1. What’s Blood Got to do With It? Serology 101 Workshop
Hepatitis Coordinator’s Conference
San Antonio, Texas January
Linda Moyer
Brigette Finkelstein

2. Agenda Introduction Game Show Serologic Overview Case Study Exercises
Q & A

3. Hepatitis
Jeopardy

4. HEPATITIS JEOPARDY
Hepatitis
HAV
HBV
HCV
Vaccines
100
100
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500
500

5. HEPATITIS JEOPARDY
Hepatitis
HAV
HBV
HCV
Vaccines
100
100
100
100
100
200
200
200
200
200
300
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500

6. What types of hepatitis do not cause chronic infection?
Hepatitis for $100
What types of hepatitis do not cause chronic infection?
What is…..?

7. Hepatitis A and Hepatitis E
What is…..?
Hepatitis A and Hepatitis E
Hepatitis for $100

8. HEPATITIS JEOPARDY
Hepatitis
HAV
HBV
HCV
Vaccines
100
100
100
100
100
200
200
200
200
200
300
300
300
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500

10. What sign of hepatitis does this next picture portray?
Daily Double
What sign of hepatitis does this next picture portray?
Daily Double

11. What is…..?
Jaundice
Daily Double

12. HEPATITIS JEOPARDY
Hepatitis
HAV
HBV
HCV
Vaccines
100
100
100
100
100
200
200
200
200
200
300
300
300
300
300
400
400
400
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400
500
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500
500

13. Hepatitis for $300
Which hepatitis virus causes the highest number of chronic infections in the United States?
What is…..?

14. What is…..?
Hepatitis C Virus
Hepatitis for $300

15. HEPATITIS JEOPARDY
Hepatitis
HAV
HBV
HCV
Vaccines
100
100
100
100
100
200
200
200
200
200
300
300
300
300
300
400
400
400
400
400
500
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500
500
500

16. How many types of viral hepatitis have been identified?
Hepatitis for $500
How many types of viral hepatitis have been identified?
What is…..?

17. What is…..?
Five (A,B,C,D,E)
Hepatitis for $500

18. HEPATITIS JEOPARDY
Hepatitis
HAV
HBV
HCV
Vaccines
100
100
100
100
100
200
200
200
200
200
300
300
300
300
300
400
400
400
400
400
500
500
500
500
500

19. Hepatitis A virus is transmitted primarily through what route?
HAV for $100
Hepatitis A virus is transmitted primarily through what route?
What is…..?

20. What is…..?
Fecal/Oral
HAV for $100

21. HEPATITIS JEOPARDY
Hepatitis
HAV
HBV
HCV
Vaccines
100
100
100
100
100
200
200
200
200
200
300
300
300
300
300
400
400
400
400
400
500
500
500
500
500

22. Name a risk group for whom CDC recommends hepatitis A vaccination?
HAV for $200
Name a risk group for whom CDC recommends hepatitis A vaccination?
Who are…..?

23. Who are…..?
Men who have sex with men Travelers to endemic countries Children in states with high rates of hepatitis A Illegal drug users
HAV for $200

24. HEPATITIS JEOPARDY
Hepatitis
HAV
HBV
HCV
Vaccines
100
100
100
100
100
200
200
200
200
200
300
300
300
300
300
400
400
400
400
400
500
500
500
500
500

25. What should be used for short-term protection against HAV infection?
HAV for $500
What should be used for short-term protection against HAV infection?
What is…..?

26. What is…..?
Immune Globulin (IG)
HAV for $500

27. HEPATITIS JEOPARDY
Hepatitis
HAV
HBV
HCV
Vaccines
100
100
100
100
100
200
200
200
200
200
300
300
300
300
300
400
400
400
400
400
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500
500

29. Take a look at this picture?
Daily Double
Take a look at this picture?
Daily Double

30. Which hepatitis virus is this …..?
Hepatitis B Virus
Daily Double

31. HEPATITIS JEOPARDY
Hepatitis
HAV
HBV
HCV
Vaccines
100
100
100
100
100
200
200
200
200
200
300
300
300
300
300
400
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500

32. HBV for $200
What blood test should be done routinely on pregnant women during the 1st trimester?
What is…..?

33. Hepatitis B Surface Antigen (HBsAg)
What is…..?
Hepatitis B Surface Antigen (HBsAg)
HBV for $200

34. HEPATITIS JEOPARDY
Hepatitis
HAV
HBV
HCV
Vaccines
100
100
100
100
100
200
200
200
200
200
300
300
300
300
300
400
400
400
400
400
500
500
500
500
500

35. HBV for $300
What blood test should be positive when someone responds to the hepatitis B vaccine?
What is…..?

36. Hepatitis B Surface Antibody (Anti-HBs)
What is…..?
Hepatitis B Surface Antibody (Anti-HBs)
HBV for $300

37. HEPATITIS JEOPARDY
Hepatitis
HAV
HBV
HCV
Vaccines
100
100
100
100
100
200
200
200
200
200
300
300
300
300
300
400
400
400
400
400
500
500
500
500
500

38. What is the most common way hepatitis C virus is transmitted?
HCV for $100
What is the most common way hepatitis C virus is transmitted?
What is…..?

39. What is…..?
Injection Drug Use
HCV for $100

40. HEPATITIS JEOPARDY
Hepatitis
HAV
HBV
HCV
Vaccines
100
100
100
100
100
200
200
200
200
200
300
300
300
300
300
400
400
400
400
400
500
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500

41. Name an initial screening test for hepatitis C virus infection?
HCV for $300
Name an initial screening test for hepatitis C virus infection?
What is…..?

42. Enzyme Immunoassay (EIA)
What is…..?
Enzyme Immunoassay (EIA)
HCV for $300

43. HEPATITIS JEOPARDY
Hepatitis
HAV
HBV
HCV
Vaccines
100
100
100
100
100
200
200
200
200
200
300
300
300
300
300
400
400
400
400
400
500
500
500
500
500

44. HCV for $500
Name a test that should be done to rule out false positive anti-HCV results.
What is…..?

45. Recombinant Immunoblot Assay (RIBA)
What is…..?
Recombinant Immunoblot Assay (RIBA)
HCV for $500

46. HEPATITIS JEOPARDY
Hepatitis
HAV
HBV
HCV
Vaccines
100
100
100
100
100
200
200
200
200
200
300
300
300
300
300
400
400
400
400
400
500
500
500
500
500

47. Vaccines for $100
How many doses are required to complete the hepatitis A vaccine series?
What is…..?

48. What is…..?
Two
Vaccines for $100

49. HEPATITIS JEOPARDY
Hepatitis
HAV
HBV
HCV
Vaccines
100
100
100
100
100
200
200
200
200
200
300
300
300
300
300
400
400
400
400
400
500
500
500
500
500

50. Vaccines for $300
What is the most common number of doses given to complete the hepatitis B vaccine series?
What is…..?

51. What is…..?
Three
Vaccines for $300

52. HEPATITIS JEOPARDY
Hepatitis
HAV
HBV
HCV
Vaccines
100
100
100
100
100
200
200
200
200
200
300
300
300
300
300
400
400
400
400
400
500
500
500
500
500

54. Final Jeopardy Final Jeopardy
What two pharmaceutical companies in the U.S. manufacture hepatitis B vaccine?
Final Jeopardy

55. Who are…..?
                                                                 
Final Jeopardy

56. Thank you
for playing
Hepatitis
Jeopardy

57. The diagnosis of acute HAV infection is confirmed during the acute or early convalescent phase of infection by the presence of IgM antibodies to HAV (IgM anti-HAV). IgM anti-HAV is generally present 5-10 days into the incubation period and remains detectable for up to 6 months after onset of illness. IgG anti-HAV, which also appears early in the course of infection, remains detectable for the lifetime of the individual and confers lifelong protection against infection. Commercial tests are available for the detection of IgM and total (Igm and IgG) anti-HAV in serum.
In infected persons, HAV replicates in the liver, is excreted in bile, and is shed in the stool. Peak infectivity occurs during the 2-week period before onset of jaundice or elevation of liver enzymes, when the concentration of virus in stool is highest. The concentration of virus in stool declines after jaundice appears. Children and infants can shed HAV for longer periods than adults, up to several months after the onset of clinical illness. Chronic shedding of HAV in feces does not occur; however, shedding can occur in persons who have relapsing illness. Viremia occurs soon after infection and persists through the period of liver enzyme elevation.
HAV RNA can be detected in the blood and stool of most persons during the acute phase of infection by using nucleic acid amplification methods, and nucleic acid sequencing has been used to determine the relatedness of HAV isolates. However, these methods, available in only a limited number of research laboratories generally are not used for diagnostic purposes.

58. Acute Hepatitis A: Case Definition
Clinical criteria:
Discrete onset of symptoms and
Jaundice or elevated serum aminotransferase levels
Laboratory criteria
IgM anti-HAV-positive
Case Classification
Confirmed. A case that meets the clinical case definition and is laboratory confirmed or a case that meets the clinical case definition and occurs in a person who has an epidemiological link.
Acute hep C a reportable condition since .....
Case definition...
Reported since ____ through NNDSS and NETSS
Grouped with NANB hepatitis because of limitations of diagnostics

59. Acute Hepatitis B Virus Infection
with Recovery
Typical Serologic Course
Weeks after Exposure
Symptoms
HBeAg
anti-HBe
Total anti-HBc
IgM anti-HBc
anti-HBs
HBsAg 4 8 12 16 20 24 28 32 36 52
100
Titer 30

60. Acute Hepatitis B: Case Definition
Clinical criteria:
Discrete onset of symptoms and
Jaundice or elevated serum aminotransferase levels
Laboratory criteria
IgM anti-HBc-positive or
HBsAg-positive, if IgM anti-HBc not done
Case Classification
Confirmed. A case that meets the clinical criteria and is IgM anti-HBc-positive
Suspected. A case that meets the clinical criteria, is HBsAg-positive and IgM anti-HAV-negative, but was not tested for IgM anti-HBc.
Acute hep C a reportable condition since .....
Case definition...
Reported since ____ through NNDSS and NETSS
Grouped with NANB hepatitis because of limitations of diagnostics

61. Chronic Hepatitis B Virus Infection
Progression to
Chronic Hepatitis B Virus Infection
Typical Serologic Course
IgM anti-HBc
Total anti-HBc
HBsAg
Acute
(6 months)
HBeAg
Chronic
(Years)
anti-HBe 4 8 12 16 20 24 28 32 36 52
Years
Weeks after Exposure
Titer 31

62. Chronic HBV Infection: Case Definition
Clinical criteria:
Most are asymptomatic. However, many have CLD, which can range from mild to severe.
Laboratory criteria:
HBsAg-positive two times at least 6 months apart, or
HBsAg-positive, total anti-HBc positive and IgM anti-HBc negative
Acute hep C a reportable condition since .....
Case definition...
Reported since ____ through NNDSS and NETSS
Grouped with NANB hepatitis because of limitations of diagnostics

63. Acute HCV Infection with Recovery
Typical Serologic Course
HCV RNA
Symptoms +/-
Time after Exposure
Titer
Anti-HCV
ALT
Normal 1 2 3 4 5 6
Years
Months

64. Acute Hepatitis C: Case Definition
Clinical criteria:
Acute illness with discrete onset of symptoms and
Jaundice or elevated serum aminotransferase levels
Laboratory criteria
Serum aminotransferase levels >7 times ULN and
IgM anti-HAV-negative and
IgM anti-HBc-negative (if done) or HBsAg-negative and
anti-HCV-positive and
verified by additional more specific assay or
Anti-HCV-positive by RIBA alone or
HCV RNA positive
Acute hep C a reportable condition since .....
Case definition...
Reported since ____ through NNDSS and NETSS
Grouped with NANB hepatitis because of limitations of diagnostics

65. Progression to Chronic HCV Infection
Typical Serologic Course
Symptoms +/-
Time after Exposure
Titer
anti-HCV
ALT
Normal 1 2 3 4 5 6
Years
Months
HCV RNA

66. Chronic or Resolved HCV Infection: Case Definition
Clinical criteria:
Most are asymptomatic. However, many have CLD, which can range from mild to severe.
Laboratory criteria
Anti-HCV-positive (by EIA), either
verified by an additional, more specific assay (e.g., RIBA or PCR for HCV RNA), or
with signal-to-cut-off (SCO) ratio of >3.8
Case Classification
Confirmed: Laboratory confirmed
Probable: Abnormal ALT values but anti-HCV result not verified by more specific assay and SCO unknown
Acute hep C a reportable condition since .....
Case definition...
Reported since ____ through NNDSS and NETSS
Grouped with NANB hepatitis because of limitations of diagnostics

67. CASE STUDY 1

68. Kelly went on a trip to Peru two years ago
Kelly went on a trip to Peru two years ago. One week prior to her trip, she received one dose of IG. She got the first dose of hepatitis A vaccine at the same time. She returned from her two week trip, returned to her job at the health department, and as usual was crazy busy. Two years elapsed when she finally went to her doctor for her second dose of vaccine.

69. Did she need the IG prior to travel or would the vaccine have been adequate?
Yes, she needed the IG. For optimal protection, 4 weeks needs to transpire between the 1st dose of vaccine and travel.
Given the elapsed time between the 1st and 2nd dose is Kelly now protected from HAV infection?
Yes, Why?

70. Hepatitis A vaccine is very immunogenic - general thought is that time can lapse between doses without compromising immunity. Studies have shown that protective antibody levels developed in 94%-100% of adults one month after the first dose. After the second dose, all persons had protective levels of antibody.

71. Should post vaccination testing be done on persons who received hepatitis A vaccine?
No, Why?
Hepatitis A vaccine is very immunogenic and the assay may not be adequate to pick up true protection.

72. How long does immunity last after hepatitis A immunization?
Although data on long-term protection are limited, estimates based on modeling techniques suggest that protection will last for at least 20 years.
Should pre-vaccination testing be done?
Generally no, pre-vaccination testing is done only in
specific instances to control cost.

73. Other than travelers to HAV endemic areas, what other groups does CDC recommend hepatitis A vaccine?
MSM
Illegal drug users, both injecting and non-injecting
Children living in communities with consistently increased rates of hepatitis A or periodic outbreaks.
Persons with CLD
Persons working with live virus
Persons with clotting factor disorders

74. What is TWINRIX?
On May 11, 2001, The Food and Drug Administration (FDA) licensed a combined hepatitis A and hepatitis B vaccine (Twinrix) for adults. The antigenic components in Twinrix have been used routinely in separate vaccines since 1995 and 1989 for hepatitis A and hepatitis B vaccines, respectively. Primary immunization consists of three doses (0,1,6).

75. CASE STUDY 2

76. Ting Nguyen came to America from Vietnam as an eleven year old girl
Ting Nguyen came to America from Vietnam as an eleven year old girl. After twelve years of living in Tecumseh, Kansas, she met and married her college sweetheart Wayne. Since they both came from large, traditional families, they started a family immediately. She became pregnant in the first month of marriage. Included in her first trimester prenatal screening was a serologic test for HBsAg. She was shocked to learn that she was HBsAg-positive! Her obstetrician informed her that she was probably chronically infected with HBV and most likely had been infected since birth. Ting or her mother never recalled any signs or symptoms of viral hepatitis at any point in the last 20+ years.

77. What additional information should Ting’s doctor provide to Ting and her family?
The whole family and certainly Ting’s mother should be tested for anti-HBc and for HBsAg. If members are susceptible, they should be vaccinated; if infected, they should be referred for medical consultation.

78. Should Ting plan to have a C-section?
No, data don’t suggest that method of delivery would change the outcome. The important thing is that Ting’s baby be appropriately prophylaxed at birth.
What is that prophylaxis?
HBIG and first dose of hepatitis B vaccine within 12 hours of birth. Ting should also be counseled that she should have HBsAg testing for each succeeding pregnancy. It is important to note that if HBsAg screening were not done and her birth hospital did not do the birth dose of hepatitis B vaccine, her baby would be at risk.

79. At what age should Ting’s baby be tested to determine
Can Ting nurse her baby?
Yes - just be certain the baby gets prophylaxed within 12 hrs of birth - instruct Ting on good nipple care - she can even put the baby to breast on the delivery table.
At what age should Ting’s baby be tested to determine
success or failure of prophylaxis ?
At 9-15 months
What tests should be performed?
HBsAg and anti-HBs

80. Tests were performed on Ting’s baby and anti-HBs and HBsAg were negative, what should be done next?
Revaccinate the baby and test anti-HBs in 1-2 months after last dose of vaccine.

81. CASE STUDY 3

82. Marie and Moses have been married for 10 years
Marie and Moses have been married for 10 years. They are currently in their mid 30’s and busy with professional careers. Moses’ company recently held a blood drive. Moses’ company, the “Make a Million before you are 40, Inc.” made it very clear that everyone in the company was to donate a unit of blood. Fearing job loss, Moses donated. Moses knew he had shot speed once during a party at his fraternity 15 years prior to his donation. Fearing job loss, Moses answered “no” to the injection drug use question when asked by the donor center, and dutifully, or so he thought, donated his pint of blood.

83. What should Moses have done when questioned about IDU?
He should have admitted to the one time use. Because some persons, albeit a small percentage, will test negative for bloodborne diseases even when are actually positive. However, blood banks also do RIBA/PCR testing on all repeatedly reactive EIAs, so the chance of a false negative in this situation is quite low.

84. EIA anti-HCV positive and indeterminate by RIBA
Two weeks later, Moses received a letter from the blood bank that stated he was anti-HCV positive and should contact his health professional. Moses was scared – not only for his job, but for his health as well. He immediately called his physician, Dr. Fix-it-all. Moses went in for a check up and some blood work. His blood work showed the following:
HBsAg – negative
anti-HBc – negative
EIA anti-HCV positive and indeterminate by RIBA
What should be done next?
Additional laboratory evaluation (e.g., RT-PCR, ALT)

85. The specialist repeated the PCR and it showed the presence of virus.
His PCR was negative, his ALT was 150 (ULN – 45). What should be done next?
Consultation with a specialist or referral to a specialist.
The specialist repeated the PCR and it
showed the presence of virus.

86. What if his RIBA were negative?
What if his RIBA test was initially positive
what should have been done?
Medical Evaluation
What if his RIBA were negative?
He is a false positive – nothing more needs to be done.

87. Thank you!