Viral Hepatitis Flashcards by Kat Qiao

What is Hepatitis A?

The family Picornaviridae, genus hepatovirus

Single-stranded, positive sense RNA genome

Quasi-enveloped virions

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How is Hepatitis A transmitted?

Faeco-oral versus blood-borne transmission

Incubation period of 15-50 days

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What is the epidemiology of Hepatitis A?

Approx. 1.5 millions of cases worldwide annually

Developing countries with poor socio-economic conditions

300-500 cases annually in the UK

Mostly among age 15-34 and non-travellers

Outbreaks among MSM (2016/17) & IVDU (2001 & 2017)

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What are the signs and symptoms of Hepatitis A?

Wide disease spectrum from asymptomatic to fulminant hepatitis.

Strong correlation with age: <10% symptomatic among children <6 years old versus 70% in adults.

Typical symptoms: Fever, malaise, anorexia/nausea, abdominal discomfort, diarrhoea, jaundice.

Extra-hepatic diseases.

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Is Hepatitis A acute or chronic?

Acute presentation; 99% resolution

NOT an aetiology for chronic hepatitis

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What is the timecourse of the immune response to Hepatitis A infection?

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How is Hepatitis A diagnosed?

Based on serology:

Acute infection: IgM reactive; unlikely if bilirubin level < 30umol/L
Past infection: IgM non-reactive, IgG reactive

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What are the public health implications of Hepatitis A?

Notifiable disease

Pre-exposure immunisation among population at risk

Post-exposure prophylaxis:

Within 14 days of exposure to index case: HAV vaccine +/- HNIG (for 60 years and above, chronic liver diseases inc CHB/CHC, immunocompromised contact)

Over 14 days: HAV vaccine +/- HNIG (for chronic liver diseases inc CHB/CHC, immunocompromised contact)

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What is Hepatitis B?

The family Hepadnaviridae

Double-strained DNA with reverse transcriptase

Enveloped virions

10 genotypes (A-J) with distinctive geographic distribution

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How is Hepatitis B transmitted?

Blood-borne transmission: horizontal & vertical

Incubation period of 40-160 days

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What is the typical presentation of acute Hepatitis B?

Age related presentation & prognosis in acute hepatitis B.

Neonates & children: Mostly asymptomatic or anicteric; 90% HBV-infected neonates develop CHB, and 30% among children age <5 years.

Adult: 30-50% icteric hepatitis; 10% become CHB.

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What are risks associated with acute Hepatitis B infection?

0.1-0.05% risk of fulminant hepatitis; related to co-infection with HCV/HDV.

Maternal HBeAg/Ab status & HBV viral load.

HBeAg as the most important risk predictor for vertical transmission.

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What is the definition of chronic Hepatitis B infection?

Persistence of HBsAg for 6 months or more after acute HBV infection.

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What are risks associated with chronic Hepatitis B infection?

Cirrhosis: 8-20% untreated CHB in 5 years;

Hepatocellular carcinoma: The annual risk of 2-5% among CHB cirrhotic patients; affected by host (e.g. alcohol abuse) and viral factors (e.g. high HBV viral load & qHBsAg).

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What is the epidemiology of Hepatitis B?

Approximately 296 million people are living with CHB worldwide; CHB-related mortality at roughly 820,000 people per year.

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What are the public health implications of Hepatitis B infection?

Acute hepatitis B: A notifiable disease

Pre-exposure prophylaxis:

Routine childhood immunisation in the UK since 2017
High risk population

Post-exposure prophylaxis:

Neonate born to mother living with hepatitis B.
Sexual partner: HBV vaccine +/- HBIG (within one week from the contact).
Needle stick injury.

What is Hepatitis D?

Single-stranded, circular RNA genome.

A defective virus that relies on HBV for propagation.

How is Hepatitis D transmitted?

Blood-borne transmission

Incubation period: 3-6 weeks

What is the association between Hepatitis B and Hepatitis D?

HBV/HDV simultaneous co-infection: Similar to classic acute hepatitis B; mostly self-limited. <5% chronic infection.

HDV super-infection in CHB: 80% chronic infection. Increased risk of cirrhosis and HCC than CHB alone.

How is Hepatitis D diagnosed and treated?

Anti-HDV serology; other HDV investigations rarely used.

PEG-interferon alpha licensed for HDV superinfection in CHB.

Pre-exposure HBV immunisation.

WHat are the public health implications for Hepatitis D infection?

Notifiable disease

What is Hepatitis C?

The family Flaviviridae, genus Hepacivirus.

Single-stranded, positive sense RNA genome.

How is Hepatitis C transmitted?

Blood borne transmission.

Incubation period: 2-6 weeks.

What is the epidemiology of Hepatitis C?

58 million people living with chronic hepatitis C worldwide.

1.5 million new cases every year.

What is the presentation of Hepatitis C infection?

Acute infection: * 30% spontaneous clearance * 70% become chronic hepatitis C (CHC) Hepatic versus extra-hepatic manifestation. Cirrhosis (15-30% in 20 years) & HCC as complication of CHC.

How is Hepatitis C treated?

Revolutionised the treatment for acute/chronic HCV infection. Any HCV cases should be considered: * 8 or 12 weeks * Sustained virological response (SVR) at week 12 * Pan-genotypic regimen * Single-tablet regimen * Drug-drug interaction

What are the public health implications of Hepatitis C infection?

Notifiable disease in the UK. Nil vaccine available. Nil post-prophylaxis available. Active HCV screening. Risk reduction (e.g. safe handling and disposal of sharps, protected sex).

What is Hepatitis E?

The family Hepeviridae, genus Orthohepevirus; species A strains (8 genotypoes) infect humans. Single-stranded, positive sense RNA genome. Quasi-enveloped HEV.

How is Hepatitis E transmitted?

Faeco-oral versus blood-borne transmission Incubation period: 15-60 days

What are the natural reservoirs for the different strains of Hepatitis E?

**G1 & G2:** Obligate human pathogens **G3 & G4:** Zoonotic; pigs & wild boar are natural hosts

What is the epidemiology of Hepatitis E?

Approximately 20 million new HEV cases worldwide annually 3.3m symptomatic hepatitis E 44,000 mortality annually UK is a HEV G3 endemic country

What is the clinical manifestation of Hepatitis E?

Mostly self-limited; advised against alcohol during the course Hepatic and systemic symptoms

Which groups are particularly at risk of developing Hepatitis E infection?

**Pregnant women:** G1; fulminant hepatic failure and obstetric complications (e.g. eclampsia and haemorrhage); 25% maternal mortality & high perinatal infant mortality. **Chronic liver disease patients.** **Immunocompromised patients:** May develop chronic hepatitis E (G3 & G4)/

How is Hepatitis E diagnosed?

**Immunocompetent:** HEV serology **Immunocompromised:** HEV PCR

What are the public health implications of Hepatitis E infection?

Notifiable disease HEV patient should avoid prepping food during the first 2 weeks. Immunocompromised and chronic liver disease patients should avoid consumption of undercooked meat (pork, wild boar and venison) and shellfish. **HEV vaccination:** Only licensed in China.

What is the treatment of Hepatitis E?

Only indicated in chronic hepatitis E as most acute HEV infection are self-limited.