Dr. Robert G. Gish, MD, of UC San Diego Health System Hepatology Clinic, prsesents "Hepatitis D and E: The Forgotten Viruses"

1. The UC San Diego AntiViral Research Center sponsors weekly
presentations by infectious disease clinicians, physicians and
researchers. The goal of these presentations is to provide the most
current research, clinical practices and trends in HIV, HBV, HCV, TB
and other infectious diseases of global significance.
The slides from the AIDS Clinical Rounds presentation that you are
about to view are intended for the educational purposes of our
audience. They may not be used for other purposes without the
presenter’s express permission.
AIDS CLINICAL ROUNDS

2. HDV: D is for deadly
Robert G. Gish MD

3. Epidemiology of Hepatitis Delta
Key messages
 An estimated 15-20 Million individuals are infected with HDV
worldwide!
 Hepatitis Delta is the most severe form of chronic viral hepatitis
→ No testing – no identification of HDV infection!
 The clinical manifestation of hepatitis delta differs between
regions and has changed during the last 3 decades
 Hepatitis Delta is a dynamic disease:
- Both HBV and HDV contribute to disease progression
 Migrant populations and special risks groups show particular
high HDV prevalences
 The HDV genotype matters

4. www.hepatitis-delta.org
Prevalence of Hepatitis Delta

5. HDV: Modes of Transmissions
Calle Serrano, Manns & Wedemeyer, Seminars in Liver Disease 2012
HDV Infection and Transmission requires HBsAg!

6. HDV: Modes of Transmissions
Calle Serrano, Manns & Wedemeyer, Seminars in Liver Disease 2012
HBV vaccination prevents from HDV infection!
Intrafamiliar transmission
vertical & sexual transmission,
infection during early childhood
Medical treatment
blood transfusion, unsterile syringes, etc.
Special risk groups
IV drug user, dialysis, HIV+, hemophiliacs.
HDV Transmission requires HBsAg!

7. Gaeta, Rizzetto et al., Hepatology 2000
0
5
10
15
20
25
30
0-29 30-49 >50
1987
1992
1997
Age of Patients
%anti-HDV-positive/HBsAg+
Decline of anti-HDV prevalence in
Eastern Europe in the 1990ies

8. courtesy of Dr Carballo
Migration and viral hepatitis
Germany: Wedemeyer et al., Hepatology 2007
Heidrich et al., J Viral Hepatitis 2009
France: Le Gal et al., Hepatology 2007
UK: Cross et al., J Med Virol 2008
Italy: Stroffolini et al., J Med Virol 2009
Piccolo et al., Eur J Publ Health 2010
Large proportion of immigrants
among anti-HDV-positive individuals
diagnosed after 2000

9. High anti-HDV prevalence in HBsAg-positive
HIV-infected individuals
Sorriano et al., AIDS 2011
Overall prevalence: 14.5%!

10. 1980 1990 2000 2010
ACUTE HEPATITIS DELTA
CHRONIC HEPATITIS DELTA
%ofHBsAg+patients
Hepatitis delta: evolution of clinical presentation
young patients
locally acquired
special risk groups (IVDU)
older patients
Immigrant populations
special risk groups
Severe
Acute + Chronic Disease
Mild chronic Disease Severe chronic Disease

11. Different HDV genotypes in different regions!
Wedemeyer & Manns, Nat Rev Gastroenterol 2010

12. Different HDV genotypes are associated with
different clinical outcomes
Su, Wu et al., Gastroenterology 2006

13. Su, Wu et al., Gastroenterology 2006
HBV genotypes and outcome of Hepatitis delta
in Taiwan
Multivariate Model and Adverse Outcome:
HBV Genotype C RR 13.4
Age >60 years RR 12.0
HDV Genotype 1 RR 9.8

14. Heidrich et al., Liver International 2012
HBV DNA is frequently suppressed even in
HBeAg+ Hepatitis Delta

15. Heidrich et al., Liver International 2012
The outcome of
HBeAg-positive vs. HBeAg-negative hepatitis delta

16. Schaper, Buti et al., J Hepatol 2010; Wedemeyer J Hepatol 2010
Fluctuating Patterns of Viral Dominance
in Hepatitis D

17. Decreasing HDV infection in High-Risk Groups in Taiwan
Wu et al. Hepatology 1990, J Gastroentrol Hepatol 1993, J Med Virol 2004

18. Country Prevalence Author Poster
No
India 15,2%
10,9%
Raja W.A. et al.
Asim M.
82
8
Korea 0.4% (OLT) Jung Y. J. et al. 47
Pakistan 35,2%
45,3%
40,0%
45,3%
Mumtaz K. et al.
Zaki M. et al.
Bhatti T.A. et al.
Memon M. S. et al.
71
7
13
95
Iran 7,6% Azinmehr L. et al. 11
Turkey 2,5% (Izmir)
3,4% (Izmir)
8% (SE)
9% (Ddiyarbakir)
Köse S. et al
Akpinar Z. . et al
Turhanoglu M. et al.
Gulsun S. et al.
26
40
41
58
EASL Monothematic Conference Delta Hepatitis 2010
Prevalence of Hepatitis Delta in the Asia-Pacific Region
Data presented at the EASL Delta Conference 2010

19. Anti-HDV Prevalence among HBsAg-positive patients in Europe
(E.K. Manesis, EASL Special Conference 2010)

20. Hepatitis B/D
Legal Amazonia
PERU
COLÔMBIA
EQUADOR
VENEZUELA
BRAZIL
Anti-HBc total – >70%
HBsAg - >10%
Anti-HDV ∕ HBsAg+ - 0 up to 60%
Peculiar Fulminant Hepatitis
Bolivia
Suriname/Guianas
Courtesy of Dr. R. Parana

21. Reported cases of HDV infection in Brasil
Courtesy of Dr. R. Parana
Cases -2009

22. Amazon River
near Manaus
16 November 2007
HBV genotype F and H in South America:
A zoonosis?
Courtesy of Dr. R. Parana

23. North America
Dr. nn
(a well known hepatologist from North America),
September 2012:
“Your work on hepatitis delta is nice,
but it is not relevant for us.
We simply do not find hepatitis delta in the USA”

24. HDV Epidemiology in the USA
Highly variable: <1% to 30% among chronic HBV carriers!
NHANES IV (CDC: 2003-2004)
1/28 HBsAg+ individuals was anti-HDV+ (3.6%)
Nath et al. Am J Epidemiol 1985:
Blood Donors: 1.4% Southeast to 12% Pacific region
Weisfuse et al. Hepatology 1989:
Homosexual Men: 2%
Rizzetto et al. JID 1982; Troisi et al. Blood 1993:
Haemophiliacs: 19%; Female Prostitutes 21%
Hershow et al. Ann Intern Med 1989:
Hepatitis B Carriers in Illinois: 30%

25. HDV Epidemiology in the USA
Kurcirka et al., JID 2010

26. HDV Epidemiology in the USA:
Northern California
Gish et al., EASL HDV Special Conference 2010
499 HBsAg positive patients → 42 (8%) anti-HDV positive
R Gish 2013 JGH

30. Europe 43/111 (39%) 101/532 (19%) <0.000001
Smedile et al 1982
USA 24/71 (34%) 5/118 (4%) 0.000016
Govindarajan et al 1984
Fulminant Acute
Hepatitis B Hepatitis B p value
Proportion of patients with evidence of HDV
in acute self limited vs. fulminant hepatitis B
Chronicity infrequent: 5/208 patients (2.4%) Caredda et al 1987

31. 138 acute hepatitis D
23 acute superinfection115 acute co-infection
104 resolution
(90%)
10 chronic
hepatitis (8%)
Outcome of Acute Delta Hepatitis
Buti et al, J Viral Hepat 2010 (in press)
23 chronic
hepatitis (100%)

32. 1
4
3
2
5 10 15 Years
FIBROSIS
NATURAL HISTORY

33. Delta hepatitis and HCC
Early studies: infrequent association due to
diminished life expectancy (Rizzetto & Verme, J Hepatol 1985)
A European wide study reported a 3.2 fold increased
risk compared to mono-infected pts (p<0.05); some
risk for hepatic decompenstaion (2.2 fold, p= NS)
(Fattovich et al, Gut 2000)

34. Romeo et al, Gastro 2009
HCC vs. hepatic
decompensation in
HDV cirrhosis: a 28 year
follow-up study

35. And… if you want to be more involved in hepatitis delta:

36. In Germany, it is likely that more patients
are dying from hepatitis delta than from
HIV infection.
In many other countries the scenario
might be similar.
What can we do?

37. Thanks to
Heiner Wedemeyer
J.-M Pawlotsky
Collaborators:
C. Yurdaydin (Ankara, Turkey),
G. Dalekos, K. Zachou, G. Papatheodoridis (Larissa, Greece),
T. Bock (RKI, Berlin, Germany),
E. Herrmann (Frankfurt, Germany),
E. Gordien, J.M. Pawtlosky (Paris, France),
H.P. Dienes (Cologne, Germany)
A. Erhardt (Düsseldorf, Germany)
The Hep-Net International Delta Hepatitis
Study Group!

38. Hepatitis E
Robert Gish, MD,

39. Hepatitis E- A Major Cause of
Epidemic and Sporadic Hepatitis

40. Historical Aspects ~1950s
 Retrospective serologic testing of
stored sera confirmed enteric non-A-
non-E hepatitis in New Delhi (1955-
1956)
– November 1955: Flooding of Yamuna river and
contamination of city water
– 29,000 icteric cases
 Highest attack rate in adults
– Wang DC et al., Lancet 1980; 2

41. … end of 1970s - 1980s
 Kashmir Valley, India
– Nov 1978-April 1979
– 275 clinical cases, 11-40 years old in villages
with common water source, among 16,620
inhabitants
– Rate of fulminant hepatitis was
4.4%
 Khuroo MS. Am J Med 1980; 68
 Former soviet republics of Central
Asia- Turkmenistan, Kyrgyzstan,
Uzbekistan, 1980 and 1986
Ketiladze / Favorov / Shahgildyan
 Smaller outbreaks: India (1982),
Nepal (1984), Algeria (1985),
Mexico (1986)

42. Transmission Studies
 Confirmation of new hepatitis
agent was demonstrated by
Dr. Michael Balayan in a
volunteer self-inoculation
with pooled fecal material
 12 August 1981
 Day 36: Acute hepatitis
 Duration: 3 weeks
 Days 28-45: in IEM
aggregates of 27-30 nm VLP
from stool with sero-
conversion sera, but not hep
A, B or PT NANB
Two Cy macaques inoculated
with stool suspension from the
experiment showed excretion
of same VLP, LFT elevation
and histological changes in
liver

43. Hepatitis E Virus (HEV)-
Breakthrough of 1990s
Genelabs
 1990: Reyes isolated a nucleic acid clone
representing part of hepatitis E viral genome from
bile of an experimentally-infected animal.
 1991-1992: Tam and Huang sequenced entire HEV
genome showing heterogeneity of Asian and Mexican
isolates- genotypes 1 and 2, respectively.
 1992: Dawson developed first anti-HEV EIA showing
that IgM is a short-lived marker of recent infection
 1992-2000: Improvement of serologic assays and
development of molecular tests

44. Laboratory Diagnostic Events
in Acute Hepatitis Е

45. A Modern Outbreak of Hepatitis E,
Uganda 2007-2009
Distribution of cases of jaundice during an epidemic of hepatitis E in
Kitgum District, Uganda (N = 7,919), by week of report,
October 2007 through January 2009
Teshale, et al., Emerg Infect Dis. 2010;16:126-9

46. HEV Taxonomy and
Molecular Virology
Genus- Hepevirus
Family- Hepeviridae
Genome: Single-stranded
linear RNA ~7.2 kb
Open Reading Frames: 3
Capsid gene (ORF2); 660 aa
Genotypes: 4
Single serotype
Spherical, non-
enveloped, icosaedral
particle ~32-34 nm Ø

47. Onset of HEV Infection
 Mean incubation period: 6 w (2–9 w)
 Hepatitis-like signs and symptoms:
– jaundice, fever, loss of appetite,
abdominal pain, lethargy
– High ALT
 Viremia is usual, lasting for 2 weeks
 Viruses are excreted into the bile and
shed in the feces for 4 weeks

48. Progress of Disease
 Attack rate are highest in young adults
15-40 years
 Acute hepatitis E is frequently self-
limited
 Chronic hepatitis E is recognized in
organ transplant recipients
 Mortality: overall 0.5% - 4.0%
– in pregnant women: ~20%

49. Hepatitis E in Organ
Transplant Recipients (OTR)*
 Solid OTR are at risk for acute and chronic
HEV infection.
 Overall prevalence: 1.8% - 11.3%
 Prevalence of chronic HEV infection defined
by persistent viremia: 0-6.5% (median 0.8%)
 Only genotype 3 reported
 Most common risk factors: consumption of
game and domestic meat
*Data from NIH HEV Scientific Workshop, Bethesda, 26 March 2012

50. Natural History of Hepatitis E
in OTR*
 Acute hepatitis characterized by modest ALT
elevation- median ~150 U/L (0.5-26 ULN)
 Spontaneous clearance occurs in ~40% cases
– More frequently among those infected later after the
transplantation
 Viral clearance not always associated with
development of anti-HEV IgG
 Reactivation in persons previously exposed (IgG anti-
HEV) does not occur- no need for special monitoring
 For those with chronic HEV infection cirrhosis can
occur within 2-3 years in some cases
*Data from NIH HEV Scientific Workshop, Bethesda, 26 March 2012

51. Hepatitis E as a Cause of
Acute Liver Failure*
 The US ALF Study Group has enrolled
>1800 adults since 1998
 Final analysis was conducted on 699
– 3/699 (0.4%) tested igM anti-HEV +
– 2 had high titer of IgG anti-HEV
– No HEV RNA detected
 Conclusion: Acute HEV infection is rare
cause of ALF in the United States
*Data from NIH HEV Scientific Workshop, Bethesda, 26 March 2012

52. Hepatitis E Vaccines*
 In animal studies, several truncated recombinant
HEV capsid protein have been found to induce
specific a antibodies, and to protect against liver
injury following subsequent challenge with
homologous and heterologous strains of the virus.
 An HEV DNA vaccine has also been shown to
induce serum anti-HEV antibodies in cynomolgus
macaques, and protect against a heterologous
challenge.
*Aggarval R., JGH 2011; 26; Suppl. 1

53. Recombinant
Hepatitis E Vaccines*
 The first human vaccine contained VLPs made up of a 56-kD
truncated genotype 1 HEV ORF2 protein (aa 112–607) produced
in Spodoptera frugiperda cells infected with a recombinant
baculovirus.
– Ph II-III: 20ug administered to 2000 Nepalese solders at 0, 1, 6 m.
– Efficacy rate was dose dependent: 3-doses – 95%; 2-doses – 86%
 The second vaccine- HEV 239 vaccine, contains a more
truncated HEV capsid protein (aa 368–606) expressed in
Escherichia coli
– Ph II-III: 30ug administered to 113,000 volunteers in China at 0, 1, 6 m.
– Efficacy rate was not dose dependent: 3 and 2-doses – 100%
– The Chinese vaccine has been shown to provide protection against genotype
4 HEV infections, even though it is based on genotype 1 virus
*Aggarval R., JGH 2011; 26; Suppl. 1

54. Hepatitis E Vaccine
Application*
 Whether HEV vaccines should be used for the
general population in highly endemic areas will
depend on:
– cost considerations,
– the duration of protection afforded by the vaccines and
– need for booster doses and the ability of the vaccines to
interrupt transmission of infection.
 Neither vaccine has currently reached the market.
*Aggarval R., JGH 2011; 26; Suppl. 1

55. Hepeviridae- Proposed
Classification and Host Range*
HEV Natural Host
Genus Hepevirus
Genotype 1 human
Genotype 2 human
Genotype 3 human, pig, deer, mongoose, rabbit
Genotype 4 human, pig
Putative Gt 5 rats
Putative Gt 6 Wild boar
Putative Genus Avihepeviridae
Genotype 1 chicken (Australia)
Genotype 2 chicken (USA)
Genotype 3 chicken(Europe and China)
Putative Genus Piscihepevirus
Cutthroat throut virus fish
*XJ Meng, Hepatitis E in US/An NIH Research Workshop, March 26, 2012

56. Hepatitis E in the United States
In US hepatitis E is not reportable
Previously thought to be mostly associated with travel
to hyperendemic regions
1995 and 2004 – Several case reports of isolated
autochthonous acute hepatitis E cases in MN, CA,
AZ and TX* were published
*Amon et al., JMV 2006

57. Objective
 To describe the characteristics of
incident cases of hepatitis E and
seroprevalence of HEV infection in the
United States
– Passive laboratory-based surveillance (2005-2012)
– Active laboratory-based surveillance (2009-ongoing)
– National sero-survey

58. Case Definition
 A case of hepatitis E was defined as illness in a
person in whom IgM and IgG against HEV in serum
or HEV RNA in serum or stool samples were
detected.
 A person in whom IgM but not IgG against HEV was
detected in serum was excluded unless HEV RNA
was found or IgG againstHEV was detected in follow-
up serum samples.
 A person in whom IgG but not IgM against HEV was
detected in serum samples was included if HEV RNA
was found in serum or stool samples.

59. Methods
Assays:
IgM and IgG anti-HEV (DSI-EIA)
HEV RNA in serum and/or stool
Screening
Real time RT PCR
Sequencing/Genotyping
Conventional RT PCR
Questionnaire addressed demographics,
Clinical signs and biochemical indicators,
Major risk factors
The information was not available for all patients

60. Evaluation of IgM anti-HEV
Assays
Assay
Analytic
Sensitivity
WRU/mL
Clinical
Sensitivity
(N=51; GT1-4)
Specificity
(N=228)
I - 56kD (NIH) NT 98% 78.5%
II - p166 (CDC) NT 98% 93.4%
III - IID 120 82% 92.1%
IV - MP 250 72% 93%
V – DSI 10 98% 95.2%
VI - Mikrogen 50 90% 95.6%
Drobeniuc J et al., Clin Infect Dis 2010; 51:e24-7

61. Genetic relatedness among hepatitis E virus
(HEV) strains identified in hepatitis E cases,
United States

62. Active Laboratory-based
Surveillance (ongoing)
 Confirmatory testing referral of all anti-HEV
screening-positive specimens from >40 diagnostic
laboratories
 Sep 2009 – Aug 2012
– De-duplicated and analyzed n=829
– Hepatitis E (IgG & IgM anti-HEV+) n=227 (27.4%)
 HEV PCR and genotyping - Underway
– Males 53%
– Median age 50 yr (3-94)
 >51 yr 44%
 Risk factors assessment is ongoing

63. Hepatitis E Virus Infection in
HIV-infected Persons
 To determine whether hepatitis E virus (HEV) is a
cause of hepatitis among HIV-infected persons, we
evaluated 1985–2009 data for US military
beneficiaries.
 Evidence of acute HEV infection was detected for 7
(4%) of 194 people with HIV infection.
– Prior HEV infection was detected in 5 (3%).
 HEV might be a cause of acute hepatitis among
HIV-infected persons.
Crum-Cianflone N et. al. Emerging Infectious Diseases 2012;18: 502-506

64. What is the National
Seroprevalence of anti-HEV?
● Kuniholm et al* tested a nationally
representative sample of 18,695 serum
samples from the US population for anti-HEV
IgG antibodies using a research (non-
commercial) enzyme immunoassay
● Serum from NHANES, 1988-1994, showed,
overall, 21% anti-HEV IgG
* Kuniholm et al, J Infect Dis 2009; 200:48-56

65. Comparison of NHANES III and IV
1988-94 (N= 18,695)
2009-2010 (N= 7885)
0
5
10
15
20
25
30
35
40
45
6-11
yo
12-19
yo
20-29
yo
30-39
yo
40-49
yo
50-59
yo
60-69
yo
70+
yo
1988-1994
2009-2010

66. Conclusion
 Hepatitis E indigenous to the United States is more common
than previously thought, especially among middle-aged males
 Hepatitis E virus infects organ transplant recipients and
immuno-compromised individuals leading to chronic infection
 Hepatitis E should be considered in the differential diagnosis
of suspected viral hepatitis regardless of the patient's travel
history
 Decrease in sero-prevalence of HEV infection over last 20
years requires further investigation
 The health-burden it imposes, and the role of autochthonous
transmission of genotype 3 HEV strains merits further
investigation

67. Thank You!
Email: jdrobeniuc@cdc.gov
http://www.cdc.gov/hepatitis