Microbiology

Hepatitis A-E Viruses (An Overview)

13 December 2007

HEPATITIS A – E VIRUSES: An Overview  e.g. household contact, sex contact, child day
Viral Hepatitis – Historical Perspectives care centers
o Contaminated food, water
“Infectious”
Infectious”
Enterically  e.g. infected food handlers, raw shellfish
A E transmitted
o Blood exposure
 Rare
Viral “NANB”
NANB”
hepatitis
 e.g. injecting drug use, transfusion
C

Parenterally Global Patterns of Hepatitis A Virus Transmission

“Serum”
Serum” B D transmitted Endemicity Disease Peak Age Transmission
Rate of Infection Patterns
F, G, TTV High Low to high Early Person to
? other
childhood person;
Type of Hepatitis outbreaks
A B C D E uncommon
Source of Feces Blood/ Blood/ Blood/ Feces Moderate High Late Person to
virus blood- blood- blood- childhood/ person; food
derived derived derived young adults and
body fluids body fluids body fluids
waterborne
Route of Fecal-oral Percutaneo Percutaneo Percutaneo Fecal-oral
transmissi us us us outbreaks
on permucosa permucosa permucosa Low Low Young adults Person to
l l l person; food
Chronic No Yes Yes Yes No and
Infection waterborne
Prevention Pre/post- Pre/post- Blood Pre/post- Ensure outbreaks
exposure exposure donor exposure safe Very low Very low Adults Travelers;
immunizati immunizati screening; immunizati drinking
on on Risk on: Risk water outbreaks
behavior behavior uncommon
modificatio modificatio D. Geographic Distribution
n n E. Laboratory Diagnosis
o Acute infection is diagnosed by the detection of
Hepatitis A Virus HAV-IgM in serum by EIA
o Past infection i.e. immunity is determined by the
detection of HAV-IgG by EIA
F. Vaccination Strategies: Epidemiologic Considerations
o Many cases occur in community-wide outbreaks
 no risk factor identified for 40-50% of cases
 highest attack rates in 5-14 year olds
 children serve as reservoir of infection
A. Clinical Features o Persons at increased risk of infection
o Incubation period: Average :  travelers to developing countries
30 days  homosexual men
Range : 15-50 days  injecting drug users
o Jaundice by age group: <6 yrs : <10 % G. Prevention: Immune Globulin
6-14 yrs : 40 - 50 o Pre-exposure
%  travelers to intermediate and high
>14 yrs: 70 - 80 % HAV-endemic regions
o Complications: Fulminant hepatitis o Post-exposure (within 14 days)
Cholestatic hepatitis  Routine
Relapsing hepatitis − household and other intimate
o Chronic sequelae: None
contacts
B. Serological course
 Selected situations
− institutions (e.g., day care centers)
− common source exposure (e.g., food
prepared by infected food handler)

Hepatitis B Virus

C. Mode of Transmission
o Close personal contact
virns 1 of 5
 Microbiology – Hepatitis A-E Viruses: An Overview by Dra de Castro Page 2 of 5

A. Clinical Features D. Global Patterns of Chronic HBV Infection

o Incubation period: Average 60-90 o High (>8%): 45% of global population
days  lifetime risk of infection >60%
Range 45-180 days  early childhood infections common
o Clinical illness (jaundice): <5 yrs, <10% o Intermediate (2%-7%): 43% of global population
>5 yrs, 30%-50%  lifetime risk of infection 20%-60%
o Acute case-fatality rate: 0.5%-1%  infections occur in all age groups
o Chronic infection: <5 yrs, 30%-90% o Low (<2%): 12% of global population
>5 yrs, 2%-10%  lifetime risk of infection <20%
o Premature mortality from  most infections occur in adult risk groups
chronic liver disease: 15%-25% E. Geographic Distribution
B. Spectrum of Chronic Hepatitis B Diseases F. Concentration of HBV in Various Body Fluids
o Chronic Persistent Hepatitis High Moderate Low/Not
 Asymptomatic Detectable
o Chronic Active Hepatitis blood semen urine
 Symptomatic exacerbations of hepatitis serum vaginal fluid feces
o Cirrhosis of liver wound exudates saliva sweat
o Hepatocellular carcinoma tears
C. Serological course breast milk
Acute Hepatitis B Virus Infection with Recovery G. Mode of Transmission
Typical Serologic Course o Sexual
 Sex workers and homosexuals are particular
Symptoms
at risk
o Parenteral
HBeAg anti-HBe
 IVDA, health workers are at increased risk
Total anti-HBc
o Perinatal
 Mothers who are HBeAg positive are much
Titer

IgM anti-HBc
more likely to transmit to their offspring than
HBsAg anti-HBs those who are not
 Perinatal transmission is the main means of
transmission in high prevalence population
H. Laboratory Diagnosis
0 4 8 12 16 20 24 28 32 36 52 100
o A battery of serological tests are used for the
Weeks after Exposure
diagnosis of acute and chronic hepatitis B
infection
o HBsAg
Progression to Chronic Hepatitis B Virus Infection
Typical Serologic Course  Used as a general marker of infection
o HBsAb
Acute Chronic  Used to document recovery and/or immunity
(6 months) (Years)
toHBV infection
HBeAg anti-HBe
o Anti-HBc IgM
HBsAg
Total anti-HBc  Marker of acute infection
o Anti-HBc IgG
Titer

 Past or chronic infection

o HBeAg
IgM anti-HBc  Indicates active replication of virus and
therefore infectiveness
o Anti-HBe
0 4 8 12 16 20 24 28 32 36 52
 Virus no longer replicating
Weeks after Exposure
 However, the patient can still be positive for
HBsAg which is made by integrated HBV
o HBV-DNA
Outcome of Hepatitis B Virus Infection
by Age at Infection  Indicates active replication of virus
 More accurate than HBeAg especially in cases
100 100
of escape mutants
Used mainly for monitoring response to
Symptomatic Infection (%)


Chronic Infection (%)

80 80
therapy
60 60
I. Treatment
Chronic Infection o Interferon
40 40  For HBeAg positive carriers with chronic
active hepatitis
20 20  Response rate is 30 to 40%
Symptomatic Infection o Lamivudine
0 0
 A nucleoside analogue reverse transcriptase
Older Children
Birth

1-4 yrs

inhibitor
1-6 mos

7-12 mos

and Adults

 Well, tolerated, most patients will respond

favorably
 Microbiology – Hepatitis A-E Viruses: An Overview by Dra de Castro Page 3 of 5

 However, tendency to relapse on cessation of

treatment
 Another problem is the rapid emergence of Anti-HCV
Symptoms +/-
drug resistance
o Successful response to treatment will result in the HCV RNA
disappearance of HBsAg, HBV-DNA, and

Titer
seroconversion to HBeAg
J. Prevention ALT
o Vaccination
 Highly effective recombinant vaccines are
Normal
now available
 Vaccine can be given to those who are at 0 1 2 3
Months
4 5 6 1 2 3
Years
4

increased risk of HBV infection such as health

Time after Exposure
care workers
 It is also given routinely to neonates as D. Mode of Transmission
universal vaccination in many countries o Risk Factors Associated with Transmission
o Hepatitis B Immunoglobulin  Transfusion or transplant from infected donor
 HBIG may be used to protect persons who are  Injecting drug use
exposed to hepatitis B  Hemodialysis (yrs on treatment)
 It is particular efficacious within 48 hours of  Accidental injuries with needles/sharps
the incident
 Sexual/household exposure to anti-HCV-
 It may also be given to neonates who are at positive contact
increased risk of contracting hepatitis B i.e.
 Multiple sex partners
whose mothers are HBsAg and HBeAg
 Birth to HCV-infected mother
positive
E. Geographic Distribution
o Other measures
F. Laboratory Diagnosis
 Screening of blood donors, blood and body o HCV antibody
fluid precautions
 Generally used to diagnose hepatitis C
infection
Hepatitis C Virus
 Not useful in acute phase as it takes at least
4 weeks after infection before antibody
HCV genome
appears
o HCV-RNA
 Various techniques are available e.g. PCR and
branched DNA
 May be diagnose HCV infection in the acute
A. Clinical Features phase
o Incubation period: Average 6-7  However, its main use is in monitoring the
weeks response to antiviral therapy
Range 2-26 weeks o HCV-antigen
Clinical illness (jaundice):
o 30 – 40% (20 –  An EIA for HCV antigen is available
30%)  It is used in the same capacity as HCV-RNA
o Chronic Hepatitis: 70% tests but is much easier to carry out
o Persistent Infection: 85 – 100% G. Treatment
o Immunity: No protective antibody o Interferon
response identified  May be considered for patients with chronic
B. Chronic Hepatitis C Infection active hepatitis
o The spectrum of chronic hepatitis C infection is  The response rate is around 50% but 50% of
essentially the same as chronic hepatitis B responders will relapse upon withdrawal of
infection treatment
o All the manifestations of chronic hepatitis B o Ribavirin
infection may be seen, albeit with a lower  There is less experience with ribavirin than
frequency i.e. chronic persistent hepatitis, chronic interferon
active hepatitis, cirrhosis, and hepatocellular  However, recent studies suggest that a
carcinoma combination of interferon and ribavirin is
C. Serological course more effective than interferone alone
Typical Serologic Course of HCV Infection H. Prevention
o Screening of blood, organ, tissue donors
o High-risk behavior modification
o Blood and body fluid precautions

Hepatitis D Virus
 Microbiology – Hepatitis A-E Viruses: An Overview by Dra de Castro Page 4 of 5

A. Clinical Features
o Incubation period: Average 40 days
Range 15-60 days
HDV is a defective single-stranded RNA virus that o Case-fatality rate: Overall, 1%-3%
requires the helper function of HBV to replicate. HDV
Pregnant women, 15%-
requires HBV for synthesis of envelope protein composed
25%
of HBsAg, which is used to encapsulate the HDV genome.
A. Clinical Features o Illness severity: Increased with age
o Coinfection o Chronic sequelae: None identified
 severe acute disease B. Serological course
 low risk of chronic infection
o Superinfection
 usually develop chronic HDV infection high
 risk of severe chronic liver disease
 may present as an acute hepatitis
B. Mode of Transmission
o Percutaneous exposures
 Injecting drug use
o Permucosal exposures
 Sex contact
C. Serological course

C. Epidemiologic Features
o Most outbreaks associated with faecally
contaminated drinking water
o Several other large epidemics have occurred
since in the Indian subcontinent and the USSR,
China, Africa and Mexico
o In the U.S. and other nonendemic areas, where
outbreaks of hepatitis E have not been
documented to occur, a low prevalence of anti-
HEV (<2%) has been found in healthy
populations. The source of infection for these
persons is unknown
o Minimal person-to-person transmission
D. Geographic Distribution
E. Prevention
o Avoid drinking water (and beverages with ice) of
unknown purity, uncooked shellfish, and
uncooked fruit/vegetables not peeled or prepared
by traveler
o IG prepared from donors in Western countries
does not prevent infection
o Unknown efficacy of IG prepared from donors in
endemic areas
o Vaccine?

♥end♥
D. Geographic Distribution
E. Prevention Thoughts brought about by watching Just Like
o HBV-HDV Coinfection Heaven and Prozac Nation successively. :)
 Pre or postexposure prophylaxis to prevent I have no need of food. I have no need of sleep. I have
o HBV-HDV Superinfection no needs other than occasionally chewing a breath mint.
YOU ARE THE BEST THING THAT’S EVER HAPPENED TO
 Education to reduce risk behaviors among
ME.. probably because it haven’t happened to me yet.
persons with chronic HBV infection
Now, I can pass into the next act, so poetically called:
euphoria.
Hepatitis E Virus
 Microbiology – Hepatitis A-E Viruses: An Overview by Dra de Castro Page 5 of 5

I feel so good. I feel so strong. I feel actually attractive

and I could learn to live with that feeling. But what if I’m
no good at this? I am no good at this. I am a dingy speck
on the wall of humanity and look how badly painted the
wall is!
I am becoming very, very afraid. That must be
because I’m passing into the third act called: fear.
Oh no! What if I’m wrong? What if this stinks? What if
my heart has blinders on, it had blinders on before.. in
fact it had dark, heavy patches taped all over it. How can
anyone love me if I don’t love myself? I mean, I love
myself; there are just parts between the top of my head
and the bottom of my feet that could use some
improvement. I’m not demeaning my self..
I can’t believe I ever said I felt this way. I must have
been dreaming! Wait! This is no dream.. This is a film or
movie, and one of those really dark ones too. I mean.. Is
this love? This is what they tell you about when you’re
naive.
The truth: love is hard work. And sometimes, hard
work can really hurt. Love is a game. Love is a game and
if you play.. You either win, lose or get ejected before the
game is over. There are no ties.
Maybe you’ll lose and learn some great meaningful
answer from it all (like, if it looks too good to be true, it
is). It’s easy to love something when you don’t have to
work at it. It’s harder when it asks something of you, you
just might be afraid to give.. give it anyway.
The heart is the most resilient muscle. It is also the
stupidest. So if this love you’ve found is good to you, hold
it.. keep it.. shout about it. If it isn’t, then maybe you
should just become very good friends.
So this is love, as demanding and nourishing and
difficult as it can be, and as strong and wise as it makes
you become.
There is something to be gained from commitment.
There are rewards for staying when you would rather
leave. And there’s something to be said for running up
that hill when you would rather slide down it. And so, you
let love come perch upon your shoulder.. and you don’t
turn it away.

*oh no! May space p din.. di ko n xa kaya I fill up.. oh

well. ;o) stay in love! Hehe! ;o)

*di ko sinama un geographical distribution n pix kc

magiging sobrang minute n un pix. Ky d n ntin makikita
un distribution nya. hehe. ;op if ever may gs2 magadik
nun geo pix.. txt nyo lng me.. icsend ko s inyo (nandun
din un geo pix s patho hepa trans natin). ;o)

xoxo