Acute viral hepatitis – Should the current screening strategy be modified?

https://doi.org/10.1016/j.jcv.2014.01.001Get rights and content

Abstract

Background

The epidemiology of viral hepatitis has changed. Since the introduction of safe and effective vaccines for hepatitis A and B in 1980s, the incidence of acute infections caused by these viruses has been declining in the UK. At the same time, hepatitis E virus (HEV) has been recognised as an increasingly important cause of acute hepatitis, but testing is not widely available.

Objectives

The aim of this study was to establish the viral causes of acute hepatitis, and use that data to modify the current diagnostic algorithm.

Study design

A Cognos search was performed to collate subjects tested for HAV, HBV, HCV, HEV, EBV and CMV between June 2010 and December 2012. Information included virological result and their ALT level if done within 5 days from virological testing.

Results

From 3462 subjects with suspected acute viral hepatitis, only 25% had biochemical evidence of acute hepatitis (n = 854; ALT > 100 IU/l). The frequency of detection of acute HEV infection (25/409) was over 31-times higher than that of HAV (6/3462), and 7-times higher than that of HBV (24/3462). Most cases of acute HAV, HEV, EBV and CMV infections presented with abnormal ALT levels. Most EBV infections were associated with lymphadenopathy (23/34); in comparison most of CMV infections were not associated with lymphadenopathy (18/22).

Conclusions

HEV screening should be included in the initial testing panel for acute hepatitis and screening at least for HAV and HEV might be limited to those with abnormal ALT levels.

Section snippets

Background

Viral hepatitis is one of the most common of the severe infectious diseases. The five most established viral causes include hepatitis A virus (HAV), hepatitis B virus (HBV), hepatitis C virus (HCV), hepatitis D virus (HDV) and hepatitis E virus (HEV) [1]. These diverse viruses are members of different virus families. They are all are associated with acute hepatitis, and typically target hepatocytes leading to their destruction. Several herpes viruses, such as cytomegalovirus (CMV) and

Objectives

The aim of this study was to establish the viral aetiology of hepatitis in Lothian region, South-Eastern Scotland, to collect clinical data and to use that information to modify the diagnostic algorithm currently followed in the Specialist Virology Centre at the Royal Infirmary Edinburgh, which conducts routine testing for the region.

Study design

A total of 3426 serum samples obtained from individuals with acute hepatitis were submitted to the Specialist Virology Centre at the Royal Infirmary of Edinburgh between July 2010 and December 2012. The subjects tested for HAV, HBV, HCV, HEV, EBV and CMV were identified from the laboratory database. The information collected included name, date of birth, specimen number, hospital number, location, virological test result as well as ALT level if done within 5 days from virology testing. Clinical

Results

A total of 3426 samples obtained from individuals with suspected acute hepatitis were examined during the 30-month study period. Of those, 25% had biochemical evidence of acute hepatitis (n = 854; ALT > 100 IU/l), 43% had marginally abnormal ALT levels (n = 1492; ALT >50 IU/l and <100 IU/l), 10% had normal ALT levels (n = 334; ALT < 50 IU/l) and 22% had not had ALT measured (n = 782).

All 3426 samples were screened for HAV, HBV and HCV, a subset of 409 samples were screened for HEV and a subset of 835 samples

Discussion

Laboratory testing is essential to identify the aetiology of viral hepatitis, which will determine treatment and public health interventions. In a 30-month study period, a total of 3426 samples were obtained for testing from individuals with suspected acute hepatitis. However, only 25% of them had biochemical evidence of acute hepatitis. Over 30% had either normal ALT levels or had not had their ALT levels measured at all. All confirmed cases of acute HAV, HEV, EBV and CMV infections were

Funding

None.

Competing interests

None.

Ethical approval

The East of Scotland Research Ethics Committee (10/S1402/33).

Acknowledgements

We thank Dr Gina McAllister and Mr Andrew Mitchell for a Cognos search and Dr Donald Smith for helpful comments during the preparation of the manuscript.

References (23)

  • L.J. Brant et al.

    Using automated extraction of hepatitis B tests for surveillance: evidence of decreasing incidence of acute hepatitis B in England

    Epidemiol Infect

    (2012)
  • Cited by (27)

    • Emerging and Miscellaneous Viral Infections

      2022, Greene's Infectious Diseases of the Dog and Cat, Fifth Edition
    • Hepatitis E virus infection among patients with altered levels of alanine aminotransferase

      2021, Brazilian Journal of Infectious Diseases
      Citation Excerpt :

      The overall age of HSP patients from the was 41.0 years (mean, SD 23.89 and median 42), with no statistical difference between sexes (Table 2). To the best of our knowledge, this is the first study in Brazil that evaluated the diagnosis of HEV infection in patients looking for care at emergency rooms with increased ALT levels, as investigated in other international studies.11-13 The general detection of viral hepatitis in patients with elevated ALT levels varies according to the phase of the disease and the detection method employed.

    • Etiologies and Features of Acute Viral Hepatitis in Spain

      2021, Clinical Gastroenterology and Hepatology
    • The added value of hepatitis E diagnostics in determining causes of hepatitis in routine diagnostic settings in the Netherlands

      2017, Clinical Microbiology and Infection
      Citation Excerpt :

      In the Netherlands, viral hepatitis caused by hepatitis A virus (HAV) and hepatitis B virus (HBV) has decreased considerably. Recently, HEV has been recognized as an increasingly important cause of viral hepatitis [8,9]. Often, a recent HEV infection may be mistaken for drug-induced hepatitis, especially in the elderly where poly-pharmacy is more common.

    • Hepatitis E virus is the leading cause of acute viral hepatitis in Lothian, Scotland

      2016, New Microbes and New Infections
      Citation Excerpt :

      Laboratory testing is required to establish the viral cause of acute hepatitis. Clinical presentation is similar between the different viral hepatitides and can vary from asymptomatic to fulminant (http://www.who.int/mediacentre/factsheets/fs328/en/, http://www.who.int/mediacentre/factsheets/fs204/en/, http://www.who.int/mediacentre/factsheets/fs164/en/, http://www.who.int/mediacentre/factsheets/fs280/en/) [4]. Identifying the cause of infection is important because it influences the management of patients and protection of others, whether or not this includes medical treatment.

    View all citing articles on Scopus
    View full text