病毒性肝炎防治 清泉醫院 余興焜 醫師 Sep. 13, 2011

VIRAL HEPATITIS The most common Hepatitis A Hepatitis B Hepatitis C Hepatitis D Hepatitis E Other viruses Hepatitis F virus (a hypothetical virus linked to hepatitis) GB virus C (Hepatitis G virus) Herpes simplex Cytomegalovirus Epstein-Barr virus Yellow fever The GB virus C is another potential viral cause of hepatitis that is probably spread by blood and sexual contact.[4] It was initially identified as Hepatitis G virus.[5] There is very little evidence that this virus causes hepatitis, as it does not appear to replicate primarily in the liver.[6] It is now classified as GB virus C

Viral Hepatitis

ACUTE VIRAL HEPATITIS discrete onset of symptoms nausea, anorexia, fever, malaise, or abdominal pain jaundice or elevated serum aminotransferase levels Serologic study

HEPATITIS A

Hepatitis-A endemic countries

provide lifelong protection 嬰兒及學齡前兒童感染之黃疸發生率低 15-50 days Mean: 28 days 2 months 4~6 months provide lifelong protection Hepatitis A virus (HAV) replicates in the liver shed in high concentrations in feces from 2 weeks before to 1 week after the onset of clinical illness Incubation period: 28 days (range: 15–50 days) A self-limited disease, not result in chronic infection or chronic liver disease 2 wks 2 wks

HEPATITIS A Transmission: fecal-oral Communicability: 2 weeks before to 1 wee after onset 感染力最強的時間在潛伏期的後半期，持續到出現黃疸之後幾天； 無黃疸現象之病人，則為SGOT、SGPT 上升至最高峰時。 大多數的病患在出現黃疸症狀後1 週即不具感染力。 10%–15% of patients might experience a relapse of symptoms during the 6 months after acute illness. Acute liver failure: rare (overall case-fatality rate: 0.1%) The risk for symptomatic infection directly related to age >80% of adults the majority of children having either asymptomatic or unrecognized infection Antibody produced in response to HAV infection primarily transmitted by the fecal-oral route person-to-person contact or consumption of contaminated food or water viremia early in infection persist for several weeks after onset of symptoms blood borne transmission of HAV: uncommon. HAV occasionally might be detected in saliva in experimentally infected animals, but transmission by saliva has not been demonstrated.

防疫措施--衛教宣導 注意飲水及飲食衛生，不可生飲、生食， 尤其生蠔或是水產貝類，另外也應加強 食物製備者如廚師及飲食從業人員之衛 生觀念。 保持良好衛生習慣，飯前、便後及處理 食物前需正確洗手，預防糞口途徑傳染。 注意環境衛生，特別是廁所環境清潔。

防疫措施--預防接種 為最有效的預防措施 國內提供免費接種A型肝炎疫苗條件 其他高危險群，若未具A型肝炎抗體者，加強自費接 種疫苗之宣導 設籍山地鄉、9個鄰近山地鄉之高感染平地地區（12縣市 及39鄉鎮）及金馬地區，出生滿2歲以上之學幼童 未具A型肝炎抗體之血友病病患 其他高危險群，若未具A型肝炎抗體者，加強自費接 種疫苗之宣導 如廚師及飲食從業人員 前往A型肝炎流行地區（如非洲、南美洲、亞洲、中國、 東南亞等）旅遊工作者 托兒所及幼稚園之照顧者

病人之處理:隔離 對確定A型肝炎病患住院期間，需注意排泄物的處理， 以腸胃道隔離為原則。 在發生黃疸後1週即無需隔離，可恢復工作及上學。 廚師或從事餐飲食品相關行業者，如符合「台灣法定 傳染病病例定義」之確定病例或極可能病例定義者， 應暫時停止餐飲業務，於發生黃疸後1週或在家休息2 週後，再回復工作，以避免感染源之擴散。 針對個案之接觸者（尤其是學齡前兒童），抽血篩檢 出IgM anti-HAV陽性之無明顯症狀個案，建議可在家 休息2週，並注意手部清潔、腸道與飲食衛生，以避 免感染源擴散傳染給同住家人。

Licensed dosages and schedules for VAQTA ® 1 Licensed dosages and schedules for HAVRIX ® 1 Age Dose (ELISA units)2 Volume (mL) No. of doses Schedule (mos)3 12 mos–18 yrs 720 0.5 2 0,6-12 ≥19 years 1,440 1.0 Licensed dosages and schedules for VAQTA ® 1 Age Dose (U.)2 Volume (mL) No. of doses Schedule (mos)3 12 mos–18 yrs 25 0.5 2 0,6-18 ≥19 years 50 1.0 Licensed dosages and schedules for TWINRIX ® 1 Age Dose (ELISA units)2 Volume (mL) No. of doses Schedule ≥ 18 yrs 720 1.0 3 0, 1, 6 mos 4 0, 7, 21–30 days + 12 mos3 HAV Vaccines: Inactivated whole virus vaccines Pediatric formulations (12 months - 18 years) Adult formulations (≥ 19 years) Adults: > 95% seropositive after one dose 100% seropositive after two dose Children (≥ 12 months) and adolescents > 97% seropositive after one dose 1Combined Hepatitis A and Hepatitis B vaccine, inactivated, GlaxoSmithKline. 2Enzyme-linked immunosorbent assay units. 3This 4-dose schedule enables patients to receive 3 doses in 21 days; this schedule is used prior to planned exposure with short notice and requires a fourth dose at 12 months.

HEPATITIS A SEROLOGIC TESTING Prevaccination Not indicated for children May be considered for some adults and older adolescents Postvaccination Not indicated

Can Hepatitis A vaccine be administered concurrently with other vaccines? Yes. Hepatitis B, diphtheria, poliovirus (oral and inactivated), tetanus, oral typhoid, cholera, Japanese encephalitis, rabies, and yellow fever vaccines and immune globulin can be given at the same time that Hepatitis A vaccine is given, but at a different injection site.

Can a patient receive the first dose of Hepatitis A vaccine from one manufacturer and the second (last) dose from another manufacturer? What should be done if the second (last) dose of Hepatitis A vaccine is delayed? Can Hepatitis A vaccine be given to immunocompromised persons (e.g., persons on hemodialysis or persons with AIDS)? Is it harmful to administer an extra dose(s) of Hepatitis A or Hepatitis B vaccine or to repeat the entire vaccine series if documentation of vaccination history is unavailable? Yes. Although studies have not been done to examine this issue, there is no reason to believe that using single-antigen vaccine from different manufacturers would be a problem. The second dose should be administered as soon as possible. The first dose does not need to be readministered Yes. Because Hepatitis A vaccine is inactivated, no special precautions need to be taken when vaccinating immunocompromised persons. No. If necessary, administering extra doses of Hepatitis A or Hepatitis B vaccine is not harmful.

How soon before travel should the first dose of Hepatitis A vaccine be given? among healthy persons aged 1–40 years one dose of single-antigen Hepatitis A vaccine administered at any time before older adults, immunocompromised persons, and persons with chronic liver disease or other chronic medical conditions planning to depart in <2 weeks  the initial dose of vaccine and IG (0.02 mL/kg) at a separate anatomic injection site > 2 weeks  the initial dose of vaccine

Postexposure Prophylaxis for Hepatitis A For healthy persons aged 1–40 years single-antigen Hepatitis A vaccine at the age-appropriate dose is preferred to IG For persons aged >40 years IG is preferred Vaccine can be used if IG cannot be obtained For children aged <12 months, immunocompromised persons, persons with chronic liver disease, and persons who are allergic to the vaccine or a vaccine component IG should be used.

Immune globulin available for short-term protection (approximately 3 months) against Hepatitis A, both pre- and post- exposure administered within 2 weeks after exposure for maximum protection

HBV HEPATITIS

Typical serologic course of acute hepatitis B virus infection with recovery 60–150 days Average 90 days 潛伏期長短與感染的病毒量、傳染途徑及宿主本身因素有關 (6個月內消失) 數週 4 weeks 15 weeks

HEPATITIS B DNA virus (4 subtypes: adr, adw, ayr, ayw) Humans: only known host May retain infectivity for more than 7 days at room temperature More than 350 million chronically infected worldwide Human carcinogen: causes of up to 80% of hepatocellular carcinomas

流行病學 在臺灣早期主要傳染因素，來自於母體垂直傳染。 受感染者年齡愈小，愈容易成為慢性帶原者 在美國 新生兒感染約90％會成為慢性帶原者 5歲以下幼兒感染，約25～50％會成為慢性帶原者 成人感染則成為慢性帶原者之危險性約在5％以下 在美國 成年人之表面抗體（anti-HBs）陽性率為5％，表面抗原陽性率為0.5％ 在已開發國家，B型肝炎病毒感染之高危險群體包括 靜脈注射毒癮者 性伴侶多之異性戀者 同性戀者 需經常接觸血液、體液之醫療檢驗人員。

傳染方式 B型肝炎表面抗原可在體液及分泌液內被 發現，但只有血液、精液及陰道分泌物顯 示具感染性 由受污染注射器、週產期感染及性行為 家庭接觸感染共用刮鬍刀、牙刷 接受針灸、刺青、紋眉、穿耳洞等行為

HBV TRANSMISSION Communicability: Perinatal transmission 1-2 months before and after onset of symptoms Chronic carriers Perinatal transmission If mother positive for HBsAg and HBeAg 70-90% of infants infected 90% of infected infants become chronically infected If positive for HBsAg only 10% of infants infected

預防方法--衛生教育 使用拋棄式注射針、筒，針灸之針，穿耳洞之針等需 充分消毒滅菌，並鼓勵民眾避免不必要的輸血、打針、 針灸、刺青、穿耳洞等行為。 養成良好個人衛生習慣，不與別人共用刮鬍刀、牙刷、 針頭、毛巾、指甲剪，以免刮破皮膚或黏膜而感染。 e抗原陽性之帶原者需特別注意防範傳染他人，尤其是 工作上常需接觸傷口之醫療人員及牙醫。 加強輸血檢驗，血袋需做B型肝炎表面抗原檢驗。 對受血者做追蹤監視，包括每一位受血者其供血者之 資料紀錄，以便能通知捐血中心（單位）哪些供血者 可能為帶原者。

預防方法--預防接種 台灣自1986年7月開始全面實施新生兒接種B型肝炎疫 苗 孕婦懷孕7、8個月時應接受B型肝炎產前篩檢。 6歲兒童Ｂ型肝炎帶原率: 實施預防注射前之10.5%下 降至注射後之0.8%。 孕婦懷孕7、8個月時應接受B型肝炎產前篩檢。 所有嬰幼兒於出生後2～5天、1個月、6個月，應完成 三劑B型肝炎疫苗接種 若母親檢驗結果為e抗原陽性，其新生兒應於出生後 儘速注射一劑B型肝炎免疫球蛋白，最遲不要超過24 小時。 依據我國效益追蹤研究，母親表面抗原及ｅ抗原陽性 時，其新生兒於出生時按時注射一劑B型肝炎免疫球蛋 白及完成B型肝炎全程疫苗注射，其保護效益約為84％。 成人如未曾感染B型肝炎病毒且未曾接種B型肝炎疫苗 者，應接種B型肝炎疫苗。

接觸者處理 對接觸患者有感染之虞者的預防措施，可 注射B型肝炎免疫球蛋白及疫苗。B型肝炎 免疫球蛋白是高效價的B型肝炎表面抗體， 需於暴露病源之後儘快注射。 被B型肝炎病毒污染之器物刺到（如：針頭） 或觸碰到粘膜時，需儘速（最遲不得超過 24小時）注射一劑B型肝炎免疫球蛋白（對 成人之劑量為0.06 mL/kg或注射5 mL）。

Protection by Age Group and Dose HEPATITIS B VACCINE Formulations: Recombivax HB (Merck) Engerix-X (GSK) 5 mcg/0.5 ml (pediatric) 10 mcg/0.5 ml(pediatric) 10 mcg/1.0 ml (adult) 20 mcg/1.0 ml (adult) 40 mcg/1.0 ml (dialysis) Protection by Age Group and Dose Dose Inants Teens and Adults 1 16-40 % 20-30 % 2 80-95 % 75-80 % 3 98-100 % 90-95 % Factors that my lower vaccine response rates are age 40 years or older, male gender, smoking, obesity, and immune deficiency

Combined Hepatitis B–Haemophilus influenzae type b conjugate vaccine * Combined Hepatitis B–Haemophilus influenzae type b conjugate vaccine. This vaccine cannot be administered at birth, before age 6 weeks, or after age 71 months. † Combined Hepatitis B, diphtheria, tetanus, acellular pertussis adsorbed, inactivated poliovirus vaccine. This vaccine cannot be administered at birth, before age 6 weeks, or at age >7 years. § Combined Hepatitis A and Hepatitis B vaccine. This vaccine is recommended for persons aged ≥18 years who are at increased risk for both Hepatitis B virus and Hepatitis A virus infections. †† Adult formulation administered on a 2-dose schedule. §§ Higher doses might be more immunogenic, but no specific recommendations have been made. ¶¶ Dialysis formulation administered on a 3-dose schedule at 0, 1, and 6 months. *** Two 1.0-mL doses administered at one site, on a 4-dose schedule at 0, 1, 2, and 6 months.

Prevaccination Serologic Testing Not indicated before routine vaccination of infants or children Recommende for All persons born in Africa, Asia, the pacific Islands, and other regions with HBsAg revalence of 2% or higher Household, sex, and needle-sharing contactsd of HBsAg-positive persons Men who have sex with men Certain persons receiving cytotoxic or immunosuppressive therapy

Postvaccination Serologic Testing Not routinely recommended following vaccination of infants, children, adolescents or most adults Recommended for: Chronic hemodialysis patients Other immunocompromised persons Persons with HIV infection Sex partners of HBsAg+ person Infants born to HBsAg+ women (at 9-18 months) Certain healthcare workers

Booster doses of Hepatitis B vaccine For hemodialysis patients annual testing for antibody to Hepatitis B surface antigen (anti-HBs) <10 mIU/mL. For other immunocompromised persons (e.g., HIV-infected persons, hematopoietic stem-cell transplant recipients, and persons receiving chemotherapy) not been determined anti-HBs levels decline to <10 mIU/mL

Management of Nonresponse to Hepatitis B Vaccine Complete a second series of three doses Should be given on the usual schedule of 0, 1 and 6 months Retest 1-2 months after completing the second series Persistent nonresponse to hepatitis B vaccination <5% of vaccinees do not develop anti-HBs after 6 valid doses Check HBsAg status If exposed, treat as nonresponder with postexposure prophylaxis

Prevention of Perinatal Hepatitis B Virus Infection Begin treatment within 12 hours of birth Hepatitis B vaccine (first dose) and HBIG at different sites Complete vaccination series at 6 months of age Test for response at 9-18 months of age

Recommended Postexposure Prophylaxis for Occupational Exposure to Hepatitis B Virus Vaccination and antibody status of exposed person Treatment Source HBsAg positive Source HBsAg negative Source unknown or not available for testing Unvaccinated HBIG x1 and initiate HB vaccine series Initiate HB vaccine series Previously Vaccinated Known responder No treatment Known nonresponder HBIG x1 and initiate revaccination or HBIG x2 If known high-risk source, treat as source were HBsAg positive Antibody response unknown Test exposed person for anti-HBs If adequate, no treatment is necessary If inadequate, administer HBIG x1 and vaccine booster If inadequate, administer vaccine booster and recheck titer in 1-2 months Hepatitis B immune globulin: 0.06 ml/kg administered intramuscularly The option of giving one dose of HBIG and reinitiating the vaccine series is preferred for nonresponders who have not completed a second 3-dose vaccine series. For persons who previously completed a second vaccine series but failed to respond, two doses of HBIG are preferred.

HEPATITIS B VACCINE CONTRAINDICATIONS Severe allergic reaction to a vaccine component or following a prior dose Moderate or severe acute illness Adverse reactions: Adults Infants and Children Pain at injection site 13-29% 3-9% Mild systemic complaints (fatigue, headache) 11-17% 0-20% Temperature ≤37.7 °C 1% 0.4-96% Severe systemic reaction Rare

How long does protection from Hepatitis B vaccine last? Can a patient receive the first dose of Hepatitis B vaccine from one manufacturer and subsequent doses from another manufacturer? If there is an interruption between doses of Hepatitis B vaccine, does the vaccine series need to be restarted? Can Hepatitis B vaccine be administered concurrently with other vaccines? How long does protection from Hepatitis B vaccine last? Yes. No differences in immune response are observed when vaccines from different manufacturers are used to complete the vaccine series. No, the series does not need to be restarted. If the vaccine series was interrupted after the first dose, the second dose should be administered as soon as possible. The second and third doses should be separated by an interval of at least 8 weeks. If only the third dose is delayed, it should be administered as soon as possible. Yes. When Hepatitis B vaccine has been administered at the same time as other vaccines, no interference with the antibody response of the other vaccines has been demonstrated. Separate body sites and syringes should be used for simultaneous administration of injectable vaccines. Studies indicate that immunologic memory remains intact for at least 20 years among healthy vaccinated individuals who initiated Hepatitis B vaccination >6 months of age. The vaccine confers long-term protection against clinical illness and chronic Hepatitis B virus infection. Cellular immunity appears to persist even though antibody levels might become low or decline below detectable levels. Among vaccinated cohorts who initiated Hepatitis B vaccination at birth, long-term follow-up studies are ongoing to determine the duration of vaccine-induced immunity.

Can Hepatitis B vaccine be given after exposure to HBV? Is there any benefit or risk in vaccinating a person who has been infected with HBV? Yes. After a person has been exposed to HBV, appropriate prophylaxis, given as soon as possible but preferably within 24 hours, can effectively prevent infection. The mainstay of postexposure immunoprophylaxis is Hepatitis B vaccine, but in certain circumstances the addition of HBIG will provide increased protection. Persons who have already been infected with HBV will receive no benefit from vaccination. However, there is no risk to a previously infected person who receives vaccination.

How is HBV infection treated? For acute infection no medication is available; treatment is supportive. For chronic infection several antiviral drugs (interferon alfa-2a or 2b, pegylated interferon alfa-2a, lamivudine, adefovir dipivoxil, entecavir, tenofovir and telbivudine)

HCV HEPATITIS

致病原（INFECTIOUS AGENT） RNA病毒 目前有6種主要基因型和50種以上的次要基因亞型 基因型1、2和3廣泛分佈於全球 1a主要在西歐和北美 1b常見於日本、台灣、南歐和東歐 4主要存在於非洲，其中4a為埃及之主要基因亞型 5存在於南非 6多發現於東南亞如香港和越南 台灣地區之C型肝炎病毒基因型分佈近似於日本，以亞 型1b為主，約佔全部C型肝炎病毒之45-71%。

臺灣C肝炎病例概況 全國15歲以上人口，C型肝炎的盛行率 為3.87% 地理區域 宜花東為最高10.2% C型肝炎的高盛行率地區，多集中在中南部沿海地區和部份原住 民社區 澎湖縣白沙鄉30-64歲居民達24.3% 雲林縣台西鄉40歲以上居民達55.1% 以前臺灣C型肝炎感染主要來自於輸血造成，但自1992年7月起， C型肝炎抗體檢驗納入血液篩檢項目後，幾乎罕見輸血後C型肝 炎之發生。 依據全國法定傳染病通報資料顯示，其中急性病毒性C肝炎， 2007-2009年每十萬人口發生率分別為0.66、0.56、0.57。年齡層 分佈，以20-34歲個案為最多

傳染方式 藉由受污染之血液或血清製劑感染，如同B型肝炎 受污染之針、注射器為重要傳染途徑 高危險群體 C型肝炎與B型肝炎的垂直傳染比較 受血者 靜脈注射毒癮者 洗腎者 需常接觸血液之醫療人員 C型肝炎與B型肝炎的垂直傳染比較 C型肝炎在周產期感染的比率要低很多 發生母子間垂直傳染的機率大約為5%

20~30% Fever Fatigue Dark urine Clay-colored stool Abdominal pain 4-12 wks 2-3 wks Fever Fatigue Dark urine Clay-colored stool Abdominal pain Loss of appetite Nausea Vomiting Joint pain Jaundice 4-10 wks

可傳染期 1至數週

預防保健 目前無C型肝炎疫苗可預防 特別注意避免行為如 輸血、打針、刺青、紋眉、穿耳洞等 與他人共用牙刷、刮鬍刀、針頭、針筒 及輸液管等 多重性伴侶及嫖妓等行為

How likely is HCV infection to become chronic? Is it possible for someone to become infected with HCV and then spontaneously clear the infection? How likely is HCV infection to become chronic? Why do most persons remain chronically infected with HCV? What is the risk for HCV infection from a needlestick exposure to HCV- contaminated blood? (1.8%) Approximately 15%–25% of persons clear the virus from their bodies without treatment and do not develop chronic infection; the reasons for this are not well known. HCV infection becomes chronic in approximately 75%–85% of cases. A person infected with HCV mounts an immune response to the virus, but replication of the virus during infection can result in changes that evade the immune response. This may explain how the virus establishes and maintains chronic infection. After a needlestick or sharps exposure to HCV-positive blood, the risk of HCV infection is approximately 1.8% (range: 0%–10%).

What are the chances of someone developing chronic HCV infection, chronic liver disease, cirrhosis, or liver cancer or dying as a result of Hepatitis C? Of every 100 persons infected with HCV, approximately 75–85 will go on to develop chronic infection 60–70 will go on to develop chronic liver disease 5–20 will go on to develop cirrhosis over a period of 20–30 years 1–5 will die from the consequences of chronic infection (liver cancer or cirrhosis)

Is there a Hepatitis C vaccine? Can a patient have a normal liver enzyme (e.g., ALT) level and still have chronic Hepatitis C? Is there a Hepatitis C vaccine? Can persons become infected with a different strain of HCV after they have cleared the initial infection? What is the risk of acquiring HCV infection from transfused blood or blood products? less than 1 chance per 2 million units transfused What should be done for a patient with confirmed HCV infection? It is common for patients with chronic Hepatitis C to have liver enzyme levels that go up and down, with periodic returns to normal or near normal levels. Liver enzyme levels can remain normal for over a year despite chronic liver disease. Prior infection with HCV does not protect against later infection with the same or different genotypes of the virus. This is because persons infected with HCV typically have an ineffective immune response due to changes in the virus during infection. For the same reason, no effective pre- or postexposure prophylaxis (i.e., immune globulin) is available No vaccine for Hepatitis C is available. Research into the development of a vaccine is under way. HCV-positive persons should be evaluated (by referral or consultation, if appropriate) for presence of chronic liver disease, including assessment of liver function tests, evaluation for severity of liver disease and possible treatment, and determination of the need for Hepatitis A and Hepatitis B vaccination.

Can superinfection with more than one genotype of HCV occur? Is it necessary to do viral genotyping when managing a person with chronic Hepatitis C? Can superinfection with more than one genotype of HCV occur? Because there are at least six known genotypes and more than 50 subtypes of HCV, genotype information is helpful in defining the epidemiology of Hepatitis C and in making recommendations regarding treatment. Knowing the genotype can help predict the likelihood of treatment response and, in many cases, determine the duration of treatment. Patients with genotypes 2 and 3 are almost three times more likely than patients with genotype 1 to respond to therapy with alpha interferon or the combination of alpha interferon and ribavirin When using combination therapy, the recommended duration of treatment depends on the genotype. For patients with genotypes 2 and 3, a 24-week course of combination treatment is adequate, whereas for patients with genotype 1, a 48-week course is recommended. Once the genotype is identified, it need not be tested again; genotypes do not change during the course of infection. Superinfection is possible if risk behaviors (e.g., injection drug use) for HCV infection continue, but it is believed to be very uncommon.

Does chronic Hepatitis C affect only the liver? Diabetes mellitus three times more frequently in HCV-infected persons Glomerulonephritis a type of kidney disease caused by inflammation of the kidney Essential mixed cryoglobulinemia a condition involving the presence of abnormal proteins in the blood

Does chronic Hepatitis C affect only the liver? Porphyria cutanea tarda an abnormality in heme production that causes skin fragility and blistering Non-Hodgkins lymphoma somewhat more frequently in HCV-infected persons

What topics should be discussed with patients who have HCV infection? Patients should be informed about the low but present risk for transmission with sex partners. Sharing personal items that might have blood on them, such as toothbrushes or razors, can pose a risk to others. Cuts and sores on the skin should be covered to keep from spreading infectious blood or secretions. Donating blood, organs, tissue, or semen can spread HCV to others. HCV is not spread by sneezing, hugging, holding hands, coughing, sharing eating utensils or drinking glasses, or through food or water.

What follow-up testing is recommended for health care personnel exposed to HCV-positive blood? For the source, perform baseline testing for anti-HCV. For the person exposed to an HCV-positive source, perform baseline and follow-up testing, including baseline testing for anti-HCV and ALT activity AND follow-up testing for anti-HCV (e.g., at 4–6 months) and ALT activity. If earlier diagnosis of HCV infection is desired, testing for HCV RNA may be performed at 4–6 weeks.

HEPATITIS D

HEPATITIS D also known as "delta hepatitis HDV: acute or chronic An incomplete RNA virus requires the helper function of HBV transmitted through percutaneous or mucosal contact with infectious blood either coinfection or superinfection with HBV infection acute or chronic 通常為突然發病，症狀與B型肝炎類似，只有B型肝炎帶原者，才能感染D型肝炎。D型肝炎病毒與B型肝炎病毒可共同感染，或D型肝炎病毒可次加感染於B型肝炎帶原者。D型肝炎病毒次加感染於B型肝炎帶原者時，常可能被誤診為慢性B型肝炎的急性發作，同時感染時血清AST（GOT）及ALT（GPT）之上升可呈雙峰，前者由B型肝炎，後者由D型肝炎引發。感染急性D型肝炎有可能引起猛爆性肝炎，但同時感染時比較少發生。同時感染不易引起慢性感染，但重疊感染時常變為慢性感染。在臺灣通常是藉由檢測血清中抗體或肝臟內的病毒抗原來診斷，抗體的檢測較常被用為診斷依據。病毒RNA經由核酸雜交方法測知。 當D型肝炎病毒複製時會暫時抑制B型肝炎病毒的複製。 臺灣一般而言，並不十分嚴重，但在特定危險群，如靜脈藥癮者、性工作者若為B型肝炎帶原者，則有頗高的感染率（40～85％）。

Acute HDV, Superinfection Chronic HDV, Superinfection HBV-HDV Coinfection Acute HDV, Superinfection Chronic HDV, Superinfection

防疫措施 感染B型肝炎者，才有可能感染D 型肝炎，故預防B型肝炎病毒感染 即可預防D型肝炎病毒感染

HEPATITIS E

以年輕人及中年人最高 通常男性感染率較高 兒童及老年人發生E型肝炎的情形較不常見 E型肝炎病毒流行區通常發生於環境衛生較不好的開發中國家包括印度、緬甸、尼泊爾、巴基斯坦、蘇聯、阿爾及利亞、利比亞、索馬利亞、墨西哥及中國大陸

15 – 60 days Mean: 40 days

TRANSMISSION AND EXPOSURE usually spread by the fecal-oral route (fecally contaminated drinking water) Most asymptomatic (1:2-13) Symptoms: Fever Fatigue Loss of appetite Nausea Vomiting Abdominal pain Jaundice Dark urine Clay-colored stool Joint pain

Who is most likely to have symptomatic HEV infection? symptoms of HEV infection most common among older adolescents and young adults (aged 15–44 years) Children infected with HEV usually mild or no symptoms Pregnant women more likely to experience severe illness, such as fulminant hepatitis, and death (20%) 懷孕第三期的孕婦感染E型肝炎時，其致死率有報告達20％

How serious is Hepatitis E? Most people with Hepatitis E recover completely. The overall case-fatality rate is ≤4%. Pregnant women more serious fatal in 10%–30%, particularly t in their third trimester.

Can Hepatitis E become chronic? Yes, but this appears very rare, and are so far reported only in organ transplantation patients.

DIAGNOSIS AND TREATMENT antibody to Hepatitis E or HEV RNA Treatment: usually resolves on its own without treatment no specific antiviral therapy for Hepatitis E

PREVENTION Relies primarily on good sanitation and the availability of clean drinking water (Boiling and chlorination of water will inactivate HEV) Immune globulin: not effective in preventing Hepatitis E. 免疫球蛋白（IG）無法預防E型肝炎 No FDA-approved vaccine for Hepatitis E

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