# Presentation: 883640

## Concentration of Hepatitis B Virus 

**Concentration of Hepatitis B Virus **
**in Various Body Fluids**

**High**

**Moderate**

**Low/Not**

**Detectable**

- blood

- semen

- urine

- serum

- vaginal fluid

- feces

- wound exudates

- saliva

- sweat

- tears

- breastmilk

**Notes:**
1
1
1

## Sexual

- Parenteral
- Perinatal

**Hepatitis B Virus **
**Modes of Transmission**

**Notes:**
2
2
2

## Risk Factors for Acute Hepatitis B

**Risk Factors for Acute Hepatitis B**
**United States, 1992-1993**

*** Includes sexual contact with acute cases, carriers, and multiple partners.**
** ****Source: CDC Sentinel Counties Study of Viral Hepatitis**

**Heterosexual***
**          ****(41%)**

**Homosexual Activity (9%)**

**Household Contact (2%)**

**Health Care Employment (1%)**

**Other (1%)**

**Unknown (31%)**

**Injecting**
**Drug Use**
**(15%)**

**Notes:**
3
3
3

## Objectives

- Prevent chronic HBV Infection
- Prevent chronic liver disease
- Prevent primary hepatocellular carcinoma
- Prevent acute symptomatic HBV infection

- Elimination of Hepatitis B Virus Transmission United States

***Objectives***

**Notes:**
4
4
4

## Strategy

- Prevent perinatal HBV transmission
- Routine vaccination of all infants
- Vaccination of children in high-risk groups
- Vaccination of adolescents
- all unvaccinated children at 11-12 years of age
- “high-risk” adolescents at all ages
- Vaccination of adults in high-risk groups

- Elimination of Hepatitis B Virus Transmission United States

***Strategy***

**Notes:**
5
5
5

## *

**Estimated Incidence of Acute Hepatitis B**
**United States, 1978-1995**

**Vaccine**
**licensed**

**HBsAg screening**
**of pregnant women recommended**

**Infant**
**immunization**
**recommended**

**OSHA Rule**
**enacted**

**Adolescent immunization recommended**

*****

**Decline among homosexual  men & HCWs**

**Decline among injecting**
**drug users**

**80**

**70**

**60**

**50**

**40**

**30**

**20**

**10**

**0**

**78**

**79**

**80**

**81**

**82**

**83**

**84**

**85**

**86**

**87**

**88**

**89**

**90**

**91**

**92**

**93**

**94**

**95**

**Year**

**Cases per 100,000 Population**

******* Provisional date**

**Notes:**
6
6
6

## Hepatitis C Virus

**Hepatitis C Virus**

**hypervariable**
**region**

**capsid**

**envelope**
**protein**

**protease/helicase**

**RNA-dependent**

**RNA polymerase**

**c22**

**5’**

**core**

**E1**

**E2**

**NS2**

**NS3**

**33c**

**NS4**

**c-100**

**NS5**

**3’**

**Notes:**
7
7
7

## Hepatitis C - Clinical Features

**Hepatitis C - Clinical Features**

- Incubation period:			Average 6-7 wks
- 								Range 2-26 wks
- Clinical illness (jaundice):	30-40% (20-30%)
- Chronic hepatitis:			70%
- Persistent infection:			85-100%
- Immunity:					No protective antibody
- 								response identified

**Notes:**
8
8
8

## Primary Etiology of Chronic Liver Disease

- Mutually Exclusive Groups

** ****Source: CDC unpublished data**

**Hepatitis C Virus**
**26%**

**Hepatitis C Virus**
**and Alcohol 14%**

**Alcohol 24%**

**Cryptogenic**
**17%**

**Other 5%**

**Hepatitis B Virus (11%)**
**and Alcohol (3%)**
**14 %**

**Jefferson County, Alabama, 1989**

** ****(n=140)**

**Notes:**
9
9
9

## Hepatitis C Virus Infection

**Hepatitis C Virus Infection**

**Typical Serologic Course**

**Symptoms**

**Time after Exposure**

**Titer**

**anti-HCV**

**ALT**

**Normal**

**0**

**1**

**2**

**3**

**4**

**5**

**6**

**1**

**2**

**3**

**4**

**Years**

**Months**

**Notes:**
10
10
10

## Risk Factors Associated with

- Transfusion or transplant from infected donor
- Injecting drug use
- Hemodialysis (yrs on treatment)
- Accidental injuries with needles/sharps
- Sexual/household exposure to anti-HCV-positive contact
- Multiple sex partners
- Birth to HCV-infected mother

**Risk Factors Associated with**
**Transmission of HCV**

**Notes:**
11
11
11

## Estimated Incidence of Acute Hepatitis C

**Estimated Incidence of Acute Hepatitis C**
**United States, 1982-1993**

** ****Source: CDC Sentinel Counties Study of Acute Viral Hepatitis**

**Year**

**Cases per 100,000**

**Surrogate testing**
**of blood donors**

**Anti-HCV test**
**(1st generation)**
**licensed**

**Anti-HCV test**
**(2nd generation)**
**licensed**

**Decline among**
**injecting drug users**

**Decline among**
**transfusion recipients**

**1983**

**1985**

**1987**

**1989**

**1991**

**1993**

**0**

**5**

**10**

**15**

**20**

**25**

**Notes:**
12
12
12

## Risk Factors for Acute Hepatitis C

**Risk Factors for Acute Hepatitis C**
**United States, 1990-1993**

**Transfusions (4%)**
**   ****None (1%)**

**Other High Risk/**
**Low Socioeconomic Status (44%)**

**Sexual/Household (10%)**

** ****Hemodialysis (1%) Occupation (2%)        **

** ****Injecting**
**Drug Use (38%)        **

** ****Source: CDC Sentinel Counties Study of Acute Viral Hepatitis**

**Notes:**
13
13
13

## Slide 14

**Notes:**
14
14
14

## Prevention of Hepatitis C

- Screening of blood, organ, tissue donors
- High-risk behavior modification
- Blood and body fluid precautions

**Prevention of Hepatitis C**

**Notes:**
15
15
15

## “Recent studies indicate that IG does not protect against infection with HCV. Thus, available data do not support the use of IG for postexposure prophylaxis of hepatitis C. There are no data on the efficacy of IG for postexposure prophylaxis of other (non-HCV) parenterally-transmitted non-A, non-B hepatitis.”

- “Recent studies indicate that IG does not protect against infection with HCV. Thus, available data do not support the use of IG for postexposure prophylaxis of hepatitis C. There are no data on the efficacy of IG for postexposure prophylaxis of other (non-HCV) parenterally-transmitted non-A, non-B hepatitis.”

- Postexposure Prophylaxis for Hepatitis CAdvisory Committee on Immunization Practices (ACIP)
- Revised Recommendation, February 1994

**Notes:**
16
16
16

## No protective antibody response identified

- Prior studies of IG use to prevent post-transfusion hepatitis may not be relevant
- IG prepared from high anti-HCV titer plasmadid not prevent infection in chimpanzees

- Postexposure Prophylaxis for Hepatitis C
- Issues and Considerations for Recommendations

**Notes:**
17
17
17

## Public Health Service Guidelines

**Public Health Service Guidelines**
**for Counseling Anti-HCV-Positive Persons**

- Anti-HCV-positive persons should:
- Be considered potentially infectious
- Keep cuts and skin lesions covered
- Be informed of the potential for sexual transmission
- Be informed of the potential for perinatal transmission
- no evidence to advise against pregnancy or breastfeeding
- Anti-HCV-positive persons should not:
- Donate blood, organs, tissue, or semen
- Share household articles (e.g., toothbrushes, razors)

**Notes:**
18
18
18

## Hepatitis D (Delta) Virus

**Hepatitis D (Delta) Virus**

**HBsAg**

**RNA**

**δ**** antigen**

**Notes:**
19
19
19

## Hepatitis D - Clinical Features

- Coinfection
- severe acute disease
- low risk of chronic infection
- Superinfection
- usually develop chronic HDV infection
- high risk of severe chronic liver disease

**Hepatitis D - Clinical Features**

**Notes:**
20
20
20

## Hepatitis D Virus

- Percutanous exposures
- injecting drug use
- Permucosal exposures
- sex contact

**Hepatitis D Virus**
**Modes of Transmission**

**Notes:**
21
21
21

## HBV - HDV Coinfection

**HBV - HDV Coinfection**

**Typical Serologic Course**

**Time after Exposure**

**Titer**

**anti-HBs**

**Symptoms**

**ALT Elevated**

**Total anti-HDV**

**IgM anti-HDV**

**HDV  RNA**

**HBsAg**

**Notes:**
22
22
22

## HBV - HDV Superinfection

**HBV - HDV Superinfection**

**Typical Serologic Course**

**Time after Exposure**

**Titer**

**Jaundice**

**Symptoms**

**ALT**

**Total anti-HDV**

**IgM anti-HDV**

**HDV RNA**

**HBsAg**

**Notes:**
23
23
23

## Geographic Distribution of HDV Infection

**Geographic Distribution of HDV Infection**

**HDV Prevalence**

**High**

**Intermediate**

**Low**

**Very Low**

**No Data**

**Taiwan**

**Pacific Islands**

**Notes:**
24
24
24

## Hepatitis D - Prevention

- HBV-HDV Coinfection
- Pre or postexposure prophylaxis to prevent HBV infection
- HBV-HDV Superinfection
- Education to reduce risk behaviors among persons with chronic HBV infection

**Hepatitis D - Prevention**

**Notes:**
25
25
25

## Hepatitis E Virus

**Hepatitis E Virus**

**Notes:**
26
26
26

## Hepatitis E - Clinical Features

**Hepatitis E - Clinical Features**

- Incubation period:		Average 40 days
- 							Range 15-60 days
- Case-fatality rate:		Overall, 1%-3%						Pregnant women, 15%-25%
- Illness severity:		Increased with age
- Chronic sequelae:		None identified

**Notes:**
27
27
27

## Hepatitis E Virus Infection

**Hepatitis E Virus Infection**

**Typical Serologic Course**

**Weeks after Exposure**

**Titer**

**Symptoms**

**ALT**

**IgG anti-HEV**

**IgM anti-HEV**

**Virus in stool**

**0**

**1**

**2**

**3**

**4**

**5**

**6**

**7**

**8**

**9**

**10**

**11**

**12**

**13**

**Notes:**
28
28
28

## Hepatitis E - 

- Most outbreaks associated withfecally contaminated drinking water
- Minimal person-to-person transmission
- U.S. cases usually have history of travelto HEV-endemic areas

**Hepatitis E - **
**Epidemiologic Features**

**Notes:**
29
29
29

## Geographic Distribution of Hepatitis E

**Geographic Distribution of Hepatitis E**

- Outbreaks or Confirmed Infection in >25% of Sporadic Non-ABC Hepatitis

**Notes:**
30
30
30

## Prevention and Control Measures for Travelers to HEV-Endemic Regions

**Avoid drinking water (and beverages with ice) of unknown purity, uncooked shellfish, and uncooked fruit/vegetables not peeled or prepared by traveler**
**IG prepared from donors in Western countries does not prevent infection**
**Unknown efficacy of IG prepared from donors in endemic areas**
**Vaccine?**

- Prevention and Control Measures for Travelers to HEV-Endemic Regions

**Notes:**
31
31
31