Scott Webb: Despite vaccines and vaccine recommendations, hepatitis is more common than you'd think. And joining me today to tell us about the main types of hepatitis and what we can all do to avoid contracting it, is Dr. Divya Ahuja. He's an Infectious Disease Physician with PRISMA Health and an Associate Professor of Clinical Internal Medicine at the University of South Carolina School of Medicine, Columbia.

This is Flourish, the podcast brought to you by PRISMA Health. I'm Scott Webb. Doctor, thanks so much for your time today. We're going to talk about hepatitis, and I know there's different types of hepatitis, so maybe let's start there. Maybe you can tell us the difference between the different types of hepatitis.

Scott Webb: Hepatitis, if you break the word down, it means inflammation of the liver and anything which has an itis at the end of it, it means inflammation. So hepatitis simplistically speaking means inflammation of the liver. Now inflammation of the liver can come from many different things. One of the commonest things that we all imbibe once in a while is alcohol. Some people imbibe it more often than once in a while, and alcoholic hepatitis is one of the commonest hepatitis that we see. People get admitted and they're very sick from it. There are other medications that can cause hepatitis. As you know, Tylenol, which we all take once in a while, if somebody takes too much Tylenol, that can cause a hepatitis, and there are other less common things. But one of the things that we are going to talk about today is the infectious causes of hepatitis. Which infections can cause a hepatitis. Now we will focus on actually A, B, and C Hepatitis. But just to give you a sense of which infections can cause hepatitis, almost any infection can. If we just throw our minds back a couple of years, people admitted with COVID, almost all of them had some degree of liver enzyme elevation. So the liver is the organ that leads to hepatitis.

Divya Ahuja, MD: A lot of them had inflammation of the liver because COVID caused that. People with influenza can get hepatitis, and so there are many infections that can cause hepatitis. But today we are going to focus on three specific hepatitis viruses.

Host: Yeah. So let's, let's do that then. You know, it sounds obviously that there can be many causes. It sounds very common, as you say, even related to COVID, which we all have lived through. So let's talk about that. How does one get hepatitis or the various types A, B, and C?

Divya Ahuja, MD: Just to take a step back, uh, there are more than A, B, and C, but because the other ones D and E are less common, we may not talk about them. Although there has been recent data that Hepatitis D may also be under reported in the country. So I'll touch on that briefly. But hepatitis A not very common in the United States and is getting less common by the year because every child gets vaccinated. But in the last two, three years there have been small outbreaks, mainly some in men who have sex with men, some in homeless people, and it is transmitted through the oral fecal route ie contaminated water or poorly washed salads and things like that.

So since it is less common in the US, it is not something we see that often, but it is far more common in the developing world. So if you have somebody who's just come back from a trip to south America or India or Africa, and they have Hepatitis ie, they have their liver enzymes are high, then one has to consider hepatitis A.

 By the way, every child should be vaccinated to hepatitis A. I think in the last few years we've forgotten the value of vaccines because we've all got it into our heads that vaccines hurt and they don't help.

Host: Hmm.

Divya Ahuja, MD: We've forgotten in this country how vaccines have saved millions of lives. And they continue to save millions of lives, and every child should get a Hepatitis A vaccine. And now, since 2020, hepatitis B vaccine is also now given universally to almost every person who wants the vaccine and every child is vaccinated. So that's a segue into Hepatitis B, slightly different virus.

It is not transmitted through water or food or salads. It is transmitted more through blood products, sexual contact, sharing razors, and then from mother to child. But once again, given the recent increase in Hepatitis B that we've seen in the country, the CDC and other authorities recommend everybody should be vaccinated. One of the things in infectious diseases that we talk about is how do we reduce the burden of a particular infectious disease in the country? A lot of people in the country, in the United States have forgotten that there used to be polio, there used to be TB. There used to be so many other infections like measles, mumps, but they've gone down because of vaccination.

Host: Yeah.

Divya Ahuja, MD: But in any infectious disease, whether it is COVID, whether it is influenza or monkey pox that we had recently, the first thing is to diagnose. The second thing is to try and treat as many as possible. And the third thing is to try and prevent, and sort of thinking of these three pillars of infectious diseases; for Hepatitis A, almost everybody with Hepatitis A gets better without any serious outcomes. They feel lousy for a week, 10 days, but then they get better and almost no one dies from it.

Host: Okay.

Divya Ahuja, MD: And there is no chronic Hepatitis A. So once you've had hepatitis A and I had Hepatitis A back in India when I was in medical school 35 years ago. I was sick as a dog for a while, got better, and I have lifelong immunity.

Host: Yeah.

Divya Ahuja, MD: Hepatitis B is a little bit different. Once somebody gets Hepatitis B and they don't clear the virus, that virus stays in them for life. And over the next 20, 30 years, it can lead to liver damage, which is also called cirrhosis of the liver, and in some cases it can lead to cancer of the liver. So Hepatitis B is a little bit different from Hepatitis A where there is an acute illness. Most people don't know they get the illness. But over the next 20, 25 years, those who get chronic Hepatitis B, ie, those who cannot clear the virus, may end up getting cirrhosis or cancer.

So hepatitis B is more nuanced. It does have a chronic phase, but there is a superb vaccine for it. So once again, it is a preventable illness. And in fact, there are only two vaccines we have that prevent cancer. Hepatitis B is one of those vaccines that if you vaccinate a person to Hepatitis B, you prevent them from getting Hepatitis B, you can potentially prevent them from getting cancer. And the other vaccine that prevents cancer is the wart vaccine. The human papillomavirus vaccine. So there are only two vaccines that can prevent cancer. And Hepatitis B vaccine, which we should all be getting, every child should be getting, is a preventable illness and potentially can prevent cancer down the line.

Host: Yeah. So, you mentioned that a lot of times when people have Hepatitis B, they may not even realize that they do. And I wanted to ask you about that. Like, what are generally the symptoms of hepatitis and is it common that folks just don't even know that they have it? They maybe just don't feel well, but they don't necessarily know that they have hepatitis? I mean, take us through that.

Divya Ahuja, MD: Sure. Good question. And the thing is that the majority of people who get Hepatitis B or Hepatitis C will not have symptoms.

Host: Okay.

Divya Ahuja, MD: So they get the infection. If a and getting into the weeds a little bit, if a child is infected, let's say a child is infected from the mother, either during a pregnancy or in early childhood, they are less likely to clear the infection and the Hepatitis B stays in them for life. If an adult gets infected, they are much more likely to clear the infection. And they are less likely to have Hepatitis B caused problems throughout their lives. So chronic Hepatitis B chronic means something that stays for a long time. Chronic Hepatitis B is far more common if a child or infant gets infected as opposed to if an adult gets infected.

But if an adult does get infected, they are unlikely to have symptoms. Those who have symptoms; about one third will have symptoms. The symptoms could be fever. Or body aches, nausea, vomiting, some abdominal pain. The urine turns dark, but like I said, the majority of people who get Hepatitis B or Hepatitis C will not have symptoms.

They will get the infection. They won't know they have the infection until their doctor or their provider checks them for it. That is something that we should be asking our providers to do. That check me for Hepatitis B, and you should do a test for Hepatitis C. It is in the CDC guidelines that every American between the ages of 18 to 60 years old should be tested for Hepatitis B and Hepatitis C at least once in their lifetime.

Because those who have the infection, the majority won't have symptoms. They won't know that they have it. And if left untreated or left unmonitored down the line, it can cause cirrhosis and in a small percent it can also cause cancer of the liver.

Host: Yeah, and you mentioned that, a Hepatitis A is one of those things that will pass, but B and C, can be chronic and can cause and lead to all these other health issues like cirrhosis and other things. So let's talk about treatment options. Let's say that someone comes in, they do the right thing, as you're saying, as you're encouraging doctors to do, they're testing for Hepatitis B and C, and so it's been diagnosed. How generally then, is Hepatitis treated?

Divya Ahuja, MD: Yeah. And the one thing we didn't talk about yet, which is one of my pet projects is hepatitis C. And we talked about Hepatitis B. It is estimated there are roughly about 800,000 or 900,000 Americans who have Hepatitis B and I think it's good to put that into perspective that there are about 340 million Americans.

Of those, roughly about 1 million or just less than 1 million have hepatitis B. So I think that's important to put into perspective that almost one out of 350 or one out of 400 or one out of 450 Americans will have Hepatitis B. So it's not that uncommon.

Host: Right.

Divya Ahuja, MD: Hepatitis B treatment is a little bit more nuanced. Hepatitis B, if somebody has chronic hepatitis B. So remember, not everybody gets chronic Hep B. An adult, if they get it, they will clear the virus. But let's say somebody does get chronic Hepatitis B and they're unable to clear the virus, and the virus hangs around in them for decades and decades. So when they go and see their provider, they will do some extra testing to see how much the virus is. We can measure the amount of virus in the blood. We can measure the liver enzymes to see how much damage there is. We can do certain tests that tell us if and how much the liver is damaged, and because Hepatitis B is difficult to cure, once you have chronic Hepatitis B, not everybody gets placed on treatment because even if you put people on treatment, even after years of treatment, you cannot get rid of the virus.

You can just control it. Think of Hepatitis B a little bit like HIV.

Host: Hmm.

Divya Ahuja, MD: The numbers are almost the same. There are about 1 million Americans with HIV, so about one out of 350 Americans have HIV. I just want that to sink in. One out of 350 Americans have HIV, and if you take a young African American men who have msm or just an msm, their risk is even higher.

But HIV and Hepatitis B, we cannot eradicate, we can just control with the treatment and with Hepatitis B, it is not clear. Does controlling an asymptomatic person with a very small amount of virus in their blood, does it make any difference? And so in some patients with Hepatitis B, we don't place them on treatment. We just monitor the virus. Hepatitis C is a little bit different. Hepatitis C is something that we can easily eradicate, and I'll talk about Hepatitis C for a minute.

Host: Yeah.

Divya Ahuja, MD: Hep C is even more common than HIV and Hepatitis B. It's estimated there are about 2 million Americans with chronic Hepatitis C. So almost one out of 150 Americans or one out of 200 have chronic Hepatitis C. Hepatitis C virus is transmitted mainly by blood or blood products. So prior to 1990, before all the blood in the country was screened for Hepatitis C, people got it through blood transfusions. Or back in the Woodstock era, if somebody was shooting up and things like that, they would get it from IV drugs or a hemophiliac or patients who needed blood products, they would get it from the blood products because we did not even know there was a virus called Hepatitis C up until 1989. After the virus was discovered, since 1991, all blood and blood products in the United States have been screened. So the risk of getting Hepatitis C from a blood transfusion is extremely low, if not almost zero. So nowadays, how do people get hepatitis C?

Host: Right.

Divya Ahuja, MD: All of us are aware of the opioid crisis in the country.

Host: Yeah.

Divya Ahuja, MD: And in the last 10 years, all the Hepatitis C that has happened in the country has not been from blood products, but is in patients who are using IV drugs, whether they're shooting up IV oxy or fentanyl or heroin or whatever, or meth. And that has led to a big jump in the numbers. We thought we'll be able to get rid of Hep C. And I'll talk about the treatment in a minute, but the numbers continue to go up and almost every year there are almost 30 or 40,000 new infections because of all the IV drugs and patients sharing needles. And the fact that our lawmakers still don't see the benefit of syringe exchange programs.

Host: Yeah.

Divya Ahuja, MD: Syringe exchange programs have clearly been shown to be of benefit in multiple areas. But, because of whatever reasons they think of, we currently don't have a syringe exchange program in the state, and I think that'll really be of benefit.

But getting back to Hepatitis C, blood products, razors, contaminated needles are the most common way of Hepatitis C transmission. Once a person gets Hepatitis C, let's say a hundred people get infected with Hep C, about 40% will clear the virus, but about 50 to 60% will develop chronic Hepatitis C.

So unlike Hepatitis B, where most adults will clear the virus, Hepatitis C, most adults cannot clear the virus. So if an IV drug user, let's say 25 year old, uses meth, shares a needle, the needle is contaminated with Hepatitis C because somebody else used it and they get Hepatitis C, it is more than likely that that person will get the virus and then cannot clear the virus, and so they get chronic Hepatitis C.

And once again, just like with Hepatitis B, the majority of patients will not have any symptoms. So they will continue to use needles or share needles, and they could potentially transmit it to others also. And that is why it is so important that we test for Hepatitis C and Hepatitis B in our substance use facilities.

As you know, DAODAS and other facilities test those provide, MAT or they provide treatment for opioid use disorders, all those facilities should be testing for Hepatitis C and Hepatitis B routinely, because that is where the biggest burden is at this time, in opioid use centers. But we just don't do that. They don't have the funding for it. And the other thing is that Hepatitis C is very, very treatable. Very curable. It is one of the few viral infections we can completely eradicate from the body. I mentioned to you that Hepatitis B, there is no good cure. We can control it, but we cannot eradicate it.

Hepatitis C on the other hand, is very easy to eradicate. If we had this conversation in 2011, 11 years ago, we had lousy treatment for it. We used to use interferon, ribovirin, nonsense like that. But in 2013, I think all of your listeners would've heard of HARVONI. It came out in 2013. It was priced very high. At that time, gilead was selling it for $1,100 a pill. So they were making tons of, they made billions of it $1,100 for one pill, $84,000 for a three month course. And they really made billions off this, on the cost of the American taxpayers.

Um, but, it is a superb drug. It can completely eradicate the virus. And 97 or 98% of people who get treated with HARVONI or EPCLUSA or MAVYRET, these are the new medicines, 98% i e, the vast majority of people will completely clear the virus from their body. So Hepatitis C is a curable disease and it is the hope of everyone, including the CDC, the World Health Organization and us here in South Carolina, that by 2030 we should be able to eradicate Hepatitis C. Because if we treat people, we reduce the virus in the population. We have syringe exchange programs, we should be able to eradicate it completely.

And I'm going to toot my horn for just a second here. Or in fact, South Carolina's. Three years ago, there were only three states in the country that were on track to eliminate Hepatitis C by 2030. And for once, South Carolina was in the top three. It was Massachusetts, Washington State, and South Carolina.

Because of some of the Telehealth we've done, because of our Medicaid policies, we were actually on, this is a report from Johns Hopkins that came out in 2021, that there were only three states on track to eliminate Hep C. Now, since then, there have been some policy changes and we, our numbers have gone up and down.

We dropped down to 48 from number three in the country, and then we go back up again.

Host: Sure.

Divya Ahuja, MD: But we will be able to eradicate Hepatitis C from the state if our lawmakers and all can, you know, start working together productively.

Host: Well so and as you said, the key thing is testing, right? So with B it's just about sort of controlling and managing it. But C really, you know, can be eradicated. But of course we have to test for it and test for it at the right facilities and then know what to do and treatment options and so on. And this has been, just so educational today Doctor. I did want to come back though. You mentioned the connection between alcohol and hepatitis. Just wanted to ask if alcohol-induced hepatitis is different from cirrhosis. Is that the same thing? Maybe you can explain that to me.

Divya Ahuja, MD: Sure. Hepatitis is inflammation of the liver, right? It can It be an infection, can be a medication, can be alcohol. There are certain medications we give, like methotrexate, et cetera. They can cause hepatitis. Most hepatitis is transient, ie people drink alcohol. So if I was to drink a six pack a day for a week and you check my liver enzymes a week later, my liver enzymes may be slightly up. But they will revert back to normal if I stop binging like that.

But if somebody continues to drink, you know, and we have young people, it's a shame. It's tragic to see how young, otherwise productive people, who you know, they come in after having had a nine months of alcohol binge where they're drinking a fourth or a pint of liquor a day. The liver enzymes start going up, but because they continue to insult the liver starts getting fibrosed, they start getting cirrhosis of the liver.

So from just inflammation, it starts getting scar tissue buildup. That scar tissue gets laid down more and more, and the cells get disrupted. And so it goes from a healthy liver, which was slightly inflamed to a permanently inflamed liver, to a liver that starts developing scar tissue. Collagen, extracellular matrix, et cetera, gets deposited.

And if they continue to do this, or if somebody has untreated Hepatitis B or untreated Hepatitis C, they get cirrhosis because that scar tissue keeps getting laid down in different parts of the liver. The liver starts shrinking, getting starts getting scarred. And then gets permanently damaged. It takes decades to develop cirrhosis.

You don't develop cirrhosis overnight, but once you get cirrhosis, your risk of cancer goes up. And so everybody with cirrhosis should be screened with an ultrasound of the liver every six months because their risk of liver cancer is high. So whether the cause of cirrhosis is alcohol or hepatitis B or Hepatitis C, every cirrhotic should be getting an ultrasound and every provider should be getting an ultrasound on them every six months. Now granted it's expensive, there's nothing cheap in healthcare. Our healthcare is stupidly expensive. But, those are the recommendations from the American Society and the European Society to screen everyone for cancer.

Host: Well, Doctor, I want to thank you for your time today. I have the luxury of hosting these and learning from experts and sometimes when I'm on with one like you, I just want to stay on all day. But that would be maybe a tough listen for listeners. So, I think we'll leave it there today. But I want to thank you for your time, your expertise, your compassion. This has been great. Thanks so much.

Scott Webb: Thank you very much for having me on.

Host: For more information and other podcasts just like this one, head on over to prismahealth.org/flourish. This has been Flourish, a podcast brought to you by PRISMA Health. I'm Scott Webb. Stay well.