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The Alphabet of Hepatitis 101: An Overview. Jeff Wagers Program Specialist, HIV/STD Prevention & Care Branch May 19, 2009. Objectives. Define hepatitis and list the causes Describe some general facts and symptoms of hepatitis Discuss the basics of Hepatitis A, B, and C

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the alphabet of hepatitis 101 an overview

The Alphabet of Hepatitis 101:An Overview

Jeff Wagers

Program Specialist,

HIV/STD Prevention & Care Branch

May 19, 2009

  • Define hepatitis and list the causes
  • Describe some general facts and symptoms of hepatitis
  • Discuss the basics of Hepatitis A, B, and C
  • Describe the prevention strategies of hepatitis A, B and C
causes of hepatitis
Causes of Hepatitis
  • Inflammation of the Liver
  • Caused by:
    • Alcohol
    • Drugs/medications
    • Toxins/chemicals
    • Autoimmune diseases
    • Bacteria
    • Viral Infections (hepatitis A, B, C, D and E)
viral hepatitis
Viral Hepatitis
  • Hepatitis A Virus
  • Hepatitis B Virus
  • Hepatitis C Virus
  • *Hepatitis D Virus – only causes problems for people infected with HBV
  • *Hepatitis E Virus – not common in US
facts about viral hepatitis
Facts About Viral Hepatitis
  • Infect liver cells which causes inflammation
  • Differ in how they are transmitted and treated
  • Infection with one does not “turn” into another
  • None are airborne
  • All types may cause similar symptoms
  • Hepatitis A, B, D are vaccine preventable
  • May cause liver damage over time, esp. if severe or long-term
  • Hepatitis B and C can be chronic
symptoms of hepatitis infection
Symptoms of Hepatitis Infection
  • Jaundice
  • Fatigue
  • Abdominal Pain
  • Loss of Appetite
  • Nausea
  • Diarrhea
  • Fever
  • Dark Urine (HCV)
  • Often No Symptoms
hav transmission
HAV Transmission
  • Hepatitis A is transmitted through fecal-oral contact:
    • Rimming (oral/anal sex)
    • Food preparation
    • Changing diapers
    • Contaminated water
    • Contaminated shellfish
hav transmission 2
HAV Transmission (2)
  • Casual contact does not spread the virus
  • HAV-infected person can be considered infectious from 2 weeks before to 1 week after the onset of illness (may be longer in children)
  • Often there are no symptoms, especially in children
symptoms of hav infection
Symptoms of HAV Infection
  • Takes 15-50 days to develop symptoms (average is 30 days)
  • Duration of symptoms: usually less than 2 months
  • Often abrupt onset of symptoms
  • No chronic disease
  • Once infected, always immune
  • Jaundice varies by age group
who is at risk for hav infection
Who is at risk for HAV infection?
  • Household and sexual contacts of infected people
  • Travel to countries and areas of the US where HAV is common
  • Men who have sex with men
  • People who engage in oral/anal sex
  • IDU and non-injecting drug users
hav prevention
HAV Prevention
  • Vaccination is the best protection (2 shots)
  • Wash hands after using the restroom, changing diapers
  • Thoroughly wash food
  • Use of gloves
  • Harm reduction for oral/anal sex & IDU
  • Avoid contaminated water in high-incidence countries
who should get vaccinated
Who Should Get Vaccinated?

Those at risk, as well as:

  • Routine childhood vaccination in high risk areas
  • HIV-infected persons
  • People with chronic liver disease (Hepatitis B and C)
  • Lab workers, occupational exposure
  • Some populations (Native American, Alaskan Natives)
hbv prevalence
HBV Prevalence
  • 1 out of 20 people have been infected
  • 1 out of 200 people are chronically infected (1.25 million)
  • Number of new infections each year has declined from about 260,000 in mid-1980s to about 60,000 in 2004 (75% reduction)
  • More than 11,000 people are hospitalized each year because of HBV infection
  • ≈5,000 people die each year from HBV-related liver disease
acute hbv infection
Acute HBV Infection
  • About 60-70% of adults with HBV infection may experience symptoms of acute infection
  • Symptoms usually appear within 4-6 weeks
  • Infectious during acute phase
  • 90-95% will develop an effective immune response and clear virus from body
  • 5-10% develop chronic infection
chronic hbv infection
Chronic HBV Infection
  • Some may have few or no symptoms
  • 15-40% of those with chronic infection may develop liver disease, including liver cancer, cirrhosis or liver failure
  • This means that about 2-3 of 100 people with HBV infection may develop serious symptoms of liver disease, including cirrhosis or liver cancer.
  • Infectious during chronic phase
hbv transmission
  • Blood or body fluids from an infected person enters the body of a person who is not immune:
    • Unprotected sexual activity
    • Sharing injection drug equipment
    • Tattooing
    • During birth from infected mother to baby
    • Contact with open sores of infected person
    • Occupational exposure such as needle sticks or contaminated surgical instruments
    • Household contact such as: sharing razors, toothbrushes, nail clippers contaminated with infected person’s blood
reported risk characteristics among adults with acute hepatitis b united states 2001 2003
*Reported Risk Characteristics Among Adults with Acute Hepatitis B: United States, 2001-2003

Injection drug use

No identified risk









*Other: Household contact, institutionalization, hemodialysis, blood transfusion, occupational exposure

Source: Sentinel Counties Study of Viral Hepatitis, CDC (n=483)

who is at risk for hbv infection and should be vaccinated
Who is at risk for HBV infection? (and should be vaccinated!)
  • Sexual contacts of people with HBV infection
  • People with more than one sex partner within 6 months
  • History of STD/STI
  • MSM
  • IDU
who is at risk for hbv infection 2
Who is at risk for HBV infection? (2)
  • Healthcare workers or public safety workers who might be exposed to infected blood or body fluids
  • Certain household contacts of people with chronic HBV infection
  • Dialysis patients
  • Incarcerated persons and persons who work in correctional facilities



hbv prevention
HBV Prevention
  • Vaccination
  • Avoid sharing injection drug equipment
  • Avoid unprotected sex
  • Screen pregnant women and vaccinate all exposed infants
who should get vaccinated24
Who should get vaccinated?

Persons engaging in high risk activities and also:

  • 18 yrs of age or younger, including babies
  • People with HIV, Hepatitis C, and previous or current liver disease
  • People from or people traveling to countries with high rates
  • Alaska Natives and Pacific Islanders
hbv and hav vaccines
HBV and HAV vaccines
  • HBV-3 dose over 6 months
    • One dose is better than none, two are better than one, and it’s best to get all three!
    • If a person misses a dose or gets behind schedule, provide the next dose as soon as possible. It’s not necessary to add doses or restart.
  • HAV-2 dose 6 months apart
  • Both are safe, effective, few side effects
hcv prevalence
HCV Prevalence
  • 3% of the world population infected (150-200 million)
  • 1.6% of the US population have been infected (4-5 million)
  • At least 3.2 million people are chronically infected
  • 50-90% of IDUs infected
  • 14-42% of incarcerated people infected
  • Up to 42% of homeless people may be infected
  • 8,000-10,000 Americans die each year from HCV-related complications
  • Liver failure due to HCV is leading cause of liver transplants in the US
acute hcv infection
Acute HCV Infection
  • Only 10-25% have symptoms when first infected (1 out of 4).
  • Antibody detection: typically 6-7 weeks
    • Can take up to 24 weeks (6 months)
  • 15-20% spontaneously clear the virus, within three months of infection
chronic hepatitis c infection
Chronic Hepatitis C Infection
  • Usually no symptoms until (or unless) the liver is seriously damaged
    • may be 10 to 30 years after infection.
  • More rapid progression may occur if coinfected with HIV
  • *About 80% develop chronic infection
  • Most remain stable for years
  • Of those with chronic infection:
    • 5-20% develop cirrhosis and serious illness
    • 1-4% develop liver cancer and/or need a transplant
    • 1% will die as a result of HCV disease
  • .
sources of infection for hepatitis c

Previously Acquired ( <1990s )

Newly Acquired ( 1995-2000 )

Injection Drug Use

Injection Drug Use









Other *

Other *









Sources of Infection for Hepatitis C



* In a medical setting; healthcare work, perinatal

Based on Sentinel Counties, NHANES III

hcv transmission idu
HCV TransmissionIDU
  • Most efficient route is percutaneous (direct passage of blood into skin)
  • Sharing of needles, syringes and other paraphernalia from injection drug use is the greatest risk for HCV
  • Injection drug use, even once many years ago, is a risk
  • As many as 90% of IDUs are infected with HCV within 5 years of first injecting
  • IDU accounts for >65% of all new infections
hcv transmission transfusions intranasal drug use
HCV Transmission Transfusions/ Intranasal Drug Use
  • Transfusions:
    • Blood transfusion or organ transplant prior to 1992
    • Clotting factor prior to 1988
    • 90% of hemophiliacs treated before 1988 became infected
  • Intranasal Drug Use
    • Transmission may occur.
    • More studies are needed to determine as an independent factor
hcv transmission sexual
HCV TransmissionSexual
  • Sexual transmission occurs, but it is not the most efficient route
  • Accounts for 10-18% of HCV+ cases
  • Increased risk for people having sex that involves tearing and blood contact
  • Multiple partners and active STDs can increase risk
  • MSMs not at higher risk
hcv transmission perinatal
HCV TransmissionPerinatal
  • Risk of infected mother to infant at birth is less than 5%
  • HIV/HCV coinfection increases risk of HCV transmission up to 20%
  • No data to suggest that C-section is more effective than vaginal delivery in lowering perinatal transmission
  • Breast-feeding not a risk
    • unless nipples are cracked / bleeding
hcv transmission tattooing healthcare workers
HCV TransmissionTattooing/ Healthcare Workers
  • Tattooing and Body Piercing
    • Use of contaminated and homemade equipment increases risk
    • tattooing in prisons or in street settings
    • shared ink
  • Healthcare Workers:
    • Risk from needlestick:


0.3% 2% 30%

    • Prevalence of HCV in healthcare workers is same as in general population
    • Standard universal precautions
hcv transmission household contact
HCV TransmissionHousehold Contact
  • Transmission may occur by sharing items contaminated with blood
    • razors, toothbrushes, clippers
  • Casual contact does not transmit HCV
    • kissing, hugging, sharing food, etc.
hcv diagnosis
HCV Diagnosis
  • Antibody Test
    • EIA or RIBA
      • A positive antibody test does not necessarily mean that someone has chronic HCV infection
      • Confirmatory testing must be done.
    • Qualitative
      • Confirmatory test
    • Quantitative (viral load)
      • Determines viral load
hcv diagnosis 2
HCV Diagnosis (2)
  • Genotype (genetic strain)
    • 75% of US infections are Genotype 1
    • Six known genotypes
    • Genotype testing only needs to be performed once
      • a person’s HCV genotype doesn’t change
    • Knowing your genotype is important when considering treatment
hcv prevention idu
HCV Prevention – IDU
  • Stop injecting!
  • Use a new sterile syringe to prepare and inject drugs obtained from a reliable source
  • Use sterile water
  • Use a new or disinfected cooker and a new piece of cotton
  • If must reuse, clean with bleach and water
  • Clean injection site before injection with alcohol swab
  • Always dispose syringes safely after one use
hcv prevention sex
HCV Prevention - Sex
  • If you are having sex
    • Have sex with one uninfected person or not at all
    • Use a latex condom correctly each time
hcv prevention general
HCV Prevention - General
  • There is no vaccine
  • Do not donate blood, body organs, other tissue or semen
  • Do not share items that might have blood on them
    • personal care (e.g., razor, toothbrush)
    • home therapy (e.g., needles)
  • Cover cuts and sores on the skin


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