Living with hepatitis B: The myth of the healthy carrier

​First published on Hepatitis Australia's website in December 2019.

Image by Mabel Amber, still incognito... from Pixabay 

If you’ve been told that you are “just a healthy carrier”, read on for a myth-busting update.

Acute versus chronic

When a person is first infected with the hepatitis B virus, it’s called an acute infection. If that person cannot get rid of the infection after six months, then this becomes a chronic infection, which is lifelong [1]. 

In the past, people who seemed well despite chronic infection were labelled “healthy carriers”. However, this term is inaccurate as people with chronic hepatitis B: 

• risk transmitting hepatitis B to others such as close contacts, sexual partners and unborn babies.
​
• have nearly a one in four risk of dying from cirrhosis, liver cancer or liver failure [2]. 

Where did the term “healthy carrier” come from?

The term “carriers” was initially used to identify people found to have the hepatitis B virus in their bloodstream for six months. However, these “carriers” varied widely. Some were highly contagious, some had no symptoms, and some had significant liver disease. 

In simple terms, we didn’t understand the hepatitis B virus very well. 

This led to many people being told by doctors that they were “just healthy carriers” and that they needed no follow up. Others were told their infection had “resolved” or was “inactive”, without being warned that it may reactivate, even without symptoms [3]. 

Why we should stop using the term “healthy carrier

Some people still use this term even though it is unhelpful. Here are some possible consequences:

• People may miss out on receiving proper healthcare if they hold a false belief that they are healthy. 
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• People who describe themselves as healthy carriers may feel they are less likely to experience stigma and discrimination [4] than those who say they have chronic hepatitis B virus. Unfortunately, this can actually increase stigma surrounding the condition by making it more hidden. You may like to read more about your rights and responsibilities on this page, or by phoning the Hepatitis Infoline. 

• Using the term “healthy carriers” might falsely imply that there are additional ways of passing on the virus as well as the usual transmission routes, or that healthy carriers are unlikely to transmit the infection to others. 

What we know now

The reason people with chronic hepatitis B vary widely is that hepatitis B has four identifiable phases [5]:

• Silent (Immune tolerance - phase 1): Hepatitis B virus is replicating but there is no active liver damage.

• Damage (Immune clearance – phase 2): Hepatitis B virus is attacking the immune system and the immune system is fighting back. Liver is getting damaged.

• Control (immune control – phase 3): Immune system has virus under control and there is no further liver damage.

• Escape (immune escape – phase 4): Virus is active again and liver is being damaged.  

Your doctor can order tests* to see which phase your hepatitis B is in, and therefore what screening and/or treatment would be best. You should visit your doctor for liver check-ups  every six months longterm to reduce the risk of liver damage.

Screening may comprise blood tests, or scans such as liver ultrasound and ultrasound elastography (commonly known as Fibroscan®). 

Treatment may be anti-viral replication medication, or interferons to stimulate immune control [7] – as well as other actions like having a healthy lifestyle .

Living with hepatitis 

The goal of screening and treatment is to prevent, stop or even reverse the effects of hepatitis B on your liver [7]. 

Screening is important for those felt to be at higher risk groups, such as Asian men over 40, Asian women over 50, and Aboriginal and Torres Straits Islanders over 50.  One study found that more than one-third of people with chronic hepatitis B lived much longer if they had six-monthly screening, compared to no screening [6].

In general, treatment is recommended to people whose hepatitis B is in the Damage (phase 2) and Escape (phase 4) phases, and all those with cirrhosis which is a severe form of liver scarring [7]. 

International research shows that appropriate treatment for chronic hepatitis B can reduce the risk of liver cancer by up to 75%, or  three-quarters [8]. Treatment also reduces risk of transmission to others, and most importantly, gives you the best chance to live a long and healthy life.
You can find out more about testing, monitoring and treatment here.

References

1. Hepatitis B Foundation. 2019. Acute vs. Chronic Infection. [ONLINE] Available at: https://www.hepb.org/what-is-hepatitis-b/what-is-hepb/acute-vs-chronic/. [Accessed 3 October 2019].
2. Australasian Society for HIV Medicine. 2019. Prevalence and epidemiology of hepatitis B. [ONLINE] Available at: http://54.66.239.154/prevalence-and-epidemiology-of-hepatitis-b/. [Accessed 3 October 2019].
3. Hoofnagle, J., 1987. Chronic Type B Hepatitis and the “Healthy” HBsAg Carrier State. Hepatology, [Online]. 7/4, 758-763. Available at: https://aasldpubs.onlinelibrary.wiley.com/doi/pdf/10.1002/hep.1840070424 [Accessed 3 October 2019].
4. Ellard, J., 2013. Stigma, Discrimination and Hepatitis B - A review of current research. Australian Research Centre in Sex, Health & Society (ARCSHS), [Online]. Available at: https://siren.org.au/wp-content/uploads/2016/08/Stigma-Discrimination-and-Hepatitis-B-A-review-of-current-research.pdf [Accessed 18 November 2019].
5. Chronic Hepatitis B: Phases (2018). [ebook] Available at: https://www.hepqld.asn.au/wp-content/uploads/2018/06/FACTSHEET_-_Chronic_Hepatitis_B_Phases-1.pdf [Accessed 13 Nov. 2019].
6. Zhang, B., 2004. Randomized controlled trial of screening for hepatocellular carcinoma. Journal of Cancer Research and Clinical Oncology, [Online]. 130(7), 417-22. Available at: https://www.ncbi.nlm.nih.gov/pubmed/15042359 [Accessed 21 November 2019].
7. Australasian Society for HIV Medicine. 2018. Treatment of chronic hepatitis B virus infection. [ONLINE] Available at: http://54.66.239.154/treatment-of-chronic-hepatitis-b-virus-infection/. [Accessed 3 October 2019].

8. Cancer Council Victoria. N.D. Hepatitis and liver cancer. [ONLINE] Available at: https://www.cancervic.org.au/for-health-professionals/community-health-professionals/hepatitis-b-and-liver-cancer. [Accessed 3 October 2019].

* As the range of HBV tests can be confusing, your GP may appreciate being pointed to this handy decision-making aid.