1. Viral
Hepatitis

3. Why Hepatitis virus testing is done ?
Identify the type of hepatitis virus causing a hepatitis infection.
Screen people (such as doctors, dentists, and nurses) who have an increased chance of getting hepatitis virus infection.
Screen potential blood donors and donor organs to prevent the spread of hepatitis .
Find out whether a person has antibodies after getting a hepatitis vaccine .
Find out if a hepatitis virus infection is the cause of abnormal liver function tests.
If you had this vaccine and you now have antibodies to the hepatitis A virus (anti-HAV antibodies) in your blood, this means the vaccination was effective (you are immune to hepatitis A).

4. Hepatitis A virus ﴾ HAV﴿

5. Characteristics of HAV
HAV causes hepatitis A (The most common of the known types of viral hepatitis)
A member of the enteroviruses (picornaviridae family).
Single -stranded RNA genome.
Icosahedral, naked and 27 – 32 nm
in diameter
Have short incubation period: 2 – 6 weeks.
Unlike other RNA viruses, this virus is Icosahedral rather than helical
 Naked viruses pertain to those that only have nucleocapsid, which is a protein capsid that covers the genome of the virus.

6. HAV transmission HAV is transmitted by fecal-oral route.
Transmitted person-to-person by ingestion of contaminated food or water or through direct contact with an infectious person.
Virus appears in the feces roughly 2 weeks before the appearance of symptoms, so in this period the virus is infective.
Children are the most frequently infected group.

7. A tiny amount of the virus will cause the infection.
Unlike HBV, HAV is rarely transmitted via the blood, and chronic infection doesn’t occur.
Acute, there is no chronic carrier state occurs, and there’s no predisposition to hepatocellular carcinoma and the complications are rarely serious.
The infection with this virus for the first time does not provide protection from infection again.
Personal hygiene, such as careful hand washing, can minimize the risk of the virus transmission to other person.

8. Signs and symptoms of HAV virus:
Jaundice (yellow skin and whites of eyes, darker yellow urine and pale feces) as a result of high bilirubin.
A short, mild, flu-like illness.

9. Laboratory diagnosis of HAV:
Detection of the virus in the feces only in the first 2 weeks of infection by used immune-electron microscopy.
Liver function test will show elevated transaminases (ALT, AST, LDH, ALP) and elevated measurements of bilirubin in blood & Urine.
RIA or ELISA for IgM in the first 2-3 weeks and later for IgG.
HAV Rapid IgM or IgG -Assay
Isolation of the virus in cell culture but usually not available in the clinical laboratory.
mmune electron microscopy n. The use of an electron microscope to examine viral specimens bound to specific antibody.

10. Treatment for HAV:
There is no specific treatment for HAV and most people fight off the virus naturally (self-limited), returning to full health within a couple of months.
The doctor will advise avoiding alcohol and fatty foods as these can be hard for the liver to process and may exacerbate the inflammation.
Patients should get plenty of rest and eat a nutritious diet.
They should also ensure they do not spread HAV by washing their hands after using the toilet and before preparing food.
Patients with more severe symptoms may be monitored in hospital for a short period.

11. Hepatitis B virus ﴾ HBV ﴿

12. Characteristics of HBV:
Belongs to the hepadnaviridae family.
Spherical, double- shelled DNA containing particles.
Icosahedral, enveloped and 42 nm in diameter.
Incubation period: 2 – 6 months ( days).

13. HBV Structure
Subviral lipoprotein particles (Excess envelope)

14. 4- Sharing contaminated needles or other equipment
HBV transmission:
1- Vertical transmission
From mother to baby
2- Sexual transmission
3- Blood transfusion
- Vertical transmission can occur during pregnancy, delivery and brestfeeding
- Immunization of the baby at birth prevents the transmission of hepatitis B
Through a blood transfusion in a country where blood is not screened for blood-borne viruses such as HBV
Acupunctureform of alternative medicine and a key component of traditional Chinese medicine 
5- Parenteral transmission
By using non-sterilized equipment for tattooing, acupuncture or body piercing
4- Sharing contaminated needles or other equipment

15. Signs and symptoms of HBV:
The clinical appearance of hepatitis B disease is similar to that of hepatitis A. However, with hepatitis B, symptoms tend to be more severe and life threatening.
A short, mild, flu-like illness.
Nausea.
Fatigue.
Abdominal pain.
Weight loss.
Jaundice.
Itchy skin.

16. If a person lives with hepatitis B infection for a number of years then they may develop the following complications:
Chronic hepatitis.
Liver cirrhosis.
Liver cancer.
Liver fibrosis is the scarring process that represents the liver’s response to injury. the liver repairs injury through the deposition of new collagen. Over time this process can result in cirrhosis of the liver, in which the architectural organization of the functional units of the liver becomes so disrupted that blood flow through the liver and liver function become disrupted. Once cirrhosis has developed, the serious complications of liver disease may occur, including portal hypertension, liver failure and liver cancer. The risk of liver cancer is greatly increased once cirrhosis develops, and cirrhosis should be considered to be a pre-malignant condition. Cirrhosis and liver cancer are now among the top ten causes of death worldwide,

17. Laboratory diagnosis of HBV:
Liver function tests, abnormally elevated transaminases (ALT and AST), bilirubin, alkaline phosphatase (ALP) and lactate dehydrogenase (LDH).
The presence of HBsAg confirms diagnosis as it appears in most patients , tested by ELISA and RIA.
Serological testing via Hepatitis marker testing
Detection of viral DNA load in the serum which is a strong evidence that the infectious virions are present.
Liver biopsy and PCR.
Reduction of the viral load in patients with chronic hepatitis B is used to monitor the success of drug therapy.
أول واحد يطلع هو HBsAg بداية وجوده تعني انه الحالة acute
يفترض يضل ل 6 شهور وبعدها يختفي لكن في حال ضل + بعد 6 شهور معناه انه الحالة تحولت ل chronic
HBcAg لا يوجد في السيرم اذا بدي ادور عليه لازم أخد من المريض liver biopsy

18. Serological HBV Markers:
HBcAb “Total”
HBcAb “IgM”
Hbe Ab
Hbe Ag
HBs Ab
HBsAg
Stage of disease -
+/- +
Incubation period
Acute hepatitis
Chronic carrier state
“low infectivity”
Chronic active state “high infectivity”
Convalescence
Past infection
Vaccination
HBs Antigen (HBsAg): Part of the virus surface. Appears 2–6 months after infection and proves that someone has acute or chronic hepatitis B. If HBsAg disappears and protective antibodies appear (HBsAg negative, anti-HBs positive), this is considered a “cure”.
HBs antibody (anti-HBs): The immune system creates this antibody to destroy the HBsAg of the virus. Anti-HBs appears if an infected person clears their virus (”cure”), or if a healthy person is successfully vaccinated.
HBc antibody (anti-HBc): Created by the immune system against the core of the hepatitis B virus. Always becomes positive in an infection and stays for life, no matter if the infection is cleared or becomes chronic.
anti-HBc  “Was there any contact with a hepatitis B virus?“
HBe antigen (HBeAg): can only be found in the original ”wild type“ of the hepatitis B virus. HBeAg is an indirect sign that the virus is replicating actively. However, HBeAg is also a vulnerable part of the virus. The immune system might create anti-HBe antibodies and destroy HBeAg. This is not a cure, but the virus is being controlled by the immune system, and cannot replicate well anymore. HBe antibody (anti-HBe): Specialized to destroy the HBe antigen. In chronic hepatitis B, these antibodies can sabotage the virus and inhibit its replication for many years or even decades: HBeAg negative, anti-HBe positive. This is called HBeAg seroconversion. This is not a cure, but the virus is at least being controlled by the immune system.

19. HBV immunization:
Hepatitis B vaccine is pure HBsAg produced by recombinant DNA.
The vaccination schedule most often used for adults and children has been three intramuscular injections, the second and third administered 1 and 6 months after the first.
A blood test is taken once the course of injections is completed to check they have worked.
Immunity should last for at least 5 years.
Hepatitis B vaccine is recommended for all babies so that they will be protected from a serious but preventable disease. Babies and young children are at much greater risk for developing a chronic infection if infected, but the vaccine can prevent this.

20. Can hepatitis B be treated
1.Acute hepatitis B
If someone is exposed to the hepatitis B virus in the previous seven days or less, he can receive an injection of hepatitis B immune globulin that may prevent developing the disease.
Besides this, there is no treatment for acute hepatitis B.
Prevent further liver damage

21. Two types of treatment exist
2. Chronic hepatitis B
Two types of treatment exist
Interferon which is a medication administered by a needle and
Antiviral medicines that are taken by mouth
These treatments do not provide a cure, but they offer control of the virus so that further damage to your liver can be prevented.
Treatment usually lasts 6 months, during which time the patient will be carefully monitored.
Chronic : وجود الIgG و وجود الفيروس
Regardless of whether the infection is producing symptoms or not, the patient will be advised to avoid alcohol, get plenty of rest and maintain a healthy diet

22. Hepatitis C virus ﴾ HCV ﴿

23. Characteristics of HCV:
Belong to the flaviviridae family.
Enveloped, RNA containing particles.
Icosahedral with 60 – 70 nm in diameter.
Incubation period: 15 – 150 days.

24. HCV transmission:
Transmission of hepatitis C virus is similar to hepatitis B virus, can transmit via any activity where blood may be involved
However ; the modes of sexual transmission and passing the virus from an infected mother to her baby via breast milk are much less common.
Notice
Chronic infections occur in 75-85% of infected persons.
And about 20% of individuals who become infected with HCV will clear the virus from their body within 6 months, though this does not mean they are immune from future infection with HCV.

25. Progression of Hepatitis C disease
HCC = Hepatocellular carcinoma
(ESLD) = end-stage liver disease

26. Laboratory diagnosis of HCV:
1. Serological blood tests used to detect antibodies to HCV with ELISA Technique.
This test doesn’t distinguish between an acute, chronic, or resolved infection.
2. Using molecular nucleic acid testing methods such as :
- RT-PCR (polymerase chain reaction) RIBA (recombinant immunoblot assay)
- TMA (transcription mediated amplification) b-DNA (branched DNA)
These tests have the capacity to detect not only whether the virus is present, but also to measure the amount of virus present in the blood
(the HCV viral load).
Anti-HCV antibodies can be detected in 80% of patients within 15 weeks after exposure, in >90% within 5 months after exposure, and in >97% by 6 months after exposure.

28. Additional tests
3. The HCV viral load is an important factor in monitoring the success to interferon-based therapy
4. Liver function tests.
5. Liver biopsy.

29. Treatment for HCV:
Hepatitis C does not always require treatment as the immune response in some people will clear the infection, and some people with chronic infection do not develop liver damage.
When treatment is necessary, the goal of hepatitis C treatment is cure. The cure rate depends on several factors including the strain of the virus and the type of treatment given.
Treatment combines the antiviral drugs interferon and ribavirin.
Notice: There is no vaccine for Hepatitis C virus.

30. None A, none B hepatitis viruses
Hepatitis D virus
HDV is unusual in that it can replicate only in cells also infected with HBV because HDV uses HBsAg as its envelope protein.HBV is thereforethe helper virus for HDV.
HDV is transmitted by the same means as HBV.
Hepatitis E virus
HEV is transmitted by fecal-oral route and it is a common cause of water-borne hepatitis in many developing countries.
Clinically the disease resembles hepatitis A.

31. HIV Human Immunodeficiency Virus
A = Acquires not inherited
I = weakens the immune system
D = create deficiency of CD4 cells
S = syndrome = a group of illnesses taking place at the same time
HIV Human Immunodeficiency Virus

32. Characteristics of HIV:
 The causative agent of acquired immunodeficiency syndrome (AIDS).
Belong to the lentivirus subfamily of the retrovidridae family.
Enveloped, icosahedral, RNA containing particles.
Have envelope glycoproteins: gp120 and gp41.
Infect immune system (T helper lymphocyte; CD4).
Incubation period: 3 – 5 years.
GP 41
Transmembranous glycoprotein
GP 120
Doking glycoprotein

33. Mode of transmission of HIV:
In general, transmission of HIV follows the pattern of HBV, except that the dose of HIV infection required to cause infection is much higher than HBV.
Sexual contact (primarily).
Sharing contaminated intravenous needles.
Infected mother to her baby, either across the placenta,
at birth, or via breast milk.
Blood transfusions and tissue transplantation.

34. Signs and symptoms of HIV:
Often people who are infected with HIV don't have any symptoms at all.
It is important to remember that a person who has HIV can pass on the virus immediately after becoming infected, even if they feel healthy.
It's not possible to tell just by looking if someone has been infected with HIV
Some people experience a flu-like illness, develop a rash, or get swollen glands for a brief period soon after they become infected with HIV. However, these are also common symptoms of other less serious illnesses, and do not necessarily mean that a person has HIV.
 “Latency” means a period where a virus is living or developing in a person without producing symptoms. During the clinical latency stage, people who are infected with HIV experience no symptoms, or only mild ones.
Common opportunistic infection in AIDS

35. AIDS:
This is the stage of HIV infection that occurs when your immune system is badly damaged (CD4 <200 cells/mm3) and you become vulnerable to opportunistic infections.
Without treatment, people who progress to AIDS typically survive about 3 years. Once you have a dangerous opportunistic illness, life-expectancy without treatment falls to about 1 year.
 Antiretroviral therapy administration and a low viral load, the patient may enjoy a near normal life span and most likely never progress to AIDS. 
(In someone with a healthy immune system, CD4 counts are between 500 and 1,600 cells/mm3. antiretroviral therapy or ART

36. Laboratory diagnosis of HIV:
1- Serological screening:
Antibody detection:
ELISAs are the most frequently used method for screening of blood samples for HIV antibody but false positive and false negative reactions may occur.
Another test systems available include passive particle agglutination, immunofluorescence, Western blots and RIBA bioassays.
Western blots are regarded as the gold standard

37. Antigen screening:
HIV antigen can be detected early in the course of HIV infection before the appearance of antibody.
It is undetectable during the latent period (antigen-antibody complexes are present) but become detectable during the final stages of the infection.
Capsid P24 antigen tests measure one of the proteins found on HIV virus by ELISA assays.
It was argued that the routine use of antigen screening tests in the blood transfusion service may result in earlier cases of HIV infection being identified.

38. 2-Virus isolation:
Virus isolation is accomplished by the cultivation of the patient's lymphocytes with fresh peripheral blood cells of healthy donors or with suitable culture lines such as T-lymphomas.
However virus isolation is tedious and time consuming (weeks), therefore virus isolation is mainly used for the characterization of the virus.
3. Demonstration viral nucleic acid:
This can be accomplished by PCR techniques due to its extremely high sensitivity.
مملTedious =

39. 4. HIV viral load:
HIV viral load in serum may be measured by assays which detect HIV-RNA e.g. RT-PCR.
HIV viral load has now been established as having good prognostic value, and in monitoring response to antiviral chemotherapy.
Patients with a low viral load during the incubation period had a better prognosis than those with a high viral load.
Despite the increasing use of HIV-RNA assays, measurement of CD4 still has important value in monitoring disease progression and response to antiviral chemotherapy.
HIV viral load appears to has the greatest prognostic value.

40. CD4 count:
CD4 count gives an indication of the stage of disease.
“The measurement of HIV viral load tells us where  the disease is going, whereas CD4 count tells us where the disease is at this moment”
Early immune deficiency
CD4 count > 500 cells/mm3
intermediate immune deficiency
CD4 count ( ) cells/mm3
Advance immune deficiency
CD4 count < 200 cells/mm3

41. The end