VIRAL HEPATITIS

-
 What is Viral Hepatitis ?

• Viral hepatitis is a systemic disease

with primary inflammation of the
liver by any one of a heterogenous
group of hepatotropic viruses

2
Various hepatotrophic viruses are:
Major - Hepatitis A,B,C,D and E
Minor - cytomegalovirus , Epstein Barr virus,
Yellow fever virus , rubella virus
Rare – Herpes simplex virus , varicella and
adenovirus
Historical perspectives
 Global Scenario:

• viral hepatitis accounted for 1.45 million

deaths in 2013( a 63% increase compared with
the 0.89 million deaths in 1990)

• Morbidity also increased in terms of years

lived with disability from 0.65 to 0.87 million
and disability-adjusted life-years from 31.7
millions to 42.5 millions
 Global Scenario:
• Most of the morbidity and mortality is caused
by hepatitis B and C infections; 96% of
mortality and 91% disability-adjusted life-
years in 2013
• with estimated 400 million people with
chronic hepatitis B and C infection
High mortality rates in Oceania, Africa
and Asia
• Hepatitis-related mortality was highest ≥33.50
deaths per 100 000 population per year in
Oceania, western sub-Saharan Africa, and
central Asia
• However, in absolute numbers, east Asia and
south Asia have the greatest number of
hepatitis deaths (52% of the total number of
deaths)
• in May 2016, WHO adopted the first-ever
global hepatitis strategy with a goal to
eliminate viral hepatitis as a public health
threat by 2030

• defined as a reduction in incidence by 90%

and mortality by 65%
 National Scenario
• Viral Hepatitis A outbreak in Gorkha in fiscal
year 2071/72 where total 147 case has been
reported including 1 death.
Statistic of Out Patient Morbidity of
Hepatitis Infection- 2071/72
Eastern Central Western Mid Far Total
Western Western

Hepatitis 467 1112 683 183 232 2677

A

Hepatitis 155 1877 317 53 132 2534

B

Hepatitis 114 285 170 52 36 657

E
 Inpatient Morbidity 2071/72
Disease Total Total Death

F M Total F M

Hepatitis A with hepatic coma 1 4 5 0 0

Hepatitis A without hepatic coma 42 48 90 0 0

Acute hepatitis B 1 5 6 0 1

Acute hepatitis B without delta-agent and 11 21 32 0 1

without hepatic coma
Acute hepatitis E 10 26 36 0 1

Other acute viral hepatitis 28 58 86 0 0

Unspecified viral hepatitis 24 34 58 0 0

Unspecified viral hepatitis hepatic with 4 3 7 0 0

coma
Unspecified viral hepatitis without hepatic 31 40 71 0 0
coma
 Hepatitis A
- formerly known as “infectious hepatitis” or
“epidemic jaundice”
- It is an acute infectious disease caused by hepatitis
A virus heralded by non-specific symptoms like fever,
chills, headache, fatigue and generalized weakness
followed by anorexia, nausea, vomiting, dark urine
and jaundice.
- the disease is benign with complete recovery in
several weeks.
EPIDEMIOLOGICAL DETERMINANTS

HOST

AGENT ENVIRONMENTAL
FACTORS
 Agent Factors

(a) AGENT:
Hepatitis A Virus
(enterovirus of
picornaviridae family)
(b) Resistance:
-virus is fairly resistant to low pH, heat and chemicals.
-can survive more than 10 weeks in well water
- withstand heating upto 60 deg C for an hour
- inactivated by U.V rays and autoclaving
(c) Reservoir of infection:
human cases are the only reservoir of infection
(d) Period of infectivity:
The risk of transmitting HAV is greatest from 2 weeks
before to 1 week after the onset of jaundice.
(e) Infective material:
-mainly man’s faeces
-blood, serum and other fluids during the brief stage
of viraemia
(f) Virus excretion:
in faeces for 2 weeks before and after onset of
jaundice
Environmental factors:
can occur throughout the year but especially
more common during rainy seasons

Host factors:
- Age: more frequent in children than adults ,
however can occur in any age and severity increase
with the age.
- Sex: both sexes are equally susceptible
- Immune: immunity after attacks last for life
Modes of transmission:
(i) faeco-oral route
- directly (person to person)
- by contaminated food, water or milk
(ii) parenteral route
(iii) sexual transmission

Incubation period:
-10 to 50 days
- is proportional to the dose of virus ingested
Clinical presentation:
1.Prodormal phase or pre-icteric phase:
fatigue, joint and abdominal pain, malaise,
vomiting, lack of appetite and hepatomegaly
2.Icteric phase:
yellowish colouration of skin , sclera and mucous
membranes
3. Recovery phase
Diagnosis:
1. Demonstration of viruses in blood, faeces, bile by
immunoelectron microscopy
2. Viral isolation
3. Detection of antibody by ELISA
4. Biochemical tests:
-Alanine aminotransferase
- Bilirubin
- Protein
5.Molecular diagnosis: RT-PCR
Prevention:
(i) Control of reservoir: difficult due to
-faecal shedding of virus at its height during
incubation period.
-large number of subclinical cases
-absence of specific treatment
-low socio-economic status of population
(ii) Control of transmission:
hygiene measures and sanitation
(iii) Control of susceptible population
Immunization
1. Active immunization:
-Formaldehyde inactivated vaccines
-live attenuated vaccines
2. Passive immunization:
human immunoglobulin ( gamma globulin) given
before exposure to virus or during early incubation
period.

Treatment :
Non-specific and by dietary modification and proper
rest
 HEPATITIS D
- It is an infection caused by Hepatitis D virus(HDV).

- HDV is also called as subviral satellite as it can only

propagate in the presence of hepatitis B virus.
Incubation period:
-2-12 weeks
- shorter in HBV carriers who are superinfected with
HDV.

Mode of transmission:
-similar to that of HBV, though HDV does not appear
to be sexually transmitted disease.
- can be transmitted perinatally (but rare in Asia)
• Clinical features:
-Infection is dependent on HBV replication as HBV
provide HbsAg envelope for HDV
-Two types of infections are seen:
(i) Co-infection: HDV and HBV are transmitted
together at the same time
(ii) Super infection: HDV occurs in person already
harbouring HBV.
Diagnosis :
-Demonstration of delta antigen in the liver cells by
immunofluorescence
- Demonstration of anti delta antibodies :
IgM 2-3 weeks after infection and later replaced by
IgG

Prevention:
- In co-infection, by vaccinating with hepatitis B
vaccine in risk areas.
- In superinfection, educating people With hepatitis B
to reduce risk behaviours
 HEPATITIS E
-It is the inflammation of liver caused by Hepatitis E
virus.
-infection is usually acute and self-limiting with low
mortality rates.
-however, it is often severe and associated with
fulminant hepatic failure in pregnant women and
immuno-compromised patients.
EPIDEMIOLOGICAL DETERMINANTS

Agent Hepatitis E virus

Young adults
(15-40 years)
Host Environmental
factors
Incubation period:
-> 3-8 weeks with mean of 40 days
-> period of communicability is unknown
Animal reservoir : pigs

Mode of transmission:
(i) faeco-oral route
(ii)ingestion of products derived from infected
animals
(iii) transfusion of infected blood products
(iv) vertical transmission
Diagnosis:
-detection of HEV antibodies
-detection of HEV RNA by RT-PCR
Treatment:
usually self-limiting

Prevention:
-maintaining hygienic practices like hand-washing
-adhering to WHO safe food practices
-avoiding drinking water of uncertain purity
 HEPATITIS G
• Hepatitis G virus is a virus in flaviviridae family
known to infect human

• but prevalence of this infection is still unknown.

 HEPATITIS B
• Serum Hepatitis
• Is an acute systemic infection with major
pathology in the liver , caused by hepatitis B
virus
• Transmitted mainly by parenteral route
• Incubation period – 6 weeks to 6 months
 EPIDEMIOLOGICAL DETERMINANTS
Agent Factors :
a) Agent :
• HBV is complex , 42 nm , double stranded DNA
virus – Dane particle
• Replicate in liver cells
• Three morphological forms-
Small spherical particle , 22 nm
Tubules of varying length
Dane particle
b) Reservoir of infection :
Man is the only reservoir of infection which
can be spread either from carriers or from
cases

c) Infective material
Contaminated blood
Saliva , vaginal secretions , semen
d) Period of communicability:
incubation period and acute phase of
disease
 Host Factors

a) Age:
• Outcome is age dependent
• Development of chronic HBV infection is
inversely related to age
• Occurs in 80 to 90 % of persons infected
perinatally , 30 % infected in early childhood ,
5% infected after 6 years of age
b) High risk groups :
• Infection in surgeons is estimated to be 50 times
greater than that in general population
• Other high risk groups:
Recipients of blood transfusions , health care
and laboratory personnels , homosexuals ,
prostitutes , percutaneous drug abusers , infants
of HBV carrier mothers , recipients of solid organ
transplants , immunocompromised patients
b) Hepatitis B and HIV infection :
• 10% of the 40 million people infected with
HIV worldwide are co-infected with HBV
• Mortality rate increases among HIV positive
due to HBV co-infection
c) Humoral and cellular responses:
Three antigens: HBsAg , HBcAg , HBeAg
and corresponding antibodies
 Modes of Transmission
a) Parenteral route
b) Perinatal transmission
c) Sexual transmission
d) Other routes
 HEPATITIS C
Hepatitis C is a contagious liver disease that
results from infection with the hepatitis C
virus
Incubation period:
2 weeks to 6 months
Symptoms:
Following infection approx. 80% of people do
not exhibit any symptoms
Symptomatic may exhibit fever , fatigue ,
decreased appetite , nausea , vomiting ,
abdominal pain , dark urine , grey colored
faeces , joint pain and jaundice
• 75% to 85% of newly infected persons develop
chronic disease , 60% to 70% of chronically
infected people develop chronic liver disease ,
5 to 20% develop cirrhosis , 1 to 5% die from
cirrhosis or liver cancer

• In 25% of liver cancer patients the underlying

cause is hepatitis C
 Treatment
• Combination of antiviral therapy with
interferon and ribavirin
 PREVENTION
PRIMARY PREVENTION:
There is no vaccine for hepatitis C. Risk of
infection can be reduced by avoiding
• Unnecessary and unsafe injections
• Unsafe blood products
• Unsafe sharps waste collection and disposal
• Use of illicit drugs and sharing of injection
equipment
• Unprotected sex with hepatitis C infected
people
• Tattoos , piercings , acupuncture etc
performed with contaminated equipment
Secondary and Tertiary Prevention
For people infected with hepatitis C virus ,
WHO recommends:
• Education and counseling on options for care
and treatment
• Immunization with hepatitis A and B vaccines
to prevent co-infection
• Early and appropriate medical management
including antiviral therapy if appropriate
• Regular monitoring for early diagnosis of
chronic liver disease
 VACCINATION
Hepatitis A vaccine
a. Formaldehyde Inactivated vaccine
b. Live attenuated vaccine
• Persons ≥ 12 months of age
• 2 doses 6 months apart into the deltoid
muscle
• Protective efficacy is 94%
Hepatitis B Vaccine
• Plasma derived Vaccine
• HBsAg harvested from carriers, inactivated
• Adult dose: 1ml- 0, 1, 6 months, IM, Booster
3-5 years
• Children under 10 years: half of the adult dose
• In Nepal, Hep B vaccine is added to National
Immunization Program in 2005 where 3 doses
are being given in 1 month interval to infants
of 6 weeks age.
Hepatitis B Immunoglobulin (HBIG)
• For those acutely exposed to HBsAg positive
blood
a. Surgeons, Nurses, Laboratory workers
b. Newborn infants of carrier mothers
c. Sexual contacts of acute hepatitis B patients
d. Patient who need Protection against HBV
infection after liver transplantation
• upto 48 hrs of exposure0.05-0.07ml/Kg , 2
doses-30 days apart, provides short term
passive protection lasts for approx. 3 months
THANK YOU