NEPMU-2
Norfolk, VA
(757) 444-7671
Objectives
• Describe the Clinical Syndromes of Viral
Hepatitis
• List the modes of Transmission
• Understand and be able to interpret
Diagnostic (laboratory) tests
• Know the Treatment and Occupational
Impact of Viral Hepatitis
• List Preventive Measures for each Hepatitis
type
• Describe Immunization protocols
Hepatitis
• Inflammation of the Liver that can be viral,
chemical or drug-induced
• Viral Hepatitis: Systemic infection which
causes inflammation of the liver
• Currently 5 recognized types of viral
hepatitis: A, B, C, D, E
• All 5 viruses cause similar illness, but
have distinct antigenic properties
Acute Hepatitis: Symptoms
Common Uncommon
• Malaise 76-94% • Respiratory
• Anorexia 71-96%
• Dark urine 65-94% symptoms
• Nausea 61-81% • Headache
• Abdominal pain 26-68%
• Scleral icterus 48% • Fever
• Vomiting 20-37% • Muscle pain
• Rash
• Joint pain
• Itching
Asymptomatic hepatitis is also common
Acute Hepatitis: Signs
Jaundice 70-90%
Hepatomegaly 14-69%
Tender liver 20-86%
Rash 40%
Splenomegaly 3-21%
Fever 1-8%
High LFTs 100%
Acute Viral Hepatitis by Type, United
States, 1982-1993
34%
47%
16% Hepatitis A
Hepatitis B
Hepatitis C
3% Hepatitis
Non-ABC
Fulminant
deaths/year 100 150 ? 35
Chronic 0 1-1.25 3.5
infections million million 70,000
Anti-HAV Prevalence
High
Intermediate
Low
Very Low
Hepatitis A: Clinical Aspects
• Onset: usually abrupt
• Duration
Mild lasting 1-2 weeks
Severe lasting months
Rarely fatal
• Children usually asymptomatic
5-10% jaundiced
1-2 week duration
• Adults are usually symptomatic
Jaundiced
Nausea, vomiting, & fever are common.
Hepatitis A: Clinical Aspects
• Incubation
15-45 days, average 30 days
• Greatest infectivity
2 wks before jaundice appears
• Fecal viral shedding
Greatest during late
incubation and prodrome
Diminishes rapidly after
jaundice occurs
Hepatitis A: Transmission
Serum
Saliva
Urine
30
Percentage of Cases
Personal
20 Drug use contact
Day care center
10
Foreign travel
Outbreak
0
1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993
Year
Source: CDC, Viral Hepatitis Surveillance Program
Age-specific Mortality Due to
Hepatitis A
Age group Case-Fatality
(years) (per 1000)
< 3.0
5-14
5 1.6
15-29 1.6
30-49 3.8
>49 17.5
Total 4.1
Source: Viral Hepatitis Surveillance Program, 1983-1989
Hepatitis A: Prevention
• Immunization
• Sanitation & Education
Safe food, water and ice
Good personal hygiene
• Standard Immune globulin prophylaxis (IG)
80 - 90% effective if given within two weeks of
exposure
Immunization 2 weeks prior eliminates need
Indications:
Close personal contacts
Day Care center outbreaks
Fellow food handlers
Restaurant patrons if deficiencies in hygiene or if handler
prepared unheated food
Hepatitis A Vaccine
• Two dose series: Initial plus booster in 6-12
months
All Active duty and Select Reserves
95% protection after first dose
Four week period for antibody development
• HAVRIXR OR VAQTAR, interchangeable
• TWINRIXR (Hepatitis A&B combination vaccine)
Three dose series
Interchangeability: dose 1 with TwinrixR - give 2nd
dose of HAVRIXR OR VAQTAR A and 2 & 3rd dose of
HEP B vaccine
Dose 1 and 2 with TwinrixR – Another dose of
HAVRIXR OR VAQTAR not necessary, give dose 3rd
dose of HEP B vaccine
Hepatitis A and Food Workers
HBsAg Prevalence
≥ 8% - High
2-7% - Intermediate
<2% - Low
Hepatitis B: Clinical Aspects
• Incubation period: 45-180 days, average
60-90 days
• Onset insidious (subtle and treacherous)
• Symptoms more severe
Malaise, arthralgias, rash, nausea & vomiting
• Often hospitalized
• One in 200 die from acute disease
• Chronic liver disease kills ten times as
many
Hepatitis B: Transmission
• Virus present in blood, semen, saliva
• Percutaneous
Contaminated needles (tattoos, piercing, drugs,
etc)
Blood transfusion
Perinatal
• Permucosal
Sexual contact
Continuous close contact
Concentration of Hepatitis B
Virus
in Various Body Fluids
Low/Not
High Moderate Detectable
}
90% of infants Risk of chronic
30% of 5 year olds infection is lower
6% of adults after acute illness
20
,000))
15
Rate (per 100,000
10
0
0-14 15-19 20-29 30-39 40+
Age Group (Years)
Source: CDC Viral Hepatitis Surveillance Program
Hepatitis B Prevention
• Education
Needles, sex, universal precautions
• Vaccine
Pre-exposure, active immunity
• HBIG
Post-exposure
Passive immunity
Hepatitis B Vaccine
• Recombivax-HER or Engerix-BR
Interchangeable - 3 dose series
Day zero, day 30, 6 months
1/2 dose (0.5 ml) OK for under age 30
• Post-vaccination testing
Identify non-responders in high risk jobs
Non-responders receive one additional 3-
dose series of hepatitis B vaccine, but not
a third
HBIG (Hepatitis B immune
globulin)
• Post-exposure prophylaxis
Passive immunity
High concentration of anti-HBs
• Indications
Perinatal exposure to HBsAg+ mother
Percutaneous or permucosal exposure to
HBsAg+ blood
• Sexual exposure to HBsAg+ person
Also need 3 dose vaccine series
Hepatitis D (Delta) Virus
δ antigen HBsAg
RNA
Hepatitis D
• Virus-like particle
• Defective RNA virus
• Requires HBV co-infection to replicate
• Similar to Hepatitis B
• No fecal-oral transmission
• Highest rates in Italy, Venezuela, Africa,
Romania, central Asia and the Middle East
Hepatitis D: Diagnosis
• Serologic test for hepatitis D antibody
Hepatitis D: Complications
• 10-15% develop cirrhosis within two years
• 70% eventually develop cirrhosis
• 2-20% fatality rate
• 25-50% of fulminant liver failure in hepatitis
B actually due to hepatitis D co-infection
• Hepatitis D Prevention:
Hepatitis B vaccine
Hepatitis C
“transfusion related non-A, non-
B hepatitis”
• Caused by RNA flavivirus
• Accounts for 16% acute hepatitis in U.S.
• Transmission similar to hepatitis B
Blood, sex, body fluids
• Usually asymptomatic or mild disease
• Chronic infection very common
• 20% of community acquired hepatitis
• 90% post-transfusion hepatitis
• Blood banks started screening in 1990: <1% risk
now
Hepatitis C Diagnosis
1. Symptoms
2. Elevated LFTs
3. Rule out other causes of hepatitis
4. Confirmed by serology
Serologic test detects HCV antibody
Positive in chronic cases
May not be positive in acute phase
Rule out other causes of acute hepatitis
negative
ALT
(liver
functio
n test)
Norma
l
0 1 2 3 4 5 6 1 2 3 4
Month Years
s Time after
Exposure
Features of Hepatitis C
Transfusion 10%
(before screening)
Other* 5%
Unknown 10%
• No vaccine
• IG does not protect
Viral Hepatitis - Review
Type of Hepatitis
A
A B
B C
C D
D E
E
Source of feces blood/ blood/ blood/ feces
blood-derived blood-derived blood-derived
virus body fluids body fluids body fluids
B HBsAg – INFECTIOUS
HBeAg – DEGREE OF INFECTIVITY
VACCINATION AND ADMINISTRATION OF
HBIG WITHIN 24 HOURS OF NEEDLE STICK, 14
DAYS AFTER SEXUAL CONTACT
IgM anti-HBc – ACUTE INFECTION
CHRONIC HEPATITIS TREATED WITH ALPHA
Anti-HBs – VACCINATED OR CLEARED
INTERFERON AND LAMIVUDINE
INFECTION