Hepatitis viruses overview

Author(s): Christina Levick, MRCP

Queen Alexandra Hospital, Portsmouth, UK [email protected]

Hepatitis is major cause of morbidity and mortality worldwide, particularly in the developing world. The major causes of infective hepatitis are hepatitis viruses A, B, C, D or E. In the acute phase, there are no clinical features that can reliably differentiate between these viruses. Infection may be asymptomatic or can present as jaundice, fevers, abdominal pain, fatigue or vomiting. An acute hepatitis infection can last days to months, but can also cause fulminant liver failure. 


Some hepatitis virus infections become chronic, leading to cirrhosis and the development of hepatocellular carcinoma. The difficulty in finding and treating these patients is that chronic infection is often asymptomatic until these endpoints develop. Co-infection with different hepatitis viruses or with HIV tends to worsen the prognosis. Treatment decisions and regimes are complex and are beyond the scope of this summary. National hepatitis guidelines are currently in development.


World Hepatitis Day took place on 28th July 2014 to raise awareness of the disease and so in this article a table summarising the key features of hepatitis virus infections is presented in Table 1.

Table 1. Key features of hepatitis viruses [1, 2]

Hepatitis virus






Prevalence/incidence worldwide


1.4 million per year



240 million with chronic hepatitis B

(5-10% prevalence in Sub-Saharan Africa)

130-150 million

15 million

20 million per year




Faecal-oral via food/water

Parenteral via body fluids

Parenteral via blood, vertical transmission

Parenteral via blood and sexual contact

Faecal-oral via water, undercooked meat of an infected animal, blood transfusion



14-28 days

30-180 days


2 weeks- 6 months

3-7 weeks when infected simultaneously with hepatitis B.

Shorter if superinfection of hepatitis D on chronic hepatitis B


3-8 weeks

Duration of infection





Acute or chronic

Spontaneous clearance is rare in perinatal/childhood infection, but 95% when infected in adulthood

Acute or chronic

Spontaneous clearance in 15-45%

Acute or chronic

Self-limiting in 95% when simultaneous infection with hepatitis B

Chronic in 80% when superinfection on chronic hepatitis B



May become chronic in immunosuppressed

Other disease features


Higher morbidity with age

90% infected before 10 years old in developing countries

Assess for fibrosis

Assess for fibrosis

Requires co-infection with hepatitis B

Higher morbidity if pregnant or co-existing liver disease

Zoonotic reservoir

When to test

Acute hepatitic illness


Acute hepatitic illness

Evidence of chronic liver disease

High risk groups*/post exposure


Acute hepatitic illness

Evidence of chronic liver disease

High risk groups/post exposure

HBsAg positive patients

Chronic hepatitis B with symptomatic/severe illness

Acute hepatitic illness


Diagnostic tests

HAV IgM and IgG or RT-PCR

HBsAg in all

Persistence > 6 months indicates chronic infection

IgM to HBcAg in acute infection

HBeAg denotes high infectivity

Anti-HCV antibodies

NAT to confirm current vs. past infection

Genotyping if positive


Anti-HDV antibodies


HEV IgM and IgG



Rarely fatal

15-25% mortality from cirrhosis or hepatocellular carcinoma in chronic infection obtained in childhood

15-30% develop cirrhosis within 20 years of infection

Cure rates with treatment vary from 50-90%

10 times higher mortality than hepatitis B alone

Cirrhosis takes 5-10 years to develop

20% mortality if pregnant



Supportive treatment

Acute hepatitis B: Supportive treatment

Chronic hepatitis B:

IFN or antiviral nucleoside antagonists e.g. tenofovir, entecavir

IFN and RBV and/or newer antivirals

Choice depends on availability and genotype


No effective treatment

Some help with IFN-α

Liver transplant if fulminant

Supportive treatment

RBV if fulminant or chronic


Water hygiene Sanitation

Screening high risk groups, barrier contraception, blood donor screening, safe disposal/sterilization of sharps

Screening high risk groups, blood donor screening, safe disposal/sterilization of sharps

As for hepatitis B

Water hygiene


Safe food preparation

Vaccine availability



Can be effective when given up to 2 weeks post exposure


Childhood vaccination programme recommended


No, but hepatitis B vaccine effective

Yes, but not available globally

*High risk groups include men who have sex with men, sexual partners of known infected individuals, individuals with multiple sexual partners, intravenous drug users, unscreened blood transfusion recipients, children of known infected mothers, high prevalence areas.



HAV                Hepatitis A virus

HBcAg Hepatitis B core antigen

HBeAg Hepatitis B envelope antigen

HBsAg Hepatitis B surface antigen

HBV                 Hepatitis B virus

HCV                Hepatitis C virus           

HDV                Hepatitis D virus

HEV                Hepatitis E virus

IFN                  Interferon

NAT                Nucleic acid test

RBV                 Ribavarin

RT-PCR            Reverse transcriptase polymerase chain reaction



 Rizzetto M. Hepatitis D: thirty years after. J Hepatol. 2009 May;50(5):1043-50. http://www.ncbi.nlm.nih.gov/pubmed/19285743

  1. World Health Organization. Health topics: Hepatitis http://www.who.int/topics/hepatitis/en