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Hepatitis, a general term referring to inflammation of the liver, may result from various causes, both infectious (viral, bacterial, fungal, and parasitic organisms) and noninfectious (alcohol, drugs, autoimmune diseases, and metabolic diseases.

There are 5 main hepatitis viruses referred to as type A, B, C, D and E.

Generally, hepatitis A can cause mild to severe illness. Safe and effective vaccine is available to prevent hepatitis A.

Hepatitis A virus (HAV) infection usually is mild and self-limited, and infection confers lifelong immunity against the virus. Overall mortality is approximately 0.02%. In general, children younger than 5 years and adults older than 50 years have the highest case-fatality rates. Older patients are at greater risk for severe. Three rare complications are relapsing hepatitis, cholestatic hepatitis, and fulminant hepatitis failure (FHF).

HEV infection is usually mild and self-limited. The case-fatality rate reaches 15-20% in pregnant women. HEV infection does not result in chronic disease.

Video:
https://www.youtube.com/watch?v=y6XfSQ_zQgQ

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HEPATITIS A

Occurrence

Occurs through out the world.

Highly endemic in some area, such as Central and South America, Africa, the Middle East, Asia and Western Pacific.

Reservoir

Human are the only natural reservoir of the virus.

Gastrointestinal tracts of humans.

Incubation Period

The  incubation period of hepatitis A is usually 14 to 28 days.

Communicability

Viral shedding persists for 1 – 3 weeks.

Infected person transmit virus during 1 – 2 weeks before the onset of disease until 1 weeks after the onset (jaundice).

Corresponds to period of peak level alanine transaminase (ALT).

HEPATITIS E

Occurrence

Has been found in most parts of the world.

Endemic in Central Asia. While Central America and the Middle East have reported outbreaks.

Reservoir

Human and some primates acts as a reservoirs.

Genotype 3 is associated with swine, but rarely cause disease in human.

Incubation Period

The incubation period following exposure to HEV ranges from 2 to 10 weeks, with an average of 5 to 6 weeks.

Communicability

Unknown

Detected in stool 14 days after the onset of jaundice and 4 weeks after the ingestion of contaminated food and water.

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Hepatitis can be classified into viral hepatitis and non-viral hepatitis (non-infectious hepatitis)

1.Causes of viral hepatitis:

1) Hepatitis A: Hepatitis A virus (HAV)

A single stranded RNA virus that belong to picornaviruses group

Lacks of lipid envelope or having no lipid envelope.

27 nm diameter in size.

Has an icosahedral capsid.

Contains approximately 7,500 bases which codes for a poly protein which is processed to give rise to viral proteins VP-1, VP-2, VP-3 and others.

2) Hepatitis E: Hepatitis E virus (HEV)

RNA virus which belongs to the caliciviridae family.

Non-enveloped virus.

32-34 nm in diameter.

Contains 3 Open reading frame (ORFs):

ORF 1 -  encodes a non-structural polyprotein including methyltransferase, protease, helicase, and polymerase.

ORF 2 - encodes for viral capsid protein

ORF 3 - encodes for an immunogenic protein

2. Causes of non-infectious hepatitis:

Parasites (Protozoan such as Entamoeba histolytica)

Excessive consumption of alcohol

Medications such as high dose of acetaminophen (Tylenol)

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Hepatitis A and hepatitis E present with similar symptoms. The diseases may develop without any signs or symptoms, or symptoms may be nonspecific. The common symptoms for both hepatitis A and E are:

mild fever

loss of appetite

malaise

right upper quadrant pain with any jarring motion

nausea and vomiting

abdominal pain

joint pain

dark urine and pale stooL

jaundice

Commonly, hepatitis A and E are asymptomatic in young adult age from 15 to 40 years old. In children, they are usually no obvious symptoms with only mild illness without jaundice which cause it to be undiagnosed.

Hepatitis E are rarely develop into severe and progressed to fulminant stage, except when it occur during pregnancy. It will cause acute liver failure, fatal loss and mortality. in 20-25% pregnant women can die if they get hepatitis E in their third trimester. Beside, chronic hepatitis E also may occur in immunosuppressed person such as organ transplant recipient.

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HEPATITIS A

Fecal- oral route
Ingestion of contaminated water or food. This occurs when the uninfected person ingested the water or food that has been contaminated with small and undetected faeces of infected person.

Certain sex practices
it usually occurs due to sex between women and women, men and men. This also can occur when the infected person has sexual activity with uninfected person.

Direct contact with infected people
can occur through dirty hand of infected person prepares for their family members

Poor personal hygiene
Do not wash hand and hair, usually occur in child care center as usually children do not properly do hand washing.

Blood exposure rare
it can be amplified in neonatal intensive care units

HEPATITIS E

Fecal- oral route Ingestion of under-cooked or uncooked meat and consumption of contaminated water

Poor sanitation- due to improper handling of sewage which cause virus

Transfusion of infected blood products

Vertical transmission from pregnant mother to infants

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Acquired through fecal oral transmission.

After ingestion, HAV/HEV survives gastric acid

Moves to the small intestine and reaches the liver via portal vein

Replication of HAV occurs exclusively within the cytoplasm of the hepatocyte.

Replication of HEV occurs in cytoplasm of the hepatocyte, small intestine,colon and lumph nodes.

Once mature, the HAV travels through sinusoidal

Enters bile canaliculi, released into small intestine and systemic circulation

Excreted in feces

HAV is not directly cytopathic to the hepatocyte

Hepatic injury occurs as a result of the host immune response to HAV.

Hepatocellular damage and destruction of infected hepatocytes

Mediated by human leukocyte antigen-restricted, HAV-specific CD8+ T lymphocytes and natural killer cells

Interferon-gamma appears to have a central role in promoting clearance of infected hepatocytes.

Video:
https://www.youtube.com/watch?v=Neqvdwi5fHc

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Hepatitis can be diagnosed by several tests and methods which are listed as following:

1) Medical history:

The physicians are more likely to ask about the patients' history of travels, sexual activities, exposure to contaminated shellfish and water or any intake of medications.

2) Level of serum transaminase:

Alanine transaminase (ALT) and aspartate transainase (AST) will show increased amount due to hepatocytes injuries.

3) Serum albumin:
Individuals with hepatitis will show low level of serum albumin as the liver function to synthesize albumin is affected.

4) Serum bilirubin:
There will be a significant increase of bilirubin level in individuals with hepatitis because the liver fails to excrete bilirubin from the body due to cell injuries.

5) Serological tests:

Hepatitis A: there will be presence of IgG anti HAV, and IgM anti HAV in people with Hepatitis A

Hepatitis E: there will be presence of IgG anti HEV and IgM anti HEV in people with Hepatitis E

6) Stool examination:
There may be presence of RNA virus in the feces of the infected individuals.

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There is no specific treatment both both Hepatitis A and E
supportive measures are taken to control the symptoms and to give comfort.

Have adequate rest

Fluid replacement by drinking plenty of fluid

Eat a healthy and balanced diet

Avoid alcohol consumption

Avoid unnecessary medications such as acetaminophen and paracetamol

PREVENTION

HEPATITIS A

Hepatitis A vaccination

Keep proper hygiene especially before eating/out from toilet

Do not eat unclean or uncooked food

Proper sewage disposal within the community to avoid contamination

Reduce or avoid sexual activities

HEPATITIS E

Avoid consuming uncertain supply of water and ice

Do not consume undercook food as well as unpeeled food including fruits

Practice a proper self-hygiene especially hand washing

Establish a proper community disposal system of sewage

Video:
https://www.youtube.com/watch?v=vqvSG9hqGUs

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For all forms of acute hepatitis, histology is characterized by "lobular disarray," which includes:

Ballooning degeneration

Spotty necrosis

Predominantly sinusoidal and lobular mononuclear cell infiltrate (neutrophils and eosinophils)

Kupffer cell hyperplasia

Scattered apoptotic bodies

Canalicular cholestasis

Hepatocellular regeneration

Video: https://youtu.be/l4m3f2KCxLM

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Hepatocyte injury – diffuse swelling (ballooning degeneration).

Hydropic cytoplasm, granular eosinophilic, Councilman bodies and necrosis.

Bile plugs brown pigmentation – in canaliculi and hepatocytes – indicate cholestasis, this due to cessation of the contractile activity of the paricanalicular actin microfilament web.

Lobular inflammation – with interphase and ductular reaction.

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HEPATITIS A
In a rare cases, hepatitis A can progress to acute liver failure. It usually appear in older adults and patient who have chronic liver disease. If this occurs, the patient will be hospitalized. Even in cases of liver failure, a full recovery is likely. It is very rare for the patient to perform liver transplant.

HEPATITIS E
Complications include contracting a long-lasting hepatitis, neurological disorders, and severe liver damage or liver failure, which could potentially be fatal.

Pregnant woman are a highlighted to be at high risk group. Hepatitis E can affect both unborn child and possibly their themselves.

Hepatitis E may also be much dangerous in people who have a history of liver disease or chronic liver disease. People who performed a liver transplant and take immunosuppressant drugs may also be at a higher risk of complications.

For further information regarding complication of hepatitis A:
https://about-hepatitis.com/hepatitis-complications

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To gain more information about hepatitis A , can access this website freely as this website has been provided and proven by Ministry of Health Malaysia:

http://www.myhealth.gov.my/en/hepatitis-a-b-c-2/

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MYTH: “If I got hepatitis A, I am immune to others form of hepatitis”

TRUTH:  People who have hepatitis A get lifelong protection against hepatitis A only but they are still at risk of infection with other forms of hepatitis. There is vaccine available for Hepatitis A and Hepatitis B but others not.

MYTH: Bland food and boiled vegetable are the right kind of food for Hepatitis infected person

TRUTH: Nutrition is most important in improving the liver function and limiting food may cause protein malnutrition during prolonged disease.

MYTH: All hepatitis infections are fatal diseases

TRUTH: No, the infection not fatal. In fact, in India about 20 – 40 million infected persons who are living healthy lives, the majority could live till old age.

MYTH: Hepatitis A & E virus can spread within the family

TRUTH:  By the times jaundice appears the patients not shedding virus in stool and becomes non- infectious. Epidemics of hepatitis E usually results from contamination of a water source with sewage.

MYTH: Vaccines available against all types of hepatitis virus

TRUTH: Vaccines only available against hepatitis A and b

MYTH: Hepatitis A is the most common cause of hepatitis in adults in India

TRUTH: By the age of 10 years, more than 95% of children are already positive for Hepatitis A indicate poor sanitation and hygiene in the country.  Hepatitis E is the most common cause of acute viral hepatitis in adults in India. Unhygienic street food is one of the causes of Hepatitis E.