Hepatitis Learning Guide
Hepatitis Learning Guide
Hepatitis Learning Guide
Hepatitis of Viral
Learning GuideHepatitis
Section 1
About This Learning Guide
The overview of each type of viral hepatitis has been developed in a case
study format to better demonstrate the practicality of the materials. As you
progress through the sections, review the learning objectives and complete
the quizzes on major points covered in the text.
Table of Contents
Introduction ............................................................................................................................................................3
Glossary................................................................................................................................................................61
Appendix ..............................................................................................................................................................65
References...........................................................................................................................................................66
Diagnosing the specific agent responsible for viral hepatitis is difficult because the signs and
symptoms of each type are similar. Furthermore, many individuals who contract the disease have
few or no symptoms. Hepatitis, then, presents a challenge to physicians who must try to integrate
epidemiological, clinical, and serological data before making patient management decisions.
Hepatitis can be caused by viruses, bacteria, drugs, toxins, or excess alcohol intake. Only within
recent years have physicians been able to differentiate the five major types of viral hepatitis. In large
part, the ability to distinguish the viruses that cause hepatitis is the result of the development of
serological tests for specific markers.
The five distinct viruses currently known to cause hepatitis, which will be discussed in this text, are
referred to as hepatitis A, B, C, D, and E. Other viruses are presumed to be associated with, or to
cause, hepatitis but have not yet been linked to a disease. Cytomegalovirus (CMV) and Epstein-Barr
virus (EBV) may also cause hepatitis.
Jaundice (icterus). When the liver’s ability to dispose of metabolic waste is impaired, bilirubin
accumulates in the blood. Bilirubin is derived from the breakdown of red blood cells and contains
a yellow pigment. When high levels of bilirubin accumulate in the blood, the skin and the whites
of the eyes turn yellow.
The variability of symptoms. The symptoms of hepatitis vary considerably from one individual to
another, even when the same causative agent is involved. Because symptoms are not specific
to the causative agent, it is impossible to distinguish among the various causative agents of
hepatitis based on clinical symptoms alone; serological testing is required.
Serological Markers
Serology pertains to antigen/antibody reactions in vitro. Viral hepatitis assays detect the presence
of specific viral antigens and/or antibodies in serum. A physician uses these results to identify,
differentiate, and monitor a hepatitis infection.
Diagnose
Monitor
• To evaluate for late seroconversion and/or disease resolution in a known HBV carrier
• To monitor the success of immunoprophylaxis in cases of potential perinatal transmission
of HBV (9 – 15 months after birth)
• To ensure immunity has been achieved after vaccination for HBV
The Acute Viral Hepatitis Panel* is the first laboratory tool for identifying the specific virus responsible
for a patient’s hepatitis. The Acute Viral Hepatitis Panel tests for four serological markers: anti-HAV
IgM (IgM antibody directed against HAV), HBsAg (hepatitis B surface
antigen), anti-HBc IgM (IgM antibody directed against the hepatitis B
core antigen), and anti-HCV (antibody to HCV). Acute Viral
Additional panels will be discussed in the upcoming sections.
Hepatitis
Panel
The Acute Viral Hepatitis Panel tests for four
serological markers: anti-HAV IgM (IgM
antibody directed against HAV), HBsAg
(hepatitis B surface antigen), anti-HBc IgM
(IgM antibody directed against HBcAg), and
*As defined in CPT code #80074
anti-HCV (antibody to HCV).
4. How are liver function tests used in the diagnosis of viral hepatitis?
(Choose one or more of the following)
a. To indicate the status of liver function
b. To indicate roughly the amount of liver damage
c. To indicate the viral agent involved
Case Study #1
Janet, a 26-year-old daycare teacher felt fatigued, had diarrhea, and was
running a fever. Assuming it was just the flu, she rested for a couple of
days. When symptoms continued for more than a week, she went to her
physician. Janet informed her physician of her symptoms, including the
fact that her stools had changed color. Upon further examination, the
physician observed that both her skin and the whites of her eyes were Janet
slightly yellow. Daycare Teacher.
This last observation, in particular, prompted the physician to check
Janet’s bilirubin and liver enzymes. Laboratory tests showed that Janet’s
bilirubin and ALT levels were abnormally elevated. At this point, the
physician ordered the Acute Viral Hepatitis Panel. Below are the results
of the Acute Panel:
In this case, the panel definitively diagnosed an acute infection with HAV. While the hepatitis A virus
is rarely detectable in serum, the IgM antibody to HAV (anti-HAV IgM) is detectable in serum and
indicated that Janet had acute hepatitis A.
Capsid
Single-Stranded RNA
Routes of Transmission
Transmission usually occurs enterically (fecal-oral) through:
• Close person-to-person contact
• Ingestion of contaminated food or water
These routes could be facilitated by poor personal hygiene and poor sanitation.
Evaluation of the risk factors associated with HAV infection relative to Janet’s history suggested that
she was probably exposed to HAV by one of the daycare attendees. Most likely a diapered child was
infected and transmission may have occurred by Janet not washing her hands well after diapering.
As a young adult working in a daycare center where hepatitis A is occurring, Janet was in a typical
at-risk situation.
Incidence/Prevalence
• In the U.S. there are an estimated 125,000 to 200,000 3, slide 5 total infections per year. About
one third of the U.S. population has serologic evidence of ever having had HAV infection 3A, slide 13
• In terms of morbidity, approximately 100 deaths per year are associated with fulminant
hepatitis A 3, slide 5
• Almost one-third of reported HAV cases are in children younger than the age of 15 3A, slide 14
• The map below represents prevalence patterns of HAV infections worldwide
• Large, nationwide outbreaks tend to occur every 10 – 15 years; the last outbreak was
in 1995 3A, slide 12
Clinical Illness
ALT
Viremia
HAV in stool
0 1 2 3 4 5 6 7 8 9 10 11 12 13
Week
Within three weeks Janet’s symptoms had disappeared. She can now be
considered immune to the hepatitis A virus. There is no chronic carrier state
for hepatitis A.
Therapy
There is no specific therapy available.
Vaccination
Hepatitis A vaccinations, providing long-term
protection, are available for individuals
older than two years of age.
Hepatitis A Virus
VIRUS FAMILY Picornaviridae
INCUBATION 15 – 50 days
CHRONICITY None
___________________________________ ___________________________________
2. Individuals most at risk for contracting HAV include:
a. Food-handlers
b. Children in day-care centers as well as their families
c. Individuals in close contact with an infected individual
d. Law enforcement personnel
3. Which of the following describe the incidence of hepatitis A?
a. Approximately 100 deaths from fulminant HAV are reported each year in the U.S.
b. Recently HAV incidence in the U.S. has been estimated at 125,000 – 200,000 cases per year
c. Almost one-third of reported HAV cases are in children younger than 15 years of age
d. All of the above
4. Which of the following describe the most common symptoms and clinical course
associated with HAV? (Choose one or more of the following)
a. Jaundice always occurs
b. Onset is usually abrupt
c. Most cases involving children under age 6 are asymptomatic (70 percent)
d. Patients are potentially infectious for up to several weeks before onset of symptoms
Case Study #2
Susan, a college student, had been experiencing the following symptoms
for over a week: persistent fatigue, loss of appetite, nausea, vomiting,
and abdominal pain. She scheduled an appointment at her campus health
clinic. After completing her patient history, this is what the physician
learned:
• About one week ago, Susan had become sexually active with Susan
a new boyfriend College Student.
• Both Susan and her partner had multiple sex partners before
they started dating
• Susan had not always used condoms with her partners
• The symptoms appeared about one week ago, and were still present
The physician ordered tests for other sexually transmitted diseases, HIV, and pregnancy; all came
back negative. Because of Susan’s persistent abdominal tenderness, the physician ordered liver
function tests. Susan’s bilirubin and liver enzyme results were elevated, prompting the physician
to order an Acute Viral Hepatitis Panel. Below are the results:
Susan was HBsAg positive, indicating that she was infected with HBV. Susan’s test results also
showed that anti-HBc IgM was present, indicating an acute HBV infection.
Hepatitis B surface
antigen (HBsAg)
Hepatitis B core
antigen (HBcAg)
DNA
Polymerase
Dane Particle
Risk Factors for Acute Hepatitis B in the U.S., 1992 – 93.3B, slide 12
Heterosexual* (41%)
Source: Centers for Disease Control and Prevention Sentinel Counties Study of Viral Hepatitis
*Includes sexual contact with acute cases, carriers, and multiple partners.
Individuals at Risk
• Sexual contacts of an acute or chronically infected person
• Injecting drug users
• Persons with multiple sex partners or a history of sexually transmitted diseases
• Infants born to HBV infected mothers
• Individuals who have occupational contact with blood:
– Medical and dental workers
– Laboratory and support personnel
– Public service employees (i.e., paramedics, EMTs)
• Recipients of unscreened blood or blood-derived products that have not undergone a viral
inactivation process
• Hemodialysis patients (due to poor equipment sterilization, not blood)
• Household contacts of HBV infected individuals
• Institutionalized populations (i.e., individuals in prisons and facilities for the
developmentally disabled)
• Persons born in HBV endemic areas (i.e., Africa, Asia, Eastern Europe, and South America)
Susan had unprotected sex with multiple partners which placed her at risk for HBV infection.
3B, slide 9
Source:
*Note: The map of HBsAg prevalence generalizes available data, patterns may vary within countries.
Susan’s age placed her in the population with the largest percentage
of new cases that occur each year.
350 Million
Worldwide, it is estimated
that there are 350 million
HBV carriers.
Symptoms
HBsAg anti-HBs
HBeAg
anti-HBe
anti-HBc IgM
Time
When a patient tested with the Acute Viral Hepatitis Panel has positive results for surface antigen
(HBsAg) and IgM antibody to the core antigen (anti-HBc IgM), the diagnosis of acute hepatitis B
is established. To follow the patient’s progress, serial testing with the monitoring panel is indicated.
This panel consists of four hepatitis B markers: HBsAg, HBeAg, anti-HBe, and anti-HBs.* With the
hepatitis B monitoring panel, a physician can:
• Determine the patient’s potential for developing chronic HBV infection
due to the persistence of the surface antigen (HBsAg)
• Determine relative infectivity (HBeAg)
• Monitor seroconversion from HBeAg to anti-HBe, which usually indicates progression
toward a resolution of the disease
• Monitor seroconversion from HBsAg to anti-HBs positivity, which indicates resolution
of the disease and establishment of immunity
In Susan’s case, the results of the monitoring panel would help identify her degree of infectivity.
The results show that Susan was highly infectious. At this point the physician informed Susan
of the following:
• Need to advise sex partners and household contacts of her infectious state
• Clinical course of the hepatitis B virus infection and possible outcomes
• Importance of NOT DONATING BLOOD
The physician also informed her that she was going to be monitored every month until resolution
of the disease. Six months later, the results were negative for HBsAg and HBeAg and positive for
anti-HBe and anti-HBs. This indicated that Susan had resolved the infection.
If Susan’s HBsAg had persisted for more than six months, she would have been
considered chronically infected with HBV.
HBeAg anti-HBe
HBsAg
Total anti-HBc
Titer
IgM anti-HBc
0 4 8 12 16 20 24 28 32 36 52
Weeks after exposure Years
Anti-HBs (antibody to the surface antigen) is the only marker for determining immunity to a HBV
infection. Anti-HBs appears early in recovery and the titer may eventually decline. Other indicators
of recovery are normal liver enzyme levels and negative tests for HBsAg.
The first hepatitis vaccine available in the United States was produced from the plasma of persons
chronically infected with HBV. The hepatitis B vaccines currently available are produced by
recombinant DNA technology.
Because immunity to hepatitis B is dependent on a highly individual response to the vaccine, it
is recommended that following the vaccine series, an anti-HBs test be done for certain groups.
Anti-HBs testing is recommended for:
• Healthcare workers
• Babies born to HBV infected mothers
• Sex partners of persons with chronic HBV infection
• Immunocompromised individuals
Quantitation of anti-HBs is possible using a panel of anti-HBs standards that determine antibody
levels. Standards are run to generate a standard curve. Results are calculated as anti-HBs
concentration in mIU/mL by comparing the sample result to the curve.
Pre-Vaccination Testing
Anti-HBc total, total antibody (i.e., IgM and IgG) to the hepatitis B core antigen, is an indicator of
a current or previous HBV infection. It is also used with anti-HBs and HBsAg for screening at-risk
populations for hepatitis B to determine their immune status. Individuals found to be positive for
both anti-HBc and anti-HBs are presumed to be immune by prior natural infection. Those found
to be negative are at risk for HBV infection and should be recommended for vaccination. The
CDC recommends a prevention strategy that includes prenatal testing for HBsAg to identify
pregnant women whose newborns require prophylaxis and whose household members require
vaccination.5, p6
The level of circulating anti-HBs is used to determine the effectiveness of vaccination. The hepatitis
B vaccine is designed to induce only anti-HBs (the protective antibody) and will not induce an anti-
HBc response. In the U.S., an antibody level of 10 mIU/mL or higher indicates immunity.5, p8 Outside
the U.S., other levels of antibody may be used to determine immunity. These levels may vary from
country to country.
Prevention/Prophylaxis
Measures to prevent HBV infection include:13
• Worldwide screening of blood and blood products
• Destruction of disposable needles, and adequate sterilization of reusable materials
such as surgical or dental instruments
• Effective use of universal precautions and barrier techniques (such as use of sterile
equipment, the wearing of gloves, and wearing of eye/face protection)
Due to the lack of a fully effective therapy, prophylaxis against HBV infection is essential. Prophylaxis
is effective using either Hepatitis B Immune Globulin (HBIG) to provide temporary, passive protection,
or the hepatitis B vaccine to provide active, prolonged immunity.
Hepatitis B vaccine. The conventional regimen is a series of three intramuscular doses of the
vaccine given over a six-month period: initial vaccination, again at 30 days, and the third dose at
6 months. This regimen induces an adequate antibody response in over 90 percent of healthy young
adults and in more than 95 percent of infants, children, and adolescents (up to age 19).5, p8
• Immunization is one of the most medically efficient and cost-effective means of controlling
viral hepatitis 5, p3
• Countries with universal vaccination programs are seeing declines in chronic HBV
infections13, p45
• Achieving universal immunity requires an increase in public awareness of the severity
of health problems caused by HBV 13, p52
In the United States, the CDC recommends that hepatitis B vaccinations be a part of childhood
immunization programs, and the CDC has expanded their recommendations for HBV vaccinations
to include all unvaccinated children at age 11 – 12 as well as all “high-risk” children and adolescents
of all ages.3B, slide 14
Hepatitis B Immune Globulin (HBIG) is administered for temporary passive protection from hepatitis
B. Post-exposure prophylaxis with both hepatitis B immune globulin and hepatitis B vaccine should
be offered to infants born to HBV infected mothers, infants less than 12 months of age whose
mothers or primary care givers have acute hepatitis B, and sex partners of individuals with acute
hepatitis B. Unvaccinated healthcare workers who sustain a needlestick injury from a patient
infected with HBV should also receive HBIG and should start the hepatitis B vaccine series.5
Prenatal Screening
Infants born to mothers who are chronically infected with hepatitis B have
a high probability of contracting the infection, of becoming chronically
infected, and of developing chronic liver disease later in life. Therefore,
HBsAg testing is recommended in the U.S. for prenatal screening of all
pregnant women.5, p3
Women should be tested early in their pregnancy. If the mother’s HBsAg
status is unknown at the time of admission for delivery, HBsAg testing
should be performed as soon as possible. If test results are not available,
the infant should receive the hepatitis B vaccine. If the mother is identified
HBV and
as HBsAg positive, the infant should also be given hepatitis B immune
globulin (HBIG) within 12 hours of birth, and the vaccine series should be
Infants
Infants born to mothers who are chronically
completed as scheduled.5, p4
infected with hepatitis B have a high
Routine vaccination of all infants is now recommended.3B, Slide 14 probability of contracting the infection,
of becoming chronically infected, and of
developing chronic liver disease later in life.
Researchers have developed assays that detect and accurately measure HBV DNA. These assays
detect the viral genome and measure the level of circulating virus in an infected individual. The level
of HBV DNA in the blood is often referred to as “viral load.”
Investigational applications for hepatitis B virus DNA assays include:
• Directly assess circulating virus in an infected individual
• Predict response to antiviral therapy based on pretreatment viral load
• Monitor the effectiveness of antiviral therapy (HBV DNA falls rapidly in patients
who respond to treatment)
• Provides additional information to help confirm a diagnosis in cases with ambiguous
serology
If a physician can determine viral load, then he or she can better gauge whether or not to initiate
therapy, as well as more accurately monitor its effect.
Case Study #3
Donald, a 39-year-old emergency room nurse, accidentally stuck himself
with a needle as he removed it from a patient’s vein. When he reviewed
the patient’s chart, he noticed that this individual was anti-HCV positive.
He immediately scheduled an appointment with his physician. Even
though the needlestick occurred less than 24 hours previously (too soon
for an antibody response), the physician still ordered an Acute Viral Donald
Hepatitis Panel to check for current infection with HAV, HBV, and/or HCV. Emergency Room Nurse.
An HIV test was also ordered.
All tests came back negative, including HIV. Because of the recent exposure to the hepatitis C virus,
the physician advised Donald that follow-up testing would be needed in order to rule out an HCV
infection.7
Routes of Transmission
HCV is a blood-borne virus. There are no known cases of HCV transmitted enterically (oral-fecal)
through breast milk, semen, or saliva. The following routes of transmission are well-documented:
• Percutaneous
– Contaminated needlestick (injecting drug use and occupational exposure)
– Hemodialysis
– Human bite
– Transplant or transfusion of unscreened blood or blood products
– Acupuncture, tattooing, and body-piercing with unsterilized needles
• Permucosal
– Sexual intercourse
– Perinatal – infant born to HCV infected mother
– Contact with infected household objects (i.e., toothbrush or razor that may have blood on it)
1%
10%
4%
Injecting Drug Use (60%)
Sexual (15%)
10%
Transfusion (before screening) (10%)
Individuals at Risk
• Injecting drug users
• Persons occupationally exposed to blood
• Hemodialysis patients
• Transfusion and transplant recipients (prior to 1992)
The route by which Donald was exposed to HCV, as well as his occupation, put him at risk
for a HCV infection.
Prevalence of infection
> 10%
2.5 – 10%
Source: WHO, 2001
1 – 2.5%
Three months after the needlestick incident, Donald’s anti-HCV result was still negative and his liver
enzymes were normal. As a precaution, his physician routinely tested Donald for anti-HCV. At the
one-year follow-up, he remained negative for anti-HCV, and the physician
reassured him that although exposed to HCV, he had not become infected.
Chronic HCV
Infection
About 60 – 85 percent of HCV infected
cirrhosis.
anti-HCV
Symptoms +/-
HCV RNA
Titer
ALT
Normal
0 1 2 3 4 5 6 1 2 3 4
Months Years
Time After Exposure
HCV is diagnosed serologically by detecting antibodies specific to the hepatitis C virus (anti-HCV),
and by ruling out other viruses such as HAV or HBV. There are limitations on using any anti-HCV
assay alone to diagnose or monitor a case of hepatitis. Retesting for anti-HCV may be necessary if
the initial result is negative, but clinical signs and symptoms suggest a HCV infection. Furthermore,
anti-HCV does not distinguish between an acute, chronic or resolved infection. A supplemental test,
RIBA (recombinant immunoblot assay), can also be used to confirm a positive anti-HCV result.10
Nevertheless, as a screening assay for the blood supply, current anti-HCV assays have been very
effective in the U.S. at reducing post-transfusion hepatitis to a very low level.
Researchers have developed assays that detect and accurately measure HCV RNA. These assays
detect the viral genome and measure the level of circulating virus in an infected individual. The level
of HCV RNA in the blood is often referred to as the “viral load.” Several polymerase chain (PCR) tests
for HCV RNA are now available.9, p13
Applications for hepatitis C virus RNA assays include:9, p13
• Directly assess circulating virus in an infected individual
• Evaluate suspect HCV infection before seroconversion occurs
• Assess viral load before antiviral therapy is administered (patients with low, pretreatment
viral load are more likely to respond; however, a high HCV RNA should not preclude
treatment) 9, p14
• Monitor the effectiveness of antiviral therapy (interferon and ribavirin)
• Detect HCV infection in cases with ambiguous serology
Prevention/Prophylaxis
There is currently no vaccine for HCV. The difficulty in developing a
vaccine is due, in part, to the mutability of the HCV genome. In addition,
there is no effective, short-term prevention such as HBIG or immune
globulin. In the absence of the above, all precautions to prevent HCV
infection must be taken. Universal
WHO recommendations on measures to prevent HCV include:
• Screening of blood and blood products
Precautions
Effective use of universal precautions and
• Destruction of disposable needles and adequate sterilization barrier techniques (such as use of sterile
of reusable material such as surgical or dental instruments equipment and the wearing of gloves) are
some of the recommendations to prevent
• Effective use of universal precautions and barrier techniques HCV infection.
(such as use of sterile equipment, the wearing of gloves, and
wearing eye/face protection)
• Education about the risks of using unsterilized material
and high-risk drug and sexual behaviors
Case Study #4
William, a patient with chronic HBV infection and a 20-year history of
illegal injection drug use, had been experiencing the following symptoms
for about two weeks: nausea, abdominal pain, and diarrhea. Given
William’s chronic HBV infection, the physician suspected superinfection
with another virus. He ordered the Acute Viral Hepatitis Panel and a HIV
test. William
Patient with chronic HBV infection and a
20-year history of illegal injection drug use.
The lab results came back negative for HIV, HAV, and HCV. In order to rule out a superinfection with
hepatitis D, the physician ordered an anti-HDV test as well.
The lab result was positive for anti-HDV, confirming a HDV superinfection of this chronically infected
patient. William was counseled on the severity of his situation. A superinfection can often lead to
fulminant hepatitis or hepatocellular carcinoma. The mortality rate for HDV infection is 2 – 20
percent.16, p16 The physician continued to periodically run the chronic hepatitis B panel, anti-HDV,
and liver enzymes. This individual was never able to resolve his HBV and HDV infections and died
one year later of liver failure.
Hepatitis B surface
antigen (HBsAg)
Hepatitis D
antigen (HDAg)
Single-stranded
negative sense RNA
Routes of Transmission
• Similar to those for HBV (except perinatal transmission is rare) 3D, slide 3
• Percutaneous 3D, slide 3
– Contaminated drug use equipment
– Transfusion of infected blood and blood products16, p20
• Permucosal 3D, slide 7
– Sexually transmitted, although less efficient than for HBV
*Note: The map of anti-HDV prevalence generalizes available data and patterns may vary within countries.
Jaundice
Symptoms Total anti-HDV
IgM anti-HDV
Titer
ALT
IgM anti-HDV
IgM anti-HDV
HDV RNA
Titer
HBsAg
Total anti-HDV
Therapy
• Individuals with chronic HDV and HBV infection should follow HBV therapy
• There is no therapy specifically for chronic hepatitis D
Case Study #5
Eight weeks after Elizabeth returned from her vacation in Central America,
she went in for her annual physical. She joked with her physician about
consuming both unbottled beverages and food from local vendors without
getting a typical case of “travelers diarrhea.” Elizabeth had recently been
experiencing what seemed to be the flu. She explained her symptoms of
fatigue and abdominal pain to her physician. Elizabeth
Due to the late onset of Elizabeth’s symptoms in relation to her travel, and Vacationed in Central America
comment about drinking unbottled water, the physician wanted to rule out eight weeks ago.
The results ruled out HAV, HBV, HCV, and HDV, and after ruling out parasites, the physician suspected
HEV due to Elizabeth’s recent vacation to an endemic area. Currently, a diagnostic test for anti-HEV is
available in Europe, Asia, and Latin America, but not in the U.S.
Single-stranded RNA
Routes of Transmission
Transmission usually occurs enterically (fecal-oral) through:
• Ingestion of contaminated water supplies or food (most common)
• Poor personal hygiene
• Person-to-person (uncommon)
Since Elizabeth had recently visited a region where HEV is endemic, she was at risk for transmission
through the ingestion of contaminated water or food purchased at open-air markets.
Individuals at Risk
• Residents of endemic regions
• Travelers to endemic regions
Low ≤2%
Endemic Areas
• Leading cause (>50%) of acute sporadic hepatitis in both children and adults in some high
endemic areas3E, slide 4
• Occurrence in the United States is mostly associated with travel to endemic regions3E, slide 4
Clinical Course
• Incubation period is 15 – 60 days, with an average of 40 days3E, slide 2
• Symptoms are usually abrupt
• Symptoms are similar to other types of viral hepatitis infection: malaise, anorexia,
nausea/vomiting, abdominal pain, and fever
• The highest rates of symptomatic disease (jaundice) have been in young
to middle-age adults3E, slide 2
• Lower disease rates in younger groups may be accredited to anicteric and/or
subclinical HEV infection 3E, slide 2
• No chronic cases have been reported
• Mortality worldwide is approximately 1 – 3 percent. In pregnant women,
mortality reaches 15 – 25 percent 3E, slide 2
Symptoms
ALT
IgG anti-HEV
Titer
IgM anti-HEV
Virus in Stool
0 1 2 3 4 5 6 7 8 9 10 11 12 13
Weeks After Exposure
Prevention/Prophylaxis
• IgG anti-HEV persists and appears to provide at least short-term protection against
disease3E, slide 3
• There is currently no vaccine or immune globulin available to prevent the transmission
of HEV
• Long-term prevention relies primarily on provision of safe drinking water, prudent hygiene,
and avoiding uncooked shellfish, fruits, and vegetables in endemic areas3E, slide 6
Therapy
There is currently no therapy available.
Hepatitis A Virus Hepatitis B Virus Hepatitis C Virus Hepatitis D Virus Hepatitis E Virus
VIRUS FAMILY Picornaviridae Hepadnaviridae Flaviviridae Hepadnaviridae Not Classified
MORTALITY ≤ 39 years: ≤ 0.3% 0.5 – 1.0% 10,000 – 12,000 2 – 20% About 1 – 3%,
≥ 40 years: 2.1% annually 15 – 25% in pregnant
women
1) A,B,C,D,E; 2) Any four of the following: fatigue, myalgia, loss of appetite, nausea, diarrhea,
constipation, fever, jaundice; 3) False; 4) a and b; 5) d
1) d; 2) HBsAg, HBeAg, Total anti-HBc, anti-HBc IgM, anti-HBe, anti-HBs, and if listed, HBV DNA
could be included in this list as well; 3) c; 4) True; 5) False (70%); 6) Nausea, diarrhea, malaise, dark
urine, jaundice; 7) b; 8) c; 9) a, c, d; 10) HBsAg, HBeAg, anti-HBe and anti-HBs; 11) False; 12) b;
13) False (provides prolonged immunization); 14) d; 15) True
1) Any two of the following: injecting drug use, use of inadequately sterilized or completely
unsterilized healthcare equipment, transfused blood not screened for HCV, organ or tissue
transplants from an HCV infected donor, sexual or household contacts, perinatal exposure, body
piercing, tattooing; 2) c. 170 million; 3) d. 60 – 85%; 4) b. 10 – 20%; 5) b.; 6) False. There is currently
no vaccine for HCV, and immune globulin is not recommended.