Monday, September 3, 2012


Andrew and granddad Rollosson
This weekend we drove over to Eastern Washington to attend my brother's wedding and visit family. Andrew met his great grandmother, my youngest brother and my new sister-in-law, more of his cousins, and one of Holly's uncles and his family. Andrew usually sleeps through being passed around friends and relatives but, when he ends up back in my arms, he curls up in a ball and grabs ahold of my shirt as if to say, "okay daddy, that's enough!" For me, the best part of this three-day weekend has been the amount of time I've been able to spend with my son.

Andrew received his first hepatitis B vaccine a few minutes after he was born. As I prepared to write an entry on hepatitis B vaccine I realized that this is a topic that I cannot adequately cover in a single post, so I've decided to start by writing an overview on hepatitis. This will also serve as a basis for my entry on hepatitis A vaccine when that time comes.

According to Steadman's medical dictionary, the word hepatitis comes from the Greek words hepar, meaning liver, and the suffix -ites, which commonly refers to inflammation or disease. The symptoms of hepatitis are caused by impairment of normal liver functions; these include breaking down toxins, hormones, drugs, and other substances, making clotting factors, and making albumin, a protein that holds water in the blood vessels. The liver also takes bilirubin, a byproduct of the breakdown or red blood cells, out of the blood and uses it to make bile, which aids in the digestion of fats.

Early symptoms of acute hepatitis include fatigue, malaise, muscle and joint pain, nausea and vomiting, and pain over the liver. Jaundice is yellow discoloration of the skin and sclera (whites of the eyes) from deposition of bilirubin. While jaundice is the most recognizable symptom of acute hepatitis, newborn jaundice is not caused by hepatitis.

There are many causes of hepatitis; both infectious and non-infectious. Non-infectious hepatitis include alcoholic hepatitis, autoimmune hepatitis, drug-induced hepatitis, and ischemic hepatitis. Acetaminophen (Tylenol®) is a common cause of drug-induced hepatitis. Many cold and allergy preparations contain acetaminophen, so unintentional overdoses can occur when these medications are combined.

Aside from the hepatotropic viruses, several other viruses can cause hepatitis including cytomegalovirus (CMV), Epstein-Barr virus (EBV), herpes simplex virus (HSV), varicella-zoster virus (VZV), and yellow fever virus. Bacterial causes of hepatitis include brucellosis, leptospirosis, Lyme disease, and syphilis.

Hepatotropic viruses

Hepato, liver + -tropic, having an affinity for (Steadman's).

There are five known hepatotropic viruses that cause disease in humans: hepatitis A virus (HAV), hepatitis B virus (HBV), hepatitis C virus (HCV), hepatitis D virus (HDV), and hepatitis E virus (HEV). There is another hepatotropic virus, GB virus type C (formerly known as hepatitis G virus), but it is not known to cause disease in humans. All five hepatotropic viruses can cause acute hepatitis, but only HBV, HCV, and HDV can cause chronic hepatitis.

Like other viruses, hepatotropic viruses invade cells and use the cells' protein synthesis mechanisms to make copies of themselves. However, hepatotropic viruses do not damage the liver directly. Hepatocytes ("liver cells") infected with a hepatotropic virus are targeted and killed by the immune system. In general, infants and young children are more "tolerant" of infection with hepatotropic viruses and are therefore more likely to have no symptoms or only mild symptoms of acute infection than adults. Unfortunately, this also means that people infected with either hepatitis B virus or hepatitis C virus as children, especially during infancy, are much more likely to be chronically infected with those viruses than adults. Adults tend have more severe acute symptoms but clear the infection more effectively than children.

Hepatitis A virus and hepatitis E virus are transmitted by the fecal-oral route. That means that to be infected with either HAV or HEV, something that a person eats, drinks, or otherwise puts in her or his mouth must be contaminated with feces. There are a lot of very common pathogens transmitted by the fecal-oral route. In two weeks, Andrew will have his first dose of rotavirus vaccine. Rotavirus, which causes diarrhea in infants, is transmitted by the fecal-oral route. Norovirus, which causes diarrhea and vomiting and is common called "stomach flu" (pet peeve: it's not the flu!), is also transmitted by the fecal-oral route. HAV, HEV, rotavirus, and norovirus are highly contagious, so it only takes a small inoculum (infecting dose) for a person to become infected and get sick with one of these viruses.

Hepatitis A used to be a very common childhood infection in the U.S. (I had it when I was 6 years old). The incidence of hepatitis A has dropped dramatically since the recommendation for universal childhood immunization with hepatitis A vaccine (CDC, 2006).

There are sporadic outbreaks of hepatitis E in the U.S., but it is much more common in developing countries. Like hepatitis A, HEV infection is usually self-limiting, however, hepatitis E is much more severe in pregnant women and is a significant cause of maternal death.

I had planned to write that there is no hepatitis E vaccine until I saw the table of contents for the September 2012 issue of Emerging Infectious Diseases: Hepatitis E, a vaccine preventable cause of maternal deaths. The State Food and Drug Administration of China approved a hepatitis E vaccine.

Hepatitis B virus, hepatitis C virus, and hepatitis D virus are transmitted by blood and bodily fluids. My next post will be on hepatitis B, so I'll go into more detail about transmission and epidemiology of these viruses as well as the effects of chronic hepatitis.

I'll end by quickly discussing a recent Centers for Disease Control and Prevention (CDC) recommendation. There are an estimated 2.7 to 3.9 million people in the United States infected with hepatitis C virus, most of whom are unaware of their infection. In the U.S., the majority of people infected with hepatitis C virus are between 45 and 65 years of age. The CDC therefore recommends that all persons born between 1945 and 1965 ("baby boomers") be tested for hepatitis C. People who are infected with hepatitis C virus will be advised how to avoid progression to cirrhosis of the liver and hepatocellular carcinoma (liver cancer). There are also treatments available to prevent progression to severe disease.


Centers for Disease Control and Prevention. (2006). Prevention of hepatitis A through active or passice immunization: recommendations of the Advisory Committee on Immunization Practices (ACIP). Morbidity and Mortality Weekly Report, 55(7), 1-23.

Centers for Disease Control and Prevention. (2012). Recommendations for the identification of chronic hepatitis C virus infection among persons born during 1945-1965. Morbidity and Mortality Weekly Report, 61(4),

Cohen, A. (2000). Liver disease. In L-E. C. Copstead & J. L. Banasik (Eds.) Pathophysiology: biological and behavioral perspectives (2nd ed.). Philadelphia: Saunders.

Curry, M. P. & Chopra, S. (2009). Acute viral hepatitis. In G. L. Mandell, J. E. Bennett, & R. Dolin. (Eds.). Mandell, Douglas, and Bennett’s principles and practice of infectious diseases. (7th Ed.). [Electronic version].

Dienstag, J. L. (2009). Chronic viral hepatitis. In G. L. Mandell, J. E. Bennett, & R. Dolin. (Eds.). Mandell, Douglas, and Bennett’s principles and practice of infectious diseases. (7th Ed.). [Electronic version].

Ferrante, M. A. (2003). Endogenous metabolic disorders. In C. Goetz (Ed). (2003). Textbook of clinical neurology (2nd ed.). Philadelphia: Saunders.

Labrique, A. B., Sikder, S. S., Krain, L. J., West, K. P., Christian, P, Rashid, M., et al. (2012). Hepatitis E, a vaccine-preventable cause of maternal deaths. Emerging Infectious Diseases, 18(9),

Mast, E. E. & Ward, J. W. (2008). Hepatitis B vaccine. In S. A. Plotkin, W. A. Orenstein, & P. A. Offit (Eds.) Vaccines (5th Ed.) [Electronic version].

Ryder, S. D. (2010). Viral hepatitis. In J. Cohen, S. M. Opal, & W. G. Powderly (Eds.) Infectious diseases (3rd Ed.). [Electronic version].


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