Martin Williams investigates the main types of hepatitis, to show how they are diagnosed and to what extent they can affect premiums
Over the past few years, more questions have been asked in relation to hepatitis and protection products. So what is hepatitis and what effect does it have on life assurance?
Hepatitis is a viral infection that affects the liver and there are many different strains of the disease, but the most common seen when underwriting life assurance are hepatitis A, hepatitis B and hepatitis C. Causes include viruses, toxic chemicals, alcohol consumption, parasites and bacteria and certain drugs. The main symptoms of hepatitis are nausea, fever, weakness, loss of appetite and jaundice.
Hepatitis A
Hepatitis A, also called infectious hepatitis, is the most common and mildest form of viral hepatitis, with a rapid recovery experienced in most cases. The spread of the infection is mainly by infected food or water. The condition is relatively benign and generally lasts from three to six weeks. Hepatitis A is endemic in much of Africa, the Middle East and Indian subcontinent. It is rare in industrialised countries where the general standard of hygiene is high. Hepatitis A is often called a 'traveller's disease' as travellers to endemic regions are at higher risk of infection as most will not have developed immunity to hepatitis A from past exposure.
Hepatitis A can be diagnosed by a simple blood test and as it normally has a rapid recovery rate, it will not concern an underwriter as long as there has been a full clinical recovery. Caution, however, may be used in underwriting income protection (IP) where hepatitis A is still present due to the possibility of fatigue caused by the condition.
Hepatitis B
Hepatitis B is an inflammatory response of the immunological defence system taking place in the liver, which is triggered by the hepatitis B virus (HBV). Of adults who have been infected with the HBV virus, more than 95% recover, but in 1%-5% persistent infection might be associated with chronic hepatitis. The HBV virus is present worldwide and there are an estimated 300 million carriers.
The virus is spread either by blood transfusion of infected blood or blood products, by contaminated needles or by close personal contact. It can also be spread by vertical transmission from mother to infant. The latter is particularly prevalent in China, South East Asia and most of Africa where between 10% and 15% of the population are chronically infected. The prevalence rates in Europe, North America and Australasia are about 1% or less.
The disease is similar to hepatitis A, but more severe. Skin rashes and joint pains often precede the main symptoms. Most individuals recover within a few months, or can become asymptomatic carriers of the virus. However, some remain chronic carriers of the virus or develop chronic hepatitis and some can develop complications, including cirrhosis of the liver, or liver cancer.
As with hepatitis A, diagnosis can be made by a simple blood test that identifies the hepatitis B virus or shows abnormal liver function. There is no specific treatment for HBV, so prevention is considered to be the best method to keep the virus under control. This is why blood products are now screened and individuals working in high risk areas, such as hospital staff or doctors, are regularly screened.
Current therapy is designed to support and maintain comfort and, as with most forms of hepatitis, alcohol consumption should be minimised, if not stopped completely. This will help the liver to recover more quickly.
Hepatitis C
Hepatitis C, also known as non-A, non-B hepatitis or post-transfusional hepatitis, is an inflammatory response of the immunological defence system taking place in the liver, which is triggered by the hepatitis C virus (HCV).
HCV was identified in 1989 and was recognised as the cause of 90% of post-transfusional hepatitis and for 60-90% of all forms of viral hepatitis not caused by either A or B.
As with HBV, hepatitis C is primarily transmitted by direct exchange of blood and the most efficient transmission occurs via blood transfusions, blood products or the transplantation of organs.
HCV in blood donors ranges from 0.07% in the northern hemisphere to 1.9% in the southern hemisphere. HCV has a higher prevalence in southern Europe and South East Asia. Individuals with haemophilia and IV drug users have a higher rate of HCV infection, but since the screening of HCV in donor blood was introduced, the incidence of post-transfusional hepatitis has fallen dramatically.
Hepatitis C causes liver cell destruction and can be linked with significant liver dysfunction. Following infection with HCV, in about half the cases the liver cells regenerate with little residual damage, but chronic infection occurs around 50% of the time. Chronic infection has a high rate of liver damage with signs of necrosis of liver tissue and/or cirrhosis.
Many people infected with HCV often have few or no symptoms and might only show signs of a flu-like illness. Diagnosis may only be made by chance during investigation of late-onset symptoms or when donating blood. As with HBV, diagnosis is made from the results of a blood test and further investigations including a liver biopsy made be performed to assess the condition of the liver.
Hepatitis C rarely remits spontaneously, but chronic HCV is sometimes treated with Interferon. Although a high percentage of those treated can relapse, a small percentage of this group can achieve long-term remission. The factors that can help in long-term remission are diagnosis at a younger age, short duration of the infection and no cirrhosis or advanced liver disease.
On receiving the application, an underwriter will always request a report from the individual's doctor, where there is a history of hepatitis B and hepatitis C, requesting confirmation of the current hepatitis status and sight of any hospital reports. Even if the individual has been advised they are clear of the virus, this ensures there has been no long-term liver damage. Also, the evidence received would indicate the source of the infection, especially relevant if IV drug abuse or high levels of alcohol were found.
Terms would not be considered where the virus has been diagnosed within the last six months. Terms would depend upon the current hepatitis status and degree of liver damage. It is possible for terms for hepatitis B to range from a small minimal loading to declinature where there has been severe liver damage. Where there has been a full clinical recovery with no liver damage, standard terms could be considered. Ratings for hepatitis C would be more severe ranging from 100% to 300% and, again, where there has been severe liver damage terms may not be available. It is unlikely that terms would be available for disability benefits where HCV has been diagnosed.
Martin Williams is a senior underwriter at Scottish Equitable Protect
