Hepatitis A
! The causative agent is hepatitis A virus
(HAV)
1.4
The virus
! ! ! ! !
Picornaviridae, genus Hepatovirus. 27-30 nm diameter particles. Plus-stranded 7.5 Kb RNA genome. Seven genotypes / Single serotype. HAV grows slowly in cell culture without cytopathic effect. primates.
HAV Genome
5 NCR
LA LB
! In developing
Transmission
! Fecal-oral route. ! Person-to-person contact. ! Inadequately cooked food. ! Blood-products-associated
transmission noted in Europe.
P1
1C 1D
P2
2A 2B 2C 3A 3B
P3
3C 3D
% anti-HAV
NCR 3 Poly A
Vpg
In India, Hepatitis A virus is the main causative agent of acute hepatitis in children. It accounts for significant number of FHF cases in children.
18%
70 60 50 40 30 20 10 0
Disease
Ninety percent infections in children lead to subclinical presentation. Proportion of clinical cases increases with age. Fulminant hepatic failure is a rare serious complication. Does not lead to chronicity.
Markers / symptoms during HAV infection
JAUNDICE ALT SYMPTOMS IgM ANTI- HAV IgG ANTI- HAV
Laboratory diagnosis
! IgM-anti-HAV is the diagnostic marker
for hepatitis A.
6-10
25+ 1998
82%
110 100
Non-A
% anti-HAV
70 60 50 40 30 20 10 0
FECAL HAV
15+
Hep B or D 12%
Fulminant hepatitis
53
Year-round PCR-based HAV-RNA positivity 35 30 25 20 15 10 5 0 Affluent Sewage plant Effluent % PCR +ve
Dendrogram depicting nucleotide sequence identity among HAV strains in VP1/2A region of HAV genome
L07730 PANAMA 54 52 IN D 9 4 -2 /V P 1 IIIA 54 54 100 99 IN D 9 8 -7 /VP 1 IIIA IN D 0 1 - 10 /VP 1 IN D 9 6 - 3 /V P 1 N O R 21 L 0 7 7 2 4 Nepal L 0 7 7 2 5 India L 2 0 5 2 8 Japan 87 L 0 7 7 2 9 SierralL e o n e GenotypeVIIIB GenotypeVII GenotypeII GenotypeIA Genotype IIIA
%ANTI-HAV
Hepatitis A in adults
12 10
Prolonged fecal excretion and viremia observed in Indian patients and experimental monkey. Several animal species shown to be anti-HAV positive.
GenotypeIB
% Hep A Cases
8 6 4 2 0
GenotypeV
Isolates indicating mixed genotypes are shown in blue color. Scale indicates genetic distance
Multivariate analysis identified lower middle socioeconomic status (22.9 fold), age > 15 years (8.9 fold) and family size > 4 (1.6 fold) as independent risk factors influencing exposure to HAV. Thirty percent HAV RNA positivity in neat sewage samples documents extremely high viral load in the environment. This also represents a potential threat for contamination of drinking water leading to endemicity and extensive outbreaks.
Co-circulation of subgenotypes IB and IIIA with predominance of IIIA detected. Mixed infection with IB and IIIA identified in inidividual hepatitis A patients.
All epidemic HAV isolates from Pune (prefix 03) and around Pune (red) belong to genotype IIIA.
0314456 0313824 12 037108 0313832 26 037082 26 0314447 037107 0314484 IIIA 3 DAUND-B2 DAUND-S1 DAUND-SW 8 9 DAUND-B1 M34084 44 DAUND-S2 037114 49 0313267 AY032861 VII 88 AF268396 88 M14707 IB 77 AF314208 85 M20273 54 AF357222 AF485328 83 K02990 IA 48 AB020565 33 X75215 39 81 X83302 D00924 V M59286 IV
0.2
54
Vaccines
! Both killed and attenuated hepatitis A
vaccines are available. Most countries do not have definite policies for hepatitis A vaccination.
Prevention
Supply of safe potable water. High standards of public and personal hygiene. Education of food handlers. Vaccination of high-risk individuals: Children from high socioeconomic status. Young food handlers. Siblings of hepatitis A patients. HBV/HCV carrier children.
Patent
A patent on
Hepatitis B
56
Hepatitis B
! The causative agent is hepatitis B virus
(HBV).
% Positive
HBsAg
20
HBsAg+anti-HBc
15
10
HBsAg
anti-HBc
Percentage
1982
1992 Children
1998
1982
1992 Adults
1998
Year
35 30 25 20 15 10 5 0
Rural
HBsAg anti-HBc
Children
1983
Aduilts
Children
1998
Adults
! Acute self-resolving hepatitis. ! Fulminant hepatitis. ! Asymptomatic carrier state. ! Chronic hepatitis. ! Cirrhosis. ! Hepatocellular carcinoma.
Maharashtra
Bhiwandi
Thane
HBV prevalence in Pune was determined according to socio-economic status viz. lower middle class status (LMS) and higher socio-economic status (HS).
HBV exposure according to socio-economic status, Pune 1998
LMS HS
Pune
10
20
30
40
50
60
70
HBsAg
anti-HBc
Percent Positives
30 25 20 15 10 5 0
Transmission routes
Parenteral Inapparent parenteral Sexual Vertical Horizontal
Onges
Shompens
6-10
11-15
16-25
25+
Age Groups
Nicobarese
58
Andamanese
10
20
30
40
50
60
70
80
90
100
HBsAg
anti-HBc
Diagnostics
As early as 1980, highly sensitive and specific ELISA for the detection of HBsAg was developed at NIV. This represents the first indigenously developed HBsAg ELISA in India. These ELISA reagents were certified by WHO. In 1981, again for the first time, ELISA for the detection of anti-HBs antibodies was developed.
Chronic Hepatitis B
2% 16%
36%
39%
Delta Rn
23%
82%
Acute Hepatitis B
14%
Fulminant Hepatitis B
13%
Cycle Number
86%
Negative
Mutants
Wild
Risk of Chronic hepatitis 4.3-fold higher with HBV pre-C wild 3.2 fold higher chances of asymptomatic carrier state with pre-C mutants Pre-C mutant not associated with fulminant hepatitis
! An important
development was standardization of Quantitative Real Time HBV DNA PCR assay employing primers and probes designed at NIV.
! Immune response to several plasmaderived and recombinant vaccines evaluated in Indian population.
38 99
60 ASC1027 (19)
CLD2235 (25)
99
GNTYP-H
0.01
in western India. Did not influence outcome of HBV infection. Genotype D highly prevalent in tribes from Andaman and Nicobar islands
61
60
One orphan selected by needy parents and born to HBsAg carrier mother was vaccinated, followed for seroconversion and finally adopted
l Several family contacts immunized l Several HBsAg carriers counselled at a young age l Immunized would-be spouses before marriage l Immunized children at birth, born to HBsAg positive mothers < Based on NIV results immunization of dental students and dentists was made mandatory in Maharashtra < Orphans screened for HBsAg before adoption
Hepatitis C
62
Hepatitis C
! Earlier known as post-transfusion
non A-non B hepatitis (PT-NANB).
Experimental transmission
! So far, chimpanzee is the only animal
model for HCV.
A new subtype of HCV, 3i, first identified in western India, was later found in other parts of the country.
Transmission
! Parenteral
transmission important mode. is the
The disease
! Mostly subclinical. ! High chronicity potential (>70%). ! 50-70% of chronically infected
individuals develop chronic liver disease.
Genotypes
Samples from 149 HCV RNA positive patients from different parts of India were genotyped on the basis of phylogenetic analysis.
WEST
2.82%
Epidemiology
! Anti-HCV prevalence among age
stratified general population is low.
The virus
Belongs to family Flaviviridae; positive sense, ssRNA genome (~9.4 kb). Classified into 6 genotypes.
45.07% 52.11%
NORTH
Delta Rn
SOUTH
25.00% 38.89%
plasmapheresis unit had shown 90% anti-HCV positivity, most antibody positives being HCV RNA positive.
14 12
Diagnosis
! No marker distinguishes between
acute and chronic infections.
36.11%
Cycle Number
75.00%
4
Genotype 4 Nontypable
gp35
E1
gp70
E2
P7
Ns1
P23
Ns2
P70
Ns3
P8
Ns4A
P27
NS4B
P56/58
NS-5A
P68
NS-5B 3 NTR
Genotype 1 Genotype 3
2 0
Percentage
Blood products being imported in India are screened for HCV RNA at NIV.
10
EAST
25.00%
8 6
Structuralprotins
Nonstructural proteins
1982
1983
1986
Year
65
Voluntary Blood Donors 1 / 217 0 / 346 1 / 180 0 / 178 0 / 400 0 / 259 0 / 445
Similar trend continues till 2004
Other studies
Association with blood banks As serological tests for HCV were still evolving (1st, 2nd & 3rd generations), the NIV together with local blood banks sorted out the problems of specificity and sensitivity, based on the use of confirmatory Recombinant Immunoblot Assay (RIBA) and PCR tests. Interferon treatment A national facility for the detection of HCV RNA, employing nested RT PCR was set up in July 1995. Samples from different parts of India were screened as a prerequisite for the initiation of interferon therapy as well for the assessment of success of therapy. ICMR's multi- centric trial for combination therapy NIV is responsible for all the virological aspects of this trial, including detection and quantitation of HCV RNA and sequencing-based genotyping.
Dentists
Leprosy Patients
Hepatitis E
Prevention
In the absence of possibility of vaccine for hepatitis C in the near future, strict adherence to universal precautions in relation to parenteral transmission mode seems the best available choice.
66
Epidemiology
The disease was believed to be restricted to developing countries wherein both epidemic as well as sporadic forms exist. However, recent studies have documented hepatitis E among persons from several developed countries without any history of travel to endemic countries. Studies conducted at NIV and in different countries have shown that HEV has predilection for young adults. However, an outbreak of hepatitis E among residential school children at Talegaon, India (1988) was recorded. Moreover, ~ 70% anti-HEV positivity among children from Shompen tribe from Andaman and Nicobar Islands was also documented. Hepatitis E is the major cause of epidemic hepatitis in India. NIV has investigated over 100 outbreaks of
The virus
! Recently classified as a member of a
newly designated Hepeviridae family. ! 27-30nm spherical particles. ! The genome is a single-stranded, positive sense RNA of about 7.2 kb.
5 ORF-1: 5 kb ORF-3: 369 nt 3 ORF-2: 2 kb
Acute, self-limiting; occasionally leads to fulminant hepatitis. No chronicity recorded. Usually affects young adults; high mortality among pregnant women, especially in the third trimester.
Diagnosis
Detection of IgM-anti-HEV by ELISA. In very early acute cases, IgM antibodies may not be detectable, HEV RNA by nested RT PCR may be the method of choice. Diagnostic test development
! ORF-2
Genotypes
HEV strains are classified into 4
protein (both swine and human HEV) expressed in baculovirus system proved to be a highly reactive antigen for ELISA. Based on recombinant ORF-2 antigen, ELISA could efficiently detect both IgM and IgG-anti-HEV antibodies. collected during all HEV epidemics (1976-2004) showed anti-HEV IgM and IgG antibodies.
79 80 93 67 52
! Sera
hepatitis E.
99 98
TAIWAN CH-T11 HF-030 HF-054 AF134812 TW6310E TW8E-2 TW6196E TW2494E US2 US-SW US1 MEX86 NAFR83 49 D11092 96 L08816 L25595 PAK87
gnosed. NIV ELISA was comparable with the commercially available, Genelab ELISA.
2
Maharashtra State
3 2 2 8 1
87 99 100 41
INDFHFL INDFHFL
70 87
MAD93
61 BUR83 BUR89 45 AKL90 AKL90 76 HYD87 64 TK4-95 49 NEP4-94
1
8 1
5 3
1999-2000 2002-03
Indian strains: All human strains - genotype 1 All swine strains - genotype 4
69
Goa
% ANTI-HEV+VE
% PCR +ve
Initial studies conducted by NIV showed that ~ 60% of the sporadic hepatitis cases among adults are of NANB type. With the availability of ELISA for IgM-anti-HEV detection, over 40% of sporadic cases among adults were diagnosed as hepatitis E.
45 40 35
About 15% of neat sewage samples collected year round were HEV RNA positive, 7-fold higher risk of infection in sewage workers was documented.
20 15 10 5 0 Affluent Effluent Sewage Plant
HEV as zoonosis
! In 1994, wild caught rhesus (36.7%)
and bonnet (19.1%) monkeys from India were shown to be anti-HEV positive.
1998
Age group
HSS
LMSS
Rural
% HEV Cases
30 25 20 15 10 5 0
Children
Adults
% POSITIVE
Parenteral transmission ! 1.5% (3/200) voluntary blood donors from Pune positive for HEV RNA.
detected in pigs, dogs, cattle, rodents, and chickens from India. Goats were negative.
Pigs
No of Cattle No of Pigs
300 200 100 0 0 0.2 0.4 0.6 0.8 1
Cattle
Though high mortality in pregnant women is the characteristic feature of hepatitis E, in sporadic situation, nonpregnant women as well as men were shown to succumb to fulminant hepatitis E. During epidemics, the estimated ratio of clinical:subclinical infections based on serology was shown to be 1:26 in pregnant women.
6-10
11-15
16-25
25+
AGE GROUP
1982
1992
1998
No of Dogs
60 40 20 0 0 0.2
Dogs
No of Rodents
300 200 100 0 0 0.2
Rodents
0.4
0.6
0.8
0.4
0.6
0.8
% POSITIVE
Swine HEV
6-10 11-15 16-25 25+
Transmission
Water contamination Leaky water/drainage pipelines running in close proximity or other means of contamination at the source of water reservoirs results in explosive outbreaks.
AGE GROUP
1983
1998
Anti-HEV positivity documented in pigs from states of Maharashtra, Karnataka and Andaman & Nicobar Islands. Mean age of pigs for seroconversion was 4.8 + 1.6 months. In contrast to other countries, different genotypes circulate in humans (genotype-I, 1976-2004) and pigs (genotype IV, 1985-2000) in India.
% POSITIVE
6-10
11-15
16-25
25+
AGE GROUP
1982
1998
70
TT virus
Phylogenetic analysis of HGV isolates (western India)
IND2 IND5 Peru-72442 IND3 IND4 IND9 IND21 64 Germany-532 87 US7 IND1 69 IND6 94 IND20 HGV-VT58 GHP7 HGV-VT10 88 TH-K10 94 75 HGV-MY67 CHN-NJ1 KR3 TH-T80 III NU60 GHP2 65 Kenya 98 GA9 GA22 IV Zair9 94 Ed3 98
d Ag
! Discovered in 1997 in Japan. ! Disease potential questionable. ! Parenteral and enteric modes of
transmission.
35 nm
The virus
I
Occurs as co- or super-infection with HBV. Leads to severe course of liver disease. Though HDV replication is HBV dependent, its prevalence is not a simple function of HBV prevalence. Parenterally transmitted. Prevalence of anti-delta positivity
Fulminant Hepatitis
II
1a 1
0.02
C2 64 80 79
Paid plasma donors
99 Be7 BLDN20
5
CK7 JaM21
4
99
56
Hemophiliacs Patients suffering from FHF Patients suffering from liver disease(s) Non-A-E acute viral hepatitis patients Voluntary Blood Donors
0 2 4 6 8 10 12 14 16 18
0.05
53 99 93
TS003 A4 H4 C1 75 NIV-48
% anti-delta Positivity
76
77
Non-A to E agents
! Despite use of sensitive and specific
serological and molecular assays, all acute viral hepatitis cases cannot be diagnosed.
78