Overview of Viral Hepatitis for Health Care Professionals

Many people with hepatitis do not have symptoms and do not know they are infected. If symptoms occur with an acute infection, they can appear anytime from 2 weeks to 6 months after exposure. Symptoms of chronic viral hepatitis can take decades to develop and are typically the same as those for acute infection.

Hepatitis A

• Less than 30% of children that are less than 6 years old have symptoms, which do not typically include jaundice
• More than 70% of older children and adults have jaundice

Hepatitis B

• Most children less than 5 years old do not have symptoms
• 30%–50% of people 5 years and older develop symptoms
• Newly infected immunosuppressed adults generally do not have symptoms

Hepatitis C

• Jaundice might occur in 20%–30% of people
• Nonspecific symptoms like anorexia, malaise, or abdominal pain might be present in 10%–20% of people

Hepatitis A

None

Hepatitis B

Chronic infection develops in approximately:

• 90% of infants after acute infection at birth
• 30% of children newly infected at ages 1–5 years
• 5% of people newly infected as adults

Hepatitis C

Chronic infection develops in most newly infected people

Hepatitis A

• Most people with acute disease recover with no lasting liver damage
• Death is uncommon but occurs more often among older people and/or those with underlying liver disease

Hepatitis B

• Most people with acute disease recover with no lasting liver damage
• Acute illness is rarely fatal
• 15%–25% of people with chronic infection develop chronic liver disease, including cirrhosis, liver failure, or liver cancer

Hepatitis C

• Approximately 5%–25% of people with chronic hepatitis C will develop cirrhosis over 10–20 years
• People with hepatitis C and cirrhosis have a 1%–4% annual risk for hepatocellular carcinoma

Hepatitis A

• IgM anti-HAV

Hepatitis B

• HBsAg, plus
• IgM anti-HBc

Hepatitis C

• No serologic marker for acute infection

Hepatitis A

• Not applicable—no chronic infection

Hepatitis B

When screening for the first time, tests for chronic infection should include three HBV seromarkers:

• HBsAg
• anti-HBs
• Total anti-HBc

For periodic risk-based testing, consider using the triple panel test; or anti-HBc followed, if positive, by HBsAg and anti-HBs

Hepatitis C

• Assay for anti-HCV
• Qualitative and quantitative nucleic acid tests (NAT) to detect and quantify presence of virus (HCV RNA)

Hepatitis A

• Not applicable—no chronic infection

Note: testing for past acute infection is generally not recommended

Hepatitis B

• All adults aged 18 years and older at least once in their lifetime
• All pregnant people should be tested for HBsAg during an early prenatal visit in each pregnancy
• Infants born to HBsAg-positive people (HBsAg and anti-HBs are only recommended).
• Anyone who requests testing regardless of risk because many may be reluctant to disclose stigmatizing behaviors

Testing for people with a history of risk, regardless of age, if they were susceptible during the period of increased risk; and periodic testing if there is ongoing risk while susceptible, including:

• People born in regions with intermediate and high HBV endemicity (HBsAg prevalence ≥2%)
• People born in U.S. not vaccinated as infants whose parents were born in regions with high HBV
• Household or sexual contacts of people who are HBsAg-positive
• Men who have sex with men
• People who inject, or have injected, drugs
• Patients with alanine aminotransferase levels (≥19 IU/L for women and ≥30 IU/L for men) of unknown etiology
• People with end-stage renal disease including hemodialysis patients
• People receiving immunosuppressive therapy
• People with HIV
• Donors of blood, plasma, organs, tissues, or semen
• People with current or history of sexually transmitted infection
• People who are currently or formerly incarcerated
• People with HCV infection

Hepatitis C

• Universal screening for:
  • All adults aged 18 years and older at least once in their lifetime
  • All pregnant people during every pregnancy, except in settings where the prevalence of HCV infection is less than 0.1%.
• One-time testing regardless of age or setting prevalence:
  • People with HIV
  • People who ever injected drugs and shared needles, syringes, or other equipment including those who injected once or a few times many years ago
  • People with persistently abnormal ALT levels
  • People who received clotting factor concentrates produced before 1987
  • People who received an organ transplant or a transfusion of blood or blood components before July 1992
  • People who were notified that they received blood from a donor who later tested positive for HCV infection
  • Health care, emergency medical, and public safety personnel after needle sticks, sharps, or mucosal exposures to HCV positive blood
  • Children born to people with HCV infection in pregnancy
• Routine periodic testing for people with ongoing risk factors, while risk factors exist including:
  • People with selected medical conditions such as those who ever received maintenance hemodialysis
  • People who currently inject drugs and/ share needles, syringes, or other drug preparation equipment
• Any person who requests hepatitis C testing

Hepatitis A

• No medication available
• Best addressed through supportive treatment

Hepatitis B

• Acute: no medication available; best addressed through supportive treatment
• Chronic: regular monitoring for signs of liver disease progression; antiviral drugs are available

Hepatitis C

• AASLD/IDSA recommends treatment of acute HCV and chronic without a waiting period. More than 95% of people with hepatitis C can be cured regardless of HCV genotype with 8–12 weeks of oral therapy

Hepatitis A

Children

• All children aged 12–23 months
• Unvaccinated children and adolescents aged 2–18 years

People at increased risk for HAV infection

• International travelers
• Men who have sex with men
• People who use injection or noninjection drugs
• People with occupational risk for exposure
• People who anticipate close personal contact with an international adoptee
• People experiencing homelessness

People at increased risk for severe disease from HAV infection

• People with chronic liver disease
• People with HIV infection

Other people recommended for vaccination

• Pregnant women at risk for HAV infection or severe outcome from HAV infection
• Anyone who requests vaccination

Vaccination during outbreaks

• Unvaccinated people in outbreak settings who are at risk for HAV infection or at risk for severe disease from HAV

Implementation strategies for settings providing services to adults

• People in settings that provide services to adults in which a high proportion of those people have risk factors for HAV infection

Hepatitis B

• All infants, and unvaccinated children and adolescents who are 18 years old and younger
• All adults aged 19 through 59 years
• Adults aged 60 years and older who request vaccination
• Adults aged 60 years and older with known risk factors for hepatitis B

Hepatitis C

• There is no hepatitis C vaccine