Hepatitis Type Comparison

Viral classification

ssRNA (+)

dsDNA (uses reverse transcriptase)

ssRNA (+)

ssRNA (–) Requires HBV infection

ssRNA (+)

Geography

Endemic in Asia, Africa, and Middle East

Worldwide with highest rates in sub-Saharan Africa and East Asia

Worldwide with highest prevalence in Middle East

Worldwide with higher prevalence in Middle East and South America

Worldwide, concentrated in LMIC with poorer sanitation

Antigen(s)

HAV

• HBsAg
• HBcAg
• HBeAg
• HBcAg
• HBeAg
• HBsAg

HCV core antigen

• HDVAg
• HBVsAg

HEV Ag

Antibodies

Anti-HAV

• Anti-HBs
• Anti-HBc
• Anti-HBe
• Anti-HBc
• Anti-HBe
• Anti-HBs

Anti-HCV

• Anti-HDV
• Anti-HBsAg

Anti-HEV

Diagnosis

• Clinical syndrome + Anti-HAV IgM
• Anti-IgG in previous infection

• Acute: HBsAg, Anti-HBc IgM
• Chronic: HBsAg, Anti-HBc IgG
• Marker of replication: HBeAg, HBV DNA

Anti-HCV with HCV RNA confirmation

Anti-HDV IgM or IgG

Transmission

Fecal-oral

Body fluids (sexual transmission most common worldwide)

Blood > body fluids (sexual transmission possible but less common than HBV)

Body fluids

Fecal-oral (food-borne, zoonotic, and vertical)

Epidemiology

High rates seen in MSM, illicit drug rusers, travelers, and sporadic outbreaks from water sources

• United States: Higher rates in MSM, ESRD on dialysis, patients with Down syndrome, and PWID
• Worldwide: Peri-natal and early childhood

• PWID/needle-sharing
• Blood/serum products (if untreated)

Greatest risk in PWID

• Highest rate in young adults (15–40)
• Outbreaks associated with contaminated water source and shellfish consumption
• Risk of fulminant liver failure in pregnancy

Chronicity Y/N? And relation to age at time of infection?

None

• Yes
• Infections at <5 years have 80–90% risk of chronicity
• Infections in adults 10–20% risk of chronicity

• Yes
• Infections at <5 years have 10–20% risk of chronicity
• Infections in adults 80–90% risk of chronicity

• Yes
• Can be co-incident infection with HBV
• Can be superinfection in patients with chronic HBV

None

Treatment

Supportive

• Pegylated interferon-α (historically, rarely used now, but only curative option)
• Nucleoside analogues/Reverse transcriptase inhibitors

• Direct acting anti-viral combination therapy (NS3/4A inhibitors, NS5B inhibiros, NS5A inhibitors)
• Ribavirin added to DAAs if cirrhosis
• Interferon-α no longer recommended

No specific HDV treatment

Supportive

Prevention

• HAV Immunoglobulin as prophylaxsis in at-risk and exposed persons
• HAV vaccine

• Hepatitis B Immunoglobulin for post-exposure prophylaxis
• HBV vaccine

No vaccine

Prevention of HBV transmission and disease prevents HDV

Sanitation

Comments

Long incubation period (14–15 days) allows use of HAV-IG and vaccine as post-exposure prophylaxis

• HCC risk without cirrhosis
• Very long incubation period (30–180 days)

HCC risk with cirrhosis