Hepatitis A, B and C Virus

The phases of the Acute Viral

Hepatitis
The classical phases of the Acute viral hepatitis

Pre-icteric Icteric Convalescense

“Flu-like” syndromes malaise

Appetite
History taking Dyspepsia +
Tea-colour urine

jaundice
Physical exam hepatomegaly jaundice
<

Laboratorium Alt/ASTALP/ AST/ALT/AP/

GGT/BIL.↑, GGT,BIl.↓/N
Blood ALT/AST ↑ seromarker + Seroconversion

Urine Uro/bili + Uro/bili + Uro/bili. ±.

Hepatitis A Virus
 Hepatitis A Virus

 Naked RNA virus

 Related to enteroviruses, formerly known as
enterovirus 72, now put in its own family:
heptovirus
 One stable serotype only
 Difficult to grow in cell culture: primary marmoset
cell culture and also in vivo in chimpanzees and
marmosets
 4 genotypes exist, but in practice most of them are
group 1
 Hepatitis A - Clinical
Features
 Incubation period: Average 30 days
Range 15-50 days
 Jaundice by <6 yrs, <10%
age group: 6-14 yrs, 40%-50%
>14 yrs, 70%-80%
 Complications: Fulminant hepatitis
Cholestatic hepatitis
Relapsing hepatitis
 Chronic sequelae: None
 Hepatitis A Virus Transmission

 Close personal contact

(e.g., household contact, sex contact,
child day care centers)
 Contaminated food, water
(e.g., infected food handlers, raw shellfish)
 Blood exposure (rare)
(e.g., injecting drug use, transfusion)
 Laboratory Diagnosis

 Acute infection is diagnosed by the detection of HAV-IgM

in serum by EIA.
 Past Infection i.e. immunity is determined by the detection
of HAV-IgG by EIA.
 Cell culture – difficult and take up to 4 weeks, not
routinely performed
 Direct Detection – EM, RT-PCR of faeces. Can
detect illness earlier than serology but rarely
performed.
Hepatitis B Virus
 Hepatitis B Virus - Virology
 Double stranded DNA virus,the + strand not complete
 Replication involves a reverse transcriptase.
 Complete Dane particle 42 nm, 28 nm electron dense core,
containing HBcAg and HBeAg. The coat and the 22 nm
free particles contain HBsAg
 At least 4 phenotypes of HBsAg are recognized;
adw, adr, ayw and ayr.
 The HBcAg is of a single serotype
 Hepatitis B virus (HBV) has been classified into 8
genotypes (A-H).
 It has not yet been possible to propagate the virus
in cell culture.
 Prevalence of HBsAg Carrier State

HBV - Epidemiology

>8%
2-8%
<2%

WHO
 Transmission of HBV
Horizontal transmission Vertical transmission

Host Recipient Mother

Child to child Perinatal

Contaminated needles
Sexuals
Health care workers Infant
Transfusions
6% infected after age 5 years
become chronically infected 90% infected infants become
Chronically infected
No clear risk factors in 20-30% patients
 Concentration of HBV
in Various Body Fluids
High Moderate Low/Not
detectable
Blood Semen Urine
Serum Vaginal fluid Feces
Wound exudates Saliva Sweat
Tears
Breast milk
CDC
 Hepatitis B disease Progression
Liver
Cancer (HCC)
5-10% of CHB
individuals

>30% of CHB
individuals
Acute Chronic Liver Liver Death
Infection Infection Cirrhosis Transplantation

>90% of infected
children progress to
chronic disease
<5% of infected
Immunocompetent
LiverFailure
adults progress to
(decompen-
chronic disease.
sation))

23% of patients decompensate

within 5 years of developing
cirrhosis
 Early Childhood HBV Infection

Risk of Chronicity
Age at infection (years) Proportion who become carriers(%)
<1 70 – 90

2–3 40 – 70

4–6 10 – 40

7 6 - 10
HBV - Natural History

Clinical Outcome of Chronic

Hepatitis B
Chronic HBV Infection

Inactive Carrier
State Chronic Hepatitis

Cirrhosis

HCC
 Hepatitis B Virus

Gene Products and Functions

Polymerase Terminal protein (priming)
Reverse transcriptase, RNAse H
Surface Envelope proteins
Pre - S1 Receptor binding,
Regulation of cccDNA, viral assembly
Pre - S2 Viral assembly, fusion sequence
S Primary structural component,
major antigenic determinants
Core
HBeAg Secreted, immunomodulatory function
Core Nucleocapsid component
HBX Pleiotropic effects
 Diagnosis
 A battery of serological tests are used for the diagnosis of acute and
chronic hepatitis B infection.
 HBsAg - used as a general marker of infection.
 HBsAb - used to document recovery and/or immunity to HBV
infection.
 anti-HBc IgM - marker of acute infection.
 anti-HBcIgG - past or chronic infection.
 HBeAg - indicates active replication of virus and therefore
infectiveness.
 Anti-Hbe - virus no longer replicating. However, the patient can still
be positive for HBsAg which is made by integrated HBV.
 HBV-DNA - indicates active replication of virus, more accurate than
HBeAg especially in cases of escape mutants. Used mainly for
monitoring response to therapy.
 HBV - Diagnosis

Serological Markers of Acute HBV Infection

HBV DNA

HBeAg Anti-HBe
Anti-HBs
Anti-HBc

HBsAg Anti-HBc
IgM

0 2 4 6
Months Year
Years
Serologic Profiles in patients with
Hepatitis B Infection
Serological Acute HBV Recovered Chronic Inactive Occult
tests from HBV Hepatitis B carrier Hepatitis B

HBsAg + - + + -

Anti HBs - + -/+ - -

Anti HBc + + + + -
Total

HBeAg + - +/- - -

Anti HBe - + -/+ + -

HBV DN A + - +/>105 +/<104 +/<103

copies copies copies
 The Variables to define Chronic
Hepatitis B (CHB)
Chronic Hepatitis B

ALT HBeAg Anti HBe HBV DNA

To measure the
Necroinflammatory +active replica- Positive,not always Levels of viral
of hepatocytes tion mean nonactive/ Replication,
Noninfectious-> Branched/PCR
Precore/core pro DNA
Active hepatitis ↑ moter Mutant
Negative->not indicating
Nonreplicative/
Normal, Noninfectious-> -decision to initiate Tx
not always mean Pre-core/core promo - initial evaluation of Tx
Inactive. ter MUTANT - forecasting the pro-
gression of the disease
>2UNL,meaningful
 Chronic Hepatitis B
HBsAg + (>6m)

Active Inactive

N/ N N
ALT

+ − HBeAg −

− + Anti-HBeAg +

≥105 ≥104 HBV DNA <3x102

Copies/ml

Wild Mutant
Common Mutant Type of B hepatitis virus

1. Escape mutant
Mutant on S Ag
Detected in Chronic hepatitis or as a novel acute hepatitis.
The marker is HBsAg + and anti-HBs +,in a patient.

2. Pre-core or core promoter mutant

Mutant on pre-core/E Ag
In chronic active B hepatitis ,HBeAg - ,anti-HBe +,but
HBV DNA +

3. YMDD mutant
Mutant that develops during lamivudine therapy.
This mutant type resistant to Lamivudine.
 Relative Risk of HCC for various serum HBsAg-HBeAg

10-
HBsAg+,HBeAg+

8-

% 6-
cumulative
incidence

4-

HBsAg+,HBeAg -
2-

HBsAg-,HBeAg-
0
1 2 3 4 5 6 7 8 9 10 Years

Relative risk of HCC versus uninfected individuals:

60,2 in patients HBsAg+and HBeAg +
9,6 in patients HBsAg +,but HBeAg-

Yang HI et al,New Engl J Med 2002;347:168-174

 Adjusted Relative Risk of Liver Cancer
for various serum HBV DNA and ALT levels
Number of Number of liver Adjusted relative
HBV DNA level subjects cancer cases risk 95% CI
ALT < 1 x ULN

Undetectable(<102) 908 13 1,0

<105 1825 37 1,6(0,9-3,0)

>105 868 93 10,2(5,7-18,4)

ALT ≥1 x ULN

Undetectable (<102) 43 3 4,3(1,2-15,9)#

<105 61 3 1,6(1,2-15,1)

>105 146 27 16,9(8,1-33,7)*

# p<0,05. *p>0,01
Ilouje UH et al J.Hepatol 2005;42:S179(abst 495)
 Hepatitis C Infection

•Transmission is mainly related to contact with blood

and blood product.

•The main routes of spread are blood transfusion and the use
of shared,non-sterilized needles and syringes.

•Since 1991 ,transfusion-related hepatitis C has virtually dis-

appeared;now through needles/syringesIDU/tattouage etc.

•The rest the transmission is undetermined (50%?)

HCV - Epidemiology

Prevalence

Worldwide 170 million (3%)

United States
Anti-HCV positive 3.9 million (1.8%)
HCV RNA positive 2.7 million (1.4%)

Alter MJ et al., New Engl J Med 1999; 341:556

Lavanchy D & McMahon B, In: Liang TJ & Hoofnagle JH (eds.)
Hepatitis C. New York: Academic Press, 2000:185
 Risk Groups for HCV Infection

High Risk Groups Moderate Risk Groups

*Blood transfusion (before 1991) *High risk sexual behaviour,multiple

*Frequent exposure to blood products:
haemophilia,transplants,haemodyalisis
chronic renal failure,cancer chemothera-
py.
partners,history of herpes simplex
type 2 infection
*Cocaine use,with sharing of intranasal
administration equipment.

*Injecting drug users, even if use was

brief and/or many years ago.

*Healthcare workers with needlestick

injuries.

*Infants born to HCV-infected mothers,

particularly those coinfected with HIV.
 HCV - Epidemiology

Current Likelihood of Transmission

Transfusion ~ 1 in 1,000,000
Maternal-Infant
 Mother HIV-negative ~ 5%
 Mother HIV-positive 15 - 20%

Heterosexual partner ~1 in 1,000 per yr

Needlestick injury
 HCV-positive source ~ 5%
 HCV status unknown ~ 1%

Terrault NA, Hepatology 2002 ;36(Suppl 1):S99

Roberts EA, Yeung L. Hepatology 2002 ;36(Suppl 1):S106
HCV - Natural History

Outcome Following Hepatitis C

Infection
Acute hepatitis C

55 - 85%

Chronic infection

70%

Chronic hepatitis
1 - 4%/yr
20% HCC

Cirrhosis

Decompensation
4 - 5%/yr
Time
(yr)
10 20 30
HCV - Diagnosis

Diagnostic Tests

 Hepatitis C antibody tests (EIA-RIBA)

 Qualitative HCV RNA tests

 Quantitative HCV RNA tests

 Genotyping
HCV - Diagnosis

Acute hepatitis C infection

1000
HCV RNA positive
800
Anti-HCV
600
ALT
(IU/L)
400
Symptoms

200

Normal
0
ALT
0 2 4 6 8 10 12 24 1 2 3 4 5 6 7
Weeks Months
Time After Exposure
Hoofnagle JH, Hepatology 1997; 26:15S
HCV Diagnosis

Low prevalence popu Indicate

lationpoor positive past/present/resolve
predictive value infection

Antibody test
for
Hepatitis C

Immunocompromized *EIA +(low risk) Inexpensive

low sensitivity *RIBA(confirmatory) sensitive-spesific

ALT  + risk factor+,anti HCV +

95% have Hep C
 Prognostic Tests

 Genotyping – genotype 1 and 4 have a worse prognosis overall and

respond poorly to interferon therapy. A number of commercial and in-
house assays are available.
 Genotypic methods – DNA sequencing, PCR-hybridization e.g. INNO-
LIPA.
 Serotyping – particularly useful when the patient does not have detectable
RNA.
 Viral Load – patients with high viral load are thought to have a poorer
prognosis. Viral load is also used for monitoring response to IFN
therapy. A number of commercial and in-house tests are available.
Conclusion
 Acute infection is diagnosed by the detection of
HAV-IgM in serum by EIA.
 Past Infection i.e. immunity is determined by the
detection of HAV-IgG by EIA.
 Cell culture – difficult and take up to 4 weeks,
not routinely performed
Clinical Features of Hepatitis B
Transmission
Oral Not likely
Percutaneous Common
Sexual Common
Perinatal Common
Incubation period 60-180 (days)
Clinical Illness at 10 - 15%
presentation
Clinical Features of Hepatitis B
Jaundice 5 –20%
Fulminant <1%
Diagnostic tests
Acute infection HBsAg, IgM anti- HBc
Chronic infection HBsAg, IgG anti-HBc
Immunity IgG anti-HBc, anti-HBs
Case-fatality rate 1 – 3%
Chronic infection >90% infants
<5% adults
HBV - Diagnosis

Clinical Significance of Serological

Markers for HBV Infection
HBsAg Acute/Chronic
infection
Anti-HBc IgM Acute infection
HBeAg High infectivity
Anti-HBe Low infectivity
Anti-HBs Immunity
Anti-HBc IgG and HBsAg Chronic infection
Anti-HBc IgG and anti-HBs Resolved infection
Clinical Features of Hepatitis C

Jaundice 5 – 10%
Fulminant Rare
Diagnostic tests
Acute infection HCV RNA (anti-HCV)
Chronic infection HCV RNA (anti-HCV), >6 months
Immunity Unknown
Case-fatality rate 1 – 2%
Chronic infection 60 – 85%
 Clinical Features of Hepatitis C
Transmission
Oral No
Percutaneous Common
Sexual Yes, rare
Perinatal Yes, low frequency
Incubation period 14 – 160 (days)
Clinical Illness at 5 - 10%
presentation
HCc Ag Dx and monitoring Tx
Indirect marker of HCV
replication;predicting
EVR <sensitive to replace
HCV RNA to demonstrate
eradication
 Diagnosis of Hepatitis B Infection
Is HBsAg present?

Yes
No

Is IgM anti-HBc present?

No
Yes

Chronic Hepatitis
Acute Hepatitis

Is HBeAg/anti HBe or HBV DNA present? Is anti-HBs present?

HBeAg +,antiHBe – HBeAg -,antiHBe + HBeAg -,antiHBe + Yes No

HBV DNA + HBV DNA + HBV DNA -

Recovered or No HBV
Replicative Non-Replicative Vaccination Infection
Replicative
HBV Infection HBV Infection HBV Infection
 HCV Infection Testing Algorithm for
Diagnosis of Asymptomatic Persons
Negative
EIA for anti-HCV Stop

Positive

Negative
RIBA for anti-HCV RT-PCR for HCV-RNA

Positive
Negative Indeterminate Positive

Stop Additional Lab. Evaluation Medical

(eg.PCR,ALT) evaluation

Negative PCR Positive PCR

Normal ALT Abnormal ALT