2. Hepatitis: Inflammation of the liver, characterized by the
presence of inflammatory cells in the tissue of the organ
VIRAL HEPATITIS: Infection of liver caused by
hepatotropic viruses
Hepatitis viruses A, B, C, D, andE
Cytomegalovirus, Epstein–Barr
virus, Yellow fever virus
3.
4.
5. Hepatitis: Global burden of disease
About 1 million people die each year from causes related to viral
hepatitis (2.7% of all deaths)
An estimated 57% of liver cirrhosis and 78% of primary liver cancer
are due to HBV or HCV infection
HBV related disease:
About 2 billion people have been infected
About 600 000 people die each year
HCV related disease:
About 150 million people are chronically
infected with HCV (about 10 times higher than
HIV estimates)
More than 350 000 people die each year
WHO (2013). Media Centre. Hepatitis C Fact Sheet No 164. UpdatedJuly 2013;
WHO (2013) Media Centre. Hepatitis B Fact sheet No 204. Updated July 2013.
WHO (2013). Immunization, Vaccines and Biologicals.Hepatitis.
6. Hepatitis B and C: WHO European Region
Hepatitis B and C each is estimated to affect up to 2% of the
population in the Region
13.3 million people living with chronic hepatitis B, 15
million with chronic hepatitis C
Together, they cause over 120 000 deaths per year
Two-thirds of infected persons live in eastern Europe and central
Asia
Co-infection of HCV and HIV is common, especially among people
who inject drugs
Only 1 in 5 persons exposed to the hepatitis B and C virus develops
acute symptoms,but chronic infection is common
Hope VD et al. (2013). Prevalence and estimation of hepatitis B and C infections in the WHO
European Region: a review of data focusing on the countries outside the European Union and
the European FreeTrade Association
WHO Regional Office for Europe. Hepatitis.
Hope VD et al. (2013). Prevalence and estimation of hepatitis B and C infections in the WHO European Region: a
review of data focusing on the countries outside the European Union and the European FreeTrade Association
WHO Regional Office for Europe. Hepatitis. . www.euro.who.int/hepatitis
.
7. Self limiting disease No evidence of chronic disease
Average incubation period of 28 days ( 15 – 50 days)
Nonspecific constitutional signs, symptoms( usually last 2 months)
No evidence of chronic liver disease or persistent infection
Rare cause of Acute liver failure 6.8% of all ALF cases(US)
8. HAV: Structure
Virus:
Genus –Hepatovirus, Picornaviridae family
Nonenveloped ,single stranded RNA virus
27- 32 nm diameter,Icosahedral symmetry
Unlike other members of the family
Requires a long adaptation period to grow
in cell culture:Replicates slowly
Rarely produces a cytopathic effect
More resistant to heating and chlorine
inactivation
Seven genotypes with unique geographical
distribution
Only a single serotype of HAV exists
9. HAV Viral markers: IgM anti- HAV
Has been used as the primary marker of acute
infection
Comprised mainly of antibodies against capsid
proteins
Positive at the time of onset of symptoms
Usually accompany the first rise in the alanine
aminotransferase (ALT) level
10. HAV Viral markers: IgM anti- HAV
Methods used:
Radioimmunoassay
Immunochemical staining
Enzyme-linked immunosorbent assay
Immunoblotting
Dot blot immunogold filtration
Remain positive for 3-6 months after the primary
infection and for as long as 12 months in 25% of
patients
11. HAV Viral markers: IgG anti- HAV
Appears soon after IgM and generally persists for many
years
The presence of anti-HAV IgG in the absence of IgM
indicates past infection or vaccination rather than acute
infection
IgG provides protective immunity
Antibodies to structural proteins are produced following
immunization with hepatitis A vaccine
A small proportion (8to 20%) of vaccinated persons have a transient IgM anti-
HAV response
IgG anti-HAV is produced by all successfully immunized persons
Commercially available tests for total anti-HAV are not sensitive enough to
detect antibody concentrations in a significant proportion of immunized
persons
12. HAV Viral markers
IgG and IgA anti-HAV are also detected in saliva,
urine, and and feces
Saliva tests have been reported as an alternative to
conventional serum testing as a screening tool in
outbreak investigations and epidemiological studies
However, the sensitivity of detecting anti-HAV in
saliva is 1 to 3 log10 units lower than that with serum
13. HAV Viral markers: Molecular diagnosis
Viremia occurs within 1 to 2 weeks after HAV exposure
and persists through the period of liver enzyme elevation
HAV RNA detection is the most sensitive technique for
screening clinical specimens(serum, plasma, saliva, fecal
suspension and environmental samples)
Can be detected in blood earlier than antibodies
Viremia may be present for a much longer period during the
convalescent phase
Serum: 102 to 105 copies/ml
Stool: High viral load(2 to 3 log10 units higher than
serum),detected until 81 and 90 days
Saliva: 1 to 3 log10 units lower than that found in serum
14. HAV Viral markers: Molecular diagnosis
Patients with severe infection: Higher initial
viral load than patients with less severe
infection
The molecular diagnosis of hepatitis A is not
used in clinical laboratories and blood banks,
as is currently done for HIV, HBV and HCV
infections
15.
16. Belongs to Hepadnavirus family : Dane
particle
Outer lipid envelope : Embedded
proteins involved in viral binding
Nucleocapsid : Encloses the viral DNA
8 genotypes, 4 serotypes
17. Genotype A,D : USA, Europe
B,C : Asia
A,E,G: Africa
Genotype B : less severe
disease,less HCC than
Genotype C
18. Serology for HBV:
Antigen Antibodies
Hepatitis B Surface
Antigen (HBsAg)
Antibody to Hepatitis B Surface
Antigen (Anti HBs)
Hepatitis B Core Antigen
(HBcAg)
Antibody to Hepatitis B Core
Antigen (Anti HBc IgM & Anti
HBc)
Hepatitis B ‘e’ Antigen
(HBeAg)
Antibody to Hepatitis B ‘e’
Antigen (Anti HBe)
19.
20. 1st virological marker
detectable in serum usually
between 8th and
12th weeks of infection
It preceeds elevation of
aminotransferase
activity and clinical
symptoms by 2-6
weeks
It remains elevated
during the entire icteric
or symptomatic phase
of the disease.
Typically, it disappeares
1-2 months after the
onset of jaundice and
rarely persists beyond 6
months.
Hepatitis B
Surface antigen
(HBsAg)
21. AASLD: Chronic Hepatitis B is defined as
HBsAg positivity for more than six months
Chronic HBV Infection
22. Strategies for
prevention of HBV is
based on providing
susceptible persons
with anti HBs
The
protective
antibody
Anti HBs
HBsAg prepared
by recombinant
DNA technology
Almost indefinite protection
Booster required after 5 yrs
Hepatitis B surface antibody (Anti HBs)
23.
24. Hepatitis B core antigen
Expressed on the surface of the nucleocapsid
core Not secreted and remains within
hepatocytes
Anti HBc IgM
First antibody to appear
Indicates acute HBV infection
May be the only marker in core window
Anti HBc IgG: Persists along with
Anti HBs in patients who recover from acute infection
HBsAg in patients who progress to chronic HBV infection
25.
26. HBeAg
Secreted into
the circulation
Not essential for
replication in vivo
Accessory
protein of HBV
An index of viral
replication,
infectivity, severity
of disease, and
response to
treatment
High probability of
progression to a chronic
carrier state when
HBeAg persists longer
than 12 weeks
Pregnant women
withHBeAg positive
have a risk of
transmission of virus to
fetus is > 90%.
Hepatitis B e antigen
27. Hepatitis B e antibody (Anti Hbe)
Detectable when HBeAg disappears (12 -16 wks)
HBeAg is a marker of replicative infection
Seroconversion to Anti HBe indicates resolution of
infection( switch from active state to inactive carrier
state)
HBeAg seroconversion is an important therapeutic
milestone and goal
28.
29. HBV DNA
Directproduct & hallmarkof infection Measure of virus
replication in the liver and infectivity
Liverdiseaseprogression intrinsically linked to extent of viral replication
Clinicalapplication:
Management of HBVcarriers
Identify of diseaseprogression
Selectcandidatesfor antiviraltherapy
Guidetreatment with nucleoside/nucleotideanalogues
Loss of detectable HBV DNA is an earlier indicator of response to
antiviral therapy than loss of HBeAg
35. About 180 million people are infected
with hepatitis C virus 3 percent
of global population
3-4 million people become infected
with HCV annually
About 25 million people are infected
in Europe
HCV prevalence 5 times exceeds HIV
prevalence
36. Infection remains chronic in 70-85% of infected individuals.
In 20-40% cases ,Chronic hepatitis C infection leads to end stage
liver diseases: Cirrhoses, hepatocellular carcinoma and liver failure
after 20-30 years of infection
37. Anti HCVAnti HCV HCV RNA
qualitative and quantitative
HCV RNA
qualitative and quantitative
Serologic and virologic markers of HCV infection
38. Major laboratory methods for HCV diagnosis:
1984- ELISA
1985 -Western blot
1995 -Qualitative and quantitative PCR
2003 -HCV genotyping
2007- HCV quantit. test (using Real Time PCR)
2010 -HCV NS5B and 5’UTR/Core region sequencing
39. HCV : Antibody testing
Indicated for standard testing/ screening
A negative test rules out chronic infection
Techniques
EIA : Most sensitive
Rapid Immunoassay tests: PoC testing
Recombinant Immunoblot assay
No further testing indicated
40. HCV : RNA assays
Indicated for confirming presence or absence
of infection, monitor response to treatment
Not a measure of severity of disease
Techniques
PCR based methods: Detect RNA at 25 IU/ml
TMA based methos: Detect RNA at 10 IU/ml
Signal amplification technology: Technically
easier, less sensitive ( Detect RNA at 615 IU/ml)
41. Quantitative tests : Used before treatment to
measure baseline viral load and to assess on
treatment response to therapy
Qualitative tests: Capable of detecting low
levels of HCV RNA
Indicated for confirming the diagnosis
48. Interpretation ofHCV
assays
Anti HCV HCVRNA interpretation
+ + Acute or chronic HCVdepending
upon clinical context
+ -- Resolution of HCV
-- + Early acute HCV,chronic HCVin
immunosuppressed states
-- -- Absenceof HCV
49.
50. VIRION: Defective virus which shows
similarities with the viroids in plants
Spherical, Consists of a particle 35
nm in diameter consisting of the
delta antigen surrounded by an
outer coat of HBsAg
HBV capsid
HDV nucleoprotein
NUCLEIC ACID: (-) ss RNA, circular
Satellite virus : replicates only in
the presence of HBV
51. 63
Consequences of hepatitis B and delta virus infection
Low risk of chronic infection
Severe acute disease
Usually develop chronic infection
High risk of severe CLD
May present as an acute hepatitis
52. Presence of HBsAg is necessary for diagnosis
of HDV infection
Additional presence of IgM anti HBc is
necessary for diagnosis of acute HBV/HDV
coinfection
53. Anti HDV antibody
Total anti HDV antibody
Appears after four weeks of acute infection
Repeated testing required
May be the only way to diagnose acute HDV infecton
IgG anti HDV
High titre present in chronic infection
Correlates well with ongoing HDV replicationAdditional presence
of IgM anti HBc is necessary for diagnosis of acute HBV/HDV
coinfection
IgG anti HDV
Rarely used ,not approved for clinical use
54. HDVAg
Acute Infection: Appears early
Detection by EIA is short lived
Chronic Infection: Present in high titres
Serum HDV RNA
Can be detected by RT-PCR based assays
May detect viral loads of as low as 10 genomes/ml
Primary end point of treatment: Suppression of HDV RNA
55.
56.
57.
58. Calicivirus-like viruses
Unenveloped RNA virus, 32-34nm in diameter
+ve stranded RNA genome, 7.6 kb in size
Very labile and sensitive
59.
60.
61. Anti HEV IgG
Appears shortly after IgM response
Titre increases throughout the acute phase
into convalescent phase
Discordance between assays present
Anti HEV IgM
Appears during the early phase of clinical
illness Disappears rapidly over four to
five months
Low sensitivity
62. HEV RNA assay
Stool:
Detected approximately one week before the onset of illness
Can persist as long as two weeks thereafter
Serum:
Detected two to six weeks after infection
Can persist for two to four weeks in those who resolve acute
infection
Primary end point of treatment: Disappearance of RNA
63. A LT IgG anti-
H E V
Ig M a n ti-
H E V
V ir u s in
s t o o l
Typical Serologic Course
Symptoms
Titer
0 1 2 3 4 5 6 7 8 9 10 11 12 13
Weeks after Exposure