Hepatitis B, C and D

HEPATITIS B

• Hepatitis B (formerly known as "serum" hepatitis) is an acute

systemic infection with major pathology in the liver, caused by
hepatitis B virus (HBV) and transmitted usually by the
parenteral route. It is clinically characterised by a tendency to
a long incubation period (6 weeks to 6 months) and a
protracted illness with a variety of outcomes. Usually, it is an
acute self-limiting infection, which may be either subclinical or
symptomatic. In approximately 5 to 15 per cent of cases, HBV
infection fails to resolve and the affected individuals then
become persistent carriers of the virus. Persistent HBV
infection may cause progressive liver disease including chronic
active hepatitis and hepatocellular carcinoma.
• Based on the different HBsAg carrier rates, countries of the Region can
be divided into three epidemiological patterns. The Type 1 occurs in
Nepal and Sri Lanka and is characterized by a low HBsAg carrier rate of
0.9 to 1.0 per cent. The second pattern (Type 2) can be found in Bhutan,
India, Indonesia and Maldives where carrier rate is high in the general
population (5 to 7 per cent). In India alone there are an estimated 43 to
45 million HBsAg carriers and, among them 10 to 12 million also have
HBeAg. Type 3 is observed in Bangladesh, DPR Korea. Myanmar and
Thailand, where the carrier rate is very high and ranges from 9 per cent
to 12 per cent
• AGENT : Hepatitis B virus was discovered by Blumberg in 1963.
Efforts to grow this virus have been so far unsuccessful. HBV is a
complex, 42-nm, double-shelled DNA virus, originally known as the
"Dane particle". It replicates in the liver cells. HBV occurs in three
morphological forms in the serum of a patient: (a) small spherical
particles with an average diameter of 22-nm. These particles are
antigenic and stimulate production of surface antibodies. The
purified 22-nm particles are used in the preparation of hepatitis B
vaccine: (b) tubules of varying length and diameter, and (c) the
Dane particle which corresponds morphologically to hepatitis B
virus. A person who is serologically positive for the surface antigen
is circulating all morphological forms, of which 22-nm particles
constitute the bulk. Of the three morphological forms, only the
Dane particle is considered infectious, the other circulating
morphological forms are not infectious.
• Hepatitis B virus has three distinct antigens - a surface antigen, also
known as "Australia antigen" (HBsAg), a core
Modes of transmission
• Parenteral route :
Hepatitis B is essentially a blood-borne infection. It is transmitted by infected
blood and blood products through transfusions, dialysis, contaminated
syringes and needles, pricks of skin, handling of infected blood, accidental
inoculation of minute quantities of blood such as may occur during surgical
and dental procedures, immunization, traditional tattooing, ear piercing,
nose piercing, ritual circumcision, acupuncture, etc. Accidental percutaneous
inoculations by shared razors and tooth brushes have been implicated as
occasional causes of hepatitis B.
• Perinatal transmission :
Spread of infection from HBV carrier mothers to their babies appears to be
an important factor for the high prevalence of HBV infection in some
regions, particularly China and SE Asia . The risk of infection varies from
country to country and may reach 40 per cent. The mechanism of perinatal
infection is uncertain . Although HBV can infect the foetus in utero, this
rarely happens and most infections appear to occur at birth, as a result of a
leak of maternal blood into the baby's circulation, or ingestion or accidental
inoculation of blood . Infection of the baby is usually anicteric and is
recognized by the appearance of surface antigen between 60-120 days after
birth
• Sexual transmission :
There is ample evidence for the spread of infection by intimate
contact or by sexual route. The sexually promiscuous, particularly
male homosexuals, are at very high risk of infection with hepatitis B.
• Other routes :
Transmission from child-to-child, often called horizontal
transmission, is responsible for a majority of HBV infections and
carriers in parts of the world other than Asia. The researchers believe
that the spread occurs through physical contact between children
with skin conditions such as impetigo and scabies, or with cuts or
grazes. Often transmission occurs when children play together or
share the same .
Transmission by blood sucking arthropods (e.g., mosquitoes, bed
bugs) is suspected, but there is no convincing evidence to support
this suggestion

• In short, transmission occurs in a wide variety of epidemiological

settings. It can spread either from carriers or from people with no
apparent infection, or during the incubation period, illness or early
convalescence.
DNA-yeast derived vaccine : An alternate vaccine against hepatitis B has been licensed for the
first time in USA in 1987. the recombinant DNA vaccine elaborated from cultures of yeast
cloned with HBsAg s-gene. Several field trials have shown that this genetically engineered
vaccine is as immunogenic, safe and effective as the plasma-derived vaccine and is more
cost-effective than the plasma derived vaccine. The fact that this vaccine does not depend
on the scarce plasma resource is an added advantage .
• Over 90 per cent of recipients of the vaccine mount perceptive antibody to hepatitis B. The
dose for adult is 10-20 mg initially (depending on the formulation) and again at 1 and 6
months; for greatest reliability of absorption, the deltoid muscle is preferred for injection.
The newborn and paediatric dose is one-half the adult dose. Protection appears to be
excellent even if litre wanes-at least up to 9 years ~ and booster reimmunization is not
routinely recommended (30).
Hepatitis B immunoglobulin (HB1G)
• For immediate protection, HBIG is used for those acutely exposed to HBsAg-positive blood,
for example (a) surgeons. nurses or laboratory workers {b) newborn infants of carrier
mothers, and (c) sexual contacts of acute hepatitis B patients. The HBIG should be given as
soon as possible after an accidental inoculation (ideally within 6 hours and preferably not
later than 48 hours). At the same time the victim's blood is drawn for HBsAg testing. If the
test is negative, vaccination should be started immediately and a full course given. If the
test is positive for surface antibody, no further action is needed
• The recommended dose is 0.05 to 0.07 ml/kg of body weight; two doses should be given 30
days apart . HBIG provides short-term passive protection which lasts approximately 3
months . Since the median incubation period is said to be lower than 100 days two doses of
HBIG given one month apart should suffice. The general use of HBIG for long-term
prophylaxis has not been recommended because of its limited availability, its high cost and
risk (although remote) of complications through repeated use over a long period of time .
• Delta hepatitis infection always occurs in
association with hepatitis B (carrier state). The
mode of transmission of this infection, its
prevention and control are identical to those
for hepatitis B. Immunization against hepatitis
B also protects against delta infection.
 HEPATITIS C
• Until a few years ago, the only types of viral hepatitis that could be confirmed
were type A and type B. All others were described as non-A, non-B, that is
neither A nor hepatitis B viral infection could be confirmed in blood tests of
patients. Since the hepatitis C virus (HCV) was identified in the year 1989, it
has been shown to be the major cause of parenterally transmitted non-A,
non-B (PT-NANB) hepatitis .
• The incidence of HCV infection world-wide is not well known, but from the
review of published prevalence studies, WHO estimates that 3 percent of the
world population is infected with HCV and around 170 million individuals are
chronic carriers at risk of developing liver cirrhosis and liver cancer. In many
countries, particular population subgroups such as voluntary blood donors
have a very high prevalence of HCV infection specially in the developing
world. In the USA an estimated 4 million people have contracted the disease,
4 time more than HIV infection. Approximately 30,000 new acute infections
and 8000 - 10000 deaths occur each year. It has also become a leading reason
for liver transplantation.
Prevalence of chronic hepatitis C infection
• The hepatitis C virus is a single-stranded RNA virus with properties similar to
those of flavivirus. It bears no genomic resemblance to hepatitis B or D. The
virus is mainly transmitted through transfusion of contaminated blood or
blood products. Upto 50% of cases are related to intravenous drug users
who share needles. The risk of sexual and maternal - neonatal transmission
is small . A low rate of secondary transmission to household contacts has
been recognized. For health care workers it is an occupational hazard
requiring adherence to universal precautions. Traditional practices such as
circumcision, tattooing and scarification with contaminated instruments can
spread HCV infection. The incubation period averages 6-7 weeks, and clinical
illness is often mild, usually asymptomatic with a high rate of (more than
50%) chronic hepatitis, which may lead to cirrhosis of liver or liver cancer. It
may take as long as 20 years to develop in to liver cancer, and is more likely
to do so in men than in women, and in alcohol consumers.
• Major prevention problems persist in the developing countries. Many
of them cannot afford the anti-HCV blood test kits, where the use of
contaminated equipment for injection and other medical and dental
procedures is widespread. Efforts are therefore necessary to
persuade the manufacturers of tests to lower the costs for
developing countries. Health education programmes are also needed
to inform the general public and health care workers about the risk
of transmitting infection with the use of unsterile equipment.
Surveillance on a global scale needs to be strengthened in order to
improve medical knowledge of transmission of the virus.
• Interferon is the only drug that has been found effective in the
treatment of HCV infection. However, treatment is very expensive
thousands of dollars for the drug alone - and must be administered
by injection several times a week for several months. Moreover,
some patients, experience serious side-effects. Also, about half of the
patients go into remission, but 50 per cent relapse when the
treatment is stopped; only 25 per cent have long-term remission.