Hepatitis is an umbrella term that describes any situation involving inflammation of the liver. In this country, that usually means a viral infection with one of three candidates: hepatitis A, hepatitis B, or hepatitis C. It is important to emphasize from the beginning that exposure to any one of these viruses provides no protection from any of the others. These are completely distinct pathogens; the only thing they share is a predilection for liver cells.

In this article, we will review the healthy liver, and what happens when the liver is under viral attack. Then we will examine the interplay between massage therapy and various forms of hepatitis. The goal is to point out that this professional hazard is a serious—but completely manageable—issue.

Liver Function: It’s Amazing!

Entire textbooks have been devoted to the topic of liver function; in this context, we will review just a few of its important jobs.

• Fluid receiver. The liver receives blood from the left and right hepatic arteries, as well as from the portal system.

• Bile. The liver manufactures bile, which emulsifies fats. Bile has several ingredients, but one of them is bilirubin: a byproduct of red blood cell recycling, delivered through the portal vein from the spleen. Bilirubin is dark golden-brown, and it is a coloring agent for feces.

• Blood proteins. The liver manufactures many of the substances in our plasma that assist with blood clotting and other functions.

• Detoxification. The liver extracts potentially toxic metabolic wastes from the bloodstream. Sometimes it converts these products into a format that the body can manage more easily—the conversion of ammonia to urea is a good example. The liver also filters out excessive masculine and feminine hormones.

Here Come the Viruses

Viral infections of the liver can range on a continuum from mild to very severe. No matter which virus causes the infection, the signs and symptoms are related to a liver that is temporarily or permanently losing function: fatigue, headache, and nausea are the most common complaints. These may be accompanied by complications that are discussed below.

Hepatitis A

Hepatitis A is the least serious of all the hepatitis infections. This virus concentrates in the digestive tract, so it is spread most easily through oral-fecal contamination. We occasionally hear about outbreaks of hepatitis A where fecal matter has entered the food or water supply.

The good news about hepatitis A is that one infection imparts lifelong immunity, and that this virus is only rarely associated with serious consequences. For most people, it is an inconvenience with unpleasant symptoms that may last several weeks, but it is not a threatening infection.

Hepatitis B

Hepatitis B is a slow-acting virus that can silently and progressively destroy the liver. It causes long-term, low-grade inflammation that leads to scarring around and between hepatocytes; this interferes with liver function, and has wide-ranging implications for general health.

Two of the unique features of the hepatitis B virus are its stability outside of a host, and its high concentration in the blood. This means that it can last on surfaces for many hours, and it can be transmitted with very minimal contact: a shared toothbrush or razor may be all that it takes. Used hypodermic needles, tattoo equipment, or piercing equipment are also possible vectors. Hepatitis B can also be spread through other intimate fluids, including semen and vaginal secretions.

About 5 percent of all hepatitis B patients develop a chronic version of this infection, with continued communicability and a risk of severe liver damage. For this reason, it is important to treat hepatitis B; interferon, lamuvidine, and ribovarin are the typical recommendations.

Hepatitis C

From the early 1970s to 1989, epidemiologists knew that a third liver-loving virus was becoming common, and they called it “hepatitis non-A, non-B.” (Now we have identified hepatitises C, D, E, F, and G, although D–G are not considered threatening.)

Hepatitis C is an extremely slow-acting virus. Because the liver can easily compensate for lost function, several years or even decades can pass between exposure and the development of symptoms. Hepatitis C appears to be most communicable by direct blood-to-blood contact. This includes contaminated transfusions or organ transplants, shared needles, or contaminated tattoo or piercing equipment. There is some controversy about whether hepatitis C can be spread through unprotected sex; this appears to be an efficient mechanism only when there is significant tearing of mucous membranes. Blood tests for hepatitis C are accurate within a few months of exposure, so it can be diagnosed long before symptoms begin.

Hepatitis C is treated with drugs that limit viral activity, specifically interferon, ribivarin, and some other medications that can improve the prognosis for this infection, but they carry a long list of side effects.

One of the most serious concerns with hepatitis C is that only about a quarter of the people who are infected can expect to recover without treatment. In other words, 75 percent of people with hepatitis C are at risk for being communicable throughout their life, and for developing serious liver problems.

Story 1: “One of my clients is a fisherman. He told me in the middle of his last session that he had just tested positive for hepatitis C. That was when I noticed that his hands were covered with little nicks and cuts, and my own hands weren’t perfect either. That week, I went to the health department to be tested, and it turns out that I am also positive for hepatitis C. Is it possible that I caught it from this client?”

Truthfully the answer to this question is almost certainly not. It is most likely that this therapist was exposed many years ago. But our job is to reduce the risk of spreading this virus throughout our environment to as close to zero as possible, and we do that by following good hygienic practices.

Hepatitis Complications

The consequences of viral attacks against the liver are related to progressive loss of function. Here is a short list of complications:

• Jaundice. If the liver is impeded in making bile, bilirubin backs up through the body, staining the skin, and mucous membranes, yellow.

• Excessive bleeding. Clotting proteins cannot be produced by a damaged liver, so the potential for bruising or bleeding becomes a serious problem.

• Ascites. When the liver is clogged with scar tissue, fluid seeps from the major blood vessels into the abdominal cavity. Because this fluid is essentially stagnant, it becomes vulnerable to spontaneous infection and life-threatening peritonitis.

• Sexual dysfunction. When liver function is impaired, men may develop feminizing characteristics (enlarged breasts, atrophied genitals), and women may develop masculinizing characteristics (excessive body hair, loss of the menstrual cycle).

• Psychosis. Impaired liver function means that ammonia accumulates in the bloodstream, damages the blood-brain barrier, and leads to temporary or permanent brain damage.

• End-stage liver disease. This includes cirrhosis, liver failure, or liver cancer. Hepatitis B and C kill about 15,000 people in this country every year.

Where Does Massage Fit?

Since between 3 and 4 million people in this country are infected with either hepatitis B or hepatitis C (or both), the chances for massage therapists to have an infected client are relatively high. Clients may or may not know about their status, or they may choose not to share their status with you. What implications does this have for bodywork choices?

Story 2: I did my massage school outreach paper on a client with hepatitis C who was being treated with interferon and ribovarin. I did 10 sessions with him and the massage significantly reduced the side effects of the interferon (which can include muscle soreness, flu-like symptoms and depression/irritability). 

People with an advanced form of hepatitis B or C may be prone to bruising and bleeding. Skin rashes from systemic toxicity are common. Many people with hepatitis report general malaise; this may be due to the virus, or it may be connected to antiviral medications. Massage may be able to help with this, as long as it’s done with caution to avoid overtreatment.

Story 3: “I have a client who has both hepatitis B and hepatitis C. I have another client who’s been trying to get pregnant for several years, and she finally succeeded. Next week, she is scheduled to see me immediately after my client with hepatitis. Is there any chance that she could be at risk by following this person?”

For advice about this precarious situation, I called the infection control department at my local hospital. The expert there assured me that standard precautions—that is, swabbing surfaces with a good cleaner, changing linens, and of course washing hands—are adequate to be sure that every client is safe.

In massage therapy settings, we must practice good hygiene: we make sure that the surfaces our clients touch are regularly cleaned; we wash any fabrics that one client contacts before another client uses them; and we make sure that our own best defenses—our clean, intact skin and our good constitutional health—are in place before we see clients.

Ultimately, it doesn’t matter whether our clients are positive for hepatitis B or C or the Creeping Gombooh. When we use good hygienic practices, we are prepared for the possibility that any of our clients may have a blood-borne infection, and we protect ourselves and them from any risk of transfer.

Author’s note: My deepest thanks to all the contributors who brought me their hepatitis experiences; it is my honor to share your generosity.

  Ruth Werner is a writer and educator and is approved by the NCTMB as a provider of continuing education. She wrote A Massage Therapist’s Guide to Pathology (Lippincott Williams & Wilkins, 2009), now in its fourth edition, which is used in massage schools worldwide. Werner is available at www.ruthwerner.com or wernerworkshops@ruthwerner.com.