INFLAMMATON OF THE LIVER Hepatitis D-C-E Viruses part ІІ

1. INFLAMMATON OF THE LIVER Hepatitis D-C-E Virusespart ІІ Dr. Osama AL Jiffri

2. Hepatitis D (Delta) Virus

3. 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

4. Hepatitis D (Delta) Virus d antigen HBsAg RNA

6. Hepatitis D Virus Modes of Transmission • Percutanous xposures • injecting drug use • Mucosal exposures • sex contact

7. Geographic Distribution of HDV Infection Taiwan Pacific Islands HDV Prevalence High Intermediate Low Very Low No Data

8. 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

10. Sequelae of hepatitis D virus

11. 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

12. Hepatitis D: Diagnosis • Serology: • ELISA test (only on research )

13. 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

14. Hepatitis C Non A -non B HEPATITIS

15. 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

16. 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

17. Sources of Infection forPersons 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

18. 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

19. 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)

20. Features of Hepatitis C Virus Infection Incubation periodAverage 6-7 weeks Range 2-26 weeks Acute illness (jaundice)Mild (<20%) Case fatality rate Low Chronic infection60%-85% Chronic hepatitis10%-70% Cirrhosis<5%-20% Mortality 1%-5% Age- related

21. 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

23. 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

24. 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

25. HCV Infection Testing Algorithmfor Diagnosis of Asymptomatic Persons STOP Negative Screening Test for Anti-HCV Positive OR Negative NAT for HCV RNA RIBA for Anti-HCV Positive Negative Indeterminate Positive STOP Additional Laboratory Evaluation (e.g. PCR, ALT) Medical Evaluation Negative PCR, Normal ALT Positive PCR, Abnormal ALT Source: MMWR 1998;47 (No. RR 19)

26. 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)

27. Hepatitis E Virus

28. Hepatitis E Non-enveloped single stranded RNA virus Resembles calicivirus or Norwalk agent Similar illness to Hep A except high mortality in pregnant women

29. Geographic Distribution of Hepatitis E

30. Hepatitis E - Epidemiology • Most outbreaks associated withfecally contaminated drinking water • Minimal person-to-person transmission • U.S. cases usually have history of travelto HEV-endemic areas

31. 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

32. 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 10 11 12 13 Weeks after Exposure

33. 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?

34. Heptitis viruses

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38. THE END THE END The End R. B.

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