Viral HepatitisTutorialTutorial

FEATURE A B C D E G TTV

Family Piconavi

ridae

ssRNA+

Hepadna

viridae

dsDNA

Flaviviri

dae

ssRNA+

Unclssifi

ed

ssRNA-

Hepeviri

dae

ssRNA+

Flaviviri

dae

ssRNA+

Anellovi

ridae

ssDNA-

Genus Hepato

virus

Orthohe

padnavirus

Hepaci

virus

Deltavirus Hepevirus Tentative

Hepaci

virus

Anello

virus

Mean IP (days) 20-30 60-90 60-90 60-90 20-30 ? ?

Hepatitis Viruses

Typical onset Sudden Slow Slow Variable Sudden ? ?

Age preference Child –

young

adult

All All All All ? ?

Severity Usually

mild

Modera

te

Can be

severe

Severe

in

HBV+

Usually

mild

? ?

Acute Fulminat

hepatitis

<0.5% <1-2% 0.5-1% high 1-2% ? ?

FEATURE A B C D E G TTV

Chronicity None Low-Mod High Mod-high None Likely Likely

Carrier state None Yes Yes Yes None Likely Likely

Serologic

detection

Yes Yes Yes Yes Yes No No

Transmission Faeco-

oral

Blood

Sexual

Blood

Sexual

Blood

Sexual

Faeco-

oral

Blood

Sex

Blood

?Faeco-

Hepatitis Viruses (Cont)

Sexual

Perinatal

Sexual

Perinatal

Sexual Sex

Vertical

?Faeco-

oral

?Vertical

Hyper Ig

protection

Yes Yes ? Yes (B) None ? ?

Vaccine + + - (B) - - -

Antiviral

Treatment

- IFN

3TC

Adefovir

IFN

Ribavirin

- - - -

Symptoms

ALTALT

Total anti-HAVTotal anti-HAV

Titer

Titer

Hepatitis A Virus InfectionTypical Serologic Course

Hepatitis A Virus InfectionTypical Serologic Course

FecalHAV

IgM anti-HAVIgM anti-HAV

Months after ExposureMonths after Exposure

Titer

Titer

0 1 2 3 4 5 6 12 24

HBs

Ag

Hbe

Ag

Anti-HBc Anti

HBe

Anti

HBsInterpretation

IgM IgG

+ + - - - - Incubation period

+ + + + - - Acute hepatitis B infection

+ + - + - - Carrier state

+ - +/- + + - Carrier state

- - +/- + + + Convalescence

HBV

- - - + - + Recovery

- - + - - - HBV Infection without detectable HBsAg

- - - + - -

Possibilities:

(1) HBV infection in remote pass,

(2) “low level” HBV carrier

(3) “window” bet disappearance of HBsAg

and appearance of HBsAb,

(4) False positive or non specific reaction

- - - - - + Vaccine type response

Common HBV Serology Patterns

Interpretation HBsAgAnti-

HBcIgM

Total

Anti-

HBc

Anti-

HBS

No evidence of HBV infection - - - -

Acute HBV infection + + + -

Chronic HBV (if HBsAg + for >6mths) + - + -Chronic HBV (if HBsAg + for >6mths) + - + -

(1)“Window” period

(2) HBV infection in remote pass,

(3) “low level” HBV carrier

(4) False positive

- + + -

Previous HBV infection - - + +

HBV vaccine response - - - +

HBs

Ag

Anti HBc Anti

HBs

Anti-DeltaInterpretation

Total IgM Total IgM

+ + + - + + Acute coinfection with HBV and

Delta

+ + - - + +Acute Delta superinfection (anti-

Delta low), or chronic Delta

superinfection (anti-Delta low)

HDV

+ + - - + -

Recovery from acute Delta

superinfection (anti-Delta low), or,

rarely, chronic Delta

superinfection (anti-Delta level

high), usually without symptoms

- + - - + -Previous HBV and Delta infection

with probable recovery

- + - + + -Recovery from HBV and Delta

infection

Streptavidin

Level 3+ anti-human IgG, strong positive

Level 1+ human IgG, moderate positive

Level + human IgG, weak positive

C1

INNO-LIA

C2

E2

NS3

NS4

NS5

HCV Antigens

INNO-LIA

• Negative For HCV Ab-all HCV Ag lines negative

-only one HCV Ag lines + (except NS3)

• Positive For HCV Ab-at least 2 HCV Ag lines + or >-at least 2 HCV Ag lines + or >

• Indeterminate for HCV Ab-one HCV Ag line 1+ or >-NS3 + or >

Interpreting HCV Test Results

Anti HCV/HCV infection Positive

(1) Anti-HCV screening test positive and RIBA/NAT positive; or

(2) Anti-HCV screening test positive, NAT negative, RIBA-positive

Anti-HCV/HCV infection Negative

(1) Anti-HCV screening test negative; or

(2) Anti-HCV screening test positive, RIBA negative

(3) Anti-HCV screening test positive, NAT negative, RIBA negative

Anti-HCV Indeterminate

An indeterminate anti-HCV result is defined as anti HCV screening test positive, RIBA indeterminate

Algorithm For The Serologic Diagnosis Of HAV, HBV, HCV, HDV & HEV

Anti-HAV

IgM

Request anti-HAV IgG to

exclude previous infection*Recent HAV infectionNegative Positive

*Exclude recent transfusions, Ig, or maternal Ab

Anti-HEV

IgM

Request anti-HEV IgG to

exclude previous infection*

Recent HEV infectionNegative Positive

Algorithm For The Serologic Diagnosis Of HAV, HBV, HCV, HDV & HEV

HCV infection unlikely

Request HCV RNA if

indicated

Anti- HCVActive or previous

HCV infection

HCV RNA

assay

Negative Positive

assay

Active

HCV

Previous HCV

suspected

Negative Positive

Algorithm For The Serologic Diagnosis Of HAV, HBV, HCV, HDV & HEV

HBsAgNegative PositiveAnti-HBc

Total

No active HBV infection Indicates either active or

previous HBV infection

Negative Positive

Request anti-HBs test Request anti-HBs test

No previous

HBV infection

Vaccine type

response*

Active HBV

cannot be

excluded

Previous HBV

infection; immunity

confirmed*

*Exclude recent transfusions, Ig, or maternal Ab

Negative NegativePositive Positive

Active HBV infection

either acute or chronic

HBsAgNegativePositive +anti-HBc positive

Anti-HBc

IgM

Anti-HDV

IgG

Recent / Chronic

Negative PositiveHDV

HBeAg

Anti-HBeNo active

HDV Anti-HDV

Positive Negative

NegativeRecent /

Ac HBV

infection

Chronic

HBV

infection

Anti-HBe

HBV

infectivity is

relatively high

HBV

infectivity is

relatively low

Anti-HBe

positive

HBeAg

positive

Neither

positive

HDV infection

acute or chronic

HDV

infection

Anti-HDV

IgM/

HDVRNA

Negative

Positive