is chronically infected. This means that the disease can vary in intensity from time to time when it is chronically established. I suggest that you ask your physician to obtain a blood test called an IgM antibody to hepatitis B core. He or she may have done this already. If it is positive, you have picked up the infection recently. Also, a test called hepatitis B surface antigen has been done, and the results should be made available to you. If you have recently recovered from acute hepatitis B, it is likely to be at a low level or negative at this point. By contrast, all chronically infected patients are positive for this blood test. Your HBV DNA level is greater than 1000 IU, which means that your body is still producing small amounts of replicating virus. The HBV DNA test measures the genes of the virus. Please note that on the basis of the limited information you have given me, I suspect that the IgM anti-HBc test will be negative and that you have been diagnosed with chronic HBV infection. You have probably had a recent flare (that is, an episode of reactivation), and you need to be serially monitored with blood tests to ensure that your virus is remitting, entering a more quiet stage of replication. This is what we refer to as viral latency, which means it is not likely to be aggravating your liver. Should your ALT or AST become further elevated or remain elevated and your HBV DNA level increase further, you may need to undergo a liver biopsy. Usually liver disease becomes active when the viral DNA level is greater than 100,000 copies (not 1010 copies, as in your case). This would be reported as an HBV DNA level of >105. A liver biopsy can be performed as an outpatient procedure, and the stage of your disease—specifically the amount of liver scarring you may or may not have—would indicate whether you need antiviral therapy. Unfortunately, not all patients respond permanently to the currently available therapies, and these tend to be expensive when given for a long period of time, so a biopsy is often a prime indicator as to whether treatment is indicated. Good luck. Can someone in the inactive stage of hepatitis B infection be reinfected by someone who also has HBV, whether inactive or active, or is someone immune to reinfection only if he or she is naturally immune or has been vaccinated? Submitted 3/1/07 Most persons with chronic hepatitis B infection will eventually enter the inactive phase of the disease. Persons in this phase have normal liver enzyme levels and low or absent levels of HBV DNA, and their liver disease quiets down and improves. When a person is in this stage his or her immune system is able to suppress the virus. Many persons will remain in the inactive disease phase for life. However, the virus can reactivate in some persons even in the inactive phase; their liver enzymes will rise to abnormal levels and HBV DNA levels will also increase. Persons in the inactive hepatitis B phase are less infectious to others but, under the right circumstances, can still transmit the virus. There is evidence that some persons with chronic hepatitis B infection can be reinfected with another strain of hepatitis B since a few people have been found to be infected with more than one genotype of the virus, which means that they were likely infected more than once. We don’t know under what circumstances this occurs but it probably would be less likely in someone in the inactive hepatitis B phase, whose immune reaction to the virus would be much stronger. Someone in the immune-active phase, on the other hand, would have elevated ALT and HBV DNA levels, and his or her immune system would not be strong enough to suppress the virus at that time. Similarly, someone in the immune-tolerant phase would have very high levels of virus but show very little immune reaction against the virus. Persons who are immune either by naturally clearing the virus after infection or by successful vaccination would be very unlikely to get reinfected. Finally, it is important to know that persons in the inactive phase are not “cured” as they are still infected with the hepatitis B virus and need to be monitored with liver enzyme (ALT, AST) testing every 6 to 12 months for life, as they could experience a reactivation of their infection at any time, resulting in potential liver damage. In addition, when infected men reach the age of 40 and infected women reach the age of 50, they need to be monitored for the development of HCC with liver ultrasound and AFP testing. I have had chronic hepatitis B for about 6 years now. For the past 4 years, I have been taking a tablet of Hepsera® (adefovir) daily. For the first 2 years, I took it with Zefix, also 1 tablet daily. My wife is currently 4 months pregnant. Is the child's health endangered? My wife is not taking any drugs whatsoever and is in good health. I would like to know if Hepsera has any known side effects on unborn babies. Submitted 2/26/07 Your hepatitis B infection and use of Hepsera should have no ill effects on your unborn baby. Your wife should be tested for hepatitis B (hopefully she was tested and immunized before the pregnancy.)  If she does not have hepatitis B and is immune, then there is no chance of the baby becoming infected during pregnancy or delivery.   The infant should be immunized soon after birth and should have a blood test several months after the full vaccine series to confirm immunity to hepatitis B.   The recommendations are different if the pregnant woman has hepatitis B. In this situation, there is a chance that she could transmit the infection to the newborn baby near the time of delivery.  However, she would not be advised to take Hepsera.  No reports describing the use of adefovir (Hepsera) in pregnant women are available. Thus, there is not enough clinical experience with Hepsera to confirm its safety in pregnancy. Until more information is available, doctors are advised to be very cautious about prescribing adefovir for pregnant women.  Safe and effective vaccines and immunoglobulin products that can prevent transmission of the virus to the newborn would be a better choice. I have chronic hepatitis B and have a question about my serum HBV DNA test results, which were as follows: December 2005: 512 IU/mL (909 copies/mL) April 2006: <100 IU/mL (<160 copies/mL) February 2007: 10,400 IU/mL (23,046 copies/mL) My ALT and AST levels have been normal, averaging around 20 IU/L. I stopped taking lamivudine in August 2005 after about 1 year. Before starting me on adefovir, my doctor suggested waiting a couple of months to see what happened. When I had blood work done in December 2005, my doctor said I may not need to start adefovir at that time. I have not started it yet, but my most recent test results showed a rise in my HBV DNA level. What exactly does this mean? Does HBV DNA level always fluctuate or should I be worried and start adefovir right away? What if the HBV DNA level drops again in a few months? What would that mean? Would my diet or dietary supplements affect the HBV DNA results? I have tried many herbal and Oriental medicines and supplements during the past year or two. I am concerned because I do not want to start adefovir due to its side effects and the consequences of stopping it down the road. Submitted 2/20/07 The answer depends on your age and HBeAg status, and whether you have had a liver biopsy showing significant disease. If you are younger than approximately 30 years of age, you might just follow your HBV DNA for a longer period. If you are older, a liver biopsy or, as an alternative, a noninvasive test to assess the status of your liver might help determine the need to start therapy. The usual HBV DNA threshold for starting treatment is 2,000 IU/mL for patients who are HBeAg-negative and 20,000 IU/mL for patients who are HBeAg-positive. However, these HBV DNA levels apply to those who also have an elevated ALT level and/or significant disease on liver biopsy. Serum HBV DNA levels often fluctuate in patients with HBeAg-negative chronic hepatitis B, and diet or supplements should not affect the results of this blood test. Finally, adefovir is associated with virtually no side effects, except for a low risk of kidney dysfunction, but stopping therapy down the road could be associated with a flare of hepatitis B. I am a 43-year-old former hospital worker. When all the hospital employees were screened before having hepatitis B vaccination, I tested positive (for what?) but couldn’t have the vaccine. They said I probably had a mild case years before that went undiagnosed. I was then told I could never give blood. Last year I was tested again and told that my results were >10,000 (of what, I don’t know) and told again that I do not need the vaccination and still cannot give blood. My question is, what are these values? Am I testing positive for the antigen, the antibody, or what? They also said that they have never seen the value (>10,000) so high before. Any information you could give me would be appreciated. Submitted 2/19/07 First you should request your medical records and test results to know precisely which tests were positive and what assay has the high value of >10,000. My presumption is that you may have acquired silent infection with hepatitis B virus and that your HBsAg (the standard serologic test for infection with this virus) is positive. The value of >10,000 could be your serum HBV DNA level, which is determined by a virologic test that indicates the activity of the virus. On the other hand, you might not be infected and have one or more antibodies to hepatitis B as markers of prior hepatitis B with recovery. The high value of >10,000 could be anti-HBs, which can either be reported as positive or negative, or as a quantitative value measuring the strength of the antibody. Thus, as you can see, you may be infected or recovered from hepatitis B, which is an important distinction. If you are infected, you need to see a consultant for evaluation and determine if there is a need for therapy. I am 27 years old and have been tested for hepatitis B. My results are as shown below. What is your diagnosis? My doctor says that no treatment is needed now, just observation until the virus reaches the liver. Is there a cure or any way to prevent the virus reaching the liver? Is my doctor correct about his decision? HBsAg positive (29.63, Dec. 2006; 27.13, May 2006) PCR (9.73 ×105 copies/mL, Dec. 2006) Anti-HBs negative IgM negative Anti-HBc positive HBeAg negative Anti-HBe positive SGOT, 60 ui/L (Dec. 2006) SGPT, 99 (Dec. 2006) and 78 (May 2006) Bilirubin Dircte 2.7 mg/L (Dec. 2006) Bilirubin totale 7.7 mg/L (Dec. 2006) Biopsy result (Feb. 2007) Macroscopic description: 30/1/2007 Le Specimen recu est constitue de trios fragments tissulaires de 0,3 a 1,2 cm. (BN) Microscopic description Colorations Speciales: PAS, Diastase, Reticuline, Trichrome de Masson. Les Coupes examinees interessent 30 mm de tissu hepatique interpretable. Les espaces portes sont elargis, fibreux, sans septa remarquable. L'inflammation portale est minime a moderee, sans nodule lymphoide identifiable. La necrose parcellaire est minime, de meme que la necrose acidophile intralobulaire. Il n'est pas note de steatose. L'un des espaces portes objective une fibrose concentrique peri-canalarie. L'infiltrat est par endroit emaille de quelques polynucleaires neutrophiles. (GS) Diagnostic: Foie, Biopsies a L'aiguille: Aspect d'hepatite chronique avec activite minime, et fibrose portale sans septa (Metavir: A1, F1). Submitted 2/17/07 You have chronic hepatitis B. The liver biopsy showed that your hepatitis is mild (score A1F1). Your doctor is right. You do not need treatment. However, you should have regular follow-ups, with measurement of serum ALT (SGPT) levels and HBV DNA levels every 3 to 4 months. Treatment might become a possibility if the serum ALT levels are found to be increasing. I am a 27-year-old woman living in Germany. The results of a blood test I underwent 5 days ago for hepatitis and HIV showed that I was HBsAg negative, anti-HBc negative, and anti-HBs positive (>1000 IU/L). My doctor told me that “serologically” there is no infection but that since my antibody level was higher than 100 IU/L, I should receive “another” vaccination after 10 years. This is my problem: I don’t remember receiving a vaccination against hepatitis B to begin with. Could it be that I was infected and that the organisms managed to survive? If this is the case, can I still have the virus and I can transmit it to my boyfriend? Submitted 2/12/207 Your blood tests showed that you probably were vaccinated against HBV. HBV vaccine has been a standard childhood immunization practice for many years in many parts of the world. In the United States it became common practice to administer this vaccine to children in the 1980s, and I presume that Germany also implemented this policy then. It is unlikely that you were exposed to the virus because you were anti-HBc negative. Either way, you are not at any risk of transmitting the virus to your boyfriend. I am a 24-year-old Indian man with no symptoms of hepatitis B. However, I have been tested as being HBsAg-positive, HBeAg-negative/anti HBeAb-positive, and HBV DNA–negative. Most of my liver function tests are normal but my serum ALT level is 70 IU/L, which is high. Am I in the carrier stage of hepatitis B? Will my HBsAg-positive test result convert to HBsAg-negative automatically or with treatment? I’m very worried because I am a Marine engineer and have been turned down for a job in the Merchant Navy based on my HBsAg status. I have been told by my doctor that I cannot seroconvert. Some people have advised me to start yoga and ayurvedic treatment as they have heard of some cases in which the virus has been reversed successfully. Submitted 2/7/07 The incidental detection of hepatitis B is not uncommon. Nearly 45 million persons with the virus are estimated to be living in India and their virus could be detected only during a physical examination. They have no symptoms of liver disease, and when they are told the results of their blood tests they are often understandably upset. Since you have no symptoms of disease, presence of the virus should not be equated with the presence of disease. Your blood tests reveal that you have a low-replicative virus, something confirmed by the absence of HBV DNA in your blood. However, it would be important to undergo DNA testing with a Cobas Amplicor or Abbott assay. An ALT level of 70 IU/L does concern me, however. It could be due to the virus or may be a result of fat in the liver. If you have a family history of diabetes, fat is a possibility. I would advise you to undergo ultrasound of the abdomen. If not, hepatitis B could be a problem. In that case, though, a high ALT level may actually be an advantage, as an increase due to HBV infection means a better chance for treatment success You should (1) undergo ultrasound examination for fat in the liver and blood tests for serum lipid levels, (2) undergo HBV DNA testing by sensitive quantitative assay, (3) talk to your physician about a liver biopsy if your ALT level remains elevated, and (4) talk to your physician about starting antiviral therapy if your viral load is >10,000 copies; if it is lower you can wait. Once you begin antiviral therapy you may need to continue it for at least 3 years. Please note that the chances of permanent cure are still not more than 60%. There are very little scientific data to support the use of yoga and ayurvedic therapies. What is your recommendation regarding the management of infants born to mothers whose HBsAg status is not known at birth? I am aware of a mother who was found to be positive only when her baby was already 3 months old. The baby has not received any hepatitis B vaccine since birth. Submitted 2/1/07 The Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention makes the following recommendation for the management of infants born to women with unknown HBsAg status: “Infants born to mothers whose HBsAg status is unknown should receive hepatitis B vaccine <12 hours of birth. The mother should have blood drawn as soon as possible to determine her HBsAg status; if she is HBsAg positive, the infant should receive HBIG as soon as possible (no later than age 1 week).” Since the infant in question was already 3 months old when the maternal hepatitis B was found, there is no indication for HBIG at this point. The infant should be tested now for HBsAg and, if negative, immediately begin the series of three hepatitis B vaccine doses. The infant should then be tested for HBsAg and antibody 3 to 6 months after completing the vaccine series. In a patient who has chronic active hepatis B, does the level of inflammation seen on liver biopsy fluctuate with disease activity (ie, fluctuating viral loads), or does it remain static? Submitted 1/31/07 The level of inflammation may vary over time, although not in direct proportion to fluctuations in viral load. Since this is an immunologically mediated disease process, the viral load in some patients may actually increase as liver inflammation decreases (eg, in a patient with HBV/HIV coinfection and dropping CD4 counts). However, HBV viral load has been correlated with the risk of developing HCC. If a mother has hepatitis B and gives birth to a child, do the antibodies in the mother’s body transfer to the baby? Does the baby automatically have hepatitis B? Should the child receive a vaccine at birth or be given antibodies? Submitted 1/26/07 If the mother is immune to hepatitis B (ie, has protective antibodies) either from a resolved infection or vaccination, some of these antibodies will be transmitted to the newborn. However, these antibodies will last for only 2 to 15 months, depending on the titer. They will not protect the infant for very long, so the infant will need to be vaccinated according to the normal procedure. If the mother actually has hepatitis B, she does not have any protective antibodies. There may be antibodies called “e antibodies” or “core antibodies” in her blood, but they are part of the infection, and do not confer any protection. In this case, the infant is certainly at risk for becoming infected. The infant should receive HBIG within 12 hours of birth, and the first dose of vaccine before discharge from the newborn nursery. He or she will then need the subsequent doses of vaccine to complete the series, and should be tested at about 1 year of age for HBsAg and antibody to make sure he or she did not become infected and is indeed immune. If I get hepatitis B once can I get it again? Submitted 1/26/07 It is highly unlikely that a healthy person who acquires acute HBV infection that resolves will acquire the disease again. By “resolves,” I mean that the person does not develop chronic HBV infection (is HBsAg negative and anti-HBs positive), and does not develop or acquire any immunosuppressed condition in the future. However, a person who develops HBV infection can be chronically infected for the rest of his or her life and have ongoing related medical problems. In addition, people who may have had resolved acute HBV infection in the past could experience disease reactivation related to immunosuppression later in life. I recently donated blood and was informed that I tested positive for HBsAg. I told my doctor about this and when I underwent further testing I was found to be positive for both HBsAg and anti-HBsAg. My liver enzymes are normal, and my liver ultrasound result was also normal, but my doctor has referred me to a hepatologist to run more tests. What does all this mean? Submitted 1/25/07 You have HBV infection, and may have had it for a while. The HBsAg to which you refer is part of the outside coat of the virus. Sometimes infected patients will also have antibodies to this viral protein, but they maintain their infections as long as, and have the same natural history as, carriers of the virus who are HBsAg positive without antibodies. My 28-year-old cousin is infected with HBV. His blood tests showed that he was HBsAg positive, HBeAg negative, and anti-HBe positive, and that his HBV DNA level was very low. Recently he ran a fever and experienced severe headaches. His doctors say that he is chronically infected, but I am confused. Please tell me if his condition is chronic or acute. Submitted 1/17/97 Your cousin probably has chronic hepatitis B. To confirm this, the test for HBsAg should be repeated in 6 months. Your cousin may be in what is known as the inactive hepatitis B phase. Persons in this phase are negative for HBeAg, positive for anti-HBe, and have absent or very low levels of HBV DNA. They also have normal liver enzymes, ALT and AST; your cousin’s doctor should have tested this. About 60% to 70% of persons in the inactive hepatitis B phase will show the same laboratory values, but 30% to 40% will have a reactivation of their hepatitis B with liver enzymes rising to abnormal levels and increased levels of HBV DNA. Many patients demonstrate no symptoms when this reactivation takes place, but it may result in liver damage and even cirrhosis or HCC later in life. The good news is that there are antiviral medications against hepatitis B that can control reactivation by reducing the level of the virus and, thus, decrease the risk of HCC and cirrhosis. Right now it looks like your cousin won’t need these medications if his liver enzymes are normal. However, he will need to have his liver enzymes checked every 3 to 6 months for the first year and then every 6 months for life, as he could experience disease reactivation at any age. When he reaches the age of 40 he should undergo a liver ultrasound and AFP tests every 6 months to check for HCC, as the risk is higher for men over 40 years of age. Also, any family members of your cousin, persons who live with your cousin, and your cousin’s sexual partners should be tested for HBsAg and, if negative, given a course of hepatitis B vaccine. If any of them are found to be HBsAg positive, they should undergo the same tests as your cousin. If a person who has no open sore or cut in the mouth swallows the semen of someone infected with hepatitis B virus (HBV)—and if the infected individual is in the inactive or immune-tolerant stage of HBV infection—will the person get infected with the virus? Won’t the HBV instantaneously die upon contact with the various powerful acids within the stomach? Submitted 1/15/07 HBV is indeed inactivated by gastric acid, and thus swallowing virus does not lead to infection. Open sores in the mouth allow any HBV present in semen to be transmitted to the bloodstream through the break in the oral mucosa and thus to result in infection. The likelihood of spreading HBV by exposure to open wounds is highest when there is active viral replication in the source person. Active viral replication is indicated by either the presence of HBeAg or high levels of HBV DNA, or both, in the source person with chronic HBV infection. Thus, persons with chronic hepatitis B that is active, and also those who are in the immune-tolerant phase and have high levels of HBV DNA, are more likely to spread HBV than are individuals who are inactive carriers showing little viral replication and having low or undetectable HBV DNA levels. I am a 29-year-old medical student from Africa, studying in China. Just recently I was sick with meningitis and when the doctors tested my blood they found out that I was HBsAg positive, HBeAg negative, anti-HBeAg positive, and had undetectable HBV DNA levels, with normal liver function test and liver ultrasound results. My doctor says that I don’t need treatment and that I am not a candidate for liver biopsy. My questions are: (1) Do I need to undergo any further tests? (2) How can I trace the hepatitis from my family members, and what treatment, if any, might they need? (3) When will I be a candidate for treatment, and which drug is best as a first choice? (4) I will be graduating and going back home in a few months, and I am not very sure I can get the necessary drugs in west Africa. Could you recommend a Web site or place where I can easily access the drugs needed for treatment? (5) Do you think I can still be a doctor even if I’m an HBV carrier? If yes, can you please give me some tips on protecting my patients and at the same time preventing myself from being coinfected with HDV, HCV, or HIV? Thank you so very much. Submitted 1/9/07 First I’m glad to hear you’ve recovered from meningitis; that can be frightening. When persons have HBsAg in their blood for 6 months or more and have antibodies to HBeAg but not HBeAg itself, along with evidence that there is no liver inflammation, they are considered to have inactive hepatitis B. For many doctors, a long-term pattern of normal liver enzymes and undetectable HBV DNA levels is sufficient proof that the condition is inactive without the need for a liver biopsy. No treatment is needed for persons with this condition. However, it is important for such persons to be monitored, such as with liver enzyme testing and HBV DNA measurement. Also, if persons with inactive hepatitis B become immunosuppressed (as a result of cancer treatment, for example), they need to undergo treatment for HBV to hold the infection in check until their immunity comes back. The risk of giving hepatitis B to others is lower when you have inactive hepatitis B than when you have an active form with higher HBV DNA levels. However, all sexual and close household exposures should be screened for possible infection, and those susceptible should be vaccinated against hepatitis B. Doctors and other health care providers can give HBV infection to patients, although the risks of that occurring are markedly reduced in persons who don’t perform procedures that involve potential contamination and those with inactive hepatitis B. Exposure-prone procedures include surgery and delivering babies. The risk to patients needs to be weighed against the alternatives and need for the health care provider’s services. A local committee should decide on a case-by-case basis. In general, that risk would be very low for persons with HBV DNA levels that are <200 IU/mL. In Africa, the availability of HBV medications varies by country and district. In almost all areas lamivudine can be obtained, since its use is widespread for combating HIV infection through both the Global Fund and the US PEPFAR programs. Likewise, tenofovir and the related Truvada, which consists of emtricitabine and tenofovir, may be available, but at greater cost. Though not licensed for HBV yet, tenofovir is a potent anti-HBV agent. I apologize for not commenting directly, but I cannot specifically address your case. Hopefully the general information I provided will be helpful. Good luck with your studies. I am a 32-year-old Afghani man. I received the first dose of the HBs vaccine 1 month ago and the second one 2 days ago, but I just had my blood checked and I’m still HBsAb negative. How can I be sure that the vaccines have been effective, and do I need to receive another dose of the vaccine now or can I stop it? Submitted 12/26/06 You need to receive three doses of the hepatitis B vaccine; preferably Engerix-B, 20 mg injected into the deltoid area at 0, 1, and 6 months, and then check your hepatitis B antibody titers 1 month after the third dose for a proper response. If your response is positive for HBsAb titers, you may not need a booster dose for a long period. If, however, you do not develop a response after the third dose, you will need to get double the dose, but this is needed infrequently in normal hosts. A poor response is seen commonly in patients with chronic renal failure and patients who are immunocompromised. In 1996, after being tested for hepatitis while working in a hospital, I was found to be positive for HBsAb. My doctor asked me if I’d received an HBV vaccine before and I told him I hadn’t. He said my situation must have been the result of past exposure, though I couldn’t recall any. That said, I had lived with a roommate, who had liver problems, for less than a year, though I was careful to avoid exposure to his blood or open wounds. Then the doctor suggested that I might have had a brief viral attack but that my immune system cleared it quickly. He didn’t give me any advice or suggestions beyond telling me that I did not need to be vaccinated. My test results as of 2006 are: • HBsAg, non-reactive • Anti-HBs, reactive (>150 mIU/mL) • Anti-HBc “A,” reactive • HBV DNA, undetectable • Liver CT, no sign of hepatitis B Right now I’m very concerned about the chance that my wife, who tested negative for HBsAg in 1991, may become infected. My questions are: (1) If I had, indeed, become infected from my roommate, whom I moved away from 4 months before I met my wife, would my body have had enough time (4 months) to produce anti-HBs? (2) Have there been reports of people who were positive for anti-HBs, but not from vaccination, and had no history of having been HBsAg-positive or whose pattern of exposure was not known? Would such people have relatively low infectivity because their immune system responds quickly and effectively? (3) Our daughter was immunized 15 years ago, by receiving three shots and a booster; would she be well protected from infection? Thank you very much for your assistance and time. Submitted 12/9/06 HBsAb can develop in 1 to 6 months (you had mentioned 4) but infected people would most likely have significant signs and symptoms of acute hepatitis, such as jaundice, malaise, and nausea with abdominal pain, so I don’t think you were infected then. Most likely you had developed immunity to the HBV before you started living with your roommate. You would not be infectious. In regards to your daughter, HBsAb levels can decrease over 15 years. Therefore, it would be advisable to re-check your daughter for HBsAb, and if the test is still negative, she should be tested for HBcAb and HBsAg. If both are negative, she should have one booster shot again and be tested for HBsAb in 2 weeks. If she has been immunized successfully in the past, she should have a robust elevation of HBsAb with only one shot. I am HBsAg positive, HBeAg negative, my ALT level is 50 U/L, and my HBV DNA level is not detectable by PCR. My questions are (1) what is my status?, (2) should the fact that I’m a smoker have an effect on my condition?, and (3) would it be safe for me to go to school overseas, something I had been planning to do? Submitted 12/6/06 (1) Likely you’re an inactive carrier. I would recommend repeat testing for your ALT and HBV DNA levels on two or three more occasions over the next 3 to 12 months to make sure your HBV DNA levels remain undetectable and ALT level remains normal or minimally increased; this will rule out a fluctuating course of HBeAg-negative chronic hepatitis. (2) Smoking is associated with many health hazards, including an increased risk of liver cancer, so I would strongly recommend cessation. (3) Sure you can go abroad to study, but in the United States and some European countries, HBV carriers might face restrictions regarding the practice of medicine or dentistry or being admitted into medical or dental schools. The regulations vary from country to country and with time. I am HBV positive and have a cut on my right hand. Recently I put my hand down on a counter and left blood there. How many days can the virus stay infectious on the countertop? Submitted 11/10/06 HBV is spread primarily by the parenteral and percutaneous routes through contact with tainted bodily fluids or tissues. Nevertheless, the indirect spread of HBV, although very uncommon, can theoretically occur when one comes into contact with an object that is freshly contaminated with tainted blood. There has been concern that inner-city children and park workers might be at risk of contact with sharps that could be contaminated with HBV. In one study, just fewer than 5% of discarded syringes found in four parks had detectable HBsAg, the serologic marker of HBV used to determine the presence of the virus. In this study, the infectivity of these syringes was difficult to assess, as it was not known if the virus was viable. However, HBV and possibly other viruses such as HCV and HIV can be detected in the environment for several weeks. Factors affecting virus survival include the viral load, ambient temperature, sunlight and humidity, and the volume of bodily fluid present. That said, one must be careful in interpreting studies of the presence of detectable virus in the environment, as another study showed that even though HBV DNA could be detected by sensitive assays such as PCR, injection of infectious samples into susceptible ducklings showed no infection. Thus, I can only speculate regarding the answer to the infectivity of fresh blood on a countertop. Based on the very limited studies of this issue, I would think that this material would be most infectious when fresh and less infectious over subsequent days or especially weeks. For it to cause infection would require contact with damaged skin such as an open wound. I am a 26-year-old Pakistani man with no symptoms of hepatitis B. However, I have been tested as being HBsAg-positive and HBeAg-negative by PCR. My viral load is not detectable. Most of my liver function tests are normal but my ALT level is above the normal range. Am I in the carrier stage of hepatitis B? Do I require treatment? Can my HBsAg-positive test result convert to HBsAg-negative automatically or with treatment? I’m very worried because I have been turned down for a job based on my HBsAg status. Submitted 10/23/06 Thank you for your questions. To take them in turn, yes, you are likely in the inactive hepatitis B carrier stage. Since your viral load is not detectable by PCR, which is a very sensitive test, and you are HBeAg-negative, your infection is stable at this time. However, there is about a 30% chance that your hepatitis B could become active, so you will need to undergo regular follow-ups every 6 to 12 months throughout your life. You should have your doctor check your liver function tests, especially ALT, at every visit, and if your ALT is elevated he should repeat the HBV DNA measurement by PCR. If you have an elevated ALT and an HBV DNA level that is more than 10,000 c/mL or 2000 IU/mL, you should be evaluated for treatment, probably first undergoing a liver biopsy to see if the virus is damaging your liver and causing any scarring. When you reach the age of 40, if you are still HBsAg-positive, you should undergo screening for liver cancer with AFP and liver ultrasound every 6 to 12 months so any carcinoma can be detected early. You do not need treatment at this time. There are now six drugs licensed in the USA for the management of hepatitis B. These drugs can suppress the virus but do not cure the disease. Since your immune system has suppressed the virus at this time you do not need medication. Most persons who have reached your stage of hepatitis B can keep the virus suppressed throughout their lives, but as I mentioned earlier there is about a 30% chance that the virus will reactivate. If that occurs with you, you could need treatment in the future; that is why you need to undergo lifelong monitoring of your hepatitis B infection. Some people, about 0.5% per year, will clear HBsAg and develop anti-HBs. This more often occurs in people over 40 years of age. If this occurs, your risk of complication goes way down. However, the virus can still be present in very low levels, and if your immune system were to be suppressed, the virus could reactivate, so you should still be monitored yearly if you do lose HBsAg. Finally, there is no reason why you should be denied a job. The chance of you infecting a coworker would be extremely low. You should not be discriminated against. Since you are in the inactive phase, it would be difficult for you to transmit the virus to others. You do not need to tell your employer that you have hepatitis B. If you have a steady sexual partner, you should have your partner tested and, if your partner is negative for hepatitis B, vaccinated. Until your partner is fully vaccinated you should use a condom. Once your partner has been tested immune, condoms would no longer be necessary to protect against hepatitis B. Also, if you get any open cuts, cover them with a bandage and if you bleed on any surface, use any household detergent, which kills the virus, to clean up the blood. You can participat