This document discusses occupational exposure to bloodborne viruses such as hepatitis B, hepatitis C, and HIV among healthcare workers. Healthcare workers are at risk of contracting serious viral infections through needlestick injuries or contact with infected bodily fluids. Vaccination and proper post-exposure management are important for preventing transmission of bloodborne viruses. Professionals with frequent occupational exposure include emergency room staff, surgeons, dentists, and those working in dialysis units or blood banks.

1. VIRAL HEPATITIS
HCV & HEV
Dr. Aashish Choudhary
MD (AIIMS)
Assistant Professor
Virology Lab.
Department of Microbiology
18 August 2015

2. Viruses causing hepatitis
• Viral hepatitis - by hepatotropic viruses
- HAV, HBV, HCV, HDV and HEV
• Hepatitis by other (non-hepatotropic) viruses
- usually occurs as a part of systemic involvement
- Human cytomegalovirus (HCMV)
- Epstein-Barr virus (EBV)
- Herpes simplex viruses (HSV) 1&2
- Varicella-Zoster virus (VZV)
- Measles virus
- Adenovirus etc.

3. A
“Infectious”
“Serum”
Viral hepatitis
Enterically
transmitted
Parenterally
transmitted
E
NANB
B D C
Viral Hepatitis - Historical Perspectives

4. HAV HBV HCV HDV HEV
Family Picornaviridae Hepadnaviridae Flaviviridae Delta agent
(satellite virus)
Hepeviridae
Nucleic acid ssRNA dsDNA ssRNA ssRNA ssRNA
Routes of
transmission
Fecal-oral Parenteral Parenteral Parenteral Fecal-oral
Chronic hepatitis No Yes Yes Yes No
(Yes- HEV genotype 3)
Oncogenic
potential (HCC)
No Yes Yes - No
Vaccine available Yes Yes No HBV vaccine is
protective
(Recently finished
trials)
Viruses causing hepatitis - an overview

5. Viral hepatitis - various clinical presentations
• Acute viral hepatitis (AVH)
• Chronic viral hepatitis - Chronic hepatitis B (CHB)
- Chronic hepatitis C (CHC)
• Transaminitis
• Acute liver failure (ALF), Fulminant hepatic failure (FHF)
• Acute-on-chronic liver failure (ACLF)
- acute (precipitating) event on an underlying chronic liver disease (CLD)
↓ ↓
• Alcoholic liver disease (ALD)
• Chronic hepatitis B (CHB)
• Chronic hepatitis C (CHC)
• Non-alcoholic fatty liver disease (NAFLD)
• Drug induced liver injury (DILI)
• Autoimmune hepatitis (AIH)
• Cryptogenic liver disease
• Acute viral hepatitis by HAV
• Acute viral hepatitis by HEV
• Acute viral hepatitis/reactivation (HBV)
• Super-infection with HDV
• Drug induced liver injury (DILI)

6. HEPATITIS C VIRUS
(HCV)

7. HCV
• Family Flaviviridae
• Genus Hepacivirus
• enveloped, 30-60 nm diameter
• ss RNA, +ve sense
• transmission - blood exposure
• 6 genotypes (1 to 6)
• commonest indication for liver transplantation worldwide

8. HCV Epidemiology - Global
• globally significant viral pathogen
• estimated global sero-prevalence - 3% of the world population
• translates to >180 million people worldwide
• developed world
- 0.6 to 2.2%
• developing world
- 0.8 to 6.5%

9. HCV Epidemiology - India
• seroprevalence ≈ 0.9% (0.5 to 2%)
• higher in certain populations
- professional blood donors
- injection drug users

10. HCV Genotypes
• HCV - 6 genotypes
• nomenclature - 1,2,3,4,5 and 6
• sub-genotypes
• India
HCV
Genotype
%
1 31
2 <1
3 63
4 5
5 <1
6 2

11. Routes/Modes of transmission
• injection drug use (IDU)
• unsafe therapeutic injections
• blood transfusion
• invasive medical procedures - surgery, dental procedures, dialysis
• occupational (needle stick injury)
• other routes - tattooing
- body-piercing
- ritual scarification
• unlikely routes - peri-natal
- sexual

12. HCV replication

13. HCV genome
- 9.6 kbp coding for about 3,000 amino acids

14. HCV - Structural proteins Functions
Core protein
(core antigen)
Forms the nucleocapsid
E 1, 2
(envelope gene proteins)
Peplomers
• E2 binds HCV receptor CD 81 on hepatocytes
• also binds - Scavenger-receptor - SR-B1
- Tight junction proteins - Claudin-1, Occludin
• good target for development of antiviral molecules that block HCV entry

15. HCV
Non-Structural (NS) proteins
Functions
NS 2 Cysteine protease
NS 3 Serine protease, RNA helicase
NS 4 A Serine protease cofactor
NS 4 B Membrane alterations
NS 5 A Phosphoproteins
NS 5 B RNA dependent RNA polymerase

16. HCV - natural course
HCC
Decompensatedcirrhosis
HCV exposure
Acute HCV infection
Symptomatichepatitis
(≈ 15%)
Asymptomaticinfection
(≈ 85%)
Chronic infection
Chronic Active
Hepatitis
Cirrhosis
over 20 years
60% 85%
Spontaneous
clearance
Spontaneous
clearance
40% 15%

17. HCV - recovery vs. chronic infection

18. Persons for whom HCV screening is recommended

19. HCV - Laboratory diagnosis
1. Antibody detection (Serology): ELISA/CLIA/RIBA
- Anti-HCV (persist for many years, possibly life)
3. Antigen detection:
- HCV Core Ag (positive between 3 to 6 wks. approx.)
2. Molecular assays: for detection of HCV RNA
- Reverse transcriptase PCR (RT-PCR)
4. HCV Genotyping

20. Anti-HCV - ELISA generations
ELISA core E1,
E2
NS1 NS2 NS3 NS4 NS5 Sensitivity
(%)
Specificity
(%)
1st generation - - - - - c100-3 - 60-80 30-60
2nd generation c22-3 - - - C200,
HC-31
C200,
HC-31
- 92-95 88-95
3rd generation c22p - - - c33c c100-3,
5-1-1p
NS5 97-99 99-100

21. HCV assays - Interpretation
Anti-HCV HCV RNA
(plasma/serum)
Interpretation(s)
+ +
+ -
- +
- - Absence of CHC infection
Hepatitis C infection - acute/chronic
1. Recovery from HCV
2. False positive serology result
1. Early acute HCV infection
2. Chronic HCV in an immunocompromised host

22. HCV - Management of CHC
• symptomatic treatment
• Pegylated IFN-α + Ribavirin combination - standard of care
- genotypes 1 & 4- for 48 wks.
- genotypes 2 & 3- for 24 wks.
• Newer antivirals - Telaprevir, Boceprevir - esp. for genotype 1
• Liver transplantation (LDLT, Cadaveric LT)

23. Anti-virals for HCV
Agent Mechanism of action
Interferon-α Specific interruption of IRES-directed HCV translation ,
Immunomodulation
Ribavirin Inhibition of cellular IMP dehydrogenase,
Inhibition of NS5B-encoded RNA dependent RNA polymerase
Boceprevir,Telaprevir,
Simeprevir, Danoprevir
NS3/4 serine protease inhibition
Sofosbuvir Nucleo(t)ide NS5B polymerase inhibition
Daclatasvir NS5A inhibition
Miravirisin Micro-RNA-122 (miR-122) sequestration and inhibition of its interaction
with host targets
Alisporivir Disruption of NS5A cyclophilin interaction
Tegobuvir Nonnucleoside NS5B polymerase inhibition

24. HEPATITIS E VIRUS
(HEV)

25. HEV - Introduction
• Family- Hepeviridae; Genus- Hepevirus
• virion- 27-34 nm, non-enveloped
• ssRNA, positive sense
• 7.2-kb genome
• 4 genotypes- HEV1,2,3 and 4
• one serotype

26. Discovery of HEV
• 1983- Balayan MS successfully transmitted the disease into himself
• oral administered pooled stool extracts of 9 patients
• developed acute viral hepatitis
• demonstrated virus particles in his own stool by IEM

27. HEV - Global prevalence

28. HEV - Seroprevalence according to age
• Developing countries
- low in children <15 yrs.
- increases rapidly from ages 15-30 yrs.

29. HAV vs. HEV
HAV HEV
Transmission Fecal-oral Fecal-oral
Age at presentation of AVH First decade of life;
≤ 10 - 15 yrs.
Older adolescents/adults;
≥ 20 - 50 yrs.
Sero-prevalence (IgG) Anti-HAV IgG:
- ubiquitous (≈ 100%) by age 10
- protective into later life
Anti-HEV IgG:
- 20-40% in adults
- low (5-10%) before 15 yrs.
The paucity of infections (very low incidence of AVH,
low Anti-HEV IgG prevalence) in persons ≤ 15 yrs. is
unexpected for a fecal-oral pathogen where
environmental conditions facilitate such transmission.

30. HEV - Epidemiology
HEV in developing countries HEV in developed countries
Genotypes 1 and 2 3 and 4
Source of infection Humans Zoonotic (pigs are primary host)
Route of infection Fecal-oral via infected water Fecal-oral via infected pig meat,
infected water
Clinical icterus (%) during
AVH
≈40% ≈75%
Outbreaks Yes, can involve thousands of cases No
(occasional small case clusters
from point-source food outbreaks)
Person-to-person spread Very limited No
Seasonality Yes
e.g. outbreaks during monsoons
No

31. HEV - Global distribution of genotypes
• HEV has 4 genotypes- HEV1, HEV2, HEV3, HEV4

32. HEV - transmission routes

33. Delhi, 1955-1956
• 1 Dec.1955 to 20 Feb.1956
• first large outbreak of hepatitis E - later attributed to HEV (serologically)
• Jamuna river flooded its banks following monsoons
• Wazirabad water treatment plant got contaminated
by nearby sewage drains
• 29,300 cases reported
• single peak, rapid dissipation; no secondary or tertiary waves
• mortality in pregnancy- 11%
Viswanathan R. Hepatitis Frontiers, 1957

34. HEV epidemics - India
Year Region / City Population
affected (N)
Mortality,
Overall (%)
Mortality,
Pregnancy (%)
1955-56 Delhi 29,300 0.2 5/48 (11)
1960 Kharagpur 65 - -
1961 Aurangabad 865 0.3 -
1966 Siliguri 4,287 0.1 -
1975-76 Ahmedabad 2,572 2.4 -
1978 Kashmir 275 3.6 6/8 (75)
1990-91 Kanpur 79,091 0.1 13/48 (27)
2008 Shahbad (Har) 160 - -
2010 Nellore 23,915 1.3 -
Acharya SK , Natl Med J India, 2006
Vivek R, Trop Med Int Health, 2010

35. HEV genome
• 7.2-kb genome, three ORFs
• ORF 2 and 3 overlap with each other
ORFs Codes for Protein Functional domain(s)
ORF 1 Nonstructural proteins
(NS)
1,693 aa • RNA-dependent RNA polymerase
• Cysteine protease
• RNA helicase
• Methyltransferase
ORF 2 Structural (viral capsid) proteins 660 aa • Virion assembly
• Interaction with target cells
• Immunogenicity
ORF 3 Phosphoprotein 113-114 aa • Viral morphogenesis and release

36. HEV - Clinical spectrum
• Acute Viral Hepatitis (AVH)
• Acute-on-chronic liver failure (ACLF)
• Fulminant Hepatic failure (FHF) in pregnancy
• Chronic Viral Hepatitis E - in the immunocompromised
• Extrahepatic manifestations

37. HEV - Viral and lab. parameters
• AVH-E Incubation period = 4 weeks (2 weeks to 6 weeks)
Krain LJ. Clin Microbiol Rev, 2014

38. Clinical features of HEV
- comparison of developing vs. developed counties
HEV in developing countries HEV in developed countries
Genotypes 1 and 2 3 and 4
Age of infection (yrs.) 15-30 yrs. > 50 yrs.
Gender (M:F) ratio 2:1 > 3:1
Clinical course Self-limiting hepatitis in most Self-limiting hepatitis in most
Deaths in pregnant females Yes
(20-25% in 3rd trimester)
No
Chronic hepatitis E No Yes; genotype 3 only

39. HEV in pregnancy
- maternal & neonatal health
• Maternal - ↑ risk of hemorrhage, eclampsia
- Fulminant hepatic failure (FHF)
- Hepatic encephalopathy
- DIC
• Fetal - stillbirths
- vertical transmission- ↑ neonatal morbidity & mortality
• Case fatality rate (CFR)- 10-42%, usually in the 3rd trimester
• HEV genotypes 1 & 2 only Adverse outcomes are unique
to genotypes 1 & 2
(NOT genotypes 3 & 4)

40. HEV - Laboratory diagnosis
1. Antibody detection (Serology): ORF2, ORF3 peptides
- Anti-HEV IgM (persist for 2-3 mo, rarely 6 mo.)
- Anti-HEV IgG (persist for a few yrs.)
2. Antigen detection: ORF2, ORF3
- HEV Ag (positive between 3 to 6 wks. approx.)
3. Molecular assays:
- RT-PCR
4. Immune Electron Microscopy (IEM)

41. Chronic hepatitis E
• Solid Organ Transplant (SOT) recipients
- liver, kidney, kidney-pancreas, heart, lung etc.
• HIV patients
• Hematological patients - receiving chemotherapy
- Hodgkin’s ds, CML, B-cell CLL, Hairy cell leukemia etc.
• is a zoonosis- caused by HEV genotype 3 (HEV3) only
• clinical course: AVH → chronic hepatitis E → cirrhosis
(can be rapidly progressive)

42. HEV vaccines
Manufacturer Truncated
capsid
antigen
(ORF2)
HEV
genotype
used
Expressed
from
Vaccinated
population
Dose Regimen
(months)
HEV genotype
in population
tested
Efficacy
(95% CI)
GlaxoSmithKline,
Belgium
aa 112-607 HEV 1 Baculovirus
in insect cells
Military
(young
Nepalese men)
20 µg, with
alum
0, 1, 6 HEV 1 95.5%
(89% - 99%)
Xiamen Innovax
Biotech, China
aa 368-606 HEV 1 Escherichia
coli
General
(Chinese adults,
all ages)
30 µg , with
alum
0, 1, 6 HEV 4 100 %
(72%-100%)
Plotkin. Vaccines, 2013

43. OCCUPATIONAL EXPOSURE
TO BBV’s
___(HIV, HBV AND HCV)___
- NEEDLESTICK INJURY
(NSI)
Dr. Aashish Choudhary
MD (AIIMS)
Assistant Professor, Virology
AIIMS

44. Introduction
• HCW or HCP [Health care worker or personnel]
- are occupationally exposed to bloodborne pathogens
- do contract serious/chronic viral infections at their workplace
• Bloodborne viruses (BBVs) - HBV
- HCV
- HIV
• Immunization /or post-exposure management
- crucial elements in preventing BBVs

45. Occupational exposure
• percutaneous exposure
- skin has been broken by a needle or other sharp object
- needle stick injury
- cut with a scalpel blade
• mucocutaneous exposure
- contact of eyes/mouth/nose or non-intact skin with body fluids
- blood splash to the eye
• human scratch or bite

46. HIV Virus
Hepatitis B Virus (HBV)
Hepatitis C Virus (HCV)
Occupational exposure

47. Professionals with frequent occupational exposure
• staff in the ER, trauma centre, casualty
• nursing staff
• interns, medical students
• surgeons and OT staff
• obstetricians, labor room personnel
• clinical waste handlers
• lab. technicians
• physicians
• dentists
• health facility cleaning staff, mortuary staff

48. Where NSI’s occur ?
Inpatient units
Operating rooms
Emergency Department
Procedure Room

49. How NSIs occur?
During use After use and before disposal
(incl. recapping a needle)
During or after disposal After appropriate disposal

50. Risk of BBVs following NSI
BBV Risk following NSI
(%)
HBV 5 - 30
HCV 3 - 10
HIV
- percutaneous
- mucosal
0.3
0.09

51. Management of Occupational blood exposures
• provide immediate care to exposure site
• determine risk associated with exposure
• evaluate exposure source
• evaluate exposed person
• provide counseling
• give PEP (for exposures posing risk of BBV transmission)
• perform follow-up testing

52. • remove gloves
• contaminated wound - encourage bleeding
- wash with soap and water
• contaminated intact skin - wash with soap and water
• contaminated eyes - rinse open eyes with saline/water
• contaminated mouth - spit out any fluid, rinse with water
In the event of Exposure - Do’s

53. • do NOT panic
• do NOT squeeze blood from wound
• do NOT reflexively place finger into mouth, in an attempt to
suck the puncture site
• do NOT apply disinfectant (bleach, alcohol, betadine etc.)
In the event of Exposure - Dont’s

54. What are the risk factors for acquiring BBVs?
1. type of body fluid involved
- blood, serum, plasma
- any biological fluids visibly contaminated with blood
2. quantity of blood
3. type of needle/sharp
- hollow bore needles have more risk than suture needles
4. depth of injury
5. infectivity of source patient
- HBV, HCV, HIV viral load

55. Blood testing required
• in specific situations - viral load: HBV, HCV, HIV
Source [Patient] Exposed [HCW]
HBsAg HBsAg
Anti-HCV [HCV Ag-Ab] Anti-HCV [HCV Ag-Ab]
Anti-HIV 1&2 [HIV 1&2 Ag-Ab] Anti-HIV 1&2 [HIV 1&2 Ag-Ab]
Anti-HBs (titers)

56. Hepatitis B virus
(hbv)

57. Initiate HBV
vaccine series
Exposed
Order Anti-HBs (titers)
Post-Exposure Prophylaxis (PEP)
may be indicated
Exposed
Order Anti-HBs (titers)
HBV - NSI Algorithm
Source
HBsAg - Non-reactive
Source
HBsAg - Reactive
Anti-HBs (titers)
< 10 mIU/ml.
Anti-HBs (titers)
≥ 10 mIU/ml.
No further action
Exposed 0 (Baseline) 6 weeks 12 weeks 24 weeks
HBsAg √ √ √
Anti-HBs (titers) √ √ √

58. HBV - Post-exposure prophylaxis
Exposed
(Vaccination and response status)
↓
Source
HBsAg - Reactive
Completed course of HBV vaccine
Known non-responder (Anti-HBs < 10 mIU/ml.)
HBIG (1 dose) + Initiate
HBV vaccination series
OR
HBIG (2 doses)
Known responder
but Anti-HBs < 10 mIU/ml.
HBIG (1 dose) + HBV
vaccine (1 booster)
Not vaccinated for HBV
HBIG (1 dose) + Initiate
HBV vaccination series
HBIG dose - 0.06 ml/kg I.M.

59. Hepatitis C Virus
(HCV)

60. Source - Confirm HCV status, HCV RNA
Exposed - Follow up,
Refer to Hepatology
No further action
HCV - NSI Algorithm
Source
Anti-HCV - Non-reactive
(HCV RNA in specific situations)
Source
Anti-HCV - Reactive
Exposed 0 (Baseline) 6 weeks 12 weeks 24 weeks
Anti-HCV √ √ √
HCV RNA (CDC) √ √

61. Human Immunodeficiency Virus
(hiv)

62. Exposed
Post-Exposure Prophylaxis
(PEP) may be indicated
No further action
HIV - NSI Algorithm
(Pre-test and post-test counseling mandatory)
Source
Anti-HIV 1&2 - Non-reactive
(HIV RNA in specific situations)
Source
Anti-HIV 1&2 - Reactive
Exposed 0 (Baseline) 6 weeks 12 weeks 24 weeks
Anti-HIV 1&2
[HIV 1&2 Ag-Ab]
√ √ √ √

63. HIV - PEP for percutaneous injuries
• ideally, PEP should begin immediately, within 2 hours of
exposure, but definitely within 72 hrs.
2 hrs to 72 hrs.
are crucial