Millions of Indians may be living with hepatitis B without knowing it: A liver transplant surgeon explains why the silent virus is so dangerous

Most people worry about illnesses that arrive with obvious warning signs, a high fever, severe pain or sudden weakness. Hepatitis B rarely behaves that way. It can quietly damage the liver for years, sometimes decades, without causing symptoms. By the time many people learn they have it, the disease may have already progressed to cirrhosis, liver failure or even liver cancer. That silent nature is one reason India continues to carry one of the world's largest hepatitis B burdens. For most families, these numbers feel distant until someone close is diagnosed. By then, the disease may already have caused serious damage.Many people imagine that a serious liver disease would announce itself with obvious warning signs. Unfortunately, hepatitis B rarely does."India has the second highest hepatitis-B burden globally with an estimated 40–50 million chronic carriers. Hepatitis-B is one of the viruses causing chronic hepatitis and in the long run leading to end-stage liver disease or cirrhosis and liver cancer. As a liver transplant surgeon who deals with end stages of this virus, we see devastating results, cirrhosis, liver failure and liver cancer (hepatocellular carcinoma)," said Dr Ankur Garg, Group Director, Liver Transplant & GI Surgery, Paras Health, Gurgaon.That explains why specialists often refer to hepatitis B as a silent infection.According to Dr Garg, the virus can quietly inflame the liver for years without causing noticeable symptoms."Hepatitis-B is often in a silent carrier state and does not lead to any clinical symptoms or concerns for years or decades. The virus causes slow, silent chronic inflammation in the liver. By the time symptoms occur in the form of jaundice, fatigue, lethargy or abdominal swelling, the liver is heavily scarred (cirrhosis). This is the time surgeons often meet such patients for the first time, and it becomes shocking for the patient and family to hear that liver transplant is the only option now."That is one reason liver specialists emphasise screening even when a person feels completely healthy.One of the biggest misconceptions is that hepatitis B spreads only through risky behaviour. In reality, many infections in India happen much closer to home."It is frequently passed down in families. It spreads via blood and bodily fluids. The most common form of transmission is either mother to child (vertical transmission), this being the most common in India when a pregnant mother passes this to her newborn child. The second is household spread (horizontal transmission). The virus can survive outside the body for up to a week. Sharing razors, toothbrushes, nail clippers or even minor cuts and scrapes within the household can easily transmit the virus to other members," explained Dr Garg.That changes how people should think about the infection.A hepatitis B diagnosis in one family member should encourage other close relatives to get tested. It is not about creating fear. It is about protecting those who may have been unknowingly exposed over the years.The WHO notes that hepatitis B is not spread through hugging, sharing food, coughing or casual social contact, which is why people living with the infection should never face stigma.Not every health story comes with a hopeful ending. This one does.Hepatitis B is preventable through vaccination, and preventing infection also reduces the risk of future liver cirrhosis and liver cancer.India introduced the hepatitis B vaccine into its Universal Immunisation Programme in phases beginning in 2002 and later expanded coverage across the country. Children born after widespread implementation are far more likely to have received protection than many adults who were born earlier."It is preventable and highly treatable but rarely curable. Vaccination has a very good bearing, 100% protection. India introduced vaccination against hepatitis-B in universal immunisation in 2002. However, millions born before 2002 are often not vaccinated."A hepatitis B diagnosis often creates panic because many people immediately think of liver failure. Doctors say that is no longer the reality for most patients.Modern antiviral medicines can keep the virus under control for years, reducing the risk of severe liver damage when taken under medical supervision."If someone tests positive, just taking one pill, for example entecavir or tenofovir, a day will keep this virus silent for more than 99% of the cases, although resistant cases do exist. However, these medicines will not cure the infection; they will keep the virus suppressed," said Dr Garg.That distinction matters. Treatment suppresses the virus and helps protect the liver, but regular follow-up with a liver specialist remains essential.Perhaps the most powerful message from liver transplant surgeons is also the simplest. Do not wait for symptoms. By the time symptoms appear, the liver may already have suffered years of silent damage.Dr Garg recommends a straightforward approach, "Because of India's high burden, transplant surgeons and hepatologists recommend a simple, proactive rule of thumb: Get a simple HBsAg blood test once. If you are negative, ensure you are vaccinated. If you are positive, don't panic, regular monitoring with a doctor can ensure you stay perfectly healthy and never have to see a transplant surgeon in an operating room."For many people, that single test may bring reassurance. For others, it could detect an infection early enough to prevent irreversible liver disease.Sometimes the most important health decisions are not the dramatic ones. They are the quiet, preventive steps taken long before illness ever announces itself.This article includes expert inputs shared with TOI Health by:Dr Ankur Garg, Group Director Liver Transplant & GI Surgery, Paras Health, Gurgaon. Inputs were used to explain why hepatitis B remains a major public health challenge in India, how the virus silently damages the liver, and why timely testing, vaccination and medical follow-up are essential.