Hepatitis Virus

Peigang WANG
Email: pgwang@ccmu.edu.cn

May 26, 2016

 The word of Hepatitis

• The word “Hepatitis” originated

from the Greek hêpar which means
"liver“.

• Its suffix -itis means

"inflammation”. Similar words
include pulmonitis and arthritis.
 The Disease of Hepatitis

Hepatitis is the inflammation in liver, and is

characterized by the presence of inflammatory
cells in this organ.

Clinically, hepatitis may occur without symptoms,

but usually leads to the following symptoms:
Jaundice
Poor appetite
Fatigue
 Jaundice

Jaundice is a yellowish pigmentation of the skin,

the conjunctival membranes, and other mucous
membranes caused by high blood bilirubin levels.

One main cause for high blood bilirubin is

hepatocytes damage occurs during hepatitis.
 The Progress of Hepatitis
Hepatitis can manifest either as an acute or as a
chronic disease.

Acute hepatitis is self-limiting in some cases, or

progress to chronic hepatitis, or cause acute liver
failure in rare instances.

Chronic hepatitis may progress over time to

fibrosis and cirrhosis.

Liver cirrhosis increases

the risk of hepatocellular
carcinoma.
 Hepatitis viruses
belong to animal (human) virus

Many viruses can cause hepatitis, but only

hepatitis A virus (HAV), HBV, HCV, HDV, and
HEV are described as “hepatitis virus”.

Besides hepatitis viruses, some other

viruses, such as Epstein-Barr virus,
cytomegalovirus, and yellow fever virus,
cause inflammation of the liver but are not
called hepatitis virus.
 Section 1

Hepatitis A Virus (HAV)

 The identification of HAV

In 1973, to identify the

causative agent of infectious
hepatitis (now named hepatitis
A), Dr. Feinstone and Prof.
Purcell analyzed three positive
stool specimen, observed
under electron microscopical
examination and finally isolated
virus that results in the
hepatitis A (HAV).
I . Biologic Properties

HAV is a member of the family Picornaviridae

(pico + rna + virus). It is a 27nm, non-enveloped
spherical particle, containing a single-stranded RNA
genome.

Genome: +ssRNA (7.5kb) capsid

 Biologic Properties

HAV is stable to the treatment with 20% ether,

acid (pH l.0 for 2 h) , and heat (60℃ for l h) .
The relative resistance of HAV to disinfection
procedures emphasizes the need for extra
precautions in dealing with hepatitis patients and
their products.
 Biologic Properties

Cell culture:
Many primate cell lines can support the
growth of HAV.
However, the cytopathic effect (CPE) is
rarely observed.
 Cytopathic effect，CPE

Normal cells Cells with CPE

CPE produced in monolayers of

cultured cells by virus (not by HAV)
 Biologic Properties
Serotype: Single serotype worldwide

Animal model: chimpanzee

II. Pathogenesis & Immunity

A. Transmission
HAV is transmitted by the fecal-oral route. Humans are
the reservoir for HAV.

The other TRANSMISSION route: Close personal contact.

 Largest outbreak occurred in Shanghai in 1988

This was described in a popular textbook by Jawetz, Melnick &

Adelberg’s Medical Microbiology, 24th Ed., 2007 (p478)
 “The consumption of raw oysters or improperly steamed
clams obtained from water polluted with sewage has
resulted in several outbreaks of hepatitis A.
The largest outbreak of this type occurred in Shanghai
in 1988, when over 300,000 cases of hepatitis A were
attributed to uncooked clams from polluted water.”

clams
CONCENTRATION OF HAV IN VARIOUS
BODY FLUIDS

Feces
Body Fluids

Serum

Saliva

Urine

100 102 104 106 108 1010

Infectious Doses per mL
 CLINICAL FEATURES

• Disease: hepatitis A
acute disease
asymptomatic infection
No chronic infection

•Jaundice by <6 yrs <10%

age group: 6-14 yrs 40%-50%
>14 yrs 70%-80%
Incubation period: Range 15-50 days
• Average 30 days
Immunity

The immune response consists initially of IgM

antibody, which is detectable at the time jaundice
appearance. It is therefore important in the
laboratory diagnosis.
The appearance of IgM is followed l-3 weeks
later by the production of IgG antibody, which
provides lifelong protection.
EVENTS IN HEPATITIS A VIRUS INFECTION

Clinical illness

Infection ALT

IgM IgG
Response

Viremia

HAV in stool

0 1 2 3 4 5 6 7 8 9 10 11 12 13
Week
 III. Laboratory diagnosis

• Serologic assays:
to detect HAV in stool or Abs in serum.
IgM: early stage
IgG: 4-fold rise in the titer
• RT-PCR: to detect nucleic acid of HAV.
Ⅳ. Treatment & Prevention

No specific antiviral therapy is available.

Hepatitis A vaccines:
a formalin-inactivated virus vaccine, or a
live attenuated virus vaccine
• Hygiene (e.g., hand washing)
• Sanitation (e.g., clean water sources)
• Immune globulin (pre-/post-exposure)
 Section 2

Hepatitis B Virus (HBV)

HBV particles under electron microscopical examination

I. Properties
A. Classification and structure
The Hepadnaviridae (Hepa + DNA + virus)
family member.
 Dane particle
Three kinds of particles can be seen in the blood of
HBV infected patients. Among these three particles, the
big spherical particle is infectious, but small spherical
particle and Filament are not. The big spherical particle,
Dane particle, has a diameter of 42 nm: within the
envelope is the viral nucleocapsid, or core. The core
contains viral genome (3.2kb), and a polymerase.
small spherical
particle

Filament

Dane particle
B. Genomic structure
There are four overlapping genes coding for the core,
surface and polymerase proteins and an X protein.
The preC -C (precore -core) region encodes hepatitis B
core antigen (HBcAg) and hepatitis B e antigen (HBeAg).

• Four open reading

frames (ORF) :
S, C, P, X.
B. Genomic structure

The ORF of surface

antigen gene is divided
into pre-S1, pre-S2 and S
domains by three in-frame
start codons.
This ORF can be
translated into three
proteins: LHBs, MHBs and
SHBs.
B. Genomic structure

The P coding region is specific for the viral

polymerase, which is an enzyme involved in HBV
DNA synthesis and RNA encapsidation.
The X open reading frame encodes the viral X
protein (HBx, a non-structural protein), which
modulates host-cell signal transduction and can
affect host and viral gene expression.
 Genome and Replication

Genome: （-）DNA contains four ORFs

gene gene products

S S1 pre S1
S2 pre S2 medium
large
S S small
C C HBcAg
pre C HBeAg
P DNA Pol, RTase
X HBxAg
C. Replication cycle
The right figure shows that
the incoming HBV virions are
bound by cell-surface
receptor(?). After membrane
fusion, the DNA is presented
to the cytosol and transported
to the nucleus.
There in the nucleus, HBV
DNA genomes (relaxed
circular DNA, rcDNA) are
converted by DNA polymerase
to a covalently closed circular
form (cccDNA).
C. Replication cycle
The cccDNA serves as the
transcriptional template to
transcript pre-genomic RNA
and mRNA by host RNA
polymerase II. Viral mRNA is
then transported to the
cytoplasm, where its
translation yields the surface,
core, and polymerase proteins,
as well as the X and preC
polypeptides.
Next, the viruses are
assembled in the cytosol, and
are exported from the cell.
II. Pathogenesis and immunity
A. Pathogenesis
1. Virus：
2. immune damages:
B. transmission：
– Blood ~ Blood transfusion, Sharing
needles and syringes
– Sexual ~ Having sex without condoms
with someone who has hepatitis B
– Vertical ~ Mother to infant: Being born
to a mother who has hepatitis B
 Concentration of Hepatitis B
Virus in Various Body Fluids
Low/Not
High Moderate Detectable

blood semen urine

serum vaginal fluid feces
wound exudates saliva sweat
tears
breast milk
 Hepatitis B - Clinical Features
• Incubation period: Average 60-90 days
Range 45-180 days
• Clinical illness (jaundice): over 5 yrs, 30%-50%
• Acute case-fatality rate: 0.5%-1%
• Chronic infection: <5 yrs, 30%-90%
over 5 yrs, 2%-10%
carriers 350m
• Premature mortality from
chronic liver disease: 15%-25%
 Acute Hepatitis B Virus Infection
with Recovery
Typical Serologic Course
HBeAg anti-HBe
Symptoms
Total anti-HBc
Titer

HBsAg IgM anti-HBc anti-HBs

0 4 8 12 16 20 24 28 32 36 52 100
Weeks after Exposure
 Progression to Chronic Hepatitis B
Virus Infection
Typical Serologic Course
Acute (6 months) Chronic (Years)
HBeAg anti-HBe
HBsAg

Total anti-HBc
Titer

IgM anti-HBc

0 4 8 12 16 20 24 28 32 36 52 Years
Weeks after Exposure
 Ⅲ. Laboratory Diagnosis (1)

• HBV: Hepatitis B virus (particle, DNA).

• HBsAg: Hepatitis B surface antigen. Marker
of infectivity when found in serum.
• anti-HBs: Antibody to HBsAg. Marker of
immunity when found in serum.
• HBcAg: Hepatitis B core antigen. No
commercial test available for this.
• anti-HBc: Antibody to HBcAg. Marker of past
or current infection.
 Ⅲ. Laboratory Diagnosis (2)

• IgM anti-HBc: IgM is an antibody subclass of

anti-HBc, which indicates recent infection with
HBV (<4-6 mos.).
• IgG anti-HBc: IgG is a subclass of anti-HBc. ,
which indicates “once” infection with HBV.
• HBeAg: Hepatitis B “e” antigen, which can only
be present if HBsAg is positive. It is a marker of
high degree of infectivity.
• Anti-HBe: Antibody to “e” antigen, which may
be present in infected or immunized person.
 Interpretation of Hepatitis B Panel
HBsAg negative
HBeAg negative susceptible (vaccine required)
Anti-HBs/HBc/HBe negative
HBsAg positive
HBeAg negative carrier
Anti-HBs/HBc/HBe negative
HBsAg/HBeAg negative
Anti-HBc/HBe negative immune due to vaccine
Anti HBs positive
HBsAg positive
HBeAg positive acutely infected (big 3 positives)
IgM anti-HBc positive
Anti-HBs/HBe negative
HBsAg positive
Anti HBc positive chronically
IgM anti-HBc negative infected
Anti HBs negative
HBsAg positive
Anti HBe positive recovering from acute infection
Anti-HBc IgG positive (small 3 positives)
IV. Specific Prevention & Treatment

A. Passive B. Active
immunization immunization

• Hepatitis B • Vaccine
immunoglobulin (HBsAg)
(HBIG)
 Hepatitis B can be prevented!
If you have never had hepatitis B, and
HBsAb-, you should get 3 shots . . .

1 2 3

Month 0 1 6
 Baby Shots for Hepatitis B
if the mother has Hepatitis B

At birth 1 month old

Hepatitis B + H-BIG Hepatitis B

Vaccine Vaccine

6 months old

Hepatitis B
Vaccine
C. Therapy

The goals of therapy in patients with HBV

infection are a reduction in the level of viremia
and amelioration of hepatic dysfunction.
All the following drugs are nucleoside or
nucleotide analogues that target the viral reverse
transcriptase.

Lamivudine (LAM), Adefovir (ADV), Entecavir

(ETV), Telbivudine (LdT), Tenofovir (TDF)
 Section 3

Hepatitis C Virus (HCV)

I . Biologic Properties

A. Structure and genomic structure

• Flaviviridae
• Morphology: spherical form, 40-60nm
enveloped
Symmetry of capsid: icosahedra
Genome: +ssRNA, 9.6kb
7 genotypes, 1b in China
 Hepatitis C virus (HCV)
RNA-enveloped virus belonging to the Flaviviridae.

E2 ssRNA
E1 lipidmembranecore
 HCV receptors:

‐ Human CD81,
‐ SR‐BI (Scavenger 
Receptor Class‐B Type‐I),
‐ CLDN (claudin‐1), 
‐ OCLN (occludin) are 
considered receptors for 
HCV cell entry.  

Pietschmann T: Final entry key for hepatitis

C. Nature, 2009,457:797-8
II. Pathogenesis & immunity
A. Transmission & Epidemiology

• Approximately 170 million people

infected worldwide, 38 million in China
• Morbidity: 2 - 4%
• Transmission route: via blood
• Close association with chronic liver
disease
• No vaccine is available.
C. Clinical findings

Incubation period Average 6-7w

Range 2-26 w
Acute illness (jaundice) Mild (<20%)
Case fatality rate Low
Chronic infection Age- 60%-85%
Chronic hepatitis related 10%-70%

Cirrhosis <5%-20%
B. Pathogenesis & Immunity
HCV infects hepatocytes.
Antibody and T-cell responses can be
detectable, but are usually unable to clear the
virus, and do not protect against reinfection.
Serologic Pattern of Acute HCV Infection
with Recovery

anti-HCV
Symptoms +/-

HCV RNA
Titer

ALT

Normal
0 1 2 3 4 5 6 1 2 3 4
Months Years
Time after Exposure
Serologic Pattern of Acute HCV Infection with
Progression to Chronic Infection

anti-HCV
Symptoms +/-

HCV RNA
Titer

ALT

Normal
0 1 2 3 4 5 6 1 2 3 4
Months Years
Time after Exposure
Ⅲ. Laboratory Diagnosis

HCV infection is diagnosed by detecting

antibodies to HCV in an ELISA.
An alternative approach is to detect viral RNA
by amplification of DNA after reverse-
transcription polymerase chain reaction (RT-
PCR).
Ⅳ. Treatment & Prevention

A combination of peglylated alpha interferon

(Peg-IFN IFN-ɑ) and ribavirin (RBV) is the
treatment of choice for chronic hepatitis C.

Current clinical development of new anti-HCV

drugs is viral protease inhibitors, Telaprevir(TVR)
and Boceprevir(BOC)，etc.
Preventing HCV Transmission
to Others
Avoid injecting drug use
• Donate blood, body organs, tissues
or semen with safe screen
• Do not share items that might have
blood on them
– personal care (e.g., razor, toothbrush)
– home therapy (e.g., needles)
• Cover cuts and sores on the skin
 Section 4

Hepatitis D Virus (HDV)

I . Biologic Properties

- Identified in 1977
- Size of 35-37nm
- The genome: negative-sense ssRNA, only
l.7kb in length. HDAg coded.
- A defective virus, enclosed within the hepatitis
B surface antigen
- Replicates only in HBV-infected cells
 Hepatitis D Virus
antigen HBsAg

RNA
 Hepatitis D Virus

• Modes of Transmission:
By the same means as HBV
• Modes of Infection:
Co-infection, and superinfection
 Hepatitis D - Clinical Features

• Co-infection (at the time of first infection with

HBV)
– severe acute disease
– low risk of chronic infection
• Superinfection (during a subsequent exposure
with HBV)
– usually develop chronic HDV infection
– high risk of severe chronic liver disease
 HBV - HDV Co-infection

Typical Serologic Course

Symptoms

ALT Elevated
anti-HBs
Titre
IgM anti-HDV

HDV RNA

HBsAg
Total anti-HDV

Time after Exposure

 HBV - HDV Superinfection
Typical Serologic Course
Jaundice
Symptoms

Total anti-HDV
ALT

Titre

HDV RNA
HBsAg

IgM anti-HDV

Time after Exposure

 Lab Diagnosis & Prevention

• Diagnosis depends mainly on tests for IgG

and IgM antibodies. Both the HDAg and
genomic RNA can also be detected in the
blood.
• Prevention: Immunization against HBV also
protects against infection with HDV.
 Section 5

Hepatitis E Virus (HEV)

 I. Biologic properties

• Size: 30-32nm
• non-enveloped particle
• Genome: +ss RNA (7.5Kb)
• One serotype, 4 genotypes
• Family : Caliciviruses - Hepeviridae
• Genomic organization:
 Hepatitis E - Clinical Features

• Transmission: Fecal-oral route

• Incubation period: Average 40 days
Range 15-60 days
• Chronic liver disease: Rare
• Case-fatality rate: Overall: 2%
Pregnant women: 15-20%
• Illness severity: Increased with age
 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

 III. Laboratory diagnosis

• Antibody assay:
ELISA for detecting IgM or IgG
• IEM:
Viral particles in patient’s stool
• PCR:
HEV RNA in stool or serum
 Treatment and Prevention

• No specific anti-viral drug

• Vaccine: recombinant
• Avoid drinking water of unknown
purity, or eating uncooked shellfish
 Questions for review

1、What are the biologic properties of HAV?

2、What are the structures of Dane particle?
3、What are the clinical implications of hepatitis B
panel (the Ag-Ab system)?
4、What are the genomic organizations of HCV?
5、What is the difference between co-infection and
superinfection of HDV?
6、Make your own list to compare all of the 5 hepatitis
viruses.
 Summary of hepatitis viruses
Virus Hepatitis A Hepatitis B Hepatitis C Hepatitis D Hepatitis E

Family Picornaviridae Hepadnaviridae Flaviviridae Unclassified Unclassified

Genus Hepatovirus Orthohepadnavirus Hepacivirus Deltavirus Hepatitis E-like
Virion 27 nm 42 nm 60nm 35 nm 30–32 nm
symmetry spherical spherical spherical spherical icosahedral
Envelope No Yes (HBsAg) Yes Yes (HBsAg) No
Genome ssRNA dsDNA ssRNA ssRNA ssRNA
Genome size 7.5 kb 3.2 kb 9.4 kb 1.7 kb 7.6 kb
Stability Heat-/acid- Acid-sensitive Ether-sensitive Acid-sensitive Heat-stable
stable acid-sensitive
Transmission Fecal-oral Parenteral Parenteral Parenteral Fecal-oral
Prevalence High High Moderate Low, regional Regional
Fulminant Rare Rare Rare Frequent In pregnancy
disease
Chronic disease Never Often Often Often Rare
Oncogenic No Yes Yes ? No
May 26, 2016
 REVIEW QUIZ

1. A 23-year-old woman is planning a 1-year trip

through Europe, Egypt, and the lndian subcontinent and
receives a vaccine for hepatitis A．The current hepatitis
A vaccine is

(A) An envelope glycoprotein subunit vaccine

(B) A recombinant DNA vaccine
(C) A formalin-inactivated virus vaccine, or a live attenuated
virus vaccine
(D) A chimeric poliovirus that expresses HAV neutralizing
epitopes
 2. A middle-aged man complained of acute onset of
fever, nausea, and pain in the right upper abdominal
quadrant．There was jaundice，and dark urine had been
observed several days earlier. A laboratory test was
positive for HAV lgM antibody．The physician can tell the
patient that
(A) He probably acquired the infection from a recent blood
transfusion
(B) He will probably develop chronic hepatitis
(C) He will be at high risk of developing hepatocellular carcinoma
(D) He will be resistant to infection with hepatitis E
(E) He may transmit the infection to family members by person-to-
person spread for up to 2 weeks
 3. The following persons are at increased risk for
HAV infection and should be routinely vaccinated

(A) Persons traveling to or working in countries that have high

levels of HAV infection
(B) Men who have sex with men
(C) Users of illegal drugs (both injecting and noninjecting)
(D) Persons who have an occupational risk for infection
(E) Persons who have a clotting factor disorder
(F) Susceptible persons who have chronic liver disease
(G) All of the above
 4. A 36-year-old nurse is found to be both HBsAg-positive and
HBeAg-positive. The nurse most likely

(A) Has acute hepatitis and is infectious

(B) Has both HBV and HEV infections
(C) Has a chronic HBV infection
(D) Has cleared a past HBV infection
(E) Was previously immunized with HBV vaccine prepared
from healthy HBsAg-positive carriers
 6. Which of the following exposures poses a
risk for hepatitis infection?

(A) A nurse sustains a needlestick while drawing up insulin to

administer to an HBV-infected patient with diabetes
(B) While cleaning the bathroom，a house-keeper’s intact skin has
contact with feces
(C) An operating room technician with chapped and abraded hands
notices blood under his gloves after assisting in an operation on a
patient with HCV infection
(D) A child drinks out of the same cup as her mother, who has an
HAV infection
(E) A shopper eats a sandwich prepared by a worker with an
asymptomatic HBV infection
 7. The following statements about HCV
infection and associated chronic liver disease
are correct except that

(A) HCV is responsible for 40％ of chronic liver disease

(B) Chronic infection develops in most (70-90％) HCV-infected
persons
(C) HCV-associated liver disease is the major occasion for liver
transplantation
(D) HCV viremia occurs transiently during early stages of
infection
(E) HCV-infected patients are at high risk (5-20%) for liver cancer
 8. A 30-year-old student goes to the emergency room because of
fever and anorexia for the past 3 days. She appears jaundiced. Her
liver is enlarged and tender. A laboratory test shows elevated
aminotransferases. She reports a history of having received hepatitis
B vaccine 2 years ago but has not had hepatitis A vaccine. The
results of her hepatitis serologic tests are as follows: HAV IgM-
negative, HAV IgG-positive, HBsAg-negative, HBsAb-positive,
HBcAb-negative, HCV Ab-positive. The most accurate conclusion is
that she probably

(A) Has hepatitis A now, has not been infected with HBV, and had
hepatitis C in the past
(B) Has hepatitis A now and has been infected with both HBV and
HCV in the past
(C) Has been infected with HAV and HCV in the past and has
hepatitis B now
(D) Has been infected with HAV in the past, has not been infected
with HBV, and has hepatitis C now
 REVIEW QUIZ

9. Hepatitis D virus (deIta agent) is found only in

patients who have either acute or chronic infection with
HBV. Hepatitis D virus

(A) ls a defective mutant of HBV

(B) Depends on HBV surface antigen for virion formation
(C) lnduces an immune response indistinguishable from that
induced by HBV
(D) Is related to HCV
(E) Contains a circular DNA genome
 REVIEW QUIZ

10. An epidemic of jaundice caused by the recently

characterized hepatitis E virus occurred in some region.
Hepatitis E virus is

(A) Found in rodents and pigs

(B) A major cause of blood-borne hepatitis
(C) The cause of a disease that resembles hepatitis C
(D) Capable of establishing chronic infections
(E) Associated with an increased risk of liver cancer
 11. Several different viruses can cause hepatitis．One
of the following statements applies to all four viruses
HAV, HCV, HDV，and HEV．

(A) Contains a single-stranded RNA genome

(B) ls transmitted primarily by the parenteral route
(C )ls transmitted primarily by the fecal-oral route
(D) ls associated with fulminant hepatitis
(E) Undergoes sequence variation during chronic infection
 bacteria, actinomyces

prokaryotic mycoplasma,chlamydia
microorganism spirochetes, Richettsia

fungi
microorganisms
eukaryotic protozoa
(microbes)
microorganism
algae
plant virus
bacteriophage
noncellular virus mycophage
microorganism
animal/human
virus

hepatitis virus