Viral Hepatitis by Andy King

1. Viral Hepatitis
Andy King
Consultant Gastroenterologist/Hepatologist
Birmingham Heartlands Hospital

3. HEPATITIS A
Self limiting
Fulminant in <1%, older, CLD
70% symptomatic
Nausea, vomiting, anorexia,
fever, malaise
Jaundice in 40%
ALT often >1000
LFTs peak at one month after
exposure
Jaundice resolves by 2 weeks
Complete recovery usual by 2-
3 months
Treatment Supportive
Care with Hepatotoxics
Diagnosis : IgM HAV positive
(3-6 months)
IgG positive lifelong after
exposure
Faeco-oral transmission
Contaminated Food/Water

4. HAV Vaccination
Pre exposure
Travellers to areas of
high/intermediate prevalence
CLD
Haemophilia
MSM
IVDU
Post exposure
Contact of HAV infection
Outbreaks (local health
protection team)

5. HEPATITIS E
Self limiting
Most cases Asymptomatic
Diagnosis: IgM HEV positive,
(5 months)
HEV RNA PCR but short
viraemia
Supportive Treatment
Possible role for Ribavirin
Asia/Africa – contmainated
water
Europe/America –porcine
zoonosis
Immunosuppressed/ CLD High Risk
Pregnancy / CLD – 25-75% Mortality
0.5-4% Liver Failure
ALT +++, usually back to normal 1-6 weeks
Occasional prolonged cholestasis

6. Hepatitis B
• Largely imported – Asia, Africa, E. Europe
• Most infectious BBV (x100 more than HIV)

7. Hepatitis B Transmission
Endemic Countries
Vertical transmission (in utero,
birth, breast feeding)
Early childood, close
interpersonal contact
Unsterilised medical
equipment
UK
Unprotected penetrative sex
Sharing any drug equipment
(not just needles)
Unsterilised tattoos/piercings
Needlestick
Rarely – toothbrush/razor
NOT contaminated food/water or casually in home/workplace

8. Serology
OPD^22021466
----------------------------------------
Hepatitis B HBsAg POSITIVE by EIA
Hepatitis B HBsAg. Confirmed by Neutralisation
Hepatitis B anti HBc POSITIVE by EIA
Hepatitis B anti HBc IgM Negative by EIA
Hepatitis B HBeAg Negative by EIA
Hepatitis B anti HBe POSITIVE by EIA
Hepatitis B Anti HBs Negative
Hepatitis C Antibody Negative by EIA (Abbott)
These results confirm previous findings.
Please retest at 2-12 weeks after last exposure,
for Hepatitis C if clinically indicated

10. Meaning Acute
Infection
Chronic
Infection
Cleared
infection
Immunised Healthy
Carrier
HB core
Antibody
Exposure
+ + + - +
HB surface
Antigen
Infection
+ + - - -
HB surface
Antibody
Immunity
- - + + -

11. c Ab s Ag s Ab
+ + -

12. c Ab s Ag s Ab
+ - +
c Ab s Ag s Ab
+ + -

13. c Ab s Ag s Ab
+ - -

14. c Ab s Ag s Ab
+ + -
> 6 months

15. c Ab s Ag s Ab
+ + -
c Ab s Ag s Ab
+ - +
> 6 months

16. c Ab s Ag s Ab
+ + -
c Ab s Ag s Ab
+ + -
> 6 months

17. c Ab s Ag s Ab
- - +
Immunised

18. c Ab s Ag s Ab
+ - -
c Ab s Ag s Ab
+ + -
c Ab s Ag s Ab
+ + -
c Ab s Ag s Ab
+ - +
c Ab s Ag s Ab
+ - +
c Ab s Ag s Ab
+ + -
c Ab s Ag s Ab
- - +
Immunised
> 6 months

20. Liver Events HCCa
Liver Mortality Mortality
HBV Treatment

22. Reduced Risk
Cirrhosis
HCCa
Mortality
Prevent Transmission

23. HBV Vaccination
Pre exposure
Drug Users (partners and
children)
Sex workers
Close family contact esp sexual
Family adopting children from
high prevalence area
Regular blood products (eg
haemophilia)
CRF, CLD
Travelling to areas of high
prevalence
Occupational risk
Immediate post exposure
Neonatal
Needlestick
(+/- Immunoglobulin)

24. Hepatitis C
200 million worldwide
3% worlds population
1.5 million deaths per year from HCV related liver disease
80% Acute HCV asymptomatic
80% become Chronic
Most common symptom = Fatigue

31. HCV Transmission
Drug Users - ANY drug equipment
27% users had shared in last 6 months, lack of disclosure
Don’t forget anabolics, novel psychoactives, historical drug use
even if only once
Piercings/tattoos/shaving – rarely from razors, nail clippers,
toothbrushes
Vey low risk to household contacts
Vertical: approx 5%, breast feeding NOT contraindicated

32. HCV Transmission
Needlestick
1:50 risk from known HCV
Sexual : uncommon but possible (0-2 per 1000 yrs)
increased if coinfected HIV/STI or traumatic sex
Transfusion :clotting factor<1987, blood <1991, transplant <1992
Medical/dental treatment in areas where HCV common and
infection control poor - Pakistan, India, Africa, E Europe

33. Never
Exposed
Current
Infection
Spontaneous
Clearance
Successful
Treatment
Antibody
- + + +
RNA
‘viral load’ Not needed 12 – 100000+ <12 <12
Genotype
Not needed 1-6 Not needed Not needed

34. HCV Ab +
HCV RNA
Detectable

35. Liver Failure
HCCa
Liver Mortality
Mortality
HCV Treatment

40. Interferon 6 mo

41. 144
Genotype 3, no cirrhosis, 8 weeks
Genotype 3, cirrhosis, 12 weeks
Genotype 3, cirrhosis, 12 weeks
25
50
100
75
% 97 100 100
ABT-493
+ ABT-530 + RBV
ABT-493
+ ABT-530
0
ABT-493
+ ABT-530
2016…

42. 144

43. 144

47. Primary Care:
Adults and children at increased risk of infection
Migrants from medium or high prevalence countries
Current or Past Drug Use
Newly registered – ever used drugs?
Hep B Testing AND Vaccination to those at Increased risk of
infection
Annual Hep C testing to those at Ongoing risk of infection

48. Public Health:
Overall responsibility for Contact Tracing
Advise and oversee other organisations to ensure surveillance
and follow up of Hepatitis B and C
eg GPs providing HBV vaccination and specialist referral

50. Questions?
andrew.king@heartofengland.nhs.uk