Hepatitis viruses

Dr. V. Preethi
Asst. Professor, Microbiology, CHRI
 Viral Hepatitis
Hippocrates described existence of Epidemic
Jaundice in 400 BC
Documented outbreaks of Jaundice in Europe in
17th and 18th centuries
Krugman et al differentiated b/n “infectious” and
“serum” hepatitis in 1967
Blumberg detected “Australia antigen “ in 1967
Feinstone and associates detected HAV in stool
IEM
 What is viral hepatitis?
It is a disease, caused by viruses rather than other agents,
which is characterised by a number of features
principally inflammation of the liver
dominant symptom is jaundice
associated with liver enzymes in the plasma
loss of liver excretory and synthetic functions
usually self limiting but may be chronic
may be protected against by active or passive
immunisation
 Viral Hepatitis

As a manifestation of a general infection

for example: Glandular fever (EBV),Varicella and CMV
As a manifestation of an overwhelming infection
for example: Yellow fever, viral hemorrhagic fevers
As a manifestation of infection by one of the
hepatotropic viruses
for example: hepatitis type B (HBV)
 Hepatitis Viruses

Hepatitis Viruses
HAV
HBV
HCV
HDV
HEV
Hep G virus (GB virus C)
 Hepatitis causing Viruses

Other viruses •CMV

Yellow Fever •EBV
Lassa fever •HSV
Rift Valley Fever
•VZV
Congo – Crimean fever
•HHV – 6
Marburg
•Measles
Ebola
•Rubella
•Enteroviruses
 Hepatitis A
• Belongs to Picornaviridae
• Genus – Hepatovirus
• Icosahedral particle – 27 – 32nm
• Capsid has three polypeptides – VP1, VP2 & VP3
• Linear ssRNA genome 7.5 kb
• Only one single serotype
• Genotypes – 7, Human – 4 genotypes (I, II, III, IV)
• Grows in cell culture - no CPE
 Epidemiology
• Humans are the only hosts
• Transmission is Faeco-oral
• Man – Man transmission is seen
• Also transmitted by – contaminated water, food,
uncooked/undercooked food
• Raw shellfish is important source

• Incubation period – 15 -50 days

• Virus in stool – 1 wk prior and 1 wk after exposure
9
 Clinical Features
Acute or Subacute condition.
Self limiting
Incubation period – 15 – 50 days
Adult infections are associated with acute icteric
hepatitis in 70% of cases
Symptoms – flu like symptoms, chills, headache,
fever, loss of appetite.
Signs – Bilirubinuria, Raised enzyme levels
Pale or clay colored stool
 Clinical Features -
complications

Cholestasis
Fulminants hepatitis
Relapsing disease
Triggering of autoimmune diseases
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
 Laboratory Investigations

General investigations
Microbiologic investigations
IgM antibody detection assays
Detected 5 – 10 days prior to onset and till 45 – 60 days after
onset
Antigen detection in stool
Viral culture in not done for diagnosis
 Vaccination
• Passive immunisation – within 2 wks (IG 2IU/Kg BW)
Sexual and Household contacts – Immediately
Casual contacts – not required
• Active immunisation -Inactivated virus vaccines
Havrix, Vaqta
Vaccine candidates
Children living in High endemic areas
Persons with high risk of acquiring disease
MSM
IVDAs
International travellers
Recipients of Blood or Plasma products
Chronic liver diseases
 Hepatitis E virus

• Spherical, enveloped
virus
• Positive sense ss RNA
• Had been placed in
Calciviradeae
• Currently place in
Hepeviradeae
 Clinical features

Incubation period: Average 40 days (15 – 40 days)

Disease is self limited , with no evidence of chronic
infection
Cholestatic disease can occur
High rate of severe or fulminant hepatitis in pregnant
women
Liver transplant is indicated in fulminant hepatitis
Babies born to women with acute infection are at high risk
of perinatal morbidity
 Hepatitis E Virus Infection
Typical Serologic
Symptoms
Course

ALT
IgGanti-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

Outbreaks or Confirmed Infection in >25% of
Sporadic Non-ABC Hepatitis

18
 Laboratory Diagnosis

Serologic analysis
IgM or IgG assays
Utilise synthetic proteins from ORF2/ORF3 or viral
genome
Vary in sensitivity
RT – PCR
Positive test does not prove infectivity
 Hepatitis E has zoonotic
origin?
Hepatitis E virus is classified into 4 genotypes (I – IV)
Genotype 1 – epidemics and sporadic cases in Asia
and Africa
Genotype 2 – Nigeria
Genotype 3 – discovered from several swine herds in
USA
Genotype 4 – sporadic human infections in China and
Taiwan; has also been associated with swine
infections
Hepatitis B - Introduction

The most widespread of the hepatitis viruses

More than 2 billion estimated to have been infected, 350
million carriers probably
Chronic liver disease can lead to cirrhosis and even
Hepatocellular carcinoma
 Basic virology

Enveloped DNA virus belonging to family Hepadnaviridae

Double stranded DNA virus,the + strand not complete

Replication involves a reverse transcriptase

 Basic virology

Three types of particles seen on EM:

Spherical particles 22nm
Tubular/ filamentous 22 nm diameter, varying length
Large spherical 42 nm (Dane particle)
Basic virology
 Basic virology

Enveloped virus
Envelop has HBsAg
The nucleocapsid has
core protein or HBcAg
Soluble non particulate
protein - HBeAg
 Genome
Incomplete circular
dsDNA
S gene – HbsAg

C gene – HBcAg,
HBeAg

P gene – DNA
polymerase, RT

X gene – transcriptional
transactivator, HBxAg
Antigenic nature of HBsAg

Common group reactive antigen a

Two pairs of type specific antigens –

d, y
w, r
ayr and ayw seen in India commonly
 ESCAPE MUTANTS

ESCAPE MUTANTS
Unusual variants
Lacking group specific antigen ‘a’
Most common is G145R glycine to arginie at aa145
Persistent viral replication despite appropriate post
exposure prophylaxis
Inability to detect them by routine antigen detection
based serologic test
 HBcAg

HBcAg
Core protein is major component of nucleocapsid
Not expressed on cell surface and not detected in
serum
IgM antibodies to this antigen indicates recent infection
HBeAg & DNA Polymerase
HBeAg
Translation from Pre C ORF
Expressed on surface of infected hepatocytes
Serum detection of HBeAg indicates active
infection
Polymerase
Translated from P ORF
Transcriptional transactivator
Translated from ORF ‘X’
Enhances expression of other viral proteins
 Pre-core Mutants

Does not produce HBeAg

Higher risk of cirrhosis , carcinoma
High loads of HBV DNA detectable
Difficult to treat
 Epidemiology

Transmitted through
Perinatal
Percutaneous
Sexual contact
Much more efficient than HIV at spread
Found in blood, semen, cervical secretions and saliva
Geographic Distribution of Chronic HBV
Infection

HBsAg Prevalence
 8% - High
2-7% - Intermediate
<2% - Low
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 Epidemiology
Perinatal infection is the predominant mode of
transmission in high-prevalence areas
Horizontal transmission, particularly in early childhood,
accounts for most cases of chronic HBV infection in
intermediate-prevalence areas.
Unprotected sexual intercourse and intravenous drug use
in adults are the major routes of spread in low-prevalence
areas.
India falls in area of intermediate prevalence
 Epidemiology

People with chronic infection act as the reservoir of

infection

Following infection about 5 – 10% of adults, 30% of

children and 90% of neonates become carriers
 Pathogenesis
HBV is not cytopathic per se to
hepatocytes
Host immunity plays a major role in
cellular injury
Perinatal infections are always
asymptomatic and progresses to
chronicity in 90% of cases
Expression of HBeAg intrauterine may play
a role in development of tolerance
 Clinical features

Acute hepatitis B
IP of 1-6 months
Malaise, fatigue, anorexia, nausea, vomiting, and right
upper quadrant discomfort
Jaundice, tender hepatomegaly
Subclinical or anicteric cases common
 Complications

Complications
Fulminant hepatic failure
May be related to massive immune responses
against the virus
Chronic hepatitis B
Cirrhosis
Hepatocellular carcinoma
 Diagnosis

Serological demonstration of viral markers

First to appear is HBsAg
Anti HBc appears a week or two after the appearance of
HBsAg
 Acute Hepatitis B Virus Infection with Recovery
Typical Serologic Course
Symptoms

HBeAg anti-HBe

Total anti-HBc
Titre

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 Chronic
(6 months) (Years)
HBeAg anti-HBe
HBsAg
Total anti-HBc
Titre

IgM anti-HBc

0 4 8 12 16 20 24 28 32 36 52 Years

Weeks after Exposure

Interpretation of serologic markers for
Hepatitis B
Interpretation of serologic markers for
Hepatitis B

HBsAg - used as a general marker of infection.

HBsAb - used to document recovery and/or immunity to
HBV infection.
anti-HBc IgM - marker of acute infection.
anti-HBc IgG - past or chronic infection.
Interpretation of serologic markers for
Hepatitis B

HBeAg - indicates active replication of virus and therefore

infectiveness.
Anti-Hbe - virus no longer replicating. However, the
patient can still be positive for HBsAg which is made by
integrated HBV.
HBV-DNA - indicates active replication of virus, more
accurate than HBeAg especially in cases of escape
mutants. Used mainly for monitoring response to therapy
 Treatment

Interferon therapy
Lamivudine
Adefovir
 Prophylaxis

Active immunization
Major immune response is directed to common
‘a’ determinant
Now recombinant vaccines are used
HBsAg expressed on yeast cells by plasmid
expression
Only S gene is cloned
 Prophylaxis

Universal hepatitis B vaccination is done in >150

countries including India
Site of vaccination
Upper arm
Anterolateral aspect of thigh
Not to be administered in gluteal region
 Prophylaxis
Active Immunisation
Dose –
Engerix – B – 1ml X 3 doses – 0,2, 6
Protective titre – 10 IU/ml

Perinatal transmission –
Passive – Active immunisation of infant
immediately at birth
 Prophylaxis

Protective titers
No consensus on exact protective antibody levels
Antibody titers of 10 IU/L considered protective
For high risk exposure 100IU/L
 Hepatitis B and Primary Liver cancer

Persistent HBV is associated with high risk of developing

hepatocellular carcinoma
Precise mechanism of oncogenesis is yet to be
elucidated
HBsAg carriers have 200 fold risk of developing HCC
Immunohistochemistry of HBV associated Hepatic
cancers produce HBsAg
Molecular cloning shows HBV genome integrated in host
genome
 Hepatitis D virus

Defective RNA virus

Require HBV for replication
HDV is coated with HBsAg
HBV is required for release of mature virus from hepatocyte
and also for entry into new one

Spherical particle – 36 nm particle

ssRNA
 Clinical features of Hepatitis
D
• Coinfection
– severe acute disease
– low risk of chronic infection
• Superinfection
– usually develop chronic HDV infection
– high risk of severe chronic liver disease
Mode of transmission

• Percutanous exposures

– injecting drug use

• Permucosal exposures

– Sexual contact
 HBV - HDV Coinfection
Typical Serologic Course
Symptoms

ALT Elevated

anti-HBs
Titer

IgM anti-HDV

HDV RNA

HBsAg
Total anti-HDV

Time after
Exposure
 HBV - HDV Superinfection
Typical Serologic Course
Jaundice

Symptoms

Total anti-HDV
ALT
Titer

HDV RNA
HBsAg

IgM anti-HDV

Time after
Exposure
 Geographic Distribution of HDV Infection

Taiwan

Pacific Islands

HDV Prevalence
High
Intermediate

Low
Very Low

No Data
 Laboratory diagnosis
Antibody to HDV
IgM & IgG
HDV RNA
HDAg
Co-infection
Anti HBcAg with HDV markers
HBsAg, HBeAg & HDV RNA
Super-infection
HD viremia followed by anti HD IgM and IgG
 Prevention - Hepatitis D

• 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
 Hepatitis C virus
Previously k/a NonA, Non B hepatitis agent
Later identified as Hepatitis C Virus
Family – Flaviviridae
Genus – Hepacivirus

Size – 50 – 60 nm
ssRNA (+Sense)

Considerable genetic and antigenic diversity

 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 10%-70% (most asx)
Cirrhosis <5%-20%
Mortality from CLD 1%-5%
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
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
 Laboratory diagnosis
Serologic assays
Anti HCV antibodies are detected
II generation – C22, C33c, C100-3
IV generation ELISA kits – NS5
Radioimmune binding
Specificity better than EIA kits
RT – PCR
RNA detection
Qualitative
Quantitative
 Persistence of HCV
infection

60 – 80% of HCV progresses to chronicity

Morbidity of chronic HCV infections
Age of acquisition
Concomitant alcohol abuse
Gender
Coexisting viral disease
Host immune response
 Prevention
No vaccines available currently
Sequence diversity in viral groups and sequence
heterogenicity within a patient
Secondary transmission is preventable
Barrier contraception
materno-fetal transmission seen at RNA
concentrations >107 copies/ml
Thank you