1. Four inmates have presented with upper abdominal pain and diarrhea, symptoms consistent with hepatitis A. 2. The latest patient reports eating raw seashells from home, indicating potential fecal-oral transmission of hepatitis A through contaminated food. 3. Outbreaks of hepatitis A can occur in closed settings like prisons where hygiene and sanitation may be challenges, allowing the virus to spread among susceptible individuals. Testing is needed to confirm hepatitis A as the cause.

3. Brief History of Hepatitis
• A breakthrough of understanding Hepatitis came
in 1963 by Dr. Baruch Blumberg.
• He discovered an antigen that detected the
presence of Hepatitis B (HBV) in blood samples.
• Later discovered an unusual antigen from a blood
sample of an Australian Aborigine, which they
called the Australian antigen.
• After further research, it was recognised to be the
antigen that caused Hepatitis B - 1967

4. Cont.
• Hepatitis A- Early 1970s
• In 1989 Hepatitis C virus (HCV) was isolated,
unfortunately there is no vaccine for Hepatitis
C.
• Hepatitis E (HEV) – Identified in 1990
• Hepatitis G(HGV) - Identified in 1995

5. Hepatitis Viruses

6. Cont.
Hepatitis
A
B
CD
E

8. Cont.
• Hepatitis A is a viral liver disease that can cause
mild to severe illness.
• Is caused by the hepatitis A viruses(HAV).
• Almost everyone recovers fully from hepatitis A
with lifelong immunity. However, a very small
proportion of people infected with hepatitis A
could die from fulminant hepatitis.
• A safe and effective vaccine is available to
prevent Hepatitis A.
• The incubation period of Hepatitis A is usually an
average of 10-50 days.

10. How Is It Spread?
• HAV is found in the feces of people(fecal-oral
route) with hepatitis A and is usually spread by
close personal contact. (including sexual
intercourse or living in the same household)
• It can also be spread by eating food or drinking
water contaminated with HAV and by travelling
internationally where HAV infection is occurring.
• Waterborne outbreaks, though infrequent, are
usually associated with sewage-contaminated or
inadequately treated water.

11. Symptoms
• Symptoms of hepatitis A range from mild to
severe, and can include:
Fever
Malaise
Loss of appetite
Diarrhoea
Nausea
Jaundice
Dark coloured urine
Abdominal discomfort

13. Cont.
• Hepatitis B is a viral infection that attacks the
liver and can cause both acute and chronic
disease.
• Is caused by the Hepatitis B virus (HBV)
• According WHO, an estimated of 240 million
people are chronically infected with hepatitis B
and more than 686 000 people die every year due
to complications including cirrhosis and liver
cancer.
• Hepatitis B can be prevented currently by a
vaccine.

14. Pathogenesis of Hepatitis B
• Proliferative Phase: Episomal form produces
complete viral particles (infectivity)
• Target viral antigens (HBsAg,HBcAg)expressed on the
surface in association whith HLA class 1.
• Cytotoxic T lymphocytes directed against multiple
HBV epitopes kill infected hepatocytes.
• Antiviral antibodies apperar- infectivity ends, hepatitis
ends.
• Replication continues- carier with chronic hepatitis
• Intergrative Phase: Intergrated into DNA(chronic
hepatitis)

15. How Is It Spread?
• The Hepatitis B virus can survive outside the body for
at least 7 days.
• The incubation period is 75 days on average, but can
vary from 30 to 180 days.
• In highly endemic areas, hepatitis B is most commonly
spread from mother to child(perinatal transmission) or
through horizontal transmission (exposure to infected
blood).
• Hepatitis B is also spread by percutaneous or mucosal
exposure to infected blood and various body fluid, as
well as through saliva, menstrual, vaginal and seminal
fluids.

16. Cont.
• Sexual transmission of hepatitis B may occur,
particularly in unvaccinated men who have sex
with men and heterosexual persons with multiple
sex partners or contact with sex workers.
• Transmission of the virus may also occur through
the reuse of needles and syringes either in health-
care settings or among persons who inject drugs.
• In addition, infection can occur during medical,
surgical and dental procedures, through tattooing,
or through the use of razors and similar objects
that are contaminated with infected blood.

17. Symptoms
• Most people do not experience any symptoms
during the acute infection phase. However, some
people have acute illness with symptoms that last
several weeks, including:
• Jaundice
• Dark urine
• Extreme fatigue
• Nausea
• Vomiting

19. Cont.
• Hepatitis C is a liver disease caused by the hepatitis C virus.
The virus can cause both acute and chronic hepatitis
infection, ranging in severity from a mild illness lasting a
few weeks to a serious, lifelong illness.
• Globally, between 130–150 million people globally have
chronic hepatitis C infection.
• Approximately, 700 000 people die each year from hepatitis
C-related liver diseases.
• Antiviral medicines can cure approximately 90% of persons
with hepatitis C infection, thereby reducing the risk of death
from liver cancer and cirrhosis, but access to diagnosis and
treatment is low.
• There is currently no vaccine for hepatitis C; however
research in this area is ongoing.

20. Pathogenesis of Hepatitis C
• Inoculation of the pathogen.
• Viremia
• Viral integration and replication in hepatocytes,
also maybe in blood cells, bone marrow, lymph
nodes and spleen.
• Activation of immune system with low immune
response.
• Mutation changeability of the virus.
• Persistence of the virus.

21. How Is It Spread?
• The hepatitis C virus is a bloodborne virus. It is
most commonly transmitted through:
 injecting drug use through the sharing of
injection equipment;
 the reuse or inadequate sterilization of medical
equipment, especially syringes and needles in
healthcare settings; and
 the transfusion of unscreened blood and blood
products.
The incubation period for hepatitis C is 2 weeks
to 6 months.

22. Symptoms
• Following initial infection, approximately 80% of
people do not exhibit any symptoms. Those who
are acutely symptomatic may exhibit:
Fever
Fatigue
Decreased appetite
Nausea
Vomiting
Dark urine
jaundice

24. Cont.
• Also referred to as hepatitis D virus (HDV) and
classified as hepatitis delta virus, is a disease caused by
a small circular enveloped RNA virus.
• It is considered to be a sub-viral satellite because it can
only propagate in the presence of the hepatitis B viruses
(HBV).
• Hepatitis D virus (HDV) is a virus-like particle
consisting of a coat of hepatitis B viruses (HBV)
surface antigen and a unique internal antigen, the delta
antigen.
• Reservoirs- humans
• Hosts- humans

25. Cont.
• Vertical transmission from mother to child is
rare.
• Approximately 15 million people across the
world are chronically coinfected with HDV
and HBV.
• Currently there is no effective antiviral
treatment for hepatitis D.
• Hepatitis D infection can be prevented by
hepatitis B immunization.

26. Pathogenesis of Hepatitis D
• Sexual, parenteral, and perinatal transmission.
• Replication by RNA-directed RNAPol(Host
RNA Pol II)
• Requires concurrent HBV infection (needs it
for HBsAg)
• HDV greatly exacerbates liver damage caused
by HDV
• Chronic infections are a major cause of PHC

27. How Is It Spread?
• The routes of HDV transmission are the same as for
HBV: percutaneously or sexually through contact with
infected blood or blood products.
• Vertical transmission is possible but rare.
• Vaccination against HBV prevents HDV coinfection,
and hence expansion of childhood HBV immunization
programmes has resulted in a decline in hepatitis D
incidence worldwide.
• However, in some settings, the increase of hepatitis D
prevalence has been observed in people who inject
drugs, or as a result of migration from areas where
HDV is endemic.

28. Symptoms
• The symptoms for hepatitis D are similar to
hepatitis B, such as:
Fatigue
Abdominal pain
Nausea and vomiting
Jaundice
Fever

30. Cont.
• Hepatitis E is a liver disease caused by infection with a
virus known as hepatitis E virus (HEV).
• Every year, there are an estimated 20 million HEV
infections worldwide, leading to an estimated 3.3
million symptomatic cases of hepatitis E, and 56 600
hepatitis E-related deaths.
• Hepatitis E is usually self-limiting but some cases may
develop into fulminant hepatitis (acute liver failure).
• A vaccine to prevent hepatitis E virus infection has
been developed and is licensed in China, but is not yet
available elsewhere.

31. Cont.
• The virus has at least 4 different types:
genotypes 1, 2, 3 and 4. Genotypes 1 and 2
have been found only in humans. Genotype 3
and 4 viruses circulate in several animals
(including pigs, wild boars, and deer) without
causing any disease, and occasionally infect
humans.
• Usually the infection is self-limiting and
resolves within 2–6 weeks.

32. Pathogenesis of Hepatitis E
• Similar to Hepatitis A.
• Virus replicates in the gut initially, before
invading the liver, and virus is shed in the stool
prior to the onset of symptoms.
• Viremia is transient

33. How Is It Spread?
• The hepatitis E virus is transmitted mainly
through the faecal-oral route due to faecal
contamination of drinking water.
• Ingestion of undercooked meat or meat products
derived from infected animals.
• transfusion of infected blood products.
• Vertical transmission from a pregnant woman to
her fetus.
• Incubation period following exposure to the
hepatitis E virus ranges from 2 to 10 weeks, with
an average of 5–6 weeks.

34. Symptoms
• An initial phase of mild fever, reduced appetite
(anorexia), nausea and vomiting, lasting for a
few days; some persons may also have
abdominal pain, itching (without skin lesions),
skin rash, or joint pain.
• Jaundice (yellow discolouration of the skin and
sclera of the eyes), with dark urine and pale
stools.

37. Hepatitis In Fiji
• The common one in Fiji is Hepatitis A- spread
through contaminated food or water.
• Hepatitis A outbreak in ____ during 20_?
• There were 160 clinical cases of hepatitis A
from which 15 were laboratory confirmed. The
attack rate as 349 per 10000 amongst the
population in the Nukuloa nursing zone.
• There was no reported deaths.

38. Management

39. Hepatitis A
• Hepatitis A- There is no specific treatment for
hepatitis A. Recovery from symptoms
following infection may be slow and may take
several weeks or months.
• Therapy is aimed at maintaining comfort and
adequate nutritional balance, including
replacement of fluids that are lost from
vomiting and diarrhoea.

40. Hepatitis B
• Management-prevent progression of the disease
Pharmacotherapy
• Nucleos(t)ide reverse transcriptase inhibitors (eg, tenofovir disoproxil
fumarate, lamivudine)
• Hepatitis B/hepatitis C agents (eg, adefovir dipivoxil, entecavir, telbivudine,
PEG-IFN-a 2a, interferon alfa-2b)
Dietary changes
-For individuals with decompensated cirrhosis (prominent signs of portal
hypertension or encephalopathy
• A low-sodium diet (1.5 g/day)
• High-protein diet (ie, white-meat protein [eg, chicken, turkey, fish])
• Fluid restriction (1.5 L/day) in cases of hyponatremia
Liver transplantation
• Orthotopic liver transplantation
- fulminant hepatic failure
- end-stage liver disease

41. Hepatitis C
• ACUTE HEPATITIS C
-Acute hepatitis C is detected infrequently.
-When it is identified, early IFN therapy should be considered.
• CHRONIC HEPATITIS C
- Combinations of antiviral medications can help fight viral infections and
prevent serious liver problems such as cirrhosis and liver cancer.
Treatment for chronic hepatitis :
• pegylated interferon
• Ribavirin
newer medicines
• simeprevir
• sofosbuvir
• Aclatasvir
• a combination of ledipasvir and sofosbuvir
• a combination of ombitasvir, paritaprevir and ritonavir, taken with or without
dasabuvir
• Note: Ribavirin is contraindicated in pregnancy.

42. Hepatitis D
• There are no known treatments for acute or
chronic hepatitis D.
• You may be given large doses of a medication
called interferon for up to 12 months.

43. Hepatitis E
• Acute Hepatitis E
 patient with severe acute hepatitis E can be
treated with ribavirin for 21 days.
 ribavirin therapy is contraindicated in
pregnancy.

44. Tests
1.Hepatitis A
-blood test - proteins (antibodies) made by the body in response
to the virus.
 IgM anti-HAV antibodies are found if you have an active or a
recent infection
 IgG anti-HAV antibodies are found if you have had an infection
in the past or when you have had the hepatitis A vaccine.
2. Hepatitis B
-blood test-
• Hepatitis B antigens and antibodies
• Test to see whether HCV ,HAV, Epstein Bar virus are causing
the infection
• Test to see if infected with hepatitis D along with HBV.

45. Cont.
3.Hepatitis C
- BLOOD TEST
• looks for antibodies against HCV
• looks for the genetic material (RNA) of the hepatitis C virus
• find out the kind of hepatitis C virus (genotype) you have.
4. HEPATITIS D
-blood test- that can detect anti-hepatitis D antibodies in
your blood
5.HEPATITIS E
-BLOOD TEST -detection of IgM and IgG anti-HEV
antibodies and detection of HEV RNA.
-presence of HEV RNA indicates current infection

46. Cont.
Blood tests to check for liver damage
• Bilirubin, albumin, prothrombin time –to test how
well the liver is working
• ALT , AST, Alkaline phosphatase, lactic
dehydrogenase (LDH)- to test whether the liver is
damaged or inflamed.

47. Prevention
• Hepatitis A
 Hepatitis A vaccine- offers immunity to adults &
children older that 1 yr of age.
 Practicing good hygiene and sanitation
 Avoid unclean food and water.
• Hepatitis B
 Hepatitis B vaccine offers the best protection. All
infants and unvaccinated children, adolescents
and adults are at risk.

48. Cont.
• Those not vaccinated can prevent hepatitis B
by reducing exposure to virus by:
 Using protection e.g. condoms
 Not sharing needles
 Not sharing personal items e.g. toothbrush,
razors, with an infected person

49. Cont.
• Hepatitis C
 There is no vaccine.
 Hand hygiene: including surgical hand preparation, hand
washing and use of gloves;
 Safe handling and disposal of sharps and waste;
 Provision of comprehensive harm-reduction services to
people who inject drugs including sterile injecting
equipment;
 Testing of donated blood for hepatitis B and C (as well as
HIV and syphilis);
 Training of health personnel; and
 Promotion of correct and consistent use of condoms.

50. Cont.
• Hepatitis D
 Prevention and control of HDV infection requires
prevention of HBV transmission through hepatitis B
immunization, blood safety, injection safety, and
harm reduction services. Hepatitis B immunization
does not provide protection against HDV for those
already HBV infected.

51. Cont.
• Hepatitis E
 Prevention is the most effective approach against the
disease. At the population level, transmission of HEV
and hepatitis E disease can be reduced by:
 maintaining quality standards for public water supplies;
 establishing proper disposal systems for human feces.
• On an individual level, infection risk can be reduced by:
 maintaining hygienic practices such as hand-washing
with safe water, particularly before handling food;
 avoiding consumption of water and/or ice of unknown
purity.

53. Case Study
• A 37 yr old male Itaukei, from prison,
presented pain in the upper quadrant.
• He has been having diarrhoea for 5 days.
• He is now the 4th inmate to have been
presenting such problems.
• Upon further investigation, the patient gives
history of eating seashells brought from home
which he had shared with others.

54. Cont.
Upon examination:
Patient was found to have Jaundice
His vitals were normal
Mild tenderness on RUQ
His chest was clear
Jaundice: sclera and palms

55. What is your differential
diagnosis?????? 

56. Cont.
• Cholecystitis
• Typhoid
• Viral hepatitis

57. Cont.
• Blood test (CBC)
Hemoglobin
WBC
Hemitocrite
• LFT
ALT greater than AST, greater than
10000mIU/mL
• Serology
Hep A positive
Immunoglobinuline HAVIgM

58. Cont.
• Hepatitis A

60. References
• http://www.cevhap.org/index.php/en/about-
viral-hepatitis/a-brief-history-of-hepatitis
• http://www.who.int/mediacentre/factsheets/fs3
28/en/