Understanding Hepatitis
and the Appropriate Barrier Protection

Hepatitis D DEFINITION The Hepatitis D Virus (HDV) is always associated with HBV infection. HDV is completely dependent upon HBV for replication, since it is a defective single-stranded RNA. By itself, it is unable to synthesize a viral coat. The coating is composed of HBsAg, which is used to encapsulate the HDV genome.53 CLINICAL MANIFESTATIONS HDV infection can be discernible as either a coinfection or superinfection of a patient with chronic HBV. The clinical manifestations that might present include: Severe acute disease (children with HDV could also have severe clinical manifestations). Low risk of chronic infection. Superinfection. Risk of severe chronic liver disease. Coinfection HBV and HDV are both transmitted parenterally. Persons with HBV-HDV coinfection often have a more severe acute disease and a higher risk of fulminant hepatitis (2%-20%) in comparison with patients infected with HBV alone. It has been noted that chronic HBV infection appears to occur less frequently in persons with an HBV-HDV coinfection.54 Superinfection Superinfection occurs in persons already infected with HBV. It results in acute hepatitis in a patient who already has chronic HBV. Carriers who acquire HDV superinfection are more likely to develop chronic HDV infection because the patient cannot make Anti-HbsAg. INCUBATION PERIOD The incubation period is anywhere from 2-8 weeks.55 CAUSE The hepatitis D or delta virus. It is a helical nucleocapsid that requires the hepatitis B envelope (HbsAg) to be infectious.56 DIAGNOSIS HDV may be possible in anyone infected with the hepatitis B virus and can be diagnosed by performing a RT-PCR serological test.57 The serologic course of HDV infection is dependent on whether the infection is a coinfection or a superinfection. Coinfection During the course of infection, both IgM antibody to HDV (anti-HDV) and IgG anti-HDV are noted; the anti-HDV usually declines and becomes undetectable after the infection. No serologic marker persists to indicate if the patient was ever infected with HDV. 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.58 Of those with a coinfection, about 25% of Hepatitis Delta Antigen (HDAg) can be detected in serum.59 When HDAg is detectable, it generally disappears. Most of these patients do not develop a chronic infection. Superinfection Titers of both IgM and IgG anti-HDV are only detectable in serum for a very short period of time. The patient cannot make Anti-HbsAg, and remains chronically infected with both HBV and HDV. POST-EXPOSURE PROPHYLAXIS There is no post-exposure prophylactic for this disease. The only prophylactic to this virus is HBV vaccination.60 LONG-TERM EFFECTS Expectations are similar to those for acute hepatitis B. It is dependent upon whether the patient has a coinfection or superinfection. The acute illness usually subsides over a few weeks, and the liver enzyme levels return to baseline within a few months.61 TRANSMISSION HDV infection has a direct relationship to chronic HBV infection. Hepatitis D occurs when contact with an infected person’s blood, semen, or other bodily fluids allows the virus to enter the body of a person who is not immune. The following situations can lead to infection: Unprotected anal or vaginal sex. Sharing needles used for drugs, body piercing, or tattooing. Contact with open sores. Sharing razors, toothbrushes, nail clippers, or washcloths. Living in a household with a person with ongoing HBV infection. Human bites. Needlesticks or sharps exposures on the job. An infected mother can transmit the disease to her baby during birth.62,63 WHO IS AT RISK? HDV infection has a direct correlation to the occurrence of chronic HBV infection. Those at risk would be chronic HBV carriers: Persons with multiple sex partners or the diagnosis of a sexually transmitted disease. Men who have sex with other men. Sexual contacts of infected persons. Injection drug users. Infants/children of immigrants from areas with high rates of HBV infection. Healthcare and public safety workers. People who live in the same house with someone who has a lifelong HBV infection. People who have hemophilia and other blood clotting disorders. People who travel to areas where HBV and HDV are common. Hemodialysis patients.64,65 TREATMENT Currently, there is no antiviral effective in the treatment of acute or chronic HDV. Treatment with alpha interferon has not proven to be successful in treating HDV. Liver transplantation is to be considered in fulminant cases.66 INFECTION CONTROL AND PREVENTION Infection Control Because HDV is reliant upon HBV for replication, it is important to protect yourself from HBV. Hepatitis B vaccination is the best protection, as hepatitis B is preventable. Currently, there is no cure for hepatitis B. For those having sex with multiple partners, properly using a condom during every sexual encounter is a must. This may reduce the risk of transmission. Do not use drugs. Those using drugs should stop and get help through a treatment program. Sharing of syringes/needles, drugs, and water increases risk of infection. Do not share personal daily care items that could have blood on them, such as razors and toothbrushes. Due to the risk involved, reconsider tattooing or body piercing. There is a possibility of becoming infected with the hepatitis virus if the tools have not been adequately cleaned/disinfected between uses. Always follow routine Standard Precautions that include the following: Hand Washing This is the number one way to reduce the spread of the disease. Wash hands immediately after gloves are removed, between patient contacts, and when otherwise indicated to avoid transfer of microorganisms to other patients or environments. Gloves Wear gloves manufactured from proper barrier protection materials when touching blood, bodily fluids, secretions, excretions, and contaminated items. Put on clean gloves just before touching mucous membranes and broken skin. Change gloves between tasks and procedures on the same patient after contact with material that may contain a high concentration of microorganisms. Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces, and before going to another patient. Wash hands immediately to avoid transfer of microorganisms to other patients or environments. Masks, Eye Protection, Face Shields Wear a standard surgical mask and eye protection or a face shield to protect mucous membranes of the eyes, nose, and mouth during procedures and activities that are likely to generate splashes or sprays. Prevention Healthcare personnel that come in contact with blood or bodily fluids should be vaccinated against hepatitis B. Hepatitis B vaccination is the best protection. Being immunized for hepatitis B will prevent hepatitis D; however, it is not curable. In 2001, the Federal Needlestick Safety and Prevention Act strengthened the requirements related to the use of safety-engineered sharp devices. To reduce employees’ occupational exposure to HIV, hepatitis B, and other bloodborne diseases, the Act requires the use of safety-engineered sharp devices and needle-less systems in hospitals and other healthcare settings.67 Healthcare institutions require reporting of all exposures to blood and bodily fluids. Immediate first aid and follow-up care is extremely important for all healthcare workers. The source patient as well as the healthcare worker will need to be tested for HIV, HBV, and HCV. Those who are HDV positive should not donate blood, organs, or tissue. VACCINE RECOMMENDATIONS The hepatitis B recombinant vaccine should be given to anyone 18 years and younger. It should also be given to adults at risk.68 FACTS, STATISTICS, AND TRENDS The CDC has determined through longterm studies of chronic HBV carriers with HDV superinfection that 70%-80% of patients have developed evidence of chronic liver disease with cirrhosis, compared with 15%-30% of patients with chronic HBV infection alone.69 There are approximately 35 fulminant cases/deaths per year.70 70,000 Chronic infections of HDV occur per year.71

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