Transcript Epidemiology and Prevention of Viral Hepatitis A to E:

Epidemiology and Prevention
of Viral Hepatitis A to E:
An Overview
Hepatitis Branch
Centers for Disease Control and Prevention
Viral Hepatitis - Historical Perspective
“Infectious”
Viral hepatitis
“Serum”
A
E
Enterically
transmitted
C
Parenterally
transmitted
NANB
B D
F, G,
? other
Viral Hepatitis - Overview
Type of Hepatitis
A
Source of
virus
Route of
transmission
Chronic
infection
Prevention
B
C
D
E
feces
blood/
blood/
blood/
blood-derived blood-derived blood-derived
body fluids
body fluids
body fluids
feces
fecal-oral
percutaneous percutaneous percutaneous
permucosal
permucosal
permucosal
fecal-oral
no
yes
pre/postexposure
immunization
pre/postexposure
immunization
yes
yes
blood donor
pre/postscreening;
exposure
risk behavior immunization;
modification risk behavior
modification
no
ensure safe
drinking
water
Acute Viral Hepatitis by Type, United States, 1982-1993
34%
47%
16%
3%
Source: CDC Sentinel Counties Study on Viral Hepatitis
Hepatitis A
Hepatitis B
Hepatitis C
Hepatitis
Non-ABC
Estimates of Acute and Chronic Disease
Burden for Viral Hepatitis, United States
Acute infections
(x 1000)/year*
Fulminant
deaths/year
Chronic
infections
Chronic liver disease
deaths/year
HAV
HBV
HCV
HDV
125-200
140-320
35-180
6-13
100
150
?
35
0
1-1.25
million
3.5
million
70,000
5,000
8-10,000
1,000
0
* Range based on estimated annual incidence, 1984-1994.
Hepatitis A Virus
Hepatitis A - Clinical Features
• Incubation period:
• Jaundice by
age group:
• Complications:
• Chronic sequelae:
Average 30 days
Range 15-50 days
<6 yrs,
<10%
6-14 yrs, 40%-50%
>14 yrs, 70%-80%
Fulminant hepatitis
Cholestatic hepatitis
Relapsing hepatitis
None
Age-specific Mortality Due to Hepatitis A
Age group
(years)
<5
5-14
15-29
30-49
>49
Total
Case-Fatality
(per 1000)
3.0
1.6
1.6
3.8
17.5
4.1
Source: Viral Hepatitis Surveillance Program, 1983-1989
Hepatitis A Virus Infection
Typical Serologic Course
Symptoms
Total anti-HAV
Titer
ALT
Fecal
HAV
0
1
IgM anti-HAV
2
3
4
5
6
Months after Exposure
12
24
Body Fluid
Concentration of Hepatitis A Virus
in Various Body Fluids
Feces
Serum
Saliva
Urine
100
102
104
106
Infectious Doses per ml
Source: Viral Hepatitis and Liver Disease 1984;9-22
J Infect Dis 1989;160:887-890
108
1010
Hepatitis A Virus Transmission
• Close personal contact
(e.g., household contact, sex contact, child
day care centers)
• Contaminated food, water
(e.g., infected food handlers, raw shellfish)
• Blood exposure (rare)
(e.g., injecting drug use, transfusion)
Incidence of Hepatitis A, United States, 1952-1993
Rate (per 100,000)
40
30
20
10
0
1952
1960
1970
1980
Year
Source: CDC, National Notifiable Diseases Surveillance System
1990
Reported Cases (per 100,000)
Age-specific Incidence of Hepatitis A
United States, 1983-93
25
20
15
5-14 years
15-24 years
25-39 years
10
0-4 years
5
40+ years
0
1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993
Year
Source: CDC, National Notifiable Diseases Surveillance System
Sources of Hepatitis A Virus Infection by
Mutually Exclusive Groups, United States, 1983-93
Percentage of Cases
40
30
Personal contact
20
Day care center
10
Foreign travel
Drug use
Outbreak
0
1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993
Year
Source: CDC, Viral Hepatitis Surveillance Program
Global Patterns of
Hepatitis A Virus Transmission
Endemicity
High
Disease Peak Age
Rate of Infection
Transmission Patterns
Low to
High
Early
childhood
Person to person;
outbreaks uncommon
Moderate
High
Late
childhood/
young adults
Person to person;
food and waterborne
outbreaks
Low
Low
Young adults
Very low
Adults
Person to person;
food and waterborne
outbreaks
Travelers; outbreaks
uncommon
Very low
Geographic Distribution of HAV Infection
Anti-HAV Prevalence
High
Intermediate
Low
Very Low
Hepatitis A Vaccine Efficacy Studies
Vaccine
Site/Age
Group
N
Vaccine
Efficacy
(95% CI)
HAVRIX 
(SKB)
2 doses
360 EL.U.
Thailand
1-16 yrs
38,157
94%
(79%-99%)
VAQTA 
(Merck)
1 dose
25 units
New York
2-16 yrs
1,037
100%
(85%-100%)
JAMA 1994;271:1363-4
N Engl J Med 1992;327:453-7
Hepatitis A Vaccination Strategies
Epidemiologic Considerations
• Many cases occur in community-wide outbreaks
– no risk factor identified for most cases
– highest attack rates in 5-14 year olds
– children serve as reservoir of infection
• Persons at increased risk of infection
– travelers
– homosexual men
– injecting drug users
Routine Childhood Hepatitis A Vaccination
• Benefits
– established delivery system
– vaccination before risk period
– potential to interrupt transmission
• Unresolved issues/considerations
–
–
–
–
immunogenicity in infants
development of combination vaccines
duration of protection
cost-effectiveness
ACIP Recommendations - Hepatitis A Vaccine
Preexposure Vaccination
• Persons at increased risk for infection
– travelers to intermediate and high
HAV-endemic countries
– homosexual and bisexual men
– drug users
– persons with chronic liver disease
• Communities with high rates of hepatitis A
(e.g., Alaska Natives, American Indians)
– routine childhood vaccination
Features of Community-wide
Hepatitis A Outbreaks
Usual Age
of Casepatients
Annual
Incidence/
100,000
Outbreak
Periodicity
Type of
Community
Anti-HAV
Prevalence
High rate
<5 yrs old
30%-40%
>15 yrs old
70% -100%
5-14 yrs
700-1000
5-10yrs
well defined
geographically
or ethnically
Intermediate
rate
<5 yrs old
10%-25%
>15 yrs old
<50%
5-29 yrs
50-200
may be
periodic
less defined
than in
high-rate
communities
Populations
ACIP Recommendations - Hepatitis A Vaccine
Control of Community-wide Outbreaks
High-rate communities
• Routine vaccination of young children
• Accelerated catch-up vaccination of
older children
ACIP Recommendations - Hepatitis A Vaccine
Control of Community-wide Outbreaks
Intermediate-rate communities
• Targeted vaccination can be considered for groups
or areas with highest disease rates
(e.g., specific age groups, census tracts,
drug users)
• Factors to consider:
– feasibility of vaccinating target groups
– program cost
– ability to sustain vaccination of young children
ACIP Recommendations - Hepatitis A Vaccine
Prevaccination Testing
• Considerations:
–
–
–
–
cost of vaccine
cost of serologic testing (including visit)
prevalence of infection
impact on compliance with vaccination
• Likely to be cost-effective for:
– adults born, or who lived in, high endemic areas
– adults >40 years of age
– older adolescents and young adults in certain groups
(American Indians, Alaska Natives, Pacific Islanders)
ACIP Recommendations - Hepatitis A Vaccine
Postvaccination Testing
• Not recommended because of the high
response rate among vaccinees
• No commercially available test to
measure vaccine response
Recommended Doses and Schedules
of Hepatitis A Vaccine
HAVRIX
Doses
EL.U.* (ml)
Schedule
(months)
0, 1, 6-12
Age
No.
Doses
Children and
adolescents
2-18 years
3
360 (0.5)
Adults
>18 years
2
1,440 (1.0)
Group
*ELISA units
0, 6-12
Hepatitis A Prevention - Immune Globulin
• Preexposure
– travelers to intermediate and high
HAV-endemic regions
• Postexposure (within 14 days)
Routine
– household and other intimate contacts
Selected situations
– institutions (e.g., day care centers)
– common source exposure (e.g., food prepared by
infected food handler)
Hepatitis B Virus
Hepatitis B - Clinical Features
• Incubation period:
Average 60-90 days
Range 45-180 days
• Clinical illness (jaundice): <5 yrs, <10%
5 yrs, 30%-50%
• Acute case-fatality rate:
• Chronic infection:
0.5%-1%
<5 yrs, 30%-90%
5 yrs, 2%-10%
• Premature mortality from
chronic liver disease:
15%-25%
Acute Hepatitis B Virus Infection with Recovery
Typical Serologic Course
Symptoms
anti-HBe
HBeAg
Total anti-HBc
Titer
0
4
anti-HBs
IgM anti-HBc
HBsAg
8
12
16
20
24
28
32
36
Weeks after Exposure
52
100
Progression to Chronic Hepatitis B Virus Infection
Typical Serologic Course
Acute
(6 months)
Chronic
(Years)
HBeAg
anti-HBe
HBsAg
Total anti-HBc
Titer
IgM anti-HBc
0
4
8 12 16 20 24 28 32 36
Weeks after Exposure
52
Years
Rate (per 100,000)
Rate of Reported Hepatitis B by Age Group
25
United States, 1990
20
15
10
5
0
0-14
15-19
20-29
Age Group (Years)
Source: CDC Viral Hepatitis Surveillance Program
30-39
40+
Age at Aquisition of Acute and Chronic HBV Infection
United States, 1989 Estimates
Adult
(83%)
(4% ) Perinatal (24%)
(4%) Children (12%)
(1-10 yrs)
(8%) Adolescent (6%)
Acute HBV Infections
Adult
(59%)
Chronic HBV Infections
100
80
80
60
60
Chronic Infection
40
40
20
20
Symptomatic Infection
0
Birth
1-6 months
7-12 months
Age at Infection
1-4 years
0
Older Children
and Adults
Symptomatic Infection (%)
Chronic Infection (%)
100
Outcome of Hepatitis B Virus Infection
by Age at Infection
Global Patterns of Chronic HBV Infection
• High (8%): 45% of global population
– lifetime risk of infection >60%
– early childhood infections common
• Intermediate (2%-7%): 43% of global population
– lifetime risk of infection 20%-60%
– infections occur in all age groups
• Low (<2%): 12% of global population
– lifetime risk of infection <20%
– most infections occur in adult risk groups
Geographic Distribution of Chronic HBV Infection
HBsAg Prevalence
8% - High
2-7% - Intermediate
<2% - Low
Concentration of Hepatitis B Virus
in Various Body Fluids
High
Moderate
blood
serum
wound exudates
semen
vaginal fluid
saliva
Low/Not
Detectable
urine
feces
sweat
tears
breastmilk
Hepatitis B Virus
Modes of Transmission
• Sexual
• Parenteral
• Perinatal
Risk Factors for Acute Hepatitis B
United States, 1992-1993
Heterosexual*
(41%)
Injecting
Drug Use
(15%)
Homosexual Activity (9%)
Household Contact (2%)
Health Care Employment (1%)
Unknown (31%)
Other (1%)
* Includes sexual contact with acute cases, carriers, and multiple partners.
Source: CDC Sentinel Counties Study of Viral Hepatitis
Elimination of Hepatitis B Virus Transmission
United States
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
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
Cases per 100,000 Population
Estimated Incidence of Acute Hepatitis B
United States, 1978-1995
80
Vaccine
licensed
70
HBsAg screening
Infant
of pregnant
immunization
women
recommended recommended
60
OSHA Rule
enacted
50
Adolescent
immunization
recommended
40
30
20
Decline
among
homosexual
men & HCWs
10
0
Decline among
injecting
drug users
*
78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95
* Provisional date
Year
Hepatitis C
Prepared by
Hepatitis Branch
Centers for Disease Control and
Prevention
9/25/00
Features of Hepatitis C Virus Infection
Incubation period
Acute illness (jaundice)
Case fatality rate
Chronic infection
Chronic hepatitis
Cirrhosis
Mortality from CLD
Average 6-7 weeks
Range 2-26 weeks
Mild (<20%)
Low
75%-85%
70% (most asx)
10%-20%
1%-5%
•
Chronic Hepatitis C
Factors Promoting Progression or
Severity
Increased alcohol intake
• Age > 40 years at time of infection
• HIV co-infection
• ?Other
– Male gender
– Other co-infections (e.g., HBV)
Serologic Pattern of Acute HCV Infection
with Recovery
anti-HCV
Symptoms +/-
Titer
HCV RNA
ALT
Normal
0
1
2
3
4
Months
5
6
1
Time after Exposure
2
3
Years
4
Serologic Pattern of Acute HCV Infection with
Progression to Chronic Infection
anti-HCV
Symptoms +/-
Titer
HCV RNA
ALT
Normal
0
1
2
3
4
Months
5
6
1
Time after Exposure
2
3
Years
4
Hepatitis C Virus Infection, United
States
New infections (cases)/year 1985-89
1998
242,000 (42,000)
40,000 (6,500)
Deaths from acute liver failure
Rare
Persons ever infected (1.8%)
3.9 million (3.1-4.8)*
Persons with chronic infection
2.7 million (2.4-3.0)*
Of chronic liver disease - HCV-related
40% - 60%
Deaths from chronic disease/year
8,000-10,000
.
New Infections/100,000
Estimated Incidence of Acute HCV
Infection
United States, 1960-1999
140
120
100
80
60
40
20
0
1960
Decline in injection
drug users
Decline in
transfusion recipients
1965
1970
1975
1980
1985
1989
Year
Source: Hepatology 2000;31:777-82; Hepatology 1997;26:62S-65S
1995
1999
Prevalence of HCV Infection
United States, 1988-1994
Group
Anti-HCV Est. Infections
Percent of
Positive millions (95% CI) Infections
Total
1.8%
3.9 (3.1-4.8)
100%
Race/ethnicity
White
Black
Mex American
Other
1.5%
3.2%
2.1%
2.9%
2.4 (1.8-3.1)
0.8 (0.6-1.0)
0.3 (0.2-0.3)
0.5 (0.3-1.0)
61%
20%
7%
13%
Percent Anti-HCV Positive
Prevalence of HCV Infection by
Age6 and Gender, United States, 1988Males
1994
5
Total
4
3
2
Females
1
0
6-11
12-19
20-29
30-39
40-49
Age in Years
Source: CDC, NHANES III
50-59
60-69
70+
Transmission of HCV
• Percutaneous
–
–
–
–
Injecting drug use
Clotting factors before viral inactivation
Transfusion, transplant from infected donor
Therapeutic (contaminated equipment, unsafe injection
practices)
– Occupational (needlestick)
• Permucosal
– Perinatal
– Sexual
Percentage of Cases
Reported Cases of Acute Hepatitis C by
Selected Risk Factors, United States, 198380
1998*
70
Injecting drug use
60
50
40
30
20
Sexual
10
Health related work
Transfusion
0
83-84
85-86
87-88
89-90
91-92
Year
* 1983-1990 based on non-A, non-B hepatitis
Source: CDC Sentinel Counties Study
93-94
95-96
97-98
Sources of Infection for
Persons with Hepatitis C
Injecting drug use 60%
Sexual 15%
Transfusion 10%
(before screening)
Other* 5%
Unknown 10%
*Nosocomial; Health-care work; Perinatal
Source: Centers for Disease Control and Prevention
Injecting Drug Use and HCV
Transmission
• Highly efficient among injection drug
users
• Rapidly acquired after initiation
• Four times more common than HIV
• Prevalence 60-90% after 5 years
Posttransfusion Hepatitis C
% of Recipients Infected
30
All volunteer donors
HBsAg
25
20
15
Donor Screening for HIV Risk Factors
Anti-HIV
ALT/Anti-HBc
10
Anti-HCV
5
0
1965
Improved
HCV Tests
1970
1975
1980
1985
1990
Year
Adapted from HJ Alter and Tobler and Busch, Clin Chem 1997
1995
2000
Nosocomial Transmission of HCV
• Recognized primarily in context of outbreaks
• Contaminated equipment
– hemodialysis*
– endoscopy
• Unsafe injection practices
– plasmapheresis,* phlebotomy
– multiple dose medication vials
– therapeutic injections
Occupational Transmission of HCV
• Inefficiently transmitted by occupational exposures
• Average incidence 1.8% following needle stick from
HCV-positive source
– Associated with hollow-bore needles
• Case reports of transmission from blood splash to
eye
– No reports of transmission from skin exposures to blood
• Prevalence 1-2% among health care workers
– Lower than adults in the general population
– 10 times lower than for HBV infection
• Presence of recognized risk factor does not
necessarily equate with “increased risk”
•
HCW to Patient Transmission of
HCV
Rare
– In U.S., none related to performing invasive procedures
• Most appear related to HCW substance abuse
– Reuse of needles or sharing narcotics used for selfinjection
– Reported mechanism for transmission of other
bloodborne pathogens from some HCWs
• No restrictions routinely recommended for HCVinfected HCWs
Perinatal Transmission of HCV
• Transmission only from women HCV-RNA positive
at delivery
– Average rate of infection 6%
– Higher (17%) if woman co-infected with HIV
– Role of viral titer unclear
• No association with
– Delivery method
– Breastfeeding
• Infected infants do well
– Severe hepatitis is rare
Sexual Transmission of HCV
• Case-control, cross sectional studies
– infected partner, multiple partners, early sex, non-use of
condoms, other STDs, sex with trauma
– MSM no higher risk than heterosexuals
• Partner studies
– low prevalence (1.5%) among long-term partners
• infections might be due to common percutaneous exposures
(e.g., unsafe injections, drug use)
– male to female transmission more efficient
• more indicative of sexual transmission
Sexual Transmission of HCV
• Occurs, but efficiency is low
– Rare between long-term steady partners
– Factors that facilitate transmission between partners
unknown (e.g., viral titer)
• Accounts for 15-20% of acute and chronic infections
in the United States
– Sex is a common behavior
– Large chronic reservoir provides multiple opportunities for
exposure to potentially infectious partners
Household Transmission of HCV
• Rare but not absent
• Could occur through percutaneous/mucosal
exposures to blood
– Theoretically through sharing of contaminated
personal articles (razors, toothbrushes)
– Contaminated equipment used for home
therapies
• Injections*
• Folk remedies
Other Potential Exposures to Blood
• No or insufficient data showing increased risk
– intranasal cocaine use, tattooing, body piercing,
acupuncture, military service
• Limited number of studies showing associations that
cannot be generalized
– convenience or highly selected groups (mostly blood
donors)
• No associations in acute case-control or populationbased studies
Case-Control Studies of Acute Hepatitis C,
U.S.
Cases Controls
Exposures(prior
Not Associated
Exposure
6 months) with Acquiring
n=148 Disease,
n=200
Medical care procedures 1979-1985
Dental work
Health care work (no blood contact)
Ear piercing
Tattooing
Acupuncture
Foreign travel
Military service
Source: JID 1982;145:886-93; JAMA 1989;262:1201-5.
30.4%
24.3%
4.1%
2.7%
0.7%
0
4.1%
1.3%
29.5%
23.5%
5.0%
3.0%
0.5%
1.0%
2.5%
4.9%
Other Potential Exposures to Blood
• Biologically plausible but no data showing these
practices, procedures, or histories alone place
persons at increased risk for HCV
• May be limited to certain settings and account for
small fraction of cases
– e.g., prisons, unregulated practitioners, populations with
certain cultural practices, etc.
• Risk factor or high prevalence identified in selected
subgroup cannot be extrapolated to the population
HCV Prevention and Control
Reduce or Eliminate Risks for
Acquiring HCV Infection
• Screen and test donors
• Virus inactivation of plasma-derived products
• Risk-reduction counseling and services
– Obtain history of high-risk drug and sex
behaviors
– Provide information on minimizing risky behavior,
including referral to other services
– Vaccinate against hepatitis A and/or hepatitis B
•MMWR
Infection
control
practices
1998;47 (No. RR-19)
HCV Prevention and Control
Reduce Risks for Disease Progression
and Further Transmission
• Identify persons at risk for HCV and test to
determine infection status
– Routinely identify at risk persons through history,
record review
• Provide HCV-positive persons
– Medical evaluation and management
– Counseling
• Prevent further harm to liver
• Prevent transmission to others
MMWR 1998;47 (No. RR-19)
HCV Prevalence by Selected Groups
United States
Hemophilia
Injecting drug users
Hemodialysis
STD clients
Gen population adults
Surgeons, PSWs
Pregnant women
Military personnel
0
10
20
30
40
50
60
70
Average Percent Anti-HCV Positive
80
90
HCV Testing Routinely Recommended
Based on increased risk for infection
•
•
•
•
•
Ever injected illegal drugs
Received clotting factors made before 1987
Received blood/organs before July 1992
Ever on chronic hemodialysis
Evidence of liver disease
Based on need for exposure management
• Healthcare, emergency, public safety workers after
needle stick/mucosal exposures to HCV-positive blood
• Children born to HCV-positive women
•
Postexposure Management for
HCV for prophylaxis
IG, antivirals not recommended
• Follow-up after needlesticks, sharps, or mucosal
exposures to HCV-positive blood
– Test source for anti-HCV
– Test worker if source anti-HCV positive
• Anti-HCV and ALT at baseline and 4-6 months later
• For earlier diagnosis, HCV RNA by PCR at 4-6 weeks
– Confirm all anti-HCV results with RIBA
• Refer infected worker to specialist for medical
evaluation and management
Routine HCV Testing Not Recommended
(Unless Risk
Factor medical,
Identified)
• Health-care,
emergency
and
public safety workers
• Pregnant women
• Household (non-sexual) contacts of
HCV-positive persons
• General population
Routine HCV Testing of Uncertain
Need
Not confirmed as risk factor/prevalence unknown
• Recipients of transplanted tissue
• Intranasal cocaine or other non-injecting
illegal drug users
• History of tattooing, body piercing
Confirmed risk factor but prevalence of infection low
• History of STDs or multiple sex partners
• Long-term steady sex partners of HCVpositive persons
HCV Infection Testing Algorithm
for Diagnosis of Asymptomatic
Persons
Negative
(non-reactive)
STOP
EIA for Anti-HCV
Positive (repeat reactive)
OR
RIBA for Anti-HCV
Negative
STOP
Negative
Indeterminate
Additional Laboratory
Evaluation (e.g. PCR, ALT)
Negative PCR,
Normal ALT
Positive PCR,
Abnormal ALT
Source: MMWR 1998;47 (No. RR 19)
RT-PCR for HCV RNA
Positive
Medical
Evaluation
Positive
Medical Evaluation and Management
for Chronic HCV Infection
• Assess for biochemical evidence of CLD
• Assess for severity of disease and possible
treatment, according to current practice
guidelines
– 30-40% sustained response to antiviral
combination therapy (interferon alpha, ribavirin)
– Vaccinate against hepatitis A
• Counsel to reduce further harm to liver
– Limit or abstain from alcohol
HCV Counseling
• Prevent transmission to others
– Direct exposure to blood
– Perinatal exposure
– Sexual exposure
• Refer to support group
HCV Counseling
Preventing HCV Transmission to
Others
Avoid Direct Exposure to Blood
• 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
HCV Counseling
Persons Using Illegal Drugs
• Provide risk reduction counseling, education
– Stop using and injecting
– Refer to substance abuse treatment program
– If continuing to inject
• Never reuse or share syringes, needles, or drug
preparation equipment
• Vaccinate against hepatitis B and hepatitis A
• Refer to community-based risk reduction programs
HCV Counseling
Mother-to-Infant Transmission of
HCV
• Postexposure prophylaxis not available
• No need to avoid pregnancy or breastfeeding
– Consider bottle feeding if nipples cracked/bleeding
• No need to determine mode of delivery based on
HCV infection status
• Test infants born to HCV-positive women
– Consider testing any children born since woman became
infected
– Evaluate infected children for CLD
HCV Counseling
Sexual Transmission of HCV
Persons with One Long-Term Steady Sex Partner
• Do not need to change their sexual practices
• Should discuss with their partner
– Risk (low but not absent) of sexual transmission
– Routine testing not recommended but counseling
and testing of partner should be individualized
• May provide couple with reassurance
• Some couples might decide to use barrier precautions
to lower limited risk further
HCV Counseling
Sexual Transmission of HCV
Persons with High-Risk Sexual Behaviors
• At risk for sexually transmitted diseases, e.g.,
HIV, HBV, gonorrhea, chlamydia, etc.
• Reduce risk
– Limit number of partners
– Use latex condoms
– Get vaccinated against hepatitis B
– MSMs also get vaccinated against hepatitis A
HCV Counseling
Other Transmission Issues
• HCV not spread by kissing, hugging,
sneezing, coughing, food or water, sharing
eating utensils or drinking glasses, or casual
contact
• Do not exclude from work, school, play, childcare or other settings based on HCV infection
status
Hepatitis D (Delta) Virus
d antigen
HBsAg
RNA
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 Virus
Modes of Transmission
• Percutanous exposures
–injecting drug use
• Permucosal exposures
–sex contact
HBV - HDV Coinfection
Typical Serologic Course
Symptoms
Titer
ALT Elevated
anti-HBs
IgM anti-HDV
HDV RNA
HBsAg
Total anti-HDV
Time after Exposure
HBV - HDV Superinfection
Typical Serologic Course
Jaundice
Symptoms
Total anti-HDV
Titer
ALT
HDV RNA
HBsAg
IgM anti-HDV
Time after Exposure
Geographic Distribution of HDV Infection
Taiwan
Pacific Islands
HDV Prevalence
High
Intermediate
Low
Very Low
No Data
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 E Virus
Hepatitis E - Clinical Features
• Incubation period:
• Case-fatality rate:
Average 40 days
Range 15-60 days
Overall, 1%-3%
Pregnant women, 15%-25%
• Illness severity:
Increased with age
• Chronic sequelae:
None identified
Hepatitis E Virus Infection
Typical Serologic Course
Symptoms
ALT
IgG anti-HEV
Titer
IgM anti-HEV
Virus in stool
0
1
2
3
4
5
6
7
8
Weeks after Exposure
9
10
11
12
13
Hepatitis E Epidemiologic Features
• Most outbreaks associated with
fecally contaminated drinking water
• Minimal person-to-person transmission
• U.S. cases usually have history of travel
to HEV-endemic areas
Geographic Distribution of Hepatitis E
Outbreaks or Confirmed Infection in >25% of Sporadic Non-ABC Hepatitis
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?