INFLAMMATON OF THE LIVER

Hepatitis D-C-E Viruses

part ІІ

Dr. Osama AL Jiffri

Hepatitis D (Delta) Virus
 Hepatitis D Structure
 Hepatitis D virus is found only in patients
infected with hepatitis B
 Enveloped with SS RNA and forms a small
particle coated with HBsAg 35-40nm
 Only antigen encoded is the delta antigen
 Hepatitis D (Delta) Virus
d antigen HBsAg

RNA
 Hepatitis D Virus
Modes of Transmission

• Percutanous xposures
–injecting drug use
• Mucosal exposures
–sex contact
 Geographic Distribution of HDV Infection

Taiwan
Pacific Islands

HDV Prevalence
High
Intermediate
Low
Very Low
No Data
 Hepatitis D:Pathogenesis
 Pathogenesis
– Immune mediated
– Co-infection- infection with B at the same time
(more severe)
– Superinfection: acquisition of Hep D in
chronically Hep B
Sequelae of hepatitis D virus
 Hepatitis D - Clinical Features

• Coinfection
–severe acute disease
–low risk of chronic infection
• Superinfection
–usually develop chronic HDV infection
–high risk of severe chronic liver
disease
 Hepatitis D: Diagnosis
 Serology:
 ELISA test (only on research )
 Hepatitis D - Prevention

• HBV-HDV Coinfection
Pre or postexposure prophylaxis to prevent HBV
infection
• HBV-HDV Superinfection
Education to reduce risk behaviors among
persons with chronic HBV infection
• Alpha interferon may help reduce hepatocellular
damage
 Hepatitis C
Non A -non B HEPATITIS
 Hepatitis C
Structure and Classification
 Unclassified virus, Member of the flavivirus
family (other members yellow fever and
dengue)
 Enveloped single stranded RNA virus
 Humans and chimpanzees only known
reservoirs (virus-specific protein in blood)
 6 serotypes (genotypes) and multiple
subtypes based on high variability of
envelope glycoproteins
 Exposures Known to Be
Associated With HCV Infection

 Injecting drug use

 Transfusion, transplant from infected donor
 Occupational exposure to blood
– Mostly needle sticks
 Iatrogenic (unsafe injections)
 Birth to HCV-infected mother
 Sex with infected partner
– Multiple sex partners
 Sources of Infection for
Persons With Hepatitis C
Injecting drug use 60% Sexual 15%
Transfusion 10%
(before screening)

Occupational 4%

Other 1%*

Unknown 10%

* Nosocomial; iatrogenic; perinatal

Source: Centers for Disease Control and Prevention

 Prenatal Transmission of HCV

 Transmission only from women HCV-

RNA positive at delivery
– Average rate of infection 6%
– Higher (17%) if woman co-infected with
HIV
– Role of viral titer unclear
 No association with
– Delivery method
– Breastfeeding
 HCV: Pathogenesis
 Blood-borne pathogen that infects hepatocytes
 Much like Hep A and B, liver damage and clinical
illness
 Likely cytotoxic T cells that mediate most of the
damage
 Like other chronic liver diseases (Hep B and
chronic alcoholism), can cause hepatocellular ca
(HCC)
 Features of Hepatitis C Virus
Infection
Incubation period Average 6-7 weeks
Range 2-26 weeks
Acute illness (jaundice) Mild (<20%)
Case fatality rate Low
Chronic infection 60%-85%
Chronic hepatitis Age- 10%-70%
Cirrhosis related <5%-20%
Mortality 1%-5%
 Hepatitis C: Clinical Features
 Acute infection asymptomatic in over 80% of
patients, when present, acute illness usually
mild
– Acute symptoms include jaundice, nausea,
abdominal pain, loss of appetite, dark urine
 Chronic Hepatitis C
Factors Promoting Progression or
Severity

 Increased alcohol intake

 Age > 40 years at time of infection
 HIV co-infection
 Other
– Male gender
– Chronic HBV co-infection
 Hepatitis C: Diagnosis
 Dose not grow in cell culture
 ELISA-a serological test which is usually positive
within 2-5 months after infection
– 3rd generation assays now 99% specific and sensitive
 Confirmatory testing
– PCR (positive 1-2 weeks post infection) both
quantitative and qualitative (I.e. ye/no) available
– RIBA (recombinant immunoblot assay)- looks for 2 or
more antibodies to HCV viral antigens
 Genotype testing done when treatment anticipated
 HCV Infection Testing Algorithm
for Diagnosis of Asymptomatic Persons
Negative
Screening Test for Anti- STOP
HCV
Positive
OR

Negative
RIBA for Anti-HCV NAT for HCV RNA

Negative Indeterminate Positive Positive

Additional Laboratory Medical

STOP Evaluation (e.g. PCR, ALT) Evaluation
Negative PCR, Positive PCR,
Normal ALT Abnormal ALT

Source: MMWR 1998;47 (No. RR 19)

 Hepatitis C Therapy
 Systemic effects (fatigue, myalgias,
depression, anemia)
 Standard of care is pegylated interferon
alpha and ribavirin
 Overall response rate to treatment is 40-
50% (higher for non 1 genotypes)
Hepatitis E Virus
 Hepatitis E
 Non-enveloped single stranded RNA virus
 Resembles calicivirus or Norwalk agent
 Similar illness to Hep A except high mortality
in pregnant women
Geographic Distribution of Hepatitis E
 Hepatitis E - Epidemiology

• Most outbreaks associated with

fecally contaminated drinking water

• Minimal person-to-person transmission

• U.S. cases usually have history of travel

to HEV-endemic areas
 Hepatitis E - Clinical Features

• Incubation period: Average 40 days

Range 15-60 days
• Case-fatality rate: Overall, 1%-3%
Pregnant women,
15%-25%
• Illness severity: Increased with age
• Chronic sequelae: None identified
 Hepatitis E Virus Infection
Symptoms

ALT
IgG anti-HEV

IgM anti-HEV
Titer

Virus in stool

0 1 2 3 4 5 6 7 8 9 1 1 1 1
0 1 2 3
Weeks after Exposure
Prevention and Control Measures for Travelers
to HEV-Endemic Regions

• Avoid drinking water (and beverages with

ice) of unknown purity, uncooked
shellfish, and uncooked fruit/vegetables
not peeled or prepared by traveler
• IG prepared from donors in Western
countries does not prevent infection
• Vaccine?
 Heptitis viruses
A B C D E
Virus genome SSRNA DSDNA SSRNA SSRNA Unknown

Transmission faecal- Sex,blood, Blood,other As for water-borne,

oral,food congenital HBV epidemic
,water
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