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Hepatitis Disease

Hepatitis A
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Hepatitis D
  Clinical Features
of HDV
Modes of Transmission

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      HAV / HBV / HCV / 

Hepatitis E (HEV)

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เชื้อไวรัสตับอักเสบดี พบในผู้ป่วยกลุ่มที่มีการฉีดยาเสพติด รับเชื้อจากการใช้เข็มและกระบอกฉีดร่วมกัน
เชื้อชนิดนี้ไมาสามารถเพิ่มจำนวนในเซลล์ตับได้โดยลำพัง แต่จะติดเชื้อร่วมกับตับอักเสบบี แล้วจึงเพิ่ม
จำนวนไวรัสทั้งตับอักเสบ ดี และ บี

การติดเชื้อ เช่นเดียวกับโรคตับอักเสบบี ตับอักเสบดีทำให้เกิดโรคตับอักเสบรุนแรงกว่าเชื้ออื่นๆ และอาจ
ติดเชื้อเรื้อรัง จนกลายเป็นตับแข็งในอัตราค่อนข้างสูงๆ

การป้องกัน โดยการฉีดวัคซีนป้องกันไวรัสตับอักเสบบี จะป้องกันโรคนี้ได้ด้วย 

THIS REVIEW was written by Howard J. Worman, M.D., Departments of Medicine and of Anatomy and Cell Biology, College of Physicians and Surgeons, Columbia University, New York, NY 10032. Dr. Worman has more reviews available at his Current Papers in Liver Disease site.

"The Hepatitis D Virus"
Hepatitis D By Howard J. Worman, M. D.

The hepatitis D virus (also called delta virus) is a small circular RNA virus. The hepatitis D virus is replication defective and therefore cannot propagate in the absence of another virus. In humans, hepatitis D virus infection only occurs in the presence of hepatitis B infection.

Hepatitis D virus infection is transmitted by blood and blood products. The risk factors for infection are similar to those for hepatitis B virus infection. The hepatitis D virus most often infects intravenous drug users.

A patient can acquire hepatitis D virus infection at the same time as he/she is infected with the hepatitis B virus. This is called co-infection. A patient with hepatitis B can be infected with hepatitis D virus at any time after acute hepatitis B virus infection. This is called super-infection.

Hepatitis D virus super-infection should be suspected in a patient with chronic hepatitis B whose condition suddenly worsens. There is usually an obvious history of continued exposure to blood or blood products (eg. an active intravenous drug user). A particularly aggressive acute hepatitis B infection could suggest hepatitis D co-infection. Co-infection or super-infection with hepatitis D virus in a patient with hepatitis B is diagnosed by the presence of antibodies against the hepatitis D virus. IgM antibodies indicate acute infection.

Interferon-alpha is used to treat patients with chronic hepatitis B and hepatitis D infection. Some studies have suggested that a dose higher than that usually used for hepatitis B infection may be beneficial.

Hepatitis D Virus

Hepatitis D Virus (HDV) or delta virus is a unique incomplete virus that requires hepatitis B virus (HBV) for its replication. The RNA genome is covered by an outer coat of hepatitis B surface antigen. HDV infection occurs worldwide but is endemic in certain regions including the Mediterranean basin, the Balkan peninsula, the former Soviet Union, parts of Africa and the Middle East and the Amazon basin of South America. In these regions, spread is typically intrafamilial and through sexual contact.

In non-endemic regions, such as North America, HDV infection is uncommon in the general population but does occur in intravenous drug users and persons with frequent exposure to blood products (e.g. hemophiliacs) as well as their sexual contacts.

The clinical course of HDV infection depends largely on whether the virus was acquired as a coinfection with hepatitis B or as a superinfection in an individual with a previously established chronic HDV infection. When acquired as a coinfection, HDV typically results in acute self-limited hepatitis although fulminant hepatitis and death are well described. As a superinfection the typical course is one of a rapidly progressive chronic hepatitis.

Prevention of HDV infection is based on HDV vaccination in susceptible individuals. Patients with chronic HDV infection at risk of HDV infection are advised to avoid parenteral and unprotected sexual exposures.


Hepatitis D - Clinical Features

  • Coinfection
    • severe acute disease
    • low risk of chronic infection
  • Superinfection
    • usually develop chronic HDV infection high
    • risk of severe chronic liver disease
HDV infection can be acquired either as a co-infection with HBV or as a superinfection of persons with chronic HBV infection. Persons with HBV-HDV co-infection may have more severe acute disease and a higher risk of fulminant hepatitis (2%-20%) compared with those infected with HBV alone; however, chronic HBV infection appears to occur less frequently in persons with HBV-HDV co-infection. Chronic HBV carriers who acquire HDV superinfection usually develop chronic HDV infection. In long-term studies of chronic HBV carriers with HDV superinfection, 70%-80% have developed evidence of chronic liver diseases with cirrhosis compared with 15%-30% of patients with chronic HBV infection alone.

The serologic course of HDV infection varies depending on whether the virus is acquired as a co-infection with HBV or as a superinfection of a person with chronic HBV infection. In most persons with HBV-HDV co-infection, both IgM antibody to HDV (anti-HDV) and IgG anti-HDV are detectable during the course of infection. However, in about 15% of patients the only evidence of HDV infection may be the detection of either IgM anti-HDV alone during the early acute period of illness or IgG anti-HDV alone during convalescence. Anti-HDV generally declines to sub-detectable levels after the infection resolves and there is no serologic marker that persists to indicate that the patient was ever infected with HDV. Hepatitis Delta antigen (HDAg) can be detected in serum in only about 25% of patients with HBV-HDV co-infection. When HDAg is detectable it generally disappears as HBsAg disappears and most patients do not develop chronic infection. Tests for IgG anti-HDV are commercially available in the United States. Tests for IgM anti-HDV, HDAg and HDV RNA by PCR are only available in research laboratories.

In patients with chronic HBV infection who are super-infected with HDV several characteristic serologic features generally occur, including: 1) the titer of HBsAg declines at the time HDAg appears in the serum, 2) HDAg and HDV RNA remain detectable in the serum because chronic HDV infection generally occurs in most patients with HDV superinfection, unlike the case with co-infection, 3) high titers of both IgM and IgG anti-HDV are detectable, which persist indefinitely.


In general, the global pattern of HDV infection corresponds to the prevalence of chronic HBV infection; however, several distinct features of the distribution of HDV infection have been identified. In countries with a low prevalence of chronic HBV infection, HDV prevalence is generally low among both asymptomatic HBV carriers (<10%) and among patients with chronic HBV-related liver disease (<25%). HDV infection in these countries occurs most commonly among injecting drug users and persons with hemophilia. In countries with moderate and high levels of chronic HBV prevalence, the prevalence of HDV infection is highly variable. In southern Italy and in parts of Russia and Romania, the prevalence of HDV infection is very high among both asymptomatic HBV carriers (>20%) and among patients with HBV-related chronic liver disease HBV (>60%). Other countries, including northern Italy, Spain, Turkey, and Egypt, have a moderate prevalence of HDV infection among asymptomatic HBV carriers (10%-19%) and among patients with chronic HBV-related liver disease (30%-50%). However, in most of Southeast Asia and China, where the prevalence of chronic HBV infection is very high, HDV infection is uncommon. In some South American countries in the Amazon River Basin, periodic epidemics of HDV infection have occurred among chronic HBV carriers in relatively isolated regions. Disease related to HDV infection in these outbreaks has been very severe, with rapid progression to fulminant hepatitis and case-fatality rates of 10%-20%. The cause of the atypical course of HDV infection in these populations is unknown.

*(Note: The map of anti-HDV prevalence generalizes available data and patterns may vary within countries.)


Hepatitis D - Prevention

  • HBV-HDV Coinfection
    Pre or postexposure prophylaxis to prevent
  • HBV infection HBV-HDV Superinfection
    Education to reduce risk behaviors among persons with chronic HBV infection

Because HDV is dependent on HBV for replication, HBV-HDV co-infection can be prevented with either pre- or postexposure prophylaxis for HBV. However, no products exist to prevent HDV superinfection of persons with chronic HBV infection. Thus, prevention of HDV superinfection depends primarily on education to reduce risk behaviors.


Hepatitis D Virus Modes of Transmission

  • Percutanous exposures
    • injecting drug use
  • Permucosal
    • exposures sex contact

The modes of HDV transmission are similar to those for HBV, with percutaneous exposures the most efficient. Sexual transmission of HDV is less efficient than for HBV. Perinatal HDV transmission is rare.


Fact Sheet

SIGNS & SYMPTOMS About 30% of persons have no signs or symptoms. 
Signs and symptoms are less common in children than adults.
  • jaundice
  • fatigue
  • abdominal pain
  • loss of appetite
  • nausea, vomiting 
  • joint pain
  • Hepatitis B virus (HBV)
  • 90% of infants infected at birth
  • 30% of children infected at age 1 - 5 years 
  • 6% of persons infected after age 5 years 

Death from chronic liver disease occurs in:

  • 15-25% of chronically infected persons
  • Occurs when blood or body fluids from an infected person enters the body of a person who is not immune. 
  • HBV is spread through having sex with an infected person without using a condom, sharing needles or "works" when "shooting" drugs, through needlesticks or sharps exposures on the job, or from an infected mother to her baby during birth.

Persons at risk for HBV infection might also be at risk for infection with hepatitis C virus (HCV) or HIV.



  • Persons with multiple sex partners or diagnosis of a sexually transmitted disease
  • Men who have sex with men
  • Sex contacts of infected persons
  • Injection drug users
  • Household contacts of chronically infected persons
  • Infants born to infected mothers
  • Infants/children of immigrants from areas with high rates of HBV infection (view map)
  • Health care and public safety workers
  • Hemodialysis patients
  • Hepatitis B vaccine is the best protection.
  • If you are having sex, but not with one steady partner, use latex condoms correctly and every time you have sex.
  • If you are pregnant, you should get a blood test for hepatitis B; Infants born to HBV-infected mothers should be given H-BIG (hepatitis B immune globulin) and vaccine within 12 hours after birth.
  • Do not shoot drugs; if you shoot drugs, stop and get into a treatment program; if you can't stop, never share needles, syringes, water, or "works", and get vaccinated against hepatitis A and B.
  • Do not share personal care items that might have blood on them (razors, toothbrushes).
  • Consider the risks if you are thinking about getting a tattoo or body piercing. You might get infected if the tools have someone else's blood on them or if the artist or piercer does not follow good health practices.
  • If you have or had hepatitis B, do not donate blood, organs, or tissue.
  • If you are a health care or public safety worker, get vaccinated against hepatitis B, and always follow routine barrier precautions and safely handle needles and other sharps.
  • Hepatitis B vaccine available since 1982
  • Routine vaccination of 0-18 year olds
  • Vaccination of risk groups of all ages (see section on risk groups) 

National Institutes of Health fact sheet on treatment

  • HBV infected persons should be evaluated by their doctor for liver disease.
  • Alpha interferon and lamivudine are two drugs licensed for the treatment of persons with chronic hepatitis B. These drugs are effective in up to 40% of patients.
  • These drugs should not be used by pregnant women.
  • Drinking alcohol can make your liver disease worse.



  • Number of new infections per year has declined from an average of 450,000 in the 1980s to about 80,000 in 1999.
  • Highest rate of disease occurs in 20-49-year-olds.
  • Greatest decline has happened among children and adolescents due to routine hepatitis B vaccination. 
  • Estimated 1.25 million chronically infected Americans, of whom 20-30% acquired their infection in childhood.



Hepatitis A


Hepatitis B


Hepatitis C


Hepatitis D


What is it?

HAV is a virus

that causes inflammation of the liver. It does not lead to chronic disease.

HBV is a virus

That causes inflammation of the liver. It can cause liver cell damage, leading to cirrhosis and cancer.

HCV is a virus

that causes inflammation of the liver. It can cause liver cell damage, leading to cirrhosis and cancer.

HDV is a virus

that causes inflammation of the liver. It only infects those persons with HBV.

Incubation Period

2 to 7 weeks.

Average 4 weeks.

6 to 23 weeks.

Average 17 weeks.

2 to 25 weeks.

Average 7 to 9 wks.

2 to 8 weeks.

How is it Spread?

Transmitted by fecal/oral route, through close person to person contact or ingestion of contaminated food and water. Contact with infected blood, seminal fluid, vaginal secretions, contaminated needles, including tattoo and body-piercing tools. Infected mother to newborn. Human bite. Sexual contact. Contact with infected blood, contaminated IV needles, razors, and tattoo or body- piercing tools. Infected mother to newborn. NOT easily spread through sex. Contact with infected blood, contaminated needles. Sexual contact with HDV infected person.


May have none. Others may have light stools, dark urine, fatigue, fever, nausea, vomiting, abdominal pain, and jaundice. May have none. Some persons have mild flu-like symptoms, dark urine, light stools, jaundice, fatigue and fever. Same as HBV Same as HBV

Treatment of Chronic Disease

Not applicable. Interferon and Lamivudine with varying success. Interferon and combination therapies with varying success. Interferon with varying success.


Two doses of vaccine to anyone over 2 yrs of age or older. Three doses may be given to persons of any age. None HBV vaccine prevents HDV infection.

Who is at Risk?

Household or sexual contact with an infected person or living in an area with HAV outbreak. Travelers to developing countries, persons engaging in anal/oral sex and injection drug users. Infants born to infected mother, having sex with an infected person or multiple partners, injection drug users, emergency responders, healthcare workers, persons engaging in anal/oral sex, and hemodialysis patients. Blood transfusion recipients before 1992, healthcare workers, injection drug users, hemodialysis patients, infants born to infected mother, multiple sex partners. Injection drug users, persons engaging in anal/oral sex and those having sex with an HDV infected person.


Immune Globulin within 2 wks of exposure. Vaccination. Washing hands with soap and water after going to the toilet. Use household bleach (10 parts water to 1 part bleach) to clean surfaces contaminated with feces, such as changing tables. Safe sex. Immune Globulin within 2 wks of exposure. Vaccination provides protection for 18 years. Clean up infected blood with household bleach and wear protective gloves. Do not share razors, toothbrushes, or needles. Safe sex. Clean up spilled blood with household bleach. Wear gloves when touching blood. Do not share razors, toothbrushes, or needles with anyone. Safe sex. Hepatitis B vaccine to prevent HBV infection. Safe sex.


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