SEXUALLY TRANSMITTED INFECTION

A. GONORRHEA
Definition of Gonorrhea Gonorrhea is caused by Neisseria gonorrhea, a bacterium that grows and multiplies quickly in moist, warm areas of the body such as the cervix, urinary tract, mouth, or rectum. Description of Gonorrhea About 2.5 million cases of gonorrhea occur annually in the U.S.. In women, the cervix is the most common site of infection. However, the disease can spread to the ovaries and fallopian tubes, resulting in pelvic inflammatory disease (PID); this can cause infertility and other serious problems. In a man, gonorrhea can cause urethritis and penile discharge. Gonorrhea can also be spread from a man's penis to the throat of his sex partner during oral sex (pharyngeal gonorrhea). People can transfer the bacteria from the genital area to the mouth with their fingers. Gonorrhea of the rectum may develop in women due to spread of the infection from the vaginal area, and it can also occur in receptive anal intercourse. Infection of the eye (conjunctivitis) can also occur. Gonorrhea can be passed from an infected woman to her newborn infant during delivery. The infection also occurs in children, most commonly in young victims of sexual abuse. If the bacteria spread to the bloodstream, they can infect the joints, heart valves, or the brain. The most common consequence of gonorrhea, however, is pelvic inflammatory disease (PID), a potentially serious infection of the female pelvic organs. PID can cause scarring of the fallopian tubes, resulting in infertility in as many as 10 percent of women affected. In others, the scarring blocks the proper passage of the fertilized egg into the uterus. If this happens, the egg may implant itself in the tube; this is called an ectopic pregnancy and is life-threatening to the mother if not detected early. An infected woman who is pregnant may pass the infection to her infant as the baby passes through the birth canal during delivery. Most states require that the eyes of newborns be treated with silver nitrate or other medication immediately after birth to prevent gonococcal infection to the eyes, which can lead to blindness. Because of the risk of gonococcal infection to both mother and child, doctors recommend that a pregnant woman have at least one test for gonorrhea during her pregnancy.

Causes and Risk Factors of Gonorrhea Having unprotected sex with a partner for whom a past sexual history is not known is the primary risk factor for Gonorrhea. Symptoms of Gonorrhea The early symptoms of gonorrhea often are mild, and some people who are infected have no symptoms of the disease; this is one reason why it is so readily transmitted. If symptoms of gonorrhea develop, they usually appear within 2 to 10 days of sexual contact with an infected partner, although a small percentage of patients may be infected for several months without showing symptoms. The initial symptoms in women include a painful or burning sensation when urinating or a yellowish vaginal discharge. More advanced symptoms include abdominal pain, bleeding between menstrual periods, vomiting, or fever. Men usually have a whitish-yellowish discharge from the penis and a burning sensation during urination that may be severe. Symptoms of rectal infection include anal itching, and sometimes painful bowel movements. Diagnosis of Gonorrhea Gonorrhea is diagnosed through gram stain, culture, or rapid test (DNA probe). The gram stain involves placing a smear of the discharge on a slide that has been stained with a dye and then examining it under a microscope for the presence of the gonococcus. The culture test involves placing a sample of the discharge (usually from a man's urethra or a women's cervix) onto a culture plate and incubating it for up to 2 days in order to allow the bacteria time to multiply. The accuracy of this test depends on the site from which the sample is taken. Throat cultures and rectal cultures may be done if infection of these areas is suspected. Treatment of Gonorrhea Because a high proportion of men and women who have gonorrhea also have chlamydia, the goal of treatment is to cure both infections. Your partner(s) should be treated at the same time you are. Treatment for uncomplicated gonorrhea consists of antibiotics, including ceftriaxone, cefixime, ciprofloxacin, or ofloxacin for gonorrhea along with azithromycin, doxycycline, or erythromycin for chlamydia. Prevention of Gonorrhea All sexually active persons should consider using latex condoms to prevent STDs and HIV infection, even if they are using another form of contraception. Latex condoms used consistently and correctly are an effective means for preventing disease (and pregnancy). Talk openly with your partner about STDs, HIV, and hepatitis B infection, and the use of contraception. B. SYPHILIS Definition of Syphilis This sexually transmitted disease (STD), which in its late stages can cause mental disorders, blindness, and death, is caused by a corkscrew-shaped bacterium called Treponemapallidum.

The surging number of cases reflects social and economic factor s like changing sexual habits; drug abuse, particularly trading sex for crack; rising rates of pregnancy among teenagers who do not use contraceptives to protect against infection, and declining support for public health services, which has limited tracing some cases. Health officials are also deeply concerned about the links between syphilis and AIDS. The open sores of syphilis are believed to make it easier for the AIDS virus to enter the body. The infection is acquired by direct contact with the sores of someone who has an active infection. Although the bacterium is usually transmitted through the mucous membranes of the genital area, the mouth, or the anus, it also can pass through broken skin on other parts of the body. A pregnant woman with syphilis can transmit the disease to her unborn child, who may be born with serious mental and physical problems. The syphilis bacterium is very fragile, however, and the infection is rarely, if ever, spread by contact with objects such as toilet seats or towels. Because the early symptoms of syphilis can be very mild, many people do not seek treatment when they first become infected. However, untreated infected people can infect others during the first two stages of the disease, which can last for up to 2 years. Causes and Risk Factors of Syphilis Unsafe sex is the primary causal factor in contracting primary syphilis. Symptoms of Syphilis The first symptom of primary syphilis is a usually painless open sore called a chancre (pronounced "shanker"). The chancre can appear within 10 days to 3 months (usually 2 to 6 weeks) after exposure. Because the chancre is ordinarily painless and sometimes occurs inside the body, it may go unnoticed. It is usually found on the part of the body exposed to the bacteria, such as the penis, the vulva, or the vagina. A chancre also can develop on the cervix, tongue, lips, or fingertips. The chancre disappears within a few weeks, but the disease continues. If not treated during the primary stage, the disease may progress through three other stages. Secondary syphilis is marked by a skin rash that appears anywhere from 2 to 12 weeks after the chancre disappears. The rash may cover the whole body or appear only in a few areas, such as the palms of the hands or soles of the feet. Because active bacteria are present in these sores, any physical contact - sexual or nonsexual - with the broken skin of an infected person may spread the infection at this stage. The rash may be accompanied by flu-like symptoms such as mild fever, fatigue, headache, sore throat, as well as patchy hair loss, swollen lymph glands throughout the body, and other problems. The rash usually heals within several weeks or months, and the other symptoms subside as well. The signs of secondary syphilis occasionally come and go over the next 1 to 2 years. Like the symptoms of the primary stage, those of secondary syphilis can be very mild and go unnoticed. If untreated, syphilis then lapses into a latent stage during which the patient is no longer contagious. Many people who are not treated will suffer no further consequences of the disease. However, from 15 to 40 percent of those infected go on to develop the complications of late, or tertiary, syphilis, in which the bacteria damage the heart, eyes, brain, nervous system, bones, joints, or almost any other part of the body. This stage can last for years, or even for decades. Late syphilis, the final stage, can lead to mental illness, blindness, heart disease, and death. Diagnosis of Syphilis Syphilis has sometimes been called "the great imitator" because its early symptoms are similar to those of many other diseases. People who have more than one sex partner should consult a doctor about any suspicious rash or sore in the genital area. Those who have been treated for another STD such as gonorrhea should be tested to be sure they have not acquired syphilis. There are at least three ways to diagnose syphilis: a doctor's recognition of its symptoms, microscopic identification of syphilis bacteria, and blood tests. To diagnose syphilis by identifying the bacteria, the doctor takes a small amount of tissue from a chancre and has it examined under a special "darkfield" microscope. Blood tests also provide evidence of infection, although they may give false negative results (not show signs of infection despite its presence) for up to 6 weeks after the infection occurred. Interpretation of blood tests for syphilis can be difficult, and repeated examinations are sometimes necessary to confirm the diagnosis. In some patients with syphilis (especially in the latent or late stages), a lumbar puncture (spinal tap) must be done to check for infection of the nervous system. The most common of the screening tests are the VDRL (Venereal Disease Research Laboratory) test and the rapid plasma reagin (RPR) test. More accurate blood tests specifically detect the patient's immune response to the syphilis bacterium. These tests include the fluorescent treponemal antibody-absorption (FTA-ABS) test that can accurately detect 70 to 90 percent of cases. Your physician may also recommend HIV testing. Treatment of Syphilis Syphilis is treated with penicillin, administered by injection. Other antibiotics can be used for patients allergic to penicillin. A small percentage of patients do not respond to the usual doses of penicillin. Therefore, it is important that patients have periodic repeat blood tests to make sure that the infectious agent has been completely destroyed and there is no further evidence of the disease. In all stages of syphilis, proper treatment will cure the disease, but in late syphilis, damage already done to body organs cannot be reversed. Prevention of Syphilis Patients with infectious syphilis should abstain from sexual activity until rendered noninfectious by antibiotic therapy. Talk openly with your partner about STDs, HIV, and hepatitis B infection, and the use of contraception. All sexually active persons should consider using latex condoms to prevent STDs and HIV infection, even if they are using another form of contraception.

Latex condoms used consistently and correctly are an effective means for preventing disease (and pregnancy). Since latent condoms protect covered parts only, the exposed parts should be washed with soap and water as soon after contact as possible. This applies to men and women. C. CHYLAMYDIA Infection with chlamydia is most commonly found among the following groups: Young adults (24 years and younger) People living in urban areas African Americans Those with lower social and economic status Chlamydia Causes Chlamydia is an infection caused by the bacterium Chlamydia trachomatis. The infection is transmitted in 2 ways: From one person to another through sexual contact (oral, anal, or vaginal). From mother to child with passage of the child through the birth canal. Chlamydia can cause pneumonia or serious eye infections in a newborn, especially among children born to infected mothers in developing countries. Chlamydia Symptoms Symptoms of chlamydia infection may depend on gender. Chlamydia Symptoms in Women No symptoms in 70% to 80% of cases (One study found that 3% of a sample of young adults 18 to 35 years of age had untreated chlamydia.) Bleeding after sexual relations or between menstrual periods Lower abdominal pain and burning pain during urination Discharge from the vagina Chlamydia Symptoms in Men Like women, men who are infected may not show symptoms. Estimates of those with no symptoms range from 25% to 50% of infected men. Discharge from the penis Pain, burning during urination Inflammation or infection of a duct in the testicles, tenderness or pain in the testicles

Chlamydia Diagnosis The health care practitioner will conduct the following exams and tests. Physical Examination
Tenderness for women in the area of the sex organs, pus from the vagina or penis, and fever could indicate an infection. Diagnostic Tests Diagnostic tests may be ordered that may include looking at samples of the discharge under a microscope or obtaining cultures to identify the disease-causing bacteria. Some diagnostic tests may include obtaining cultures or sending urine to the laboratory to determine if you are infected. You may also be tested for other sexually transmitted diseases because many patients with chlamydia also have other infections such as gonorrhea or trichomonas. Chlamydia Medications The health care practitioner may prescribe a single-dose antibiotic, such as azithromycin (Zithromax), taken as a pill. On the other hand, the doctor may choose an antibiotic, such as doxycycline (Atridox, Bio-Tab), to be taken as a pill twice a day for a week. Up to 95% of people will be cured after one course of antibiotics. Chlamydia Prevention Use latex condoms when having sexual intercourse. Avoid sexual contact with high-risk partners. Treat infected sexual partners or have them tested before having sexual relations. Up to one-fourth of sexual partners will be reinfected because the partner wasn't treated.
D. GARDIANELLA VAGINTIS

Definition of GardnerellaVaginalis GardnerellaVaginalis is an infection of the female genital tract by bacteria of the Gardnerellavaginalis strain, often in combination with various anaerobic bacteria. Also called bacterial vaginosis. Description of GardnerellaVaginalis Gardnerellavaginalis was originally described by Gardner and Dukes in 1955. The infection often produces a gray or yellow discharge with a "fishy" odor that increases after washing the genitalia with alkaline soaps. Gardnerellavaginalis is the most common cause of bacterial vaginitis in the sexually active mature patient. The patient complains of a malodorous, nonirritating discharge, and examinations reveal homogenous, gray-white

secretions. A transient "fishy odor" may be released on application of 10 percent potassium hydroxide to the vaginal secretion on a glass slide. Causes and Risk Factors of GardnerellaVaginalis It is assumed that the infection is sexually transmitted. The bacteria are also found in women without a history compatible with a sexually transmitted disease, and often produces no symptoms. Symptoms of GardnerellaVaginalis Symptoms of infection typically include a vaginal discharge associated with a "musty" or "fishy" odor. The amount of discharge is quite variable, and there is little vulvar or vaginal irritation associated with this infection, but the pungent odor is usually the chief complaint. Diagnosis of GardnerellaVaginalis A wet mount preparation of physiologic saline mixed with vaginal secretions should be examined under low-power and high-power objectives. There are few white blood cells and lactobacilli. The characteristic "clue cells" are identified as numerous stippled or granulated epithelial cells. This appearance is caused by adherence of almost uniformly spaced G vaginalis organisms on their surfaces. Clumps of G vaginalis organisms may also be noted attached to the edges of epithelial cells or floating free in the preparation. Cultures are seldom necessary to establish a diagnosis. Treatment of GardnerellaVaginalis The treatment of choice for G vaginalis is oral metronidazole, 500 mg twice daily for 6 days. A single dose of 2 g has proved effective in treatment of adolescent patients, but in general a 5- to 7-day course of treatment is more effective. Although it is recommended that sexual partners be treated simultaneously, it is unclear whether this significantly decreases the incidence of recurrent disease. Contraindications to metronidazole include certain blood dyscrasias and central nervous system diseases. An important side effect is intolerance to alcohol. The drug is contraindicated during early pregnancy and lactation. Cephradine, 500 mg by mouth 4 times daily for 6 days, will eliminate G vaginalis from the vagina and relieve symptoms but has little effect on the anaerobic flora of the vagina. Other oral and vaginal preparations have been prescribed but have not proved useful. Douching removes malodorous secretions temporarily but does not cure the infection. E. TRICHOMONIASIS Trichomoniasis Causes Trichomoniasis is caused by Trichomonasvaginalis, a flagellated motile protozoan. Approximately 174 million people worldwide are infected with this parasite each year, making it the most common curable sexually transmitted infection worldwide The average size of a trichomonad is 15 mm (they are not visible with the naked eye). Reproduction of the parasites occurs every 8-12 hours. Trichomonasvaginalis was isolated in 14%-60% of male partners of infected women and in 67%-100% of female partners of infected men. It is unclear why women are infected more often than men. One possibility is that prostatic fluid contains zinc and other substances that may be harmful to trichomonads.

Trichomoniasis Symptoms Women Vaginal discharge Vaginal itching Smelly, itchy, and typically frothy or foamy discharge Yellow or gray-green discharge Pain with urination possible Up to one-third of infected women have no symptoms Men The majority of infected men have no symptoms Urethral discharge Pain with urination Pain and swelling in the scrotum (from epididymitis) Exams and Tests The diagnosis is made by directly observing the trichomonads through a microscope (they are too small to be seen by the naked eye). Trichomonads are pear-shaped and have several flagella (whiplike tails) at one end. This lab test is usually ordered only if the doctor suspects trichomoniasis as a possible diagnosis. In some cases, the doctor may have to send the sample to the laboratory, and the result may not come back right away. The doctor will collect the specimen during a pelvic examination. The doctor inserts a speculum into the vagina and then uses a cotton-tipped applicator to collect a sample. The sample is then placed onto a microscope slide and sent to the laboratory to be analyzed. Trichomonads are seen rarely during urine testing. A diagnosis of trichomoniasis usually prompts a search for other sexually transmitted diseases, such as syphilis, HIV, gonorrhea, or chlamydia. Trichomoniasis Treatment

Self-Care at Home The treatment of choice is antibiotics prescribed by the doctor. In addition to antibiotics, some alternative medicine therapies are available. These therapies are not known to be beneficial, and no rigorous scientific evidence supports their use. Home therapy should not be used instead of a doctor's visit and appropriate antibiotics, as this may allow the spread of the condition as well as harmful sexually transmitted diseases, such as syphilis, HIV, gonorrhea, or chlamydia. (The author does not advise you to use these alternative therapies but these are listed to be complete.) Some people feel that natural douches once a day while lying in a warm bath may help. To increase parasite-killing activity, you may add the juice of one lemon to either of the following douches: Vinegar douche - 1 teaspoon vinegar to 1 quart warm water Live-culture yogurtdouche or a solution of Lactobacillus acidophilus one-half teaspoon to one cup of water Aromatherapy: Oil of bergamot (Citrus aurantiumvarbergamia) may help dry up irritating discharge. It can be used in douches or added to bath water Medical Treatment The treatment of choice is metronidazole (Flagyl), except in the first trimester of pregnancy, when clotrimazole is used topically. It is important not to drink alcohol while taking this drug (the combination can lead to abdominal pain and vomiting). Metronidazole (Flagyl) A large single dose is as effective as longer term treatment, but increases the risk of side effects such as nausea and vomiting. Pills taken twice a day for 7 days are an alternative. Clotrimazole (Gyne-Lotrimin, Mycelex-7) if pregnant and having symptoms Medicine is inserted into the vagina at night for 14 days. This will decrease symptoms, but the cure rate is only 20%. Partners because infected male partners often do not have any symptoms, they do not seek medical care. It is important, however, that your sexual partner is evaluated and treated. Otherwise you may become reinfected. Your partner will be given one large dose of metronidazole or may be treated for 7 days. Your doctor may not routinely write an additional prescription for your partner without evaluating him or her first. Prevention Because trichomoniasis is a sexually transmitted disease, abstinence is the preferred method to avoid contraction of this disease. Safe sex and hygiene practices may also help prevent trichomonas infection. Wear condoms. Wash before and after intercourse. Don't share swimsuits or towels. (Trichomonads survive for up to 45 minutes outside the body.) Shower immediately after swimming in a public pool.

F. HEPATITIS B What is hepatitis? The term 'hepatitis' simply means inflammation of the liver. Hepatitis may be caused by a virus or a toxin such as alcohol. Other viruses that can cause injury to liver cells include the hepatitis A and hepatitis C viruses. These viruses are not related to each other or to hepatitis B virus and differ in their structure, the ways they are spread among individuals, the severity of symptoms they can cause, the way they are treated, and the outcome of the infection. What kind of a virus is hepatitis B? The hepatitis B virus is a DNA virus, meaning that its genetic material is made up of deoxyribonucleic acids. It belongs to a family of viruses known as Hepadnaviridae. The virus is primarily found in the liver but is also present in the blood and certain body fluids. Hepatitis B virus consists of a core particle (central portion) and a surrounding envelope (outer coat). The core is made up of DNA and the core antigen (HBcAg). The envelope contains the surface antigen (HBsAg). These antigens are present in the blood and are markers that are used in the diagnosis and evaluation of patients with suspected viral hepatitis. How does hepatitis B virus cause liver injury? The hepatitis B virus reproduces in liver cells, but the virus itself is not the direct cause of damage to the liver. Rather, the presence of the virus triggers an immune response from the body as the body tries to eliminate the virus and recover from the infection. This immune response causes inflammation and may seriously injure liver calls. Therefore, there is a balance between the protective and destructive effects of the immune response to the hepatitis B virus. How is the hepatitis B virus spread (transmitted)? Hepatitis B is spread mainly by exposure to infected blood or body secretions. In infected individuals, the virus can be found in the blood, semen, vaginal discharge, breast milk, and saliva. Hepatitis B is not spread through food, water, or by casual contact. In the United States, sexual contact is the most common means of transmission, followed by using contaminated needles for injecting illicit drugs, tattooing, body piercing, or acupuncture. Additionally, hepatitis B can be transmitted through sharing toothbrushes and razors contaminated with infected fluids or blood. Hepatitis B also may be spread from infected mothers to their babies at birth (so-called 'vertical' transmission). This is the most prevalent means of transmission in regions of the world where hepatitis B rates are high. The rate of

transmission of hepatitis B from mother to newborn is very high, and almost all infected infants will develop chronic hepatitis B. Fortunately, transmission can be significantly reduced through immunoprophylaxis (see below). Rarely, hepatitis B can be transmitted through transfused blood products, donated livers and other organs. However, blood and organ donors are routinely screened for hepatitis which typically prevents this type of transmission. What are the symptoms of acute hepatitis B? Acute hepatitis B is the period of illness that occurs during the first one to four months after acquiring the virus. Only 30% to 50% of adults develop significant symptoms during acute infection. Early symptoms may be non-specific, including fever, a flu-like illness, and joint pains. Symptoms of acute hepatitis may include: fatigue, loss of appetite, nausea, jaundice (yellowing of the skin and eyes), and pain in the upper right abdomen (due to the inflamed liver). Rarely, acute hepatitis damages the liver so badly it can no longer function. This life-threatening condition is called "fulminant hepatitis." Patients with fulminant hepatitis are at risk of developing bleeding problems and coma resulting from the failure of the liver. Patients with fulminant hepatitis should be evaluated for liver transplantation. Small studies suggest that the drug lamivudine (Epivir), may be of limited assistance in these cases What are the symptoms of chronic hepatitis B? The liver is a vital organ that has many functions. These include a role in the immune system, production of clotting factors, producing bile for digestion, and breaking down toxic substances, etc. Patients with chronic hepatitis B develop symptoms in proportion to the degree of abnormalities in these functions. The signs and symptoms of chronic hepatitis B vary widely depending on the severity of the liver damage. They range from few and relatively mild signs and symptoms to signs and symptoms of severe liver disease such as cirrhosis or liver failure. Most individuals with chronic hepatitis B remain symptom free for many years or decades. During this time, the patient's blood tests usually are normal or only mildly abnormal. Some patients may deteriorate and develop inflammation or symptoms, putting them at risk for developing cirrhosis. Cirrhosis of the liver due to hepatitis B Inflammation from chronic hepatitis B can progress to cirrhosis (severe scarring) of the liver. Significant amounts of scarring and cirrhosis lead to liver dysfunction. Symptoms may include: weakness, fatigue, loss of appetite, weight loss, breast enlargement in men, a rash on the palms, difficulty with blood clotting, and spider-like blood vessels on the skin. Decreased absorption of vitamins A and D can cause impaired vision at night and thinning of bones (osteoporosis). Patients with liver cirrhosis also are at risk of infections because the liver plays an important role in the immune system. Advanced cirrhosis of the liver due to hepatitis B In patients with advanced cirrhosis, the liver begins to fail. This is life-threatening condition. Several complications occur in advanced cirrhosis: Confusion and even coma (encephalopathy) results from the inability of the liver to detoxify certain toxic substances. Increased pressure in the blood vessels of the liver (portal hypertension) causes fluid to build up in the abdominal cavity (ascites) and may result in engorged veins in the swallowing tube (esophageal varices) that tear easily and may cause massive bleeding. Portal hypertension can also cause kidney failure or an enlarged spleen resulting in a decrease of blood cells and the development of anemia, increased risk of infection and bleeding. In advanced cirrhosis, liver failure also results in decreased production of clotting factors. This causes abnormalities in blood clotting and sometimes spontaneous bleeding. Patients with advanced cirrhosis often develop jaundice because the damaged liver is unable to eliminate a yellow compound, called bilirubin. Hepatitis B virus and primary liver cancer (hepatocellular carcinoma) Patients with chronic hepatitis B are at risk of developing liver cancer. The way in which the cancer develops is not fully understood. Symptoms of liver cancer are nonspecific. Patients may have no symptoms, or they may experience abdominal pain and swelling, an enlarged liver, weight loss, and fever. The most useful diagnostic screening tests for liver cancer are a blood test for a protein produced by the cancer called alpha-fetoprotein and an ultrasound imaging study of the liver. These two tests are used to screen patients with chronic hepatitis B, especially if they have cirrhosis or a family history of liver cancer. Hepatitis B virus involvement of organs outside of the liver (extra-hepatic) Rarely, chronic hepatitis B infection can lead to disorders that affect organs other than the liver. These conditions are caused when the normal immune response to hepatitis B mistakenly attacks uninfected organs. Among these conditions are: Polyarteritisnodosa: a disease characterized by inflammation of the small blood vessels throughout the body. This condition can cause a wide range of symptoms, including muscle weakness, nerve damage, deep skin ulcers, kidney problems, high blood pressure, unexplained fevers, and abdominal pain. Glomerulonephritis: another rare condition, which is inflammation of the small filtering units of the kidney.

What medications are used to treat hepatitis B? Acute infection Acute infection with hepatitis B usually does not require treatment. In rare cases, however, the infection may cause lifethreatening liver failure. Patients with liver failure due to acute hepatitis B should be evaluated for liver transplantation. Small studies suggest that the drug lamivudine (Epivir) may be effective in this setting. Chronic infection If a person is chronically infected with hepatitis B and has few signs or symptoms of complications, medications usually are not used. These patients are watched carefully and given periodic blood tests. One test measures the 'viral load,' that is, the amount of viral DNA in the blood. Doctors will recommend treatment if there are signs that the virus is beginning to cause damage or if the viral load is high. Another reason to prescribe medication is if the patient has a positive test for the Hepatitis B e-antigen (HBeAg) in the blood. HBeAg is associated with an increased risk of progression of liver disease and its complications. In chronic hepatitis B, the goal of treatment is to reduce the risk of complications including cirrhosis and liver failure. However, it takes decades for complications to occur, which makes it difficult to study the effect of medications. As a substitute for waiting years to find out what happens, scientists have used tests like the viral load or liver function tests to evaluate if medicines are working. This is logical because it is known that people who have large amounts of the virus in their blood are at highest risk to get cirrhosis. Up to one-third of people with very high viral loads (more than one million viral copies per milliliter of blood) will develop cirrhosis over a decade, compared to only 4.5% of those with low viral loads (fewer than 300 viral copies per milliliter). Medications can reduce the number of viruses in the body and may be able to eliminate the virus from the bloodstream. Logically, this should lead to them having a low rate of progression to cirrhosis (<1% per year), although large, long-term studies have not been done. Even in people who clear the virus from their blood, low numbers of viruses still live in the liver and other cells. Thus, the medications do not cure the disease, but they can prevent or delay complications and symptoms. People who have a good response to treatment can still transmit the virus. Doctors follow blood tests that measure viral load and liver function and they may recommend liver biopsies to evaluate if the medications are working. The medications in current use for chronic hepatitis B include the interferons and nucleoside/nucleotide analogues. New agents are being developed although they are still under investigation and considered experimental. There are no accepted guidelines that tell how every patient should be treated. As a result, treatment is individualized. Is there a preferred treatment for chronic hepatitis B? There are no clear guidelines to recommend which agent to use first in treating chronic hepatitis B. Interferon is given for a defined period of time and may have a more prolonged response after the medication is discontinued than NAs. However, interferon is given as an injection, and side effects often are troublesome. NAs are given as a pill and have few side effects, but the duration of treatment is unclear, and prolonged therapy may be required. NAs may be preferred in patients with unstable disease and cirrhosis because they are thought to be less likely to cause serious flares of hepatitis with more severe liver disease. What can be done to prevent hepatitis B? Hepatitis B is a preventable disease. Vaccination and post-exposure prophylaxis have significantly reduced rates of infection. Risk can also be reduced by avoiding unprotected sex, contaminated needles, and other sources of infection. How effective is vaccination for hepatitis B? The hepatitis B vaccine contains a protein (antigen) that stimulates the body to make protective antibodies. Examples of hepatitis B vaccines available in the United States include hepatitis b vaccine-injection (Engerix-B, Recombivax-HB). Three doses (given at 0, 1, and 6 months) are necessary to assure protection. There are also combination vaccines on the market that provide protection against hepatitis B and other diseases. Examples include: Hepatitis-b-hepatitis-a vaccine - injection (Twinrix), which provides protection against both hepatitis A and hepatitis B. Haemophilus B/hepatitis B vaccine - injection (Comvax) provides protection against hepatitis B and Haemophilusinfluenzae type b (a cause of meningitis). Pediarix provides protection against hepatitis B, tetanus, pertussis (whooping cough), and polio.