Acute Viral Hepatitis Elmer R. Encarnacion,MD
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