Viral Hepatitis

DDS Programme (Year 2)

Session 2017/18 (Semester 2)
Department of Microbiology

Dr. Deepa Anbazhagan 20-05-2017

At the end of the lesson, the students should be able to :
1 Virology of hepatitis viruses
 hepatitis A virus
 hepatitis B virus
 hepatitis C virus
 hepatitis D virus
 hepatitis E virus
 hepatitis G virus
 transfusion transmitted viruses (TTV)

2 Epidemiology, pathogenesis, clinical manifestations, laboratory diagnosis,

treatment and prevention of the flowing viral hepatitis:
 hepatitis A
 hepatitis B
 hepatitis C
 hepatitis D
 hepatitis E
 hepatitis G
 post-transfusion hepatitis

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Hepatitis means inflammation and damage to the
liver, and has differing aetiologies including:

 non-infectious multisystemic conditions

 drug toxicity
 infectious agents (include viruses and less
commonly bacteria and other microbes).

There is a broad spectrum of clinical illness ranging from

asymptomatic, symptomatic with malaise, anorexia,
nausea, abdominal pain and jaundice, to acute life-
threatening liver failure.
 Viruses that cause acute viral hepatitis:

Hepatitis A virus (HAV) Viral hepatitis type A (VHA)

Hepatitis B virus (HBV) Viral hepatitis type B (VHB)
Hepatitis C virus (HCV) Viral hepatitis type C (VHC)
Hepatitis D virus (HDV) Viral hepatitis type D (VHD)
Hepatitis E virus (HEV) Viral hepatitis type E (VHE)
Hepatitis G virus (HGV) Viral hepatitis type G (VHG)
Transfusion-transmitted Viral hepatitis non A - G
virus (TTV)
The main viruses causing hepatitis in humans

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Other viruses causing hepatitis include:

 Epstein–Barr virus (mild hepatitis in 15% of infected

adults and adolescents)

 Cytomegalovirus

 Herpes simplex virus

 Intrauterine infection with rubella or

 Cytomegalovirus causes hepatitis in the new-born

 Enteroviruses
 Viral hepatitis type A (VHA)

Causal organism - Hepatitis A virus (HAV)

Family – Picornaviridae
Genus – Hepatovirus

 HAV is a 27- to 32-nm

spherical particle with cubic symmetry
 Has linear single-stranded RNA genome.
 At the 5' end of the RNA strand is a viral protein called
VPg.
 There is no antigenic cross-reactivity with the other
hepatitis viruses. (Only one serotype is known.)
 
HAV is stable to treatment with:
 20% ether
 acid (pH 1.0 for 2 hours)
 heat (60 for 1 hour)
Its infectivity can be preserved for
 at least 1 month after being dried and stored at 25 and
42% relative humidity
 years at - 20
The virus is destroyed by:
 autoclaving (121 for 20 minutes)
 boiling in water for 5 minutes
 dry heat (180 for 1 hour)
 ultraviolet irradiation
 treatment with formalin or chlorine
Epidemiology of HAV:
 HAV is widespread throughout the world.
 Outbreaks of type A hepatitis are common in families
and institutions, summer camps, day care centers,
neonatal intensive care units and among military troops.

Pathogenesis of VHA:
* HAV spreads from person to person by:
- close contact (poor hand hygiene)
- contamination of food or water (raw oysters)
- intimate contact (anal intercourse)
* route of infection = fecal-oral route (mainly)
* principal age distribution = children and young adult
Clinical features:
- sudden onset of fever with anorexia, nausea
vomiting and jaundice (more common in adult)

Outcomes of hepatitis A virus

infection:

Complications:
- uncommon, complete recovery, no chronicity
no carrier state
Laboratory diagnosis:
Specimen:
 Stool (2 weeks before and after jaundice)
 Blood (2 weeks before and 1 week after jaundice)

# immune electron microscopy

# primate cell line culture
# PCR

Serology: (routinely and widely used, ELISA)

 Anti-HAV of the IgM type is a marker of acute infection.
 Anti-HAV of the IgG type indicates the patient had a
previous HAV infection.
 
Treatment:
- There is no antiviral therapy.
- supportive therapy
Prevention and control:
- Formalin inactivated HAV vaccine made from
cell culture-adapted virus.

The vaccine is recommended to:

* children 1 year of age

* international travelers
* homosexuals and IVDUs

- proper hand wash, food sanitation

 Viral hepatitis type E

Causal organism - Hepatitis E virus (HEV)

Family - Hepeviridae
Genus - Hepevirus
Epidemiology:
 Hepatitis E virus (HEV) is transmitted enterically and
occurs in epidemic form in developing countries, where
water or food supplies are sometimes fecally
contaminated.
 Animal strains of HEV are common throughout the
world.
 There is the possibility of spread of virus from animals
to humans.
Structure and composition:
 It is 30-32 nm in size and icosahedral symmetry
 no envelope
 a positive-sense, ss RNA
 It is heat stable

Pathogenesis of VHE:
• Spreads by fecal-oral route
• Incubation period is 6 – 8 weeks
• The disease is generally mild.
• Virus is eliminated from the body on recovery
• No carrier-state
Complication:
The disease is severe in pregnant women, with a high
mortality, up to 20% during the third trimester due to
fulminant hepatitis.

Laboratory diagnosis:
- by serological tests to detect HEV specific IgM

Prevention and control:

General measures:
 cut the fecal-oral transmission
Specific measures:
 Two recombinant vaccines have undergo successful
clinical trials.
 Viral hepatitis type B (VHB)
Causal organism - Hepatitis B virus (HBV)
Family - Hepadnaviridae
Genus – Orthohepadnavirus

Epidemiology:

 HBV is worldwide in
distribution.
 Modes of transmission
and response to infection vary, depending on the age at
time of infection.
Structure and composition:

Electron microscopy of HBs Ag-positive serum reveals

three morphologic forms.

 The most numerous are spherical particles measuring

22 nm in diameter. These small particles are made up
exclusively of HBs Ag.
 Tubular or filamentous forms, which have the same
diameter but may be over 200 nm long and result from
overproduction of HBs Ag.
 Larger, 42-nm spherical virions (Dane particles) are less
frequently observed. It is the infectious particle.
Small spherical
particle

Tubular form Dane particle

 HBV (Dane particle) is 42 nm spherical particle.
 The outer surface or envelope contains HBsAg and
surrounds a 27-nm inner nucleocapsid core that
contains HBcAg.
 The viral genome consists of partially double-stranded
circular DNA.
 The full-length DNA minus strand (L or long strand) is
complementary to all HBV mRNAs.
 The positive strand (S or short strand) is variable and
between 50 and 80% of unit length.
 Different HBV isolates share 90–98% nucleotide
sequence homology.
 The particles containing HBsAg are antigenically
complex.
 Each contains a group-specific antigen a in addition to
two pairs of mutually exclusive subdeterminants, d/y
and w/r.
 Thus, four phenotypes of HBs Ag have been observed:
adw, ayw, adr, and ayr.
HBsAg and infectious particles are:
* stable at -20 °C for over 20 years
* stable to repeated freezing and thawing
* not destroyed by ultraviolet irradiation of
blood products
Infectious particles (HBV) are :
* stable at 37 °C for 60 minutes
* remains viable after being dried and stored
at 25 °C for at least 1 week.
HBV is sensitive to:
* 100 °C for 1 minute or 60 °C for 10 hours.
HBsAg is destroyed by:
* 0.5% Sodium hypochlorite
Characteristics of hepatitis B virus (HBV)
antigens (Ag) and antibodies (Ab)

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Pathogenesis of VHB:

Modes of transmission:
1) Parenteral transmission
- transfusion of infected/ contaminated blood
- transfusion with contaminated needle,
syringe or infusion set, (needle stick injury)
2) Sexual transmission
- heterosexual/homosexual/bisexual
3) Vertical transmission (from infected mother to
- fetus via placental transmission (prenatal)
- fetus contact with vaginal secretion (perinatal)
- infant via mother’s breast milk (postnatal)
HBs Ag can be detected in saliva, naso-pharyngeal
washings, semen, menstrual fluid.
Transmission from carriers to close contacts by the oral
route or by other intimate exposure occurs.
Incubation period = 50 – 180 days
(Avg. 60 – 90 days)
 After entering the body, the virus reaches the blood,
then the liver, where the result is inflammation and
necrosis.
 Much of the pathology is immune mediated, as infected
liver cells are attacked by virus specific cytotoxic T cells.
The immune response slowly becomes effective, virus
replication is reduced and eventually, although
sometimes not for many months, the blood become
non-infectious.

Clinical features:
- insidious onset
- fever (less common), jaundice
- nausea, vomiting and anorexia
- skin rash
- polyarthritis due to circulating
- glomerulonephritis immune complex
Clinical outcomes of acute HBV infection
Laboratory diagnosis of VHB:

Specimen - peripheral blood

* Electron microscopic examination
* PCR for detection of viral DNA
Serology: (routinely and widely used)
* detection of HBV antigens and antibodies
* ELISA
Tests for liver enzymes:
* Aspartate aminotransferase
* Alanine aminotransferase
* Total bilirubin
* Alkaline phosphatase
 Serological markers of HBV
HBsAg first serologic marker to appear
usually detectable 2-6 weeks in advance of
clinical and biological evidence of hepatitis
persists throughout the clinical course

disappears with clinical improvement

presence with high titre of IgM anti-HBc

indicates acute infection
persistence beyond 6 months indicates
chronic infection or carrier state
 Serological markers of HBV
HBeAg marker of infectivity
detectable in acute or chronic HBV infection
persistence beyond 10 weeks indicates likely
chronic liver disease.
associated with HBV replication, with high titres
of HBV in serum
anti HBc indicates current or previous infection

not associated with immunity.

simultaneous presence of IgM anti-HBc with
HBsAg indicates acute infection
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 Serological markers of HBV
anti HBe presence in serum of HBs Ag carrier suggests
lower titer of HBV and decreased infectivity.

anti HBs marker of recovery and immunity

detectable after HBs Ag disappears and
recovery is complete.

indicate immunity after inoculation with

hepatitis B vaccine or presence of antibody
from HBIG.

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Serum Glutamate-Pyruvate
Transaminase (SGPT) also known as
Alanine Transaminase (ALT)

Self-limited HBV infection

 Interpretation of HBV serologic markers
HBs Ag Anti-HBs Anti-HBc Interpretation
Positive Negative Negative Early acute HBV infection
Positive (+ / -) Positive HBV infection, either acute or chronic

Negative Positive Positive Previous HBV infection and immunity to

HBV infection
Negative Negative Positive - HBV infection in remote pass
- Low level HBV carrier
- Window” between disappearance of
HBs Ag and appearance of Anti-HBs
- False positive or non-specific reaction

Negative Negative Negative - Never infected with HBV

- Possibility of another infectious agent
Negative Positive Negative Vaccine type response
 
Treatment:

 recombinant interferon-
 antiviral drugs
 Lamivudine single or combine therapy
 Adefovir for long duration
 Liver transplant for chronic hepatitis with end-stage
liver damage.
Prevention and control:

1) General measures:
- aware of modes of transmission

2) Specific measures:
* Pre-exposure prophylaxis
Active immunization by hepatitis B vaccine
- plasma derived hepatitis B vaccine
- recombinant hepatitis B vaccine
- polypeptide vaccine (22nm particles.)
- recombinant of live vaccinia virus and the
HBsAg gene
Active immunization to:
 newborn babies
 health care workers/ laboratory personal

Post-exposure prophylaxis
Specific hepatitis B immune globulin (HBIG)

Passive immunization to:

 baby born to HBsAg positive mother
 needle prick injuries from a contaminated needle
 direct mucous membrane contact arising from a splash
or pipetting accident.
 
Viral hepatitis D (VHD)

Causal organism - Hepatitis D virus (HDV)

Genus = Deltavirus (Delta () virus)

Epidemiology:

 HDV is found throughout the world but with a non-

uniform distribution.
 The primary routes of transmission are believed to be
similar to those of HBV, though HDV does not appear
to be a sexually transmitted disease.
 
Structure and composition:
 35-37 nm, spherical particle
 Ag is surrounded by an HBsAg envelope
 consists of single stranded, circular negative-sense
RNA

 It is a defective virus because it can successfully

multiply in a cell only when the cell is infected with
HBV at the same time. HDV uses HBV’s S-glycoprotein
in it’s membrane to facilitate cell entry.
 It is sensitive to acid
Pathogenesis of VHD:
HDV infected blood contains very large amounts of virus.
Its spread is similar to that of the other parenterally
transmitted hepatitis viruses.
HDV infection may occur at the same time as an HBV
infection.
The resulting disease is often more severe than with
HBV alone.

Coinfection - susceptible persons who are simultaneously

infected with both HBV and HDV
Superinfection - HDV superinfection of a HBV carrier
(more severe and can cause fatal outcome).
 
Laboratory diagnosis:
Specimen - Blood/ serum
Serological test:
 detection of HD antigen ( antigen)
 detection of HD Ig M and Ig G

Anti-HDV (+) & HBs Ag (+) - infection with HDV

Anti-HDV (+) & Anti-HBc IgM (+) - co-infection
Anti-HDV (+) & Anti-HBc IgM (-) - superinfection

Prevention and control:

 No HDV specific vaccine
 Successful HBV immunization prevents HDV infection.
 Viral hepatitis type C (VHC)

Causal organism - Hepatitis C virus (HCV)

Family - Flaviviridae
Genus – Hepacivirus

Epidemiology:
 Infections by HCV are extensive throughout the world.
 The World Health Organization estimated in 1997 that
about 3% of the world population has been infected.

Hepatitis C virus was the most common cause of

transfusion-associated non-A-non-B viral hepatitis
Morphology and composition:

 60 nm in diameter and spherical particle

 envelope present
 single stranded RNA
 sensitive to ether and acid

 by RNA sequence analysis, there has at least six major

genotypes and more than 100 subtypes.
Pathogenesis of VHC:
Modes of transmission:
1) Parenteral transmission (10 – 50%)
 injecting drug users (about 80%),
 Blood and blood products recipients (10%)
chronic hemodialysis patients
2) Sexual transmission (1%)
3) Vertical transmission (3 – 10%)

 No risk of transmission has been associated with

breast feeding.
 HCV was found in saliva from more than a third of
patients with HCV and HIV co-infections.
 Incubation period is 2 – 4 months
 HCV envelope binds to the hepatocyte cell surface
membrane allowing viral entry.
 some of the HCV proteins interfere with host’s
response and other evasive measures include the high
degree of genetic diversity due to the high error rate of
RNA replication.
 six genotypes and multiple subtypes have been
identified.
 Viral clearance is associated with both the
development and persistence of strong HCV-specific
cytotoxic T cell and helper T cell responses.
 Being infected with one genotype does not protect
against the others.
Clinical outcomes of acute hepatitis C virus infection
 
Laboratory diagnosis:
Specimen - Blood/ serum

Serological tests
 detection of HCV antibody (EIA)[can not distinguish
among acute, chronic or resolved infection]
 qualitative and quantitative HCV RNA detection
 Genotype analysis

Treatment:
 Pegylated INF combined with ribavirin, telaprevir or
boceprevir
 Liver transplant for chronic hepatitis with end-stage
liver damage.
 No vaccine is available for prevention
Viral hepatitis type F:
 Hepatitis F is a hypothetical virus linked to hepatitis.
 That novel viral particles had been discovered in the stool
of post-transfusion patients.
Viral hepatitis type G:
 It is also known as GB virus C (GBV-C)
 GBV-C infection has been found worldwide and currently
infects approximately one sixth of the world's
population.
 High prevalence is observed among subjects with the risk
of parenteral exposures.
 Sexual contact and vertical transmission may occur.
Transfusion-transmitted virus (TTV)
 Viral hepatitis non A – G
 Non-A-G hepatitis consists of all of the hepatitis viruses
References:

1. Jawetz, Melnick & Adelberg’s Medical Microbiology

(27th. Ed.) (2016). Lange

2. Richard V. Goering, Hazal M. Dockrell, Mark

Zuckerman, Ivan M. Roitt, Peter L. Chiodini “ Mims’
Medical Microbiology” (5th. Ed.)(2013). Elsevier
Saunders

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