The ABCs of Hepatitis – for Health Professionals HEPATITIS A is caused HEPATITIS B is caused by the hepatitis B HEPATITIS C is caused by by the hepatitis A virus (HAV) virus (HBV) the hepatitis C virus (HCV) U.S. Statistics • Estimated 24,900 new • Estimated 21,600 new infections in 2018 • Estimated 50,300 new infections infections in 2018 • Estimated 862,000 people living with chronic in 2018 HBV infection in 2016 • Estimated 2.4 million people living with HCV infection in 2016 Routes of Fecal-oral route. Percutaneous, mucosal, or nonintact skin Direct percutaneous exposure to exposure to infectious blood, semen, and other infectious blood. Mucous membrane Transmission HAV is transmitted through: body fluids. HBV is concentrated most highly in exposures to blood can also result in • Close person-to-person contact blood, and percutaneous exposure is an efficient transmission, although this route is with an infected person mode of transmission. less efficient. • Sexual contact with an infected person HBV is transmitted primarily through: HCV is transmitted primarily through: • Ingestion of contaminated food • Birth to an infected mother • Sharing contaminated needles, or water • Sexual contact with an infected person syringes, or other equipment to inject drugs Although viremia occurs early in • Sharing contaminated needles, syringes, or infection, bloodborne transmission other injection-drug equipment Less commonly through: of HAV is uncommon. Less commonly through: • Birth to an infected mother • Needle-sticks or other sharp instrument injuries • Sexual contact with an infected • Organ transplantation and dialysis person • Interpersonal contact through sharing items • Unregulated tattooing such as razors or toothbrushes or contact with • Needle-sticks or other sharp open sores of an infected person instrument injuries Incubation Period 15–50 days 60–150 days 14–182 days (average: 28 days) (average: 90 days) (average range: 14–84 days) Symptoms of Symptoms of all types of viral hepatitis are similar and can include one or more of the following: Acute Infection • Jaundice • Fever • Fatigue • Loss of appetite • Nausea • Vomiting • Abdominal pain • Joint pain • Dark Urine • Clay-colored stool • Diarrhea (HAV only) Likelihood of • <30% of children <6 years • Most children <5 years of age do not have • Jaundice might occur in 20%–30% Symptomatic of age have symptoms symptoms of people Acute Infection (which typically do not include • 30%–50% of people ≥5 years of age develop • Nonspecific symptoms (e.g., jaundice) symptoms anorexia, malaise, or abdominal • >70% of older children and • Newly infected immunosuppressed adults pain) might be present in adults have jaundice generally do not have symptoms 10%–20% of people Potential for None Chronic infection develops in: Chronic infection develops in over Chronic Infection • 90% of infants after acute infection at birth 50% of newly infected people after Acute • 25%–50% of children newly infected at ages Infection 1–5 years • 5% of people newly infected as adults Continued on next page HEPATITIS A HEPATITIS B HEPATITIS C Severity • Most people with acute disease • Most people with acute disease recover with no • Approximately 5%–25% of persons recover with no lasting liver lasting liver damage; acute illness is rarely fatal with chronic hepatitis C will damage; death is uncommon • 15%–25% of people with chronic infection develop cirrhosis over 10–20 years but occurs more often among develop chronic liver disease, including • People with hepatitis C and older people and/or those with cirrhosis, liver failure, or liver cancer cirrhosis have a 1%–4% annual underlying liver disease risk for hepatocellular carcinoma Serologic Tests for • IgM anti-HAV • HBsAg, plus • No serologic marker for acute Acute Infection • IgM anti-HBc infection Serologic Tests for • Not applicable—no chronic Tests for chronic infection should include three • Assay for anti-HCV Chronic Infection infection HBV seromarkers: • Qualitative and quantitative nucleic • HBsAg acid tests (NAT) to detect and • anti-HBs quantify presence of virus (HCV • Total anti-HBc RNA) Testing • Not applicable—no chronic • All pregnant women should be tested for HBsAg • All adults aged 18 years and older, Recommendations infection during an early prenatal visit in each pregnancy at least once for Chronic Note: testing for past acute • Infants born to HBsAg-positive mothers (HBsAg • All pregnant women during each pregnancy Infection infection is generally not and anti-HBs are only recommended) recommended • People born in regions with intermediate and • People who currently inject drugs high HBV endemicity (HBsAg prevalence ≥2%) and share needles, syringes, or • People born in U.S. not vaccinated as infants other drug preparation equipment whose parents were born in regions with high (routine periodic testing) HBV endemicity (≥8%) • People who ever injected drugs • Household or sexual contacts of people who are • People with HIV HBsAg-positive • People who receive maintenance hemodialysis (routine periodic • Men who have sex with men testing) • People who inject, or have injected, • People who ever received drugs maintenance hemodialysis • Patients with alanine aminotransferase levels • People with persistently abnormal (≥19 IU/L for women and ≥30 IU/L for men) of ALT levels unknown etiology • Prior recipients of transfusions or • People with end-stage renal disease including organ transplants, including: hemodialysis patients - people who received clotting • People receiving immunosuppressive therapy factor concentrates produced • People with HIV before 1987 • Donors of blood, plasma, organs, tissues, or - people who received a semen transfusion of blood or blood components before July 1992 - people who received an organ transplant before July 1992 - people who were notified that they received blood from a donor who later tested positive for HCV infection • Healthcare, emergency medical, and public safety personnel after needle sticks, sharps, or mucosal exposures to HCV positive blood • Children born to mothers with HCV infection • Any person who requests hepatitis C testing should receive it Continued on next page HEPATITIS A HEPATITIS B HEPATITIS C Treatment • No medication available • Acute: no medication available; best addressed • Acute: AASLD/IDSA recommend • Best addressed through through supportive treatment treatment of acute HCV without a supportive treatment • Chronic: regular monitoring for signs of liver waiting period disease progression; antiviral drugs are • Chronic: over 90% of people with available hepatitis C can be cured regardless of HCV genotype with 8–12 weeks of oral therapy Vaccination Children • All infants • There is no hepatitis C vaccine Recommendations • All children aged 12–23 months • All unvaccinated children and adolescents aged • Unvaccinated children and <19 years adolescents aged 2–18 years • Sex partners of HBsAg-positive people People at increased risk for • Sexually active people who are not in a mutually HAV infection monogamous relationship • International travelers • Anyone seeking evaluation or treatment for a • Men who have sex with men sexually transmitted infection • People who use injection or • Men who have sex with men noninjection drugs • Anyone with a history of current or recent • People with occupational risk injection-drug use for exposure • Household contacts of people who are HBsAg- • People who anticipate close positive personal contact with an • Residents and staff of facilities for international adoptee developmentally disabled people • People experiencing • Health care and public-safety personnel with homelessness reasonably-anticipated risk for exposure to People at increased risk for blood or blood-contaminated body fluids, severe disease from HAV • Hemodialysis, predialysis peritoneal dialysis, and infection home dialysis patients • People with chronic liver • People with diabetes mellitus aged <60 years disease and people with diabetes mellitus aged ≥60 • People with HIV infection years at the discretion of the treating clinician Other people recommended for • International travelers to countries with high or vaccination intermediate levels of endemic HBV infection • Pregnant women at risk for HAV (HBsAg prevalence of ≥2%) infection or severe outcome • People living with hepatitis C from HAV infection • People with chronic liver disease (including • Any person who requests cirrhosis, fatty liver disease, alcoholic liver vaccination disease, autoimmune hepatitis, and an ALT or Vaccination during outbreaks AST level greater than twice the upper limit of normal) • Unvaccinated people in outbreak settings who are at • People living with HIV infection risk for HAV infection or at risk • People who are incarcerated for severe disease from HAV • Pregnant women who are identified as being at Implementation strategies for risk for HBV infection during pregnancy settings providing services to • Anyone else seeking long-term protection adults • People in settings that provide services to adults in which a high proportion of those people have risk factors for HAV infection Vaccination • Single-antigen hepatitis A • Infants and children: 3–4 doses given over a • No vaccine available Schedule vaccine: 2 doses given 6–18 6- to 18-month period depending on vaccine months apart depending on type and schedule manufacturer • Adults: 2 doses, 1 month apart or 3 doses over a • Combination HepA-HepB 6-month period (depending on manufacturer) vaccine: typically 3 doses given over a 6-month period Updated 2020 www.cdc.gov/hepatitis.