Acute Viral HepatitisElmer R. Encarnacion,MD

Types of HepatitisTypes of HepatitisAA BB CC DD EE GG

Source ofSource of

virusvirus

FecesFeces Blood, Blood, body body fluidsfluids

Blood, body Blood, body fluidsfluids

Blood, Blood, body body fluidsfluids

FecesFeces BloodBlood

Route of Route of TransmissiTransmissionon

Fecal-Fecal-OralOral

ChildbirthChildbirth, needles, , needles,

sex, sex, transfusiotransfusio

nn

Needles,Needles,

transfusion transfusion (sex, (sex,

childbirth)childbirth)

Needles, Needles, sex, sex,

transfusiotransfusionn

(requires (requires HBV co-HBV co-

infection)infection)

Fecal-Fecal-OralOral

TransfusionTransfusion

(requires (requires HBV, HCV, HBV, HCV, or HIV co-or HIV co-infection)infection)

Chronic Chronic InfectionInfection

NoNo YesYes YesYes YesYes NoNo NoNo

(whether it’s (whether it’s pathogenic pathogenic to humans to humans remains remains unclear)unclear)

PreventionPrevention VaccineVaccine

Immuno-Immuno-globulinglobulin

VaccineVaccine

Immuno-Immuno-globulinglobulin

Blood Blood donor donor

screening, screening, risk risk

managememanagement, nt,

educationeducation

HBV HBV VaccineVaccine

Ensure Ensure safe safe

drinking drinking waterwater

Blood donor Blood donor screeningscreening

CDC fact sheets, available at www.cdc.gov

Hepatitis A Virus

RNA virus

Incubation period: 4 weeks

Replication limited to the liver

Virus present in liver, bile, stools, and blood

Infectivity diminishes once jaundice appears

Inactivation by boiling; formaldehyde, chlorine

Prevention by vaccination

Serologic marker: Anti HAV IgM

Hepatitis B

DNA virus

Hepadnaviruses (hepatotropic)

Incubation period: 60 days

HBsAg+ precedes ALT elevation, symptoms

Extrahepatic sites: lymph nodes, bone marrow, lymphocytes, spleen, pancreas

Transmission of HBV varies by Transmission of HBV varies by geographic area:geographic area:

Mother to infant, child-to-child

China, Southeast Asia, Middle East and parts of Africa and South America

Parenteral Route (Intravenous or Intramuscular)

Intimate contact North America, Australia,

Western Europe, temperate South America

High-risk IndividualsHigh-risk Individuals

Infants born to HBV+ Infants born to HBV+ mothersmothers

Adoptive families of Adoptive families of children born in children born in endemic areasendemic areas

Recipients of blood Recipients of blood products, including products, including transfusionstransfusions

Hemodialysis patientsHemodialysis patients

Healthcare workersHealthcare workers

Sexual partners of Sexual partners of HBV carriersHBV carriers

People with sexually People with sexually transmitted diseasestransmitted diseases

Intravenous drug Intravenous drug usersusers

People with multiple People with multiple sexual partnerssexual partners

Acute vs ChronicAcute vs ChronicHepatitis BHepatitis B

AcuteAcute ChronicChronic

DefinitionDefinition disease in which disease in which HBsAg persists for HBsAg persists for less than 6 monthsless than 6 months

Persistence of Persistence of HBsAg for more HBsAg for more than 6 monthsthan 6 months

PhasesPhases IncubationIncubation

ProdromalProdromal

IctericIcteric

Immune ToleranceImmune Tolerance

ClearanceClearance

Non-replicativeNon-replicative

CharacterisCharacteristicstics

1. Usually subclinical 1. Usually subclinical in childrenin children

2. 30%-50% of adult 2. 30%-50% of adult patients develop patients develop clinical manifestationsclinical manifestations

3. May become 3. May become fulminant fulminant

1. Can be HBeAg (+) 1. Can be HBeAg (+) or (-)or (-)

2. Viral load is 2. Viral load is associated with associated with disease activitydisease activity

3. May progress to 3. May progress to fibrosis, cirrhosis, or fibrosis, cirrhosis, or HCCHCC

Signs and SymptomsSigns and Symptoms

AcuteAcute ChronicChronic

May be May be asymptomaticasymptomatic

Usually asymptomaticUsually asymptomatic

Flu-like Flu-like symptomssymptoms

Malaise/FatigueMalaise/Fatigue

Skin RashSkin Rash Extra-hepatic Extra-hepatic symptomssymptoms

JaundiceJaundice Signs/symptoms of Signs/symptoms of liver failureliver failure

Light-colored Light-colored stoolsstools

Hepatocellular Hepatocellular carcinomacarcinoma

Dark-colored Dark-colored urineurine

Pathogenesis of HBV InfectionPathogenesis of HBV Infection

Averett DR and Mason WS. Viral Hep. Rev. 1995; 1:129–42

Clinical hepatitis

HBV-infected hepatocytes

Inflammationand cell death

HBV production

Hepatocyteregeneration

Uninfected hepatocyte

s

Infection

Immunerespons

e

Re-infection

Alcohol,co-infection

etc.

Viral replication

Transplantor

Death

Immune response

Tissue damage

Scarring

HCC

Cirrhosis

Evidence of disease

Pathogenesis of Chronic HBV Pathogenesis of Chronic HBV InfectionInfection

Adapted from Dr Z Goodman, Armed Forces Institute of Pathology, Washington, DC

Host and environmental

factors(e.g. alcohol, co-

infection)

Prevention of HBV InfectionPrevention of HBV Infection

Screening of blood/organ/tissue donors Screening of blood/organ/tissue donors Hepatitis B vaccine Hepatitis B vaccine

• Available since 1981Available since 1981• Vaccination programmes adopted in >150 Vaccination programmes adopted in >150

countries worldwide countries worldwide • Inactivated or recombinant HBsAgInactivated or recombinant HBsAg• Routine vaccination of infants and previously Routine vaccination of infants and previously

unvaccinated children (by age 11)unvaccinated children (by age 11)• Catch-up vaccination of high-risk groups of all Catch-up vaccination of high-risk groups of all

ages ages • Screening pregnant women and rapid Screening pregnant women and rapid

vaccination of infants born to infected women vaccination of infants born to infected women (HBIg and vaccine)(HBIg and vaccine)

Infants born to infected mothers must be Infants born to infected mothers must be vaccinated within the first 12 hours of lifevaccinated within the first 12 hours of life

WHO-CSR, HBV Report 2002, available at www.who.int/emc-documents (12/10/2003)

Prevention of HBV Prevention of HBV InfectionInfection

Screening of blood/organ/tissue donors Screening of blood/organ/tissue donors Hepatitis B vaccine Hepatitis B vaccine

• Available since 1981Available since 1981• Vaccination programmes adopted in >150 Vaccination programmes adopted in >150

countries worldwide countries worldwide • Inactivated or recombinant HBsAgInactivated or recombinant HBsAg• Routine vaccination of infants and previously Routine vaccination of infants and previously

unvaccinated children (by age 11)unvaccinated children (by age 11)• Catch-up vaccination of high-risk groups of all Catch-up vaccination of high-risk groups of all

ages ages • Screening pregnant women and rapid Screening pregnant women and rapid

vaccination of infants born to infected women vaccination of infants born to infected women (HBIg and vaccine)(HBIg and vaccine)

Infants born to infected mothers must be Infants born to infected mothers must be vaccinated within the first 12 hours of lifevaccinated within the first 12 hours of life

WHO-CSR, HBV Report 2002, available at www.who.int/emc-documents (12/10/2003)

Treatment Algorithm Treatment Algorithm