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Viral Hepatitis

A common cause of hepatitis is an infection with a virus. The five viruses primarily associated with hepatitis are named in the order of their discovery: A, B, C, D, and E. In the United States, acute viral hepatitis is most commonly caused by hepatitis A (HAV), hepatitis B (HBV), and hepatitis C (HCV), while only HBV and HCV cause chronic hepatitis.

Hepatitis A | Hepatitis B | Hepatitis C | Hepatitis D and E

Hepatitis A (HAV) is highly contagious and is spread through water and food that have been contaminated with the virus. Rates have steadily declined since 1995, when a vaccine was introduced. In 2011, about 1,400 acute cases of hepatitis A were reported nationwide to the Centers for Disease Control and Prevention (CDC). Actual numbers may have been higher, however, since people may not have realized that they were infected. Symptoms may be flu-like and are frequently not identified as being due to hepatitis. The CDC estimates that the number of infections in 2011 was probably closer to 2,800 once corrected for underreporting and asymptomatic infections. Hepatitis A causes an acute infection but not a chronic form of the disease. Treatment usually involves only supportive therapy, and most people recover fully within about six months.

Hepatitis B (HBV) can be spread by contact with the body fluids of an infected person. The virus is most often spread through exposure to contaminated blood or needles, through unprotected sex with an infected person, and from an infected mother to baby (rarely in the U.S. but commonly in many parts of the world). Infection with HBV is the most common cause of acute viral hepatitis. According to the CDC, there were roughly 2,900 acute cases reported in the U.S. in 2011, although the number may be as much as 10 times higher because many people either had few or no symptoms or did not report the disease. Rates are highest among adults, particularly men aged 25-44.

Most adults with HBV will get better without any intervention, but about 1-3% become chronically infected and able to spread the disease to others. In 2011, there were over 39,000 reported cases of chronic hepatitis B reported to the CDC. Newborns and young children are especially vulnerable to chronic HBV infection. Up to 90% of newborns and 25-50% of children ages 1 to 5 years old who are infected with hepatitis B virus develop a chronic infection. With the advent of screening pregnant women for hepatitis B and the vaccination of newborns, the number of infected babies has fallen. Most chronic hepatitis B infections are now seen in people born in parts of the world (particularly southern and eastern Asia, southern Europe, and Africa) where infection among newborns still remains common. An estimated 350 million people around the world are chronically infected with HBV.

Hepatitis C (HCV) is spread by exposure to contaminated blood. The most common mechanism of exposure is the sharing of needles used in injecting drugs of abuse such as cocaine or heroin. Other means of becoming infected include occupational exposure of health care workers to used needles or other sharp objects, through sexual activity that results in tissue tears, from mother to baby during childbirth, and sharing personal items contaminated with blood, such as razors and toothbrushes.

In 2013, there were about 30,000 cases of confirmed acute hepatitis C reported in the United States. Many cases are not reported and many people do not know that they have an infection because they have no symptoms. Of those who become infected, about 75-85% develop the chronic form. According to the CDC, there are an estimated 2.7 million people in the U.S. who have chronic hepatitis C virus infection. About 60-70% of people with untreated hepatitis C will develop chronic liver disease. Without treatment, roughly 20-40% will develop cirrhosis over many years, and 1-5% are estimated to die from a condition that results from chronic infection, such as cirrhosis or liver cancer.

There is no vaccine available to prevent hepatitis C, but research is in progress to develop one. Currently, the best way to avoid getting infected is to limit exposure to possible sources of the virus, especially avoiding the sharing of needles to inject drugs.

Hepatitis D and E are rare in the U.S. Hepatitis D only causes an infection when hepatitis B is present and can make that infection more severe. It is usually spread by exposure to blood or infected needles. Hepatitis E is spread in a similar fashion to hepatitis A and is found primarily in Asia, Africa, and South America, although the number of cases reported in the U.S. has been rising recently.

Signs and Symptoms of viral hepatitis correspond to those of hepatitis in general. See the section on Signs and Symptoms for detailed information.

Laboratory Tests
There are a variety of blood tests that are available to help diagnose and/or monitor hepatitis caused by the specific hepatitis viruses. For testing information on the most common causes of viral hepatitis, see the pages on hepatitis A, B, and C  or see the summary information on them in the table below.

Summary Table: Most common causes of viral hepatitis

Virus Hepatitis A Hepatitis B Hepatitis C
Transmission Route Fecal-oral Infected needle or blood, sexual contact Infected needle or blood, sexual contact
Incubation Time (acute infection) 15-50 days 45-160 days 14-180 days
Onset Sudden Either sudden or slow, unnoticed Usually slow, unnoticed
Severity Mild Occasionally severe Usually slow-developing and symptoms not specific or strong
Chronic form? No Yes Yes
Associated with other diseases? None Liver cancer, cirrhosis Liver cancer, cirrhosis
Testing to Diagnose Acute Infection HAV-Ab, IgM HBsAg, Anti-HBc, IgM Anti-HCV, HCV RNA (note: may have same results as in chronic hepatitis)
Testing to Diagnose Chronic Infection or to Monitor Treatment N/A HBsAg, HBV DNA, HBeAg, Anti-HBe Anti-HCV (once), HCV RNA or viral load, HCV genotype (once)
Tests that Detect Previous Infection HAV-Ab, IgG Anti-HBs, Anti-HBc total Anti-HCV
Vaccine available? Yes Yes No
Common Treatment None Chronic form: Interferon, entecavir, tenofovir, lamivudine, adefovir Treatment for acute HCV is similar to the chronic form. However, the best regimen and when to start treatment remains uncertain. Chronic HCV is usually treated with a combination of drugs. Some examples include a pill containing sofosbuvir and ledipasvir, and a multiple drug regimen containing ombitasvir, dasabuvir, paritaprevir, and ritonavir; newer treatments are in research and will become available as the FDA approves them. Treatments may differ depending on a variety of factors and the genotype of HCV that the person carries.

Abbreviations Defined

HAV-Ab = Hepatitis A Antibody
Anti-HBs = Hepatitis B surface antibody
HBsAg = Hepatitis B surface antigen
HBeAg = Hepatitis B e-antigen
Anti-HBe = Hepatitis B e-antibody
Anti-HBc = Anti-hepatitis B core antigen
HBV DNA = Hepatitis B Virus (test for virus genetic material)
Anti-HCV = Hepatitis C Antibody
HCV RNA = Hepatitis C Virus (test for virus genetic material)
HCV Viral Load = A detection and/or count of the amount of virus in the blood
HCV Genotype = Determines the type of Hepatitis C present (1 of 6 types)

The incidence of new cases of viral hepatitis has decreased due to use of safe injection and safe sex practices (important in preventing hepatitis B and C) and the availability of vaccines for hepatitis A and hepatitis B (there is currently no vaccine available for hepatitis C). Screening units of blood for hepatitis B and C has virtually eliminated infections through blood transfusions. A systematic program to screen pregnant mothers for hepatitis B and to vaccinate all newborns has greatly decreased new cases of hepatitis B.

Support and symptom relief are frequently the only treatments required for acute viral hepatitis A and B. This usually involves plenty of rest, fluids, and nutritious food. With hepatitis A, most people recover without any complications.

With hepatitis B, some people may develop chronic forms of the disease. The goal with chronic forms is to minimize further damage to the liver, to treat underlying conditions that are causing or exacerbating the condition, and to prevent transmission of viral hepatitis to others. There are medications available to treat chronic hepatitis B, but not all people need to be treated. People with chronic hepatitis will be closely monitored to see if they develop cirrhosis or liver cancer.

About 75-85% of people with acute hepatitis C develop the chronic form and both forms can be treated, usually with a combination of drugs. Though acute HCV can be cleared by some people without medications, treatment reduces the risk that the infection will become chronic. The same drugs used to treat chronic hepatitis C are used to treat the acute form, but the best treatment for acute HCV and when to start it remains uncertain.

New treatments, vaccines, and prevention strategies for viral hepatitis continue to emerge. It is important to talk to your healthcare practitioner about the risks and benefits of currently available options.

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