Hepatitis in the Philippines

EXPERTS and officials from the Department of Health (DoH), the National Institute of Health, and the
World Health Organization (WHO) in the Philippines recently convened to review the current situation of
hepatitis in the country. The meeting hoped to gather a consensus on the understanding of the disease
burden and the program of actions needed to address the challenges posed by hepatitis in the
Philippines. The participants agreed to develop a National Hepatitis Action Plan as one of the
cornerstones in “understanding the true burden of chronic viral hepatitis in the Philippines.”

The DoH estimates that 10% to 16% of Filipino adults suffer from chronic hepatitis B infection. It is also
approximated that around 1% of the estimated 100 million Filipinos has chronic hepatitis C.

The WHO estimates that almost 40% of global mortality due to viral hepatitis occurs in the Western
Pacific Region.

Despite this high rate, the many effective drugs to combat viral Hepatitis B and C are only slightly more
accessible now due to prohibitive cost in the Philippines and elsewhere.

In the case of hundreds of millions of people with hepatitis, including Filipinos, the WHO said that
Hepatitis B and C infections lead to chronic liver disease, which is the most common causes of liver
cirrhosis and liver cancer.

Viral hepatitis is defined as “an inflammation of the liver caused by one of the five hepatitis viruses: A, B,
C, D and E.” Infections, toxic substances, such as alcohol and certain drugs, and auto-immune diseases
can also cause hepatitis.

Viral hepatitis is considered a significant public health problem because of the sheer number of people
affected, the number of deaths caused, and because of its potential for outbreaks and epidemic spread.
In particular, types B and C lead to chronic disease in hundreds of millions of people. Combined,
hepatitis B and C are the most common cause of liver cirrhosis and cancer, globally.

The five kinds of hepatitis viruses are transmitted through different routes: hepatitis A and E through
contaminated food and water; hepatitis B through unsafe blood and other bodily fluids; and hepatitis C
and D mostly through infectious blood. Hepatitis C can actually be transmitted through sexual contact as
well, though this is rare. Hepatitis D is only transmitted to individuals already chronically infected with
the hepatitis B virus.
While hepatitis A and E are typically caused by ingestion of contaminated food or water, hepatitis B, C,
and D usually occur as a result of parenteral contact with infected body fluids. Common modes of
transmission include transfusion of contaminated blood or blood products, invasive medical procedures
using contaminated equipment, and, for Hepatitis B, transmission from mother to baby at birth, from
family member to child, and also by sexual contact.

The five hepatitis viruses can cause an acute hepatitis which is characterized by fatigue, loss of appetite,
fever, and jaundice. Most persons fully recover from acute hepatitis, but a small proportion can die from
life-threatening complications.

Vaccination is still one of the most potent agents in the fight against hepatitis.

In the Philippines, about one in seven adults are infected with hepatitis B and more than half a million
have hepatitis C, says a report in Medical Observer, a Philippine-based medical and health online
publication. Hepatitis B accounts for more than two thirds of all cases of liver cancer, the second leading
cause of cancer deaths in the country, said the article “Fight vs. Chronic Viral Hepatitis Rages in the
Philippines,” in the Medical Observer.

The article estimated that the cost of hepatitis treatment and management in the Philippines can be
prohibitive, given that the urban minimum daily wage is at P450.

“Hepatitis B profile costs P1,800; ultrasound, P450; hepatitis B viral load, P4,500; viral load for hepatitis
C, P6,500; and genotyping, P14,350… Hepatitis B medication costs P135 a day or P49,000 a year that
(may possibly run) for the rest of our lives. Hepatitis C treatment costs P732 per day for at least three
months,” it said.

One notable aspect of the fight against the onslaught of hepatitis is the presence of two laws which give
teeth and more power in the implementation of the vaccination program against hepatitis B.

From 1992, the nationwide immunization program started, to which the hepatitis B birth dose
vaccination was included beginning 2006.

PhilHealth, the country’s version of a public or national health insurance program, also incorporated
hepatitis vaccination in its newborn care package.
“Sadly, the program coverage for the entire 100 million Philippine population remains at its infancy;
even the Department of Health has yet to turn up policies for viral hepatitis prevention and control,” the
Medical Observer article said:

The article, meanwhile, noted that the “local government units are already integrating hepatitis B
education in their information campaigns… that are usually integrated to their HIV programs and are
implemented of varying degrees.”
 What is hepatitis?

Hepatitis is a condition when the liver is swollen or inflamed. It is commonly caused by the hepatitis
viruses (Hepatitis A, B, and C), heavy alcohol intake, some toxins and drugs, other systemic diseases and
infections.

What are the differences among Hepatitis A, Hepatitis B and Hepatitis C?

Hepatitis A, Hepatitis B and Hepatitis C are three types of viral Hepatitis that may have similar symptoms
and manifestations but are caused by three different viruses.

Hepatitis A infection is acquired through intake of contaminated food and drink. It is self-limiting and
usually resolves without specific treatment. It is an acute infection (meaning it is newly acquired) and
does not cause people to become carriers of the virus for a long time. On the other hand, Hepatitis B
and Hepatitis C are infections that can be acquired from infected blood and body fluids. It can also begin
as acute infections, but in some, the virus remains in the body causing lifelong infection that may cause
complications in the liver such as liver cirrhosis (scarring of the liver) and liver cancer (tumor of the
liver). Hepatitis A and B can be prevented thru effective and safe vaccines. While there is no vaccine for
Hepatitis C, its spread can be prevented by avoiding contact with infected blood and body fluids.

What is Hepatitis B?

Hepatitis B is an infectious disease of the liver caused by the Hepatitis B Virus. In the acute (newly-
acquired) phase, the symptoms may be similar to having the flu and some, but not all, can have jaundice
(yellowing of the eyes and skin). In some patients, Hepatitis B can become “chronic”, meaning it can be a
long term or life-long infection. Persons with chronic hepatitis B infection are at risk for liver cirrhosis
and liver cancer.

How common does chronic or life-long infection develop in a person infected with hepatitis B?

It depends on the age that one becomes exposed to or infected. The younger a person is when infected,
the higher the chance that he or she will have life-long infection with the virus.

90% of infected infants will develop chronic infection.

Approximately 25%–50% of children infected between the 1 -5 years of age will develop chronic
infection.

The risk drops to 6%–10% when one is infected over 5 years of age.

In the Philippines and worldwide, most people with chronic hepatitis B acquire the infection at birth or
during early childhood.

Statistics How common is chronic hepatitis B in the world?

Hepatitis B affects approximately 350 million people worldwide and contributes to an estimated 780,000
deaths each year.

How common is hepatitis B in the Philippines?

Hepatitis B is a major public health problem in the Philippines. An estimated 7.3 million adult Filipinos
(16.7% of the adult population) are chronically infected making our country hyperendemic for hepatitis
B. This rate is extremely high compared to other countries and is more than double the 8% average
prevalence of HBV infection in the Western Pacific region. A 2003 survey showed the prevalence of
hepatitis B to be highest in the 20-49 year age group, which comprise the workforce or those entering
the workforce.

Transmission / Exposure How can one get Hepatitis B?

Hepatitis B is spread thru blood, semen, or other body fluids. A person may acquire the infection thru
the following activities:

Birth (spread from a hepatitis B positive mother to her baby)

Sex with an infected partner

Sharing needles, syringes, or other drug-injection equipment with an infected person

Sharing razors, nail clippers/manicure or pedicure paraphernalia or toothbrushes with an infected

person

Direct contact with the blood or open wounds of an infected person

Exposure to blood from needlesticks or other sharp instruments

Can a person unknowingly spread hepatitis B?

Yes, because many of those infected have no symptoms. An infected person can appear and feel normal.
Even without symptoms, people can spread the infection thru the activities or practices mentioned
above.

Can one get hepatitis B with unprotected sex?

Yes. In fact, Hepatitis B is 50 to 100 times more infectious than HIV and can be passed through semen,
vaginal fluids, and blood.

Can hepatitis B be spread through food?

No.Unlike Hepatitis A, it is not spread through food or water.

What are ways hepatitis B is not spread?

Hepatitis B is not spread by sharing utensils, sharing drinks, breastfeeding, hugging, kissing, holding
hands, coughing, or sneezing.

Can the hepatitis B virus survive outside the body?

The Hepatitis B virus can survive in the environment for at least 7 days.

Who are at risk for hepatitis B?

Since the Philippines is considered a hyperendemic area for hepatitis B, almost everyone without the
antibody or vaccine can become infected. The following people are at greater risk:

Infants born to infected mothers

People who have sex with an infected partner

People who have multiple sex partners

People who have a sexually transmitted disease

Men who have sexual contact with other men

People who inject drugs or share needles, syringes, or other drug equipment

People who live in the same household with an infected individual

Those who work in occupations where they are exposed to infected blood and body fluids

Hemodialysis patients

I am worried that I may have been exposed to the hepatitis B virus, what should I do?

If you believe that you might have been exposed to the virus, see your doctor. It can be prevented by
getting the hepatitis B vaccine with an additional shot called HBIG (Hepatitis B Immuneglobulin) within
24 hours of exposure. If I have recovered from acute hepatitis B and develop the antibody can I still get
it? No, if you recover from acute hepatitis B, you develop antibodies that protect you from the virus for
life. An antibody is a substance in the blood made by our immune system upon exposure to a virus.
Antibodies protect us by destroying the virus. Unfortunately, some infected people are not able to
produce antibodies to clear the virus from their bodies and carry the virus for life. If I have hepatitis B,
can I be a blood or organ donor? No, if you have ever tested positive for the Hepatitis B virus, it is
recommended that you should not donate blood, organs, or even semen because this can put the
recipient at great risk for getting hepatitis B.

Symptoms

What are the symptoms of acute hepatitis B infection?

Not everyone develops symptoms. Although majority of adults (70%) develop symptoms, many young
children do not. Adults and children over the age of 5 years are more likely to have symptoms.

Symptoms include:

Fever

Fatigue

Loss of appetite

Nausea
Vomiting

Abdominal pain

Dark urine

Clay-colored bowel movements

Joint pains

Jaundice (yellow color in the skin or the eyes)

How soon after exposure to hepatitis B will symptoms appear?

Symptoms can appear 3 months after exposure to the virus, but can appear any time between 6 weeks
and 6 months after exposure.

After infection, how long can acute hepatitis B symptoms last?

People usually have symptoms for a few weeks, but some people can feel ill for as long as 6 months.

Can a person spread hepatitis B without having symptoms?

Yes. Many people with Hepatitis B look and feel healthy and have no symptoms, but they can still spread
the virus.

What are the symptoms of chronic hepatitis B?

Most people have no symptoms and feel healthy for many years. About 15% to 25% develop
complications in the liver, such as cirrhosis or liver cancer. In the early stages of liver cirrhosis and liver
cancer, patients may remain to have no symptoms. However, tests for liver function and a liver
ultrasound may begin to show some abnormalities.

How serious is chronic hepatitis B?

It is a serious infection that can result in liver damage, liver failure, liver cancer, and death. Liver cancer
is the third most common cancer in the Philippines, affecting over 7,000 new people each year. Liver
cancer is fatal when diagnosed late and left untreated, making it the second leading cause of cancer
deaths in the country.

Tests

How will I know if I have hepatitis B?

Talk to your doctor about testing for Hepatitis B. Doctors may order one or more blood tests to check if
you:

have acute or chronic infection

have recovered from infection

are immune to hepatitis B

need to be vaccinated

What are the common blood tests to diagnose hepatitis B?

There are several blood tests your doctor can request for to diagnose hepatitis B. Listed below are some
common tests and what they mean. It is important that you ask your doctor for the proper
interpretation of your test results.

TESTS

INTERPRETATION

Hepatitis B Surface Antigen (HBsAg)

It is a protein on the surface of the virus. It is detected in the blood of individuals who are infected.

POSITIVE or REACTIVE- A person may have acute or chronic infection and may transmit the disease to
others.

NEGATIVE OR NON-REACTIVE- A person is not infected.

Anti-HBs

Protective antibody to the Hepatitis B Virus

POSITIVE or REACTIVE

- A person has received successful vaccination against Hepatitis B

- A person has recovered from the infection and is protected from future infection

Anti HBc IgM- (IgM Antibody to Hepatitis B Core Antigen)

POSITIVE or REACTIVE

This may mean that a person was infected within the past 6 months or is having a flare of chronic
hepatitis B

AntiHBcIgG- (IgG Antibody to Hepatitis B Core Antigen)

POSITIVE or REACTIVE

This may indicate exposure to the virus and that a patient either has chronic Hepatitis B, or has
recovered from Hepatitis B

HBeAg

POSITIVE or REACTIVE

This may indicate high levels of the virus in the blood, which can mean that a person can easily spread
the virus to others.

HBV DNA

Indicates the levels of virus in the blood. This test is used to determine the need for treatment and to
monitor effectiveness or response to treatment

Treatment

How is acute hepatitis B treated?

Treatment is mostly supportive in the form of rest, adequate nutrition and hydration. In some cases,
hospitalization is needed particularly for those who are unable to eat due to vomiting and lack of
appetite. Some develop signs of liver failure such as disorientation, confusion or even coma needing
urgent hospitalization. These patients may be given antiviral drugs and may need to be evaluated for a
liver transplant.

How is chronic hepatitis B treated?

There are several drugs available. The choice depends on several factors. Ask your doctor what is the
most appropriate drug for you. However, not all patients need to be treated. Patients should be
evaluated by doctors experienced in the management of hepatitis B such as internists, pediatricians,
gastroenterologists, hepatologists, and infectious disease specialists. You can click on this link to gain
access to the Hepatology Society of the Philippines (HSP) website. People with chronic hepatitis B, even
those without symptoms, need long term monitoring for the early detection of complications in the liver
such as cirrhosis and liver cancer.

How can you help keep your liver stay healthy if you have hepatitis B?

People infected with hepatitis B should have regular check-ups with their doctors. Alcohol intake should
be avoided as this can aggravate liver damage. Infected individuals need to consult their doctor before
taking any medications, herbal supplements, and over-the-counter medicines. Obesity, diabetes and
cholesterol problems need to be managed. Patients who do not have protective antibodies (anti-HAV
IgG negative or non-reactive) to hepatitis A should be vaccinated.

Prevention / Vaccination

How can hepatitis B be prevented?

There is a safe and effective vaccine to protect yourself from hepatitis B. The vaccine is given as a series
of 3 shots over a period of 6 months. It stimulates the body’s immune system to produce antibodies
that protect against the virus. In the Philippines, hepatitis B immunization is included in the Maternal,
Newborn, Child Health and Nutrition (MNCHN) Package of the Department of Health (DOH). Republic
Act 10152 (An Act Providing for Mandatory Basic Immunization Services for Infants and Children)
provides free hepatitis B vaccination and is mandatory to all infants. To increase its effectiveness in
preventing transmission of the virus, the first dose should be given to newborns within the first 24 hours
of life.
For babies born to mothers infected with hepatitis B, an additional shot called HBIG (pre-formed
antibodies against the virus) should also be given shortly after birth.

Who should get vaccinated against hepatitis B?

Because of the high rates of hepatitis B infection in the Philippines, universal vaccination is mandated.

Hepatitis B vaccination is especially recommended for:

All infants, starting with the first dose of the vaccine within 24 hours of birth

All children and adolescents younger than 19 years of age who have not been vaccinated

People whose sexual partners have Hepatitis B

Sexually active persons who have multiple partners

Persons undergoing treatment for sexually transmitted diseases

Men who have sexual contact with other men

People who share needles, syringes, or other drug equipment

People who have close household contact with someone infected

Health care and public safety workers at risk for exposure to blood or blood-contaminated body fluids
on the job

People with end-stage renal disease, including predialysis, hemodialysis, peritoneal dialysis, and home
dialysis patients

Residents and staff of facilities for developmentally disabled persons

People with chronic liver disease (aside from Hepatitis B)

People with HIV infection

Anyone who wishes to be protected from hepatitis B virus infection

When should a person get the hepatitis B vaccine series?

Children and Adolescents:

All children should get their first dose of the vaccine at birth ( or at least within 24 hrs of birth) and
complete the vaccine series by 6–18 months of age.

All children and adolescents younger than 19 years of age who have not yet received the vaccine should
be vaccinated. "Catch-up" vaccination is recommended for those who were never vaccinated or those
who did not complete the vaccine series.

Adults:

Any adult who wants to be vaccinated should talk to their doctor about getting vaccinated.

Is the hepatitis B vaccine effective?

Once the prescribed vaccination series has been completed, the vaccine gives greater than 90%
protection to those immunized.

Is the hepatitis B vaccine safe?

The hepatitis B vaccine is safe. Soreness at the injection site is the most common side effect reported.
Over 1 billion doses of the Hepatitis B vaccine have been used worldwide. The safety of the vaccine has
been evaluated by many leading health authorities including the WHO and the United States Institute of
Medicine.

I cannot remember how many doses of the hepatitis B vaccine I have received, is it bad to get extra
doses of Hepatitis B vaccine?

No, getting extra doses of hepatitis B vaccine is not harmful.

Who should not receive the hepatitis B vaccine?

The hepatitis B vaccine is not recommended for people who have had a serious allergic reaction to a
prior dose of the vaccine or to any component of the vaccine. It is not recommended for people allergic
to yeast because yeast is used when the vaccine is made. Inform your doctor if you have any severe
allergies.
Those who are infected with the virus should not receive the vaccine. It will no longer be helpful if one
is already infected.

When are booster doses of hepatitis B vaccine necessary?

A “booster” dose is given to increase or extend the effectiveness of the vaccine. They are particularly
recommended for patients undergoing hemodialysis or other people with compromised or “weak”
immune system.

Pregnancy and Hepatitis B

Should all pregnant women be tested for hepatitis B?

Yes. Hepatitis B testing should be included in routine prenatal examinations. Knowing whether a
pregnant mother has hepatitis B is important because transmission of the virus can be prevented by
giving her newborn infant the HBIG and the first dose of the vaccine within 12 to 24 hours of birth.
Completion of the vaccine series should be done as prescribed.

What if a pregnant woman has hepatitis B?

If a pregnant woman has hepatitis B, she can transmit the infection to her baby during birth. But this can
be prevented through giving the first dose of the vaccine and HBIG to her baby as soon as possible
within 12 to 24 hours of birth. Without vaccination, babies born to women with Hepatitis B can develop
chronic or life-long infection, which can lead to serious complications in their liver.

How does a baby get hepatitis B?

A baby can get hepatitis B from an infected mother during childbirth.

What happens if a baby gets hepatitis B?

Most newborns who become infected do not have signs or symptoms, but have a 90% chance of
developing chronic or life-long hepatitis B. This can lead to liver cirrhosis, liver cancer, and even death.
Do babies need the hepatitis B vaccine even if a pregnant woman does not have hepatitis B?

Yes. The hepatitis B vaccine is recommended for all infants. Republic Act 10152 mandates the
administration of three hepatitis B vaccines for all newborn infants starting at birth and over a period of
6 months. Why is the hepatitis B vaccine recommended for all babies? It is recommended for all babies
because it protects them from acquiring the infection and thus prevent them from developing serious
liver disease as they get older. Compared to adults, babies and young children are more likely to develop
life-long infection and the vaccine is effective in preventing this.

Hepatitis B and Getting Employed

Because hepatitis B is transmitted through blood and body fluids, it is not spread through usual
workplace activities. The current practice of screening for HBsAg as a basis for employment has no
evidence except in certain occupations in the health care setting which pose a high risk of transmission
because it involves exposure to potentially contaminated blood and body fluids.

Being positive for HBsAg alone should not be a basis for discrimination, work restriction and
disqualification from employment. Job applicants should not be declared unfit to work without a proper
medical evaluation and counseling.