VIRAL HEPATITIS

Viral hepatitis may be defined as infection of the liver caused by any of the following
viruses.

Causative Agents;
. Hepatitis A Virus (HAV), Hepatitis B virus (HBV) , C, D, E and G are recognized
as aetiological agents of viral hepatitis.
It is known that many other viruses may be implicated in hepatitis such as
cytomegalovirus, Epstein-Barr virus, yellow fever virus and rubella virus.
Viruses of herpes simplex, varicella and adenoviruses can also cause severe
hepatitis in immuno-compromised individuals, but are rare.

HEPATITIS A
Hepatitis A (formerly known as "infectious" hepatitis or epidemic jaundice) is an
acute infectious disease caused by Hepatitis A Virus (HAV).
The disease is heralded by nonspecific symptoms such as fever, chills, headache,
fatigue, generalized weakness, aches and pains followed by anorexia, nausea,
vomiting, dark urine and jaundice.
The disease spectrum is characterized by the occurrence of numerous sub clinical
or asymptomatic cases. The disease is benign with complete recovery in several
weeks. The case fatality rate of icteric cases is less than 0.1 per cent, usually from
acute liver failure and mainly affects older adults.

Agent factors
AGENT:
The causative agent, the hepatitis A virus, is an entero virus (type 72) of the Picornaviridae family. It
multiplies only in hepatocytes. Faecal shedding of the virus is at its highest during the later part of the
incubation period and early acute phase of illness. Only one serotype is known,
RESISTANCE:
The virus is fairly resistant to heat and chemicals. It has been shown to survive more than 10 weeks
in well water
It withstands heating to 60 deg C for one hour, and is not affected by chlorine in doses usually
employed for chlorination.
Virus Disinfection
Formalin is stated to be an effective disinfectant. The virus is inactivated by ultraviolet rays and by
boiling for 5 minutes or autoclaving.

RESERVOIR OF INFECTION:
The human cases are the only reservoir of infection. The cases range from asymptomatic infections to
severe ones. Asymptomatic (anicteric) infections are especially common in children. These cases play
an important role in maintaining the chain of transmission in the community. There is no evidence of a
chronic carrier state

PERIOD OF INFECTIVITY:
The risk of transmitting HAV greatest from 2 weeks before to 1 week after the onset jaundice. Infectivity
falls rapidly with the onset of jaundice
 INFECTIVE MATERIAL:
It is mainly man's faeces. Blood serum and other fluids are infective during the brief stage viraemia.
VIRUS EXCRETION:
HAV is excreted in the faeces for about 2 weeks before the onset of jaundice and up to one week
thereafter. The virus may also be excreted in urine

Host factors
AGE:
Infection with HAV is more frequent among children than in adults. However, susceptible people
from all ages may be infected . In young children, infections tend to be mild or sub clinical; the clinical
severity increases with age.
SEX:
Male and female, both sexes are equally susceptible,
IMMUNITY:
Immunity after attack probably lasts for life; second attacks have been reported in about 5 per cent
of patients. Most people in endemic areas acquire immunity through sub-clinical infection The IgM
antibody appears early in the illness and persists for over 90 days. IgG appears more slowly, and
persists for many years.

Environmental factors
Cases may occur throughout the year .The disease tends to be associated with periods of heavy
rainfall Poor sanitation and overcrowding favors the spread of infection giving rise to water-borne and
food-borne epidemics.

Modes of transmission
FAECAL -ORAL ROUTE:
This is the major route of transmission. It may occur by direct (person-to-person contact or
indirectly by way of contaminated water, food and milk. Water-borne transmission is not a major factor
in developed countries, where food-borne outbreaks are becoming more frequent.
Direct transmission comprises contaminated hands or objects such as eating utensils. Direct
infection occurs readily under conditions of poor sanitation and overcrowding.
PARENTERAL ROUTE: Hepatitis A is rarely, if ever, transmitted by the parenteral route (i.e., by
blood and blood products or by skin penetration through contaminated needles). This may occur during
the stage of viraemia. This mode of transmission is of minor importance.
SEXUAL TRANSMISSION: As a sexually transmitted infection hepatitis A may occur mainly
among homosexual men because of oral-anal contact

Incubation period
15 to 45 days (usually 25 to 30 days). The length of the incubation period is proportional to the dose
of the virus ingested.

Diagnosis
A specific laboratory diagnosis of hepatitis A can be obtained by
a. Demonstration of HAV particles or specific viral antigens in the faeces
b. Demonstration of a rise in anti-HAV titer
c. Detection of IgM antibody to HAV in the patient's serum. This antibody appears
 early in the illness, and persists for a limited time, usually for 3 to 4 months
after onset; IgG antibody indicates past infection and immunity.

Prevention and containment

. Control of reservoir:
Control of reservoir is difficult because of the following factors:
(a) Faecal shedding of the virus is at its height during the incubation period and early
phase of illness
(b) The occurrence of large number of sub clinical cases in the community.
(c) Absence of specific treatment, and
(d) Low socio-economic profile of the population .
Strict isolation of cases is not a useful control measure because of (a) and (b).
Usual control measures such as notification, complete bed rest and disinfection of
faeces and fomites should be done. The use of 0.5 per cent sodium hypochlorite has been
strongly recommended as an effective disinfectant
Control of transmission:
The best means of reducing the spread of infection is by promoting simple measures of
personal and community hygiene, e.g., hand washing before eating and after toilet; the
sanitary disposal of excreta which will prevent contamination of water, food and milk

Control of susceptible population:

HUMAN IMMUNOGLOBULIN
. It is recommended for
(a) Susceptible persons traveling to highly endemic areas,
(b) Close personal contacts of patients with HAV,
(c) For the control of outbreaks in institutions
. Vaccines:

Several inactivated or live attenuated vaccines against hepatitis A have been

developed, but only 4 inactivated hepatitis A vaccines are currently available
internationally
 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 characterized by a tendency to a long incubation period (6 weeks to
6 months) and a protracted illness with a variety of outcomes.
Persistent HBV infection may cause progressive liver disease including chronic
active hepatitis and hepatic-cellular carcinoma.

Agent factors
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.
Hepatitis B virus Antigens;
It has three distinct antigens - a surface antigen, also known as "Australia
antigen" (HBsAg), a core antigen (HBcAg), and an "e" antigen (HBeAg). They
stimulate the production of corresponding antibodies

RESERVOIR OF INFECTION:
Man is the only reservoir of infection which can spread either from carriers or
from cases.
The carriers of the virus, estimated to number over 350 million world-wide. The
persistent carrier state has been defined as the presence of HBsAg for more than 9
months
Cases may range from in apparent to symptomatic cases. The risk of an adult
becoming a carrier following acute infection is 5 to 10 per cent; in infants, it may exceed
50 per cent
INFECTIVE MATERIAL:
Contaminated blood is the main source of infection, although the virus has been
found in body secretions such as saliva, vaginal secretions and semen of infected persons.
RESISTANCE:
The virus is quite stable and capable of surviving for days on environmental surfaces.
It can be readily destroyed by sodium hypochlorite, by heat sterilization in an autoclave
for 30 to 60 minutes.
PERIOD OF COMMUNICABILITY:
The virus is present in the blood during the incubation period (for a month before
jaundice) and acute phase of the disease. Period of communicability is usually several
 months (occasionally years in chronic carriers) or until disappearance of HBsAg and
appearance of surface antibody.
Host factors
AGE
(a) In countries, where infection with HBV is common, much infection occurs
perinatally or during early childhood
(b) HIGH RISK GROUPS :
Certain groups carry higher risks. For example, in USA, the annual incidence of
HBV infection in surgeons is estimated to be 50 times greater than that in the general
population, and is more than twice that of other physicians. Other high risk groups
comprise recipients of blood transfusions, health care and laboratory personnel,
homosexuals, prostitutes, and percutaneous drug abusers, infants of HBV carrier
mothers and patients who are immuno-compromised. Serological screening and
vaccination of high-risk groups is highly recommended,
(c) HUMORAL AND CELLULAR RESPONSES:
Antibodies form in a week or two after onset of jaundice - the order of being
produced is , first core antibody, then "e" antibody and much later surface antibody.
The appearance of surface antibody signals recovery from HBV infection and the
development of immunity.
Routes of Transmissions

Parenteral Route;
The main route of HBV transmission is through parenteral route. For that is
more common in persons exposed to body puncture by needles.
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
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:
A, 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 bed
B, Transmission by blood sucking arthropods (e.g., mosquitoes, bed bugs) is
suspected, but there is no convincing evidence to support this suggestion
Incubation period
45 to 180 days. Lower doses of the virus result often in longer incubation period.
The median incubation period is said to be lower than 100 days
Clinical picture
The symptoms and manifestations of hepatitis B are similar to those of the other
types of viral hepatitis. But the picture is complicated by the carrier state and by
chronic liver disease, which may follow the infection. Chronic liver disease may be
severe, and may progress to primary liver cancer which, in some parts of the world, is
one of the commonest human cancers, particularly in men

PREVENTION AND CONTAINMENT

Since there is no specific treatment, prevention has been the major aim in managing viral hepatitis B.
The following measures are available:
. Hepatitis B vaccine
(i) PLASMA DERIVED VACCINE: This is based on the surface antigen (HBsAg) which is
harvested and purified from the plasma of human carriers of hepatitis B virus. The final vaccine is a
formalin inactivated sub-unit viral vaccine for intramuscular injection. Each 1.0 ml dose of the vaccine
contains 20 micrograms of hepatitis surface antigen formulated in an alum adjuvant. The vaccine is
given in 3 doses at 0, 1 and 6 months. An effective antibody response is generally attained after 3 doses
in 95 per cent of vaccinees. Immunity continues at protective levels for approximately 3-5 years.
Booster doses may be given after 3-5 years.
TABLE 1

Hepatitis B vaccine: Immunization schedule

1st dose 1 ml at elected date
2nd dose 1 ml 1 month later
3rd dose (booster) 1 ml 6 months after the
first dose
Children under 10 years of age should be given half of
above dosage at the same time intervals

Hepatitis B immunoglobulin (HBIG)

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

Passive-active immunization
Simultaneous administration of HBIG and hepatitis B vaccine is more efficacious
than HBIG alone. HBIG does not interfere with the antibody response to the hepatitis B
vaccine. ; Combined procedure is ideal.
 Other measures
Blood Screening
The blood donors should be screened for HBV infection, and serum positive for
Australia antigen should be rejected, voluntary blood donation should be encouraged
because purchased blood has shown a higher risk of post-transfusion hepatitis
Health Specific Measures
Health personnel should be emphasized to the importance of adequate sterilization of
all instruments and simple hygienic measures. Disposable syringes should be used
The Dentist should very much careful about sterilization.
Cosmetic Measures
The Equipment and materials used for puncturing the body, tattooing, ear and nose
and genetalia puncturing should be properly sterilized.

General Measure

Each and every persons and especially carriers should not share razors or tooth
brushes and use barrier methods of contraception.
The carriers should not donate blood.

HBV

Hepatitis B is similar to hepatitis A in its symptoms, but is more likely to cause chronic
long-term illness and permanent damage to the liver if not treated.
How hepatitis B is spread

The hepatitis B virus (HBV) is very common worldwide, with more than 350 million
people infected. Those with long term HBV are at high risk of developing liver cirrhosis
or liver cancer.

Hepatitis B is most frequently passed on through the exchange of bodily fluids with an
infected person. HBV is estimated to be 50 to 100 times more infectious than HIV.
 HBV can be spread in the following ways:
by unprotected (without a condom) penetrative sex (when the penis enters the anus,
vagina or mouth) with someone who is infectious. Also by sex that draws blood with
someone who is infected.
by sharing contaminated needles or other drug-injecting equipment.
by using non-sterilised equipment for tattooing, acupuncture or body piercing.
from an infected mother to her baby, most commonly during delivery. Immunisation of
the baby at birth prevents the transmission of hepatitis B.
through a blood transfusion in a country where blood is not screened for blood-borne
viruses such as HBV.

Hepatitis B cannot be spread through sneezing, coughing, hugging or coming in

contact with the faeces of someone who is infected.
Signs and symptoms of hepatitis B

Many people who become infected with HBV experience mild symptoms or no
symptoms at all, but they may still carry the infectious virus and pass it on to others.
When symptoms do appear they are similar to those of hepatitis A and may include:
a short, mild, flu-like illness.
nausea, vomiting and diarrhoea.
loss of appetite.
weight loss.
jaundice (yellow skin and whites of eyes, darker yellow urine and pale faeces).
itchy skin.

If symptoms become severe then a person with hepatitis B may be admitted to hospital.

Most adults infected with the hepatitis B virus fully recover and develop life-long
immunity. Between 2% and 10% of individuals infected as adults will become chronic
carriers, which means they will be infectious to others and can develop chronic liver
damage. Infected children, especially newborn babies, are much more likely to become
chronic carriers.

If a person lives with hepatitis B infection for a number of years then they may
develop the following complications:
chronic hepatitis.
liver cirrhosis.
liver cancer.
Where to go for help
 If you have any symptoms or you are worried you may have been infected with
hepatitis B, you should discuss your worries with a doctor. They may be able to run tests
themselves, or else will refer you to someone who can.

Some countries have specific sexual health clinics that can help you directly.
What does a positive test result mean?

A positive test result could indicate either of the following:

A past infection. This means the patient has already been in contact with hepatitis B
and their immune system has succeeded in fighting off the virus. The patient will then
have a natural immunity to the virus.
The patient is a carrier. This means the patient is carrying HBV and can pass it on to
others. The person may not display any symptoms but could be at risk of developing
chronic liver disease.

A doctor may perform a number of different types of test to distinguish between

current and past infections, and to estimate how infectious a patient with a current
infection may be.
What does a negative test result mean?

This result generally means the patient has never been infected with HBV and
therefore has no natural immunity against the virus. If the person suspects they may have
been recently exposed to HBV, the doctor may advise them to take a repeat test to
confirm their negative status, and may also advise immunisation against hepatitis B.
Treatment

In most countries a patient with a positive test result will be referred to a specialist who
will carry out further tests to determine the degree to which hepatitis B may be affecting
the liver, and what may be the best treatment options. In these tests a small sample of
liver tissue may need to be taken (a liver biopsy).

In the majority of patients with active HBV, symptoms will not be severe and treatment
will not be required. The patient will be monitored and after a few months the patient’s
immune system should fight off the virus, giving the patient natural immunity.

In around 5% of adults, 30-50% of young children (aged 1-4), and 90% of infants,
HBV infection will become chronic. The virus is more deadly to the young and those that
are infected at birth have a 25% chance of developing a life-threatening liver-related
illness.

Antiviral medication is given as treatment to those with chronic symptoms to help

prevent further liver damage. These medications may be injected or given in pill form.
Examples are Interferon Alpha, Lamivudine and Baraclude. Treatment usually lasts 6
months, during which the patient will be carefully monitored.
 Regardless of whether the infection is producing symptoms or not, the patient will be
advised to avoid alcohol, get plenty of rest and maintain a healthy diet.
Immunisation

Three immunisation injections are given over a period of 3-6 months. A blood test is
taken once the course of injections is completed to check that they have worked.
Immunity should last for at least 5 years.
Follow-up

A patient with an active infection will be advised to have regular blood tests and
physical check-ups to monitor the virus, even if they are not receiving treatment. All
carriers of HBV should expect to be referred to specialist services.

The doctor or nurse may advise the patient to avoid alcohol, fatty foods and follow a
low-salt diet. They will also describe any precautions necessary to ensure that the patient
avoids infecting others with the virus, such as not sharing toothbrushes or shaving
equipment.

It is most important to use a condom for penetrative sex to prevent passing on the
virus. Sexual partners of the patient should be tested and immunised against HBV (if not
already infected).

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